PAPUA NEW GUINEA MIDWIFERY EDUCATION REVIEW FINAL REPORT

Transcription

1 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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3 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 Data Analysis...22 PNG Midwifery Review Final Report iii

4 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 Conclusion...60 Section 5. Student Midwives...61 PNG Midwifery Review Final Report iv

5 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 Appendix 4: Student Midwives Surveys Appendix 5: Health Facility Assessment Tool Appendix 6: Midwife Self-Assessment Tool Appendix 7: List of Stakeholders and Key Informants PNG Midwifery Review Final Report v

6 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 Table 12: Summary of demographic data on clinical midwives...79 PNG Midwifery Review Final Report vi

7 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 Figure 4: Confidence of midwives in maternity emergencies...81 PNG Midwifery Review Final Report vii

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9 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. This Review was made possible by funding from WHO. PNG Midwifery Review Final Report ix

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11 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 PNG Midwifery Review Final Report 2

12 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 weeks. Many of the stakeholders and key informants supported the concept of the combined program, particularly for those staff working PNG Midwifery Review Final Report 3

13 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. Given that most of the births in PNG are attended by Community Health Workers (CHWs), the role of the midwife needs to be strengthened as an educator within their PNG Midwifery Review Final Report 4

14 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 not received subsequent communication. PNG Midwifery Review Final Report 5

15 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 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 clinical supervision to be registered midwives. PNG Midwifery Review Final Report 6

16 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. 21. Extend the capacity to train midwives through distance learning. PNG Midwifery Review Final Report 7

17 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 ( 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. Regulation of midwives can be strengthened by: PNG Midwifery Review Final Report 8

18 27. Process the registration for all students who have graduated from nursing and midwifery programs since 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. PNG Midwifery Review Final Report 9

19 Section 1: Background Midwives are recognised in most countries where they exist as the front-line caregivers 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 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) PNG Midwifery Review Final Report 10

20 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; PNG Midwifery Review Final Report 11

21 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 PNG Midwifery Review Final Report 12

22 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 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 serviced by Health Centres with some of the smaller villages having an aid post. PNG Midwifery Review Final Report 13

23 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 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 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 Healthy children PNG Midwifery Review Final Report 14

24 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 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). PNG Midwifery Review Final Report 15

25 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. PNG Midwifery Review Final Report 16

26 This work therefore involved close consultation and collaboration with key stakeholders and partners including education and health service providers. PNG Midwifery Review Final Report 17

27 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 PNG Midwifery Review Final Report 18

28 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. PNG Midwifery Review Final Report 19

29 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 copy of this tool. PNG Midwifery Review Final Report 20

30 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 ; the Strategic Plan for the PNG Health Sector ; the Minimum Standards for Health Facilities document; the National Framework for the Accreditation, Monitoring and Evaluation of Nursing and PNG Midwifery Review Final Report 21

31 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. PNG Midwifery Review Final Report 22

32 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 Port Moresby Madang Goroka Institutions/organizations University of Papua New Guinea Pacific Adventist University Lutheran School of Nursing, Divine Word University University Of Goroka Health Facilites Port Moresby Mandang Goroka Port Moresby General Hospital Six Mile Urban Health Centre Modilon General Hospital Madang Town Clinic Yagaum Rural Health Centre Mugil Rural Health Centre Nobonob Aide Post Goroka Base Hospital Asaro Health Centre Village in Asaro District PNG Midwifery Review Final Report 23

33 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. PNG Midwifery Review Final Report 24

34 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. PNG Midwifery Review Final Report 25

35 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 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 reestablished 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 PNG Midwifery Review Final Report 26

36 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 PNG Midwifery Review Final Report 27

37 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 PNG Midwifery Review Final Report 28

38 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. Findings across the four institutions are summarised in the table below. PNG Midwifery Review Final Report 29

39 Table 2: Education Facility Assessment Criteria UPNG PAU LUTHERA N UOG Graduates produced in 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 PNG Midwifery Review Final Report 30

40 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 enrolled. These rooms had no power for several months this year, is poorly ventilated PNG Midwifery Review Final Report 31

41 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 wellprepared 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. Teachers should also be aware of international initiatives, guidelines, education PNG Midwifery Review Final Report 32

42 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 Midwifery Toolkit questionnaire, developed and validated in similar countries. PNG Midwifery Review Final Report 33

43 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 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 PNG Midwifery Review Final Report 34

44 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. Each midwifery program will now be discussed individually. PNG Midwifery Review Final Report 35

45 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 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 postregistration 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 PNG. Although each subject outline is reasonably comprehensive and provides aims, objectives, contents, semester timetable, assessment details and clinical competencies where relevant, the overarching framework of the curriculum is limited. It includes an overall aim of the Bachelor of Clinical Practice (encompassing the specialist streams of midwifery/paediatrics, mental health and acute care nursing), but does not include an educational philosophy, program aims or other key program information. The theoretical component is comprised of eight, seven week subjects of six hours per subject per week. Subjects are listed in the table below: PNG Midwifery Review Final Report 36

46 Table 4: Theoretical Subjects at UPNG Semester One Applied Research in Nursing (Core*) Semester Two Nursing Ethics and Legal Aspects (Core*) Nursing Management and Leadership Skills (Core*) Antenatal Care and Reproductive Health (Specialist^) Child Health (Specialist^) Community Assessment and Rural Health Field Practice (Specialist^) Paediatric and Neonatal Nursing (Specialist^) Labour management and Postpartum Care (Specialist^) *Core subjects indicate subjects shared by other specialist strands and are not specific to midwifery. ^ Specialist subjects indicate those speciality subjects unique to the midwifery program. Given that three of the eight units are generic subjects, the theoretical time dedicated to midwifery is reduced to 210 hours. This is equivalent to 6 weeks at 35 hours per week. The WHO curriculum recommends 8 units or modules that cover the life-cycle of the woman and includes care of the child up to five years of age. Whilst the importance of topics such as research and ethics are not discounted, these aspects would be more useful if embedded within midwifery subjects as provided in the WHO modules. The practical component of the program consisted of 20 weeks (35 hours per week): 5 weeks in a rural facility and 15 weeks in a hospital or urban health facility. This results in a theory/clinical ratio of 50:50. However students on the program reported that many of them did not have this much time in the clinical area but the review team were unable to determine the reasons some students appeared to get more clinical time than others. Furthermore, due to the merger of the paediatric and midwifery programs, much of the clinical time was spent in paediatric areas such as Children s Outpatients department and the Children s Ward (see Student midwives, Section 5) which restricted the available time they had to spend in midwifery areas. PNG Midwifery Review Final Report 37

47 Pacific Adventist University PAU has offered a four year Bachelor in Health Sciences since 2004 with the Maternal and Child Health Nursing stream being first offered The first three years are offered as a Diploma of Nursing as undergraduate preparation for general nurses with the fourth year offering specialist streams in Maternal and Child Health Nursing, Rural and Community Health, and Acute Care Nursing. As with the UPNG program, midwifery is offered in a double major format with a combination of midwifery and paediatric streams. Registered Nurses are admitted to the fourth year of the bachelor if they have a existing diploma or degree. This excludes nurses who were educated in the hospital system, unlike the other three institutions who accepts these applicants. Although PAU has the capacity to admit 15 students in the Maternal Child Health Stream they have only been able to attract 7 students in 2005 and 8 students in The criteria for applicants to hold a existing diploma may limit the numbers of students PAU can attract to their midwifery program. Students are required to complete 10 subjects including two relevant electives drawn from fourth year nursing subjects or acceptable subjects from other disciplines of the University. The subjects of the Maternal Child Health stream are presented in the Table 6 below. Table 5: Theoretical Subjects at PAU Semester One Advanced Paediatrics I (Specialist) Advanced Obstetrics I (Specialist) Theories of Nursing (Core) Parish Nursing (Core) Elective Semester Two Advanced Paediatrics II (Specialist) Advanced Obstetrics II (Specialist) Health Care Management and Organisation (Core) Family Health Nursing (Core) Elective As in the UPNG program, much of the theoretical component of the program is not specific to midwifery or child health. A breakdown of the theoretical hours per subject was not provided. Total theory as recorded in the curriculum document is 569 hours, equivalent to 16 weeks (in 35 hour weeks) over the two semester program. This PNG Midwifery Review Final Report 38

48 includes lectures and tutorials. An additional 682 hours (equivalent to 18.5 weeks of 37 hour weeks) is spent in the specialty clinical areas of midwifery and child health and 74 hours (2 weeks) in management. Practical experience is obtained 2 days per week in the academic semester and a further 8 week clinical block between semester one and two and 4 weeks at the end of semester two. The program takes a total of 40 weeks to complete. This calculates to a theory clinical ratio of 50:50. The PAU midwifery curriculum is embedded within the four year bachelor degree comprised of the three year undergraduate diploma and the fourth year of speciality streams. It is therefore difficult to identify a specific midwifery philosophy or context. Lutheran School of Nursing, Divine Word University, Madang The Lutheran School of Nursing developed a midwifery course in 2003 and have just completed their third year of the midwifery program producing approximately graduates per year since The 40 week program runs over one academic year but unlike the other three midwifery programs in PNG, this one does not combine paediatrics and is only focused on maternal and newborn care. Temporary approval to run the program was granted from the Nursing Council. However, further clarification regarding some aspects of the curriculum were delivered to the Lutheran School. The School addressed each of these issues in a reply to the Council. However, further response has not been forthcoming despite frequent requests by the School including making appointments with the Council when visiting Port Moresby. Staff at the Lutheran school reported significant concerns over the inability to achieve registration by the Nursing Council for graduates of both the three year diploma nursing program and the midwifery program. Despite attempts to determine the requirements of the Nursing Council to achieve registration for its graduates, and the development of materials specific to these requirements (such as a clinical portfolio for each student), no graduate has been registered from either program since PNG Midwifery Review Final Report 39

49 Overall the Lutheran School curriculum is more contemporary that the others reviewed. Although it does not state to support the international definition of a midwife, it clearly articulates a comprehensive model of midwifery care that incorporates women s centred care, working in partnership with women and working under the principles of primary health care. It also incorporated contemporary teaching and learning styles such as the use of case studies and research activities in the area of maternal and child health. Furthermore, unlike the other programs reviewed, this course offers each subject that is situated within a midwifery context. The subjects in the midwifery program are listed below in table 5. Table 6: Theoretical Subjects at Lutheran School of Nursing Semester One Foundation Studies Christian and socio-cultural factors and their impact on health Foundations in midwifery The neonate Semester Two Promoting Health through education and research Clinical leadership and management Advanced Midwifery Community midwifery and women s health issues The only additional subject area that would compliment the Lutheran program and assist the new graduates provide more effective care to women and children in PNG would be to incorporate some topic areas that address growth and development and common childhood illnesses for children up to five years of age. The incorporation of some child health that is community focused (not hospital) is supported by the WHO curriculum. Clinical experience is gained over 20 weeks, delivered in two 10 week blocks in the latter part of each semester. A total of 14 weeks of this time is spent in labour ward, unlike the small amounts of time other students receive from other institutions. Unlike the PAU and UPNG students, Lutheran students are not required to spend time in PNG Midwifery Review Final Report 40

50 rural health centres. The rationale given for this was that the students were mostly from rural health centres and had extensive experience in this context. It was believed that it was more important for the students to gain clinical experience in hospitals under the supervision and expertise of senior midwifery and medical staff. Students are provided with a detailed logbook to record their clinical activities. Although the students are only required to sign off up to five episodes of many of the competencies, staff encouraged them to achieve many more. The competencies were well linked to the Midwifery Competencies released by the Nursing Council in The Lutheran School currently support two fulltime midwifery teachers. These teachers visit the students on a daily basis in the clinical areas, however did not work continually with these students at this time, relying on staff in the clinical areas to provide this. Students are placed in a number of hospitals around the area in an attempt to more adequately spread the placement of student midwives across the area and decrease the demands the students would place on midwifery staff in the Modilon Hospital in Madang. The entry criteria for entrance into the midwifery program was as a Registered Nurse licensed with the Nursing Council and a 1000 word essay outlining why they wanted to become a midwife and also demonstrating adequate writing skills. Lutheran School staff spoke highly of their program and believed it produced high quality graduates. Whilst the amount of time in clinical practice was considered better than most of the other programs in PNG, they reported that they were considering increasing the time of the program to 18 months to further consolidate clinical skills. They discussed increasing the student numbers to 40 from the 22 they currently accepted and believed they had the accommodation and classroom infrastructure to support this increase. However they believed they would require additional teaching staff, particularly in the area of clinical supervision. This would result in one intake every two years with the students completing after 18 months and the next six months of the calendar year being spent on material revision and development. PNG Midwifery Review Final Report 41

