Competency-Based Training in Basic Emergency Obstetric and Newborn Care (BEmONC) Improves Providers Performance in Tanzania

Scholastica Chibehe, Christina Lulu Makene, Victor Mponzi, Marya Plotkin, Sheena Currie, Gaudiosa Tibaijuka, Maryjane Lacoste, Dunstan Bishanga

Background
The MAISHA program is a USAID-funded program that has worked with the Tanzania Ministry of Health and Social Welfare (MOHSW) since 2008 to improve the quality of maternal and newborn health care in Tanzania. Strategies include:

Development of a national learning resource package which utilizes competency-based training approaches Training of over 880 health care providers in Basic Emergency Obstetric and Newborn Care (BEmONC) Standards-driven quality assurance approach using national BEmONC standards Strengthening of supportive supervision nationally

What Is BEmONC and Why Is It Important?

The provision of Basic EmONC services includes: administration of parenteral antibiotics, uterotonics and anticonvulsants; assisted vaginal delivery; manual removal of placenta; removal of retained uterine products; and neonatal resuscitation when indicated. It is important for management of the main pregnancy complications, which can result in maternal and newborn death.

Competency in BEmONC
MAISHA focuses on developing BEmONC competency in health care professionals by:

Developing national training team Strengthen regional hospital as training sites Strengthen 2 sites in each district to provide BEmONC Zonal and Regional staff for continuous coaching and mentoring of providers / facilities Encourage self/internal /external assessment using BEmONC standards

Competency-based Training (CBT)

CBT of health care providers builds knowledge, skills and attitudes and stresses learning by doing ; developing a specific set of competencies for quality job performance

Competency Based Training

What if we taught people to drive a car or plane by only having them read about it in a book?

Methods
Data presented is drawn from two sources:
1. Training scores from BEmONC training conducted in Iringa , Tanzania in March 2012 2. Facility scores from Standards Based Management and Recognition (SBM-R) standards assessments from 14 health facilities from 4 assessments August 2010 Sept 2012

Phases of Skill Development

Skill acquisition

Skill competency

Skill proficiency

Participants practice newborn resuscitation

Preceptor shows participants how to examine placenta

An example of competency-based training scoring for a BEmONC training

Student Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antenatal care consultation Assessment of a woman in labour Conduct normal delivery Newborn resuscitation Episiotomy /perineal repair Postpartum care Management of Pre-eclampsia/ eclampsia

S S S C M S S

S S S S M S S

S S S C M S S

S S M C M S S

S S M M M S S

S S S M M S S

S S S C M S S

S S M M M S S

S S M M M S S

S S M M M S S

S S M M M S S

S S M M M S S

S S M S M S S

S S S M M S S

S S M M M S S

Manual removal of the placenta Bi manual compression of the uterus

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

M M

Post abortion care (MVA) Vacuum Extraction Assisted Breech delivery Assessment of mother and baby/24 hours

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

M M M S

S M M S

M M M S

The following pre and post test training scores show dramatic improvement among the students on BEmONC skills.
120%

100%

80%

60%

PRE TEST POST TEST

40%

20%

0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Following training, providers return to their health facility to use the competencies they have acquired in training and implement quality improvement using SBM-R. Graph X shows improvement in BEmONC standards achievements over a 22 months period in 14 health facilities from 2010 to 2012 in Pwani region, Tanzania
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline assessment 1st Intern. Assessment 2nd Intern.Assessment

Challenges
Maintaining consistent quality of BEmONC training and supervision of providers in scale up nation-wide Inadequate supplies of life-saving drugs and equipment for quality services Transfer of trained staff between facilities sometimes leaves facilities with no trained staff Shortage of skilled staff to provide BEmONC services

Conclusion
Training health care providers using a competency-based training approach and supporting quality improvement and improved supervision can lead to improved care

Best results seen if providers immediately and effectively use competencies and are motivated to improve performance

Challenges mitigate the uptake and use of competency-based training approaches Supportive supervision is necessary and the involvement of Health Management Teams

Acknowledgements
The authors recognize the Ministry of Health and Social Welfare (MOHSW) of Tanzania for leadership for maternal and newborn health.

Institutions: Jhpiego Tanzania

This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Cooperative Agreement No. 621-A-00-08-00023-00. The contents are the responsibility of the Mothers and Infants, Safe Healthy Alive (MAISHA) program and do not necessarily reflect the views of USAID or the United States Government.