Situation Analysis of Community Midwives Training in Sindh April-May 2012

Imtiaz Kamal SRN;SCM; B.Sc; MA SecretaryGeneral NCMNH President MAP

List of Acronyms and Abbreviations BPS B.Sc CMW CMWI EmONC DoH DMC DoH DoPW : EDO FHT FP FWV FWW Govt. : IMR LHV LHW MAP M.B.B.S MCH MNCH MMR MoH MoPW NMR NCMNH Ob/Gyn PHC PHS PMA PNC PTS RHC RM RN SBA SOGP SOM SON TBA UNICEF UNFPA WHO : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Basic Pay Scale Bachelor of Science Community Midwife Community Midwifery Initiative Emergency Obstetric and neonatal Care Department of Health District Midwifery Committee Department of Health Department of Population Welfare Executive District Officer Female Health Technician Family Planning Family Welfare Visitor Family Welfare Worker Government Infant Mortality Rate Lady Health Visitor Lady Health Worker Midwifery Association of Pakistan Bachelor of Medicine and Bachelor of Surgrey. Mother and Child Health : Mother Newborn and Child Health Programme Maternal Mortality Ratio Ministry of Health Ministry of Population Welfare Neonatal Mortality Rate National Committee for Maternal and Neonatal Health Obstetrics and Gynaecology Primary Health Care Public Health School Pakistan Medical Association Pakistan Nursing Council Preliminary Training School Rural Health Centre Registered Midwife Registered Nurse Skilled Birth Attendant Societies of Obstetricians and Gynaecologist of Pakistan School of Midwifery School of Nursing Traditional Birth Attendant United Nations Childrens Fund United Nations Population Fund World Health Organisation 2

Appreciation
All the Schools of Midwifery have participated in this Situation Analysis. The principals and the tutors took time and made the effort to fill the Questionnaires to the best of their ability. Their efforts are very much appreciated. Special thanks are due to: Dr. Nabeela Ali for her support to conduct this activity; Dr. Sahib Jan Badar for her positive acceptance of the situation and need for change; The two coinvestigators, Nasim Abbasi and Mehmooda Afroz for the field work:; Anadil Khan and Sara Haider for manual compilation of data while remaining patient and working very hard to confirm the accuracy of the information received; Ali Raza for working untiringly on the tables; Dr. Iftikhar Mallah for his help in following up with the respondents to get the questionnaires back on time ; The Staff of MNCH Directorate, particularly Mr. Shafiq, for very promptly providing information related to CMWs; Those with whom the investigators met personally deserve special gratitude. It was very encouraging and refreshing to receive frank and accurate Information. TAUHs contribution in this Situation Analysis is also gratefully acknowledged .

Table of Contents Topic Page #

Introduction1 Definition of midwife.2 Definition of Midwifery..2 Midwives can Save Lives ..3 B. Emergence of Community midwife...3 C. Situation Analysis of Midwifery Education in Sindh4 1. Objective of the Situation Analysis..4 2. Methodology....4 3. Factors Influencing Validity of Data.5 D. Findings6 1. Implementation of the CMW curriculum6 2. Meeting Requirements of Training (Tables 10 & 11)...6 3. Support System for the Schools of Midwifery 7 4. Factors Influencing the Quality of Teaching.8 5. Problems.9 6. Twelve point Action Plan for immediate attention..10 7. Recommendations for the near future..11 8. For facilitating action...13 Conclusion.14 PART 2 ;.Tables ( 1 to 21)..15-36 List of Tables 1. Institutions training CMWs 2. Numbers of Schools training various categories of midwives 3. Establishment, Inspection and Recognition of Midwifery Schools by Pakistan Nursing Council (PNC) 4. (a) Faculty Strength of Midwifery Schools (b) Visiting faculty of Midwifery Schools 5. Bed Requirements of Allied Hospital 6. Practical Obstetrical Experience 7. OPD Experience 8. Each Students Experience in Service Areas 9. (a) Language of Instruction (b) Reasons for using Urdu and or Sindhi 10. Teaching in the classroom 11. Teaching of Major skills (procedures) 12. Method of Teaching Midwifery Skills /Procedures 13. (a ) Teaching and Performance of Midwifery Skills 4

14. 15. 16. 17. 18. 19. 20. 21.

(b) Collaboration with Allied Hospital(s) Provision of Text books to the Students Audio Visual Aids Evaluation of Teaching / Learning Outcome Approaches to Practical Experience Planning of CMW Training Source of access to information for faculty and students Choice, Orientation and Capacity of faculty Professional Development Opportunities

Part 3 The Past, the Present and The Future of Midwifery Education in Pakistan...37

Annexes
Annex 1 : Annex - 2 : Annex - 3 : Annex - 4 : Annex - 5 : Annex - 6 : Annex - 7 : Annex - 8 : List of Schools Interview guide to get information from the principals and tutors Institutions Visited and Person Interview guide for Obstetricians and Doctors in Ob/Gyn unit Interview guide for clinical supervisor Interview guide for Medical Superintendent/focal person Interview guide for Midwifery Student Evaluation of the Teaching Session

Preface This Situation Analysis of Midwifery Education is the second one performed in Sindh with a gap of 12 years. The previous one covered all the schools. This one focuses only on public sector schools of midwifery. The findings are a mixture of some positive change but much is the same as was 12 years ago. There has been improvement in the material resources of the schools. There are some well equipped skill labs. Some schools have computers also. There is a new curriculum for Community Midwifery students. There is teaching learning printed material in English and in Urdu. Development partners are contributing to the development of midwifery schools. Some very beautiful new schools have been built specifically for midwifery training which gives identity to midwifery as a profession. The Midwife is emerging on the scene of maternal and child health. Sindh government projects midwifery in a big way on or around the 5 th of May every year to celebrate International day of the Midwife. The positive attitude of, and openness of discussions with those met and interviewed shows that there is sincere interest in improving the educational standards of midwifery education in Sindh. The situations which are static, however, are a cause for great concern. There are four major weaknesses which existed 12 years ago and remain exactly as they were. The first is the limited capacity of the teachers to teach midwifery effectively; the second major gap is the theory only midwifery training with extremely limited (even none) practical experience; the third is the examination system which does not include testing of competencies (it is possible to get a diploma on the basis of answering a few questions) and the fourth gap is the inspection system of certifying the overall quality of the institutions ( schools and hospitals). Many of these institutions do not meet the requirements of educational institutions capable of producing competent midwives. The silver lining is that these weaknesses are now not pushed under the carpet. They are being brought out in the open. They are being discussed and efforts for change are becoming visible. This Situation Analysis is one such effort. It has been a most rewarding exercise. At last midwifery is receiving some long overdue recognition Imtiaz Kamal Principal Investigator Secretary General, NCMMNH President, Midwifery Association of Pakistan

Situation Analysis of Community Midwives Training in Sindh

Introduction Pakistan is the 6th most populous country in the world. Its Maternal Mortality Ratio (MMR) at 276 per 100,000 live births, is the highest in South Asia The urban ratio is 175 and rural is 319. The provincial ratios are: Punjab 227; Khyber Pakhtunkhwa 275; Sindh 314; and Balochistan 785. Most of the women who die are poor and from rural areas for whom skilled care at birth is either unavailable or inaccessible. 61% of deliveries occur at home and are attended by Traditional Birth Attendants (TBAs) or family members. Skilled Birth Attendants (SBAs) conduct 34% of facility based deliveries and only 5 per cent of home births (1). To this are added very low contraceptive prevalence, fairly high abortion rates due to unwanted and untimed pregnancies and marital fertility still at 6 children The most deprived are the rural, poor and marginalized women. The government of Pakistan has tried many approaches to take skilled care to the rural areas but it has not been very successful. This included the Lady Health Visitor (LHV), a legacy inherited from the British Raj. She came from urban and periurban areas, got trained in the city and stayed in the city. Training the Dais for a year and registering them was another effort. More than a decade ago their training was stopped but the previously registered Dais can still re register with Pakistan Nursing Council (PNC) if they so wish. Thousands of traditional birth attendants (TBAs) were also trained and left on their own to practice without supervision or support. They went back to their old practices within 3 to 6 months. A direct entry midwifery training programme produced thousands of midwives. They got absorbed either in the primary health care facilities or in the small maternity homes in the private sector. Midwifery was made compulsory for the nurses as a pre requisite for promotion in the public sector. Almost every female nurse holds a diploma in midwifery but very few opt for midwifery as a profession. The main reason is that whether one is an LHV, a midwife or a nurse-midwife there is no defined future for a midwife in Pakistan. There is no career pathway, nor are there any opportunities for professional growth and upward mobility. A midwife, if she wishes to remain a midwife, remains at the lowest rung of the professional ladder. ( BPS 6) The profession of midwifery has not been allowed to develop as a distinctly separate profession in Pakistan. It has always been dominated by nursing e.g. Nursing Training is for four years. Three years of nursing and one year of midwifery. * __________ * A communication from Registrar PNC to Midwifery Association of Pakistan 1

Definition of A Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognized 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 practice midwifery. The midwife is recognized 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 midwifes 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 counseling 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 womens health, sexual or reproductive health and child care. A licensed midwife may practice midwifery in any setting including the home, the community, the health facilities or as a self employed professional. ( For competencies of a midwife see Annex 2)

Definition of Midwifery Modern midwifery can be defined as, The art and science of providing professional services to the pregnant women throughout the maternity cycle, to ensure uneventful pregnancy, safe delivery and normal puerperium.