51 The facilities of the School were adequate with a large classroom and adequate library resources for a country with limited resources. A computer laboratory of 25 computers provided student with good computer access. However these computers were not connected to the internet and students and staff were required to visit the Divine Word University in Madang to access Internet facilities at a cost of K15 per hour of use. University of Goroka In 2004 UOG began to develop an 18 month double major in maternal child health as a post graduate diploma. However this required applicants to hold an existing bachelor s degree and when it became apparent that there would be insufficient numbers with such a qualification the program was altered to become a 12 month Bachelor in Clinical Maternal and Child Health. This would allow hospital trained nurses to be eligible to apply and thus increase student numbers. The 12 month Bachelor in Clinical Maternal and Child Health was first offered in September 2005, with the first intake of 11 students completing the program in September In addition, a further 24 students commenced a second program in July 2006 and a third intake is expected to commence in January A copy of the curriculum document was sent to the Nursing Council in December 2005 but as yet (December 2006) no further correspondence has been received from the Nursing Council. Therefore formal approval to run the course has not been given; however, NDoH instructed GOH to proceed with the program. The UOG program is a 52 week program, providing significantly more time than the other one year programs that are in fact only 40 weeks. However a total of 16 weeks of the UOG program consists of the training of village volunteers in child health (8 weeks) and maternal health (8 weeks). At the beginning of the program, each student is appointed a village volunteer who comes into Goroka and undertakes training, by the student (who is prepared for this teaching role prior to them coming) in both maternal and child health. Each student then spends two, four week clinical blocks in the volunteers village where they work in partnership with the volunteer. The student undertakes a situational analysis of the village and attends community development PNG Midwifery Review Final Report 42

52 activities to strengthen community functioning. Students, volunteers and university staff visit each family in the home and undertake a full assessment. However they do not have access to any resources or medical supplies such as blood pressure machines or drugs. They therefore refer any resident to the nearest health facility should they detect a problem requiring further care. This component of the UOG program provides a much stronger focus on community and primary health care than the other training institutions in midwifery. However, their effectiveness could be strengthened if they were given access to basic medical equipment and supplies. Regardless of this the students gain a much greater insight into some of the causes of ill health as well as the community benefiting from health assessment, education and promotion. UOG is commended for developing this innovative model and it is recommended that it be considered by other institutions. However this placement is provided at a cost of reduced clinical time in the hospital. Many of the first intake of students were hospital-based, and were experienced clinicians in their relevant specialist field (midwifery or paediatrics). This could have been a strategy to upgrade hospital staff initially to provide appropriate levels of leadership for subsequent student intakes. It appears the subsequent intakes of students will comprise a higher percentage of rural nurses. The theoretical component of the program offers twelve subjects summarised in the table below. Of these 12 subjects only four of these subjects are specific to midwifery and the theoretical hours allocated to each subject was not provided. PNG Midwifery Review Final Report 43

53 Table 7: Theoretical subjects in UOG program Semester One Foundations in Child Health Advanced Child Health Professional Issues in health care English for post vocational training Communication in health care Community/Rural/Urban child health issues Semester Two Foundations in Maternal Health Advanced Maternal Health Health Research Academic Writing Community/Rural/Urban maternal health issues Neonatal Clinical time in the hospital consists of two weeks of clinical placement every month, except when the students are placed in the rural village for a total of eight weeks. The clinical time in the hospital is divided between labour ward, postnatal ward, antenatal clinic, special care nursery, family planning clinic, HIV ward, childrens outpatients, and children s ward. The child health placements are provided in the first semester with the maternal health ones occurring in the second semester. A clinical timetable was provided to the review team and it was calculated that each student receives approximately only three weeks in labour ward. The staff reported that depending on the needs of the students, this timetable is flexible and students can be moved to areas where more experience is required. It still appears the amount of time in labour ward remains inadequate. Improved exposure to labour ward could be achieved by decreasing the time spent in other areas, such as SCN, children s outpatients, and children s wards. It was also suggested to staff that given that most maternal and childhood mortality occurs in pregnancy, birth or within the first 28 days, that the maternity component of the program extend longer than 6 months by reducing the total time in paediatrics or increasing the overall length of the program. Similarly, whilst the village volunteer training and residential component is considered to be an innovative and important component of the program, the time allocated to these activities could be reduced from 16 to 8 weeks and would still retain its usefulness. PNG Midwifery Review Final Report 44

54 At the time of the review, the current intake of 24 students were only halfway through their program and there is an additional intake of up to 40 students commencing in January. There is significant concern that there are insufficient resources provided in the program to adequately support this large number of students, particularly for clinical and village placement. Clinical placement is currently only provided through the Goroka Base Hospital and with the large increase in student numbers anticipated, other hospitals will need to be approached to provide clinical placement, though this will be reliant on appropriate clinical supervision being available. Distance education Currently UPNG is developing a midwifery program that is appropriate for distance mode of delivery. This would result in students in rural areas being able to undertake the midwifery program with access to local hospitals for clinical supervision. However for such a model to be successful, local hospitals must have the capacity to support students in the clinical area, including specific preparation for clinicians to support students. This could be possible through the preceptor program currently available through NDoH. It is also recommended that if distance programs are to be available, that students travel to the university offering the program for a minimum of one week intensive block in each semester of study. Curriculum Analyses The program of education for midwives must prepare midwives who are competent to practise to an agreed, or understood, scope of practice. The Midwifery Toolkit developed by WHO includes a generic curriculum which translates the international definition of a midwife into an education program which can be adapted for use in any country. A number of other documents underpin this curriculum including the WHO Mother-Baby Package (WHO), the ICM core competencies (ICM, 1999a), the ICM Code of Ethics for Midwives (ICM, 1999b) and the other documents in the Strengthening Midwifery Toolkit. The curriculum outlined in the Toolkit identifies the essential bases for practice, irrespective of how midwifery education is offered in a country s educational system: whether as direct entry, as part of a nursing program, or post-basic program following nursing (WHO, 2006b). PNG Midwifery Review Final Report 45

55 The WHO curriculum has clear minimum requirements for clinical experience in midwifery programs. This is considered one of the most important aspects of midwifery education to ensure that the students develop into competent practitioners on completion of the program. An analysis of the four midwifery curricula was undertaken. Comparisons were made with the curriculum that is outlined in the Midwifery Toolkit: Developing a Midwifery Curriculum for Safe Motherhood (WHO 2006). A summary of the curricula for all four institutions providing midwifery education is provided in the table below PNG Midwifery Review Final Report 46

56 Table 8: Curriculum Evaluation Criteria UPNG PAU LUTHERAN UOG The curriculum has been reviewed and revised in the last five years Yes Yes Yes Yes Minimum entry requirement (for post registration) courses) is: Registration or Licence to practice nursing, good health, commitment to women s Yes NO Yes Yes health Teacher student ratio has been agreed and conform to national norms Yes Yes Yes Yes Not The curriculum is approved by the Midwifery NO Yes Yes form Regulatory Authority al The curriculum is delivered in, or has the approval of an appropriate educational body/institution Yes Yes Yes Yes The curriculum is at the educational level equivalent to the curriculum of other health care Yes Yes Yes Yes practitioners The curriculum is based on sound educational theories of adult learning that fosters the critical???? Yes Yes thinking and problem solving of students The curriculum has a clear philosophy of midwifery that values midwives working with women in a partnership and recognising that NO NO Yes Yes childbirth is a natural life event for most women The curriculum is organised to ensure students can link theory to practice. Practice placements allow them to practice what they have been taught in the Yes Yes Yes Yes classroom The curriculum is lead by an experienced midwife teacher who has a background in midwifery and Yes Yes Yes NO has been trained as a teacher Teaching and learning resources are adequate and expose students to recent research findings Yes Yes Yes NO PNG Midwifery Review Final Report 47

57 Students have opportunities to practice in the clinical area under the direct supervision of an experienced midwife and have their practice assessed On completion of the education program midwives are able to practice as autonomous/self directing practitioners (able to practice as outline in the International definition of a midwife) On completion of the education program midwives are able to practice as a fully participating member of a multi-disciplinary team On completion of the education program midwives are able to provide midwifery care in any setting, community, clinic, health facility hospital or home On completion of the education program midwives are able to provide all essential life saving skills to both women and the newborn All assessments are clearly identified in the curriculum and assessment points are known to the students Clear criteria has been set for all theory and clinical assessments All assessors, including clinical assessors have been specially prepared for their role The curriculum has a clear and transparent Quality Assurance mechanisms, students able to give feedback to teachers Student records ensure that individual progress can be tracked throughout the program. Not consistently students often attend normal births unsupervised NO NO Yes NO Yes Yes Yes Yes NO NO Yes NO NO NO NO NO Yes Yes Yes NO Yes Yes Yes Yes Clinical midwives are often used to assess students and most have not undertaken preceptor training. Yes Yes Yes Yes Yes Yes Yes Yes * required but approval by the Nursing Council has not been obtained Discrepancies against any of the items listed in the above table will now be further elaborated. PNG Midwifery Review Final Report 48

58 Entry Criteria The entry criteria for admission to the midwifery programs was not consistent over the four institutions. PAU required nurses with hospital based certificates to upgrade to a diploma level prior to admission and the other three accepted hospital trained nurses but required 2-3 years experience as a registered nurse, some with experience in the specialty area. This is not supported by international recommendations which state that registered nurses need only be in good health and demonstrate a commitment to the area of women s health. Approval by Regulatory Authority 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. UOG submitted their curriculum over twelve months ago but have not received formal approval to provide the program. There appears to be considerable tension between UPNG and the Nursing Council with the UPNG staff reporting that the Council was involved in all advisory bodies overseeing the curriculum development, and the Council reporting that UPNG has failed to answer numerous written requests for document submission. The other institutions claim that they have attempted to provide the necessary information to the Nursing Council to facilitate the process of their students receiving registration, but claim lack of communication from the Council and ongoing problems with their students receiving registration. The consequences of this communication breakdown is that graduates from all midwifery programs over the past several years (the exact number was unable to be determined) are currently practicing without registration. These issues will be further discussed in Section 7 on Regulation. Educational Theories and Critical Thinking Although all of the curricula reviewed documented a range of teaching and learning strategies and principles of adult learning and problem based learning, it was difficult to establish how effective these strategies were to develop critical thinking and reflective practice. On discussions with clinical midwives and graduates of the programs, clinical practise appears to remain task oriented. Stakeholders reported that early identification of complications were often not optimal. Critical thinking allows clinicians to more appropriately identify risk factors and early deviations of normality PNG Midwifery Review Final Report 49

59 and can be promoted in education programs through the use of case studies, role plays, case review and case management. Midwifery Philosophy Two of the four curricula reviewed (UPNG and PAU) situated their midwifery programs within general nursing curricula. This fails to specify the unique role of midwives in line with the international definition of the midwife. Fundamental to midwifery practice is the relationship the midwife has with the woman, which should be based on partnership, to ensure the well being of the childbearing woman and her baby. To do this, midwives must believe in the woman s ability to assume responsibility for her health and that of her families and through partnership become more empowered. This professional ethos is often seen separate to nursing philosophies, which is often situated within an ill-health model of curative care. Clinical Supervision Although all institutions reported sending their teachers to the clinical field to supervise students, this appeared to be in an adhoc manner in most placements, although PAU appeared the most formalised. It is acknowledged that at some institutions there are insufficient numbers of education staff to be with all students at all times. However there was a concern that most of the normal births the students were conducting, were done so unsupervised by any staff, clinical midwife or education staff. Ability to Practice Autonomously, in any Setting, with Life Saving Skills With 85% of people in PNG living in the rural areas, many graduates will return to work in these areas, often as the most senior clinician in maternity. Many of the students were proficient at normal pregnancy and birth prior to entry to these programs. The greatest need of the programs is to prepare the students to deal with the complications that may arise, and the review team felt this was not achieved consistently across the four institutions, particularly the combined midwifery and paediatric programs. PNG Midwifery Review Final Report 50

