Teacher as role model in developing professional behavior of medical students: a qualitative study.

Objectives: This study aimed to explore students' perspectives on the attributes of medical teachers as role models to students' professional behaviour in the educational process. Methods: A phenomenological study was conducted to obtain participants' perceptions concerning the professional attributes of medical teachers. The participants were 21 final-year medical students in the School of Medicine, Universitas Gadjah Mada, who had completed and passed the national examination. The participants were recruited purposively to represent genders and performance (i.e., high-performing and average-performing students). The participants were divided into two focus groups based on their performance, each facilitated by non-teaching faculty members to avoid bias. Thematic analysis was conducted to analyze focus group transcripts by two independent coders. Codes were synthesized into themes related to the study aims. Results: Seven themes were identified related to observed role model attributes, for instance, passionate lecturers, caring and empathetic, supportive and involving, objectivity, incompetence and compromising, poor communication and conflict, and time management. Subsequently, five themes were identified in participants' responses towards the observed role model, for instance, exemplary models, respect and motivating, confusion and inconvenience, avoiding and hate, and value collision and harmonization. Conclusions: This study revealed a range of role model attributes and responded positively and negatively during learning encounters. As negative attributes are also prominent and observed by students, there is a need for medical schools to perform faculty development for the professional enhancement of medical teachers. Further study should be conducted to investigate the impact of role modelling on learning achievement and future medical practice.

The Efficacy of Divabirth Vaginal Dilator to Prevent Pelvic Floor Trauma During Labor: A Protocol Study.

Background: Vaginal birth may have a negative impact on nerve structure and function, pelvic floor muscle structure, and function. Reducing the risk of pelvic floor injuries during vaginal birth is one of the most effective ways to prevent labor morbidity in women. There is a lack of tools developed based on this approach, especially in Indonesia. Therefore, we aimed to know the efficacy of a vaginal dilator called Divabirth based on labor outcomes. Methods: This clinical study involved subjects who are randomly grouped in to the control and treatment groups. Subjects in the treatment group are told to utilize vaginal dilator devices for 20 minutes each session, a maximum of two sessions per day, lasting 5 minutes every cycle, from 35 weeks of gestation until delivery. Discussions: The current research contributes valuable information to developing a vaginal dilator intervention program for pregnant women to reduce perineal laceration and improve labor outcomes. It may also help to lower their medical and treatment expenditures. We expect its success to be a step forward in improving reproductive health status. Highlights: Vaginal birth may have negative impact on nerve and pelvic floor muscle structure and functionLack of tool has been developed to reduce the risk of pelvic floor injuries during vaginal birthA study protocol of vaginal dilator usage to know the efficacy based on labor outcomes.

Challenging the status quo: results of an acceptability and feasibility study of hypertensive disorders of pregnancy (HDP) management pathways in Indonesian primary care.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in Indonesia. Focused HDP management pathways for Indonesian primary care practice have been developed from a consensus development process. However, the acceptability and feasibility of the pathways in practice have not been explored. This study reports on the implementation process of the pathways to determine their acceptability and feasibility in Indonesian practice. METHODS: The pathways were implemented in three public primary care clinics (Puskesmas) in Yogyakarta province for a month, guided by implementation science frameworks of Medical Research Council (MRC) and the Practical Robust Implementation and Sustainability Model (PRISM). The participating providers (general practitioners (GPs), midwives, and nurses) were asked to use recommendations in the pathways for a month. The pathway implementation evaluations were then conducted using clinical audits and a triangulation of observations, focus groups (FGs), and interviews with all of the participants. Clinical audit data were analysed descriptively, and qualitative data were analysed using a mix of the inductive-deductive approach of thematic analysis. RESULTS: A total of 50 primary care providers, four obstetricians, a maternal division officer in the local health office and 61 patients agreed to participate, and 48 of the recruited participants participated in evaluation FGs or interviews. All of the providers in the Puskesmas attempted to apply recommendations from the pathways to various degrees, mainly adopting preeclampsia risk factor screenings and HDP monitoring. The participants expressed that the recommendations empowered their practice when it came to HDP management. However, their practices were challenged by professional boundaries and hierarchical barriers among health care professionals, limited clinical resources, and regulations from the local health office. Suggestions for future scale-up studies were also mentioned, such as involving champion obstetricians and providing more patient education toolkits. CONCLUSION: The HDP management pathways are acceptable and feasible in Indonesian primary care. A further scale-up study is desired and can be initiated with investigations to minimise the implementation challenges and enhance the pathways' value in primary care practice.

