Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000–2020

BMC Medical Education, Volume 22, No. 1, Year 2022

Ukuhunyushwa

Background: Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice. Methods: Searches were conducted for the years 2000–2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice. Results: The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making. Conclusion: To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers. The study protocol was published in the BMJ Open in 2021 [26] and outlines the methodology for the design and conduct of the scoping review. Arksey and O’Malley’s [27] scoping review framework was applied in line with the five stages (i) identifying the research question; (ii) identifying relevant studies; (iii) selecting studies; (iv) charting the data; and (v) collating summarizing and reporting the results. This scoping review was conducted to identify in-service training materials used for midwifery care providers in sub-Saharan Africa between 2000 and 2020. It was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist (http://www.prisma-statement.org/Extensions/ScopingReviews), which is outlined in Additional file 1. All authors discussed and agreed on the research questions. The aim of the scoping review was to summarize existing in-service training materials used in sub-Saharan Africa between 2000 and 2020, and map their content to the ICM Essential Competencies for Midwifery Practice [22] (ICM 2019). Our review posed the following questions: The review sought to include only in-service training materials that are freely available to midwifery care providers. We acknowledge that there are other sponsored and freely available training materials for midwifery care providers. Access to these however, is inequitable as they are only free to those midwifery care providers working in health care facilities where such sponsored training is implemented. The study protocol outlined that in-service training materials would also be mapped to the Quality Maternal and Newborn Care framework [24]. However, it was noted that the five components of the framework were too general and following further consideration, the decision was made to map the training materials to the ICM Essential Competencies only. The research questions were assessed, and studies selected specific to the following Population, Concept, Study Design and Context criteria presented in Table 1. All studies and grey literature that included information on available in-service training materials used for midwifery care providers in sub-Saharan Africa were included for review. As the focus of the scoping review was on training materials based on evidence, only those developed and used after 2000 onwards were included as evidence of clinical care changes constantly and new guidelines and recommendations are updated to ensure best practice. Inclusion criteria for identifying eligible studies Articles were excluded from the scoping review if: The search strategy was conducted for all relevant existing literature, without language restrictions, based on search terms relating to the research questions and restricted to the years 2000–2020 using the following online bibliographic databases: Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus, and Google Scholar. Additional file 2 contains terms used for searches of the electronic databases. The search in Google Scholar generated 6,350 results. The authors reviewed the first 150 titles returned by Google Scholar as relevance diminished after this stage. Grey literature searches were performed and included organizations known to be active in global maternal and newborn health improvement (i.e., United Nations Population Fund (UNFPA), World Health Organization (WHO), Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), International Confederation of Midwives (ICM), International Federation of Gynecology and Obstetrics (FIGO), International Pediatric Association (IPA). The reference list of all eligible studies was hand-searched to identify any additional relevant studies. Following the searches outlined above, the citations were imported into Covidence (https://www.covidence.org), an online tool developed to support the screening and data extraction processes. The imported citations underwent independent title and abstract screening by two reviewers (A-BM and JW). Screened abstracts identified for inclusion had their full texts independently reviewed by two reviewers (A-BM and JW). Two identified full-texts were written in French and were screened by A-BM. Reasons for exclusion of full texts were documented. See additional file 3 which shows the PRISMA flow diagram charting this process. A pre-designed data extraction tool in Microsoft Excel was used to extract data from included studies. Information retrieved included study characteristics (country, year of study and setting). Data collected pertaining to in-service training and educational area of focus, those trained, as well as details related to the design of the in-service training (formal education sessions, training facilitators, on-site training, off-site training, use of simulation, ongoing mentorship, online training), as well as details of identifiable in-service training materials. JW and HH mapped the training materials to the ICM Competencies, and a third reviewer A-BM randomly checked 20% of the mapped training materials to ensure agreement. To map the content of the in-service training materials to the ICM Essential Competencies for Midwifery Practice, the educational area of focus of the in-service training materials was identified, and content mapped to the corresponding pertinent categories and indicators within the ICM Competencies [22]. Presenting our results using descriptive statistics, as outlined in our protocol paper, was therefore not appropriate, as comparisons between tools would be meaningless. Results are therefore presented using narrative description based on themes arising.

