Overview
Integral to the midwifery workforce is the training and education of midwives. The review explored the current capacity of the educational institutions to produce an adequate and sustained supply of midwives with the ability to offer quality midwifery care. Midwives must have necessary skills for saving the lives of mothers and babies. The review identified a number of gaps and areas for potential action to increase capacity of the midwifery workforce.
Midwifery Training in PNG
Post basic certificate programs for Registered Nurses were established in the early 1960s. The College of Allied Health Science, under the auspices of the National Department of Health controlled these programs from 1969 until the late 1990s. The Diploma of Advanced Clinical Practice commenced in 1995 through CAHS. Following affiliation between CAHS and UNPG the Bachelor of Clinical Nursing specialising in Midwifery first commenced in 2002.
At the time the Government pledged ‘a midwife in every health facility by 2010’, only 20 midwifery graduates are year were being produced through UPNG. This pledge led to the development of midwifery programs in several other institutions. As a result, programs are now being offered by the four institutions being reviewed in this report (University of PNG, Pacific Adventist University, University of Goroka and Divine Word University in Madang). A fifth program was planned to be re- established at St Mary’s school of nursing in Vunapope but no significant progress appears to have been made.
The care of women in pregnancy and birth is part of the core training for general nurses in PNG and many nurses continue to provide this care to women. Therefore many students (though not all) enter the midwifery program with significant experience in normal birth and care in pregnancy. Hence, in PNG, midwifery has always been seen as an extension of the role of the Registered Nurse. Internationally there is a trend towards establishing a distinction between the nursing and midwifery
professions. This is because midwifery is often seen as unique and separate to nursing with a philosophy of working with women in a social model of health that recognises pregnancy and birth as a normal physiological event that should be kept separate to the medical model of illness that dominates medical and nursing services. To this end many countries have commenced a three year ‘direct entry’ education program for midwives that is seen as a shorter route into midwifery undertaking nursing first and then midwifery.
However, this is not so for all countries. In PNG the health centres in rural and remote areas require a broader scope of practice than only midwifery. As 85% of PNG people live in rural areas, it is unlikely that a direct entry midwifery program will be considered for some time.
Post-registration education in Paediatrics has also been a long standing program in PNG due to the high population numbers in this age group and the high levels of childhood morbidity and mortality. Other specialty nursing programs apart from Midwifery and Paediatrics include Acute Care Nursing, Nurse Education and Mental Health. Midwifery and Child Health are recognised as important continuum and this led to the two courses being formally combined two years ago in three of the four institutions and are now offered as a Bachelors degree as a ‘double major’. Essentially this resulted in two, one year programs being merged into one, one year program. As the one year programs are offered within an academic year, the time spent is actually only 40 weeks (although UOG run their program in 52 weeks). Three of the four universities in PNG that offer midwifery now provide this ‘double major’ with only the Lutheran School of Nursing at Madang maintaining a ‘midwifery only’ program.
Scope of Practice
Within the health care professions, a scope of practice generally refers to what health care professionals are able to do. In PNG, there is a general acceptability on the midwives scope of practice though it is not clearly documented. However, other health workers such as Registered Nurses and Community Health Workers are currently providing maternity care to pregnant and birthing women. Although the scope of practice of these cadres of health workers was not reviewed, there was some
concern that they are working outside their scope of practice, particularly the CHWs. Having clearly articulated scope of practice for all heath workers can:
• Provide guidance to practitioners and employers about what they can and cannot expect of a practitioner;
• Form part of the regulatory framework;
• Be used to legally protect certain acts thereby limiting competition and protecting professional interests;
• Inform the educational requirements and content of educational programs; • Inform the way groups of health workers work; and,
• Assist policy makers and workforce planners in relation to models of service delivery, workforce development and the allocating of health and educational resources.
(WHO 2006)
Developing clarity about the scope of practice can also assist in identifying when practice falls outside the traditional or accepted boundaries. Research undertaken in the United Kingdom in relation to the scope of professional practice identified the positive role that a defined scope of practice has to play in the nursing, midwifery and visiting health professions (UKCC, 2000). The research identified that a scope of practice provides a framework within which practitioners can justify what they are able to do and identify what they are not in a position to do, due to a lack of skills or knowledge, and how this may be remedied. The International Definition of the Midwife has been used to guide the definition of the role and scope of practice development and accreditation of education standards and registration or licensing in many countries.
International Definition of a Midwife
The internationally accepted definition of a midwife is:
A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to
practise midwifery. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practise in any setting including the home, community, hospitals, clinics or health units (ICM, 2005).
The PNG midwife appears to work within this definition, although the international definition does not appear in any of the documentation reviewed. To assist in the formal recognition of the role of the midwife and to strengthen the education programs to prepare midwives, adopting the International Definition of a Midwife is recommended.
