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Training of Trainers – Community Midwives Workshop Report Fatima Memorial Hospital, Shadman, Lahore, Pakistan


INTRODUCTION Pakistan at present is facing the challenge of achieving the millennium development goals 4 & 5 to reduce the child and maternal, mortality & morbidity rate up to 2015. An estimated 350 to 550 Pakistani women die for every 100,000 live births. Pakistan's high maternal and infant mortality rates reflect the country's shortage of trained health workers and its inadequate health infrastructure. Currently, more than 65 percent of women in Pakistan deliver their babies at home, and onl y eight percent of these home births are supervised by a trained attendant. Only 36 percent of Pakistani mothers currently deliver their babies with the assistance of a skilled birth attendant. Deaths among newborns, infants and children have not decreased in the past 10 years.1 There is global consensus on the need for skilled attendants at childbirth hence midwife specifically is the most appropriate health care professional for women during pregnancy, childbirth and the postnatal period. Fatima Memorial System has always taken a lead in initiating health sector reforms in the past and this time again took this initiative of training the present and potential health work force at Saida Waheed FMH College of Nursing. It is a unique model of public and private partnership to address the acute shortage of health work force. It is not only providing quality education and training to students enrolled in Diploma in General Nursing, Community Midwifery, Post Basic Diploma Courses, B.Sc Nursing (04yrs)Program and Post RN B.Sc (02yrs)Program but is also focusing on the professional development of the current public and private sector nursing staff and faculty, who are the nursing leaders of the future. Although the midwifery training is already being imparted to develop this cadre of health work force but the concerned stakeholders felt the need to have a comprehensive program in line with the practices laid down by the International Council of Midwifery .Thus a task force was constituted comprising of local and foreign nursing and midwifery experts.

1

Source; USAID Report April -June 2008


1. OBJECTIVE OF T RAINING To improve the teaching of Midwifery, including Community Practice, resulting in improving the maternal health and reducing the child mortality

2. SPECIFIC OBJECTIVES This three-weeks training is initiated with the intentions to strengthen teaching abilities of the faculty for through pupil midwifery and community midwifery courses and in the long run to improve the performance of services provided by the health care organizations. By the end of this training, participants will be expected to: 1. Strengthen midwifery faculty skills by improving theoretical knowledge and clinical competencies. 2. Standardize the curriculum for advanced midwifery in line with the International Midwifery Council 3. Develop an understanding of Code of Conduct; Regulatory mechanism for midwifery practices. 4. Focus on Professional Relationship, Collaboration of midwives with other team members and Allied professions. 5. To update the theoretical knowledge of midwifery tutors 6. To help upgrade professional practical skills of midwifery tutors


P ARTICIPANT PROFILE The participants for the training were nurses from different cities of Punjab. The diversified representation provided an excellent platform for them to meet and interact with each other about their currently methodology and issues they are facing within their communities. It also provided an excellent opportunity to voice their problems and concerns to the policy makers. NAME

CITY

Attia Khatoon

Multan

Fauzia Zafar

Gujrat

Imrana Yasmin

Multan

Iqra Habib

Chinniot

Ireen Zaib un Nisa

Multan

Isbella James

Hafizabad

Musarat Parveen

Khanewal

Nusrat D/O Gh. Muhammad

Muzafargarh

Razia Sultana

Shahiwal

Rehana Kokab

Jhang

Rubina Benjamin

Lahore

Shaheen Kousar

Lahore

Surriaya Bano

Narowal

Tanveer Akhter

Chakwal

Zakira Firdous

Lahore


TRAINER PROFILE Keeping in view the need of the content, different trainers and one facilitator were decided upon. The list of trainers included:

Dr. Ayesha Nauman

Dr. Fatima Imran Prof. Dr. Jovaria Mannan Dr. Attiqa Muzzammil Prof. Dr. Taslim Malik Dr. Naveed

Director Human Resources Senior Registrar Professor of Pediatrics Associate Professor Visiting Consultant PG Trainee

