Strengthening the Health Workforce for Maternal and Newborn Care

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Dr. Kim Ozano: Hello listeners, and welcome to Connecting Citizens to Science.

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I'm Dr.

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Kim Ozano, and this is a podcast where we hear about current research and debates in global health.

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In this second episode of our three part mini series, which has been focused on quality improvement for the integration of HIV, TB, and malaria services in antenatal and postnatal care, we are focusing on the critical role of capacity strengthening.

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We all know that healthcare workers have a crucial role to play in the provision of quality care to prevent maternal and newborn mortality and stillbirths.

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When complications arise during pregnancy, labour or delivery, or when a baby is born small or unwell, a trained health worker can mean the difference between life and death.

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Therefore, building and maintaining a sizable force of health workers with the skills to care for mothers and newborns can really drive significant gains in maternal and newborn health, and health workers, including physicians, midwives, nurses, and community health workers, are that safe pair of hands that can deliver maternal and newborn care.

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So, in this episode, we will be hearing about how the Quality Improvement Programme has improved early diagnosis, reduced maternal complications, and strengthened communication and teamwork among healthcare workers.

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Dr. Rael Mutai: To be able to make significant contribution and advancement on maternal and newborn health, investment in healthcare workers remains critical.

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And one of those areas that really needs to be looked into is their capacity building.

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Dr. Kim Ozano: Today's guests include Dr.

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Leonard Katalambula, who is the head of Department of Public Health at the University of Dodoma where he works as a lecturer.

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Dr.

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Leonard Katalambula is also the lead investigator for the Quality Improvement Programme that we will be discussing today.

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He is joined by Sylvia Kimtai, who is the sub county reproductive health coordinator in Kenya and has been involved in delivering quality improvement training to support Kenya and Tanzania in both face to face and blended learning approaches.

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She also mentors nurses, midwives, and clinical officers on quality improvement.

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And joining us again today is our co host, Dr.

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Rael Mutai, who is the regional technical advisor for maternal and newborn health in Kenya country director from Kenya at the Liverpool School of Tropical Medicine.

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Dr.

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Mutai is also a public health specialist with over 23 years experience in health and development, including clinical practice, sexual and reproductive health advocacy and policy, health planning, and healthcare financing.

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Rael is also the regional technical advisor supporting the quality improvement programme.

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So, join us as we hear about the challenges, successes, and the transformative impact of strengthening the capacity of health workers on the frontline.

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Rael, welcome to the podcast.

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It's great to have you here for the second in this three part miniseries.

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Please set us up for this episode by talking through some of the challenges related to achieving high quality care for mothers and newborns.

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Dr. Rael Mutai: Thank you, Kim, I'm really glad to be here.

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Primary health care, and especially when it comes to pregnancy, the labour, delivery, and the postnatal period, it's mainly provided by nurses and midwives.

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When you look at the statistics in East Africa, and more so in Kenya and Tanzania, the bulk of the primary health care workers are nurses and midwives.

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And these are the people who really attend to the women and the children when they present themselves for care.

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Now the gap in our setup is that we still have high burden of maternal and newborn mortality, and that is because of gaps in the quality of care.

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These quality gaps are partly associated with the availability of the healthcare workers, the quality skills at their competencies.

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The challenge is that we do not meet the WHO recommendation in terms of the number of health care workers per 10, 000 population.

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In fact, most of our countries are about 13 compared to the 44 that is required to be able to address the needs of that population.

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And the other challenge is that even where health care workers are available, they are not equitably distributed.

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So you have one side of the country having fairly a good complement of the health care workers and in another place, the health care workers are quite few and beyond the numbers, you know, its about their capacity, really the skills and the competencies to be able to provide those basic services.

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Dr. Kim Ozano: That's really insightful, Rael.

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Just to clarify, when you mention the quality gaps in care and the challenges around capacity and skills, what would you say are the most urgent areas to address in order to make a real impact on maternal and newborn mortality rates?

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Dr. Rael Mutai: What we find is that once healthcare workers have graduated from the pre-service training institutions, most of the times the funds are required to be able to run those kinds of capacity building in interventions are not there.