Human Papillomavirus (HPV) Health Savings as an Alternative Solution: HPV Vaccination Behavior in Adolescents.

OBJECTIVE: This study aimed to measure the effects of reproductive health savings (tabungan kesehatan reproduksi, Takespro) on human papillomavirus (HPV) vaccine initiation program and the quality of the decision making to get vaccinated, as measured by knowledge, attitudes, beliefs, and self-efficacy toward HPV vaccination. METHODS: This quasi-experimental study was conducted on 128 students randomly allocated to intervention and control groups. This research was conducted in junior high schools. The intervention group received the health education "Takespro HPV" intervention through videos and booklets for 6 months at school. Participants in the control group received usual care from the school. Data were collected using a questionnaire of knowledge, attitudes, beliefs, and self-efficacy about HPV vaccination modified by researchers based on previous research and tested for validity and reliability. Data were analyzed using Mann-Whitney test and independent t-test. RESULTS: A total of 40 participants were actively enrolled in the intervention group, and 88 were passively enrolled in the control group. The health education that was part of the Takespro HPV intervention improved the knowledge (p < 0.05) and self-efficacy (p < 0.05) of the intervention group compared with the control group. The attitude and belief variables showed no significant difference (p > 0.05). Forty students exhibited the health reproduction savings behavior at schools. However, the savings amount was insufficient to get HPV vaccination at the initiation phase. CONCLUSION: "Takespro" HPV intervention can be considered an alternative to increasing the coverage of HPV vaccination in adolescents in Yogyakarta.
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The elephant in the room: an exploratory study of hypertensive disorders of pregnancy (HDP) management in Indonesian primary care settings.

BACKGROUND: Indonesia has the highest maternal mortality rate in South East Asia, that a third of the mortality is caused by hypertensive disorders of pregnancy (HDP), including preeclampsia and eclampsia. Research suggests that maternal deaths from HDP are avoidable with appropriate initial management in primary care. However, little is known regarding the exact way HDP management is conducted in Indonesian primary care. This research aims to explore the way HDP management is provided, including its barriers and facilitators in Indonesian primary care settings. METHODS: This research applied a practical qualitative methodology using interviews with a topic guide. It is guided by the implementation science framework of the Medical Research Council (MRC) framework and Practical Robust Implementation and Sustainability Model (PRISM) to design and evaluate complex healthcare interventions. Primary care key stakeholders from Yogyakarta province were recruited from May-December 2018. The interviews were conducted in face-to-face, telephone, and teleconference interviews. Data from the interviews were analysed thematically using a mix of inductive and deductive approaches. RESULTS: A total of 24 participants were interviewed, consisting of four general practitioners, five midwives, three nurses, three obstetricians, a cardiologist, five policymakers and three women with a previous history of HDP. Referrals are the usual management performed for HDP women in primary care and the primary care providers' practice is challenged by three identified themes: (i) providers' limited confidence to perform HDP management, (ii) fragmented continuity of care, and (iii) community beliefs. Many participants also desired to have more focused guidance to improve HDP management in primary care practice. CONCLUSION: Even though Indonesian antenatal care and referrals are generally accessible, there are many challenges and fragmentation of HDP management. The most prominent challenge is the primary care providers' lack of confidence in performing the management and the 'elephant' of an urgent need of practice guidelines in primary care that has never been appropriately described in the literature. Further development of an evidence-based primary care-focused guidance will potentially improve primary care providers' skills to perform optimal HDP management and provide appropriate education to their patients.

How students and specialists appreciate the mini-clinical evaluation exercise (mini-CEX) in Indonesian clerkships.