I-AI Digest

Study Justification:

The study aimed to address the high levels of maternal and neonatal mortality in sub-Saharan Africa, which are linked to poor quality of care and gaps in pre-service training for midwifery care providers. In-service training packages have been developed to overcome these gaps, but their effectiveness and alignment with international competency standards were unclear. This study aimed to review and summarize the in-service training materials used in sub-Saharan Africa between 2000 and 2020 and assess their alignment with the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice.

Highlights:

– The study identified 41 in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020.
– The majority of the training materials focused on emergency obstetric care in a limited number of countries.
– The content of the training materials largely met the ICM Essential Competencies, but gaps were noted in the aspect of woman-centered care and shared decision making.
– Many of the in-service training materials were not readily and/or freely accessible.

Recommendations for Lay Reader and Policy Maker:

– Midwifery care providers should have access to evidence-based in-service training materials that include antenatal care, routine intrapartum care, and prioritize woman-centered care and shared decision making.
– Efforts should be made to ensure the availability and accessibility of in-service training materials for midwifery care providers in sub-Saharan Africa.
– Policy makers should consider investing in the development and dissemination of high-quality in-service training materials that align with international competency standards.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of training programs.
– International Organizations (e.g., United Nations Population Fund, World Health Organization): Provide technical support, funding, and guidance.
– Professional Midwifery Associations: Contribute to the development and review of training materials.
– Training Institutions: Involved in curriculum development and training delivery.
– Researchers and Academics: Conduct research to inform evidence-based training practices.

Cost Items for Planning Recommendations:

– Development of evidence-based in-service training materials: Includes research, curriculum development, and content creation.
– Training Delivery: Costs associated with training facilitators, on-site or off-site training, simulation equipment, and ongoing mentorship.
– Translation and Localization: Costs for translating and adapting training materials to local languages and contexts.
– Dissemination and Access: Costs for making training materials freely accessible online or through other means.
– Monitoring and Evaluation: Costs for monitoring the implementation and effectiveness of training programs.

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The scoping review conducted a comprehensive search of multiple databases and grey literature, which increases the likelihood of capturing relevant in-service training materials. The review also mapped the content of the training materials to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice, providing a clear framework for evaluation. However, the abstract does not provide information on the quality assessment of the included studies or the methodology used for data extraction. To improve the strength of the evidence, the authors could consider conducting a systematic review instead of a scoping review, which would involve a more rigorous assessment of study quality and a meta-analysis of the findings. Additionally, providing more details on the search strategy, inclusion/exclusion criteria, and data extraction process would enhance the transparency and replicability of the study.

