Pre-service midwifery education in sub-Saharan Africa: A scoping review.

BACKGROUND: In response to a global call for more midwives, maternal health stakeholders have called for increased investment in midwifery pre-service education. Given the already long list of challenges and the increasing burden on health care systems due to the COVID-19 pandemic, the need to prioritize investment is acute, particularly in sub-Saharan Africa. An important first step is to examine the current evidence. METHODS: We conducted a scoping review of the peer-reviewed literature about pre-service midwifery education in sub-Saharan Africa. A search of studies published between 2015 and 2021 in French or English was conducted using six databases (PubMed, CINAHL, Embase, Scopus, Web of Science and African Index Medicus). RESULTS: The search yielded 3061 citations, of which 72 were included. Most were a mix of qualitative and quantitative cross-sectional, country-specific studies. Organized by pre-service educational domain, the literature reflected a misalignment between international standards for midwifery education and what schools and clinical sites and the larger administrative systems where they operate, reliably provide. Inadequate infrastructure, teaching capacity in school and clinical settings and clinical site environment were factors that commonly impede learning. Literature related to faculty development and deployment were limited. CONCLUSION: Schools, faculty and clinical sites are overwhelmed yet recommendations by key stakeholders for change are substantive and complex. Efforts are needed to help schools map their current status by pre-service education domain and prioritize where scarce resources should be directed. These results can inform research and investments in pre-service midwifery education in sub-Saharan Africa.

Quality of pre-service midwifery education in public and private midwifery schools in Afghanistan: a cross sectional survey.

BACKGROUND: Midwives are the key skilled birth attendants in Afghanistan. Rapid assessment of public and private midwifery education schools was conducted in 2017 to examine compliance with national educational standards. The aim was to assess midwifery education to inform Afghanistan Nurses and Midwives Council and other stakeholders on priorities for improving quality of midwifery education. METHODS: A cross-sectional assessment of midwifery schools was conducted from September 12-December 17, 2017. The Midwifery Education Rapid Assessment Tool was used to assess 29 midwifery programs related to infrastructure, management, teachers, preceptors, clinical practice sites, curriculum and students. A purposive sample of six Institute of Health Sciences schools, seven Community Midwifery Education schools and 16 private midwifery schools was used. Participants were midwifery school staff, students and clinical preceptors. RESULTS: Libraries were available in 28/29 (97%) schools, active skills labs in 20/29 (69%), childbirth simulators in 17/29 (59%) and newborn resuscitation models in 28/29 (97%). School managers were midwives in 21/29 (72%) schools. Median numbers of students per teacher and students per preceptor were 8 (range 2-50) and 6 (range 2-20). There were insufficient numbers of teachers practicing midwifery (132/163; 81%), trained in teaching skills (113/163; 69%) and trained in emergency obstetric and newborn care (88/163; 54%). There was an average of 13 students at clinical sites in each shift. Students managed an average of 15 births independently during their training, while 40 births are required. Twenty-four percent (7/29) of schools used the national 2015 curriculum alone or combined with an older one. Ninety-one percent (633/697) of students reported access to clinical sites and skills labs. Students mentioned, however, insufficient clinical practice due to low case-loads in clinical sites, lack of education materials, transport facilities and disrespect from school teachers, preceptors and clinical site providers as challenges. CONCLUSIONS: Positive findings included availability of required infrastructure, amenities, approved curricula in 7 of the 29 midwifery schools, appropriate clinical sites and students' commitment to work as midwives upon graduation. Gaps identified were use of different often outdated curricula, inadequate clinical practice, underqualified teachers and preceptors and failure to graduate all students with sufficient skills such as independently having supported 40 births.

A Canadian Massage Therapy Education Environmental Scan.

BACKGROUND: Massage therapists have been a part of Canadian's health care since 1919. The profession has gone through great change over the past 100 years including adjustments to entry-to-practice education. An important recent change was the implementation of massage therapy (MT) education program accreditation. In light of the likely disruption as a result of programs becoming accredited, a scan of the current state of MT education in Canada was undertaken. METHODS: An environmental scan informed by seminal medical education efforts was used to describe the thoughts and opinions of MT education stakeholders in Canada. Specifically, stakeholders were interviewed regarding the current state of MT education and their comments were analyzed for common themes. RESULTS: Twenty-one stakeholders participated. Four themes were constructed: variation, isolation, stagnation, and accreditation. Variation is described as the impact of differences in content and quality of the education provided in MT colleges. Isolation is described as the feeling of the participant being separated, or disconnected, from the regulator, accreditor, or colleagues due, at least in part, to a lack of communication or networking opportunities. Stagnation is described as a lack of activity, growth, or development within MT education. Participants talked about accreditation, both as a solution for some of the challenges previously mentioned, and as a potential challenge in itself. CONCLUSIONS: Several challenges to MT education were described by stakeholders that they hoped would be remedied by national MT program accreditation. Despite some limitations, this environmental scan forms a baseline for stakeholder views on massage education in Canada upon which future comparisons can be made. While the environmental scan results are most useful when applied to the MT in Canada context, stakeholders in other countries may also find them interesting and valuable when considering challenges facing their own education programs.

