Elsevier

Midwifery

Volume 78, November 2019, Pages 104-113
Midwifery

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis

https://doi.org/10.1016/j.midw.2019.08.007Get rights and content

Highlights

  • Quality midwifery care requires quality midwifery education. This review is the first to examine all forms of midwifery education in LMICs and identified nineteen studies of pre- and in-service midwifery education in low- and middle-income countries.

  • There is a notable dearth of studies on the education of midwives educated to international standards who are able to provide the full scope of midwifery competencies in low- and middle-income countries and instead studies tended to focus on in-service education for emergency intrapartum care.

  • Evaluations of midwifery education programmes in low and middle income countries were consistently of a low quality and programmes lacked an educational framework and a theoretical basis for their pedagogical approach, thereby limiting generalisability to other contexts.

  • There is a lack of evidence on whether changes in knowledge and skills translate into care providers’ behaviour change or positive outcomes for women and newborn infants.

  • There is inconsistent implementation and understanding of the terms ‘midwife’ and ‘midwifery’ internationally and this causes confusion and renders measuring the most effective way of providing pre and in-service education difficult.

  • This startling lack of evidence on midwifery education is at odds with the fundamental contribution that good quality midwifery could make to survival, health, and well-being and could explain at least in part the underinvestment in midwifery globally.

Abstract

Background

Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally.

Objective

To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care.

Design

Rapid Systematic Evidence Review

Methods

A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively.

Findings

Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery.

Key conclusions

There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed.

There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes.

Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

Introduction

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 (LMICs) (Renfrew et al., 2014). The Lancet Series on Midwifery demonstrated that 83% of all maternal deaths, stillbirths and newborn deaths could be averted, and 56 sexual, reproductive, maternal, newborn and adolescent health outcomes could be improved through the provision of midwifery care which provides all the skills and competencies needed. This would require personnel to be educated to the international standards of the midwife, and to be fully integrated into the health system (Homer et al., 2014; Renfrew et al., 2014; Van Lerberghe et al., 2014).

The pressing need for quality midwifery care is highlighted by the failure over the past two decades to meet Millennium Development Goals (MDG) 4 and 5 (defined as a reduction in under 5 mortality by two thirds and reduction in the maternal mortality by two thirds respectively). More specifically, if we consider MDG indicator 5.2 (proportion of deliveries attended by a skilled health professional, defined as health professionals educated and trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborn infant) we can see that whilst there was an increase in the proportion of births attended by ‘skilled health personnel’ from 59% in 1990 to 71% in 2014, maternal mortality has only fallen by 46% to 230 maternal deaths per 100,000 live births in LMICs (United Nations, 2015). Moreover only half of pregnant women in LMICs receive the recommended minimum of four antenatal care visits (MDG indicator 5.5; United Nations, 2015). Further improvements in the quality of the care for women and newborn infants is therefore necessary to respond to the Sustainable Development Goals (SDGs) 3.1 and 3.2 (defined as a reduction in global maternal mortality ratio to less than 70 per 100,000 births and a reduction in neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births respectively).

Effective midwifery education is essential to the provision of the good quality maternal and newborn care that will save lives and improve health and well-being (Fullerton et al., 2003). There is, however, considerable variation in the provision of midwifery care and the content, duration and quality of midwifery education globally. Only 15% of ‘skilled birth attendants’ in LMICs describe themselves as midwives (Hobbs et al., 2019). Some LMICs have started working towards strengthening education, regulation and association of midwives to the standards set by the International Confederation of Midwives (ICM), the global professional organisation for midwives (Castro Lopes et al., 2016). Despite these attempts there are serious challenges to the implementation of good quality midwifery education. For instance, a review of pre-service programme curricula for four cadres of health-care providers of maternity care in Northern Nigeria identified that no programme met all of the criteria for minimum entry requirement for students (i.e. completion of secondary education), the length of the programme, the theory: practice ratio, the curriculum model, the minimum number of births conducted during training, clinical experience, competencies, the maximum number of students allowable or the proportion of Maternal, Newborn and Child Health components (MNCH) as part of the total curriculum (Adegoke et al., 2013). In addition, a political commitment in Bangladesh to produce 1,500 midwives is going forward without the development of educational institutions that have the skills and capacity needed (UNFPA Evaluation Office, 2016). It is therefore important that attempts of governments, professional organizations and multilateral organizations to develop midwifery education are assessed and amended before scaling up.

A previous systematic review examining the development of midwifery educator capacity in teaching in LMICs identified a lack research studies specific to midwifery education (West et al., 2016). However, since the search was last performed a number of new studies have been published. In addition, there is an urgent need for a broader review which considers all forms of pre- and in-service training to provide guidance about the most effective means to delivery midwifery skills education.

Section snippets

Review aims and questions

The aim of this rapid systematic review was to determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care.

There were two main review questions:

  • 1

    What is the evidence for the effectiveness of interventions aimed at the education, training and preparation of pre-service care providers in LMICs to provide high quality maternal and newborn care

Methods

A rapid systematic review of the literature was conducted and took a collaborative, targeted and efficient approach which was developed in conjunction with policymakers (Gavine et al., 2018). The protocol for the review was developed in conjunction with a Technical Advisory Group and is available upon request. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidance (Moher et al., 2009).

Results

The original search yielded a total of 2648 titles and the updated search yielded an additional 164 records. Thus a total of 2812 records were screened against the inclusion criteria. At this stage 2686 were excluded on the basis of title and abstract as they did not meet the inclusion criteria. The full-texts of the remaining 125 articles were retrieved and examined for eligibility. A further 106 articles were excluded for the following reasons: did not evaluate an educational intervention (n

Discussion

This review found limited quantity and quality of evidence for establishing the effectiveness of interventions aimed at the education, training and preparation of pre-service and in-service care providers in LMICs. In total 18 studies met the inclusion criteria with seven focusing on pre-service education and 11 focusing on in-service education. This is in contrast to a systematic review which examined the effectiveness of post-registration nursing and midwifery on practice and identified 61

Conclusion

There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs. Whilst there is some evidence that suggests that EMOC is effective in improving care providers’ skills, there is a dearth of evidence on transfer of learning to the workplace, changes in organisational practice attributable to the training, or in outcomes for women and their newborns. Given the state of the evidence, it is not currently

Ethical approval

Not applicable

Funding sources

Department for International Development (UK Gov)

Declaration of Competing Interest

None declared

Acknowledgements

This work was funded by a grant from the UK Department of International Development. The views expressed here are those of the authors and not the view of the funder.

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