Improving the Competency of Maternity Care Providers in Kenya
This is the final episode of our mini-series, focusing on the programme Improving Quality of Maternal and Newborn Health in Kenya. This is an FCDO funded programme, the Foreign Commonwealth Development Office, and it is led by the Liverpool School of Tropical Medicine.
In each of the episodes we have been discussing the different ways that the programme has strengthened the capacities of health workers, mainly midwives and nurses, to deliver high quality care, to reduce maternal and newborn morbidity and mortality. In previous episodes, we have heard how data has been used in decision-making through the maternal and perinatal death surveillance and response approach.
We've also heard about pre-service training and teaching and how it has been improved so that nurses and midwives feel more competent and capable of step into their roles on the frontline. In this episode, we're going to be focused on in-service training.
We hear about real life examples where the programme’s revised approaches to mentorship and training have improved outcomes and saved lives, including an example from Dr. Shaban, who joined us straight out of theatre!
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.
Veronica Musiega - Advanced practice nurse (midwifery speciality), Vihiga County, Department of Health Services
Veronica is the County reproductive health coordinator for Vihiga county. She is a national trainer in EmONC as well as EmONC mentor. She facilitates training, mentorship, support supervision and co-ordination of EmONC activities in the county and at National level.
Veronica has trained MPDSR at National level and within Vihiga county and has planned, initiated and coordinated MPDSR activities at County, Subcounty, Facility and community level. Under her co-ordination, various fora and networks have been developed at sub county and county level to manage EmONC emergencies and address gaps in provision of EmONC services.
Veronica heads a team that performs county supportive supervision in EmONC, providing technical assistance and addressing gaps in service delivery; as well as developing work plans to improve on reproductive health.
She is the secretary to the county MPDSR committee and has led the team to compile Biannual MPDSR report which is disseminated at county level and contributes to the national MPDSR reports. In addition, Veronica has spearheaded the implementation of the MPDSR committee actions.
Sylvia Kimtai - Subcounty Reproductive Health Coordinator, Kapseret Subcounty, Department of Health Services, County Government of Uasin Gishu
Sylvia is a midwife, a national EmONC trainer and mentor, who has working in maternal and newborn health since 2008 to date. Currently, she coordinates reproductive health services in Kapseret subcounty.
She has facilitated over fifty EmONC and MPDSR training sessions in various parts of Kenya. She mentors a team of mentors across maternity units in the county who also mentor their colleagues with the health facilities. She manages a WhatsApp forum/platform where EmONC mentors within Uasin Gishu county actively interact, share best practices and address challenges faced.
Sylvia provides technical support to other EmONC mentors both virtually and through onsite support supervisory visits to their health facilities. She also conducts support supervision in health facilities on maternal and newborn care including conducting periodic EmONC functionality assessments on performance of EmONC signal functions to address gaps in availability of services.
She is the Secretary to Sub county MPDSR committee and also member of the facility MPDSR Committees.
Sylvia is the custodian of EmONC training equipment in her county and ensures mentors access the equipment during mentorship.
Dr. Nassir Shaban - Resident Obstetrician Gyanaecologist, Msambweni County referral hospital, Kwale County.
Dr. Nassir was trained by LSTM eight years ago and since then has been collaborating with LSTM on various capacity strengthening projects focusing at improving Maternal and Neonatal Health. He has facilitated training of midwives, medical officers and consultants OBGY on Emergency Obstetrics and Neonatal Care (EmONC) ; as well as Advanced comprehensive obstetric surgical and anaesthesia skills.
Dr. Nassir’s biggest dream is to significantly contribute to reduction of maternal mortality and improve neonatal outcomes in his resource-constricted health institutions, something he works very hard to achieve through training and capacity strengthening amongst his colleagues and team players in health.
On matters of research, Dr. Nassir has a special interest. He has worked with LSTM towards publishing a couple of research papers on Maternal and Neonatal Health, latest one which will be featured in the upcoming Health Conference in South Africa in April 2023.