Understanding the Landscape of Behavioral Health Pre-service Training to Inform Evidence-Based Intervention Implementation.

Reports on the behavioral health workforce highlight the need to enhance evidence-based capacity; evidence-based interventions incorporated into pre-service graduate curricula (coursework and fieldwork) are needed to meet this goal. Improving educational practices across pre-service settings will require understanding of and careful attention to the contextual factors that exert pressure on curricula. The authors believe efforts to change educational practices can be enhanced by application of implementation science principles. This Open Forum delineates the key contextual factors that influence pre-service education, highlights gaps in the literature, and proposes an agenda for future research at the intersection of behavioral health workforce development and implementation science.

Blending virtual with conventional learning to improve student midwifery skills in India.

India's state of Bihar has suboptimal quality of pre-service training for auxiliary nurse midwives. To address this, state government of Bihar implemented a blended training model to supplement conventional classroom teaching with virtual training. A 72-hour virtual training package with updated content on key maternal and newborn health practices was developed for final year students and broadcasted from one instructor location simultaneously to two auxiliary nurse midwives training centres. This pre-post intervention study compared skills of two auxiliary nurse midwife student cohorts. Eighty-five students from pre-intervention cohort of academic year 2012-13, received only conventional teaching during the final year. The 51 students in the post-intervention cohort from successive academic year 2013-14, received a combination of the both conventional and virtual training. The two cohorts were objectively assessed on identified midwifery skills. A passing score was set at achieving 75% or higher. The students exposed to blended learning scored 32.57 points (p = <0.001) more than their counterparts, who received only conventional teaching. In the post-intervention cohort, 55% students (N = 28) passed as compared to none in the pre-intervention cohort. We found blended learning approach effectively improved access to quality training, and identified key midwifery skills of auxiliary nurse midwife students from remote locations.

Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program.

BACKGROUND: The shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010. OBJECTIVE: We analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned. DESIGN: We performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs. SETTING: For the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development. PARTICIPANTS: Midwives who had graduated from either IHS or CME schools. FINDINGS: CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9-66.6%) on the clinical competency assessment compared to 57.3% (49.9-64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,784 per graduate. KEY CONCLUSIONS: The pre-service midwifery education experience of Afghanistan can serve as a model to rapidly increase the number of skilled birth attendants. In such settings, it is important to ensure the provision of continued practice opportunities and refresher trainings after graduation to aid skill retention, a co-operative and supportive work environment that will use midwives for the reproductive health skills for which they were trained, and selection mechanisms that can identify the most promising students and post-graduation deployment options to maximise the return on the substantial educational investment.

'Midwives are the backbone of our health system': lessons from Afghanistan to guide expansion of midwifery in challenging settings.

BACKGROUND: over the last decade Afghanistan has made large investments in scaling up the number of midwives to address access to skilled care and the high burden of maternal and newborn mortality. OBJECTIVE: at the request of the Ministry of Public Health (MOPH) an evaluation was undertaken to improve the pre-service midwifery education programme through identification of its strengths and weaknesses. The qualitative component of the evaluation specifically examined: (1) programme strengths; (2) programme weaknesses; (3) perceptions of the programme's community impact; (4) barriers to provision of care and challenges to impact; (5) perceptions of the recently graduated midwife's field experience, and (6) recommendations for programme improvement. DESIGN: the evaluation used a mixed methods approach that included qualitative and quantitative components. This paper focuses on the qualitative components which included in-depth interviews with 138 graduated midwives and 20 key informants as well as 24 focus group discussions with women. SETTING: eight provinces in Afghanistan with functioning and accredited midwifery schools between June 2008 and November 2010. PARTICIPANTS: midwives graduated from one of the two national midwifery programmes: Institute of Health Sciences and Community Midwifery Education. Key informants comprised of stakeholders and female residents of the midwives catchment areas. FINDINGS: midwives described overall satisfaction with the quality of their education. Midwives and stakeholders perceived that women were more likely to use maternal and child health services in communities where midwives had been deployed. Strengths included evidence-based content, standardised materials, clinical training, and supportive learning environment. Self-reported aspects of the quality education in respect to midwives empowerment included feeling competent and confident as demonstrated by respect shown by co-workers. Weaknesses of the programme included perceived low educational requirement to enter the programme and readiness of programmes to commence education. Insecurity and geographical remoteness are perceived as challenges with clients' access to care and the ability of midwives to make home visits. KEY CONCLUSIONS: the depth of midwives' contribution in Afghanistan - from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence - is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.