Educational Facility Assessment
The environment where student-learning takes place plays an important role in the effectiveness of education programs. For that reason, an ‘Education Facility Assessment Tool’ (adapted from the WHO Midwifery Toolkit and provided in Appendix 1) was used in a ‘walk through’ assessment of the educational establishments that were visited. The tool was used to assess the training and education facilities available for midwifery training, the resources available for the midwifery teachers and the students, dormitory facilities, models and equipment, library facilities and information technology infrastructure.
Table 2: Education Facility Assessment
Criteria UPNG PAU LUTHERA
N UOG
Graduates produced in 2006 33 8 22 11
Offices for midwife teachers Yes Yes Yes NO
Computers for teachers Yes Yes Yes NO
Teachers experienced midwives with specialist
teaching preparation Yes Yes Yes Not all
Internet access for teachers Yes Yes NO NO
Adequate Classroom facilities Yes Yes Yes NO
Adequate IT facilities for students NO Yes Yes NO
Internet access for students Yes Yes NO NO
Adequate practice labs Yes Yes NO NO
Clinical laboratory with models available and
equipment NO Some Some NO
Accommodation for students Yes Yes Yes Yes
Formal Curriculum Committee Yes Yes Yes Yes
Adequate written information regarding course
given to students Yes Yes Yes NO
Multiple educational methods used Yes Yes Yes Yes
Formal mechanism for student complaints Yes Yes Yes Yes
Adequate library facilities Yes Yes Yes NO
Adequate access to midwifery texts NO Yes Yes NO
Clinical supervisors for all areas Yes Yes Yes Yes
Formal preparation for clinical supervisors Yes Yes Yes Yes Adequate time spent with students in the
clinical area NO NO NO NO
Adequate security for students and staff Yes Yes Yes Yes
The education institutions were well equipped and 50% of midwifery teachers had education and Masters Qualifications. Lutheran and PAU have computer facilities for students, and UPNG will soon have their computers installed. UOG had poor computer access for both students and staff. Internet access both for teachers and students was available in PAU and UPNG. At the Lutheran School of Nursing, staff
and students were required to travel to the Divine Word University and pay for internet access. UOG students had no internet access and had to pay for private word processing for typing their assignments.
Classrooms were of adequate size and well ventilated though lacked the necessary equipment to provide lectures using ‘powerpoint’ presentations, relying instead of overhead projectors and paper based handouts. To encourage regular updating of materials and suitable medium for guest lecturers (usually doctors) the use of ‘powerpoint’ is recommended and will save the institutions time and money in resource production.
Library facilities appeared adequate, with the exception of UOG, although many of the text books were older than 10 years. Electronic resources did not appear to be utilised effectively in any of the institutions visited. There are now a number of databases and electronic resources available free of charge to resource-poor countries such as PNG. Library and education staff should be encouraged to access these services. Band Width is poor in PNG resulting in slow download time but many resources are also available on CD Rom and could be uploaded to university servers and networked to staff and student computers, negating the need for high-speed technology.
The need for more training aids and mannequins was recognised with some universities (UPNG and UOG) having no training models and others not utlising the models they had effectively. Lack of airconditioning in some of the rooms led to rapid deterioration of some of the models.
The resources available for the maternal and child health program at UOG were significantly less than other institutions. Although the facilities at UOG appeared satisfactory, the teachers of the maternal child health program are situated off campus in converted rooms within the accommodation dormitories at the Goroka Hospital. The facilities here included a small office, inadequate to house the three teachers allocated to use it, a small storeroom and a classroom with the capacity to accommodate approximately 15 people and insufficient for the 24 students currently
and not an ideal environment for either teaching or learning. The staff reported, however, that next year they will be relocating to the main UOG campus and this situation should be remedied.
Recommendations for Midwifery Facilities
The midwifery training institutions can be strengthened by:
1. Increasing the amount of mannequin (models) for practical training, particularly for life saving skills such as manual removal of the placenta, PPH and neonatal resuscitation.
2. Ensuring the appointment of midwifery teachers who are both academically and clinically competent midwives.
3. Ensuring computer and internet access for staff and students.
4. The use of powerpoint to be available for teaching within the facilities.
Teachers of the Midwifery Education Program
High quality midwifery education can only be achieved by having sufficient well- prepared midwife teachers. It is essential that midwifery teachers not only have good academic ability, but are also experienced and competent clinical midwives. In order to maintain their clinical skills they should spend regular and frequent periods working with and supervising students in clinical practice.
Midwife teachers require an in-depth knowledge of evidence-based midwifery, both theory and practice, and should also ideally be capable of conducting their own research. The midwife teachers also need a good knowledge of the principles and practice of education and to be comfortable with, and committed to, modern, participative approaches to adult education, because it is widely accepted that these are most effective. Broadly this means adopting a student-centred, rather than a teacher-centred approach to education and using a range of teaching and learning methods which encourage students to be actively involved in their own learning.
Midwife teachers also need opportunities for ongoing professional development on a regular basis to enable them to keep up-to-date in both midwifery and education if they are to maximise their effectiveness and maintain their interest and enthusiasm.
documents and resolutions related to maternal child health and reproductive health issues.