At the National level, Dr. Nassir has been involved in the revision of National EmONC training curriculum, development of EmONC mentorship package as well as development of the "Continuum of Care" package in collaboration with the Ministry of Health.
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Transcript
Hello listeners, and welcome to the final episode of our mini-series where we have been focused on the programme
Kim Ozano:This is an FCDO funded programme, the Foreign Commonwealth Development Office, and it is led by the Liverpool School of Tropical Medicine.
Kim Ozano:In each of the episodes we have been discussing the different ways that the programme has strengthened the capacities of health
Kim Ozano:In previous episodes, we have heard how data has been used in decision-making through the maternal and
Kim Ozano:We've also heard about pre-service training and teaching and how it has been improved so that nurses and midwives feel more
Kim Ozano:In this episode, we're going to be focused on in-service training and as with the other three
Kim Ozano:She is the country director of the Liverpool School of Tropical Medicine in Kenya and is a medical anthropologist by background,
Kim Ozano:So Lucy, welcome back to the podcast in this final episode.
Kim Ozano:Lucy, why do we need in-service training on top of all the quality training that you have been
Lucy Nyaga:Good afternoon from Kenya and thank you very much Kim, to just give a background to
Lucy Nyaga:First, you know, previously the way the curriculum of the in-service was designed, it was not comprehensive and when nurses,
Lucy Nyaga:So when they went out to the field, the only way that we could cover that gap is then to be able to train them on
Lucy Nyaga:You know, as things change, as the world change, so does medicine, so does new health challenges come
Lucy Nyaga:Through continuous development and also through continuous, uh, medical education.
Lucy Nyaga:So that's why it's necessary.
Lucy Nyaga:However, we'll hear in the context of this programme, uh, that, uh, inservice training is
Lucy Nyaga:Through this programme, we've put systems in place that will ensure we have less and less of in-service training, reducing that impact
Lucy Nyaga:We have three guests who have been, beneficiaries of the training and mentorship that Liverpool School of Tropical Medicine, together
Lucy Nyaga:So our guests today, therefore, to highlight more on this, Dr.
Lucy Nyaga:Nassir Shaban, Dr.
Lucy Nyaga:Nassir Shaban is an obstetrician gynecologist working at the Msambweni County Referral Hospital, Kwale County at the coast of Kenya.
Lucy Nyaga:We also have Veronica Musiega a senior midwife working in Vihiga county as a county reproductive health coordinator.
Lucy Nyaga:Vihiga County in the Western, uh, part of Kenya and we have Sylvia Kimtai, a senior midwife, working in Uasin Gishu
Lucy Nyaga:Veronica, what is the scope of this programme that LSTM implemented and how was the in-service training received by the midwives in Kenya?
Veronica Musiega:The in-service training, basically it is for healthcare providers, mainly the nurses, the
Veronica Musiega:So normally they have gaps in issues or key resuscitation obstetric emergency areas.
Veronica Musiega:These are the areas we sharpened their skills in and mainly we were identifying how our participants from the MNH departments, especially
Veronica Musiega:That composes of about 32 participants.
Veronica Musiega:After the training where we follow them map in their various facilities, just to ensure that uh,
Veronica Musiega:So we follow it up and where we have gaps, we continue it with the mentorship.
Veronica Musiega:Remember, the five day training, we were using the mannequins and the modules, but now when it comes to the actual clients, maybe
Veronica Musiega:We follow them up in mentorship.
Veronica Musiega:The mentorship, again, we can do it even on actual patients, the mannequins again, so that their skills are more
Veronica Musiega:Yeah, so for Vihiga County from 2019, it was a cost sharing programme where the county chipped in with the part of the training
Lucy Nyaga:Thank you very much, Veronica, Sylvia, how was the in-service training received by the
Sylvia Kimtai:Before the EmOC training, most midwives were not confident enough to manage mothers and babies and once they were
Sylvia Kimtai:And also, after the training, most midwives now knew the kind of drugs or the kind of supplies that they might need in their maternity.
