Building Midwifery Capacity in Papua New Guinea Caroline Homer Faculty of Health UTS

1. Building Midwifery Capacity in Papua New GuineaCaroline HomerFaculty of HealthUTS

2. Many acknowledgements • WHO PNG • UTS WHO CC • PNG National Department of Health • WHO MCHI Clinical Midwifery Facilitators and obstetricians • AusAID • Midwifery Course Coordinators at the 4 Schools • Midwives and doctors at the hospitals and health centres • PNG Midwifery Society • PNG O&G Society Thank you also to colleagues and women for the photos in this presentation

3. Objectives • Outline the WHO PNG Maternal and Child Health Initiative • Present findings from a Mid-Term Review

4. Maternal and Child Health Initiative • Funded by AusAID • Initially 2 year project • Undertaken by WHO PNG • UTS WHO Collaborating Centre sub-contracted to provide particular activities including recruitment, employment and monitoring and evaluation

5. Why this initiative?

6. Maternal and Child Health in PNG Controversy over these data – household survey data show MMR increasing form 360 to 733 per 100,000 live births from 1996-2006 “PNG needs to triple - quadruple its midwifery workforce” Source: SoWMR 2011

7. The broader health system • Lack of resources • Limited workforce • Problems with equipment and drugs • Limited baseline data • Small numbers of educators and clinical staff • Problems • Availability, accessibility, acceptability and quality

8. Ministerial Taskforce • The Minister for Health and HIV/AIDS convened a Ministerial Task Force • To explore the reasons for the deterioration in maternal health • establish a way forward to protect the future health of PNG girls and women • …. a range of strategies and recommendations made

9. ‘Making Pregnancy Safer’ Strategies • Core strategies : • Comprehensive, integrated reproductive health services with strong family planning services • Skilled care for all pregnant women by trained providers with strong midwifery skills during pregnancy and especially during childbirth • Skilled Emergency Obstetric Care (EmOC) for all women (and infants) with life-threatening complications supported by timely referral

10. Addressing the components of effective midwifery (ICM)

11. Aims of the MCHI • Improving maternal and child health: by equipping midwives and midwifery educators with appropriate and up-to-date knowledge and competencies • Increasing the quality of the health workforce: by contributing to improving the quality of midwifery training • Improve services in priority provinces: by increasing obstetric service delivery in two regions

12. Working along-side … • Four midwifery schools in PNG • University of PNG in Port Moresby • Pacific Adventist University in Port Moresby • Lutheran School of Nursing in Madang • University of Goroka • 8 international midwives recruited to each of the schools

13. Improving maternity care in 2 districts • Two obstetricians for district hospitals • St Mary’s, Vunopope • Kundiawa • Provide clinical care, teaching and mentoring to PNG medical officers nurses and midwives

14. Activities • WHO PNG • Work with NDoH • Provide coordination, support and technical advice • Assist with workshops • Support ongoing regulation processes • Supplied midwifery educational resources to the schools including textbooks, teaching resources and mannequins • Undertake site visits • Provide mentoring and support to MCHI obstetricians

15. UTS WHO CC • Employment of the MCHI team • 3 workshops per year • Course coordinators, educators, clinicians, MCHI team • Mentoring and support • Weekly teleconferences • Monitoring and evaluation

16. Evaluation • Mid-Term Review (end 2012) • 26 interviews • Educators, obstetricians, CMFs, clinicians, students, WHO and NDoH • 8 focus groups • Course coordinators, CMFs and MCHI obstetricians, clinicians • 17 reports • each midwifery school (course coordinators and CMF complete these) and MCHI obstetrician every 4 months

17. Surveys • 8 course coordinators • 6 CMFs and MCHI obstetricians • 38 clinicians and key stakeholders • 48 current students • Workshop evaluations

18. Findings • Findings suggest benefits although it is early days • Evidence of increased or improved: • learning opportunities for midwifery educators about teaching • clinical education experience for students • quantity of midwifery graduates • quality of the midwifery curricula • opportunities for key stakeholders and participating PNG clinicians to collaborate and strengthen skills