BACKGROUND: Cultural differences might challenge the acceptance of the implementation of assessment formats that are developed in other countries. Acceptance of assessment formats is essential for its effectiveness; therefore, we explored the views of students and specialists on the practicality and impact on learning of these formats. This study was conducted to explore Indonesian students' and specialists' appreciation of the implementation of the Mini-Clinical Evaluation Exercise (Mini-CEX) in Indonesian clerkships. METHODS: This study was conducted at the Universitas Gadjah Mada, Indonesia. Participants were 52 students and 21 specialists in neurology and 78 students and 50 specialists in internal medicine. They were asked to complete a 19-item questionnaire that covered the characteristics of the mini-CEX such as its practicality, and the impact on learning and professional development. We used a Mann-Whitney U test to analyse the data. RESULTS: In total, 124 students (46 from neurology and 78 from internal medicine) and 38 specialists (13 from neurology and 25 from internal medicine) participated in this study. Students and specialists were positive about the practicality of the mini-CEX and the impact of this assessment format on learning and on professional development. The Mann-Whitney U test showed that there were no significant differences between students' and specialists' opinions on the mini-CEX, except for 2 items: specialists' appreciation of direct observation (mean rank = 93.16) was statistically significantly higher than students' appreciation of it (mean rank = 77.93; z = 2.065; p < 0.05), but students' appreciation of the item that students' past mini-CEX results affected their recent mini-CEX outcomes (mean rank = 85.29) was significantly higher than specialists' appreciation of it (mean rank = 69.12; z = 2140; p < 0.05). CONCLUSION: Students and specialists were positive about the mini-CEX in Indonesian clerkships, although it was developed and validated in another culture. We found only small differences between their appreciations, which could be explained by the patterns of specialist-student interaction in Indonesian culture as large power distance and low individualism country.

The development of an evaluation tool to assess professional behavior and clinical competencies from the graduates' perspective.

PURPOSE: This study was designed to develop an evaluation tool for assessing professional behavior and clinical competencies from the graduates' perspective. METHODS: This study employed mixed method in a sequential exploratory design. The semi-structured interviews were conducted with three graduates from different cohorts. The qualitative analysis of the interviews found six emerging themes for professional behavior and clinical competencies development. These themes were then developed into a 55-item questionnaire. The questionnaire was then distributed to 84 medical graduates for exploratory factor analysis (EFA) from February to April 2019. The quantitative data were analyzed using IBM SPSS ver. 21.0 (IBM Corp., Armonk, USA) for principal axis factoring. After conducting EFA, we proceeded with confirmatory factor analysis (CFA) with another 120 graduates to validate the tool. RESULTS: Eighty-four graduates completed the questionnaire for EFA. Upon completion of EFA, 35 out of 55 items of the questionnaire were found to be valid and reliable. The most appropriate fit was seven factors, which explained 58.18% of variance between them after 15 iterations with Cronbach's α of 0.916. The personal satisfaction factor was noted to be weak. It was therefore added to patient management factor due to its similar intention. The final EFA factor after the modification was six. The CFA found that 34 out of 35 items was valid and reliable that representation of the latent variables. CONCLUSION: The questionnaire has achieved the desired construct validity score and can be used as an evaluation tool to assess professional behavior and clinical competencies from the graduates' perspective.

Opportunities for improving hypertensive disorders of pregnancy (HDP) management in primary care settings: A review of international published guidelines in the context of pregnancy care in Indonesia.

Almost all of global maternal mortality caused by HDP occurs in low to middle-income countries (LMIC). However, limited guidance is available to local primary care practitioners who are usually the main health care providers. This review examined existing international practice guidelines to identify potential practices to improve HDP management in Indonesian primary care settings. We performed structured literature search strategies and snowballing searches in six databases (MEDLINE, Web of Science, EMBASE, CINAHL, Cochrane reviews and Google Scholar) for guidelines that were published between 2007 and 2018 using relevant keywords and phrases of 'guidelines', 'hypertensive disorders of pregnancy' or 'preeclampsia' and 'primary care'. The AGREE II instrument was used to assess quality and reporting of the eligible guidelines. Thematic analysis was performed on all of the guidelines and the results were discussed among the project investigators. Sixteen international practice guidelines or similar management recommendations were reviewed. Almost all of them were partially applicable, with some managements potentially able to be adopted to Indonesian primary care settings. Three main themes for improving HDP management were identified, namely clinical management, care planning, and professional communication. These potential improvements in managing women with HDP in Indonesia may also be relevant in other LMIC. Further contextualisation is required to facilitate their adoption in practice settings.