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And even the mechanism to ensure that each and every health care worker working in maternal and newborn care undergoes continuous professional development.

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Most of the time, the mechanism is not assured.

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So what this project to do is to build the competencies of the health care workers in post.

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It does not employ new additional health care workers, but works with what is available to really bring them up to skill as per the recommendations.

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So, welcome Dr.

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Leonard Katalambula and welcome Sylvia to this podcast.

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My first question to Dr.

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Leonard, as you work in the University of Dodoma, which is a big institution that trains healthcare workers, many cadres of healthcare workers, the majority of whom are midwives and nurses, in your role and in your position working in this project and as part of your normal duties in the university, could you give us your thoughts in regards to how this programme has impacted capacity building at institutional level and specifically for the healthcare workers in the Dodoma region?

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Dr. Leonard Katalambula: Continuous professional development is very important for skill development and also quality improvement of services that are provided.

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The programme has impacted on the knowledge and the skills of health care workers and have refreshed their minds in the area of health care workers of specialities and we have that evidence on the importance of the training that they have been given.

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So, it is very important to have this kind of training and also mentorship and coaching to be done to health care workers frequently so that we can update their knowledge and skills.

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Dr. Rael Mutai: Thank you very much, Leonard.

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Sylvia, given your experiences as a frontline healthcare worker and also one who is responsible for capacity building, please share your experiences, in terms of how this capacity building initiative, more so the actual trainings and the mentorship, how has it impacted the healthcare workers and healthcare service delivery.

Sylvia Kimtai: 00:07:02

Before uh, the training, we had really several cases of eclampsia being diagnosed during labour and delivery.

Sylvia Kimtai: 00:07:12

We had mothers coming in with undiagnosed diabetes again during labour and delivery.

Sylvia Kimtai: 00:07:17

We are all aware that if we give quality care during the antenatal period, then that automatically translates to better outcomes during labour and delivery.

Sylvia Kimtai: 00:07:29

So, after the training the nurses were taken through integration of, um, HIV, tuberculosis and malaria into antenatal care and postnatal care.

Sylvia Kimtai: 00:07:42

So through that the nurses and midwives are able to diagnose early cases of preeclampsia.

Sylvia Kimtai: 00:07:50

The mothers are managed well, and by the time they get into labour and delivery, they're already are stable enough and there's basically good outcomes during that time.

Sylvia Kimtai: 00:08:02

We've also had reduced cases of postpartum haemorrhage, because one, the nurses and midwives are able to diagnose anaemia early during the antenatal period.

Sylvia Kimtai: 00:08:15

They've been able to treat anaemia, and of course, by the time the women come to labour and delivery, their haemoglobin level is okay.

Sylvia Kimtai: 00:08:25

We also had cases of mothers coming at labour and delivery with undiagnosed diabetes.

Sylvia Kimtai: 00:08:31

So, currently in my county, we are able to do a random blood sugar at every trimester.

Sylvia Kimtai: 00:08:39

And that has gone a long way to really diagnose diabetes early, and of course the women are managed.

Sylvia Kimtai: 00:08:48

Also before that, we really had a low uptake of uh, HIV uh, testing during the postnatal period.

Sylvia Kimtai: 00:08:57

And most of the times we would get babies being uh, diagnosed with the HIV at six months or at one year and after the training, we really sensitise the nurses and midwives on the importance of testing these women postnatally at six weeks and also at six months, and of course, every six months until cessation of breastfeeding.

Sylvia Kimtai: 00:09:23

So there's really an increase in HIV testing during the postnatal period.

Sylvia Kimtai: 00:09:28

And we've been able to diagnose women with HIV early enough, put them on anti-retroviral drugs.

Sylvia Kimtai: 00:09:36

Of course, once you put a mother on anti-retroviral drugs, the viral load will go down and there is really a low risk of that mother transmitting HIV to her baby.

Sylvia Kimtai: 00:09:48

So for me, I have seen a lot of impact since we trained the nurses and midwives on ANC and PNC.

Sylvia Kimtai: 00:09:57

Dr. Kim Ozano: Thanks, Sylvia.

