PAPUA NEW GUINEA MIDWIFERY EDUCATION REVIEW FINAL REPORT

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PAPUA NEW GUINEA

MIDWIFERY EDUCATION REVIEW

FINAL REPORT

2006

Dr Sue Kruske

Charles Darwin University, Australia

For

WHO and National Department of Health

Papua New Guinea

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Table of Contents

List of Tables ...vi

List of Tables ...vi

List of Figures ...vii

Acknowledgements...ix

Executive Summary ...2

Overview...2

Stakeholders and Key Informants ...2

Midwifery Education Facilities...3

Curriculum Analysis ...3

Health Services ...5

Regulation and Registration of Midwives ...5

Recommendations...6

Section 1: Background...10

Midwifery in the International Context ...11

Papua New Guinea...12

Midwifery education in PNG...15

Terms of Reference for a Review of Midwifery Education in PNG ...16

Section 2. Methodology for Conducting the Review...18

Methodology ...18

Overview of Data Collection and Analysis ...18

Data Collection Tools and Analysis ...18

Tool 1. Education Institution Assessment Tool...19

Tool 2. Midwifery Teacher Questionnaire...20

Tool 3: Curriculum Evaluation Tool...20

Tool 4: Student Midwife Assessment Tool ...20

Tool 5. Health Facility Assessment Tool...20

Tool 6. Midwife Self Assessment Tool ...21

Focus Groups Discussions ...21

Stakeholders and Key Informants ...21

Desk Review ...21

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Section 3. Results...23

Overview...23

Site Visits ...23

Stakeholders and Key Informants ...24

Key Findings of Stakeholders and Key Informants...24

Section 4: Midwifery Education ...26

Overview...26

Midwifery Training in PNG...26

Scope of Practice...27

International Definition of a Midwife...28

Educational Facility Assessment ...29

Recommendations for Midwifery Facilities ...32

Teachers of the Midwifery Education Program...32

Recommendations for Midwifery Teachers...35

Program Reviews ...36

University Of Papua New Guinea...36

Pacific Adventist University ...38

Lutheran School of Nursing, Divine Word University, Madang...39

University of Goroka ...42

Distance education ...45

Curriculum Analyses ...45

Entry Criteria ...49

Approval by Regulatory Authority ...49

Educational Theories and Critical Thinking ...49

Midwifery Philosophy ...50

Clinical Supervision...50

Ability to Practice Autonomously, in any Setting, with Life Saving Skills ....50

Clinical Assessors ...51

Comparisons with PNG programs and International standards ...51

Clinical Practice ...53

Combining Midwifery with Paediatrics...57

Recommendations for Midwifery Programs...58

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Essential Midwifery Competencies Results...61

Focus Group Discussions...64

Conclusion ...67

Section 6. Health Services ...69

Equipment ...69

Workforce ...70

Fee for service payment ...71

Maternal Complications and Life threatening emergencies ...71

Post Partum Haemorrhage ...71

Pre-eclampsia and Eclampsia ...74

HIV ...76

Resuscitation of the Newborn...77

Clinical Midwives...77

Results of the Midwifery Self Assessment ...79

Recommendations for Health Services...81

Section 7: Regulation of Midwives...83

Overview...83

Recommendations for Nursing Regulation and Accreditation ...85

Conclusion ...85

Section 8: Conclusion ...86

References...88

Appendix 1: Education Institution Quality Assessment Tool...90

Appendix 2: Midwife Teacher Questionnaire...98

Appendix 3: WHO Framework for Evaluating Curriculum ...106

Appendix 4: Student Midwives Surveys...108

Appendix 5: Health Facility Assessment Tool ...112

Appendix 6: Midwife Self-Assessment Tool...116

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List of Tables

Table 1: Site visits...23

Table 2: Education Facility Assessment ...30

Table 3: Educational qualifications of midwife teachers...34

Table 4: Theoretical Subjects at UPNG...37

Table 5: Theoretical Subjects at PAU...38

Table 6: Theoretical Subjects at Lutheran School of Nursing ...40

Table 7: Theoretical subjects in UOG program...44

Table 8: Curriculum Evaluation...47

Table 9: Comparisons between the four curricula and WHO International Standards52 Table 10: Student Midwives Surveyed from 2005 and 2006 programs ...61

Table 11: Range and average of key skills in midwifery...66

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List of Figures

Figure 1: Student confidence in normal pregnancy and birth...62

Figure 2: Student confidence in managing maternal emergencies ...62

Figure 3: Confidence of midwives in normal pregnancy and birth ...80

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Acknowledgements

The consultant (Sue Kruske) would like to thank all those who participated in the Midwifery Education Review, particularly Estelle Jojoga from University of Papua New Guinea, Julie Aengari from Pacific Adventist University, Elizabeth Natera from the Lutheran School in Madang and Lilian Sewi from University of Goroka for extending themselves to accommodate us on our visits to their facilities. Not only did they facilitate access to university processes, they ensured our comfort and safety whilst visiting their towns and arranged transport to rural health facilities and villages. This ensured a comprehensive ‘snapshot’ of the lives of PNG families.