Abstract

The study protocol was published in the BMJ Open in 2021 [26] and outlines the methodology for the design and conduct of the scoping review. Arksey and O’Malley’s [27] scoping review framework was applied in line with the five stages (i) identifying the research question; (ii) identifying relevant studies; (iii) selecting studies; (iv) charting the data; and (v) collating summarizing and reporting the results. This scoping review was conducted to identify in-service training materials used for midwifery care providers in sub-Saharan Africa between 2000 and 2020. It was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist (http://www.prisma-statement.org/Extensions/ScopingReviews), which is outlined in Additional file 1. All authors discussed and agreed on the research questions. The aim of the scoping review was to summarize existing in-service training materials used in sub-Saharan Africa between 2000 and 2020, and map their content to the ICM Essential Competencies for Midwifery Practice [22] (ICM 2019). Our review posed the following questions: The review sought to include only in-service training materials that are freely available to midwifery care providers. We acknowledge that there are other sponsored and freely available training materials for midwifery care providers. Access to these however, is inequitable as they are only free to those midwifery care providers working in health care facilities where such sponsored training is implemented. The study protocol outlined that in-service training materials would also be mapped to the Quality Maternal and Newborn Care framework [24]. However, it was noted that the five components of the framework were too general and following further consideration, the decision was made to map the training materials to the ICM Essential Competencies only. The research questions were assessed, and studies selected specific to the following Population, Concept, Study Design and Context criteria presented in Table 1. All studies and grey literature that included information on available in-service training materials used for midwifery care providers in sub-Saharan Africa were included for review. As the focus of the scoping review was on training materials based on evidence, only those developed and used after 2000 onwards were included as evidence of clinical care changes constantly and new guidelines and recommendations are updated to ensure best practice. Inclusion criteria for identifying eligible studies Articles were excluded from the scoping review if: The search strategy was conducted for all relevant existing literature, without language restrictions, based on search terms relating to the research questions and restricted to the years 2000–2020 using the following online bibliographic databases: Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus, and Google Scholar. Additional file 2 contains terms used for searches of the electronic databases. The search in Google Scholar generated 6,350 results. The authors reviewed the first 150 titles returned by Google Scholar as relevance diminished after this stage. Grey literature searches were performed and included organizations known to be active in global maternal and newborn health improvement (i.e., United Nations Population Fund (UNFPA), World Health Organization (WHO), Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), International Confederation of Midwives (ICM), International Federation of Gynecology and Obstetrics (FIGO), International Pediatric Association (IPA). The reference list of all eligible studies was hand-searched to identify any additional relevant studies. Following the searches outlined above, the citations were imported into Covidence (https://www.covidence.org), an online tool developed to support the screening and data extraction processes. The imported citations underwent independent title and abstract screening by two reviewers (A-BM and JW). Screened abstracts identified for inclusion had their full texts independently reviewed by two reviewers (A-BM and JW). Two identified full-texts were written in French and were screened by A-BM. Reasons for exclusion of full texts were documented. See additional file 3 which shows the PRISMA flow diagram charting this process. A pre-designed data extraction tool in Microsoft Excel was used to extract data from included studies. Information retrieved included study characteristics (country, year of study and setting). Data collected pertaining to in-service training and educational area of focus, those trained, as well as details related to the design of the in-service training (formal education sessions, training facilitators, on-site training, off-site training, use of simulation, ongoing mentorship, online training), as well as details of identifiable in-service training materials. JW and HH mapped the training materials to the ICM Competencies, and a third reviewer A-BM randomly checked 20% of the mapped training materials to ensure agreement. To map the content of the in-service training materials to the ICM Essential Competencies for Midwifery Practice, the educational area of focus of the in-service training materials was identified, and content mapped to the corresponding pertinent categories and indicators within the ICM Competencies [22]. Presenting our results using descriptive statistics, as outlined in our protocol paper, was therefore not appropriate, as comparisons between tools would be meaningless. Results are therefore presented using narrative description based on themes arising.

Izinto zokwakha

Emisha

Based on the information provided, the scoping review identified several innovations that can be used to improve access to maternal health in sub-Saharan Africa. These innovations include:

1. Development of evidence-based in-service training materials: The review highlighted the importance of providing midwifery care providers with access to evidence-based in-service training materials. These materials should cover a wide range of topics, including antenatal care, routine intrapartum care, and woman-centered care. By ensuring that training materials are based on the latest guidelines and recommendations, healthcare providers can deliver high-quality care to pregnant women and reduce maternal and neonatal morbidity and mortality.

2. Freely accessible training materials: The review noted that a significant number of in-service training materials are not readily and/or freely accessible. To improve access, it is important to make these materials available online and free of charge. This will enable midwifery care providers, especially those working in resource-limited settings, to easily access and utilize the training materials to enhance their knowledge and skills.

3. Use of technology for training: The review did not specifically mention the use of technology for training, but it is an innovation that can greatly improve access to maternal health. Online platforms, mobile applications, and virtual training programs can be utilized to deliver training materials to midwifery care providers, regardless of their location. This can overcome geographical barriers and reach a larger number of healthcare providers, ensuring that they receive the necessary training to provide quality maternal care.

