Title Meeting the Millennium Development Goals 3 and 5: Do our midwives meet competence level?

Solange Mianda, MSc (MPH), PhD student; School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal %mail& solange'(oe)*+gmail'com ,*-.,*,.-+stu'u/(n'ac'(a Phone n0& **,1 12.)*3-.2 Dr 4nna 5oce, senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal' %mail& voceas+u/(n'co'(a 6el& **,1 27,)*---2 8ord count& ,,,-, 4uthor biographic Solange Mianda is a PhD student at the department of public health medicine at the Universit of !"a#ulu$Natal' Dr 4nna 5oce& is a senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal' I declare that there is no actual or potential conflict of interest in relation to this article

A stract S/illed attendance has increased "orld"ide to address the challenge of maternal and perinatal mortalit ' Ho"ever the provision of s/illed attendance onl reflects the presence of the health care "or/er and not their s/ills and /no"ledge' 6o e9plore the issue of s/illed attendance this stud "as designed' 6"ent five mid"ives of five district hospitals in a health district of !"a#ulu$Natal "ere assessed' :bstetric /no"ledge of the mid"ives from both shift (da and night) on the da of data collection "ere evaluated using multiple choice ;uestion on normal labour, cord prolapsed, prolonged labour, postpartum haemorrhage, pregnanc induced h pertension, H<5 and puerperal sepsis' 6he obstetric s/ills tests assessed mid"ives abilit to& use the partogram as a decision$ma/ing tool in labour, plot information on a partogram and manage post$partum haemorrhage through the administration of an :b=ective Structured >linical %9amination (:S>%)' 8hile the ma=orit of deliveries occurred in health facilities in South 4frica, results from this stud reveal inade;uate /no"ledge and s/ills in mid"ives attending births in district hospitals of this health district, the presence of s/illed attendant is not necessaril the provision of s/illed care' !e" words: s#illed attendance$ midwives$ competence level$ midwives s#ill and #nowledge

Introduction %ver ear "omen and babies die as a result of child bearing, "ith most of these deaths

occurring in sub$Saharan 4frica (?radsha" et al ,*7,)' 6he millennium development goals (MD@s) called for a t"o$third reduction in under$five mortalit and three$;uarter in maternal mortalit b ,*7. "orld"ide, increased s/illed attendance at birth is the ma=or strateg to achieve these goals (N ango et al ,*7*)' S/illed attendance comprises both the s/illed attendant and the environment "ithin "hich the care is provided' 6he health care "or/ers providing care must possess ade;uate s/ills defined as core s/ills to provide effective care during labour' (4detoro et al ,*77) Having a s/illed professional attending birth is important in that it helps avoid maternal and perinatal deaths (4dego/e et al ,*77)' 8orld"ide, births attended b s/illed professionals have increased (4dego/e et al ,*77)' South 4frica has increased the availabilit , accessibilit and utilisation of deliver services to "omen in labour UN<>%A, ,**B& 3*)' ?et"een ,**2 and ,*7* an average 3-'2C of "omen delivered in a health facilit , attended either b a registered mid"ife or a doctor (UNDP, ,*77, p' B; UN<>%A, ,**B, p' B)' Despite the increase of s/illed attendance, maternal and perinatal deaths are still high in the countr ' Man of these deaths health care "or/ers related (?radsha" et al ,*7,); sho"ing no progress to"ards meeting MD@s re;uirements (?radsha" et al ,*7,)' <n the effort to improve maternal and ne"$born care the perinatal problem identification (PP<); the national confidential en;uiries into maternal deaths (N>>%MD) and saving babies and saving mothers "ere introduced in South 4frica to reflect on the causes of maternal and perinatal deaths and suggest appropriate measures to avoid maternal and perinatal deaths (?radsha" et al ,*7,), but "ith almost no change on maternal and perinatal deaths that are still high in the countr as a "hole and in !"a#ulu DNatal in particular (?radsha" et al ,*7,; NaPeMM>o ,*77, Moodle E ,*7*)' 6he proportion of deliveries "ith s/illed attendance onl reflects on the presence of a health care provider but do not reflect on their competencies (4dego/e et al ,*77)' 6his stud "as designed to investigate the provision of s/illed attendance in district hospitals "here the ma=orit of deliveries occur, in one health district of !"a#ulu$Natal; "ith the follo"ing ob=ectives& to assess the obstetric /no"ledge and s/ills of health care "or/ers attending births'