60 Clinical Assessors Student midwives rely on clinical midwives to assist in supervision, teaching and assessment. The NDoH has developed a training package on Preceptor training and ran a number of courses in Some of the staff working in the facilities had undergone this training, though most had not. There appeared to be some problems with accrediting this program and hence no training was offered in It is believed that approval has now been given to run the program and it is hoped that it will recommence training in 2007 which will assist health staff in clinical teaching, mentoring and assessment. Comparisons with PNG programs and International standards A further summary of the four programs, measured against international standards is provided in the table below. PNG Midwifery Review Final Report 51

61 Table 9: Comparisons between the four curricula and WHO International Standards Criteria Length of program (post registration) Ratio Theory : Practice Curriculum model Minimum no. births evidence based practice, with foundation in Primary Health Care 20 (ideal 40 +) International Lutheran School of Nursing, UPNG PAU Standard Madang University of Goroka Minimum of 40 weeks with 3 40 weeks with one 40 weeks with two weeks holiday 52 weeks with 3 weeks holiday (double 18 months or weeks holiday weeks holiday (midwifery only) major) 78 weeks (double major) (double major) 40% : 60% 50% : 50% 50% : 50% 50% : 50% 40% : 60% Competencybased, Competencybased, Competency-based, Competency-based, midwifery philosophy not stated nursing philosophy, Christian values philosophy, primary health care, health promotion Verbally told 10 but space for 3 Space to record six 5 minimum though space to assessments in in clinical logbook record 45 in clinical logbook. clinical logbook Competency-based, primary health care, health promotion Not provided to review team PNG Midwifery Review Final Report 52

62 Clinical Practice Although all four programs report using competencies to assess students clinical skills, specific information regarding what competencies were required varied. No program reflected a comprehensive list of all essential skills and knowledge required to provide safe, high quality care to women and their families. The International Confederation of Midwives in partnership with WHO have prepared recommended midwifery competencies and the skills needed to achieve these competencies. These competencies articulate the skills and knowledge that midwives require in order to provide safe, effective care in pregnancy, childbirth and the postnatal period for care of mothers and newborns, and include the knowledge and skills necessary to achieve them. The skills have been divided into basic and the essential life-saving skills which are essential if the midwife is to make a difference to the outcome of pregnancy and childbirth to promote Safe Motherhood and make pregnancy and childbirth safer. These essential competencies also provide useful guidelines for those responsible for the education and training of midwives/midwifery practitioners. They also provide information for those in government and other policy arenas who need a deeper understanding of exactly what a midwife does and the education and training required to enable midwives fulfil their role. The competencies, which form the basis for good practice, are grounded in current research, where it is available. They are generic and need to be adapted within countries or regions to meet local realities and to correspond with new evidence as it emerges. Clinical assessments in the four institutions are based on the PNG Midwifery Competencies. With the exception of the Lutheran School of Nursing, the competency checklists and performance criteria are relatively reductionist, with little evidence of integrating the competencies into practice-based skills or performance cues. Three of the four institutions did not provide their students with a comprehensive clinical logbook. The Lutheran School of Nursing was the exception and provided a good example of a clinical logbook with useful cues or examples listed against the broader PNG Midwifery Review Final Report 53

63 midwifery competency statements. Although the Lutheran School was the most useful, and could be used as a template for all institutions, the overall numbers of most clinical requirements also need increasing in line with WHO recommendations. Adequate time in the clinical area is essential if student midwives are able to practice effectively following completion of their education program. Although the time allocated for clinical practice was between 50 and 60% of the overall program, the time is spent across paediatrics and midwifery and is generally insufficient. There were no minimum time requirements for each area of practice and some students spent only one week in labour ward over the entire program (see Section 5 for more information). Curriculum documents provided by the four institutions failed to provide detailed information regarding the amount of time spent in individual clinical areas. However it was determined that time spent in key areas such as labour ward was inadequate. It is most important that students become competent in life-saving skills. Ensuring the students are competent in these skills is critical for all midwifery graduates but particularly those who will return to practice in district hospitals and rural health centres. Overall the development of skills in complications and maternity and newborn emergencies was grossly insufficient. More information on clinical competence is provided in Sections 5 and 6. WHO have developed an outline on the minimal amount of clinical experience students should gain throughout the program. Some of these include: A minimum of 100 antenatal examinations. A minimum of 40 normal deliveries. Assist at 3 breech deliveries. Conduct a minimum of 3 vacuum extractions, under supervision. Perform at least one medio-lateral episiotomy. Perineal suturing on at least 3 women. Assess the condition of the newborn at birth and resuscitate, as required. PNG Midwifery Review Final Report 54

64 Examine 100 newborn babies, noting any abnormal conditions, and take appropriate and timely action. A minimum of 100 postnatal examinations, identify any abnormal signs or symptoms and take appropriate and timely action. Care for at least 100 postnatal women and their newborn infants, giving appropriate health education and advice, and providing the support, midwifery care and prophylactic treatments which are required. Assist mothers with breast feeding, as appropriate, and give correct advice and care to women who develop breast problems. Give emergency care, under supervision, to women with obstetric and gynaecological problems, eg abortion, ectopic pregnancy, ante and postpartum haemorrhage, prolonged, pre-labour rupture of the membranes, obstructed labour, retained placenta, eclamptic fits, puerperal sepsis. Management of shock. Cardio-pulmonary resuscitation on a model. Resuscitation of the newborn, first observation, then assistance and finally practice, under supervision. Liaise with the community in order to have an effective system to ensure that rapid referral is possible when complications occur and to make arrangements for referral, when required. Liaise with the community to give information about the health services which are available and devise and implement strategies to increase the uptake of care by a skilled attendant. Provide health education in the community and first level health facilities to pregnant women, families and to adolescents, with emphasis on good nutrition, healthy life-styles, immunizations, the avoidance of harmful practices, the prevention of sexually transmitted diseases and unwanted pregnancies. Liaise with schools, churches, mosques, women s groups and places of employment to provide appropriate health education. Provide information and counselling on safe sex and contraceptives at family planning clinics and provide women with the method of their choice and follow-up care. PNG Midwifery Review Final Report 55

65 Perform appropriate screening tests and give appropriate prophylactic treatments and/or immunizations, as required, e.g. for STIs, tetanus toxoid, anti-malarials, mebendazole, vitamin A if in deficient areas, iron/folate. Liaise with other health care professionals in the community to monitor the health and well being of mothers and their infants, the uptake of care and devise strategies together to further improve the quality and uptake of care and health facilities. Liaise with traditional birth attendants, spiritual healers and other untrained personnel in the community who are involved in care before, during or after childbirth in order to encourage safe practices, the acceptance of training opportunities where they exist, information on the early recognition of complications and the promotion of early referral when complications arise. It is clear that a number of these skills are not provided in the PNG programs. This outline should only be used as a guide, but should include the minimum where numbers are stipulated. In skills such as breech or vacuum, PNG may consider increasing these numbers as many midwives will work in facilities where they will be the most skilled provider of maternity services and higher level skills in complications such as breech, manual removal and vacuum are required. Some of the staff and students who participated in this review stated that it was difficult for students to access large numbers of births, particularly those with complications. However, the rostering of students in clinical areas often did not include night duty or weekends, though some students did make themselves available at these times. Improved access to the development of essential skills in maternity emergencies could be enhanced by more creative placement of students that included all shifts, including weekends and nights, and accessing other hospitals throughout PNG. Once the minimum number of births is determined, they should be included in Nursing Council guidelines and students who fail to meet these requirements will not be permitted to graduate until all skills are attained to the level of competent practice. A record of these skills needs to be included in each student s clinical logbook. PNG Midwifery Review Final Report 56

66 Combining Midwifery with Paediatrics As seen in this review, PNG has seen a recent trend to combine midwifery training with paediatrics. Whilst the overlap of these two areas is recognised, it is unlikely that competence would be gained in either area in the current time frame of weeks. Many of the stakeholders and key informants supported the notion of the combined program, particularly for those staff working in the rural areas. However, some informants recognised the clear shortcomings of the current structure and supported the reestablishment of two distinct programs. A significant number of students in the combined paediatrics and midwifery programs, particularly in the UPNG and UOG programs, were hospital based paediatric nurses. As such many had minimal experience as a registered nurse in maternity services. Their motivation to do the programs was not to become midwives, but rather to advance their skills in paediatrics. These students appeared much less competent to perform as midwives on completion of the program, though they no doubt increased their capacity as paediatric nurses. These nurses mostly returned to the paediatric areas in the hospital. Therefore targeting this part of the workforce to do the programs will do little to address the midwifery shortage in PNG. The WHO recommends that midwifery curriculum includes a child health component with the following subject headings Monitor nutritional status, growth and development Screening and developmental tests Nutrition of the young child, including weaning and food supplements Failure to thrive Signs of infection or illness Immunizations and other prophylactic treatments recommended for child 0to 5 years Advice given to mothers on the care of their child Serious conditions which require referral for expert consultation or treatment Organisation of referral to an appropriate referral centre where there is expert paediatric help. PNG Midwifery Review Final Report 57

67 It should be recognised that these components of child health are aimed to prepare midwives to care for children in the community setting and relies on specialist medical care for those children requiring transfer to hospital. Much of the paediatric components offered in the double majors in PNG appear to be focused on hospitalbased care with nurses being taught to do high order acute care skills such as lumbar punctures. It was beyond the scope of this review to determine if these skills are required in midwives in PNG, although many rural facilities do not have the laboratory facilities to deal with lumbar puncture specimens, which negates the need for nurses or midwives working in these areas to be competent in this skill. Recommendations for Midwifery Programs The results of the review found that there is a wide range of clinical experience offered to students across the four programs in the area of midwifery, particularly exposure to labour ward. The theoretical component was considered stronger in the midwifery-only program (offered through the Lutheran School of Nursing in Madang) than the other programs due to it s focus on midwifery only and the development of all subjects within a midwifery context. The other three programs share a range or 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 those students, educators and clinical midwives failed to demonstrate an indepth understanding of these events, particularly pre-eclampsia (See Sections 5 and 6). Apart from the Lutheran School program in Madang, the clinical components of the programs are significantly inadequate. More time is required in the key maternity areas of labour ward and antenatal clinic. A minimum number of procedures should be recommended across all institutions in line with WHO recommendations. Given that most of the births in PNG are attended by CHWs, the role of the midwife needs to be strengthened as an educator within their local health structure with a responsibility to supervise, mentor and teach the other cadres of health personnel currently providing services. PNG Midwifery Review Final Report 58

68 In summary, education programs in midwifery can be strengthened by: 1. Basing PNG programs on the WHO international curriculum, modified to meet the contextual needs of this country. 2. Increasing the length of the program to 12 months (52 weeks) for midwifery only with a 6 month additional component for child health/paediatrics. 3. 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. 4. 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. 5. Ensure that each student achieves all minimum clinical requirements before allowing them to graduate. 6. Improve access to clinical skill development through rostering of students on all shifts including night-duty and weekends, and also other hospitals in PNG. 7. All programs should develop a midwifery specific curriculum and not embed the program within nursing. 8. Subjects should be midwifery specific where possible. 9. The entry criteria be revised and standardised to incorporate international recommendations that accept registered nurses with hospital based certificates. 10. More attention be devoted throughout the program to develop life saving skills, particularly management of pre-eclampsia, eclampsia, and resuscitation of the newborn. 11. 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. 12. 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. 13. Extend capacity to train midwives through distance learning. PNG Midwifery Review Final Report 59

69 Conclusion Findings presented in this section suggest significant restructuring of midwifery education is essential to ensure graduates are suitably equipped to provide effective high quality care to women in PNG. There are many guidelines and materials available through WHO to assist in this process. PNG Midwifery Review Final Report 60