Need vs. Financing Capability: Human Papillomavirus Vaccinations among Adolescents.

BACKGROUND: The incidence of Human Papillomavirus (HPV) infection and cervical cancer in adulthood may be prevented by HPV vaccination in adolescence. Currently, the HPV vaccination coverage rate in developing countries is about 15%. The reason for this low vaccination coverage is most likely due to a lack of information among adolescents and adults. PURPOSE: To explore adolescents, parents and teachers' needs, obstacles, and expectations around the HPV vaccination. METHODS: This research used a qualitative method with a focus group discussion. The research participants were divided into three groups: 21 female students, 17 parents, and 20 teachers. This research was conducted in junior high schools that have programs run by their adolescent reproductive health counseling information centers. The data were analyzed by employing content analysis. RESULTS: HPV vaccination has not been made a priority for adolescents because: 1) There is a lack of available education about HPV and HPV vaccinations for adolescents, parents, and teachers. 2) The high cost for parents to vaccinate their children. 3) Adolescents, parents and teachers believe that the HPV vaccine needs to be administered to adolescents, but they feel that the vaccine is not affordable. CONCLUSION: It is important to consider a program which will provide accurate information about the HPV vaccination to the community, especially adolescents. Financial management, such as insurance or vaccination savings schemes, may be one way to overcome the problem of the HPV vaccination's cost.

Community-based educational design for undergraduate medical education: a grounded theory study.

BACKGROUND: Community-based education (CBE) is strategically important to provide contextual learning for medical students. CBE is a priority for countries striving for better primary health care. However, the CBE literature provides little curriculum guidance to enhance undergraduate medical education with the primary health care context. We aim to develop a CBE framework for undergraduate medical education (from macro, meso, and micro curriculum levels) to engage students and teachers with better, more meaningful learning, within primary health care settings. METHODS: We used a grounded theory methodology by interviewing eight medical educationalists and ten CBE teachers, followed with the coding process by sensitizing the concepts of 'medical education' and 'primary care', to explore any new concepts. The primary data originated from a developing country where the paradigm of high-quality primary health care is mostly unfamiliar. Three senior researchers from international associations of general practices from different countries provided validation to the results. RESULTS: We identified a new framework for a community-based educational program. The micro-curriculum should offer opportunities for small group activities, ranging from simple to complex learning, emphasizing clinical skills, leadership, and teamwork to improve self-directed and collaborative practice. Sufficient role models and constructive feedback within primary care contexts are robust facilitators. For the meso-curriculum, comprehensive coordination on teacher-training and CBE program is needed. To ensure the sustainability of the program, faculty leaders and managers should include the macro-curriculum with a national postgraduate general practice curriculum and provide strong commitment. CONCLUSIONS: We designed a 'CBE-tree' model for the undergraduate medical curriculum. By using the CBE framework developed in this study, students and teachers may better comprehend the essential of primary health care.

Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol.

BACKGROUND: National and international guidelines for the management of hypertensive disorders of pregnancy (HDP) are available in developing countries. However, more detailed clinical pathways for primary care settings are limited. This study focuses on Indonesia, where 72% of women who died from HDP and its complications had received less appropriate treatment according to international guidelines. There is an urgent need to develop primary care focused pathways that enable general practitioners (GPs), midwives and other relevant providers to manage HDP better. OBJECTIVES: This paper describes a study protocol for the development of HDP management pathways for Indonesian primary care settings. METHODS: This study design is informed by Implementation Science theories and consists of three phases. The exploratory phase will involve conducting semi-structured interviews with key Indonesian primary care stakeholders to explore their experiences and views on HDP management. The development phase will apply evidence from the literature review and results of the exploratory phase to develop HDP management pathways contextualised to Indonesian primary care settings. Consensus will be sought from approximately 50 experts, consist of general practitioners (GPs), midwives, obstetricians, nurses and policy makers using Delphi technique survey. The evaluation phase will involve a pilot study to evaluate the pathways' acceptability and feasibility in a sample of Indonesian primary care practices using mixed methods. DISCUSSION: The implementation science frameworks inform and guide the phases in this study. Qualitative interviews in the exploratory phase are conducive to eliciting opinions from key stakeholders. Using Delphi technique at the development phase is suitable to seek participants' consensus on HDP management in primary care. Observations, focus group discussions, interviews as well as analysis of patients' medical records at the evaluation phase are expected to provide a comprehensive investigation of the implementation of the pathways in practice settings.

