Research and Institutional Collaborations for Sustainable Solutions to Maternal and Newborn Health
This episode is the very first of four of a mini-series shining a spotlight on the programme Improving Quality of Maternal and Newborn Health.
This episode will help us understand a bit more about the programme, and then we'll move on to focus on a Liverpool School of Tropical Medicine partnership with two Kenyan universities where they aim to train healthcare workers on advanced obstetric and anesthetic skills training.
The principal investigator, Professor Charles Ameh, from the Liverpool School of Tropical Medicine, outlines the programme for us;
"The programme in Kenya, which has run for the past five years has three main work streams;
One is on quality of care. The other one is on the pre-service education. Then we have in-service education, and then we have a cross cutting theme of implementation research.
We have supported the facility based reviews of maternal deaths so that we can learn from each maternal death of every woman that had an adverse outcome of how to improve the quality of care and then on the national level, we have instituted a robust system of confidential enquiries into maternal deaths to help us see patterns and key issues that can be picked up in terms of policy practice, training, and development of healthcare workers.
The systems in Kenya are strengthened in terms of providing that next generation of healthcare providers that can be confident and competent to address preventing maternal deaths, managing complications, and also learning from these incidences to continuously improve their quality of care. Furthermore, when we look at the medical schools, the postgraduate schools, their capacity to improve the quality of their research and disseminate this research at a national, international, and regional level has improved significantly with this programme."
More about our guests:
Lucy Nyaga (Co-host) - Country Director, Liverpool School of Tropical Medicine, Kenya
Lucy is the Country Director, Liverpool School of Tropical medicine, in Kenya. She has a background in Medical Anthropology and Public Health with extensive experience in promoting implementation of research results into policy and practice with a special focus on maternal and neonatal health (MNH). With twenty years’ experience working in health programming, her experience and expertise in MNH has involved managing and implementing programmes that incorporate implementation research to inform effective programming and policy influence. Working with a range of organisations ranging from governments, academic and research institutions, UN agencies, and national & INGO, Lucy has led and contributed to key MNH research that has then led to policy influence in Eastern Africa.
Prof. Charles Ameh - Head, Department for International Public Health & Leader Emergency Obstetric and Quality of Care (EmOC&QoC) Unit. Liverpool School of Tropical Medicine
Prof. Charles Ameh, is a Professor in Global Health, a co-Director World Health Organisation Collaborating Centre for Research and Training in Maternal and Newborn Health, and Head International Public Health Department, Liverpool School of Tropical Medicine. He is also a member of the WHO Maternal, Perinatal Death Surveillance and Response Technical Working Group, a member WHO Technical Advisory Group on Maternal Mortality and Maternal Cause of Death Estimation.
Prof. Ameh has an established international reputation in Emergency Obstetric Care, Antenatal and Postnatal capacity strengthening (undergraduate and postgraduate), Obstetric Early Warning Systems, MNH quality of care including Maternal, Perinatal Death Surveillance and Response and Health System Strengthening in low-income countries. Prof. Ameh has substantial online teaching expertise and has published considerably in the field of global maternal health. He is an adjunct faculty at the department of Obstetrics and Gynaecology, University of Nairobi, external examiner to Moi University Kenya and London School of Tropical Medicine and Hygiene. Prof. Ameh is also on the editorial board of several leading global Public Health journals. He has trained health workers and residents in obstetrics and gynaecology in emergency obstetric care training in over 15 countries in Africa and Asia.
Prof. Eunice Cheserem - Chair of the Department of Obstetrics and Gynaecology. University of Nairobi.
Eunice has 30 years of teaching experience at both Undergraduate and Postgraduate levels in the Department of Obstetrics and Gynaecology, and is leading in the training of subspecialists in the field of Gynaecological Oncology. She uses research to enhance the capacity of upcoming gynaecologists and Obstetricians to improve best practice.
Dr Paul Nyongesa - Consultant Obstetrician and Gynaecologist, Moi Teaching and Referral Hospital Eldoret and Senior Lecturer, Dept of Reproductive Health. Moi University School of Medicine, Eldoret, Kenya
Dr. Paul Nyongesa is a consultant obstetrician/gynecologist with Clinical Duties in the Division of Reproductive Health at Moi Teaching and Referral Hospital and a senior lecturer at the department of Reproductive Health Moi University School of Medicine. He is a member of various professional organisations which include the Kenya Medical Association, Kenya Obstetrics and Gynaecological Society and the Liverpool School of Tropical Medicine Maternal and Perinatal Death Surveillance (MPDSR). He is also a National Maternal Mortality Data Assessor for Kenya. He helped write the first Confidential Enquiry into Maternal Deaths (CEMD) for Kenya in 2017. He has published more than 30 articles on Maternal and Newborn Health in peer reviewed and reputable journals.