70 Section 5. Student Midwives Midwives who had recently completed their educational program were considered important sources of information regarding the quality and appropriateness of their training. Student midwives in the hospitals and educational facilities visited by the review team were asked to complete a student-midwife self assessment tool (see Appendix 4). It was considered necessary to attempt to ascertain if these new graduates were competent in key areas necessary to provide safe high quality care to women and their families. Forty six essential midwifery competencies, from the list of core competencies developed by the ICM were chosen for assessment (see Appendix 4). Respondents were asked to indicate if they felt confident in each of the skills listed. The tool was introduced by members of the review team and was completed anonymously. Due to the timing the review was undertaken (November-December 2006) many of the students had completed their program requirements and were not available for interview or assessment. For that reason graduates from both the 2005 and 2006 programs were included in the sample. The number of graduates from the four programs is summarised below: Table 10: Student Midwives Surveyed from 2005 and 2006 programs Institution Number of graduates UPNG 6 PAU 4 Lutheran 2 Goroka 9 Total 21 Essential Midwifery Competencies Results Of the 46 essential competencies listed, the students were asked to indicate if they felt confident in each area by marking a tick next to each skill. Most of the students ticked confident next to most of the normal skills. It can be seen by the figures below that the students surveyed reported high levels of confidence in most indicators in the PNG Midwifery Review Final Report 61

71 management of normal pregnancy and birth. The main exception was around HIV counselling, screening and management of HIV where only 14% of students indicated confidence. Of the other five indicators, there were some students who were not confident in basic midwifery skills such as antenatal examination, screening and management of sexually transmitted infections, active management of third stage and examination of the newborn. Figure 1: Student confidence in normal pregnancy and birth Normal Birth percent antentatal sti hiv counselling normal birth active management examination newborn confident not confident There was a much lower level in the confidence of students around the management of emergency skills, such as breech, cord prolapse, cannulation, manual removal of the placenta, resuscitation of the newborn and the management of eclampsia. These are seen in Figure 2 below. Figure 2: Student confidence in managing maternal emergencies Maternity emergencies percent cannulation breech cord prolapse newborn resus eclampsia pph mrop confident not confident PNG Midwifery Review Final Report 62

72 In addition to the assessment of competencies, the following data were also collected. Facility where they undertook midwifery education Work Experience prior to midwifery education Why they chose to train as a midwife If they were living away from their family to study Amount of clinical experience during the training program Did they have adequate supervision in the clinical area Did they have adequate support in the university If they thought the teachers at the university were up to date in midwifery Where they intended to work on completion of their training If they felt ready to care for women as autonomous practitioners All of the midwifery graduates were registered general nurses prior to undertaking their midwifery education. They had been taught about pregnancy and normal birth in their general nursing program. Many were experienced in antenatal care and normal birth, having been required to carry out these duties as a registered nurse, particularly in the rural areas. Their motivation to do midwifery was to develop skills and knowledge in the complications in pregnancy and childbirth and to reduce the maternal mortality and morbidity rates. Approximately half the students moved away from their families to undertake their midwifery training. Only PAU provided accommodation for married couples and families, and actually only accepted married students if their families were prepared to move to the Port Moresby campus with their spouses for the duration of the program. The amount of reported clinical practice time varied greatly amongst the students and often did not support the amount of time reported by the institution, though this may have been a misinterpretation of the question. The total documented clinical time ranged from 6 to 18 weeks with an average of 13 weeks, with Lutheran students reporting the most time in labour ward. Approximately 75% of the students believed they had not received adequate supervision in clinical practice and this was supported in the focus group discussions (see below). PNG Midwifery Review Final Report 63

73 With the exception of UOG students most other respondents reported that they felt adequately supported by the university and that they believed their midwifery teachers were up to date on relevant midwifery issues. UOG students unanimously identified inadequate support from both the university and in the clinical areas. Although they spoke highly of the paediatric component of the program, UOG students had no midwifery educator until the last four months of their program. They were particularly disadvantaged in the amount of midwifery education they received, including both theoretical and practical. UOG students also had very poor support from the university in terms of computer and internet access, library facilities and midwifery text books. All students reported unanimously that they felt capable of caring for women as autonomous practitioners but some stated they required more practice in complications. Focus Group Discussions Whist the results of the self reported student midwife assessment suggests high levels of confidence in most of the essential skills required to work effectively as a midwife, this was not supported by the information these students gave through the focus group discussions. It was believed that the students were reluctant to offer criticism of the program on paper (with the exception of UOG students) but were more likely to express their opinions verbally. Consequently students experiences were also elicited through focus group discussions. Overall the students did not believe they had adequate experience in the clinical area. Many of the students had experience in the provision of midwifery care, including birth, and expressed confidence in normal birth. However, they did not feel confident in their skills to deal with maternity emergencies. This is of particular concern for the students who were returning to rural and remote areas where some of them would be the only clinician with midwifery education. The poor level of supervision was evident in the amount of time some of the students spent in the birthing environment, the low number of births they attended, and the high percentage of births they did attend unsupervised by either a university PNG Midwifery Review Final Report 64

74 supervisor or a midwife. Many of the students who undertook clinical placement at PMGH reported competition for births with medical students and large numbers of midwifery and undergraduate students often being on the labour ward at once. However, it appeared the students usually only worked in daylight hours during Monday to Friday. Some students recognised that they would benefit from coming to the labour ward out of these hours and PAU students in particular spoke of working night duty. With approximately 1,000 births per month at PMGH, it seems inconceivable that students would have problems accessing adequate birth numbers and rostering of students should include all shifts including weekends and nights. The amount of time the students spent in labour ward also varied considerably with Lutheran students reporting up to 50 births and most UPNG, UOG and PAU students reporting 5-15 births. One UPNG student reported spending only one week in labour ward throughout her program. This student had no prior experience in caring for birthing women. The rural experience was also varied with many UPNG students being sent to run down health centres where no births occurred in the 4-6 weeks they were stationed there. The range and average of normal births and three essential life saving skills are provided in the table below. Competence in these skills is considered essential for students returning to rural areas with no other colleagues who had midwifery or obstetric training. Although Lutheran students reported much higher numbers of normal births, their experience in complications was similar to other institutions. However, it should be noted that only two Lutheran students were available for interview, due to the timing of the review. PNG Midwifery Review Final Report 65

75 Table 11: Range and average of key skills in midwifery Institution Normal Births Breech Vacuum MROP UPNG (6) 5-20 (ave 12) 0-5 (ave 2) 0-5 (ave 2) 0-5 (ave 2) PAU (4) (ave 15) 2-4 (ave 3) 3-5 (ave 4) 3-5 (ave 4) Lutheran (2) (ave 40) 2-4 (ave 3) 2-3 (ave 2) 3 (ave 3) Goroka (9) (ave 15) 0-2 (ave 1) 0-2 (ave 1) 0-1 (ave 0) The confidence of students in the university lecturers who supervised the students in the clinical area also varied. UPNG staff did not spend as much time with students in the clinical area as other institutions, although many students reported the lecturers tended to drop by rather than spend any time with the students. This was supported by clinical staff in the Port Moresby General Hospital. Some students reported a lack confidence in the clinical skills of the university staff, preferring to refer to the clinical midwife on duty. Others however, believed their midwife lecturers were clinically up to date. UOG students had the most limited midwifery support, largely due to the access of only one midwife teacher, who did not take up her position until 8 months into the program. Other UOG lecturers provided support in the clinical areas of midwifery but these lecturers were not midwives and the capacity to teach students in this speciality area was therefore limited. All students reported that some of the clinical midwives were very approachable and supportive whereas others were not supportive and the students felt reluctant to ask questions or seek support. Attitudes from health staff to women and their families is known to be an important factor in the provision of health services and has been identified as a problem within health services in PNG (Larsen et al., 2004, Garner et al., 1996). Attitudes to women were difficult to assess using the tools employed in this review. However, it was apparent that the UOG students were significantly more influenced in this area than other programs and it was believed this was due to the community development activity of volunteer training and residential placement within the volunteers village. UOG students reported this aspect of their education to be particularly beneficial with many students recognising they are now much more aware of some of the influencing factors of poor health and access to health services. Furthermore they believed they PNG Midwifery Review Final Report 66

76 were now much more empathetic to the situation of the woman which resulted in more sensitive and appropriate care. The students were questioned on their management of a number of clinical scenarios known to be essential for the provision of safe practice, particularly in the rural areas in the absence of more senior medical or midwifery staff. Responses from the participants revealed significant concerns in the level of competence in these key areas. The students were questioned on their knowledge around active management of third stage and the management of preeclampsia. On the topic of management of third stage, the students were unable to describe the difference between active and physiological management though on closer questioning it appeared they had been taught the mechanisms of active management. However there was some concern over the practice of stimulating the uterus before expulsion of the placenta. This practice was also confirmed in discussions with both educational and clinical staff and is discussed further in Section 6. When asked about the signs and management of preeclampsia, many of the students were not able to report that it was a multi-system disorder that could present in a number of ways. They recognised high blood pressure was a sign and that they should check the urine for protein but did not appear to recognise the other more dangerous signs of hyper-reflexivity or other neurological or multi-system indicators. The biggest concern held by ALL students was the issue of their registration. No student from any program in 2005 and 2006 had received registration at the time the review was undertaken. This caused significant distress in most of the students interviewed. Interviews with the review team appeared to increase this distress as some feared that if the review determined that the courses were inadequate they would never become registered. Issues around registration is further discussed in Section 7 Conclusion Information obtained from the students supported the findings in other components of this review. The clinical component is currently inadequate in the courses, particularly the combined midwifery/paediatrics programs. Although the students all considered PNG Midwifery Review Final Report 67

77 themselves capable of caring for women in pregnancy and childbirth, verbal responses to key questions around maternity emergencies did not support this. PNG Midwifery Review Final Report 68

78 Section 6. Health Services For graduate midwives to effectively provide high quality care to women and their families, they must be supported by a well functioning health service. Two decades of economic and structural reform have capped expenditure, restricted public budgets and resulted in generalised depletion of the health care workforce and the environments in which they provide care. Three hospitals, three rural health centres and one Aide Post were visited as part of this review (for full list see Table One in Section 3 of this report). Whilst a comprehensive review of health services was not included in the Terms of Reference a walk-through assessment was undertaken and some of the deficiencies identified that would influence the ability of midwives to reduce the high levels of maternal and child health morbidity and mortality. The facility assessment tool (Appendix 5) was used as a guide to assess the general condition and hygiene of the facility, water and sanitation facilities and infection control and waste management practices. Equipment Many key informants reported that the essential equipment and medical supplies were often not available and influenced the quality of care they were able to offer. Birthing bundles frequently ran out requiring staff to soak instruments in antiseptic solution for reuse on birthing women. Suture material was often not available and led to clinical midwives keeping their own supply of needles soaked in solution for use on perineal repair. Sphygmomanometers were often broken in labour wards and antenatal clinics resulting in the inability to monitor women s blood pressure, essential in the appropriate management of preeclampsia. Syntocinon and other oxytocics frequently were unavailable that would result in increasing rates of post partum haemorrhage and difficulties in managing haemorrhages when they occurred. The current system relies on the pharmacy to replenish supplies. It appears there is an urgent need to address the process. PNG Midwifery Review Final Report 69

79 Minimum standards developed by NDoH are not enforced and most health services do not have the resources or funding to implement the standards. Workforce Much of the maternity care for women in PNG is provided by non-midwives, namely registered nurses and Community Health Workers. This includes all hospitals, included the Port Moresby General Hospital, although a larger percentage of nonmidwifery care can be found in smaller hospitals and rural health centres. In the smaller rural health facilities visited by the review team CHWs provided all care to women and only when complications arose was a nurse or a midwife summonsed. Although the CHWs are acknowledged as having a wealth of experience and indeed, are the backbone of health services, serious concerns were raised on the quality of care women received when complications occurred. The opportunity to interview CHWs were limited as the review team were usually met by senior staff and when CHWs sat in on focus group discussions, they rarely spoke of their experiences or opinions of the service. On several occasions, more senior staff were not available and CHWs were questioned on the type of care they provided to women in childbirth. Although the numbers of interviewees was small, it was clearly apparent that the CHWs had limited knowledge on the causes or management of women with complications. If PNG is to address the high levels of maternal and perinatal mortality and morbidity, CHWs require closer supervision and more education on the early detection and referral of maternal complications. At each facility, the review team requested to see case notes for any labouring or postnatal women at the facility. Documentation was minimal and the level of care was of concern, particularly in the rural facilities. Observations were taken on each woman on admission to labour ward and included maternal temperature and pulse, fetal heart rate, strength and frequency of contractions and a vaginal examination. Often these were the only observations recorded for the duration of labour. Many of the women in rural facilities did not have a recorded blood pressure and the intramuscular administration of ergometrine was routine for management of third stage and each woman was placed on oral ergometrine three times a day for several days post PNG Midwifery Review Final Report 70

