African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey.

BACKGROUND: Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE: To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS: A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS: In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS: Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

African midwifery students' self-assessed confidence in antenatal care: a multi-country study.

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

Evaluation of an educational board game to improve use of the partograph in sub-Saharan Africa: A quasi-experimental study.

BACKGROUND: The partograph is a tool used to record labour observations and support decision-making. Although used globally, it has not reached its full potential. We aimed to determine whether an educational board game can improve labour-monitoring skills and influence practice. STUDY DESIGN: A quasi-experimental study, underpinned by Kirkpatrick's evaluation model, was used. Midwives and student midwives from Malawi, Kenya and Tanzania were given an identical hypothetical case-scenario of a woman in labour pre-and post-implementation of a game, to assess recording and interpretation abilities. This was supplemented by qualitative inquiry 3 months post-game-playing using semi-structured interviews (n = 24) and expert case-record reviews (n = 24). Quantitative data were analysed using the paired t-test and qualitative data were subjected to framework analysis. RESULTS: 95 midwives and 97 students participated. In each country the mean test scores improved; Kenya from 86.5 (6.7) to 95.5 (3.7) (paired t = 11.82, p < 0.001), Malawi from 83.6 (6.7) to 94.6 (4.1) (paired t = 13.35, p < 0.001), and Tanzania from 83.8 (6.2) to 94.9 (4.1) (paired t = 15.27, p < 0.001). Qualitative findings revealed six themes: 'an enjoyable way of practicing,' 'learning and re-learning,' 'improved clinical decision-making', 'promoting team-work', 'a catalyst for additional learning' and 'barriers to transference of learning'. Expert case-record review demonstrated good adherence to recommendations. CONCLUSION: Board games have the ability to improve labour-monitoring knowledge. Retention of information was apparent and application of learning into practice was encouraging. Health-system barriers need to be resolved for midwives to apply theory to practice. Whether such application results in improved clinical outcomes is uncertain and requires further evaluation.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

Success Stories: Overcoming Barriers to Research in Southern and Eastern African Countries.

There is an ever-growing need for clinically focused, culturally relevant research on which nurses can base their practice. However, there may not be a concurrent rise in efforts to strengthen infrastructure needed to promote research in developing and low-income countries. In such cases, nurse researchers must find innovative ways to address and overcome barriers to research. This article presents five exemplars of nurses conducting high-quality nursing research in resource-poor settings in southern and eastern Africa. Furthermore, it suggests strategies to address these barriers, such as piggybacking on larger studies, interdisciplinary collaboration, and partnership with influential stakeholders. These tactics may be used to increase research productivity elsewhere.

Clinical Nursing and Midwifery Research Priorities in Eastern and Southern African Countries: Results From a Delphi Survey.

BACKGROUND: Because of the profound shortage of nurse and midwifery researchers in many African countries, identification of clinical nursing and midwifery research is of highest priority for the region to improve health outcomes. OBJECTIVES: The aim of this study was to gain consensus from experts on the priorities of clinical nursing and midwifery research in southern and eastern African countries. METHOD: A Delphi survey was conducted among experts in the region. Criteria for "expert" included (a) a professional nurse, (b) a bachelor's degree or higher in nursing, (c) published research, (d) affiliated with a school of nursing with at least a master's level nursing program, and/or (e) identified by the African core collaborators as an expert in the region. A list of candidates was identified through searches of published and gray literature and then vetted by core collaborators in Kenya, Malawi, and South Africa. Core collaborators held leadership roles in a nursing school and a doctoral degree in nursing, had conducted and published nursing research, and resided in an included country. RESULTS: Two rounds of the Delphi survey were required to reach consensus. In total, 40 participants completed both rounds, and at least one participant from each country completed both rounds; 73% and 85% response rates were achieved for each round, respectively. Critical clinical research priorities were infectious disease/infection control and midwifery/maternal health topics. These included subtopics such as HIV/AIDS, tuberculosis, maternal health and mortality, infant mortality, and obstetrical emergencies. Many other topics were ranked as important including patient outcomes, noncommunicable diseases, and rural health. DISCUSSION: Areas identified as research priorities were consistent with gaps identified in current literature. As evidenced by previous research, there is a lack of clinical nursing and midwifery research in these areas as well as nurses and midwives trained to conduct research; these priorities will help direct resources to the most essential research needs.