Irshad Begum

Director Nursing Education & Development

Saleema Dewan

Coordinator

Dr. Anis Fatima

Faculty

Shafqat Hussain Zaidi

Faculty

Masters in Human Resource Management , Diploma in Project Management, Certified in Human Resource Management, Master in Business Administration, Bachelor in Medicine and Bachelor in Surgery MBBS, FCPS MBBS, FCPS, DCH MBBS, MCPS, FCPS MBBS, FRCS MBBS, FCPS Part-I Diploma in General Nursing & Midwifery (PNC), Diploma in Nursing Management & Nursing Education, B.L.L.B From Bahauddin Zakariya University, Certificate Course Infertility Management & Reproductive Health (John Hopkins University Baltimore Mary Diploma in General Nursing & Midwifery (PNC), Diploma in Nursing Management & Nursing Education, Post Basic Diploma in Advaced Midwifery F.C.P.S-1, Diploma in Gynae & Obs (DGO),M.B.B.S MS leading to PhD in applied linguistics (continue) MA English literature, MA TEFL, PGD,ELT, Certified teacher trainer (PEF).


TRAINING M ETHODOLOGY Designed and delivery of the training is via theoretical as well as practical approach embedded in participatory techniques of adult education. The methodology is based on principles of adult learning, using a mixture of presentations, interactive discussions, and group work. The training methodology included:         

Illustrated lectures, audio visual aids in addition to verbal explanation Discussion/ Brainstorming, to share views and problems using reasoning power, to get all possible ideas from the group members Group work, to interact with each other and learn together Case studies, to develop and practice clinical decision-making skills Role plays, to develop and practice interpersonal communication sills Learning guides and checklists, to learn to provide (emergency) obstetric care Demonstration/practice on Dummy, to show how to perform a procedure Hands on training/Bedside teaching, to practice under supervision Self study, to gain deeper insight and more profound knowledge

Tools needed;       

Training Manuals, Multimedia Audio Visual Aids Mannequin Community and DHQ Health Center Visits OSCE visits Handouts


AGENDA OF THE WORKSHOP

SESSION NAME

TIME

Registration (First Day only)

9:00 –9:15 am

Orientation to Workshop (First Day only)

9:15 –9:30 am

Session #1:

09:00 –10:00 am

Tea/Coffee Break

10:00 –10:30 am

Session #2:

10:30 –11:30 am

Session #3:

11:30 –12:30 pm

Lunch & Prayer Break

12:30 – 13:30 pm

Session #3:

13:30 –14:30 pm

Closing Ceremony (Last Day only)

10:00 – 12:00 pm

OBJECTIVES

Introduction of participants Pre-workshop assessment

Post-workshop assessment Workshop & Trainer Evaluation Certificate presentation


WORKSHOP PROCEEDING Sessions Outline – Week I

Time Slot

Day I

Day II

Introduction 8:30 am to 10:00am

Goals and Objectives Pre-Training Assessment

Trainer

Dr. Ayesha Nauman

History Taking in Obstratical & Gaynacological Patients Calculation of EDD Dr. Anis Fatima

Day III Implication of cognitive, psychomotor and effective domain in midwifery education and clinical practice Mrs. Irshad Javed

Day IV

Day V

Day VI

Learning theories

Competency -1 Social epidemiologic and cultural context of maternal and newborn care

Mrs. Irshad Javed

Mrs. Irshad Javed

Physiology of Mestuctal cycle Physiology of Pregnancy Dr. Ayesha Nauman

Tea 10:00 to 10:30 a.m

10:30am to 11:30am

Trainer 11:30am

Sign & symptoms of pregnancy

Midwife, Midwifery, Philosophy of Midwifery Community Health Nurse/Worker

Ethics in midwifery practice

Dr. Anis Fatima Introduction to Safe motherhood

Mrs. Irshad Javed Learning objectives in the context of

Development of Lesson Plan

Mrs. Irshad Javed Group Presentation on Lesson Plan

Teaching & learning methodologies

Mr. Shafqat Zaidi Reflective Teaching

Learning theories

Mrs. Irshad Javed Initiatives at public & private

Diagnosis of pregnancy Role of ultrasound during pregnancy Mrs. Irshad Javed Developing of check list from ICM