Midwives can Save Lives History bears witness to the fact that midwives can save lives and that it can be done without riches. The recipe for success, given below, is four and a half centuries old. Midwives must be: Trained well (competent) Authorized (Regulated by law) Supported (by EmONC Services) In Pakistan, so far, the Midwife does not enjoy a professional status of the Skilled Birth Attendant or of a Specialist in Normal obstetrics. (Even today she is in BPS 6) Since the midwife did not enjoy a professional status, her education did not receive much attention. Evidence exists that for almost four decades, a majority of those who get training in midwifery, get their diplomas on the strength of theoretical knowledge. Obviously they do not meet the definition of a skilled birth attendant. In 2000 a Situation Analysis of Midwifery Education in Sindh was commissioned by UNICEF (2). It was followed by a Strategic Planning Consultative Workshop. The report was widely disseminated (3) The findings of this most recent Situation Analysis (April /May 2012 ) reveal that some positive change has taken place. Midwifery is getting some recognition but there is not much change in the standards of midwifery education and the status and identity of the midwife. Midwifery has yet to become a priority in the health policies or in the strategic planning of maternal and neonatal health. B. Emergence of the Community Midwife. To achieve the MDG 5 (a) and (b) and take skilled care to the rural areas, the government of Pakistan developed a National PC-1 for Maternal, Neonatal and Child Heath (MNCH). It had a large component of training community midwives. Out of the national target of 12,000 Community Midwives (CMW) Sindhs target was about 2000. Development partners joined the efforts and the PC 1 was implemented in 2006. A Curriculum, developed in 2003 for community midwifery was enriched and is being used. Sindh started its regular training of CMWs in 2007. Before that a project funded by USAID, Pakistan Initiative for Mothers and Newborns (PAIMAN) had trained master trainers and a couple of batches of CMWs in two districts in Sindh. When the Health Department in Sindh started implementation of CMW training they faced some challenges. Some technical assistance was needed to strengthen the midwifery programme and to plan sustainability of the CMW. Upon the request of the health authorities of Sindh, the Technical Assistance Unit for 3

Health ( TAUH) of USAID,in Pakistan, contracted a midwifery specialist to provide technical assistance. C. Situation Analysis of Community Midwives Education in Sindh was one of the ToRs of the consultant. 1. Objectives of the Situation Analysis Evaluate the implementation of the CMW curriculum Identify gaps between the prescribed requirements of training and the actual implementation of the curriculum. Assess the support system for the schools of midwifery for practical experience of the students Assess the quality of training of Community Midwives (CMWs) Identify problems faced by the faculty and the students Make recommendations to improve training of CMWs 2. Methodology 2.1 Listing of the population of the study A list of all the schools in the public sector that trained CMWS was procured from the Directorate of MNCH ( Annex 1) 2.2 Sampling It was planned to include all the 20 schools which are training CMWs 2.3 Tools A Questionnaire used for the previous situation analysis was modified to get fairly detailed information from the schools (Annex 2).. Interview Guides: 4 interview guides were developed for discussion and to exchange information with the doctor in charge of Ob/Gyn Unit, the Clinical Supervisors, the Medical Superintendents (MS) of the allied hospitals and with the CMW Students. The interview guide used for the Medical Superintendents was also used for the focal persons. (Annex 4 to 7) Evaluation of Quality of Teaching. A form was developed to assess the teaching skills of the teachers.( Annex 8)

2.4. Methods of Data Collection Meeting with principals and tutors 4

An opportunity arose (with the help of Director MNCH) to meet with the principals of all the 20 schools and a few tutors also. They were briefed about the purpose of the study. The Questionnaire was discussed with them line by line and guidance was provided to complete it. They were given two weeks in which to fill and return the Questionnaire. Out of the 20 questionnaires 18 were received back. One school was not functional. Interviews 25 % validation was planned. Therefore five schools were selected in consultation with Director MNCH. Each school was visited by two investigators. In depth interviews were held and responses documented. (For persons met see Annex 3) Evaluation of teaching The investigators attended one or two ongoing teaching sessions in each school and documented their observations using an evaluation tool. ( Annex 8). The observations were discussed with the teacher after class. It was very encouraging to note that the attitude of the teachers was very positive and they requested assistance for improvement. Compilation of Data Data was cleaned and compiled manually. It proved to be a very big challenge for the two assistants hired for the purpose. Findings were documented as received. Many responses were incomplete, at times contradictory, and largely left blank. 3. Factors Influencing Validity of Data The information received during site visits and three opportunities of personal contacts with 90 % of the principals and tutors, was quite different from what was received through the filled Questionnaires. It is felt that the verbal exchange of information is more reliable. Hence where needed, it has been added in the notes below each table 3.1. Facilitating factors All the respondents during the personal contact were very open and frank in their discussions. When assured of anonymity they stated facts. Any critical remarks based on observations, when communicated to the respondents, were received very positively. 5

 The respondents discussed their problems and asked for guidance. Most of these problems are quite genuine. The principal investigators, being a senior midwifery educator, and not a stranger to most, helped in soliciting honest responses. 3.2. Limitations The information asked for in the questionnaire was either not easily available to the respondent or there was some hesitation in putting it in writing. There were a lot of No responses. It was very obvious that it was the first time for the respondents to participate in a study. Perhaps lack of experience was the reason and not a deliberate action to leave out information The information received through the questionnaires was very different from what was found during the validation visits and during the refresher workshops given in the month of June 2012. According to the responses in the questionnaires all was well as far as teaching was concerned. Therefore valid analysis of Data became very difficult.

3.3 Assumptions The questionnaire being in English could have been one of the reasons for incomplete answers, inaccurate answers or no responses. Even though in this study the training of CMWs was the focus, it is assumed that the same strengths and gaps apply to all the categories of midwives being trained, because they are being trained in the same schools by the same teachers. In fact the curriculum of the other three categories is very sketchy, out dated and inadequate. It was last looked at in 1994. It says that it is for 4 th year students but it is also being used for LHVs and pupil midwives.

C. FINDINGS 1. Implementation of the CMW curriculum It was not possible to find out whether the curriculum is being fully covered or not because none of the schools visited had an academic calendar or a teaching plan for a quarter or a month. Teachers do keep an attendance register in which the topic taught that day is entered. But if one wanted to know what will be taught next week or next month the plan was not available 2, Meeting Requirements of Training (Tables 10 & 11) 6

In the CMW Curriculum total theory hours are 398 and practical hours are 1306. Contrary to the responses in the questionnaire, interviews with teachers, clinical supervisors and students and an analysis of the teaching time revealed that, with the current practices, it is not possible to meet the requirements of clinical experience. The reasons being: 2.1 The schools observe timings of general education schools i.e. 8.30 am to 1.30 pm or 2.00pm. There are theory classes in the morning till about 11.00am. After that the student goes to the different service areas for a maximum of two or two and a half hours. For those in the labour room, even if there is a woman in labour she may or may not deliver within those two hours. 2.2 According to the teachers, the students refuse to come in the afternoons and evenings. When asked supposing the students are ordered to comply and attend evening shifts, will the teachers agree to come in the evenings?, no teacher replied in the affirmative 2.3The theoretical part of the curriculum perhaps gets covered somehow but the practical part, i.e. skill development in the real life situations, is not being fully implemented. In the 6 schools visited (5 for validation and one for observation of training in MIS), 90% of the students had not conducted any deliveries. Of these 19 had completed their training and the others were in the 13 th month of their training. Some o f the teachers think that the students will learn to deliver babies in the community setting .Yet, with one exception, no school has reported giving community experience to the students. 2.4 There are now clinical supervisors in some of the schools. They are not clear about their role. They think that are only to supervise the students. Had their title been clinical instructor they might have understood their task. They have not had any orientation. They were neither familiar with the curriculum nor with the Log Book .There was no information available about planned clinical instruction 2.5 CMW training was planned to be a residential course. This requirement has not been implemented because majority of the students are married. This is affecting the quantity and quality of learning of students. 3. Support System for the Schools of Midwifery From the written responses it was felt that there is regular contact between the school and the hospital staff and administration (Table 13 b) From the site visits and verbal communication with the faculty it was found that the support system required for training midwives is extremely weak. With rare exceptions, there is very little collaboration between the schools and the hospitals used as field practice areas. 7

The Medical Superintendents, the doctors in charge of Ob/Gyn Units and the focal persons were not aware of the training needs of the CMW. They had seen the curriculum, or the Log Book. Some of the doctors were not aware of the presence of CMW students in their Units. According to the tutors, the clinical supervisors feel that tutors are getting an incentive for teaching (Rs. 1000 per month), but the clinical supervisors are not getting any thing. Hence they do not participate much in clinical teaching. 4. Factors Influencing the Quality of Teaching In spite of the input and efforts of MNCH Directorate, unfortunately, this is the weakest area of CMW training. There have been short courses for ALL the tutors in teaching methodology but teaching skills of most of the teachers leave much to be desired. All teachers teaching midwifery are Nursing Instructors. Majority of them have a diploma in teaching of nursing. Since there is no such diploma available for teaching of midwifery, they lack the capacity to teach midwifery All midwifery teachers are Nurse-Midwives. Having a diploma in midwifery is a requirement for promotion for female nurses. Therefore they have to get training in midwifery. Since it is an imposition, they just go through the formality. 95% of them pass their examination on the strength of some theoretical knowledge. It is rare to see a nurse midwife opt for midwifery as a career. When they have to teach midwifery they do as asked. During a ToT , a couple of years ago, many tutors admitted that it was the first time in their life to be exposed to child birth and to conduct a delivery The teaching sessions evaluated by the investigators revealed their two weaknesses i.e their weak knowledge and skills of midwifery , and their dependence on lecture method of teaching. None of the teachers observed had a lesson plan ( They knew of the teams visit). They taught from memory and demonstrated many gaps in their knowledge. Some carry the Manuals with them and dictate notes. For teaching of skills they use demonstrations in the skill lab without any check lists. Only one tutor used a check list. Institutions which are training nurses also give priority to their nursing students . They consider CMWs as additional work. Since CMW is not their main responsibility it is done because it has to e done With a couple of exceptions , the tutors have problems getting the doctors to take classes

Both Teachers and Students have language problems, mostly with English but some students have problems with Urdu also

5. Problems Teaching Problem Theoretical Teaching

Practical Teaching

Shortage of books in Urdu No books in Sindhi Irregular attendance of students, lesson have to repeated twice Weak educational background of the students makes teaching very difficult Doctors, by &large, do not take classes Table 4 (b).

Shortage of Equipment in Skill Lab Problem of transport for field work Non cooperative hospital staff Clinical supervisors do not take their responsibilities seriously Students are not given the opportunity to practice their skills Students do not want to come in the afternoons or evenings Married students come late

According to the teachers some of these problems have been identified by the inspection teams of Pakistan Nursing Council

Faculty Problems

Extreme shortage of teaching staff ( A genuine problem) Table 4 (a) Most teachers have to teach nursing students and midwifery students Heavy work load Lack of opportunity for higher education (Table 21) The difference between the ages of the students presents problems in adjusting the level of teaching Amount of incentive is very little. Money arrives late. Bank charges are high. 9

Students Problem

Language Problem Hostel and school are not close to each other. No arrangements are made for transport. Problems in hostel living Problems in getting practical experience. Stipend is received very late

Administrative Problems

School has no allocated budget Some nursing schools have a budget but the principals does not have DDO power. Transportation problem for field work New schools have no support staff (Chawkidar, Cook, Aya and Gardener)

Problems with Examination Board

Examination centers are too far away.( Center for Umar Coat students was in Jam Shoro) Lot of delays in getting information about dates of Examination, particularly for viva. Many examiners are administrators of schools and are not in touch with midwifery A lot of delay in announcing results and in issuing diplomas

Problems with Pakistan Nursing Council A lot of delay in issuing licenses Answers to letters are either very late or not received.