Sylvia Kimtai:For example, before the training, most midwives did not know even how to use the simple vacuum extractor.
Sylvia Kimtai:Most midwives did not even know how to use the manual vacuum aspiration set.
Sylvia Kimtai:And also before then, most midwives said that they used to refer many clients to the next level, and most of the times
Sylvia Kimtai:For example, they were not able to do simple procedures, like even the manual removal of the placenta or perform manual vacuum aspiration.
Sylvia Kimtai:Most of the times they would refer clients who are still bleeding to the next facility and that would actually
Sylvia Kimtai:So in a way, after the training, they gained the confidence and in a way also it led to reduction
Sylvia Kimtai:Also as a county, we were able to improve in terms of finances, because remember, as a country we have,
Sylvia Kimtai:The reduction in um, the referrals means that these women delivered in their facilities and in turn, the resources were
Lucy Nyaga:Wow, that is really interesting and, uh, really impactful.
Veronica Musiega:With the trainings that we have had in the county, I must say that there really is great improvement in the
Veronica Musiega:Earlier on an emergency, like let's say prolapse, you would find that the midwife would come along with the mother as
Veronica Musiega:So you actually wonder what is the problem, the mother is already walking and having the head press onto the cord.
Veronica Musiega:But, uh, as we speak now for the last like, uh, four cord prolapse that were pulsating, that were referred, the midwives from the
Veronica Musiega:Even, as we do supervision in our facilities, we realise that these emergencies are clearly displayed in the labour wards so that any
Veronica Musiega:They've put the emergency kit in place so that they will even and orient somebody who is new.
Veronica Musiega:In every subcounty, we will realise that we have mentors in every subcounty.
Veronica Musiega:We also have even facilities that have mentors.
Veronica Musiega:Basically everybody is sharpened and even at management level, even up to the governor's desk, they are always scared of a maternal death.
Veronica Musiega:Nobody wants to record a maternal death, and that is why everybody wants to know how to avert and be able
Lucy Nyaga:Dr.Nassir, in terms of what this adverse obstetric course is about and what it has done to you personally as a practitioner?
Nassir Shaban:The advanced obstetric and anaesthetic and neonatal care is a slightly different type of
Nassir Shaban:In this type of a package, it encompasses the anaesthetic part and a lot of surgical part.
Nassir Shaban:When we were training all the medical officers, the consultants and the nurses and the clinical officers in Kenya, it was thought that
Nassir Shaban:People also felt like the consultants are rarely on the ground, the consultants and the medical officers were spending most
Nassir Shaban:Just an example, for breach most of them will be sectioning them, but the essence of theatre and
Nassir Shaban:So actually the package on advanced surgical obstetric and anesthetic care came on time and it
Nassir Shaban:So for instance, we go deep on how to manage difficult cesarean sections.
Nassir Shaban:What are the challenges we anticipate when we have, let's say for example, low lying placenta, the accreta and all those things.
Nassir Shaban:So we go very deep on the surgical skills in such a way that once one, uh, graduates from such courses and training, they tend to be updated
Nassir Shaban:I can share a small experience.
Nassir Shaban:I was delayed a little because of, I delayed in theatre and what happened to me today, I was sectioning a woman and one
Nassir Shaban:Okay.
Nassir Shaban:I ended up with a little bit of tear, which led me to, uh, spend more time than what I anticipated to spend in theatre,
Nassir Shaban:So those are areas which the medical officers, the consultants, were lacking before this training came.
Nassir Shaban:Another one advantage, which I can say openly is for any person who is a registrar in this country, in our country,
Nassir Shaban:In fact, I can comfortably say that had had, had it not been for the skills and the trainings I was going through, I feel
Nassir Shaban:I can say at least 50%, 50% of the exam in part two exam in our universities come from the
Lucy Nyaga:This is really interesting because, you know, one of the things that we are trying to do as a Liverpool
Lucy Nyaga:It's saving life, it's actually practical, but for Sylvia and for Veronica, because I know one of the things you mentioned is that this
Lucy Nyaga:What difference in this approach has led to assistance change at your county level?