to 12:30pm

Pre Pregnancy Care & role of Pre Pregnancy Care Clinics

bloom’s taxonomy i.e., Cognitive, Psychomotor & effective domain

Trainer

Mrs. Irshad Javed

Mrs. Irshad Javed

1:30 pm. to 2:30 pm

Introduction to Community Midwifery Training Manual

Trainer 2:30 pm to 3:00pm

Mrs. Irshad Javed Feed back on today session + Assignment

Trainer

Mrs. Irshad Javed

Mrs. Irshad Javed Lunch + Prayer Break 12:30 to 1:30 pm Learning objectives in Introduction to the context of monitoring and bloom’s taxonomy i.e, evaluation Group presentation Cognitive, M & E Tools on lesson plan Psychomotor & Its importance in effective domain midwifery practice Mrs. Irshad Javed Mrs. Irshad Javed Mr. Shafqat Zaidi Feed back on today Feed back on Feed back on today session + today session + session + Assignment Assignment Assignment Mrs. Irshad Mrs. Irshad Javed Mrs. Irshad Javed Javed Mrs. Irshad Javed

sector to reduce MMR & IMR

cognitive, psychomotor and effective domain for Competency 1.

Mrs. Irshad Javed

Dr. Anis Fatima

Brief on essential competencies for basic midwifery practice by ICM

Developing of check list from ICM keeping in mind cognitive, psychomotor and effective domain for Competency 2.

Mrs. Irshad Javed Feed back on today session + Assignment

Mrs. Irshad Javed

Mrs. Irshad Javed

Mrs. Irshad Javed

Feed back on today session + Assignment


Sessions Outline – Week II

Time Slot

8:30 am to 10:00am

Trainer

10:30am to 11:30am

Day I

Day II

Group presentation and feedback on check list from ICM keeping in mind cognitive, psychomotor and effective domain for Competency 1 & 2.

Clinical experience in OPD l in various setting in the context of Competency 1,2 &3 Taking health history and physical examination

Mrs. Irshad Javed

Ms. Saleema Deewan Dr. Anis Fatima

Competency 3 - in provision of care during pregnancy in the context of cognitive, psychomotor & effective domain. Management of Normal Pregnancy

Minor age mention pregnancy, hyper amanasis gradvidarum of pregnancy

Day III

Brief on Competency 4 - in provision of care during labor and birth) in the context of cognitive, psychomotor & effective domain

Dr. Saadia Usman

Day IV

Major disorders during pregnancy Pregnancy induced hypertension Pre eclampesia Eclampesia

Day V

Major disorders in pregnancy Diabetes, mellitus during pregnancy Risk factors

Dr. Anis Fatima

Tea 10:00 to 10:30 am Diagnosis of onset Competency 5 - in of labor, labor provision of care management. 1st, for women during 2nd & 3rd stage of the postpartum labor period Lactation management and Obstetric Importance of indication for breast feeding emergency,

Day VI

Competency 6 in postnatal care of the newborn Brief session on Neonate Assessment

Dr. Anis Fatima

Prof. Jovaria Mannan

History & Examination taking of dibetes patients Ultrasonographic reviews of the fetus for congenital abnormalities and management

Developing checklist of group presentation on Competency 6 in postnatal care of the newborn Infant development in


referral or transfer for obstetrician. Trainer

11:30am to 12:30pm

Dr. Anis Fatima

Developing check list for Competency 3 (Competency in provision of care during pregnancy.