4. Integration of shared decision making: The review identified gaps in the aspect of woman-centered care and shared decision making in the in-service training materials. To improve access to maternal health, it is important to integrate shared decision making into the training materials. This approach involves actively involving women in their care decisions, considering their preferences and values, and promoting a collaborative relationship between healthcare providers and patients.

By implementing these innovations, access to maternal health can be improved in sub-Saharan Africa, leading to better outcomes for both mothers and newborns.

AI Innovations Description

Based on the description provided, the scoping review identified several recommendations to improve access to maternal health in sub-Saharan Africa. These recommendations are based on the findings of the review and aim to address the gaps and challenges identified in the in-service training materials for midwifery care providers. Here are the key recommendations:

1. Develop evidence-based in-service training materials: To reduce maternal and newborn morbidity and mortality, it is crucial to provide midwifery care providers with access to evidence-based in-service training materials. These materials should cover a range of topics, including antenatal care, routine intrapartum care, and emergency obstetric care.

2. Include woman-centered care and shared decision making: The review identified gaps in the aspect of woman-centered care and shared decision making in the in-service training materials. It is recommended to incorporate these principles into the training materials to ensure that women are placed at the center of their care and are actively involved in decision making.

3. Improve accessibility of training materials: The review found that a significant number of in-service training materials were not readily and/or freely accessible. Efforts should be made to make these materials more accessible to midwifery care providers, especially those working in resource-limited settings. This could include making the materials available online or through other means of distribution.

4. Align training materials with international competency standards: The in-service training materials reviewed largely met the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice. It is important to continue aligning the content of training materials with these international competency standards to ensure that midwifery care providers are equipped with the necessary skills and knowledge.

5. Regularly update and revise training materials: Clinical care practices and guidelines evolve over time, and it is essential to keep the in-service training materials up to date. Regular updates and revisions should be conducted to reflect the latest evidence and best practices in maternal health care.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to a reduction in maternal and neonatal mortality rates in sub-Saharan Africa.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Develop and distribute evidence-based in-service training materials: To address the gaps in pre-service training programs for midwifery care providers, it is important to develop and distribute in-service training materials that are accessible and freely available. These materials should cover a wide range of topics, including antenatal care, routine intrapartum care, and woman-centered care.

2. Increase availability of training materials: Efforts should be made to ensure that in-service training materials are readily accessible to midwifery care providers in sub-Saharan Africa. This could involve making the materials available online, through mobile applications, or through partnerships with local healthcare facilities and organizations.

3. Incorporate simulation-based training: Simulation-based training can be an effective method for improving the skills and competencies of midwifery care providers. By incorporating simulation exercises into in-service training programs, providers can practice and refine their skills in a safe and controlled environment.

4. Strengthen partnerships and collaborations: Collaboration between international organizations, local healthcare facilities, and educational institutions can help improve access to maternal health. By working together, these stakeholders can share resources, expertise, and best practices to develop and implement effective in-service training programs.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of trained midwifery care providers, the availability of in-service training materials, and the quality of care provided.

2. Collect baseline data: Gather data on the current status of access to maternal health in sub-Saharan Africa, including the number of trained providers, the availability of training materials, and the outcomes of maternal health interventions.

3. Develop a simulation model: Create a simulation model that incorporates the identified indicators and their relationships. This model should consider factors such as the distribution of training materials, the effectiveness of training programs, and the impact on maternal health outcomes.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the impact of the recommendations. Vary the parameters, such as the availability of training materials or the number of trained providers, to understand their influence on access to maternal health.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. Identify key findings, trends, and areas for improvement.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This will help ensure the accuracy and reliability of the simulations.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of the recommendations on improving access to maternal health and make informed decisions on implementing and scaling up effective interventions.

Umbhali

Dima Health

Identifiers:

DOI: 10.1186/s12909-022-03772-2

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Design:

Cross Sectional Study, Narrative Study

Study Approach:

Mixed-methods, Qualitative, Quantitative, Systematic Review

Participants Gender:

Female

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