Sylvia Kimtai:I think I will start with Uasin Gishu County.
Sylvia Kimtai:One of the things that was introduced by LSTM, was the introduction of the human resource dashboard.
Sylvia Kimtai:Before then we would train, uh, uh, midwives within a couple of weeks, a couple of months, the midwives are rotated and
Sylvia Kimtai:With the introduction of the human resource dashboard, we've seen the management committing to ensure that
Sylvia Kimtai:That has really improved on the quality of care that we've been giving.
Sylvia Kimtai:Also with the introduction of the EmOC functionality assessment, the feedback was shared with the county, we
Sylvia Kimtai:For example, if we don't have the emergency drugs, facilities do not have the manual vacuum aspiration
Sylvia Kimtai:Sharing this data with management really helped them to see where to focus when they want to buy supplies
Sylvia Kimtai:Remember we said when we were doing the trainings, we also looked for the trainer of trainers or trainer
Sylvia Kimtai:Like before, we used to have a pool of mentors either at subcounty level or a county level, and the mentors
Sylvia Kimtai:Now with this introduction from LSTM of having mentors attached to facilities or mentors being part of the maternity staff
Sylvia Kimtai:The last thing is something on communication.
Sylvia Kimtai:Eh, For me, the management has really picked up the communication tool and that has really improved referrals
Sylvia Kimtai:For me, I think Uasin Gishu is one of the counties that has really benefited from this concept from LSTM.
Lucy Nyaga:There's so many really good points coming out, but what I also pick is there's a human bit which in terms of people enjoying
Veronica Musiega:I think during the training there is, uh, a module that really cover issues of respectful care and, that is what is
Veronica Musiega:That basically started in maternity, where we expected that privacy issues, of confidentiality must be strengthened, that maternity
Lucy Nyaga:From a different perspective from Dr.Nassir, kindly talk about some best practices in terms of the human bit of the training.
Nassir Shaban:First of all, I, I appreciated the importance of patients in everything we do.
Nassir Shaban:For example, suturing the uterus, it was all about patients.
Nassir Shaban:This idea of rushing was actually something we were trying to avoid, so that you give the best to the mother so patience was everywhere.
Nassir Shaban:The way you work with your people way, the way you work with your team, the way you work with the patient, everything needed patience.
Nassir Shaban:That is number one.
Nassir Shaban:Number two was teamwork.
Nassir Shaban:I really appreciated teamwork, both on the team, which we were working with; the mentors, the mentees, and what we
Nassir Shaban:You need to have a team.
Nassir Shaban:You need to be coordinating from one another, one person to another.
Nassir Shaban:You needed that being together for a common goal, and the goal is to give the best of the patient and to have the best outcome.
Nassir Shaban:Something as I also learned was, uh, the importance of following protocols.
Nassir Shaban:That there are a lot of things which are in our facilities.
Nassir Shaban:For example, we've been talking about the muse charts.
Nassir Shaban:We've been talking about, uh, the theatre checklist.
Nassir Shaban:All these things are in our facilities, but we are not implementing them.
Nassir Shaban:We were not following them.
Nassir Shaban:We are having a lot of near misses.
Nassir Shaban:We are having a lot of mortalities and morbidities simply because we were too lazy to follow the protocols.
Nassir Shaban:It's actually the feeling of doing things on a shortcut.
Nassir Shaban:You just want to do something and leave so the issue of following protocols, following order, came
Nassir Shaban:Were we following the SOPs?
Nassir Shaban:Were we following the protocols?
Nassir Shaban:Will have saved a lot of our mothers, will have saved a lot of babies.
Nassir Shaban:We have saved a lot of, uh, resources from our facilities because everything is there, the protocols
Nassir Shaban:The last thing or the second last thing was sacrifice.
Nassir Shaban:We realised, everything need a sacrifice.