6. Twelve point Action Plan for immediate attention

PRIORITY 1. Planning and implementing regular diploma courses to qualify midwifery teachers for the future. For one or two years short ToTs can continue to be given to build the capacity of the current tutors teaching midwifery. 10

2. Approval of separate budget and separate faculty for schools of midwifery 3. Appointment and training of clinical instructors 4. Closer collaboration between the school, hospital administration and Nursing and medical staff of Ob/Gyn Unit. 5. Improving the examination system and introducing testing of midwifery skills through OSCE without any delay. 6. PNC to establishing a small committee to review the Rules and Regulations for Midwifery Practice and finalize them to guide the CMW for her permissible functions 7. Midwifery should not be mandatory for female nurses. They should have the choice to specialize in midwifery or in any other area of health care. 8. Reducing the long delay in deployment due to a long gap between the students passing their final examinations and getting their license. 9. Equipping the schools with required resources particularly human resources 10. Developing a career structure for midwifery personnel without having to become a nurse to facilitate their move up the professional ladder. 11. Pakistan Nursing Council revert to its original name Pakistan Nurses, Midwives and Heath Visitors Council. ABOVE ALL 12. Strengthening the practical training of CMWs for achievement of expected levels of midwifery competence to ensure safe practices.

7. Recommendations for the near future

7.1For Pakistan Nursing Council: Develop a standard, competency based curriculum for all categories of midwives. Clearly define Scope of Work of the midwife with Rules and Regulation for Midwifery Practice and a Code Of Conduct.

11

Disallow large teaching hospitals with medical students to have schools of midwifery Strengthen the inspection and examination systems. Develop Mechanisms to cut down on delays in the registration process of midwives..

7.2. The Provincial Health Departments: Develop a five year human resource plan, for training midwifery personnel. Establish a District Body to manage at the district level, selection training, deployment and supervision of CMWs Design a strategy, for replacing TBAs and Dais with trained CMWs Either make CMWs a part of the health system like the Lady Health Workers or let them be self employed but regulate their practice

Develop regular diploma programmes to train midwifery teachers.

Develop a career structure for the midwives to allow for continuous professional growth

Develop CMWs Work Place into a Birthing Station to offer the woman a choice of place of delivery

12

7.3. Maternal, Newborn and Child Health programme :

Select a few schools of midwifery and assist them to develop into Centers of Excellence. Use these to build the capacity of the current midwifery tutors through mentorship .

Strengthen the system for monitoring midwifery training. Ensure that the focal persons fulfil their obligation in this regard.

Focus on faculty development for the new schools

Encourage already trained and licensed nurse midwives to opt for midwifery and train them as tutors and clinical instructors.

Select a few maternity homes in the private sector to provide practical experience to the students providing them recognition through MNCH logo, indicative of high quality services

7.4 The National Committee for Maternal and Neonatal Health ( NCMNH) Midwifery Association of Pakistan : . Organise a common platform comprising obstetricians, paediatricians and midwives. This should take place in collaboration with the Society of Obstetricians and Paediatricians, and Midwives of Pakistan to ensure proper understanding of the role of midwives in obstetrical care and in saving lives.

Recommend that to eliminate the confusion between the term dai and midwife the professional midwife be called Qaabila,(the Arabic word for

13

midwife, used in Iran and Afghanistan also)

IF ACCEPTABLE Midwifery be called Qbaaleh, the Arabic word for midwifery, The schools preparing professional midwives be called Madrassa-al-Qabaaleh, and Colleges of advanced midwifery be called Kuliaat-al- Qabaaleh, (college of midwifery ) 8. For facilitating action, it is recommended that : Coordinated Efforts from ALL Stake holders are required: 8.1 Suggested partners: Department of Health and MNCH Programme Pakistan Nursing Council Directorate of Nursing, and Sindh Nurses Examination Board National Committee for Maternal and Neonatal Health Association for Mothers and Newborns WHO.UNICEF,UNFPA Development Partners Professional Bodies( SOGP,MAP, PMA) International Confederation of Midwives ( ICM)

8.2 Strategy A Strategic Planning Meeting with all the partners ( UNFPA is planning a meeting on the very near future)

The Provincial 14

 Departments of Health to take the lead and develop an Activity Plan Each partner assumes responsibility according to its mandate and capacity Partners to have time lines for honouring their commitments . MNCHs additional responsibility will be of follow up. and monitoring.

Conclusion The Midwife is emerging as the front line soldier in the struggle for reducing unacceptably high maternal and neonatal mortality and morbidity in Pakistan. All concerned have to accept the fact that there has been very little change in the standards of midwifery education since 2000. Concerted efforts are required to improve the situation. It is possible with coordinated and efforts of many partners. It can be done because there are some very positive signs of the desire for change. Major element to achieve success is ACCOUNTABILITY for implementation at each level. Otherwise, after an other decade, there might be still an other situation analysis and still a few more reports and mothers and neonates will continue to die

15

PART 2 (Tables 1 to 21)

Table 1 Institutions Training CMWs Type & Number of Schools & Type & Number of Allied Hospitals Type of School Nursing and Midwifery Public Health School Community Midwifery # 11 3 4 District Hospital Taluka Tehsil Type of Hospital # 14 2

16

Total

17

16

Public health schools do not have a hospital designated for the school . They borrow facilities. Schools teaching nursing and midwifery have the additional responsibility of training CMWs. Only few schools teach only CMWs Table 2 Number of Schools Training Various Categories of Midwives Training For Trained nurses Pupil midwives * LHVs CMW Total # 6 4 2 15 27** Length of training One Year One Year + months 1st Year of Training 18 months

The public sector schools will stop training Pupil midwives in 2013. The private sector can continue to train them if they choose to do so. ** Some schools are training more than one category hence double count

Table 3 Establishment , Inspection & Recognition of Midwifery Schools By Pakistan Nursing Council ( PNC) The School Established Recognized by PNC PNCs most recent inspection inspection before Before 2000 6 2 2 1 2001 -2005 3 2006-2010 4 2 7 1 2011-2012 2 1 1 1 17

the most recent inspection training of CMW started 1 13 1

Of the 15 schools training CMWs only 5 are recognized by PNC. This does not seem logical because midwives are being allowed to sit their finals. It would not be possible for 11 schools without recognition. An occasional unrecognized school gets affiliated with a recognized school.

Table 4 ( a) Faculty Strength of Midwifery Schools Designation Sanctioned Posts 9* Filled Posts Teaching on ad hoc basis 1 Qualification RN RM LHV BSc MBBS 4 1 2 4 1 2 1 18 2 2

Principal Midwifery Tutor, Incharge Tutors

99 4 22

5 1 7

Clinical instructior Total Ministerial Staff and cleaners

19 8

*These principals are of Nursing schools. Midwifery schools do not have separate principals. There is a total of 30 filled posts for 17 schools. This does not seem accurate. Information received from Directorate of MNCH is totally different.

Table 4 (b) Visiting Faculty of Midwifery Schools Teacher Obstetricians English Teacher Other 1 - 50 hours 3 1 51-150 hours 1 2 151 plus hours 5 Who pays the guest lectures Student School Not paid 2 4 3 1 1

English is not taught to CMWs. Only one school visited said that they have arranged an English teacher for CMW studen

Table 5 Bed Requirement of Allied Hospital PNC Requirement Ante-natal beds Lying in beds(post natal beds) Labour beds Septic Beds # A 8 30 #Less than A 4 12 #More than A 7 2 # Equal Minimum occupied to A Less More Equal than A than A to A 4 4 4 2 1 8 1 1

3 4

4 6

6 3

6 4

4 3

3 1

3 2 19

Emergency Beds

Total beds required for an Ob/Gyn Unit is 49. In District and Taluka Hospitals it is very difficult to ear mark beds for specific conditions. The concept of Lying in beds is outdated. Woman do not stay in the hospital for more than a few hours after delivery. To have 30 lying in beds is illogical. *One hospital has an Ob/Gyn ward on 60 beds with no specified number of beds for different conditions

Table 6 Practical Obstetrical Experience PNCs Requirements (A) Deliveries: Observed 5 Assisted 5 Delivered Under supervision 5 More than (A) 5 3 2 Actual experience of (each student) Less than (A) 3 4 5 Equal to (A) 7 8 5

20

Delivered Independently 10 Ante-natal Examination 2 25 1 1 25

8 4 7 5

3 5 4 5

Deliveries in journal 25 Follow up of deliveries

8 schools have admitted that they are providing less than the required amount of experience in delivering babies. Only 3 schools are providing the required amount of experience. This is a cause for great concern and requires prompt action.

Table 7 OPD Experience Students days in each clinic OPD Clinics Less than 1 week 9 9 More than 1 week 4 3 21 1 week

Ante-natal clinic Post-natal clinic (Gynaecology clinic)

Family planning clinic Well babies clinic Sick babies clinic Infertility clinic Casualty (emergency) Any other OPD service

8 6 5 5 5 6

3 1 2 1 1 1

According to this table students are getting varied experience in out patient clinics. Since PNC does not specify the length of experience in each field practice area the teachers and needs of the hospital can be the deciding factor

Table -8 Practical Experience Each students experience in the service areas Service Area Experience (number of weeks) Day Time Night Time 4 wee ks 5 8 week s 2 12 week s 2 4 weeks 3 8 weeks 12 weeks 1 2 22 4

no respon se

incorrect respons e

Ante-natal

Ward Labour and delivery ward Immediate Postpartum Room Postnatal Ward Gynaecology Ward Operation Theatre New born nursery - Normal Babies - Sick babies - Premature babies Community experience: - MCH Center - Maternity Hospitals - Public Health School - Community centers - Home visiting STD/AIDS Clinics Social Hygiene Center Any other

5 6 7 6 7 5

5 2 3

5 4 4 4 4 3 1 1

1 1 1

2 2 2 3

3 3 3 3 3 3

1 1

3 4

This table reveals the amount of time each student spends in each field practice area. From the variety of length of time in different departments it is clear that there is no standard practice. The accuracy of this information cannot be vouched for . It seems that rough estimates (and guesses) have been used to respond e.g 4 & 8 weeks of night duty in HIV AIDS Clinic.