80 delivery. The administration of ergometrine is contraindicated in the presence of elevated blood pressure. In the larger hospitals, observations included blood pressure and appeared to be conducted more frequently than once on admission. Fee for service payment According to National Health Policy and the National Health Plan, all maternity services (antenatal, birth and postnatal) are supposed to be provided free of charge. However, as the National Department of Health has no authority over the provinces (due to the Organic Law) the Hospitals, Health Clinics and Aid Posts ignore the National Health Policy and set fees for these services. The fees vary though usually involve K10-20 for admission and K2-5 for outpatients appointments including antenatal clinics. In addition, some women were charged an extra fee for blood tests (K2). Although the fees appear minimal, they are likely to be unaffordable for many women in PNG and would act as a deterrent to access services. Maternal Complications and Life threatening emergencies In order to determine the appropriate response to and management of maternal obstetric emergencies educators, clinical staff and students were asked their opinion and management of two common maternal emergencies: PPH and pre-eclampsia. These two conditions were chosen as they are two of the most common causes of maternal mortality and both can be dramatically reduced with early recognition and prompt and appropriate management. Post Partum Haemorrhage Active management of the third stage of labour (delivery of the placenta) is known to significantly decrease the amount of blood lost during childbirth and is recommended by leading international agencies to be offered to women as part of routine management by skilled attendants in childbirth (ICM and FIGO, 2004). Active Management of the Third Stage involves the routine administration of a uterotonic agent following the birth of the anterior shoulder or immediately following the birth of the child. Signs of placental separation are then observed for (lengthening PNG Midwifery Review Final Report 71

81 of the cord and a small gush of blood) and the placenta is removed using controlled cord traction (Lalonde et al., 2006). The uterotonic agent of choice in PNG is syntometrine, which involves mixing of two solutions from two ampoules 5 units of syntocinon with 0.5milligrams of ergometrine, neither of which are refrigerated. The routine administration of syntometrine has been discontinued in many countries due to the higher side effects of ergometrine (nausea, vomiting and increase in blood pressure), contraindications for use with women with elevated blood pressure, and the need to store ergometrine between 2 and 8 degrees Celsius (requiring refrigeration). Oxytocin (syntocinon), however, can be stored between 15 and 30 degrees Celsius for up to three months (Hogerzeil et al., 1993). For these reasons, international agencies therefore recommend the use of oxytocin (syntocinon) as the drug of choice for active management of third stage (Lalonde et al., 2006). Furthermore, a recent Cochrane review found no advantage of ergometrine over syntocinon in the prevention of post partum haemorrhage of over 1000mls (McDonald et al., 2005) though a small though statistically significant difference with blood loss of between 500ml and 1000ml was found. With the current practice in PNG requiring the use of two ampoules, that the ergometrine is not stored according to international recommendations, and that some women do not have their blood pressure checked on admission to labour ward, it appears reasonable that the routine use of syntocinon only is considered. All educators, clinical staff and students were asked to describe their management of third stage. Most respondents were able to describe the steps of administration of syntometrine and controlled cord traction; although several students were unaware this was termed active management. However some respondents (educators, clinicians and students) discussed feeling for (or stimulating) the uterus to contract before delivering the placenta. At one of the institutions (UPNG) the clinical checklist to measure competence included a list of performance indicators for management of third stage. The first performance indicator is recorded as directing the student to rub the fundus to contract, prior to administration of an oxytocic or delivery of the placenta. This practice is not recommended and is actually harmful as PNG Midwifery Review Final Report 72

82 it can cause excessive blood loss resulting in a postpartum haemorrhage and for it to be formally taught to new students requires urgent attention. The frequency of practice of stimulating the uterus prior to expulsion of the placenta in the clinical area was difficult to determine. The review team, however, believe it is relatively common practice and should be discouraged through dissemination of an memo, development of a policy or whatever other action the NDoH believes will reach the maximum number of providers, including CHWs. When active management is not possible due to the lack of availability of uterotonic agents, physiological (or expectant) management of third stage is recommended. In focus groups with some of the new graduates, the students were asked what they would do if oxytocics were not available. They responded that they should continue to apply controlled cord traction to remove the placenta. This practice should be discouraged as physiological management of the third stage relies on no interference by the attendant other than putting the baby to the breast and ensuring the woman is an upright position to facilitate the expulsion of the placenta by the mother using physiological means. By continuing to apply controlled cord traction, the woman is at increased risk of PPH, particularly in the absence of available oxytocics that are also required in the management of PPH (ICM and FIGO 2004). Management of post partum haemorrhage commonly involves intravenous administration of an oxytocic infusion. When clinical staff and students were asked about the dose of syntocinon used in the infusion, hospital staff reported using 20 units per 1000 mls. Misoprostol is another drug available for the management of PPH and has proven to be very effective in stimulating a sustained contraction in a previously atonic uterus. Misoprostol is currently available in some health facilities in PNG though is primarily used for induction of labour. Although it is a Category A drug which can be ordered by all health care workers (PNG NDoH, 2002), current practice in PNG makes it unavailable for use by health staff other than doctors. In PMGH it is kept in the locked drug cupboard and requires the authorisation of a medical officer prior to administration. It is thought the restricted access of the drug is due to the risk of it PNG Midwifery Review Final Report 73

83 being used inappropriately for the termination of pregnancy. Misoprostol is quite affordable (similar to oxytocics), does not require refrigeration or IV access (given per rectum) and could have a significant impact on the prevalence rates of PPH if more widely available. Stakeholders also reported that retained placenta appeared to be a significant issue in the rural areas, often requiring expensive referral in the absence of a midwife or doctor, or worse, death by haemorrhage for the woman. Students access to performing manual removal of the placenta varied amongst the students with some students reporting no opportunity to learn this skill and others doing 2 or 3 throughout their practical experience. If new graduates are returning to rural areas with no other specialist support it is essential that they are competent to manually remove a placenta and this requires more exposure to the procedure within their midwifery program. It should also be noted that the high rates of retained placenta may in part be associated with the inappropriate management of third stage and if this was corrected, less women should experience the complication. Pre-eclampsia and Eclampsia Pre-eclampsia is a multi-system disorder of pregnancy and a common cause of maternal death in PNG and internationally. The most common presentation of preeclampsia is an elevated blood pressure (international definition being two readings of 140 systolic AND/OR 90 diastolic at least 30 minutes apart). However to meet the criteria of pre-eclampsia (and distinguish between conditions such as hypertension in pregnancy or pre-existing essential hypertension, the elevated blood pressure should be accompanied by at least one other manifestation. Usually this is proteinuria, due to renal impairment. Other signs of worsening pre-eclampsia include neurological signs: vision changes, frontal headache, and hyper-reflexia, liver involvement including a palpable, or tender liver, abnormal liver function tests, and blood dyscrasias indicating coagulopathies or haemolysis. Whilst generalised oedema can be a sign of preeclampsia, this is considered to be an unreliable sign, particularly given the fairly common presentation of lower limb oedema in normal healthy women. The staff of each facility was asked how often they saw women with pre-eclampsia and the review team was told it was seldom seen. Yet the available statistics state that PNG Midwifery Review Final Report 74

84 severe pre-eclampsia and eclampsia is one of the most common causes of maternal mortality. It was apparent that many of the graduating students and experienced clinicians had very little knowledge around signs of severe pre-eclampsia and the impression gained from the review team was that life threatening conditions did not receive adequate attention throughout the education programs, nor in the clinical areas. When asked what were the signs of pre-eclampsia, most staff and students reported an elevated blood pressure, though on closer questioning many could not provide clear definitions of what constituted an elevated blood pressure. When other signs were not provided, the students and clinicians were questions further. The question appeared to perplex most respondents and they almost universally could only suggest that oedema (some even stating lower limb oedema ) was the only other sign they could provide. Clinicians providing antenatal or intrapartum care throughout PNG do not have the capacity to test urine at the clinic level, which is currently only available at the laboratory level. However, the testing for proteinuria can be done simply at the clinical level by a dipstick. Whilst the application of urine testing may not be justifiable in terms of resource allocation in PNG, the availability of these dipsticks for women presenting with other signs of pre-eclampsia would be useful to distinguish those women who require urgent referral or more aggressive management. It is acknowledged that sophisticated blood analysis is unrealistic for many health facilities in PNG, however educating the current and future workforce on some of the other clinical signs of severe pre-eclampsia would lead to earlier diagnosis and more appropriate management of this potentially life threatening disorder. The management of severe pre-eclampsia is the administration of antihypertensives (usually hydralazine) to lower the blood pressure with intravenous magnesium sulphate to prevent or control eclamptic seizures. The use of diazepam in the management of eclamptic seizures has not been recommended for some time. However, it was listed as the first drug of choice in the laminated wall charts found in many of the labour wards. PNG Midwifery Review Final Report 75

85 Throughout the review, most respondents were aware of magnesium sulphate, though many did not know why it was used, or how, and seemed to rely on the medical staff to have this information. In a major obstetric unit such as PMGH this may be understandable (though not acceptable). However in the rural areas, where medical staff are often not available, the lack of appropriate knowledge of the staff providing the care to women is of serious concern. NDoH staff informed the review team that magnesium sulphate should be available at all hospitals and health centres. However it appears the drug was not available at many of the rural centres, nor did staff know how to use it. To address the high levels of maternal mortality of pre-eclampsia and eclampsia, the knowledge and skills of all staff providing care to pregnant women must include the appropriate identification and management of this disorder. HIV Papua New Guinea was declared to have a generalized epidemic of HIV/AIDS in HIV prevalence among antenatal attendees is over 1.3 per cent in Port Moresby and 3.7 percent in some other areas. There has been significant resources provided to improve the rates of HIV screening and treatment in antenatal women. However the review team failed to observe any routine screening procedures offered to women in most of the facilities we visited. In the notes reviewed for inpatient obstetric patients, only the Haemoglobin and VDRL were recorded. When staff were questioned on the availability of HIV screening, most respondents replied that they did not have the facilities to screen women, or that when pre-test counselling was introduced that many of the women refused testing. This has led to the introduction of opt-out testing where pre-test counselling is given as a group but post-test counselling is done individually. This is an internationally recognised model, recommended by WHO as a means to ensuring maximum access to screening and treatment. However in the health facilities visited as part of this review, most women were not being counselled or screened for HIV. Testing kits, anti-retroviral medication and training are all available through the NDoH and donor agencies and health staff should be encouraged to screen more widely where these resources are available. PNG Midwifery Review Final Report 76

86 Resuscitation of the Newborn It is generally accepted that approximately 10% of infants internationally will require some degree of assistance to breathe at birth (ILCOR, 2005). The vast majority of these infants will successfully establish respirations following some assistance with positive pressure ventilation, usually delivered via a self-inflating bag and mask. During the walk through of each facility, the review team requested to look at the equipment available to resuscitate infants, should they require it. Whilst the larger facilities of PMGH and Goroka base hospital had an infant resuscitation cot and a bag and mask located within labour ward, on the two occasions we visited it was either not connected to oxygen or the oxygen bottle was empty. In other facilities such as the Modilon Hospital in Madang, the resuscitation equipment was located in the nursery, and in the smaller facilities, the staff could not locate the bag and mask though insisted they had one somewhere. When clinicians and students were questioned about the frequency and type of resuscitation administered to sick newborns, the review team were not reassured that this skill was highly developed amongst the staff. Most of the respondents reported they initiated frog breathing, even when a bag and mask was available. There is currently no evidence on the efficacy of frog breathing, but given that the appropriate equipment for effective resuscitation is available in the larger health facilities, adequate preparation of both students and staff is essential and will no doubt have a positive impact on neonatal morbidity and mortality. Clinical Midwives Reliable data on the midwifery workforce is currently not available. The PNG Nursing Council currently estimates midwifery numbers to be 567 although many of these midwives are no longer working in clinical positions. As already mentioned, it appears that graduates from midwifery courses over the past few years have not yet been registered (see Section 7 for more information). The National Department of Health, assisted by WHO, have developed a database that will provide accurate information on the nursing and midwifery workforce and will enable health planners to identify workforce shortages, particularly in the rural and remote areas. Operationalisation of this database, including the entry of labour-force data, must be given priority. PNG Midwifery Review Final Report 77