She would also like to acknowledge the other members of the review team, Ms Sulpain Passingan from the Department of Health and Mr Geoff Clark from WHO.

Extended thanks also to the support and assistance from Department of Health personnel, WHO personnel, health practitioners, and education staff.

It is not the intention of this review to diminish or discredit the hard work done by many individuals across education, policy and clinical services. Most individuals are doing the best they can possibly do in a system that is challenging and poorly resourced. It is hoped that the recommendations in this report can assist these individuals in strengthening maternity services in this country to achieve what all participants are striving for: a reduction in the devastating loss of life in women and children in PNG from conditions that are mostly preventable.

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Executive Summary

Overview

The quality of education provided for the preparation of midwives has a major influence on the ability of health services to provide skilled care for women in pregnancy, childbirth and the postnatal period. A review of midwifery education was undertaken in November and December 2006, made possible through funding by the World Health Organisation.

The National Department of Health in Papua New Guinea (NDoH) is to be congratulated on its efforts to develop strategies to reduce maternal and childhood mortality and morbidity. In particular, their success in prioritising attention on the issue of midwifery, as the key to achieving such reductions, is exemplary, especially in a country facing so many other urgent health issues.

A comprehensive review of the four education facilities currently providing midwifery education in PNG was undertaken. These included the University of Papua New Guinea (UPNG), the Pacific Adventist University (PAU), the University of Goroka (UOG) and the Lutheran School of Nursing, Divine Word University. In addition interviews were undertaken with 68 stakeholders and key informants including health policy officers, clinical service workers and Nursing Council representatives.

Stakeholders and Key Informants

It was acknowledged that there are currently insufficient midwives in PNG and that the numbers of midwives currently being trained will not address these workforce shortages. Poor maintenance of health facilities is affecting the ability to attract and maintain staff and to provide high quality and safe care. In addition essential medical supplies and equipment are often not available even though the central warehouse has supplies available.

Many women are not seeking health services for care during pregnancy and childbirth, largely due to the demographic and geographical challenges of PNG

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populations, although health service fees and staff attitudes were also thought to affect access.

Midwifery Education Facilities

Midwifery education in PNG was once considered the best in the West Pacific Region but is no longer producing the same calibre of midwife. The transfer of education to the tertiary sector occurred in 2002 and reduced the number of students being educated in midwifery. Strategies to increase the number of midwives due to a government pledge to have a midwife in every health centre in the country led to the introduction of midwifery programs in three other institutions in the last few years.

Most of the education institutions were well equipped and had qualified teachers, some of them with Master qualifications. Deficiencies included a lack of written and electronic resources in some of the institutions including inadequate computers and information technology access for teachers and students. Lacks of teaching models were also noted in most of the facilities to enable students to develop skills on mannequins prior to clinical placement.

Teachers of the programs were mostly registered midwives although some lacked recent clinical experienced that limited their capacity to be effective in the clinical setting. Stakeholders and students also reported inadequate support of university staff in the clinical area. Midwife teachers did not appear to be 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.

Curriculum Analysis

Three of the four institutions reviewed provide midwifery education in a combined ‘maternal and child health’ format. The time of the programs varied between 40 weeks in the UPNG, PAU and Lutheran programs and 52 weeks in Goroka.

Whilst the overlap of midwifery and child health is recognised, it is unlikely that competence in either discipline would be gained in the current time frame and curriculum format of 40-52 weeks. Many of the stakeholders and key informants

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in the rural areas. However, some informants recognised the clear shortcomings of the current structure and supported the reestablishment of two distinct programs.

The theoretical component was considered stronger in the midwifery-only program (offered through the Lutheran School of Nursing in Madang) compared with the other programs due to its focus on midwifery only and the development of all subjects within a midwifery context. The other three programs provide a range of generic subjects shared with other post basic courses.