Table 9 (a) Languages of Instruction 23

English only Urdu/Sindhi First in English then translation in Urdu or Sindhi Terms in English and mostly explanation in Urdu or Sindhi or

2 13 10 11

Language of instruction has emerged a constraint According to this table 2 schools are using English only to teach. This is neither necessary nor possible. Also see note below for Table 8 b. Table 9 (b) Reasons for using Urdu and or Sindhi Midwifery tutors feel more comfortable in using their national language or mother tongue All teachers feel more comfortable in using their national language or mother tongue Students feel more comfortable in using the national language or mother tongue 9 8 13

Most teachers and almost all the students have limited command over the English language and not full command over Urdu.. Many teachers are not Sindhi speaking. Many students do not understand Urdu. There have been requests from the students to translate the Manuals in Sindhi

24

Table 10 Teaching in the classroom Most of the time 12 12 6 6 1 8 1 5 7 3 2 8 8 6 6 5 Use of library Some times 3 3 7 6 9 5 7 4 2 7 3 3 3 4 2 6 Quiz 1 1 2 2 1 1 1 1 1 1 5 1 1 1 1 2 1 2 1 1 2 2 1 5 4 4 3 5 2 3 3 3 2 Very rarely Never No incorrect response response 2 2 2 3 2 2 2 3 3 3 2 2 2 2 2 2

Lecture Lecture discussion Demonstration Lecture demonstration Role play Demonstration in the demonstration room Demonstration in the real life situation Case studies in delivery book (written up) Application of knowledge Case studies (presentation) Projects Group work Notes are dictated Notes are written on the black board which the students copy Notes are provided as handouts Assignments Other methods: Please describe

According to this table Lecture and demonstration are the commonest methods of teaching. Only one school is using the real life situation for demonstrations. Notes are the next common method whether, dictated, written on the black board or provided as hand outs. This shows that the students are not being guided to use the Manuals and other books. 25

Table 11 Teaching of MAJOR Skills (procedures) Skill/Procedure Top to toe examination of women Identification of pregnancy Identification of high risk pregnancy Norman ante-natal care Screening mothers for home delivery Advising mothers for preparation of delivery Recognizing deviation from the normal course of pregnancy Admitting the women in labour Using a Partograph Care during labour Care during delivery AMTSL Retained placenta Recognizing deviation from the normal in mother and baby during puerperium Immediate postpartum care Yes Taught 7 8 6 7 7 8 7 5 6 6 5 5 4 4 5 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 2 2 1 1 2 1 2 2 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Yes No response No Only Observe Perform Incorrect response

26

Immediate care of the newborn Resuscitation of the newborn Care of low birth weight babies Care during the puerperium (mother and baby) Recognizing deviation from the normal during puerperium (mother and baby) Postnatal check up Counseling (General) Counseling for family planning Providing family planning services Health education Reporting and recording Making referrals Giving obstetrical first aid (basic EOC) Doing vaginal examination Doing episiotomy Repair of episiotomy Vacuum extraction Removal of retained placenta Management of incomplete abortion

5 1 2 3 3 4 5 4 5 5 5 5 5 5 2 2 2 3

3 4 3 4 3 2 2 2 2 2 2 2 2 2 3 3 3 2 2 2 2 2 1 1 1 1 1 1

2 1 1

1 1 1 1 1

2 1 2 1 1 1 2 2 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1

27

Post abortion care Promoting breast feeding Skills: to work in the community -Home visiting -Developing Linkages -Business skills -dealing with emergencies -any other

3 3

2 3

1 2

1 1

This is the MOST IMPORTANT table. 18 schools had filled the questionnaires. It was expected that they are teaching at least the MAJOR skills. As can be seen none of the skills is being taught be all the 18 schools. Only one or two schools have responded that the students can perform the skill taught.This is an alarming situation.

28

Table 12 Methods of Teaching Midwifery Skills/Procedures Tutor or Assistant Tutor A Demonstration in the skill lab Demonstration on the patient Competencies certified by Supervised practice of each skill 11 B 2 C 1 Clinical Instructor A 2 B 2 C 3 Head nurse or staff nurse A 2 B 3 C 1 Doctor on duty A 2 B 2 C 2 2

Skill development

No response

12

A = Always

B = Some times

C = Never

This table reveals that demonstration of skills is mostly carried out in the skill lab. Twelve respondents have stated that there is supervised practice of each skill. It seems that it is also carried out in the skill lab. During interviews with the clinical supervisors it was found that there is very little supervised practice of skills in the service areas. According to this table competencies are certified by the tutors, clinical instructors and doctors on duty. There was no evidence of this practice during the interviews.

29

Table 13 (a) Teaching and Performance of Midwifery Skills Yes Are these taught according to the textbooks ? Are there protocols and checklists for teaching/ performance of skills Can perform as taught : Always Most of the time Some of the time Not regularly 16 15 2 No

2 8 4 1

This table reveals that teaching in the skill labs is not always being practiced in the field practice areas. Regarding the protocols and checklist, with probing it was found that all those who attended ToT had two or three checklists provided to them during the workshop. No one had any protocols.

30

Meetings of relevant individuals Head of Ob/Gyn department MS of the hospital Head Nurse of Labour Room Head Nurses of the wards Person in charge in OPD

Yes

Yes occasionally 6 1 3 3 1

No

10 12 13 12 10

1 1 1

Table 13 (b) Collaboration with Allied Hospital(s)

31

According to this table there is fairly good collaboration between the school and the hospital staff. Information collected during the field visits does not support this statement. One of the recommendations of this study is ,: Better collaboration between the school and the allied hospital Table 14 Provision of Text Books to the Students School provides free textbooks Student buy textbooks Students use library copies Students use notes given by the tutor 14 2 4 8

One assumes from the amount of stipend a CMW student gets, that she will buy her own books. Majority of schools are providing free books. This practice needs to be discouraged.

32

Table 15 Teaching Aids Item Overhead Projector Slide Projector TV VCR Models Charts Films YES 9 4 8 9 12 9 3 in working order 5 2 6 5 8 5 1 used often 3 1 2 3 5 3 used some times 1 1 3 3 1 1 1 not used 7 7 5 6 1 3 2

This table reveals that Majority of schools have a variety of AV Aids. Not all are in working order and not all are used frequently. Regarding the Models, it is not clear what can go wrong with them because 4 schools have said they are not in working order. Moreover out of the 8 in the next common method working order only 5 use them often Table 16 Evaluation of Teaching/ Learning Outcome Methods used for evaluating that learning has taken place Yes 11 11 8 9 8 1 9 3 8 No

Weekly tests Monthly tests Midterm Examination Term Examination Graded assignment Projects Case studies (presentation) Graded case studies ( written) Observe performance of skills

According to this table teachers are using the variety educational evaluation methods. In practice it emerged as one of the weak links of training. Tutors have requested assistance for constructing proper tools for evaluation.

33

Table 17 Approaches to Practical Experience Yes Clinical Supervisor Do you have a copy of the logbook? Do the students have a copy of the logbook? 8 Do you have a checklist for teaching and evaluating each skill ? According to this table the clinical supervisors have a copy of the logbook and checklist for the skills. This information does not correspond with the information received from the clinical supervisors and during the refresher workshops 7 5 1 1 13 13 2 3 No Use daily 5 6 used some time 3 2 not used No response 1 1

34

Table 18 Planning of CMW Training Topics Is the curriculum followed as written Is there an annual plan for teaching activities Is there a system of recording the theoretical teaching of CMWs Is there a systems of recording the competencies of CMWs as they learn them Is there time allocation for practical experience in the hospital Knowledge of CMWs training needs (different from other midwives) Do you have a list of expected responsibilities of CMWs after graduation 10 Yes No 5

15 9 9 9 10 5 5 4 4

According to this table there is planning of learning experiences. The theoretical teaching is fairly well documented in all the schools but there was no annual or monthly plan seen in any of the schools visited. This was also confirmed by the tutors during the refresher training workshops

35

Table 19 Sources of access to information for faculty and students Source Home access by internet Training institute access by internet (general) journals/research/manuals Training institute library (books) Seminar / Conference 4 7 3 2 3 6 2 3 5 Yes 4 for faculty 2 for student 1 No 4 4 4 4 3

This table reveals a fairly true picture of sources of information to the teachers and students. Libraries are not well equipped.

36

Table 20 Choice , Orientation and Capacity of Faculty Yes Were you given a choice about training CMWs ? Did you have to add this training as an addition to your previous workload if yes, has this affected your ability to cope with your previous workload Do you think CMW tutors should be practising midwives Do you get extra allowance for teaching CMWs Have you received training on teaching methodologies ? if yes , are you using these methods in training CMWs? Can you access latest information about midwifery Are you satisfied with your ability as CMW tutor ? Do you require strengthening of your knowledge and skills ? If yes, write the topics and skills 9 10 8 13 11 No 5 5 3 2 5

15 15

9 10 7

5 4 2

Most of the tutors have received short course in ToT. It is stated that all of them are using the teaching methods learned during ToT. There was evidence from the field that one tutor was making an afford to implement what she had learned.

37

Table 21 Professional Development Opportunities Yes 12 1 6 4 1 8 No 5 14

Opportunity Available Planned continuing education programme Some times workshops were given Individuals efforts (self learning) Do not have planned opportunities In service training programmes

Scholarships for postgraduate specialization Scholarships for B.Sc degree Scholarships according to seniority

1 11 12 10 1 1

According to this table midwifery faculty have opportunities available to them for professional development.