87 Despite the lack of data, it was generally accepted by all stakeholders and key informants that there are currently inadequate numbers of midwives in PNG and that the current production of new midwives through education programs will not address this shortfall. Increasing the number of the midwifery workforce could be achieved by: Increasing the number of intakes from two to one intakes per year Establishing a part-time option for students Supporting other institutions such a Vunapope to develop and offer midwifery education Support the development of distance education programs in midwifery providing appropriate clinical supervision is available. Clinical midwives in the hospitals visited by the review team were asked to complete a midwifery self assessment tool. 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. Forty six essential midwifery competencies, from the list of core competencies developed by the ICM were chosen for assessment (see Appendix 6). 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. The tool was introduced by members of the review team and was completed anonymously. In addition to the assessment of competencies, the following data were also collected. Age. Site of practice (facility). Year Graduated. Year started work. How many years have you been a midwife? Where do you want to be working in five years time? Have you attended any postgraduate training since you finished you midwifery training? Please list some examples. Births attended in last 12 months. PNG Midwifery Review Final Report 78

88 Results of the Midwifery Self Assessment The table below illustrates the results from the demographic data collected on 16 midwives from across the three hospitals visited. These included PMGH (6), Modilon Hospital (6), and Goroka Base Hospital (4). Although ideally rural midwives would also have been included in this survey, there were no midwives rostered on duty in the rural areas at the time of the review teams visit. As can be seen below the sample represented a wide range of ages and experience though the mean years of experience was 9 years, indicating that the sample was well experienced. Most (62%) indicated they planned to be in the same facility in five years time with the other 37% reporting a variety of things they wanted to be doing in five years time, from retirement, to education, rural practice, or private health practice. Table 12: Summary of demographic data on clinical midwives Number of midwives surveyed 16 Age Range Mean age 39.5 Rural 0 Urban 100% Range of experience (in years) 1-26 Mean years of experience 9 Working 5 years from now in same institution 62% The self assessment consisted of 46 midwifery competencies, and apart from the few listed in the figures below, the midwives reported self confidence in all other competencies. The core midwifery competencies reported below were chosen as they have been identified to directly reduce maternal and infant mortality and morbidity and should be an essential part of midwifery education, both pre-service and as continuing education, to ensure midwives remain current with evidence based practice in these areas. Midwives reported high levels of confidence in most of the normal aspects of maternity care. The exception to this was in both STI and HIV counselling, screening and treatment. It is assumed that practicing midwives are not exposed to these PNG Midwifery Review Final Report 79

89 practices in their workplace and therefore lack confidence. Screening for syphilis was the only STI testing done routinely in the facilities visited by the review team. Figure 3: Confidence of midwives in normal pregnancy and birth Normal Birth antentatal care sti screening, treatment hiv counselling, teatment manage normal birth active management examine newborn percent not confident confident The other reported responses included how the midwives perceived their confidence in a number of key maternity emergencies, including the main causes of maternal mortality in PNG. The levels of confidence in these competencies were significantly lower than those in normal care of women in birth. All midwives reported confidence in their ability to manage post partum haemorrhage, but less confidence was reported in the management of breech birth (81%), cord prolapse (91%), newborn resuscitation (89%), management of eclampsia (including administration of magnesium sulphate) (56%), manual removal of the placenta (81%), and maternal sepsis (93%). All midwives should be competent in these areas to practice in any setting in PNG. Results of this survey indicates that not only are these skills important to be included in midwifery education, it also supports the need for ongoing professional development for practicing midwives. PNG Midwifery Review Final Report 80

90 Figure 4: Confidence of midwives in maternity emergencies Maternity emergencies percent breech cord prolapse newborn resus eclampsia pph mrop maternal sepsis confident not confident Recommendations for Health Services Health services can be strengthened by: 1. 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 ( micrograms inserted rectally) in the management of PPH. 2. 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. 3. Improvement of working conditions by ensuring: PNG Midwifery Review Final Report 81

91 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). 4. Funding to be secured to provide an upskilling workshop on maternity emergencies for senior clinical (midwifery and obstetric) and education staff in PNG. 5. NDoH recommence preceptor training for clinicians working with students and junior staff in the clinical areas. PNG Midwifery Review Final Report 82

92 Section 7: Regulation of Midwives Overview In order to reduce maternal and infant maternal mortality in PNG, midwives and other health professionals need a clear legal and regulatory framework which permit them to practise the essential interventions that will save lives and promote good health. The main functions of a professional regulatory system are to: Set standards for entry into the profession Ensure maintenance of standards Provide a mechanism to deal with professional misconduct Maintain an effective register of all those eligible to practise The PNG Nursing Council functions under the Medical Act, 1980 though this Act is currently under revision with a new Health Practitioners Act expecting to be presented to Parliament in This new Act will provide a more robust platform to guide Nursing Council activities. The Nursing Council appears to have been inefficient for a number of years and have recently improved their performance though a staff restructure and the support of the PNG WHO office. Of the four midwifery programs currently operating across the country, three of the four have submitted curriculum documents for approval by the Council. The review team were unable to determine if full approval had been granted to these programs. The PAU team believed they had received approval, yet the Council staff informed the team that whilst it had been approved by the education committee, it had not formally gone before the board. Lutheran staff told the review team after submission of their documents they received some points from the Council that required clarification. The Lutheran staff claim they addressed each of these points formally and in writing but had yet to receive further correspondence. The UOG team claimed they had forwarded documentation in December 2005 and had yet to receive a response 12 months later. The UNPG program had definitely not been approved because Council representatives claim the UNPG have failed to forward their Curriculum documents for review, despite a number of letters being sent to the university over the last few years. PNG Midwifery Review Final Report 83

93 A National Framework for the Accreditation, Monitoring and Evaluation of Nursing and Midwifery Programs is available though the ability to apply the document has been limited due to a lack of documented criteria on which to evaluate and monitor programs. For example, under Standard 5 of the Framework document, the institution is required to demonstrate the students have gained appropriate knowledge and skills to meet the community requirements and National Competency Standards. However, it does not state specific skills to be attained, nor the minimum number of procedures students must have achieved. The capacity of the Nursing Council to accredit the midwifery programs has also been restricted by a long backlog of nursing and midwifery graduates waiting to be registered. The Nursing Council is currently concentrating on registering graduates from undergraduate nursing programs from 2004 and it is expected that it will be some months before they can attend to the midwifery programs and graduates. This lagtime has resulted in no graduates from any program in midwifery being granted Registration to practice for a number of years. This has resulted in significant stress with both education staff and students with some education staff reporting the boycotting of classes by students and increasing agitation for the schools to fulfil their requirements in order for the students to receive registration. Although the graduates are mostly in secure employment without registration, the staff and many of the students are aware of the legal and ethical implications of this and seek a swift resolution to this longstanding problem. The process for granting Registration for both undergraduate nursing and postgraduate nursing and midwifery programs appear hampered by a laborious process where the Nursing Council is requesting the academic transcript, full assessment record book, skill logbook and evidence portfolio for each student that graduates from all 7 undergraduate institutions and 4 postgraduate institutions across the country. If adequate mechanisms were in place for the development of curricula, based on minimum standards, this process would not be required. This is because the educational institutions would be delegated the responsibility of recommending Registration based on a program developed using Nursing Council criteria that had been approved by the Council. The quality of these programs could then be monitored by sample audits undertaken by the Nursing Council, using the National Framework PNG Midwifery Review Final Report 84

94 for the Accreditation, Monitoring and Evaluation of Nursing and Midwifery Programs document. Recommendations for Nursing Regulation and Accreditation 1. Process the registration for all students who have graduated from nursing and midwifery programs since 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. 2. 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. 3. 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. 4. Set standards for minimum requirements for entry into the profession that should include registered nurses with hospital based certificates. Conclusion PNG already has many of the structures and processes in place to provide a strong regulatory framework for their health and educational institutions. This framework however, requires urgent attention to address the lack of registration being given to graduates of both nursing and midwifery programs, as well as clarifying and reducing the processes required for registration. It also requires prompt attention to the accreditation of existing courses and the development of specific requirements for clinical skills in future programs. PNG Midwifery Review Final Report 85

95 Section 8: Conclusion Midwifery has gained increasing recognition in the last years with the WHO recommending that midwives are the most appropriate practitioner to care for women in pregnancy, labour, birth and the postnatal period when no risk factors have been identified. This has occurred alongside increasing international effort to reduce maternal and newborn mortality by ensuring that every woman has access to a skilled provider. Overall the current preparation of midwives in PNG is not adequate to effectively reduce the high maternal and childhood mortality and morbidity rates. However, midwifery in this country has strong foundations and there are many competent and experienced midwives working in maternity services across the country. By increasing the amount of time in clinical practice, determining minimal numbers of procedures that must be completed prior to graduation, upskilling key education and clinical stall in maternity emergencies, and the provision of leadership on many of these issues by the Nursing Council, PNG could easily produce a highly competent workforce. Limitations of this review include: The time available to conduct the review was a total of five weeks with 3 weeks in country The timing of the fieldwork was in late November and December, at the academic year. Consequently many of the students were not available for interview. 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 the 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 PNG Midwifery Review Final Report 86

96 participants are striving for: a reduction in the devastating loss of life in women and children in PNG from conditions that are mostly preventable. PNG Midwifery Review Final Report 87

97 References Beebe, J. (1995) Basic concepts and techniques of rapid appraisal, Human Organization, 54 (1) Garner, P., Heywood, P., Baea, M., Lai, D. and Smith, T. (1996) Infant mortality in a deprived area of Papua New Guinea: priorities for antenatal services and health education, PNG Medical Journal, Hogerzeil, H., Walker, G. and de Goeje, M. (1993) Stability of injectable oxytocics in tropical climates: Results of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin, World Health Organization: WHO Publication No. WHO/DPA/93.6, Geneva: Action Programme on Essential Drugs and Vaccines ICM (1999a), Vol International Confederation of Midwives (ICM), The Netherlands. ICM (1999b) International Code of Ethics for Midwives, International Confederation of Midwives (ICM), London ICM (2005), Vol International Confederation of Midwives (ICM), Brisbane. ICM and FIGO (2004) Joint Statement Management of the Third Stage of Labour to Prevent Post Partum Haemorrhage, International Congress of Midwives and International Federation of Gynaecologists and Obstetricians ILCOR (2005) Neonatal Resuscitation Guidelines, International Liaison Committee on Resuscitation Lalonde, A., Daviss, B., Acosta, A. and Herschderfer, K. (2006) Postpartum hemorrhage today: ICM/FIGO initiative , International Journal of Gynecology and Obstetrics, Larsen, G., Lupiwa, S., Kave, H., Gillieatt, S. and Alpers, M. (2004) Antenatal care in Goroka: issues and perceptions, PNG Medical Journal, McDonald, S., Abbott, J. and Higgins, S. (2005) Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour (Cochrane Review), The Reproductive Health Library, Issue 8 (Oxford) Update Software Ltd. Available from PNG NDoH (2002) Medical and Dental Catologue. 9th Edition, National Department of Health, Port Moresby PNG Midwifery Review Final Report 88