It is believed that all courses require more attention to the complications of pregnancy and childbirth, particularly those conditions that contribute to the high rates of maternal mortality (PPH, pre-eclampsia, puerperal sepsis etc) as the response from students, educators and clinical midwives demonstrated lack of in-depth understanding of these events, particularly pre-eclampsia.

The review found that overall there is insufficient clinical experience offered to students across the four programs in the area of midwifery, particularly exposure to labour ward. Some students spent as little as one week in labour ward, though the average was 3-4 weeks. The only exception to this was the midwifery-only Lutheran program which included 14 weeks in labour ward. More time is required in the key maternity areas of labour ward and antenatal clinic, in line with WHO recommendations. The exposure to key clinical skills necessary to reduce the maternal and infant mortality, such as management of pre-eclampsia and resuscitation of the newborn was also limited.

None of the four institutions provided students with a specified number of clinical procedures. Even when a number was provided (for example, 10 normal births), many students did not achieve this and were still permitted to graduate. A minimum number of procedures should be applied across all institutions in line with WHO recommendations (see page 52) and the students must achieve these requirements prior to graduation.

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local health structure with a responsibility to supervise, mentor and teach the other cadres of health personnel currently providing services.

The University of Goroka included an innovative aspect of their program that aimed to provide local volunteer training, at the same time as placing students within the volunteers’ villages for a period of eight weeks. This was to assist the student learn about the issues facing families at the village level as well the opportunity to carry out health assessments on every household, in partnership with the village volunteer. This aspect of the program appeared to provide many benefits for both village members and students of the program. However the time allocated to this aspect of the program (16 weeks) sacrificed important clinical practice time for students to develop midwifery (particularly emergency) skills.

Health Services

Government health services appeared less resourced than Church-sponsored health services. Essential equipment was not available in many of the facilities visited with staff carrying their own supplies of needles for suturing and buying their own soap. Some of the smaller facilities did not have sphygmomanometers to monitor blood pressures, and even when they were available women may not have their blood pressure recorded. All facilities reported running out of essential medicines such as Syntocinon, required for the prevention and management of post partum haemorrhage. Clinical skills in the management of life threatening conditions were also limited in some staff at the health facilities.

Regulation and Registration of Midwives

Although it is a requirement for all midwifery and nursing programs in PNG to be approved by the regulatory authority, the Nursing Council, the UPNG curriculum has not been submitted for approval by the Nursing Council. It was difficult to ascertain if formal approval had been given to the three other programs. It is believed that this approval has not been formalised for these three institutions, though the curriculum documents had been submitted. UOG submitted their curriculum over twelve months ago but have not received formal approval to provide the program and Lutheran responded to a number of Council enquiries regarding their program, but have also

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It was noted that no graduate from any nursing or midwifery program, including undergraduate nursing programs (not included in this review) has been registered since 2004. Whilst these students continue to be employed in both Church and Government health facilities, there is significant concern amongst graduate students, health clinicians and educators regarding this issue and this is a key area for policy makers and leaders to address.

The Nursing Council could assist in the improvement of the quality of midwifery graduates by developing a set of minimum clinical skills (including a predetermined number of clinical procedures to attain those skills) that each student must attain prior to graduation. This minimum number could be based on the WHO international midwifery curriculum.

Recommendations

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.

Increasing the capacity of the midwifery teachers can be achieved through: 5. 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).

6. Increasing time spent by teachers in the clinical areas providing clinical supervision.

7. Utilising electronic resources and international literature more effectively.

8. 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

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Education programs in midwifery can be strengthened by:

9. Basing PNG programs on the WHO international curriculum, modified to meet the contextual needs of this country.

10.Increasing the length of the program to 12 months (52 weeks) for midwifery only with a 6 month additional component for child health/paediatrics.

11.A minimum number of clinical procedures be included in all curricula. For example, increase the number of manual removal of placentas that students must achieve to a minimum of five.

12.Comprehensive clinical logbooks be developed for students to record the minimal number of clinical skills, for example, space be provided to document 100 antenatal assessments, 40 normal births, 5 breech births, 5 vacuum extractions etc. Competencies can then be signed off by a competent supervisor once for each skill.

13.Ensure that each student achieves all minimum clinical requirements before allowing them to graduate.

14.Improve access to clinical skill development through rostering of students on all shifts including night-duty and weekends, and also other hospitals in PNG.

15.All programs should develop a midwifery specific curriculum and not embed the program within nursing.

16.Subjects should be midwifery specific where possible.

17.The entry criteria be revised and standardised to incorporate international recommendations that accept registered nurses with hospital based certificates. 18.More attention be devoted throughout the program to develop life saving skills,

particularly management of pre-eclampsia, eclampsia, and resuscitation of the newborn.

