P045W Competency-Based Training in Basic Emergency Obstetric and Newborn Care (BEmONC) Improves Providers Performance in Tanzania

by: Scholastica Chibehe, Christina Lulu Makene, Victor Mponzi, Marya Plotkin, Sheena Currie, Gaudiosa Tibaijuka, Maryjane Lacoste and Dunstan Bishanga affiliate: Jhpiego, an affiliate of Johns Hopkins University/Tanzania

Background
The MAISHA program is a USAID-funded program
that has worked with the Tanzania Ministry of Health and Social Welfare (MOHSW) since 2008 to improve the quality of maternal and newborn health care in Tanzania. Strategies include: Development of a national learning resource package that utilizes competency-based training approaches. Training of over 880 health care providers in Basic Emergency Obstetric and Newborn Care (BEmONC). Standards-driven quality assurance approach using national BEmONC standards. Strengthening of supportive supervision nationally.

Methods
Data presented are drawn from two sources:
1. Training scores from BEmONC training conducted in Iringa, Tanzania, in March 2012. 2. Facility scores from Standards-Based Management and Recognition (SBM-R) standards assessments from 14 health facilities from 4 assessments August 2010 September 2012.

The following pre- and post-test training scores show dramatic improvement among the students in BEmONC skills.
120%

100%

80%

60%

40%

20%

0% 1 2 3 4 5 6 7 8 9 Pre-test 10 11 12 13 14 15 16 17 18 19 20 Post-test

What Is BEmONC and Why Is It Important?

The provision of Basic EmONC services
includes: administration of parenteral antibiotics, uterotonics and anticonvulsants; assisted vaginal delivery; manual removal of the placenta; removal of retained uterine products; and neonatal resuscitation when indicated. It is important for management of the main pregnancy complications, which can result in maternal and newborn death.

Phases of Skill Development

Skill acquisition Skill competency Skill proficiency

Following training, providers return to their health facilities to use the competencies they have acquired in training and implement quality improvement using SBM-R. The graph below shows improvement in BEmONC standards achievements over a 22-month period in 14 health facilities from 2010 to 2012 in Pwani region, Tanzania.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Competency in BEmONC
MAISHA focuses on developing BEmONC
competency in health care professionals by: Developing a national training team. Strengthening regional hospitals as training sites. Strengthening 2 sites in each district to provide BEmONC. Supporting zonal and regional staff for continuous coaching and mentoring of providers/facilities. Encouraging self/internal/external assessment using BEmONC standards.

Participants practice perineal and episiotomy repair.

Baseline Assessment

1st Intern. Assessment

2nd Intern. Assessment

Challenges
Maintaining consistent quality of BEmONC
training and supervision of providers in scale-up nationwide. Inadequate supplies of lifesaving drugs and equipment for quality services. Transfer of trained staff between facilities sometimes leaving facilities with no trained staff. Shortage of skilled staff to provide BEmONC services.

Competency-Based Training (CBT)

CBT of health care providers builds knowledge,
skills and attitudes and stresses learning by doing; developing a specific set of competencies for quality job performance. What if we taught people to drive a car or plane by only having them read about it in a book?
Participants practice newborn resuscitation.

Conclusion
Training health care providers using a
competency-based training approach and supporting quality improvement and improved supervision can lead to improved care: Best results seen if providers immediately and effectively use competencies and are motivated to improve performance. Challenges mitigate the uptake and use of competency-based training approaches. Supportive supervision is necessary and the involvement of Health Management Teams is also key.

Preceptor shows participants how to examine the placenta.

An example of a skills competency-based training scoring matrix for BEmONC training

PROVIDERS NUMBER
Antenatal care consultation Assessment of a woman in labor Conduct normal delivery Newborn resuscitation Episiotomy/perineal repair Postpartum care Management of pre-eclampsia/ eclampsia Manual removal of the placenta Bimanual compression of the uterus Postabortion care (MVA) Vacuum extraction Assisted breech delivery Assessment of mother and baby/24 hours 1 S S S C M S S M M M M M S 2 S S S S M S S M M M M M S 3 S S S C M S S M M M M M S 4 S S M C M S S M M M M M S 5 S S M M M S S M M M M M S 6 S S S M M S S M M M M M S 7 S S S C M S S M M M M M S 8 S S M M M S S M M M M M S 9 S S M M M S S M M M M M S 10 S S M M M S S M M M M M S 11 S S M M M S S M M M M M S 12 S S M M M S S M M M M M S 13 S S M S M S S M M M M M S 14 S S S M M S S M M S M M S 15 S S M M M S S M M M M M S

Acknowledgments
The authors recognize the Ministry of Health and Social Welfare (MOHSW) of Tanzania for leadership in maternal and newborn health.

M = provider performed skill on models only, under supervision; S = provider performed skill with client, under supervision; C = provider performed skill competently with patient/client, under minimal supervision

This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Cooperative Agreement No. 621-A-00-08-00023-00. The contents are the responsibility of the Mothers and Infants, Safe Healthy Alive (MAISHA) program and do not necessarily reflect the views of USAID or the United States Government.