98 Sherratt, D., White, P. and Chhuong, C. (2006) Comprehensive Midwifery Review, Draft Final Report, Ministry of Health and WHO, Cambodia UKCC (2000) Perceptions of the scope of professional practice, United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), London WHO Mother-Baby Package: Implementing Safe Motherhood in Countries, Department of Reproductive Health and Research, World Health Organisation, Geneva WHO (2000) Nurses and Midwives: A Force for Health, World Health Organisation, Copenhagen WHO (2006a) Country Co-operation Strategy, World Health Organization, Port Moresby WHO (2006b) Strengthening Midwifery Toolkit: Guidelines for Policy Maker and Planners to Strengthen the Regulation, Accreditation and Education of Midwives, Final Draft, World Health Organisation, Geneva PNG Midwifery Review Final Report 89

99 Appendix 1: Education Institution Quality Assessment Tool 1. Name & Address of Institution Identifier 3. Year Established: Year commenced midwifery programme(s): (if after 1990) 4. Type of Midwifery Program offered (give details - length of course, funding by, as well as average number of participants per course and # course per year 5. Other healthcare trainings offered: (list name and length of course) i. ii. iii. iv. 6. # Midwife Teachers posts: # Vacant midwife posts: Appendix 1: Education Institution Quality Assessment 90

100 7 Qualification of Midwife Teacher(s): (identify if full-time teaching midwifery, or undertaking other roles and responsibilities in addition to teaching) i. ii. iii. iv. v. 8. # Midwifery students per intake: # Intakes per year: 9. # Class Rooms: #. Seats per classroom: 9. # Offices for midwife teachers 10. Hostel Accommodation for available? Y / N i. If yes, total # bedrooms #beds per bedroom. (average) ii. Total #beds available for midwifery students Appendix 1: Education Institution Quality Assessment 91

101 iii.total # of midwifery students in hostel at current time? 11. Running water available in all bathroom & toilets? Y/ N water etc) If no describe situation (how get water, if any problems of getting sufficient Please complete the following and supply additional information on a separate sheet Ite Criteria Yes No m 1 Staff Development/institutional capacity building The institution has been assessed within last five years to see that all teaching materials required in curriculum etc are present and in good order All new teachers are required to have undertaken specialist preparation for teaching course prior to taking up post The institution has a written orientation programme for all new teachers The institution has had external support in last five years to upgrade the facilities and / or faculty (Give name of funder and type of support provided ) Midwifery teachers have access to computers Midwifery teachers have access to the Internet 2 The Curriculum The institution has a formal committee for monitoring the curriculum that consist of both academic, clinical staff and student representatives The institution gives all students a manual outlining the curriculum, expected competencies at end of training, schedule of classes, times of assessments, etc., at commencement of the course Appendix 1: Education Institution Quality Assessment 92

102 The institution has formal written guidelines for assessing students 3 Educational Processes Teachers use multiple education methods to facilitate learning, including small group work Teachers use problem-based approach to learning to encourage independent and autonomous practice Teachers use Competency-based methodology and checklists for development of clinical skills 4 Support to Students The institution has a formal mechanism to investigate student grievances The institution has a formal student teacher committee to resolve student complainants The institution has a formal mechanism to support and counselling students who have personal problems 5 Learning Materials The institution has a well-stocked library to support midwifery students (has more than 1 copy of up to date midwifery text books, reports and journals) *please list on separate sheet all midwifery and nurse-midwifery Journals available and dates of latest issues. Also any relevant midwifery related textbooks and reports etc in local language) Students are able to borrow books and other materials from the library outside class times Photocopy facilities are available for students to use (give cost per sheet students have to pay) The library is open after official class times Appendix 1: Education Institution Quality Assessment 93

103 Other midwifery study books are available for use by students (available from Midwife teachers). ( Comment on name and # of books available language and if in good order) Computer facilities are available for its use by students Students have access to the Internet 6 Clinical Support There are clinical supervisors in all areas where students go for clinical practice including for Community placement Home births ANC (HC and community etc) PNC (HC and community etc) Facility normal births Facility management of obstetrical and neonatal complications All clinical supervisors must undergoing a formal preparation programme (in-service course) provided by institution Teachers spend time working with and supporting students in the clinical areas (when the students are on clinical placement) A formal mechanism is operating to prepare clinical sites (to ensure quality of care provided) 7 Facilities Sufficient student accommodation is available on campus (or close by) - comments on any shortages, number of rooms, occupants per Appendix 1: Education Institution Quality Assessment 94

104 room and bathrooms) Safe hygienic facilities (area) is available on site for preparing food A separate room is available for students to use in off-duty time for study Clinical / skills development laboratory is available with sufficient working models, equipment etc (comment on models and equipment available if teachers have any deficiencies according to curriculum needs - including any that are available but not in good working order) Auditorium (or large room) is available for graduations, large meetings, seminars, workshops etc., with PA system Each classroom is fully equipped with teaching aids, e.g.: Blackboard/white board, Flip chart stand Each classroom is fully equipped with desks and chairs sufficient for number of students Each classroom has working fan or Air conditioning unit or good ventilation (comment on if rooms appear well ventilated? and means of ventilation and temperature control) Over Head Projector is available and in working order and used by midwife teachers Appendix 1: Education Institution Quality Assessment 95

105 TV and video are available and in working order for use by midwife teachers (comment on videos available/ regularly used by midwife teachers) Single sex toilets available and in good order (clean and well ventilated) If accommodation is attached to institution: Recreational facilities are available for students (list facilities available for students use) TV is available for students use Security is available (comment on security systems e.g. how they ensure security of female students). Additional Notes Appendix 1: Education Institution Quality Assessment 96

106 Appendix 2: Midwife Teacher Questionnaire 97

107 Appendix 2: Midwife Teacher Questionnaire 1. Title of post (if any) Code: 2. Age: 3a. Length in current post:.. 3b. What did you do immediately before being posted as midwife teacher 4. Qualifications: Certificate/Diploma or degree (midwife, nurse):. Place of training:. Year when training completed :.. 5. Other training: (give year, title of training and length, list in order of most recent first) 6. Reasons for becoming a midwife? Appendix 2: Midwife Teacher Questionnaire 98

108 7. Reasons for becoming a midwife teacher? 8. What does the community think about midwives (is it a good job?) YES NO (give reason for answer). 9. What job would you like to be doing; next year? in 5 years? Give reasons for your answer 10. Do you think midwife teachers should conduct hands on midwifery practice? YES NO (If yes, how do you think this should be organized? If no, why not?) 11. What 3 things would make your current job easier? Appendix 2: Midwife Teacher Questionnaire 99

109 (list in rank order) Appendix 2: Midwife Teacher Questionnaire 100

110 Midwife Teacher Competence Skill Yes No Unsure Do you consider yourself to have updated 1. Experience and knowledge of; ability to practice all clinical Biological and social sciences underpinning midwifery skills to midwifery mastery level Midwifery subjects (for example management of post partum haemorrhage and resuscitation of a newborn) Application of research findings in practice (have research findings made any change to how or what you teach your students?) Attitude Can you in a short sentence describe your view on what it means to be a professional practitioner? Has experience (after graduation) of; Yes No 1. Providing pregnancy (ANC) care 2. Managing normal birth in a facility 3. Managing normal birth in home setting 4. Using a partograph 5. Managing third stage of labour using active management of 3 rd stage 6. Managing third stage of labour using physiological management of 3 rd stage Appendix 2: Midwife Teacher Questionnaire 101

111 2. Ability to conduct or use simple research using qualitative and quantitative methodologies 7. Undertake the manual removal of the placenta 8. Deliver a baby using vacuum extraction 7. Resuscitating newborns 8. Proving postnatal care to mothers and babies 9. Providing health education and counselling to women and families on health for pregnancy (healthy diet, healthy life styles, etc) 10. Assisting women and their families make a birth and emergency preparedness plan 11. Providing counselling on birth spacing 12. Assisting women breastfeed successfully 13. Managing cases of eclampsia 14. Managing cases of PPH (in first 24 hours) 15. Managing cases of severe infection after birth in mothers Do you consider yourself to have updated knowledge of; Basic epidemiology Basic statistics Yes No Unsure Analytical framework Research resources Appendix 2: Midwife Teacher Questionnaire 102

112 3. Ability to apply teaching methodologies effectively Do you consider yourself to have updated knowledge of; Learning styles (differences in students ability to learn, including learning by doing, and length of time each student needs to develop skills) Teaching and training methodologies - Classroom (different adult learning techniques) - Clinical teaching (important aspects of supporting students in the clinical area) 4. Ability to assess students fairly Do you consider yourself to have updated knowledge of; Assessment strategies formative and summative assessments) Different assessment tools (different ways to assess students clinical competence) 5. Ability to make clear, accurate, concise reports and records Do you consider yourself to have updated knowledge of; Report writing National legislation on record keeping Appendix 2: Midwife Teacher Questionnaire 103

113 6. Ability to search for up to date information Do you consider yourself to have updated knowledge of; Using a computer Using the Internet Searching for current research 6. Management skills Do you consider yourself to have updated knowledge of; Educational management theories what makes a good working environment for an educational institution) Timetabling and scheduling (how to organize students placements in clinical areas so that all students have opportunity for maximum hands on practice) Curriculum design and development (experience of involvement in developing a new curriculum) Curriculum monitoring (how to ensure effective monitoring of a curriculum) Curriculum evaluation (methods to evaluate a curriculum) Appendix 2: Midwife Teacher Questionnaire 104

114 7. Communication 8. Inter-cultural competence Do you consider yourself to have updated knowledge of; Communication techniques (factors that enhance or hinder effective communication) Presentational methodologies (what makes a good presentation) Listening techniques (what is required for effective listening) Counselling techniques (what is meant by counselling and the counselling process) Do you consider yourself to have updated knowledge of; Cultural taboos and customs in different countries or communities (related to childbirth) Cultural identity (what factors help to develop a persons sense of individual identity) Additional Notes: Appendix 2: Midwife Teacher Questionnaire 105

115 Appendix 3: WHO Framework for Evaluating Curriculum The Curriculum has been reviewed and revised in the last five (5) years Minimum entry requirement is; 12 years school, or 10 years plus entry test and/or successfully completing a foundation course, or Registration or Licence to Practice Nursing Teacher student ratio have been agreed and conform to national norms The curriculum requires approval by the Midwifery Regulatory Authority (the body established by the government to oversee midwifery and grant the right to practice) The curriculum is delivered in, or has the approval of, an appropriate educational body/institution The curriculum is at the educational level equivalent to the curriculum of other health care practitioners The curriculum is based on sound educational theories of adult learning that fosters the critical thinking and problem solving skills of students The curriculum has a clear philosophy of midwifery that values midwives working with women in a partnership and recognizing pregnancy and childbirth as a natural life event for most women The curriculum is organized to ensure students can link theory to practice, practice placements allow them to practice what they have been taught in the classroom The curriculum is lead by an experienced midwife teacher who has a background in midwifery and has been trained as a teacher YES NO Not Know n Appendix 3: Framework for Evaluating Curriculum 106

116 Teaching and learning resources are adequate and expose students to recent research findings Students have opportunities to practice in the clinical area under the direct supervision of an experienced midwife and have their practice assessed On completion of the education programme midwives are able to practice as autonomous/self-directing practitioners, (able to practice as outline in the International Definition of a Midwife) On completion of the education programme midwives are able to practice as a fully participating member of a multi-disciplinary team On completion of the education programme midwives are able to provide midwifery care in any setting, community, clinic, health facility, hospital or clients own home. On completion of the education programme midwives are able to provide all essential life-saving skills to both women and newborn All assessments are clearly identified in the curriculum and assessment points are known to the students Clear criteria has been set for all theory and clinical assessments All assessors, including clinical assessors have been specially prepared for their role The curriculum has a clear and transparent Quality Assurance mechanisms, students able to give feedback to teachers All assessment tools have been tested for validity and reliability Student records ensure that individual progress can be tracked throughout the programme Appendix 3: Framework for Evaluating Curriculum 107

117 Appendix 4: Student Midwives Surveys Code: Facility you are studying at? started completed Date What experience did you have before your training? Why did you choose to train as a midwife? Are you living away from your family to study? What does a midwife do? How much clinical practice do you have during your training? Do you have adequate supervision in the clinical area? Do you have adequate support in the university? Appendix 4: Student midwives Survey 108