Development of an Instrument for Preceptor Evaluation of Medical Graduates' Performance: the Psychometric Properties.

BACKGROUND: A preceptor has a key role in evaluating medical graduate's performance in the clinical setting. This study is conducted to develop an instrument for preceptor evaluation of medical graduates' performance in the clinical setting. METHOD: A mixed-method study design, sequential exploratory approach was chosen to develop the instrument. Initial semi-structured interviews were conducted with 4 preceptors at the teaching hospitals. Five main themes emerged from the interviews. The themes were developed into a 23-item questionnaire. Nineteen Head or Assistant Head of clinical departments were asked to review the relevance of the content. The questionnaire was later sent out to 34 preceptors and 35 paramedic staffs to participate in the construct validity study by conducting exploratory factor analysis (EFA). SPSS version 21 software was used to analyze the data and Varimax rotation method was performed to simplify and describe the data structure. RESULT: Review of the factor structures suggested that the most appropriate fit was 5 factors. Most of the questionnaire items were relevant to assess performance (4.65 + 0.15), except in item 4 of the clinical skill factor. The 23 items of the evaluation instruments showed that five factors were extracted which explained 73.9% of the variance between them. Construct validity was achieved after the instrument was run for an iteration of eight times, with Cronbach's alpha of 0.951. DISCUSSION: The instrument has achieved the desired content and construct validity score. It can be used by other institutions to assess their medical graduates' performance in the clinical setting.

Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture.

BACKGROUND: Feedback is essential for workplace learning. Most papers in this field concern individual feedback. In collectivistic cultures, however, group feedback is common educational practice. This study was conducted to investigate the perceived learning value and characteristics of individual and group feedback in a collectivistic culture. METHODS: During two weeks, on a daily basis, clerkship students (n = 215) from 12 clinical departments at Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, recorded individual and group feedback moments by using a structured form: the providers, focus and perceived learning value of feedback. Data were analysed with logistic regression and multilevel techniques. RESULTS: Students reported 2687 group and 1535 individual feedback moments. Group feedback more often focused on history taking, clinical judgment, patient management, patient counselling, and professional behaviour (OR ranging from 1.232, p < .01, to 2.152, p < .001), but less often on physical examination (OR = .836, p < .01). Group feedback less often aimed at correcting performance deficiencies (OR = .523, p < .001) and more often at comparing performance to the standard (OR = 2.447, p < .001) and planning action to improve performance (OR = 1.759, p < .001). Group feedback was perceived as more valuable than individual feedback (M = 4.08 and 3.96, respectively, ß group = .065, SE = .026, p < .01). CONCLUSION: In collectivistic cultures, group feedback may add to the array of educational measures that optimize student learning. Congruence between culture and type of feedback may be important for the effectiveness of feedback.

Influence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter?

BACKGROUND: Various feedback characteristics have been suggested to positively influence student learning. It is not clear how these feedback characteristics contribute to students' perceived learning value of feedback in cultures classified low on the cultural dimension of individualism and high on power distance. This study was conducted to validate the influence of five feedback characteristics on students' perceived learning value of feedback in an Indonesian clerkship context. METHODS: We asked clerks in Neurology (n = 169) and Internal Medicine (n = 132) to assess on a 5-point Likert scale the learning value of the feedback they received. We asked them to record whether the feedback provider (1) informed the student what went well, (2) mentioned which aspects of performance needed improvement, (3) compared the student's performance to a standard, (4) further explained or demonstrated the correct performance, and (5) prepared an action plan with the student to improve performance. Data were analyzed using multilevel regression. RESULTS: A total of 250 students participated in this study, 131 from Internal Medicine (response rate 99%) and 119 from Neurology (response rate 70%). Of these participants, 225 respondents (44% males, 56% females) completed the form and reported 889 feedback moments. Students perceived feedback as more valuable when the feedback provider mentioned their weaknesses (ß = 0.153, p < 0.01), compared their performance to a standard (ß = 0.159, p < 0.01), explained or demonstrated the correct performance (ß = 0.324, p < 0.001) and prepared an action plan with the student (ß =0.496, p < 0.001). Appraisal of good performance did not influence the perceived learning value of feedback. No gender differences were found for perceived learning value. CONCLUSIONS: In Indonesia, we could validate four out of the five characteristics for effective feedback. We argue that our findings relate to culture, in particular to the levels of individualism and power distance. The recognized characteristics of what constitutes effective feedback should be validated across cultures.