Dr. Anis Fatima

Diagnosis and management of miscarriages

Ms. Saleema Deewan Lunch + Prayer Break 12:30 to 1:30 pm Rights of the patient 1:30 pm. Maintaining Heptoses to confidentiality pregnancy 2:30 pm Documentation Record keeping Trainer

Dr. Anis Fatima

the first year

Dr. Saadia Usman

Dr.Anees Fatima

Dr. Anis Fatima

Developing check list of Competency 4 - in provision of care during labour and birth

Developing check list for competency 5 - in provision of care for women during the postpartum period

Group discussion Role play

Dr. Saadia Usman

Mrs. Irshad Javed

Dr. Anis Fatima

Group presentation and feedback on checklist from ICM for competency 4

Anemia’s in pregnancy

Gestational debates and dietary management

Trainer

Mrs. Irshad Javed

Dr. Anis Fatima

Dr. Saadia Usman

Dr. Anis Fatima

Dr. Anis Fatima

2:30 pm to 3:00pm

Feed back on today session + Assignment

Feed back on today session + Assignment

Feed back on today session + Assignment

Feed back on today session + Assignment

Trainer

Mrs. Irshad Javed

Feed back on today session + Assignment Mrs. Irshad Javed

Mrs. Irshad Javed

Mrs. Irshad Javed

Mrs. Irshad Javed

Prof. Jovaria Mannan Developing check list for competency 6 in context of cognitive, psychomotor and effective domain Prof. Jovaria Mannan

Group presentation of competency 6 Prof. Jovaria Mannan Feed back on today session + Assignment Mrs. Irshad Javed


Sessions Outline – Week III Time Slot

8:30 am to 10:00am

Trainer

10:30am to 11:30am

Trainer

Day I

Day II

Day III

Feedback of previous session brief on Competency 7 (competency in facilitation of abortion related care) in the context of cognitive, psychomotor and effective domain

Feedback of previous session Clinical Experience competency 6 Brief session on Neonate Assessment (reflexes, APGAR scoring, Resuscitation)

-Brief on community mapping. Community sensitization and mobilization Community partnership Formation of community support group for enhancing community acceptance

Dr. Saadia Usman

Saleema Dewan

Prof. Amanullah Khan Tea 10:00 to 10:30 a.m Briefing on essential factor for community visit and community experience Community visit to a public sector RHC at Sheikhupura

Developing checklist for Competency 7 Policies, protocols, and law related to abortion Medical eligibility criteria for abortion Sign and symptoms of incomplete abortion and abortion complications Dr. Saadia Usman

Clinical Experience competency 6 (continue)

Prof. Amanullah Khan

Day IV

Community visit to a public sector RHC at Sheikhupura

Day V

Day VI

Community visit to Malikpur

•Feedback of previous session •Drug related to community midwifery •Recognize the importance of rational use of drugs •Classify the group of essential drugs use in midwifery in the care of mother and new born. Mrs. Irshad Javed

Community visit to Malikpur

Administering drugs adverse effects and contradiction in relation to trimesters of pregnancy Responsibilities of a midwifery while prescribing and administering drug Mrs. Irshad Javed


11:30am to 12:30pm

Session on introduction to EMOC Obstetric indications for per-natal complications

Communication skills Interpersonal Community Clinical relationship with visit to a experience medical and other allied public sector Competency 7 in professions RHC at the context of Communication of bad Sheikhupura post abortion news to mother and related care) family for baby loss, mother death Prof. Amanullah Khan Lunch + Prayer Break 12:30 to 1:30 pm

Trainer

Mrs. Irshad Javed

1:30 pm. to 2:30 pm

Hospital policies and protocols for transfer and referral system for high risk patients to a tertiary care facility Role of midwife in EMOC

Trainer

Dr. Tasleem Malik

2:30 pm to 3:00pm

Feed back on today session + Assignment

Feed back on today session + Assignment

Feed back on today session + Assignment

Trainer

Mrs. Irshad Javed

Mrs. Irshad Javed

Mrs. Irshad Javed

Clinical experience Competency 7 (continue)

Group presentation on a case study

Community visit to a public sector RHC at Sheikhupura

Community visit to Malikpur

Essential elements of quality of care including compliance with standards, competency, continuum of care