Overall the academic quality of the midwifery teachers in the four institutions reviewed was high with approximately half of the teachers holding masters level awards. It was noted that UOG utilised teaching staff who were not midwives (only one of the three core teachers used on the program had some experience as a midwife and she did not commence employment until 8 months into the first program). Whilst most of the other institutions used experienced midwives with clinical experience, some had not practiced for some years and were not considered clinically competent by some of the key informants in the health services area (see also Stakeholder results, Section 3 and Student midwives, Section 5).
Furthermore there was lack of evidence to reassure the review team that the midwife teachers were up to date on many of the latest evidence regarding the treatment or management of many of the life threatening conditions women face in PNG. It was noted in the subject outlines (when provided) and by verbal reports from education staff, that doctors were used to deliver lectures around complications of pregnancy and labour, such as pre-eclampsia. Whilst the use of doctors to provide midwifery lectures is at times appropriate, midwife teachers should also be competent to teach these subjects.
The World Health Organization prepares a large quantity of literature related to reproductive health that is very helpful for teaching and learning purposes. Education materials produced which are suitable for midwives include: The Midwifery Toolkit, The Safe Motherhood Initiative, WHO’s Making Pregnancy Safer Initiative, The Millennium Declaration and the Millennium Development Goals (MDGs), WHO’s `The Mother-Baby Package’, WHO `Midwifery Education Modules for Safe Motherhood’, various international declarations and commitments especially those produced by the International Confederation of Midwives (ICM) and many others.
All teachers of midwifery programs across the four institutions were asked to complete a ‘Midwife Teacher Questionnaire’, (see Appendix 2) that was based on the
The teachers were asked to provide information on their: age; qualifications, previous experience, reasons for being a midwife and a midwifery teacher; if they believe midwives should conduct clinical midwifery; and three things that would assist them to be more effective in their positions.
A total of 13 teachers completed the questionnaire from a total pool of 16 teachers. Results showed the mean age of the midwifery teachers throughout the four institutions was 44 years old with an age range of 30-58 years. Approximately 50% of the teachers surveyed had post graduate teaching qualifications and were also prepared at Masters level. Most of the teachers were registered midwives (81%). A summary of the educational qualifications of the midwife teachers is provided in the table below.
Table 3: Educational qualifications of midwife teachers
Institution Total surveyed Midwife Education
qualifications Masters level
UPNG 6/6 5/6 4/6 4/6
PAU 3/5 3/3 1/3 1/3
Lutheran 2/2 2/2 2/2 2/2
UOG 2/3 1/2 0/2 0/2
Total 13/16 (81%) 11/13 (85%) 7/13 (54%) 7/13 (54%)
All respondents believed it was essential for midwifery educators to conduct clinical practice and most planned to still be teaching in five years if they had not retired. Self identified strategies to enhance their effectiveness as teachers in midwifery included:
• More staff or resources (including midwifery text books) • More time in the clinical areas
• Closer relationships with clinical staff
• More opportunities for professional development • More opportunities to do research
• IT support such as powerpoint presentations and internet access • Separate midwifery and paediatric streams
• Improved communications with Nursing Council to ensure rapid registration of graduates.
The teachers were also asked to identify if they considered themselves experienced in a number of skills and knowledge necessary to effectively prepare students for practice. A full list is provided in Appendix 2 and covered the skills to effectively teach designed under the following headings: clinical practice, research, teaching methodologies, assessment, documentation; computer and internet skills to access information; management; communication; and, intercultural competence.
Of the 13 midwifery teachers who completed the questionnaire, the respondents indicated that they were experienced in most of the 29 indicators. Some of the areas that were reported as being ‘unsure’ included: managing birth in a home setting; national legislation on record keeping; educational management theories, curriculum evaluation, vacuum extraction; listening techniques; and, cultural taboos and customs in different communities or countries.
However, the review team found limited evidence to support this self-reported high level of knowledge in some areas, particularly in maternity and neonatal emergencies.
Recommendations for Midwifery Teachers
Increasing the capacity of the midwifery teachers can be achieved through:
1. Ensuring teachers are up to date in both theory and clinical practice Upskilling in these areas could be achieved through a one week Regional Credentialling Program (available through WHO).
2. Increasing time spent by teachers in the clinical areas providing clinical supervision.
3. Utilising electronic resources and international literature more effectively.
4. Ensure teachers are also expert clinicians with continuous access to clinical practice through student supervision (providing opportunities to upskill for those who are not currently clinically competent). This requires all teachers offering clinical supervision to be registered midwives.
Program Reviews
University Of Papua New Guinea
UPNG commenced tertiary based midwifery education in 2002 with the combined ‘double major’ in midwifery and paediatrics commencing in 2005. Documents produced for the review comprised the curriculum for the 2002 program with a course timetable and subject outlines provided for each of the units provided in the new course.
The UPNG curriculum is situated within a document that encompasses all other post- registration courses offered by the school including Acute Care Nursing and Mental Health. It therefore lacks any specific attention to the philosophy of midwifery or context in which midwifery services are offered to women and their families within