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being.

BACKGROUND: The goal of fetal monitoring in labour is the early detection of a hypoxic baby. There are a variety of tools and methods available for intermittent auscultation (IA) of the fetal heart rate (FHR). Low- and middle-income countries usually have only access to a Pinard/Laënnec or the use of a hand-held Doppler device. Currently, there is no robust evidence to guide clinical practice on the most effective IA tool to use, timing intervals and length of listening to the fetal heart for women during established labour. OBJECTIVES: To evaluate the effectiveness of different tools for IA of the fetal heart rate during labour including frequency and duration of auscultation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 September 2016), contacted experts and searched reference lists of retrieved articles. SELECTION CRITERIA: All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing different tools and methods used for intermittent fetal auscultation during labour for fetal and maternal well-being. Quasi-RCTs, and cross-over designs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: All review authors independently assessed eligibility, extracted data and assessed risk of bias for each trial. Data were checked for accuracy. MAIN RESULTS: We included three studies (6241 women and 6241 babies), but only two studies are included in the meta-analyses (3242 women and 3242 babies). Both were judged as high risk for performance bias due to the inability to blind the participants and healthcare providers to the interventions. Evidence was graded as moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Intermittent Electronic Fetal Monitoring (EFM) using Cardiotocography (CTG) with routine Pinard (one trial)There was no clear difference between groups in low Apgar scores at five minutes (reported as < six at five minutes after birth) (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.24 to 1.83, 633 babies, very low-quality evidence). There were no clear differences for perinatal mortality (RR 0.88, 95% CI 0.34 to 2.25; 633 infants, very low-quality evidence). Neonatal seizures were reduced in the EFM group (RR 0.05, 95% CI 0.00 to 0.89; 633 infants, very low-quality evidence). Other important infant outcomes were not reported: mortality or serious morbidity (composite outcome), cerebral palsy or neurosensory disability. For maternal outcomes, women allocated to intermittent electronic fetal monitoring (EFM) (CTG) had higher rates of caesarean section for fetal distress (RR 2.92, 95% CI 1.78 to 4.80, 633 women, moderate-quality evidence) compared with women allocated to routine Pinard. There was no clear difference between groups in instrumental vaginal births (RR 1.46, 95% CI 0.86 to 2.49, low-quality evidence). Other outcomes were not reported (maternal mortality, instrumental vaginal birth for fetal distress and or acidosis, analgesia in labour, mobility or restriction during labour, and postnatal depression). Doppler ultrasonography with routine Pinard (two trials)There was no clear difference between groups in Apgar scores < seven at five minutes after birth (reported as < six in one of the trials) (average RR 0.76, 95% CI 0.20 to 2.87; two trials, 2598 babies, I2 = 72%, very low-quality evidence); there was high heterogeneity for this outcome. There was no clear difference between groups for perinatal mortality (RR 0.69, 95% CI 0.09 to 5.40; 2597 infants, two studies, very low-quality evidence), or neonatal seizures (RR 0.05, 95% CI 0.00 to 0.91; 627 infants, one study, very low-quality evidence). Other important infant outcomes were not reported (cord blood acidosis, composite of mortality and serious morbidity, cerebral palsy, neurosensory disability). Only one study reported maternal outcomes. Women allocated to Doppler ultrasonography had higher rates of caesarean section for fetal distress compared with those allocated to routine Pinard (RR 2.71, 95% CI 1.64 to 4.48, 627 women, moderate-quality evidence). There was no clear difference in instrumental vaginal births between groups (RR 1.35, 95% CI 0.78 to 2.32, 627 women, low-quality evidence). Other maternal outcomes were not reported. Intensive Pinard versus routine Pinard (one trial)One trial compared intensive Pinard (a research midwife following the protocol in a one-to-one care situation) with routine Pinard (as per protocol but midwife may be caring for more than one woman in labour). There was no clear difference between groups in low Apgar score (reported as < six this trial) (RR 0.90, 95% CI 0.35 to 2.31, 625 babies, very low-quality evidence). There were also no clear differences identified for perinatal mortality (RR 0.56, 95% CI 0.19 to 1.67; 625 infants, very low-quality evidence), or neonatal seizures (RR 0.68, 95% CI 0.24 to 1.88, 625 infants, very low-quality evidence)). Other infant outcomes were not reported. For maternal outcomes, there were no clear differences between groups for caesarean section or instrumental delivery (RR 0.70, 95% CI 0.35 to 1.38, and RR 1.21, 95% CI 0.69 to 2.11, respectively, 625 women, both low-quality evidence)) Other outcomes were not reported. AUTHORS' CONCLUSIONS: Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.