38

Part 3 THE PAST THE PRESENT & THE FUTURE Of Midwifery Education in Pakistan

39

THE PAST (100 years: From 1882 t0 1981) In the Last Quarter of 19th Century and First Half of the 20th Century in the Indo-Pak Subcontinent major role was played by: British Royalty Ladies of the RAJ Christian Religious Missions Individual Philanthropists

Midwifery Education Started Before Nursing Education. The First School of Midwifery opened in 1882 in King Edward Medical College Lahore Ladies of the British Raj contributed in one way or the other. Hospitals were named after them. Pakistan inherited the following: Lady Dufferin Hospital , Karachi (1894) Lady Dufferin Hospital Quetta (1896)

Countess of Dufferin Hospital, Hyderabad, (1916) Lady Aitcheson Hospital , Lahore Lady Wellingdon Hospital ,Lahore Lady Reading Hospital , Peshawar (1923)

During the Same period, the Christian Religious Missions made substantial contribution. All provided health care to women. Almost all hospitals had on the job training in midwifery and or in nursing.All Trainings were skill based : Originally the Dai-like training was more common Trainings got formalized much later as certificate /diploma courses Entry requirement was 8 years of schooling Two streams: Vernacular and Anglo-vernacular

40

Religious Missions opened more hospitals for women than the public sector The oldest one is Christian Memorial Hospital , Sialkot (opened in 1888 in two rooms with a grant of 33 Dollars) Lady Graham Hospital Hyderabad (1919) Holy Family Hospitals (Rawalpindi,1926, Karachi 1948) Nancy Fulwood hospital, Sahiwal (1935) St Teresa Hospital, Mirpur Khas (1947) United Christian Hospital , Lahore (1948) St. Elizabeth Hospital, Hyderabad (1958) Caravan Mobile Hospital Omerkot (1960, became static as Mission Hospital, Kunri, in 1975) Womens Hospital, Multan Seventh Day Hospital, Karachi St. Rapheal Hospital Faisalabad

Contributions of Individuals: Sir Ganga Ram and Janki Devi in Lahore Sobraj Maternity Hospital , Karachi Aga Khan Maternity Hospitals in Karachi and Hyderabad and a few others

Using students for services, and giving them monitory compensation in the name of stipend are two unfortunate legacies inherited from that era They still continue. Midwifery Education at the Time of Partition Very few midwifery schools 41

 Almost no Muslim Nurses or Midwives Mass Exodus of British and Anglo Indian Nurses/midwives Begum Raana Liaqat Ali Khans initiated a Campaign in 1948 for training girls mainly as nurses In 1948 started recruiting girls to be trained in Pakistan In 1949 sent a few to UK from East and West Pakistan By mid-1955, most of the 18 from West Pakistan returned as Registered Nurses and Registered Midwives. Almost all started working as nurses ONLY ONE ( Imtiaz Kamal ) SPECIFICALLY REQUESTED POSTING IN THE LABOUR ROOM. AFTER SIX MONTHS SHE WAS GIVEN A POSITION TO TEACH MIDWIFERY . 3 categories of Midwives were inherited from the British Raj The Nurse with Midwifery specialisation i.e Nurse-Midwife The Pupil Midwife LHV (The Community Midwife)

Midwifery was the only post basic specialisation available for nurses Optional as a specialisation, but mandatory for promotion of female nurses Curriculum was sketchy but skill based Every student graduated as a practicing midwife Midwives practised Midwifery by common law No Regulatory Mechanism Then No Regulatory Mechanism Now

INTERNATIONAL ASSISTANCE TO MIDWIFERY EDUCATION Some from WHO in the early fiftees. Otherwise negligible. TBA training received a lot of funding from WHO and UNICEF and others TBAs considered the quick fix and an alternative for the midwives. 42

Thousands trained and Sent back. No support. No Supervision. No contact They went back to square one within 3 to 6 months Hence Billions spent but not a dent on MMR. Mothers continued to die 80 % of the babies were delivered by Dais at home.

Gradually more midwifery schools opened BUT Without proper curriculum Without trained teachers Without plans for the utilization of midwives Without a career structure for midwives

SCHOOLS OF MIDWIFERY AND NURSING WERE OPENED TO PROVIDE CHEAP LABOUR This Unfortunate practice still continues MIDWIFERY EDUCATION A NEGLECTED AND IGNORED AREA After the early seventies, midwifery education started to deteriorate Diplomas awarded without any practical experience Old and archaic curriculum No trained teachers No advanced courses in midwifery No plans for utilization of Midwives after training Dais occupying posts of midwives No scholarships for midwifery study abroad Midwifery overshadowed/ignored and even undermined by nursing 43

Examples Pakistan Nurses, Midwives and Health Visitors Council dropped the midwife and the health visitor and became Pakistan Nursing Council Pakistan Nurses Federation enrolled Midwives as Associate Members with no right to vote To teach nursing a diploma in teaching of nursing is required. No such requirement for teaching midwifery 7 Colleges of Nursing for post basic education in nursing. None for Midwifery A Career structure for nurses, none for midwives THE IMMEDIATE PAST (This period covers the years from 1982 to 2000) In 1981, By a presidential Decree, Every Female Nurse had to Study Midwifery Quantity Vs Quality Present number of Schools Province Punjab Sindh NWFP Balochistan Total** Nursing 49 32 11 3 95 Midwifery* 88 52 13 3 156

*Includes Schools of Public Health Source: Pakistan Nursing Council

44

Q. In spite of 156 schools of midwifery why pakistan had no competent midwives? Because : For almost four decades midwifery received little Attention Curriculum is outdated (few minor changes made by a group of nurses in 1994) Most teaching is theoretical (with rare exceptions) No qualified teachers Even if she wants to work average midwife has no midwifery skills There is no future for a midwife. She starts and retires in grade 6

The present: From 2000 to date Winds of Change Started to Blow at the Turn of the Century
A few critical incidents which initiated the change 1. Situation analyses of midwifery training in indh (2000-01) and punjab (2004-05) commissioned by unicef truth came out in the open 2. Dissemination of truth to all stakeholders started in 2001. It continues Accepted by some. Still not by all. 3. In 2002, UNFPA sponsored the first ever, international day of the midwife chaired by the first lady of Pakistan. Pathetic state of midwifery was presented. It caught many an important ear. 4. A buzzing noise started 5. NCMNH doubled its efforts (some examples) a. National campaign to get posts sanctioned for midwifery teachers (2002) b. A Thematic Newsletter Dedicated to the Midwife of Pakistan (2002) c. Workshops for Nursing Instructors teaching midwifery (2003) d. After exhaustive debates with the obstetricians, defined Midwifes Role for 45

Providing First Aid in Obstetrical Emergencies e. Included the role of the midwife in the EmONC Manual (2003) f. In collaboration with MCWA (Sindh) Chapter, Conducted a National Opinion Poll for establishing Professional Midwifery Organisation (2004). Overwhelming positive response g. Provided assistance to a group of midwifery leaders in the formation of MIDWIFERY ASSOCIATION OF PAKISTAN (MAP) in 2005. Since 2005 Emergence of community midwives International assistance to midwifery FIRST EVER joint Project of midwives and obstetricians for Prevention of Post Partum Heamorrhage. Training in Active Management of Third Stage of Labour ( AMTSL) in Pakistan. Groups of tutors exposed to Workshops and Conferences. International Midiwfery through meetings,

Workshops in teaching methodology to groups of tGroups of midwifery tutors.

Availability of teaching learning materials in English and Urdu Midwifery conferences

Avaiability of inservice education opportunities for practising midwives in post abortion care and use of Misoprostol and in partograph

Advocacy for improvement of midwifery education and practice conferences and printed material

through

46

The future of midwifery education & The midwifery profession Winds of change started to below at the turn of the century Pakistan is talking MidwiferyThere is light at the end of the tunnel The dark age of midwifery will soon be a thing of the past. The midwives are at it

Serious thinking is needed before starting action many Challenges ahead The top ones are: 1. Analysis of revised midwifery curriculum to make it client centered and skill based. 2. Serious look at PC-1 for MNCH to ensure competency based training of community midwives. 3 .Immediate attention to preparing competent teachers of midwifery

4 . Approval of regulatory mechanisms for the practice of midwifery (draft with MAP) 5. Sanctioning and filling posts of midwifery teachers in all schools of midwifery. 6. Developing mechanisms at the provincial level to regulate the education and practice of midwifery 7. Strengthening health facilities to provide EmONC No midwife can save lives if she does not have back up support of emergency care(obstetrical and neonatal) 47

A plea Let us aim at optimum standards of maternal and neonatal care Think big but critically. Hurry but thoughtfully

48

Midwives Mission

Every Mother should have a live and healthy baby. Every Baby should have a live and healthy mother At the end of each pregnancy

49

References 1. 2. 3. Pakistan Demographic and Health Survey 2006-7 Kamal,I. Situation Analysis of Midwifery Training in Sindh, UNICEF, 2000 Kamal,I Strategic Planning to Improve Midwifery Training in Sindh , UNICEF 2001

4 . Kamal,I. The Past, Present and Future of Midwifery Education in PakistanPC-1

5. Maternal , Newborn and Child Health, Ministry of Health, Pakistan Maternal, Newborn and Child health . 2005-6

Midwifery Training Curriculum for Nurse midwives , Pupil Midwives

and LHVs 1994, Pakistan Nursing Council

7.

Curricula for Community Midwives (2003, and 2005, Pakistan Nursing Council ).

8.

Training Institutions for Community Midwives in Pakistan: An Initial Assessment ( 2010, PAIMAN, Population Council )

Assessment of Quality of Training of CMWs in Pakistan ( 2010 commissioned by TRF )

10 Guidelines for the Deployment of Community Midwives, National Maternal, Newborn & Child Health Programme, Contech International, HLSP, Islamabad , ( 2010. Commissioned by TRF )
11 State of the Worlds Midwifery (2011, UNFPA and International Confederation of Midwives) 12. An Informative Booklet for Public Health Specialists & Social Organisers

13. Situation Analysis for Post Devolution Health Sector Strategy of Sindh Province, Government of Sindh. 14. Strategy 2012-2020, Sindh Health Sector

50

B. Institutions visited

Annex 1

List of Schools

Nursing Midwifery School Nursing Midwifery School Nursing Midwifery School Midwifery School Nursing Midwifery School Community Midwifery School Nursing Midwifery School Nursing Midwifery School Public Health School Nursing Midwifery School Nursing Midwifery School Nursing Midwifery School Nursing Midwifery School

Badin Jamshoro Sukkur Hyderabad Hala, Matiari Tando Allah Yar Hyderabad Khairpur Larkana Larkana Mirpurkhas Umarkot Noshero Feroze
51

Nursing Midwifery School Nursing Midwifery School Nursing Midwifery School Public Health School Nursing Midwifery School Midwifery School Midwifery School Midwifery School Midwifery School

Shaheed Benazirabad Sanghar / Shadadpur Shikharpur Sukkur Thatta Dadu Tharparkar Kashmore Jamkanda, Bin Qasim Town

Annex: 2 - 7 Questionnaires

52

Annex - 2 Situation Analysis of Schools Training CMW in Sindh Interview Guide to get information from the principals and tutors Part I General Information 1. Name and Designation of Person In-charge of School of Midwifery ______________ __________________ Designation _________ Male __________ Female Name

2. Address of the school of Midwifery _____________________________________________ __________________________________________________________________________ 3. Do you have a School of Nursing also? ____ _____ Yes If Yes who is in charge of School of Nursing? _______________________ Name _____________ Designation ________ Male _________ Female No

4. Does the Midwifery School have a separate budget. Yes/No

_____

If yes who is DDO: __________ (Please ) Principal SOM

___________ Matron

__________ MS

_______ Other

5. Status of the School When was the midwifery school established? When was it recognized by PNC?

Month

Year

53

When was PNCs most recent inspection? When was the inspection before most recent inspection ? When did training of CMWs start?

