Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol

While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This may partly be explained by the quality of care provision, which dependent on several factors, including appropriately trained midwifery care providers. This study is a component of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project—a quality improvement and implementation science project. This paper outlines a study designed to assess the competencies (knowledge, skills and attitudes) of midwifery care providers in Benin, Malawi, Tanzania and Uganda. The study will use mixed methods to assess these aspects; a quantitative survey will assess the knowledge of midwifery care providers, observation of a skills drill session will assess midwifery care provider skills and attitudes, and Focus Group Discussions will be used to explore midwifery care providers’ experiences and perceptions of in-service training. Findings will be used to inform the development of an in-service training programme on basic intrapartum care for midwifery care providers.

In 2016, at the start of the Sustainable Development Goals (SDGs) era [1], pregnancy-related and newborn preventable morbidity and mortality remained unacceptably high. Despite reductions in maternal mortality between 2000 and 2017, every day approximately 810 women died in 2017 [2] and almost 6700 newborns died daily in 2019 [3]. Furthermore, estimates suggest that in 2019, for every 1000 total births, 13.9 babies were stillborn [4]. The majority of preventable maternal and newborn deaths occur in low- and middle-income countries, among the low-income population, in addition to those living in fragile settings.

Maternal and newborn deaths are a particularly sensitive indicator of the quality of a health system. Despite increases in the number of deaths from indirect causes such as non-communicable diseases, over 70% of deaths continue to occur from direct causes including haemorrhage, eclampsia, sepsis and abortion. More than 85% of newborn deaths are due to complications during and immediately after birth. High quality management of complications during this period can therefore have a significant impact on maternal and newborn deaths and stillbirths [5].

Evidence suggests that up to 2.5 million lives can be saved using evidence-based quality care [6]. Several global initiatives have been laid out such as the Sustainable Development Goals [7], the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) [8], “Strategies toward ending preventable maternal mortality” (EPMM) [9], and “Every Newborn Action Plan” (ENAP) [10]. These global initiatives have set ambitious targets for maternal and newborn health outcomes which will require quality care, strong and effective strategies and commitments.

Quality of intrapartum care is paramount to ensure the optimal health outcomes for women and newborns. In this project we define quality of care based on the “The Quality Maternal and Newborn Care Framework” developed by Renfrew et al. [11] which describes the components and characteristics of quality care. The framework is structured around five components of care; Practice categories, Organisation of care, Values, Philosophy and Care providers. Within each of these components the characteristics of care for childbearing women and infants, as well as for childbearing women and infants with complications, are framed.

A critical progress indicator, explicitly adopted for SDG 3 (indicator 3.1.2) and by both the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016–2030, and EPMM, is the “proportion of births attended by skilled health personnel” (SBA). [1, 8, 12].

For universal SBA coverage and facility births to improve maternal and newborn health outcomes it is imperative that services provided follow evidence-based recommendations and are of high quality. [13, 14] However, the provision of quality intrapartum care is affected by several factors such as access, the health workforce capacity, an enabling environment and social and cultural determinants. Knowledge and skill deficits are not only related to specific emergency obstetric care functions but also basic intrapartum competencies. Accurate comprehension of competencies of midwifery care providers plus enhanced measurement and monitoring are all essential elements to better understand the paradox between expanded SBA coverage/facility birth and maternal and newborn health outcomes. Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low and lower- and middle-income countries [15], and it would be expected that maternal and neonatal mortality would decrease when midwifery care providers are educated to provide high level quality evidence based intrapartum care. Quality includes the respectful care of women. Disrespect and abuse of women during childbirth has been widely reported in low-and-middle income countries, including documented instances of physical abuse, non-consented clinical care, limited attention to confidentiality and dignity, discrimination, abandonment, and detention in facilities [16].