19.More attention be devoted throughout the programs to develop critical thinking and reflective practice through the use of role plays, case studies, case reviews, reflection on critical incidents etc.

20.All curricula include information on evidence based practice using A Guide to Effective Care in Pregnancy and Childbirth and WHO literature such as the Reproductive Health Library.

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Health services can be strengthened by:

22.NDoH develop and disseminate a standardised policy for all education and health facilities, outlining the appropriate management of third stage and the management of PPH. This should include:

• Minimising the stimulation of the uterus prior to expulsion of the placenta. • Accurate physiological management in the absence of oxytocics.

• Routine administration of syntocinon rather than syntometrine for the active management of third stage.

The availability and appropriate administration of misoprostol (800 – 1000 micrograms inserted rectally) in the management of PPH.

23.NDoH develop and disseminate a policy to all education and health facilities, outlining the appropriate identification and management of pre-eclampsia and eclampsia. This should include:

• The availability of testing for proteinuria at the clinical level.

• Clear definitions and classifications of hypertensive disorders in pregnancy. • Contemporary evidence around signs and symptoms of the disorder.

• Current evidence around management of the disorder including appropriate use of antihypertensives and magnesium sulphate for the prevention and management of eclamptic seizures.

24.Improvement of working conditions by ensuring:

• Adequate drugs and single use items where required to increase quality and safety of care.

• Facilities provide appropriate means for ensuring infection control procedures can be followed at all times (especially hand washing hardware: running water, soap and towel).

25.Funding to be secured to provide an upskilling workshop on maternity emergencies for senior clinical (midwifery and obstetric) and education staff in PNG.

26.NDoH recommence preceptor training for clinicians working with students and junior staff in the clinical areas.

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27.Process the registration for all students who have graduated from nursing and midwifery programs since 2004. This must be attended to as a matter of urgency. For graduates from the UPNG program that has not received formal approval to offer the existing program, these students should not be penalised by withholding registration. Whilst it is recommended that the UPNG program restructure their program in line with the recommendations of this report, it is not believed the graduates from the UPNG program are significantly less competent than the other programs. Therefore to withhold registration to these students on the basis that the program was not approved would not be useful, particularly when representatives of the Nursing Council were included in the curriculum development.

28.Develop a set of minimum standards of clinical skills that each institution must incorporate into their curricula. These should be based on WHO recommendations documented in their international curriculum.

29.Conduct a review of the registration procedures required by Council in order to improve the efficiency and reduce the workload required by the Council to assess each graduate individually.

30.Set standards for minimum requirements for entry into the profession that should include registered nurses with hospital based certificates.

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Section 1: Background

Midwives are recognised in most countries where they exist as the front-line care-givers in pregnancy and childbirth. As such they are often described as the linchpins of safe motherhood and have a special role and responsibility to promote reproductive health. The role of the midwife is clearly expressed in the definition formulated by International Confederations of Midwives (ICM) in 1972 and amended in 1990 and 2005. The definition is approved and adopted by key international agencies including the International Federation of Gynaecologists and Obstetricians (FIGO) and WHO.

Critical components of a strategic approach to reducing maternal mortality and morbidity, as well as to promoting women’s health throughout their reproductive life include:

• Updating educational programs to respond to community needs

• Setting clear standards for practice to identify essential competencies for clinical practitioners and educators, as well as for the health system needed to support the functioning of a midwife, and finally

• Establishing an enabling legislative and policy framework for practice (WHO, 2006b).

To meet the challenge of providing quality care to women and their newborns, both initial and continuing midwifery education must be improved. Improvements must include:

• Technical competencies, including life-saving skills

• Skills in communication, counselling and health education to assist the midwife in developing good relationships and working with the community • Introduction to all aspects of the concept of reproductive health

• Access to all the equipment, supplies and drugs needed to give quality care and manage life-threatening conditions in the woman and newborn

• Regular, continuing education to maintain and extend midwives’ skills and encourage accountability

• Support from supervisors and regular, constructive performance appraisals. (WHO, 2006b)

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In addition to their clinical role, midwives need to be politically astute and capable of taking appropriate and skilful action to promote reproductive health and the rights and well-being of women. Each midwife must also be able to function effectively as a fully accountable member in a multi-professional team and develop collaborative working relationships with other members of the maternity services team, other health care providers and with community workers such as traditional birth attendants (TBAs) both trained and empirical, where they exist (WHO, 2006b).