A pilot quasi-experimental study to determine the feasibility of implementing a partograph e-learning tool for student midwife training in Nairobi.

OBJECTIVE: the partograph is a tool used globally to record labour progress. Although it has the potential to improve maternal and neonatal outcomes, some midwives struggle with using it in practice. Training in partograph use is limited, and the theory is often divorced from practice. Innovative ways of improving training are urgently required. We therefore aimed to determine whether the use of an e-learning tool is beneficial for learning partograph skills. DESIGN: an uncontrolled before-and-after study was conducted, informed by Kirkpatrick's four-stage model of evaluation; we report on the first two stages. We included a cohort of third and fourth year midwifery students who were studying at one university in Nairobi. The same hypothetical case scenario was used, pre- and post-implementation of the World Health Organization partograph e-learning tool, to assess students' partograph completion ability. Views on the tool were also sought, using semi-structured questionnaires. Data were analysed using standard statistical techniques and framework analysis. FINDINGS: 92 (88%) students participated. Students expressed positive views about the e-learning tool. However, the mean post-intervention score (27.21) was less than half of the maximum obtainable score. There was some improvement in test scores; year three mean score pre-intervention was 21.39 (SD 5.72), which increased to 25.10 (5.41) post-intervention (paired-t=3.47, p=0.001); year four mean score pre-intervention was 24.39 (5.98) which increased to 29.30 (6.77) post-intervention (paired t=3.85, df=91, p<0.001). In the post-test, year four students scored higher than year three students (unpaired t=3.28, df=90, p=0.001). Students were unable to plot cervical dilatation correctly, once established labour had been confirmed. KEY CONCLUSION: e-Learning training is acceptable to student midwives and has the potential to be an effective means of teaching the practical application of the partograph. However, in this study, their inability to correctly plot transference from the latent to active phase of labour suggests that the partograph itself may be too complicated. Modifications and further evaluation of the e-learning tool would be required before any widespread implementation. Furthermore, students need the clinical support to operationalise their learning; educating qualified midwives and obstetricians to be positive role models when completing the partograph would be one potential solution. Further research is required, taking on board the recommendations from our pilot study, to investigate the impact of partograph e-learning on practice and clinical outcomes.

'Moving with the times' taking a glocal approach: a qualitative study of African student nurse views of e learning.

BACKGROUND: Information technology is a rapidly increasing means of communication in education and healthcare. This is also true in low resource settings, where electronic communication provides an opportunity for sharing information about health and wellbeing and enhancing learning for healthcare professionals. METHODS: A qualitative study whereby 51 year 3 and 4 student nurses at the University of Nairobi participated in 5 focus group discussions. Data were recorded, transcribed verbatim and analyzed using a framework approach. RESULTS: Four main themes were identified, 'moving with the times', 'global networking', 'inequity as a barrier' and 'transfer of internet learning into practice'. CONCLUSIONS: Information technology is already integral to students' lives both personally and professionally and the students had a strong desire to find out what is happening globally. The familiarity of the internet contributes to the acceptance of e-learning programs as part of educational curricula. Students felt that e-learning 'is here to stay' and wanted to 'embrace the concept.' E-learning was generally welcomed however students suggested that it should be 'supplementary' to face-to-face learning. In order to incorporate e-learning ethically in low resource settings, resources should be sustainable, for example CDROMs and DVDs which are not dependant on internet access. Researching the views of qualified midwives might be the next step in promoting this valuable teaching method.