19. Numbers of midwifery students • 2011 – 49, 2011 – 73, 2013 (current) – 109

20. Having learning opportunities … • Two-way learning • “is a great privilege learning from each other” • “very good in terms of capacity building in the classroom, where I see my counterparts using different teaching methodology to make the lesson interesting” • “The presence of CMFs is fantastic. They are providing significant evidence-based knowledge to midwifery students. I also have learnt some new knowledge and skills from them too”

21. Building confidence … • “What has been significant is how we get to the students such as the different ways they are taught and the different styles we use to disseminate information during our sessions. It is more lively and interesting” • “The CMFs have instilled confidence in us to be better at what we do”

22. New ways of teaching … • “I have changed my teaching style - I use a lot of pictures to do the talking and effectively use the mannequins to do simulation as result of the exposure I have had. • Now am planning to use a lot of interaction where students can do role play and problem solving skills to make the lesson interesting and fun.”

23. Perceptions from students • Positive about learning • “best part of the course was having a clinical supervisor and teaching on bedside with the patient and lecturer” • Wanted more supervision in the clinical area • “Want more close supervision in practicum places as clinical staff in the hospitals and clinics do not have enough time to supervise the students” • “Although the lecturers had a lot of academic work to do, they still had time for us clinically. There were also too many of us for them to supervise but they still tried their best”

24. … the theory-practice gap • Challenges in bridging theory-practice gap • students are taught up-to-date information and evidence • clinicians in the hospitals may have been taught many years ago and have had little or no opportunity for upskilling or to have continuing education

25. Better quality graduates? • Stakeholders and clinicians felt it was too early to tell: • “This midwifery program has only been started recently and with the aim to improve quality of skills and improvement the expected results would be seen in 1 or 2 years time” • “It is too early for me to predict any improvement now, as time goes we would see some improvement as far as pregnant mothers are concerned. The outcome I hope would be good in 2 to 3 years time as those nurses and midwives who had been trained would be able to implement their skills”

26. Student’s confidence … • High levels of confidence • antenatal history • augment labour • care for women in labour and normal birth • actively manage 3rd stage • manage PPH • manage breastfeeding problems • Want more confidence • insert an IUD or implanon • manage eclamptic fits including MgSO4 • resuscitate a woman who collapses • manage a breech birth • undertake a vacuum extraction • manage a multiple birth

27. Improvements … • Length of the midwifery program: • Students said: • “Midwifery education should be lengthened to 2 year program, so that we have enough time” • “Midwifery is a broad subject and can be taught for 2 years instead of 1” • Focus on rural practice and supervision • “Extend rural placement so enough time to get procedures especially complications done” • More clinical supervision especially from educators

28. Clinical services in 2 district hospitals • Specific clinical services have been established in the two areas where the MCHI obstetricians are based • family planning services • increased training for registrars, midwives and nurses • weekly clinical meetings discussing cases • increased use of the partogram • increased number of operating theatre hours • Maternal deaths review • Community health worker upskillingin EmONC

29. Challenges with the Initiative • Cross-cultural challenges • Understanding the PNG context • Respecting different practices • Inequities in remuneration and conditions • MCHI and national staff • Lack of access to internet • Communication, teaching and learning • Complex governance and communication systems • NDoH, WHO, UTS, AusAID • Safety and security

30. Other activities • Regulation • The PNG Nursing Council is working towards national accreditation of midwifery education and national registration of midwives • Association • The PNG Midwifery Society has been reinvigorated, joined ICM and is in a twinning program with the Australian College of Midwives

31. Finally …. • Bold steps are needed to ensure that “every woman and her newborn have access to quality midwifery services” (Ban Ki Moon 2011) • Strengthening the midwifery workforce is a key to saving lives and improving maternal and child health

32. Thank you • WHO PNG • UTS WHO CC • PNG National Department of Health • WHO MCHI Clinical Midwifery Facilitators and obstetricians • AusAID • Midwifery Course Coordinators at the 4 Schools • Midwives and doctors at the hospitals and health centres • PNG Midwifery Society • PNG O&G Society