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Transcript
Hello and welcome to our brand new mini-series.
Kim Ozano:In this mini-series, we are shining a spotlight on the programme, Improving Quality of Maternal and Newborn Health.
Kim Ozano:This is a UK funded programme by the Foreign Commonwealth and Development Office, and is led
Kim Ozano:In each episode, we discuss the different ways that the programme has strengthened the capacities of health practitioners to deliver high
Kim Ozano:This episode, the very first of four, will help us understand a bit more about the programme, and then we'll move on to focus
Kim Ozano:So let's start by hearing a little bit more about the history of the programme, how it came about, and the structure, and who
Kim Ozano:He is a professor in global health, a co-director at the World Health Organisation Collaborating Centre for
Kim Ozano:He is also the head of the International Public Health Department at the Liverpool School of Tropical Medicine.
Kim Ozano:So Charles, tell us what is the programme all about?
Charles Ameh:Thank you so much, and Kim for that question.
Charles Ameh:So the, um, FCDO funded, um, maternal and newborn health programme in Kenya, which has run for the
Charles Ameh:One is on quality of care.
Charles Ameh:The other one is on the pre-service education.
Charles Ameh:Then we have in-service education, and then we have a cross cutting theme of implementation research.
Charles Ameh:Now we have supported the facility based reviews of maternal deaths so that we can learn from each maternal death of every
Charles Ameh:So the systems in Kenya are strengthened in terms of providing that next generation of healthcare providers that can be
Charles Ameh:Furthermore, when we look at the medical schools, the postgraduate schools, their capacity to improve the quality of their research
Kim Ozano:Thank you, Charles.
Kim Ozano:I think that sets us up very well.
Kim Ozano:So before we go on to meet the rest of the guests for this episode, let's hear from our co-host, Lucy Nyaga.
Kim Ozano:Lucy, it's great to have you here with us.
Kim Ozano:You are the country director of the Liverpool School of Tropical Medicine in Kenya, and a medical anthropologist with
Kim Ozano:So Lucy.
Kim Ozano:Welcome to the programme , we're really happy to have you here as a co-host.
Kim Ozano:Tell us a little bit about what we will be talking about in today's episode.
Lucy Nyaga:Thank you very much, Kim.
Lucy Nyaga:Good morning from Kenya.
Lucy Nyaga:My name is Lucy Nyaga.
Lucy Nyaga:I am the country director Liverpool School of Tropical Medicine based in Nairobi, Kenya.
Lucy Nyaga:We are gonna be speaking today about a programme that the Liverpool School of Tropical Medicine has implemented in
Lucy Nyaga:We are privileged today to have the principal investigator this programme, uh, Professor Charles Ameh,
Lucy Nyaga:Over to you, Professor Ameh
Charles Ameh:Thank you so much, Lucy.
Charles Ameh:The FCDO funded programme, which has been implemented by the Emergency Obstetric Care and Quality of Care Unit at the
Charles Ameh:We started by setting up a confidential enquiry into maternal deaths so essentially a robust, objective way of understanding why women died
Charles Ameh:So we set up a system in Kenya, which was only the second country in Africa, at that time, that had such a system, and as part of
Charles Ameh:We developed this, piloted it in several settings, Cambodia, Nigeria, and in Kenya, working closely with investors in Kenya and
Charles Ameh:Now this has gone on to impact how both medical students are trained and how residents are trained.
Charles Ameh:I will leave that to our colleagues from partnering institutions, the Department of Reproductive Health at
Lucy Nyaga:Thank you very much for that, uh, overview of, uh, what shall be discussing about today.
Lucy Nyaga:I would like to introduce our two wonderful guests today; Professor Eunice Cheserem.
Lucy Nyaga:Professor Cheserem is chair and associate professor in the Department of Obstetrics and Gynecology at the University
Lucy Nyaga:Dr.
Lucy Nyaga:Paul Nyongesa is a consultant obstetrician, and gynecologist at the Moi Teaching and Referral Hospital in Eldoret and it is also a senior
Lucy Nyaga:I'll ask you, Professor Cheserem to kindly tell us about the institutional collaboration and the capacity strengthening
Eunice Cheserem:In terms of institutional training, we have seen tremendous improvement in the way our registrars handle the patients.
Eunice Cheserem:We found that the way the approach was done whereby there was a bit of asynchronous training of the registrars and then, uh,
Eunice Cheserem:In terms of, uh, building capacity, uh, we want to have every student who enters the programme trained.
Eunice Cheserem:We will use, internally, the trained students, uh, the trainers of trainers to train the others.