Midwifery in the International Context

There is a trend towards more community based maternity health services utilising primary health care principles, a recognition of the importance of inter-disciplinary collaboration and the promotion of social support for childbearing women. The current wave of change occurring in maternity health services is characterised by escalating costs; crises in the recruitment and retention of both midwives and medical practitioners, particularly in rural areas; the closure of rural units; shorter hospital stays; and increasingly sophisticated information technology and biotechnology. Midwives need a strong scientific knowledge base and the ability to learn and make independent enquiry at a high level in the face of complex maternity health services where the increased availability of knowledge requires ‘rethinking, rediscovering and reforming practice’ (Page 2000:xi).

At the second WHO Ministerial conference on nursing and midwifery in Europe, in The Munich Declaration (WHO, 2000), Ministers of Health stated their belief that:

Nurses and midwives have key and increasingly important roles to play in society’s efforts to tackle the public health challenges of our time, as well as in ensuring the provision of high quality, address people’s rights and changing needs (WHO, 2000).

In the Munich Declaration which was issued by ministers at the conference (WHO, 2000), all relevant authorities were urged to ‘step up their action’ in order to strengthen nursing and midwifery by:

• Ensuring a nursing and midwifery contribution to decision-making at all levels of policy development and implementation;

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• Addressing the obstacles, in particular recruitment policies, gender and status issues, and medical dominance;

• Providing financial incentives and opportunities for career advancement; • Improving initial and continuing education and access to higher nursing and

midwifery education;

• Creating opportunities for nurses, midwives and physicians to learn together at undergraduate and postgraduate levels, to ensure more cooperative and interdisciplinary working in the interests of better patient care;

• Supporting research and dissemination of information to develop the knowledge and evidence base for practice in nursing and midwifery;

• Seeking opportunities to establish and support family-focused community nursing and midwifery programs and services, including, where appropriate, the Family Health Nurse;

• Enhancing the roles of nurses and midwives in public health, health promotion and community development. (WHO, 2000)

Papua New Guinea

Papua New Guinea is the largest developing country in the Pacific. Covering 2.2 million square kilometres, its main landmass, 85% of its total, is shared between Papua New Guinea and Papua Province of Indonesia. The remaining 15% is spread over 600 islands.

It has a population of 6.0 million (estimated 2005), with a population growth rate of 2.7 %. It remains a primarily rural society with 87% of the population living in rural areas. Around 800 languages are spoken, and each language group has a distinct culture. There are large socio-cultural differences between and within provinces. Official languages are English, Pidgin and Motu.

Access to the widely scattered rural communities is often difficult, slow, and expensive. Only 3% of the country’s roads are sealed. Many villages can only be reached on foot. Much travel between the provinces is by air. There is a persistent and serious law and order problem, which involves a combination of serious ‘conventional’ crime and public disorder, and tribal warfare. This, together with the

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poor road infrastructure and rugged terrain, pose formidable challenges to effective health services delivery nation-wide.

Health status, the lowest in the Pacific region, once steadily improving during the 1980’s has progressively declined over the last ten years. Life expectancy (2000) is estimated to be 52.5 for men, and 53.6 years for women, with Healthy Life Expectancy of 45.5 years (WHO 2006a). It is estimated that about 15% of a woman’s life span to be affected by some form of disability or morbidity. The estimations of mortality and morbidity patterns in the population are very approximate, as data are almost entirely facility based and laboratory confirmation of clinical diagnoses is rare.

Maternal mortality estimates are amongst the worst in the world at 370 per 100 000 live births (2000 figures). Causes of maternal deaths include postpartum haemorrhage, puerperal sepsis, antepartum haemorrhage, eclampsia and anaemia. Only 40% of women are cared for by trained health personnel. The infant mortality rate is 64 per 1000 live births very high compared to 38 for the other lower middle-income countries.

Chronic malnutrition is a serious problem, particularly among rural women and children, and is closely related to poverty. Overall 27% of children are considered moderately to severely malnourished and 43% of children aged 0-5 have stunted growth. Again there are marked regional variations (WHO, 2006a).

Health services across the country is provided by both the government through the National Department of Health (NDoH) and a number of Church Organisations. The Churches work in close partnership with the government and provide approximately 50% of both health services and education of the health workforce. These Churches are multi denominational and are collectively represented by the Churches Medical Services with administrative offices located within the NDoH.

Papua New Guinea is divided into four regions. Within these regions there are 19 provinces and within the provinces, 89 districts. Each region has a regional hospital with smaller district hospitals in each of the districts. Smaller communities are

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The numbers of Aid Posts have rapidly reduced over the past 10 years, leaving some villages with no health service at all. Infrastructure at the Health Centre level is minimal with the majority having no electricity or running water.