6o achieve the above ob=ectives& health care "or/ers obstetric /no"ledge and s/ills "ere measured' Mid"ives present on both shifts on the da of data collection "ere assessed using M>F ;uestionnaires and :S>% stations' Gesults sho"ed lo" level of mid"ives competence' Methods 6he stud "as conducted in one health district of !"a #ulu$Natal in ,**B' 4ll district hospitals ()) in the health district "ere selected for the stud e9cept for one hospital that did not consent to participate in the stud ' 4n e9plorator observational cross$sectional descriptive stud "as implemented; "hich evaluated the obstetric /no"ledge and s/ills of mid"ives in district hospitals' :bstetric /no"ledge and s/ills of ,. registered mid"ives present on both shifts (da and night) on the da of data collection "ere assessed using tools adapted from the perinatal education programme (P%P)' Scores "ere allocated for ever correct ans"er and percentages "ere calculated' %ach mid"ife "as assessed individuall ' 6hirt multiple choice ;uestions (M>F) covering& normal labour, cord prolapse, prolonged labour, postpartum haemorrhage (PPH), pregnanc induced h pertension (P<H), H<5 and puerperal sepsis assessed mid"ives obstetric /no"ledge' :S>% assessed mid"ives obstetric s/ills on their abilit to& plot information on a partogram, and the use of the partogram as a decision$ma/ing tool in labours and manage post$partum haemorrhage' Due to the s/e"edness of data, median scores (C) "ere calculated for obstetric /no"ledge and s/ills; !rus/al 8allis non$ parametric test "as used to measure significance bet"een variables' 6he P%P manual set B*C as passing mar/' Permissions to underta/e the stud "ere obtained from the Universit of !"a#ulu$Natal biomedical ethic committee, the provincial Department of Health, and hospital managers' >onsent "as obtained from mid"ives to participate in the obstetric /no"ledge and s/ill assessments' <t "as clearl stated to them that participation "as voluntar and "ithdra"al could happen at an stage of the stud "ithout an negative conse;uences'

%esults !nowledge and &#ill median ' scores

70 60 50 40 30 20 10 0 H 1 H 2 H 3 H 4 S kills s cores % H 5

K nowledg es cores %

Figure 1 Knowledge and skills median % scores1

4ll hospitals sho"ed the same pattern in terms of obstetric /no"ledge "ith ver poor overall scores and no statistical significant difference bet"een hospitals (P value H*'**1)' 4ll hospitals scored poorl on the /no"ledge of normal labour, prolapsed cord, PPH, P<H and sepsis' 4ll hospitals had better scores on the /no"ledge of prolonged labour and H<5' 4ll hospitals performed poorl on the overall s/ill score and there "as ho"ever a statistical significant difference bet"een hospitals (P value H *'**,)' (artogram e)ercise I and II Aigure , sho"s all hospitals "ith high scores on partogram e9ercise <, compared to the standard set b the P%P manual, no hospital met the set standard' 4ll hospitals performed similarl poorl on the partogram e9ercise <<'

The letter H was used to identify different hospitals in the health district

80 70 60 50 40 30 20 10 0 H 1 H 2 H 3 Pa r og ra m! % H 4 Pa r og ra m !! % H 5

Figure 2 Par ogram e"ercises ! and !!

(ostpartum *aemorrhage management Aigure 2 sho"s the PPH /no"ledge and s/ill median C scores "ith interesting information on the competence of mid"ives in these five district hospitals'

80 70 60 50 40 30 20 10 0 H1 H2 H3 H4 H5 P P H kn nowled g e% P P H skills %

Figure 3 PPH Knowledge and skill median % score

Discussion 4n evaluation of the P%P programme in South 4frica sho"ed an increase in the /no"ledge and s/ills of mid"ives (Gundare, 4 and @oodman S ,*7,) "hich is far from being confirmed in the present stud ' Arom the measure of s/illed attendance through the assessment of obstetric /no"ledge and s/ills of mid"ives all hospitals sho"ed poor scores on the /no"ledge and s/ills test and no mid"ife in the stud hospitals met P%P standard'

Some studies identified in the literature measuring mid"ives competence sho" differences in level of mid"ives /no"ledge and s/ills& 4 stud conducted in @hana assessing the e9tent of s/illed attendance at birth using records /ept sho"ed onl ,)C of records in the stud meeting three$;uarter of the criteria for s/illed attendance (4hlu"alia et al ,**2)' 4 stud measuring mid"ivesI competence against 8H: guidelines sho"s onl ..'BC of the providers able to ans"er correctl the /no"ledge ;uestions and -BC performing the s/ills steps correctl (Harve et al ,**-)' @bangade et al (,**2); Mc>a"$?inns et al (,**-) and Harve et al (,**1) reported inade;uate mid"ives obstetric /no"ledge in Eamaica, G"anda, %cuador and ?enin supporting these findings' 6o get a better understanding of the situation a further loo/ at different subsets, sho" better mar/s scored onl on items that tested /no"ledge of prolonged labour and H<5; the rest of subset (normal labour, Pepsis, PPH, P<H and cord prolaspe) scored poorl ' 4ll hospitals sho" a similar level of poor performance on obstetric /no"ledge; suggesting that mid"ives in this health district do not have the minimum /no"ledge re;uired of mid"ives in identif ing and managing obstetric complications' Poor /no"ledge scores indicate inade;uate /no"ledge in mid"ives to monitor, manage and supervise labour, calling for in$service training and supervision initiatives for mid"ives in the management of labour' 8hile loo/ing at the s/ills test, all hospital scored poorl overall; and the stud b Harve et al (,**-) reported similar results' :nl three of the five hospitals reported high scores for the plotting of information on the partogram, ho"ever all hospitals had poor scores in interpreting information on a partogram and all hospitals performed at a similar level' :nl the s/ill test on the management of PPH sho"ed interesting findings, as all hospitals performed poorl in the /no"ledge test so did the perform poorl on the s/ill test' :ne hospital "ith the lo"est median /no"ledge scores had the highest s/ill median score' Poor scores on plotting and interpreting information on a partograph in these hospitals indicate that there ma be other underl ing factors but not e9plored in the stud as sho"n in figure 2 for H., needing further investigations' 6his calls for further studies to e9plore the reason for the discrepancies bet"een plotting of information on a partograph and interpretation of information on a partograph' 6here is also a need for training and supervision interventions to improve the capacit of mid"ives to interpret findings and ma/e management decisions' %ssential steps in managing obstetric emergencies (%SM:%) is

