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Improving maternal health, the fifth United Nations’ Millennium Development Goal, is one of the main health concerns of many developing countries, where 90 % of the world’s maternal mortality occurs (World Health Organization [WHO], 2010). Very few countries will achieve the target of reducing maternal mortality by two thirds, as set to be achieved in the year 2015 (WHO, 2010). However, nations such as Rwanda rank among the countries that have made significant efforts to reduce maternal mortality. The United Nations Population Fund (2012) reports that the maternal mortality rate for Rwanda fell from 1071 deaths per 100,000 live births in the year 2000 to 750 deaths in 2005, then to 540 in 2008 and further decreased to 383 in 2010.
Strategies that were used to reduce maternal deaths in Rwanda include the training of maternal health professionals. The emphasis has been put on educating health professional students during their pre-service education. Such strategies appear to be making a significant impact in Rwanda. The WHO (2010) states that the proportion of births assisted by formally educated healthcare providers in Rwanda has increased from 26.7 percent in 2000 to 38.6 percent in 2005 and to 69 percent in 2010. Unlike pre-service training and its efforts of facilitating the empowerment of graduating health professionals in Rwanda, similar efforts are being enacted to strengthen in-service training for healthcare providers who focus on maternal, newborn, and child health. In 2009, the WHO indicated that health professionals need to acquire new skills to manage pregnancy-related complications, and that educational efforts should focus on continuing professional development programs (CPD).
In a number of African nations, CPD has been formalized and the oversight is directed by medical, nursing, and midwifery councils (Arunachallam, 2009; Gallagher, 2007). In South Africa, nurses believe that CPD needs to be embedded into professional practice at an organizational and personal level in order to address changing health issues within the country (Arunachallam, 2009). In Ghana, CPD has been cited as a factor in nurses` consideration of selecting staff positions in rural settings (Kwansah, et al., 2012). In this case, CPD could be seen as an intervention to support a more equal distribution of human resources in a nation and hence improve health care quality.
The Maternal, Newborn and Child Health in Rwanda (MNCHR) project was initiated in 2011 and continues until April, 2015. This project has been funded by the Canadian International Development Agency and one major aim was to provide CPD education programs to health professionals involved in the care of women and newborns. The Advanced Life Support in Obstetrics (ALSO) course is one of the education programs that was provided to health professionals (nurses, midwives, physicians) in nine hospitals of the Eastern Province in Rwanda. For each of the participating hospitals, nine health professionals were educated in a ‘train the trainer mentorship approach. ALSO training aims to equip health professionals with adequate knowledge and skills to effectively manage obstetrical emergencies. Given that the WHO (2009) reports that among countries with critical maternal health care; only 22% of them have near to sufficient number of midwives with adequate training to provide appropriate maternal health care and that only 18.5% maternal health providers are equipped to provide obstetrical emergencies, it was deemed imperative to facilitate education initiatives that could be sustainable through ongoing mentorship. It has been demonstrated that well-educated midwives working in a well-systematized health system can offer up to 90% of needed maternal health care, reducing maternal deaths by two-thirds (Campbell & Graham, 2006).
Purpose of the study
The research literature on CPD for health professionals in Africa in general, and particularly in sub-Saharan Africa is limited in nature, which might be attributed to factors such as limited resources to carry-out CPD related research. Little is known about the barriers to the success of CPD related activities. The purpose of this study was to explore the barriers that hospitals face in their efforts to get health professionals to apply the knowledge and skills learned from the ALSO CPD training into practice.
Methods
This research used a mixed methods approach with primary data collected by the researcher in the hospitals of the Eastern Province of Rwanda, where ALSO CPD was provided. This includes qualitative data involving sixteen purposive interviews with ALSO trainees (nurses, midwives and physicians). Descriptive quantitative data on turnover of ALSO trainees was obtained from hospital directors. The turnover of interest for this study was from the period of October 2012 to June 2014, corresponding to the period ALSO training have been running in the hospitals of the Eastern Province.
Selection of study population
To arrange interviews with ALSO trainees, information about the study was circulated through the hospital administrators, who then shared the study information with health professionals. Those who expressed an interest in participating in the study called or emailed the researcher, and a meeting time was set up for individual interviews. To arrange interviews with hospital directors, an information meeting was scheduled with each of them to explain the purpose of the study. Thereafter an interview date was scheduled for those who accepted to participate in the study.
Study procedures
Qualitative data were gained using semi-structured interview guides that included open-ended questions to elicit views from ALSO trainees about barriers to apply ALSO related knowledge and skills into practice. The interviews proceeded in a conversational manner to facilitate open dialogue. Interviewees were given the option to answer in English, Kinyarwanda or French, depending on which language they are more comfortable with. The interviews were audio recorded with the participants’ permission, and were approximately 30- 45 minutes in length. Interviews took place in a room that was provided by the hospital.
Quantitative data were obtained from hospital directors, using a short questionnaire. They were asked information on: the total number of ALSO trainees, the number of those who have left from the time the training was provided until the time of the interview and the reasons of turnover.
Ethical considerations
Ethical approvals to conduct this study were obtained from the Research Ethics Board in Rwanda. Oral and written informed consent was obtained from the participants immediately prior to involvement in the interview or completing the study questions.
Data analysis
For qualitative data, the audio recordings were transcribed verbatim, translated as required into English by the researcher prior to coding. Each participant’s data was assigned an ID number that was used for analytical purposes. Initial coding of transcripts was done by the researcher engaging in reflection and highlighting key data (Prince, 2008). Data analysis involved line by line, open, and axial stages of coding in a constant comparative, iterative manner to capture emergent themes. Data management and analysis were supported by NVIVO™ software. For quantitative data, the Basic Quantitative Analysis program with Excel was used. Data on turnover were gathered and grouped into three variables (Total number of ALSO trainees, total number of turnover and reasons for turnover).
Results
Results from this study showed that ALSO trainees felt that they did not receive enough opportunities to apply their new knowledge and skills after the CPD education. This is due to working on the rotation shifts basis, which results in not spending enough time in maternal health care services for any lengthy period of time. Due to limited means, the ALSO course was offered to only nine health professionals per hospital. In addition to this limitation, ALSO participants did not get the opportunity to train their colleagues to share the knowledge among additional health professionals. With this situation, only ALSO participants could practice related knowledge and skills when they were appointed to work in maternal health services. Participants revealed that when they did not work in maternity services, they forget the new practices and reverted back to their routine form of care by the time they are reappointed to the maternity services. Results of this study also showed that 45 of 72 ALSO trainees from the study participating hospitals had moved to other work placements. The reasons of turnover were: higher studies (n=19), better position (n=12) and other reasons (n=14).
Implications and Recommendations
It is important for those delivering maternal health education to create sustainable mentoring systems that could help to strengthen the application of ALSO knowledge and skills in hospitals to improve maternal health. Measures that could give ALSO participants the opportunities to apply the related knowledge and skills include: expanding ALSO education to many health professionals and having an adequate mentorship of ALSO participants, formalize ALSO CPD into hospital in-service programs, and develop enhanced health professional retention strategies.