Lucy Nyaga:The University of Nairobi and Moi University kind of had a similar approach.
Lucy Nyaga:Dr.
Lucy Nyaga:Paul, would you want add something in terms of the approach that was used to train the resident, uh, obstetricians at Moi University?
Dr. Paul Nyongesa:I think I've been in this programme since 2015, during which we have seen a lot of
Dr. Paul Nyongesa:We started off with an initial training on vacuum extraction.
Dr. Paul Nyongesa:Vacuum extraction is something that is quite useful because it reduces the number of cases that might come for cesarean section.
Dr. Paul Nyongesa:So we have worked on this and we are moving towards identifying factors that perhaps might affect this, both from the
Dr. Paul Nyongesa:The second area in terms of teaching has been from Charles himself.
Dr. Paul Nyongesa:Eventually he became our external examiner in reproductive health, and he brought in things that, uh, really improved us because
Dr. Paul Nyongesa:At the moment, I have three students who even thought that perhaps they would apply to Liverpool School of Tropical Medicine to support
Dr. Paul Nyongesa:I'm, um, an anthropologist and we do community-based education and service.
Dr. Paul Nyongesa:During that time, all the staff go with the students to the communities.
Dr. Paul Nyongesa:So if the students are in that good form, then they're able to offer services and at the same time collect research data.
Lucy Nyaga:Interesting.
Lucy Nyaga:Dr.
Lucy Nyaga:Paul, what would you say, uh, the two approaches compare in terms of what you did in 2015 and the approach that we have been using lately?
Dr. Paul Nyongesa:When we first started in 2015, it used to be face to face and Charles would have to travel from Liverpool to Eldoret
Dr. Paul Nyongesa:But as we have gone on, we've come and now we are doing Zoom links and during that time it saves now time and costs and makes
Dr. Paul Nyongesa:So I think it's still useful to us.
Lucy Nyaga:Professor Charles, what you do say about those two approaches compared to what you did
Lucy Nyaga:What differences have you seen in the two approaches?
Charles Ameh:I think one of the benefits that the Covid 19 travel restrictions brought was a rethinking of the
Charles Ameh:That challenge allowed us to re-look at the content of of that training and programme and we're able to cover those aspects that
Charles Ameh:That means that the reach of this intervention has a wider scope.
Charles Ameh:Now we were able to train people within the institutions so that there's less dependence on people coming from the UK
Kim Ozano:Eunice, how did the health workers find this new way of learning?
Kim Ozano:It sounds like it was the first time it was used.
Kim Ozano:Did they adapt very well or did they have any challenges initially?
Eunice Cheserem:For the programme when it came to us, uh, this was the season of Covid and our university and
Eunice Cheserem:Although we are not completely shifted because in healthcare you can't just do, it has to be blended.
Eunice Cheserem:We've even been able to do examinations online, the ones which can be done, uh, in the era when, uh, Covid was
Eunice Cheserem:We picked it so early, and, uh, the students are very comfortable with that.
Eunice Cheserem:Right now asynchronous learning is kind of picking, uh, you find when a tutorial is to be given on a certain topic, sometimes when
Eunice Cheserem:We have the notes and we've gone through, so what you are discussing with them at that level is the challenges they have.
Eunice Cheserem:If they have any questions, you address them.
Eunice Cheserem:That has really helped us.
Lucy Nyaga:Thank you very much.
Lucy Nyaga:Do you have any, uh, research outputs from this, uh, collaboration?
Charles Ameh:This grant is essentially an implementation research grant and it's quite important to understand that
Charles Ameh:As a result, as we come to the end of the programme in each one of the work streams, we have up to eight different pieces of
Charles Ameh:We've had the opportunity to present a lot of this work at both national, regional and
Charles Ameh:This has been really helpful in terms of generating evidence but also building the research capacity of our partners.
Charles Ameh:So we actively engage our partners in regular online research collaboration meetings, which involves, you know, residents who
Charles Ameh:A lot of information can be found from the 'Emergency Obstetric Care and Quality of Care' unit website about some of our research outputs.
Lucy Nyaga:I'll go to Paul again.
Lucy Nyaga:I know that was from a perspective of Liverpool School of Tropical Medicine in terms of the benefits research,
Lucy Nyaga:Paul, do you feel the same, how has it benefited the Moi Teaching and Referral Hospital, for example?
Dr. Paul Nyongesa:I think Lucy, it, it's self-evident on the ground that things have changed a lot since we started
Dr. Paul Nyongesa:First, in terms of research, it has stimulated a lot of interest in assessment of maternal and antenatal death
Dr. Paul Nyongesa:We have also been involved as authors in various, uh, various publications which touch directly on service
Dr. Paul Nyongesa:I see a lot of our residents and also, what we call fellows.