Sylvia Kimtai: 00:09:58

That's great to understand those tangible examples of how improving the quality of care before labour and delivery creates better outcomes.

Sylvia Kimtai: 00:10:06

And I take it from what you said that it's not just for the improved health of mother and baby immediately after birth, but those improvements will carry forward into the long term as well.

Sylvia Kimtai: 00:10:17

In this podcast, we often discuss whole systems working, and I can see how that would reduce the burden on the health system more generally, freeing up resources for use elsewhere.

Sylvia Kimtai: 00:10:28

Rael, as the regional technical advisor for the programme, how has this programme led to so many vast impacts and what has been done differently to what is the normal training within the system?

Sylvia Kimtai: 00:10:40

Dr. Rael Mutai: That is really a valid question.

Sylvia Kimtai: 00:10:42

What we know is that in pre-service training, the basic competencies are provided, but what we know is that most of these institutions, there is limited competency training.

Sylvia Kimtai: 00:10:53

The theory is very strong.

Sylvia Kimtai: 00:10:55

This project as such really try to build the capacity of these healthcare workers to know that when a mother presents for their first antenatal period, they should make the assumption that could be the only time they're going to see that mother and therefore they should get the comprehensive package of all the services that need to be done.

Sylvia Kimtai: 00:11:11

So all the tests, all the blood works, all the physical assessments need to be done, the mental screening, it's all done.

Sylvia Kimtai: 00:11:18

And the kind of training that we've offered to this health care workers is competency based with a workshop that comes perhaps at the end of it, and there's also the blended learning approach where some, they have to do their own self directed learning, go through the materials on their own, and eventually they have a face to face session where they practice even the actual screening for HIV.

Sylvia Kimtai: 00:11:39

What does the counselling entail?

Sylvia Kimtai: 00:11:41

Doing the actual test rapidly and providing the results.

Sylvia Kimtai: 00:11:44

When a mother presents with elevated blood pressure in pregnancy, what is the protocol?

Sylvia Kimtai: 00:11:49

And each of these countries, interestingly is that the protocols are there, but more often than not, the healthcare workers have not had an opportunity to be sensitised, to be taken on step by step on what exactly they need to do.

Sylvia Kimtai: 00:12:01

So this programme really builds the competencies of what are called master trainers in each project site, who are then the ones who facilitated the training of the healthcare workers from the many different facilities.

Sylvia Kimtai: 00:12:13

But of course, Kim, it was not possible to do a hundred percent saturation of the trainings.

Sylvia Kimtai: 00:12:18

You know, most places were able to do 50%, 40%, 60%, which means there is still a lot of work that needs to be done to bring all the healthcare works to scale, but more importantly, is that there is a mentorship programme that has been set in place and the healthcare workers are taking that forward beyond even these trainings.

Sylvia Kimtai: 00:12:36

Dr. Kim Ozano: Thank you so much.

Sylvia Kimtai: 00:12:36

So, in episode one, we heard how the responsiveness of the programme to meet the needs of nurses and midwives was something you had to build in because of COVID, because of all the changes as well.

Sylvia Kimtai: 00:12:47

And I love this term sensitising.

Sylvia Kimtai: 00:12:49

So it sounds to me like, It's the practical applications of those skills and the competencies are really very much part of that, so that's really interesting.

Sylvia Kimtai: 00:13:00

As the competencies are changing, what's happening to people's attitudes?

Sylvia Kimtai: 00:13:05

Are they changing too?

Lenoard Katalbula: 00:13:06

So, with the kind of training that we have given to the health care workers, most of them have confessed that their attitude have changed on how they provide service.

Lenoard Katalbula: 00:13:17

So in this is a positive contribution.

Lenoard Katalbula: 00:13:19

I think Sylvia, who is working in the facility, can again say something on the changes in the attitude of health care workers post training of the project.

Sylvia Kimtai: 00:13:31

The training had a component on respectful maternity care and that in itself was a way of trying to change the attitude of the health care providers.

Sylvia Kimtai: 00:13:43

We also had a component on communication.

Sylvia Kimtai: 00:13:46

For a very long time, we've not really had a synergy between the last midwife the clinical officer uh, and the doctor.