Nassir Shaban:Even holding these, uh, trainings, it needed a lot of sacrifices.
Nassir Shaban:Sometimes you can be reporting, especially when our dear Dr.
Nassir Shaban:Helen is around.
Nassir Shaban:Sometimes we meet very early in the morning.
Nassir Shaban:We meet at 7.30 and by the time we finish around six, we have our meetings for one one hour.
Nassir Shaban:Sometimes we leave the training hall at around 7.30 or even 8.00 you need a lot of sacrifices.
Nassir Shaban:But there's that feeling in your heart that I've given my best, I've transferred this knowledge to the people who
Nassir Shaban:The participants also, staying on a, uh, in a training from eight to around 5.30 or 6 without even touching your
Nassir Shaban:The last thing which I can mention is flexibility.
Nassir Shaban:Someone can call you and maybe you are not on duty or you are doing your part-time thing and then you're called by your junior or
Nassir Shaban:Remember when we were doing, uh, our trainings during Covid time, we, we had planned to do everything in
Nassir Shaban:Now we all had to come to Mumbasa.
Nassir Shaban:The issue of flexibility, sacrifice, following protocols, being patient and teamwork were the major, aspects of
Lucy Nyaga:It's the human aspect that really matters.
Lucy Nyaga:It doesn't matter how much training you have, but as long as you can, you know, transfer that to yourself and to your patients.
Lucy Nyaga:I think then that kind of brings out that aspect of best practice in medicine.
Lucy Nyaga:Do you feel that, having gone through this training has made any difference If you compare previously
Nassir Shaban:I can say, in places where we've trained, the outcomes are very clear.
Nassir Shaban:The results are seen.
Nassir Shaban:The only problem we have is we need to train more and more and more.
Nassir Shaban:I'm speaking on behalf of doctor of doctors so if you go to Nairobi University, for example, you go to Moi university and the small
Nassir Shaban:So my parting shot is we need to train more.
Lucy Nyaga:Sylvia one parting short in terms of how you judge your patients.
Sylvia Kimtai:We've done some client exit interviews in a couple of maternity, uh, facilities and the
Sylvia Kimtai:And one of the things that came out clearly is that they're now being handled in a respectful way and I think
Lucy Nyaga:Thank you, Veronica, some parting shot.
Veronica Musiega:I think the trainings have really helped us have behaviour change among our providers
Veronica Musiega:I remember the last week I was just I found in labor ward they had just conducted a delivery and were
Veronica Musiega:So I helped them and the baby actually came up and cried very well, and the mother was so happy and she actually
Veronica Musiega:So this was like a precious baby and the mother was so excited and she was happy with that.
Veronica Musiega:And that followed actually the skills that we had trained.
Lucy Nyaga:Thank you very much.
Lucy Nyaga:I think I'll stop there.
Lucy Nyaga:This is not the end of our conversation, we'll continue to disseminate.
Lucy Nyaga:This is a four year programme that we are trying to feed into 20 minutes of recording, uh, but I appreciate
Lucy Nyaga:Just a minute away changes when Dr.Nassir has just saved a baby in theatre.
Lucy Nyaga:Uh, the day before yesterday when Veronica saved a baby in theatre.
Lucy Nyaga:This is really impactful.
Lucy Nyaga:I mean, saved a newborn baby, made a a mother happy, made a family happy.
Lucy Nyaga:May God bless you for your good work, and we are really glad and we shall continue, you know, to engage more.
Kim Ozano:Thank you very much, Lucy.
Kim Ozano:It's really struck me, the impact of this programme is phenomenal and those real life experiences help to show how important it
Kim Ozano:So thank you to our guests.
Kim Ozano:Thank you, Lucy.
Kim Ozano:Wonderful host there, and this is the end of our mini-series.
Kim Ozano:So thank you for listening.
Kim Ozano:If you haven't already, please go back and listen to the previous episodes, which cover different
Kim Ozano:Thank you very much and bye for now.