currentl suggested and applied in the countr to improve health care professionals (Pattinson ,*7*)' +onclusion 6here are a number of interventions that can be performed b mid"ives to decrease maternal and perinatal deaths; and s/illed attendance is a /e strateg to achieve these goals' 6he above findings reveal inade;uate competence in mid"ives attending birth in this health district' 6he presence of s/illed attendant is not necessaril the provision of s/illed care, our mid"ives do not meet the competence level re;uired to meet MD@Is -J.' %fforts are needed to upgrade, monitor and maintain mid"ives competence in district hospitals'

%eference ?radsha" D, >hopra M, !erber !, Ka"n E, Moodle E, Pattinson Get al' %ver death counts saving the lives of mothers, babies and children in South 4frica (,*7,)' >ape 6o"n& MG>' N ango DD, Mutihir E6, Kaabes %P, !igbu EH, ?uba M'S/illed attendance& the /e challenges to progress in achieving MD@$. in north central Nigeria' 4fr E Geprod Health' (,*7*); 7-(,)&7,3$2B' 4dego/e 44 et al, Hofman GN, !ongn u %E' Monitoring and evaluation of s/illed birth attendance& 4 proposed ne" frame"or/' Mid"ifer (,*77) (,1) 2.*D2.3 National Perinatal Morbidit and Mortalit >ommittee (NaPeMM>o)' National perinatal mortalit and morbidit committee triennial report (,**B$,*7*)' ,*77' Moodle E' Status of Maternal and >hild Health in !#N' ,*7* Gundare, 4 J @oodman S' 4n outcome evaluation of a perinatal education programme' S4 Eournal of Human Gesource Management (,*7,) 7*(2), -,-, B' @bangbade S, Harve S4, %dson 8N, ?ur/halter ?, 4ntona/os >' Safe mother "ood studies results from ?enin' >ompetenc of s/illed attendants, the enabling environment for s/illed attendance at deliver , in hospital dela s in obstetric care (documenting the 2rd dela ) ;ualit assurance'

Harve S4, 8ong ?, Mc>a"$?inns 4, Snadino <, Urbina K, Godrige( > et al J the Nicaraguan Maternal and Neonatal health ;ualit improvement group' 4re s/illed attendants reall s/illedL 4 measurement method, some disturbing results and a potential "a fo"rd' I8orld :rganisation ?ulletin, (,**1) B. (7*)&12B$13*' MacDonagh S' 4chieving s/illed attendance for all, a s nthesis of current /no"ledge and recommended actions for scalling upI DA<D health resources centre ,**.' 7$21 Mc>a"$?inns 4, ?ar/hatler ?, %dson 8, Harve S, 4ntona/os et >' :peration research results' Safe mother"ood result from Eamaica' >ompetence of s/illed attendants, the enabling environment for s/illed attendance at deliver , in$ hospital dela s in obstetric care (documenting the 2rd dela ) (,**-)' Fualit 4ssurance pro=ect Hussein E, ?ell E, Na((ar 4, 4bbe M, 4d=ei S, @raham 8 on behalf of the S4A% stud sub$ group' 6he s/illed birth attendance inde9& proposal for a ne" measure of s/illed birth attendance at deliver ' Geproductive health Matters, (,**-) 7, (7,)& 7)*$71* 4hlu"alia ?, Schmid 6, !ouletio M, !anenda :''4n evaluation of a communit $based approach to safe motherhood in north "estern 6an(ania' <nternational Eournal of @ naecolog and :bstetrics (,**2) B,, ,27D,-*' Harve S4, 4 abaca P, ?ucagu M et al' S/illed birth attendant competence& an initial assessment in four countries, and implications for the safe motherhood movement' <nternational Eournal of @ naecolog and :bstetrics (,**-) B1, ,*2D,7*' @unathunga 8', Aernando DN' 4ssessment of communit maternal care performance of public health mid"ives of a province in Sri Kan/a& a multi$method approach' South %ast 4sian Eournal of 6ropical Medicine and Public Health (,***) 27,27*D27B' Pattinson G> ?e Prepared& 6raining and on$going %ducational <nitiatives' <n 4 Monograph of the Management of Postpartum Haemorrhage' ,*7*