Please put a in the space provided for your answer ONLY if the answer is Yes 6. Do you give midwifery training to : Yes Trained nurses Length of Training One year Remarks if any

Pupil midwives One year + months ___ LHVs 1st year of training CMW 18months 7. Faculty of midwifery school Designation Principal Midwifery Tutor Incharge or Vice Principal Tutors Clinical Instructors Total Ministerial Staff: and cleaners Number of tutors who teach midwifery students and also teach nursing students ___________ According to the curriculum Doctors are supposed to give 276 hours on obstetrics to midwifery students. Please give the following information about doctors and other guest lecturers? If any. Teacher No. of Hours Who pays the guest lecturers ? Remarks Student School Not paid 54 Sanctioned Filled Posts Posts No. BPS No. BPS Teaching on ad hoc basis No. BPS Qualification of each

Obstetricians English Teacher Other (Write)

8. PNCs Minimum bed Requirement for hospital beds for maternity unit (for CMW training) PNC Requirement Ante-natal Beds Lying in Beds (Post natal beds) Labour Beds Septic Beds Emergency beds # # 8 30 3 4 4 Actual* Minimum occupied Remarks

*Actual number in the hospital where students get their practical training 9. Practical Obstetrical Experience Requirements for Practical Experience for each student according to the CMW curriculum Deliveries : observed assisted 5 5 Actual experience of (Each student )

under supervision 5 independently 10

(No requirement for home delivery)

55

Ante-natal Examination 25 ________ Deliveries in journal 25 ________ Follow up of deliveries 25 ________

As required If you are giving less than required experience or no experience, please give reasons

More than required

less then required

None

Distribution of Students Time for Practical Experience The Midwifery Curriculum does not specify the amount of time a midwifery student should spend in various departments . Do you have an internal plan? _____________________________________________________________________________ ___________________________________________________________________ How is it decided to give students the required experience? Please explain ________________________________________________________________________ ________________________________________________________________________ How many hours or days the student spends in each OPD clinic. 10. Experience in OPD which opens _________ to __________ and ________ to ____ a.m a.m p.m p.m Is there an emergency service 24 hours ______ ______ Yes No OPD Experience Routine clinic days per week # students days in each clinic Who supervise Who keeps record

56

 Ante-natal clinic Post-natal clinic Gynaecology clinic Family planning clinic Well babies clinic Sick babies clinic Infertility clinic Casualty (emergency) Any other OPD service (write)

11. Practical Experience Each student gets how many weeks experience in the following service area Experience Service Area (number of weeks) Day time Night time
Year 1 Year 2

Remarks

Year 1

Year 2

Ante-natal Ward Labour and delivery ward Immediate Postpartum Room Postnatal Ward Gynaecology Ward Operation Theatre (New born nursery ) Normal babies Sick babies Premature babies Community experience : 57

MCH Centre Maternity Hospitals Public Health School Community centers

Home visiting STD / AIDS Clinics Social Hygiene Center Any other 12. Domiciliary Midwifery (Please your answer) Please give following information about practical experience in Domiciliary Midwifery. Do you give practical experience in home delivery ? Yes ____ No _____ If No go to Q 12 If Yes do you use a selected community ? Yes ____ No _____ What is the population of the community, which you are using ? _________________________ How far is this community from the school of midwifery ? ________________________ km How do the students go to the community if called for a delivery ? They walk School provides transport Yes If the students go for home deliveries, do they go during the day only They go anytime when called Is clinical supervisor available to accompany the student? 13. Approaches to Teaching 13.1 Languages of Instruction What language is used by most of the teachers to teach midwifery ( Please in the small box or boxes ) English only Urdu / Sindhi / Pushto First in English then translation in Urdu or Sindhi or Pushto Terms in English and mostly explanation in Urdu or Sindhi or Pushto If teachers are using Urdu or Sindhi or Pushto to explain things what are the reasons? Midwifery tutors feel more comfortable in using their national language or mother tongue No

58

All teachers feel more comfortable in using their national language or mother tongue. Students feel more comfortable in using their national language or mother tongue. 13.2 Teaching in the classroom Teaching Methods Used : ( Please tick to indicate your answer ) Most of the time Some times Very rarely Lecture Lecture discussion Demonstration Lecture demonstration Role play Demonstration in the demonstration room Demonstration in the real life situation Case studies in delivery book (written up) application of knowledge Case studies (presentation) Projects Group work Notes are dictated Notes are written on the black board which the students copy Notes are provided as handouts Assignments Other methods: Please describe Never

14. Teaching of Skills (procedures) Required for Maternity and Neonatal Care Which of the following Major skills are taught to students and certified so that they can independently perform them later Skill / Procedure Yes No Only Perform Remarks Observe Top to toe examination of woman Identification of pregnancy Identification of high risk pregnancy 59

Normal ante-natal care Screening mothers for home delivery Advising mothers for preparation of delivery Recognizing deviation from the normal course of pregnancy Admitting the women in labour Using a Partograph Care during labour Care during delivery AMTSL Retained placenta Recognizing deviation from the normal in mother and baby during puerperium Immediate postpartum care Immediate care of the newborn Resuscitation of the newborn Care of low birth weight babies Care during the puerperium (mother & baby) Recognizing deviation from the normal during puerperium(mother and baby) Postnatal check up Counseling ( General ) Counseling for family planning Providing family planning services Health education Reporting and recording Making referrals Giving obstetrical first aid ( basic EOC) Doing vaginal examination Doing epesiotomy Repair of epesiotomy Vaccum extraction Removal of retained placenta Management of incomplete abortion Post abortion care Promoting breast feeding Skills : to work in the community Home visiting Developing Linkages Business skills Dealing with emergencies Any other

60

15. Methods of Teaching Midwifery Skills / Procedures 15.1 Health Facilities used for Practical Training Please answer the following questions about the hospital(s) being used for practical training Please give names of institutions used to provide practical experience to the students ( Please fill the table below) Name of institutions used for # of normal # of Experience who practical experience deliveries complicated supervises (annual) deliveries the students (annual) if more than one HF is used 1. 2. 3.

Who teaches and who certifies the midwifery skills? (Please tick in the box of your answer) You can tick more than one person if applicable Skill development Tutor or Assistant Clinical Instructor Tutor A B C A B C Head nurse or staff nurse A B C Doctor on duty A B C

Demonstration in the Skill Lab Demonstration on the patient Who certifies that a student is capable of independently performing Each Skill? Supervised practice of each skill KEY : A = Always B = Sometimes C = Never

15.2 Midwifery Procedures and skills Are these taught according to the textbooks ? Yes ____ No ______ Are there protocols and checklists for skills Yes ____ No ______ If No, please explain how the performance of a skill / procedure is evaluated ________________________________________________________________________ 61

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 15.3 After learning the procedures in school, students go to the clinical areas. Can they perform these procedures in the real situation as taught in the school demonstration room/skill lab ? (Please tick in front of your anserr answer ) Can perform as taught _________ Always _________ Most of the time _________ Some of the time _________ Not regularly Do not perform as taught Please list those procedure (if any) which the students cannot perform in the clinical areas as taught in the school _______________________________________ ____________________________________________ ____________________________________________

If they cannot perform the procedures as taught in the schools what are the reasons? Please describe. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Yes

Yes occasionally

No

About CMWs practical training do you have meetings with the 62

relevant individuals Head of Ob/Gyn department MS of the hospital Head Nurse of Labour Room Head Nurses of the wards Person in charge in OPD Teaching learning materials: Text books and Manuals What textbooks are used by the students of midwifery. Please give name(s). of books and authors Books/Manuals Authors ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ ____________________________________ _________________________ Who provides textbooks to the students? School provides free textbooks. Student buy textbooks Students use library copies Students use notes given by the tutor

Audio Visual Aids ( Please tick answer if Yes)

63

you have

In workin g order

used often

used some times

not used

Overhead Projector Slide Projector TV VCR Models Charts Films Other (please describe) If not used please explain WHY ? _____________________________________________________________________________ _____________________________________________________________________________ __ Evaluation of Teaching / Learning Outcome What are your methods of evaluating that learning has taken place ? Weekly tests Graded assignment Monthly tests Projects Midterm Examination Case studies (presentation) Term Examination Graded case studies ( written) Observe performance of skills

64

Any other , please describe ___________________________________________________ _________________________________________________________________________ In the final examination if a student get 50% marks she can pass. Do you think if a midwife knows half of what she is supposed to know she can provide safe care to women and children (Please describe your opinion) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

16. Practical experience Yes No Used daily used some time Not used

Do you have a copy of the logbook ? Do the students have a copy of the logbook? Do the clinical supervisors have a copy of the logbook? Do the clinical supervisors have a checklist for teaching and evaluating each skill ? If there is no Logbook how do you know what skills are required to be taught? ________________________________________________________________________ If you do not have checklists for each procedure how is the skill taught and evaluated? ________________________________________________________________________ 65

_______________________________________________________________________

When you started training CMWs ,did anyone discuss with you ( Tick response) Competency of Tutors S#
a. b. c. d.

Topics Curriculum Log Book Manuals Systems of recording their competencies as they learn them Time allocation

Discussed

Not Discussed

Who Discussed

e. f.

How their training needs differed from that of other midwives g. Expected responsibilities of CMWs after graduation If you have not received TOT for training CMWs, what preparation and introduction were you given to the curriculum, manuals, Logbook and expected course structure?