Dr. Paul Nyongesa:Fellows are the subspecialty group, and I'm talking about maternal and featal medicine group.
Dr. Paul Nyongesa:They all are showing interest and are working very closely within our unit because of this collaboration.
Lucy Nyaga:Professor Cheserem, can you please highlight the key outputs or even impacts of this training, uh, on
Eunice Cheserem:I would just want to say that the registrars have shown a lot of changes in the way they manage the patients.
Eunice Cheserem:For instance, they were not very competent with the use of the vacuum and right now they are using the vacuum extraction or the
Eunice Cheserem:It has really led to a number of patients who would've gone to for cesarean section being delivered as VD
Eunice Cheserem:They have noted that, when they used to do cesarean section, they would see quite a bit of oozing thereafter
Eunice Cheserem:And so in effect, the morbidities with the oozing has gone down and they feel very confident in all the skills
Eunice Cheserem:They learned a lot in terms of what they learned from that, uh, skill acquisition.
Lucy Nyaga:Paul, uh, what would you say is the way forward?
Lucy Nyaga:This is the last leg of a programme.
Lucy Nyaga:What are the plans for the university take this forward?
Dr. Paul Nyongesa:The University, the School of Medicine specifically is looking at sustainability of this programme.
Dr. Paul Nyongesa:Sustainability in the name that we need to continue to work together in some areas, but where we have already
Dr. Paul Nyongesa:Then the administrative machine provides the supervision that is needed within the hospital, so that by the
Lucy Nyaga:Thank you very much.
Lucy Nyaga:Professor Cheserem, this kind of training, which I've read a lot of good things from, uh, those that have been
Eunice Cheserem:Our eventual aim is to mainstream the whole course in terms of putting it into the programme.
Eunice Cheserem:We already have training in emergency obstetric care.
Eunice Cheserem:We are going to look at it and as we are revising our curriculum, which is ongoing, we are just waiting to present to the Senate, we
Eunice Cheserem:We can also offer training at our own institutions, to the peripheral hospitals.
Eunice Cheserem:This can be one of the things we will look at because we do a lot of training.
Lucy Nyaga:Dr.
Lucy Nyaga:Paul what advice would you give to other universities, uh, maybe not only in Kenya, those that are planning
Lucy Nyaga:What key advice would you give them?
Dr. Paul Nyongesa:Maternal and newborn mortalities are still a problem in low and middle income countries.
Dr. Paul Nyongesa:So my advice would be to continue to foster collaboration between the developed countries and the low income countries,
Lucy Nyaga:Charles, From your experience, I know you're on the other end based in the UK at Liverpool, but from interaction
Charles Ameh:I think that improving maternal health and meeting global targets for improving maternal health and national targets,
Charles Ameh:But one key thing that we all agree about is having competent maternity care providers and the strategy for so many years has
Charles Ameh:Now, what we've introduced in this programme is targeting improving the quality of training and the quality of
Charles Ameh:So as from undergraduate level, also at specialist training level.
Charles Ameh:So my advice to other um, countries in Sub-Saharan Africa, where maternal mortality is quite high, is to consider looking
Charles Ameh:I think this will help to accelerate achievement of those sustainable development goals for maternal and newborn health.
Lucy Nyaga:Thank you Prof for that really profound and quite, seems quite low cost, uh, but, uh, quite profound.
Lucy Nyaga:Professor Cheserem, any advice that you'll give to anybody, heading for example an obstetric and gynecology
Eunice Cheserem:The main thing is to concentrate and make sure that these students we are training, come out with the skills
Eunice Cheserem:If they are given those skills, and they should be cascaded from undergraduate into this kind of training, whereby they
Eunice Cheserem:So if we emphasise this from the beginning, then our maternal outcomes and neonatal outcome will improve.
Lucy Nyaga:Thank you very much.
Lucy Nyaga:I think the key here, lets mainstream things so that healthcare providers that come out of the skills right from school and will
Kim Ozano:Thanks very much, Lucy.
Kim Ozano:I've really enjoyed this conversation and I can see both the innovation and the simplicity and systematic
Kim Ozano:So just to our listeners, this is the first episode in a four-part mini-series.
Kim Ozano:In the next episode, we will be talking about how data has been used in decision making through the maternal
Kim Ozano:We will then be talking about how pre-service, teaching and training has been improved so that nurses and midwives are more confident
Kim Ozano:So do tune in to those.
Kim Ozano:Don't forget to check out the Connecting Citizens to Science Channel for more excellent Global Health episodes.