Several studies have evaluated in-service training programmes which focused on emergency obstetric care with their findings showing that the training did, to a varying degree, result in improvements in healthcare provider knowledge/skills and changes in clinical practice [17‐19]. But improved health outcomes such as a reduction in still births, maternal mortality and the number of cases of post-partum haemorrhage are not necessarily reflected after these trainings. More recently, the COVID-19 pandemic has highlighted the need for in- service training specific to diagnosing and caring for patients with the virus, as well as in infection prevention and control.

Little in-service training has focused on basic midwifery competencies in relation to the importance of; the admission assessment, communication, respectful care, vaginal assessment and documentation [15].

Table 1 provides definitions of terminology used for this study.

This study is a component of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa project (ALERT)—“Positioning Midwifery” (https://​ki.​se/​en/​gph/​the-alert-intervention-research-project). ALERT is a hospital maternity-based quality improvement and implementation science project in Benin, Malawi, Tanzania and Uganda [20], which aims to implement an evidence-based intervention and reduce in-facility perinatal mortality and morbidity.

This formative work aims to inform the development of an in-service training programme. We will conduct an assessment of the basic intrapartum competencies (knowledge, skills and attitudes) as well as an exploration of provider experiences and perceptions of in-service training among the midwifery care providers in the 16 ALERT project hospitals. An in-service training programme will be developed and contextualized based on requirements identified by end-users and on local needs.

This study will provide a comprehensive and comparative analysis of competencies of midwifery care providers as well as their experiences and perceptions of in-service training. These findings will inform the development of an end-user focused in-service training programme to be implemented in all the ALERT project hospitals. Employing a participatory approach is anticipated to help providers in acknowledging possible gaps in their intrapartum competencies. The participatory approach will be centred on the providers and developed according to their needs. While training is likely to be successful if the providers understand why the topic is important to address, ownership of the whole process and responsibility for their own learning  are elements which will guide the training. Applying these participatory concepts is expected to enhance engagement during the in-service training.

The study also has some limitations as it will not be possible to assess all aspects of basic intrapartum care knowledge in the survey, but questions aim to cover a wide range topics related to basic care. Owing to diversity among the study settings and social determinants related to childbirth, the local health workforce as well as cultural aspects it may not be possible to generalize study findings, but transferability of results may be applicable. Due to ethical reasons skills drills were selected in place of conducting direct observations which may not provide as much insight into practices and behaviours. Nevertheless, observational studies participants have the tendency to change their behaviours simply as a result of being observed—the phenomenon known as the Hawthorne effect [29].

For the FGDs convenience sampling will be used to invite providers based on their accessibility and willingness to participate. This leads to “volunteer bias” whereby those taking part in the FGDs may not accurately represent the general population. On the other hand, purposive sampling is widely recommended since focus group discussion relies on the ability and capacity of participants to provide relevant information. FGDs lend themselves to biases commonly encountered in any group setting such as dominance effect (a dominant individual shape the discussion), halo effect (the perceived status of a group member influences the discussion), groupthink (the members in a group tend to think similarly to maintain group cohesion). [30] Even though biases may affect the outcome, the information from these discussions may provide granularities on important information which can’t be captured in the survey and the skills drills assessment.

We have received administrative clearances and support from all participating hospitals during the proposal development and approval process. We therefore believe that this support will continue even during the intervention period of the study.

We anticipate that the experiences and results in some of the sites will encourage to upscale services in other sites (e.g. including a companion during labour). One of the main advantages of ALERT is not only that study sites will be able to discuss their experiences and results but that these experiences and results can be discussed and compared across the ALERT countries.

By inviting providers to reflect on the results of the competency assessment we aim to gain an understanding of their priority training needs. By focusing on these needs as we develop the in-service training package, we aim to improve competency, which in turn, will contribute to an improvement in quality of care provided.

The study findings may contribute to informing the global agenda and national policies related to improvement in the provision of intrapartum care and the understanding of inconsistencies between the increased number of women given birth in facilities and the current level of maternal and neonatal mortality [31, 32].