Birthing services are available at most of these facilities (not Aid Posts) though many are without a midwife or doctor (see below). The number of births at each facility was difficult to ascertain but range from several per month in the smaller Health Centres to approximately 1,000 per month at the Port Moresby General Hospital.

The nurse to population ratio is 6.52 per 100,000. An additional 1000 nurses and 100 midwives are estimated to be needed to fill vacant posts, and current production rates are insufficient to fill this gap (WHO, 2006a). The NDoH released its National Health Plan 2000-2010 in the late 1990s where it was recognised the health of PNG people had not improved and in some indicators such as maternal and child health had actually deteriorated. The government announced a commitment to address this and one of the goals was to have a midwife in every health service by 2010. However at the beginning of 2007, many recognise that this goal is not possible to fulfil with most of the births across the country being unsupervised by a skilled health attendant.

The majority of women giving birth in rural health centres are cared for by Community Health Workers (CHWs). These workers undertake a two year education program that is based on health promotion and disease prevention. Within their roles the CHW are supposed to monitor women during pregnancy and refer them to a midwife for birthing services.

Another category of worker, not recognised as qualified health personnel is the Village Health Volunteer (VHV). This program was commenced in 2002 and is generic volunteer program run over four weeks and incorporates five training modules including:

• Being a better volunteer • Self help health care (first aid) • Safe motherhood

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• Learning about health (nutrition, hygiene and diseases)

Members are chosen by the community to undertake the program. More than half of the volunteers are men and an evaluation of the program was undertaken in 2006 though the results were not released at the time this review was undertaken.

The delivery of health services to people with such a large percentage living in rural and remote areas, often in geographically isolated areas, have been challenging. Health infrastructure has been insufficient and poor maintenance of buildings and inadequate resources has resulted in over 50% of rural health centres closing over the past twenty years despite the population almost doubling from 3 to 6 million people (WHO, 2006a).

The NDoH have developed a ‘Minimum Standards for Health Facilities’ document that outlines the minimum equipment and staffing levels for each category of facility. However the majority of the services, including the largest health facility, the Port Moresby General Hospital are not able to implement these standards due to workforce and funding shortages.

Midwifery education in PNG

Like many countries, midwifery education was traditionally conducted through apprentice-style training based in hospitals where registered nurses received additional education in the specialist field of midwifery. In the late 1990s midwifery education was transferred to the tertiary sector and was initially offered as an advanced diploma before becoming a bachelor degree in 2002. The move to the tertiary sector resulted in a dramatic decrease in new midwives being produced as initially only University of Papua New Guinea (UPNG) was offering a tertiary based midwifery program. Three other institutions have developed midwifery programs since 2002 and there are now four programs being offered across the country, two in Port Moresby UPNG and Pacific Adventist University (PAU), one in Goroka (University of Goroka) and one in Madang (the Lutheran School of Nursing, Divine Word University).

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Terms of Reference for a Review of Midwifery Education in PNG This review was undertaken under the following terms of reference

A: In collaboration with the Director, HRM branch, National Department of Health, the Nursing Council of Papua New Guinea, the School of Nursing, University of Papua New Guinea (UPNG), the Obstetric Division, Port Moresby General Hospital (PMGH), the Lutheran School of Nursing, Divine Word University, the University of Goroka and the Pacific Adventist University and the Papua New Guinea Midwifery Society to:

1. Review the current curricula in use for midwifery education, including clinical training and teaching, at the School of Nursing, the Lutheran School of Nursing, Divine Word University, the University of Goroka and the Pacific Adventist University, in terms of it’s appropriateness for preparing midwives in the context of practice in Papua

2. Develop a tool for the conduct of a comprehensive review of the outcome of graduates of the School of Nursing, University of Papua New Guinea, the Lutheran School of Nursing, Divine Word University, the University of Goroka and the Pacific Adventist University.

3. Develop a list of stakeholders to be consulted in the review including, but not limited to, tutoring staff of the 4 schools, graduates of the program, employers, clinical facilitators, and midwifery and obstetric colleagues.

4. Conduct a comprehensive review with stakeholders of the outcome of graduates of the School of Nursing, University of Papua New Guinea (UPNG), the Obstetric Division, Port Moresby General Hospital (PMGH), the Lutheran School of Nursing, Divine Word University, the University of Goroka and the Pacific Adventist University.