Students' understanding of "Women-Centred Care Philosophy" in midwifery care through Continuity of Care (CoC) learning model: a quasi-experimental study.

BACKGROUND: The philosophy of midwifery education is based on the 'Women-centred care' model, which provides holistic care to women. Continuity of care (CoC) is integral to the concept of holistic women-centred care and fundamental to midwifery practice. The objective of this study was to determine any differences in students' understanding of midwifery care philosophy between students who underwent the CoC learning model and those who underwent the fragmented care learning model. METHOD: We used a quasi-experiment design. This study was conducted by all final year midwifery students at two schools of midwifery in Indonesia. Fifty four students from one school attended 6 months of clinical training using the CoC learning model. The control group was comprised of 52 students from the other school. These students used the conventional clinical training model (the fragmented care learning model). The independent T-test using SPSS was used to analyse the differences between the two groups of students in terms of understanding midwifey care philosophy in five aspects (personalized, holistic, partnership, collaborative, and evidence-based care). RESULTS: There were no significant differences between the groups before interventon. There were significant differences between the two groups after clinical training (p < 0.01). The mean post-clinical score of students using all five aspects of the CoC clinical learning model (15.96) was higher than that of the students in the control group (10.65). The CoC clinical learning model was shown to be a unique learning opportunity for students to understand the philosophy of midwifery. Being aligned with midwifery patients and developing effective relationships with them offered the students a unique view of midwifery practice. This also promoted an increased understanding of the philosophy of women-centred care. Zero maternal mortality rate was found in the experiment group. CONCLUSION: The results of this study suggest that clinical trainingwith a CoC learning model is more likely to increase students' understanding of midwifery care philosophy. This in turn improves the quality ofclinical care, thereby enhancing overall health benefits for women.

Measuring students' approaches to learning in different clinical rotations.

BACKGROUND: Many studies have explored approaches to learning in medical school, mostly in the classroom setting. In the clinical setting, students face different conditions that may affect their learning. Understanding students' approaches to learning is important to improve learning in the clinical setting. The aim of this study was to evaluate the Study Process Questionnaire (SPQ) as an instrument for measuring clinical learning in medical education and also to show whether learning approaches vary between rotations. METHODS: All students involved in this survey were undergraduates in their clinical phase. The SPQ was adapted to the clinical setting and was distributed in the last week of the clerkship rotation. A longitudinal study was also conducted to explore changes in learning approaches. RESULTS: Two hundred and nine students participated in this study (response rate 82.0%). The SPQ findings supported a two-factor solution involving deep and surface approaches. These two factors accounted for 45.1% and 22.5%, respectively, of the variance. The relationships between the two scales and their subscales showed the internal consistency and factorial validity of the SPQ to be comparable with previous studies. The clinical students in this study had higher scores for deep learning. The small longitudinal study showed small changes of approaches to learning with different rotation placement but not statistically significant. CONCLUSIONS: The SPQ was found to be a valid instrument for measuring approaches to learning among clinical students. More students used a deep approach than a surface approach. Changes of approach not clearly occurred with different clinical rotations.