.. If discussed / Prepared Yes No Remarks Do you think the preparation you were given was enough to give you confidence about preparing CMW students to meet their responsibility in the community after training Have you received training on teaching methodologies ? if yes , are you using these methods in training CMWs? if no, why not? Do you have any means to access latest information about midwifery Are you satisfied with your ability as CMW tutor ? 66

Do you require strengthening of your knowledge and skills ? If yes, write the topics and skills

Any comments regarding your confidence for teaching CMWs . Sources of access to information for faculty and students Tick your response Source Yes for faculty for student Home access by internet Training institute access by internet (general) journals/research/manuals Training institute library (Books) Seminar / Conference Work load When did you start teaching Community Midwives ? Month ______ Year _______ How many batches of CMWs have you taught ? _________ What is the ratio of tutors of students (PNC requirement 2: 25) Tutor ../.. Student Categories Were you given a choice about training CMWs? Did you have to add this training as an addition to your previous workload? if yes, has this affected your ability to cope with your previous workload Do you think CMW tutors should be practising midwives Do you get extra allowance for teaching CMWs What 3 things would make your current job easier? ___ a. b. c. Are you facing any problems in your job as midwifery tutor ? __________ Yes

Yes

No

__________ No

1. Problems in theoretical teaching 67

___________________________________ ___________________________________ ____________________________________ 2. Problems in practical training ___________________________________ ___________________________________ ____________________________________

__________________________________ ___________________________________ ____________________________________

___________________________________ ___________________________________ ____________________________________

3. Faculty problems ___________________________________ ___________________________________ ____________________________________

___________________________________ ___________________________________ ____________________________________

4. Students problems ___________________________________ ___________________________________ ____________________________________ ___________________________________ ___________________________________ ____________________________________

5. Problems with Examination Board ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 6. Problems with PNC ________________________________________________________________________ ________________________________________________________________________ 68

________________________________________________________________________ ________________________________________________________________________ 7. Any administrative problems ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. Any other problems ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Any suggestions to minimize these problems: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

17. Continuing Education Activities Does the teaching staff get opportunities for learning new things or refreshing their knowledge? ________ ________ Yes No If yes, how is it done? Through regular continuing education programme Whenever an opportunity becomes available Depends upon individual efforts (self learning) Do not have planned opportunities 69

In service training programmes Remarks ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 18. Opportunities for further education What are the opportunities for further education for Midwifery tutors ? Scholarships for postgraduate specialization Scholarships for B.Sc. degree Scholarships according to seniority Remarks ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Role of Pakistan Nursing Council (PNC) in Development of Midwifery Education in Pakistan From one of the current teachers/staff members who was present at the time of the last inspection ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What were the observations and recommendations of PNC Inspectoresses ? Please describe. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did they discuss the strengths and the weak points of your midwifery school with you ? _______ ________ 70

Yes No If yes please give a summary of their observations ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did you discuss your problems / difficulties with the inspecting team? _______ Yes _______ No

If yes please give a summary of your discussions. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____________________________________________________________________________ _ If No, why not? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What was PNCs action to solve your problems (either observed by them or given to them by you) (Please tick the right answer) PNC wrote to the midwives school for more details PNC sent some suggestions to make improvements PNC took no action. Do these problems continue to exist? Some as before ______ ______ 71

Yes Is there some improvement

No

______ ______ Yes No

Please describe the improvement: ________________________________________________________________________ ________________________________________________________________________ With whose effort did the situation improve ? (You may tick 3in more than one box ) Nursing staff Medical staff School and faculty Students PNF PNC MAP Role of the Midwifery Association of Pakistan in Development of Midwifery Education MAP membership in your School of Midwifery Total Midwifery Teaching Staff Current MAP members Total midwifery students Current MAP associate members Has MAP helped in any way in solving any of your school of midwifery problems ? ______ ______ Yes No If Yes please describe __________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Has the Nurses Federation helped in any way in improving the quality of teaching in your school ? ______ _______ Yes No If Yes please describe ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 72

________________________________________________________________________D. Please give practical recommendations for the improvement of midwifery training in Pakistan: 1. Curriculum ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. Teaching Staff Development ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. The examination system of midwives ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

4. The method of inspection by PNC ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. The role of PNC for the development of Midwifery Education ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 6. The role of MAP for the development of Midwifery as a Profession ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 73

Names of Midwifery Tutors and other teacher who provided the information and participated in the identification of problems of Midwifery for the questionnaire: Name ___________________________ ___________________________ ___________________________ Teaching which subject ________________________________ ________________________________ ________________________________

Thank you very much for your effort and help.

74

Annex 3 Institutions Visited & Persons met A. School of midwifery in: 1. 2 3. 4. 5. 6. Tando Allah Yar Bin Qasim, Jam Kanda ( HANDS) Jam Shoro Thatta Tando Mohammad Khan Hala

B. Persons Met for: Getting Information; Discussions; Clarifications In MNCH Directorate Dr. Sahib Jan Badar Dr. Manzoor Ahmed Dr. M Gul Dr. Ashiq Dr. Mushtaq Mr Shafiq From TAUH Dr. Nabeela Ali Dr. Iftikhar Malla ( Sindh) Pakistan Nursing Council Ms. Nighat Durrani ( Telephonic conversations for information) UNFPA Dr. Shabir Chandio ( Sindh) In Schools of Midwifery and Allied Hospitals 20 28 5 80 21 Principals of CMW Training Schools Tutors Teaching CMWs Clinical Supervisors + Students CMWs Graduate CMWs

Directorate of Nursing , Sindh Ms. Zarina Habeeb, Ms. Mehboob Sultana, 75

C. Discussions held with: The Executive Board of Midwifery Association of Pakistan The President of International Confederation of Midwives The President and Consultants of the National Committee for Maternal and Neonatal Health ( NCMNH) and the Association for Mothers and Newborns AMAN) To find out about the sustainability mechanism of training midwives, held meeting with the Superintendent of the Lady Dufferin Hospital, Karachi and Principal of the School of midwifery attached to it. The school charges tuition fees from the students. Those who are motivated to learn midwifery join this school. Inspection mechanism of schools of midwifery and the examination system for final evaluation of CMWs, were two main topics of discussion. Both require massive restructuring Meetings in Hyderabad, with the principals and tutors of all schools to brief them bout the Situation Analysis of Midwifery Education in Sindh. Discussed in detail each item of the Questionnaire and how to respond.

76

Annex - 4 Training of CMWs Interview guide for Obstetricians and Doctors in Ob/Gyn Unit Date____________ Your hospital is being used for practical training of CMWs. Please help MNCH directorate to document the approaches being used in this hospital for training CMWs. If you feel that the quality of training needs improvement, please give realistic suggestions. Hospitals name ________________________ Category : THQ______DHQ _________ Teaching Hospital_______ Name of doctor in Charge of Ob/Gyn unit/ department______________________ Name (s) of doctor (s) participating in training of CMWs. __________________ 1. Is there collaboration between the school of nursing and your department? Yes_____NO_____ If yes , what is the nature of collaboration? Occasional meetings Regular meetings Participation in theoretical teaching Any other method used

If there is no collaboration, what is the reason?_______________________________________ ____________________________________________________________________________

2. Do you participate in the practical training of CMWs? Yes_________ No_________ If yes,. Were you given any orientation regarding the practical training needs of CMW students? Yes ______ If yes, No _______

What do you teach? ______________________________

77

How do you teach? _______________________________

______________________________________________________

If, NO, what is the reason?__________________________________

__________________________________________________________

4. Have you seen CMWs curriculum? If ,Yes, have you gone through it?

5. Have you seen the Log Book of CMWs? If Yes have you read it?

6. Do the CMW students use the Log Book? If Yes do you help them in using the Log Book_______

7. Do you know how many deliveries each student has to? a. Observe_______ b. Assist ___________ c. Conduct under supervision d. Conduct independently __________

8. Who certifies the competence level of skills leaned by each midwifery students ? ____________________________ 78

9. Can you say with certainty that the training they are getting makes them competent enough to handle normal deliveries deliveries independently? Yes_________ No___________

If Yes Please give your reasons.___________________________________ _____________________________________________________________

If No, Please give your reasons____________________________________

_____________________________________________________________ PLEASE give suggestions how to improve the quality of CMWs Training.

Annex 5

INTERVIEW GUIDE 79

Clinical Supervisor Date : ________ Interviewer : ____________________ Name Supervisor : _____________________ Name

Introduction Name of School :_________________________________________________ (Explain why the interview. Assure anonymity of respondents in the report) 1. How long have you been working as a clinical supervisor ? __________ 2. What is your responsibility as a clinical supervisor ______________________ 3. Did you get any training for this job ? 4. Do you have a copy of the curriculum? If yes , have you read it? 5. Do you use the curriculum to understand the training needs of the student? Yes ______ No _______ Yes ____ No _____ Yes ______ Yes ______ No _______ No _______

If you do not use the curriculum, how do you know what you are supposed to teach, please explain __________________________________________________________________________ __________________________________________________________________________ __ 6. Do you keep a record of what you teach ? If yes, please share. Yes ______ No _______

7. Is there any formal (explain formal) teaching on the wards/clinical areas in the field? Yes ______ If yes : who teaches ? ________ What is taught ? ____________ 80 No _______

How is it taught ? ____________

81

Part 11 (Practical Work) Name of Student: _________________________ Of the following Major skills which have you taught ? Which of these will the students be able to perform independently after they complete their training ?

Skill / Procedure

Demonstrated

Return Demonstration

Practised under supervision Yes No

(Give numbers)

Can do it

Remarks

Not alone

Yes

No

Need more practice

Top to toe examination Identification of pregnancy Identification of high risk pregnancy Normal ante-natal care Screening mothers for home delivery Advising mothers for preparation of delivery Recognizing deviation from the normal course of pregnancy

82

Admitting the women in labour Using a partograph Care during 3 stages of labour Doing vaginal examination Doing episiotomy Repair of episiotomy Vaccum extraction Using AMTSL for preventing PPH Managing PPH Removal of retained placenta Recognizing deviation from the normal course of labour Immediate postpartum care of mother Immediate care of the newborn Promoting breast feeding Resuscitation of the newborn Care of low birth weight babies Care during the puerperium of the mother 83

Recognizing deviation from the normal during puerperium of the mother Recognizing deviation from the normal during puerperium of the baby Postnatal check up Counseling (General) Health education Counseling for family planning Providing family planning services Making referrals Giving obstetrical first aid (basic EmONC) Management of abortion Management of incomplete abortion Reporting and recording Other skills

84

Problems ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you want to continue as clinical supervisor ? Yes ____ No _____ If yes , what kind of help would you like to make your job easier ? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

______________________________ Name of the Supervisor

85

Annex 6 INTERVIEW GUIDE Medical Superintendent / Focal person Hospital :______________ Name :________________

Interviewer : ________________________________________

1. Were you given any briefing about CMWs training and their role after training. 2. When midwifery students come to the hospital for practical training, do you meet with them Yes ______ No ________

3. Is the principal of Midwifery School in contact with you and Head of Obs /Gyn regarding the training requirements of CMWs. Yes______N0_______ 4. Have you seen CMW curriculum ? Yes ____ No____

5. .Do you have a training schedule of CMWs Yes ___ No_____ 6. Who is responsible for students teaching in the labour room.? ________ 7. Is any record kept for the number of deliveries done by each student ?Yes____ No___ Dont know_____ 8. If the students performance is not satisfactory at the end of their training in the labour room are they given further opportunities to do more deliveries to reach their optimum competency level? Please Explain_______________________ : ________________________________________________________

9. Who certifies their competencies?________________________ 86

10. Who certifies that they are capable of working independently as SBAs ____________________________________________________