118 Are the teachers at the university up to date in midwifery? Where do you want to work after midwifery training? (name village or town and the level of facility) Do you feel ready to care for women by yourself? Appendix 4: Student midwives Survey 109

119 TICK IF YOU ARE CONFIDENT TO DO THESE CLINICAL SKILLS Clinical skill Inspection of placenta and membranes Taking an antenatal history Perform manual removal of placenta Idenitify STIs Suture perineum Treat STIs Assess Apgar scores Council for HIV screening Rescuscitate a newborn with bag and mask Screen for HIV Assist in immediate breastfeeding Manage HIV positive women Examine newborn Venipuncture Diagnose postpartum hemorrhage Cannulate Manage postpartum hemorrhage Counsel on birth and emergency plan Diagnose infection in the newborn and give appropriate immediate care for newborn as per national protocols Record findings using home based and clinical records Diagnose sepsis in postpartum women and give immediate care according to national protocols Measurement of uterine size Recognize women with eclamptic fits Calculating EDC Manage eclamptic fits including giving magnesium sulfate Identify onset of labor Provide information on fertility regulation and contraception methods Determination of fetal position by Effectively support the breastfeeding woman Appendix 4: Student-Midwives Survey 110

120 abdominal examination Identify the second stage of labor Effectively support the woman who cannot breastfeed Manage second stage of labor Effectively monitor the growth and development of children up to five years of age Manage a normal birth Recognise and manage malnutrition in children Perform episiotomy Recognise and manage common childhood illnesses Manage a breech birth Knowledge of immunisation schedule Manage a cord prolapse Administer immunisations to women Physiological management of 3 rd stage Appendix 4: Student-Midwives Survey 111

121 Appendix 5: Health Facility Assessment Tool Code: 1. Name & Address of Facility: 2. General Details Year Established: # in-patient beds # births per year Service level: *For Referral Facility # C sections per month (average) # ANC sessions per week # ANC attendees per session (average) 4. Staffing: # Midwife posts: # Vacant midwife posts: # staff with midwifery training not currently working in clinical maternity area (comment on type of work they are currently doing) Appendix 5: Health Facility Assessment Tool 112

122 FACILITY AUDIT Item All Facilities Yes No 1. Meets all the criteria in terms of equipment and drugs for service level (check with NDoH standard) 2. Has the facility experienced any stock-out of drugs within the last 12 months? Comment on which drugs and how long 3. Has the facility experienced any period of electricity (black-out) in the last 12 months? if so add comment about average # of periods of LESS than 15 minutes # of periods between 15 and 30 minutes # of periods 1-2 hours # of periods more than 2 hours 4 Toilet and bathroom is available for women in labour 5 Patient toilets are clean, well ventilated and have water (mention if running water or containers) 6. Sink with running water is available in room for conducting births? (if not, comment if facility is available in room for washing hands) 7 Soap and means for drying hands are available in all patient care areas, including room for births? (if some area deficient mention which) 8. Light is available in room for conducting births 9 Table or a flat surface is available in or just outside room for birth that can be used for resuscitation of newborn, if required? (ask them to say what they do if they have a newborn who needs resuscitation) Appendix 5: Health Facility Assessment Tool 113

123 10 Room for birth is warm and well ventilated, and has means for protecting newborn for heat loss? 11 Equipment for decontamination is available, plus means of sterilizing equipment? (Comment on sterilizing procedure) (comment on how they clean and store equipment for birth after use) 12 Facility is clean? (Especially birthing room) (comment on level of cleanliness) 13 All in-patient admissions and births entered into General Admissions Register? (ask to see and check number of births) 14. Partograph is available for all women in labour? (ask to see) 15. Partographs is always used for all women in labour? (If any women in labour or new postnatal ask to see) 16. Each patient/client has a record card for recording treatments and nursing/midwifery care? (ask to see) 17 Safe facility for disposal of placenta is available?(comment on how they dispose of placenta) 18 Telephone (or other communication system) is available for calling for assistance in an emergency and is in good working order? 19 Has there been any maternal death in last 12 months? (If yes, ask what was the cause and how is it recorded) 21 Has there been any newborn death in last 12 months? (If yes, ask what was the cause and how is it recorded) 22 Are the protocol and procedure manuals with current information available in all areas? (Do they use WHO IMPAC) Additional Notes and comments on deficiencies and general condition of building: For Referral Hospital only A midwife is always available for all 24 hours (comment if staff shortage prevents safe operating of facility has Appendix 5: Health Facility Assessment Tool 114

124 there been any time when a midwife was not available in last 3 months, etc?, if so what was reason for this) A doctor with EmOC skills is always available 24 hours Appendix 5: Health Facility Assessment Tool 115

125 Appendix 6: Midwife Self-Assessment Tool Code: District: Date: Age: Years working in this facility Site of practice: Clinical area: Year Graduated How many years have you been a midwife? Where do you want to be working in five years time? Have you attended any postgraduate training since you finished your midwifery education. Please list some examples. Births attended in last 12 months: < >20 Do you practice clinically outside this facility? YES NO How many hours per week? Which services do you provide? Antenatal care Y/N Attend births Y/N If yes, how many births per month? Birth spacing Y/N Abortions Y/N Diagnosis and treatment of STIs Y/N Other TWO TICKS REQUIRED ON EACH LINE: Tick one of the four options on learning, and one of the two options on how confident you currently feel to perform the skill. Appendix 6: Midwife Self Assessment Tool 116

126 Clinical skill This skill was included in This skill was included in I learned this skill I have never I do not I feel my midwifery my midwifery after my midwifery learned this feel confident educational program, and educational program, but educational program skill confident to I felt confident to I did not feel confident to (via on the job to perform perform this skill at the perform this skill at the training or in-service perform this skill end of my program end of my program training) this skill Taking an antenatal history Idenitify STIs Treat STIs Council for HIV screening Screen for HIV Manage HIV positive women Venipuncture Cannulate Appendix 6: Midwife Self Assessment Tool 117

127 Counsel on birth and emergency plan Record findings using home based and clinical records Measurement of uterine size Calculating EDC Identify onset of labor Determination of fetal position by abdominal examination Identify the second stage of labor Manage second stage of labor Manage a normal birth Manage a breech birth Manage a cord Appendix 6: Midwife Self Assessment Tool 118

128 prolapse Active management of 3 rd stage Physiological management of 3 rd stage Inspection of placenta and membranes Perform manual removal of placenta Perform episiotomy Suture perineum Assess Apgar scores Rescuscitate a newborn with bag and mask Assist in immediate breastfeeding Perform newborn eye care Appendix 6: Midwife Self Assessment Tool 119

129 Recognize uterus is well contracted immediately postpartum Examine newborn Diagnose postpartum hemorrhage Manage postpartum hemorrhage Diagnose infection in the newborn and give appropriate immediate care for newborn as per national protocols Diagnose sepsis in postpartum women and give immediate care according to national protocols Recognize women with eclamptic fits Manage eclamptic fits Appendix 6: Midwife Self Assessment Tool 120

130 including giving magnesium sulfate Provide information on fertility regulation and contraception methods Effectively support the breastfeeding woman Effectively support the woman who cannot breastfeed Effectively monitor the growth and development of children up to five years of age Recognise and manage malnutrition in children Recognise and manage common childhood illnesses Appendix 6: Midwife Self Assessment Tool 121

131 Knowledge of immunisation schedule Administer immunisations to women Administer immunisations to women Appendix 6: Midwife Self Assessment Tool 122

132 Appendix 7: List of Stakeholders and Key Informants STAKEHOLDERS Name Title Institution Mrs Mary Roroi A/Director HRM Branch National Department of Health Dr Dagam, Director Curative Health Services National Department of Health Dr Polume, Principle Advisor, Family Health National Department of Health Simon Lugabai Principle Advisor, HR Training National Department of Health Vincent Micheals Coordinator Church Medical Services Prof Sir Isi Kevau Executive Dean, SoM&HS University of PNG Mrs E Jojoga, Chair, Nursing Division, SoM&HS University of PNG Dr A Tay CEO Port Moresby General Hospital Dr John Vince Deputy Dean SoM&HS, UPNG University of PNG Loa Babona Director of Nursing Port Moresby General Hospital Laitte Moses Registrar Nursing Council Julie Aengari Dean, School of Nursing, Pacific Adventist University Glen Mola Professor of Obstetrics, SoM&HS University of PNG/PMGH Micheal Iwaiz Provincial Health Adviser, Central Province Health Division Norah Changei Acting Director of Nursing NCD Urban Health Services Nira Micheal Principal, School of Nursing Lutheran School of Nursing Judy Alingou Midwife and Nurse in Charge Madang Town Clinic Dr Razafiarijaona Medical Officer/Director Yagaum Rural Hospital Galug Sual Acting Director Of Nursing Modilon Hospital Dr Geita Obstetrician Modilon Hospital Marcus Kachau Provincial Health Adviser Madang Province Health Division Fr Jan Csuba President Divine Word University Dr Michael Mel A/VC and A/PVC Academic Dev. University of Goroka Dr Jerry Semos A/PVC Administration University of Goroka Lilian Siwi Section Head, Health Programs University of Goroka Dr Joseph Appa CEO Goroka Base Hospital Sonia Vano Korowi Director of Nursing Goroka Base Hospital Kiddron Gimiseve Deputy Director of Nursing Goroka Base Hospital Appendix 7: List of Stakeholders and Key Informants 123

133 KEY INFORMANTS Gebo Nanu Lecturer paediatrics UPNG Martha Haluni Midwife and tutor in Midwifery, UPNG Nancy Buasi Midwife and Lecturer in Midwifery UPNG Dorothy Kaputin Midwife and lecturer in Administration and Education, UPNG Rebecca Evia Midwife and lecturer in Community Health Nursing UPNG Agnes Willyman Deputy Director PMGH Bonita Andrew Unit Manager, Antenatal Clinic PMGH Hellen Hukula Unit Manager PMGH Alice Baira Unit Manager PMGH Lisi Jainana Inservice Tutor PMGH Susan Kasai O&G Clinical Supervisor PMGH Jenifer Pyakalyia O&G Unit Supervisor PMGH Vigini Ure Coordinator Inservice, PMGH Gebo Tahu Paediatric Unit Supervisor PMGH Martha Semin Unit Manager, Paediatrics PMGH Salin Paediatrics PMGH Delker Margis O&G Clinical Supervisor PMGH Susan Haroi, Chairperson PNG Nursing Council Effrie Pereri Asigau Chairperson Registration PNG Nursing Council Mai Arua Deputy Registrar PNG Nursing Council Cecilia Palke Education Officer PNG Nursing Council Martha Madogi Midwife and Lecturer, School of Nursing Pacific Adventist University Hettie Asugeni Midwifer and Associate Lecturer, School of Nursing, Pacific Adventist University Lester Asugeni Midwife and Lecturer, School of Nursing, Pacific Adventist University Dianne Kono Midwife and Associate Lecturer, School of Nursing Pacific Adventist University Appendix 7: List of Stakeholders and Key Informants 124

134 Evelyn Walkai Midwife and Health Promotion Office Central Province Health Division Pana Rim, Provincial Disease Control Officer Central Province Health Division Singat Biels Midwife and Family Health Coordinator Central Province Health Division Micheal Masket Health Extension Officer Central Province Health Division Nrisai Abraham Health Extension Officer Central Province Health Division Ine Raempom Inservice Coordinator NCD Urban Health Services Jullienna Haiara Midwife NCD Urban Health Services Jenny Pyander Midwife NCD Urban Health Services Mavis Namis Midwife NCD Urban Health Services Linda Wazami Registered Nurse Madang Town Clinic Shiela Romany Registered Nurse Madang Town Clinic Mary Kililo Midwife and Midwifery Lecturer Lutheran School of Nursing Elizabeth Natera Midwife and midwifery coordinator Lutheran School of Nursing Julie Kep Strand Leader, Maternal Health University of Goroka Alice Kauba Strand Leader, Paediatrics University of Goroka Aiva Pikuri Midwife and Labour Ward Manager Goroka Base Hospital Appendix 7: List of Stakeholders and Key Informants 125