Dr. Anis Fatima

Community visit to Malikpur

Dr. Anees Fatima Ms. Saleema Deewan

Related the quality in health care to competency, continuum of care, compliance Related monitoring and supervision to quality of care. Mrs. Irshad Javed

Community visit to a public sector RHC at Sheikhupura

Community visit to Malikpur

Feed back on today session + Assignment Mrs. Irshad Javed


Sessions Outline – Week IV Time Slot

8:30 am to 10:00am

Trainer

Day I Feedback of previous session How to monitor and supervise deployed CMWs for providing them technical support

Feedback of previous session Brief session on OSCE By: Mrs. Irshad Javed

Mrs. Irshad Javed Saleema Dewan

Graded presentation on antenatal care (Group-1) Dr. Saadia Trainer Usman Graded presentation on Graded 11:30am presentation on to Postnatal Care 12:30pm (Group-2) Post Abortion (Group-3) Trainer Mrs. Irshad Javed 10:30am to 11:30am

Day II

Orientation to the participants in OSCE center. Mrs. Irshad Javed

Practice on OSCE 4 - stations

Day III

Day IV

Feedback of previous session Practical session for Practical session for OSCE on individual OSCE on individual skill competency skill competency By: By: Dr. Anees Fatima Dr. Anees Fatima Ms. Saleeema Ms. Saleeema dewan dewan Mrs. Irshad Javed Mrs. Irshad Javed Tea 10:00 to 10:30 a.m Practical session for OSCE on individual skill competency By: Practical session for Dr. Anees Fatima OSCE on individual Ms. Saleeema skill competency Dewan By: Dr. Anees Fatima Ms. Saleema Dewan

By: Mrs. Irshad Javed Mrs. Irshad Javed

Mrs. Irshad Javed

Day V

Day VI

Feedback of previous session on OSCE

Review and quarries in last three week session By: Dr. Anees Fatima Review and quarries in last three week session

Mrs. Irshad Javed

Closing Ceremony


Lunch + Prayer Break 12:30 to 1:30 pm

1:30 pm. to 2:30 pm

Trainer 2:30 pm to 3:00pm Trainer

Hospital policies and protocols for transfer and referral system for high risk Clinical experience patients to a Competency 7 tertiary care facility Role of midwife in EMOC Dr. Tasleem Malik Reflective practice

Reflective practice

Mrs. Irshad Javed Mrs. Irshad Javed

Practical session for OSCE on individual skill competency By: Ms. Saleeema Dewan

Dr. Anees Fatima

Practical session for OSCE on individual skill competency By: Dr. Anees Fatima Ms. Saleeema dewan

Post Test By: Mrs. Irshad Javed Dr. Anees Fatima

Mrs. Irshad Javed

Reflective practice

Reflective practice

Feed back

Mrs. Irshad Javed

Mrs. Irshad Javed

Mrs. Irshad Javed


FEEDBACK & COMMENTS The participants were selected from different parts of the province all having experience and adequate educational level. Their theoretical knowledge about midwifery was limited and not updated in accordance with the latest guidelines with the international bodies. They are able to list, state and memorize theory. But they often lacked comprehensive, applying and synthesizing skills to work with theoretical knowledge. We notice a language problem but the lectures were kept in the way that most of the participants were able to understand and comprehend the basic concepts which were being explained to them. The training was not only confined to theoretical lectures only but also different interactive teaching methods were used as well including audio, visual, tours to wards, health care centers and community. The NCRP team believes that we need to improve these methods while incorporating new ones as well to improve the performance. Majority of them were in favor of more hands on experience in community and treating/witnessing actual patients/cases. The participants were very eager to learn to perform different examinations techniques and even delivering a baby. They also demanded that knowledge should be transferred more through visual aid like documentaries and lectures. The participants were very eager to acquire midwifery skills and they did participate actively during lectures. The trainers focused on the fact that the professional attitude expected from an independent midwife who is working as a community midwife differs essentially from the professional attitude of a nurse. An independent midwife is a medical practitioner, trained to work autonomous, being a specialist in normal pregnancy childbirth and puerperium. This attitude was lacking in some of the participants and it takes much more time to develop this attitude under supervision of competent midwifery teachers functioning as a role - model. Regarding teaching skills we saw only a few participants who are competent teachers. Other than the operational problems faced b the participants (mainly stay and food arrangements by MNCH), the participants were satisfied with the program. They appraised the teaching quality and abilities of the trainers. Most of the participants were motivated and willing to learn these techniques and implemented once they are back. This is a positive thing since it is very important that the training shouldn’t end right here, in fact there would be no results unless they go back and actually make a difference by adopting these practices. Few participants expressed themselves that there is lack of training at district level and this training would help them implementing these techniques to their areas plus they would also teach the other community midwives in those areas. Another important session which was need of the hour was communication and community mobilization. Participants expressed that they find it difficult to communicate with the women in their areas i.e. rural far flung areas where the elderly women mostly takes the charge in case of pregnancy. The sessions on communication skills and community mapping/mobilization were included in the program and highly appreciated by the participants.