11. Do you report the progress of CMWs to MNCH. ? Yes______ No_______

12. What are your suggestions to Improve the training of midwives?

____________________________________________________________

____________________________________________________________ Annex 7 INTERVIEW GUIDE Midwifery Students Date : ________ Name of student : ________________ Level of student : _____ ______ Number of student : ________ Introduction (Explain why the interview. Assure anonymity of respondents in the report) Part I (Theoretical Teaching / Learning ) 8. Do you have a copy of the curriculum? 9. Have you read it? 10. Do you have the Log book ? Yes ______ Yes ______ Yes ______ No _______ No _______ No _______

If you do not have the Log book , how do you know what skills you are supposed to learn, please explain

87

__________________________________________________________________________ __________________________________________________________________________ __ 11. Do you keep a record of what you learn in the class room and in the ward and labour room ? Yes ______ No _______

If Yes, how ? In the Log book _______ , In the register ______

12. Is there any formal ( explain formal ) teaching on the wards/clinical areas in the field? Yes ______ If yes : who teaches you ? ________ What do they teach ? ____________ How do they teach ? ____________ _____________________________ 13. What is the approach of teachers in conducting theoretical classes? (What methods do they use for teaching) _______ , __________ , ___________ , ___________ Lecture Discussion Demonstration Role play No _______

Other : ( Describe ) __________________________________________________________

Please put X in the box 14. Are you given assignments (Homework)? Reading Writing up case studies Locating information Any other home work _______________________ _______________________

15. Are your assignments graded (Do you get marks for your assignments/homework) ? 16. Is there a library ? If Yes, 88 Yes _____ No ____

17. Do you use the library?

Yes _____ No ______

If yes, who helps you in the library ? _______________ 18. You are all learning something. What helps you most in your learning? When teachers explain nicely Notes given by the teacher Notes made by the students Reading different books Discussions with classmates Teaching by the ward sister or clinical supervisor or doctor when delivering a baby Teaching by the staff nurse when delivering a baby Teaching by the senior students when delivering a baby Asking questions from doctors when delivering a baby Talking to the women under your care Writing notes on the care given to the woman by you Making care plans for the woman during labour Use of the partograph Any other 19. How much time do you spend on your own learning, by yourself (independent study)?

89

_______________________________________________________________________ _______________________________________________________________________ __ 20. How many lectures (or formal teaching sessions) do you have in one week ? __________ 21. How many study days do you have in one week? 2 days 3 days None

On study days are you left alone to study by yourself or teachers are there to supervise and help _____________________________________________________________________ On study days, do you have to go on duty before or after study hours? Yes ___ No___

22. So far how many deliveries have you: Observed Conducted under supervision Conducted independently Conducted in the hospital Conducted in the home Written in the journal

__________ __________ __________ __________ __________ __________

90

Part 11 (Practical Work) 15. Of the following Major skills which were taught to you in the class room , skill lab and on actual mother and babies ?

Skill / Procedure

Got theory only

Taught in skill lab Yes No

Done under supervision

Can perform Not alone Yes No Need more practice

Remarks

Top to toe examination Identification of pregnancy Identification of high risk pregnancy Normal ante-natal care Screening mothers for home delivery Advising mothers for preparation of delivery Recognizing deviation from the normal course of pregnancy Admitting the women in labour Using a partograph

91

Care during 3 stages of labour Doing vaginal examination Doing episiotomy Repair of episiotomy Vaccum extraction Using AMTSL for preventing PPH Managing PPH Removal of retained placenta Recognizing deviation from the normal course of labour Immediate postpartum care of mother Immediate care of the newborn Promoting breast feeding Resuscitation of the newborn Care of low birth weight babies Care during the puerperium of the mother Recognizing deviation from the normal during puerperium of the

92

mother Recognizing deviation from the normal during puerperium of the baby Postnatal check up Counseling (General) Health education Counseling for family planning Providing family planning services Making referrals Giving obstetrical first aid (basic EmONC) Management of abortion Management of incomplete abortion Reporting and recording Other skills

93

16. Do you provide maternity care under supervision of a trained midwife: Always Sometimes Rarely 17. Are you left alone on the wards to learn or manage the ward? Never in the morning/evening Sometimes in the morning/evening Most of the time in morning/evening Never on night duty Sometimes on night duty Most of the time on night duty

18. Do the teachers who teach in the classroom take practical classes on the wards? Yes__________ No _______ Sometimes ____________ 19. Punishments Do you get any punishment ? If Yes, for what reasons and what kind of punishment (please describe)

_________________________________________________________________ _______

20. Hostel Living Is there a housekeeper(s) ? Is she a nurse? How many share a room? What about those doing night duty? Are there separate rooms for them to sleep during the day ?

Yes ______ ______ ______

No _______ _______ _______

______

_______

94

Are you allowed to live at home?

______

_______

21. Do you have space to study ? 22. Is the food all night ? 23. What happens when you become sick?

______ ______ ______ ______

_______ _______ _______ _______

24. Are you allowed to go out for shopping

or visit friends 25. Disciplinary Regulation What happens if you : Break anything _____________________________________________ Lose anything _____________________________________________ Are absent from lecture _____________________________________________ Are absent from duty _____________________________________________ (after a day off) 26. Do you do duties on the wards? If Yes describe which wards ______________________ ______________________ ______________________ ______________________ 27. Please describe any problems which you have with 27.1 Theoretical Teaching by the teachers _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _____________________

27.2 Theoretical Learning by yourself _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _____________________ 27.3 Practical Teaching in the wards or labour room. 95

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _____________________ 27.4 Practical Learning _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _____________________ 27.5 Any thing else you want to share _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ 28. . Do you know what you role will be after you finish midwifery training? Describe

96

Annex 8

Evaluation of the Teaching Session

School: _________________________________ Date___________ Teacher__________________ Observer______________ # of students ___________ Name Name Qualification of teacher Years of experience Teaching Practice in midwifery Midwifery

Nurse-Midwife with teaching diploma Nurse with a B.S.N degree LHV Nurse with LHV diploma Midwife Other ____________________ please write Has teacher attended any ToT ? if yes , when ____________ where _______________ ART I: PREPARATION for the session (Observer will complete this part BEFORE the session begins. Back of the page can be used for additional information) Topic of the session (write)_______________________ Instruction: Circle Yes if the answer is yes. Otherwise do not indicate any response. A. Session PLAN Did the teacher have a session plan? Yes Did the teacher receive a pre-prepared session GUIDE? If Yes, did she use it without any changes Yes

Yes

If she made any changes please describe the reason for the changes and their effect on the session guide. _____________________________________________ ____________________________________________________ Answer the following questions ONLY if the teacher made her own session Guide Were Objectives described If yes, were these SMART Objectives Yes Yes?

Was Method(s) for teaching described Yes If yes, was it appropriate for the achievement of objectives? 97

Was Content to be covered written? If yes, was it organized in a logical sequence? Did it focus on the objectives? Was it in point form? Were long paragraphs written ? For skill development Was there a checklist were articles to be used kept in a logical sequence Were Teaching learning activities described? If yes, were these both for the teacher and the students? Was there a variety in the activities? Did they include use of Audio and Visual Aids/ Simulated experiences/actual practice of skills. Did they include out of classroom activities

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

B. Planning of required resources Were the resources planned according to the session plan? Yes Were these available at the time of the session? Yes If No why not ? _____________________________________ _____________________________________________________ Is there evidence that the teacher has used her knowledge and experience gained during ToT (describe)

____________________________________________________________________ _ Suggestion for improvement if any

Teachers feedback on the Midwifery Manual Do you use it for planning the sessions Yes If YES answer the following:

No

sometimes

Useful: Very_____ Some_____ Not at all_______ Easy to follow : Yes Not always Interesting: Yes. Some of it ___ All of it___ .Not at all Should have been in Urdu? Yes _____ No_____ Suggestions to make it more useful 98

If you do not use the Manual please give reasons : _____________________________________________________________________ ____________________________________________________________________ _ PART II The Session The teacher: Was well groomed (neat and tidy appearance) Was Professionally dressed Was punctual Greeted the students Introduced the guest and the purpose of her visit? Described the topic of the day? Read out the objectives? Referred to the previous session? (If applicable ) Demonstrated confidence Teachers Activity Yes Yes Yes Yes Yes Yes Yes Yes Yes

1. Voice: Loud enough Yes 2. Eye Attention: To all Yes 3. Created lively atmosphere? If yes, how? Describe-----------------------___________________________________________________________ 4. Participation of students ensured? If yes, How? Describe------------------------______________________________________________________________ 5. Information: Gave correct information? Yes Provided scientific explanation Yes Explained with REASONS Yes Gave clear instructions for group work Yes (Describe any inaccuracies)___________________________________________ 6. Asked questions, invited questions, answered questions. 7. Used examples, AV Aids to clarify concepts 8. A touch of humour was present e.g told a joke Or a funny story TO CLARIFY what was being taught. 9. Use of language: At the level of students. Used correctly (Particularly when using English) Yes Yes Yes Yes Yes Yes 99

10. Used principles of the selected method (s) 11. In Demonstration/simulation exhibited her own level of competence in the skill which she was teaching. 12. Summarized. 13. Analyzed whether objective(s) were achieved 14. Introduced the next session 15. Gave home work: Followed the principles of giving an assignment. 16. Exhibited Confidence: Was sure of what She was saying/doing Students Participation

Yes Yes Yes Yes Yes Yes Yes

17. Asked questions 18. Answered Questions 19. Were alert (did not look bored) 20. Seemed eager to participate in whatever activity Was being done 21. Volunteered e.g in a role play Or for a return demonstration etc 22. Participated in group work 23. Any other evidence of students active participation. PART III Feed back to the teacher Observation discussed with the teacher Yes Teachers reaction (Positive. Defensive. Neutral etc) ____________________________________________ Supportive supervision provided? Yes (Please describe) _______________________________________________ _________________________________________________ PART IV Teachers need/request for further assistance

Yes Yes Yes Yes Yes Yes Yes

Did the teacher request further assistance to improve the quality of her teaching/Facilitation? (Describe)_______________________________________________ ______________________________________________________________ 100

PART V Feed back from the Participants (During the first monitoring visit) Find out mainly about the Participants Manual 1. Have you read it Yes If yes, how many pages _______ 2. Is it easy to understand Yes? 3. Is it useful Very___ Somewhat________ Not at all_____ 4. Will it be more useful in Urdu? 5. Is there need for such instructions? For the students (give honest answer) Comments on the three-week Programme 6. Does it meet your expectations? Yes If No Please give reasons 7. Does it meet your needs? Yes ___ All___ Some ____ None___ 8. What else would you like to be added in this programme? Please feel free to suggest _______________________________________________________ _________________________________________________________ _______________________________________________________ M&E Team Members final remarks Any additional Information or comments or suggestions Yes Yes

101