Sylvia Kimtai: 00:13:53

So in uh, the training, we really emphasised on the teamwork between the maternal and newborn team trying to help them improve on the way they communicate amongst themselves and also how they communicate to that mother who has come to the antenatal clinic and also just communicating to possibly a companion that has come to the facility.

Sylvia Kimtai: 00:14:20

Communication in a way has also just helped them to improve on their attitude.

Sylvia Kimtai: 00:14:26

And also one of the things that we also taught them during the training is for them to try and get views on the care that they offer to their women.

Sylvia Kimtai: 00:14:36

At times the nurses and midwives think that they're actually offering a good care or a better service to their mothers, but surprisingly, when they now do a client exit interview for those mothers, they're surprised that that things that they ignore yet women would really want them to do that so that they feel that they are being respected in those clinics.

Sylvia Kimtai: 00:14:58

So I think, the training as much as we were capacity building them on the knowledge and skills about antenatal and newborn.

Sylvia Kimtai: 00:15:06

I think it also just basically changed the attitude of these nurses and midwives.

Sylvia Kimtai: 00:15:11

Dr. Rael Mutai: Thank you very much, Sylvia.

Sylvia Kimtai: 00:15:13

Dr.

Sylvia Kimtai: 00:15:13

Katalambula, I know you are from a university, so a lot of research work goes on in maternal and newborn health care.

Sylvia Kimtai: 00:15:21

How is research managed, there is the Ministry of Health, which is supposed to utilise this to inform policy and strategy.

Sylvia Kimtai: 00:15:28

We have a partner like Liverpool School of Tropical Medicine working with you.

Sylvia Kimtai: 00:15:32

How has it been managing that relationship?

Sylvia Kimtai: 00:15:35

Dr. Leonard Katalambula: We usually do research for the purpose of improving either policy or practice.

Sylvia Kimtai: 00:15:40

We made sure that the project is inclusive and they incorporate all the government organs that are relevant to make sure that the findings that we get from the project are used to inform policy and the practice.

Sylvia Kimtai: 00:15:55

Our project chairperson, the board chairperson is the director from the Division of Reproductive Maternal and Child Health, but again, we have members from the local government authority, including the Ministry for Local Government Authority, the regional office, and also the district offices.

Sylvia Kimtai: 00:16:16

All these are part of the advisory board in the project.

Sylvia Kimtai: 00:16:19

And actually they are part and parcel in the implementation of the project.

Sylvia Kimtai: 00:16:25

And they know exactly what is done and what are the findings that we are having.

Sylvia Kimtai: 00:16:32

We disseminate findings in the academic forums.

Sylvia Kimtai: 00:16:35

We have been involved, we have participated in the reproductive and maternal health conference last year, but again, we participated in the Tanzania health summit to present our findings.

Sylvia Kimtai: 00:16:47

Dr. Kim Ozano: Great to hear those key organisations are part of the implementation post project too.

Sylvia Kimtai: 00:16:53

That always improves engagement.

Sylvia Kimtai: 00:16:55

I also picked up on that South-South learning element as part of your dissemination and implementation as well.

Sylvia Kimtai: 00:17:02

That can really amplify value for funders, but also expedites the learning and therefore service improvement in the region more generally, and also the integration element came out very strong from Sylvia's story where women come in and, they are screened for other ailments as well.

Sylvia Kimtai: 00:17:19

So we're at that point in the podcast where we like to wrap up with some key points of advice that you would give to others who want to strengthen the capacity of their workforce, and I can already see that the competencies you're talking about are so much more than medical based competencies.

Sylvia Kimtai: 00:17:34

There are people management and communication skills, and learning how to integrate.

Sylvia Kimtai: 00:17:39

It's really great to see that.

Sylvia Kimtai: 00:17:41

If others want to achieve the outcomes you have in this programme, what advice would you give?

Sylvia Kimtai: 00:17:46

Let's start with our co-host Dr.

Sylvia Kimtai: 00:17:48

Mutai.

Sylvia Kimtai: 00:17:49

Dr. Rael Mutai: Yeah, so thank you very much, Kim.