B: Submit a detailed report, with any appropriate recommendations, at the end of the assignment.

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This work therefore involved close consultation and collaboration with key stakeholders and partners including education and health service providers.

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Section 2. Methodology for Conducting the Review

Methodology

The WHO has developed a set of guidelines that can be used for establishing or reviewing midwifery programs according to a country’s needs and priorities. They cover the following aspects of midwifery education and practice:

Legislation and Regulation: Making Safe Motherhood Possible.

• Guidelines for the Development of Midwifery Education Programs. • Competencies for Midwifery Practice.

• Guidelines for the Development of Standards for Midwifery Practice.

• Guidelines for the Development of Programs for the Education of Midwife Teachers.

(WHO, 2006b)

These guidelines were used to guide this review.

Overview of Data Collection and Analysis

In view of the complex nature of health services in PNG and the limited time available to complete the task, a rapid appraisal approach was utilised. Key concepts of the rapid appraisal approach are taking a systems approach, triangulation of data and iterative data collection and analysis (Beebe, 1995). The systems approach utilises the insiders understanding of the situation, considers all aspects that may be affecting the functioning of the system but moves on to focus on the most important aspects to that particular context (Beebe, 1995). Triangulation of data is the second key concept in the rapid appraisal approach and involves consciously choosing different research methods, different team members and different individuals for interview to provide different perspectives. The third key concept of rapid appraisal is iterative data collection and analysis which is used to clarify uncertainties and may uncover unexpected details (Beebe, 1995).

Data Collection Tools and Analysis

A number of specific tools were developed for the review, based on tools used in similar assessments conducted in other countries. These tools included

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• Educational Institution Assessment • Midwife Teacher Assessment • Curriculum Assessment • Student Midwife Assessment • Health Facility Assessment • Midwife Self Assessment

A copy of all tools is provided in the appendices of this document.

The tools that listed key skills and competencies (the midwife teacher tool, the student midwife tool and the clinical midwife tool) were developed and tested in a previous review of midwifery in Cambodia and Mongolia, where the validity of the tool was tested and shown to have a good correlation with observed and tested competencies (Sherratt et al., 2006). They were based on the ‘Essential Core Competencies of a Midwife’ developed by the International Confederation of Midwives (ICM). The ICM is the only professional association that solely represents the voice of midwifery globally, having over 89 member Associations in 86 countries, and is a member of the new global Partnership for Maternal, Newborn and Child Health. The ICM core competencies were developed through a rigorous Delphi study, that included representatives from both member and non-member countries, many of which were from developing countries. In addition, the ICM competencies are in-line with the essential competencies required of any skilled attendant, as agreed by international consensus and published by the World Health Organisation.

Tool 1. Education Institution Assessment Tool

The education and training facility assessment tool was used in a ‘walk through’ assessment of the educational establishments that were visited. This 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. See Appendix 1 for a copy of this tool.

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Tool 2. Midwifery Teacher Questionnaire

A simplified education audit tool was used to gather data on midwifery teachers’ experiences and competencies. All midwifery teachers in the four institutions were asked to complete a self reporting questionnaire that sought details on their educational qualifications, clinical experience as a midwife and identified barriers to work performance. They were also asked to address a range of educational and clinical competencies required to practice all clinical midwifery skills to mastery level. See Appendix 2 for a copy of this tool.

Tool 3: Curriculum Evaluation Tool

This tool provides a framework to comprehensively assess programs of education for the preparation of midwives to become competent to practise to an agreed, or understood, scope of practice. The tool compares programs against a generic curriculum and includes information regarding the process in which the curriculum is developed, entry requirements, student teacher ratios, regulatory requirements, educational theories used, teacher requirements, quality of graduate attributes and quality assurance procedures. See Appendix 3 for a copy of this tool.

Tool 4: Student Midwife Assessment Tool

A self reporting questionnaire was given to as many students as possible to gain their experiences of their midwifery training, including their experience of clinical exposure and supervision. The tool also measured their level of confidence in over 45 clinical skills in the area of midwifery and child health. See Appendix 4 for a copy of this tool.