THE W AY F ORWARD 

The NCRP Team with MNCH should review the content and session outli nes and need to update and revise the content where necessary in accordance with the short and long term objectives explained in the project proposal

The theoretical part should be supported by more visual/audio aids

The handouts, notes, slide printouts, books should be provided on timely basis so participants can revise on daily basis

Feedback sessions and evaluation should be done more actively at the end of every week to monitor the progress on timely basis

At the end of program, the participants should be test on theory as well as in practical examinations with announcement of top three participants during the closing ceremony

The participants should be encouraged to do self analysis of the improvements they have achieved and how it would improve individual and collective effort when they go back to their areas

The most important thing is the actual implementations of these techniques when they go back thus follow up visits to the areas of participants to judge the performance or improvement


ANNEXURE ANNEXURE 1: LIST OF PARTICIPANTS PARTICIPANT PROFILE Name

Address

Fauzia Zafar

School of Nursing & Midwife, Gujrat

Shaheen Kausar

Public Health Nursing School, Lahore

Iqra Habib

DHQ Hospital, Chinniot

Imrana Yasmin

Public Health Nursing School Nishtar Hospital, Multan

Attia Khatoon

Public Health Nursing School Nishtar Hospital, Multan

Razia Sultana

School of Nursing DHQ Teaching Hospital, Shahiwal

Musarat Parveen

School of Nursing DHQ Hospital, Khanewal

Rehana Kokab

School of Nursing, Jhang

Ireen Zaib un Nisa

School of Nursing, Multan

Nusrat Ghulam Muhammad

School of Nursing DHQ Hospital, Muzafargarh

Zakira Firdous

Lady Aitcheson Hospital, Lahore

Isbella James

G.N. School DHQ, Hafizabad

Fauzia Zafar

School of Nursing & Midwife, Gujrat


ANNEXURE 2: EVALUATIONS F ORMS


ANNEXURE 3: EVALUATIONS

EVALUATIONS RESULT 4.0

3.0

2.0

1.0

0.0


PARTICIPANT RESPONSE ON WORKSHOP CONTENT 10.0 8.0 6.0 4.0 2.0

Strongly Disagree Disagree

0.0

Neutral Agree Strongly Agree


MOST VALUABLE ATTRIBUTES OF WORKSHOP 35

30

25

20

15

10

5

0 Valuable & Qualified and Good Good Updated and Informative Experienced behavior of learning Review Topics trainers trainers environment Content

Teaching methods

Helpful lectures

Objective

Improve Knowledge


ANNEXURE 4: P ICTURES


“It is most important to conduct such programs for community midwives since there is no trainings for them at distract level. I would definitely go back and teach others about the things we have learnt here.”

“The workshop and arrangement exceeded my expectations. I had heard a lot about the Fatima Memorial Hospital and after experiencing it firsthand I must it is one of the top institutions in the country with excellent teachers”


Training of Trainers – Community Midwives