Sylvia Kimtai: 00:17:51

To be able to make significant contribution and advancement on maternal and newborn health, investment in healthcare workers remains critical.

Sylvia Kimtai: 00:17:59

And one of those areas that really needs to be looked into is their capacity building, whether it is at the pre-service or in service.

Sylvia Kimtai: 00:18:07

And when it comes, the pre-service, what we know is that the approach and the delivery of this highly competency based skills needs to be strengthened.

Sylvia Kimtai: 00:18:16

But when it comes to the in service, where the capacity building is no longer structured, because these are people who are working, there is need to invest in continuous professional development and to continue to support the government in actually ensuring that there is a system through which at least the healthcare workers frequently, like within a year, all the healthcare workers should have gone through the basic competencies for offering antenatal care, intrapartum care, and postnatal care.

Sylvia Kimtai: 00:18:42

Dr. Kim Ozano: Very well put.

Sylvia Kimtai: 00:18:43

Thank you very much, Sylvia, your frontline experiences and what you've shared, the impact is very clear, so what advice would you give to others having already gone through this training and mentored others?

Sylvia Kimtai: 00:18:55

Yeah, I want to agree with what Dr.

Sylvia Kimtai: 00:18:57

Mutai has said, what is important is for us to have mentors, because we know as a country, we might not take everyone to a training.

Sylvia Kimtai: 00:19:06

So, if we would have mentors at every facility, really taking the lead and mentoring the rest of the staff, I think that would go a long way.

Sylvia Kimtai: 00:19:16

And also just increasing the number of staff.

Sylvia Kimtai: 00:19:19

Sometimes we train them, we give them these guidelines, but they're so much overworked, they can't be able to really give the quality of care that they would want to give.

Sylvia Kimtai: 00:19:30

So if you would get more staff in the facilities, I think that would go a long way.

Sylvia Kimtai: 00:19:35

And then of course, sometimes we also have challenges with staff transfer.

Sylvia Kimtai: 00:19:39

You've uh, trained a staff within a month or two they've transferred in an area where they are not going to offer maternal and newborn care.

Sylvia Kimtai: 00:19:48

And of course, sometimes again, you train the staff, but they don't have the equipment and the supplies that they need to use when they're offering those services.

Sylvia Kimtai: 00:19:59

So again, as much as we are training these staffs, let us also ensure that we are able to give them the necessary equipment and the supplies that they need so that they can be able to offer quality services.

Sylvia Kimtai: 00:20:12

Dr. Kim Ozano: Thank you very much.

Sylvia Kimtai: 00:20:13

A lot to take on board there and some real important lessons as well for others.

Sylvia Kimtai: 00:20:17

And finally Dr.

Sylvia Kimtai: 00:20:18

Katalambula, what's your piece of advice for others trying to achieve the same outcomes?

Sylvia Kimtai: 00:20:23

Dr. Leonard Katalambula: If I have to give advice to anyone who wants to strengthen the health care system in Tanzania, I would advise to go for skill development.

Sylvia Kimtai: 00:20:34

We know that the country invested much on infrastructure and equipment and a number of improvements have been done, but still there has been some complaints on the quality of service that is, is given, and much of the blame are taken to the skill base of health care workers.

Sylvia Kimtai: 00:20:56

So to my advice, this area needs more investment.

Sylvia Kimtai: 00:21:00

And if someone needs to invest more in the health care sector in Tanzania, I would advise to invest in the skill development of health care workers.

Sylvia Kimtai: 00:21:10

Dr. Kim Ozano: A strong case for investing in the workforce to end the episode there.

Sylvia Kimtai: 00:21:14

So wonderful conversation with our guests and thank you to Dr.

Sylvia Kimtai: 00:21:19

Mutai, Sylvia and Dr.

Sylvia Kimtai: 00:21:22

Katalambula for joining us today.

Sylvia Kimtai: 00:21:24

Remember that this is a three part miniseries focused on sharing insights from the Quality Improvement Programme for the integration of HIV, tuberculosis, and malaria services and antenatal and postnatal care.

Sylvia Kimtai: 00:21:35

For now, enjoy your day and thank you for listening.

Sylvia Kimtai: 00:21:38

Bye bye.