Tool 5. Health Facility Assessment Tool

The health system environment in which health personnel work is known to affect their performance. A simplified ‘walk-through’ assessment was made of all facilities visited. The purpose of this ‘walk-through’ assessment was to identify major challenges to the performance of the midwives. The walk through assessment was a simple checklist which focused on identification of key equipment, resources required for practice, general cleanliness and hygiene of the facility, water and sanitation facilities, infection control and waste management practices. See Appendix 5 for a

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Tool 6. Midwife Self Assessment Tool

A tool was also developed for clinical midwives to determine their level of skill and confidence in a number of areas. It was considered necessary to attempt to ascertain if clinical midwives were competent in key areas necessary to provide safe, high quality care to women and their families as this workforce is often the most influential in the learning of midwifery students and new graduates. Over forty essential midwifery competencies, from the list of core competencies developed by the ICM were chosen for assessment. Respondents were given five answer options, which included whether or not they had learned the skill and if they felt confident or not to practice the skill. The competencies included in the tool focused on those most needed to reduce maternal and infant mortality and morbidity. See Appendix 6 for a copy of this tool.

Focus Groups Discussions

To compliment the information gained from the self assessment tools, Focus Groups Discussions were employed to obtain further qualitative data on the experiences and perceptions of the different groups involved in midwifery education and health services. Wherever possible midwives, students and educators were interviewed in individual groups and asked questions particular to their area of expertise and experience.

Stakeholders and Key Informants

Meetings were held with as many stakeholders and key informants that the NDoH and WHO partners could identify and, could be accommodated within the time frame available for data collection. Semi-structured interviews were conducted with key informants around their impressions of maternity services and midwifery in PNG, the difficulties and challenges that currently exist for maternity services including the recruitment of midwives, the quality of midwifery graduates, clinical supervision for students and how they believed midwifery could be strengthened.

Desk Review

A review of pertinent reports and curriculum documents was conducted. This included: the National Health Plan 2000-2010; the Strategic Plan for the PNG Health Sector 2006-2008; the Minimum Standards for Health Facilities document; the

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Midwifery Programs; and the curriculum documents in all four institutions that provide midwifery education in PNG.

Data Analysis

The limited time of the review and the number of tools did not permit sophisticated statistical calculations. The statistical package (SPSS) was used for data analysis of the midwife, student midwife and midwifery teacher self-assessment tools. Thematic analysis of discussions with key stakeholders and the focus group members was performed.

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Section 3. Results

Overview

The major results of the review have been presented under the following sections: • Stakeholder and Key Informants responses

• Midwifery Education: facilities, teachers, curriculum • Midwifery Students

• Health services

• Regulation and accreditation of midwives and midwifery programs

Site Visits

A list of the health facilities and the educational facilities that were visited are listed in the table below.

Table 1: Site visits

Education Institutions

Location Institutions/organizations

Port Moresby University of Papua New Guinea Pacific Adventist University

Madang Lutheran School of Nursing, Divine Word University

Goroka University Of Goroka

Health Facilites

Port Moresby Port Moresby General Hospital

Six Mile Urban Health Centre

Mandang Modilon General Hospital

Madang Town Clinic

Yagaum Rural Health Centre Mugil Rural Health Centre Nobonob Aide Post

Goroka Goroka Base Hospital

Asaro Health Centre Village in Asaro District

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Stakeholders and Key Informants

A total of 68 people were interviewed as stakeholders and key informants who had been nominated by NDoH and WHO as important to the review. The list of these individuals can be found in Appendix 7.

Key Findings of Stakeholders and Key Informants

Results around questions specific to the participants’ area of expertise in relation to the Terms of Reference are documented further in the relevant sections of this report. This section reports on overall impressions of stakeholders and other key informants around the following prompt questions:

• What were their impressions of maternity services and midwifery in PNG; • The difficulties and challenges that currently exist for maternity services; • What were the key issues around:

• The recruitment of midwives; • The quality of midwifery graduates; • Clinical supervision for students, and;

• How they believed midwifery could be strengthened.

The following points summarise the key findings from discussions from stakeholders and key informants

• There are currently insufficient midwives in PNG.

• The numbers of midwives currently being trained will not address workforce shortages.

• Poor maintenance of health facilities is affecting the ability to attract and maintain staff and to provide high quality and safe care.

• Essential medical supplies and equipment are often not available even though the central warehouse has supplies available.

• Many women are not seeking health services for care during pregnancy and childbirth.

• Midwifery education in PNG was once considered the best in the West Pacific Region but is no longer producing the same calibre of midwife.

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• The current education programs preparing midwives do not provide enough time in the clinical area.

• The supervision of student midwives in the clinical area was insufficient. • That some of the midwifery teachers were not clinically competent.

• Some stakeholders believed that the midwifery and paediatric strands should be separated.

Further findings from stakeholder and key informant interviews will be included in the relevant sections of the report.

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Section 4: Midwifery Education

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

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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

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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

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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.

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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

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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

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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.

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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

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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

Figure

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References

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