Unfinished business: More investments are needed to strengthen pre-service nursing and midwifery education and training after the FCDO funded programme in Kenya

Authors

1. Duncan Shikuku – Senior Technical Officer & PhD Student – Liverpool School of Tropical Medicine
2. Edna Tallam – Registrar and Chief Executive Officer – Nursing Council of Kenya
3. Millicent Kabiru – Midwifery Educator – Kenya Medical Training College
4. Catherine Waigwe – Head of Nursing Department – Kenya Medical Training College
5. Lucy Waweru – Academic Registrar – Kenya Medical Training College
6. Kelly Oluoch – Director and Chief Executive Officer – Kenya Medical Training College
7. Dan Okoro – Sexual Reproductive Health Rights Advisor – UNFPA (Kenya)
8. Hellen Mutsi – Program Officer – Division of Reproductive & Maternal Health – Ministry of Health (Kenya)
9. Issak Bashir – Pre-service Taskforce Chair & Head, Department of Family Health – Ministry of Health (Kenya)
10. Lucy Nyaga – Country Director – Liverpool School of Tropical Medicine (Kenya Office)
11. Charles Ameh – Professor of Global Health – Liverpool School of Tropical Medicine and University of Nairobi (Obstetrics & Gynaecology Department)

Introduction

Qualified midwives supported by interdisciplinary teams and working within an enabling environment, can deliver ~ 90% of essential sexual, reproductive, maternal, newborn and adolescent health interventions and save up to 4.5 million mothers and newborns annually by 2035.

To strengthen midwifery education, investments are required to implement the International Confederation of Midwives’ – ICM 2021 – standards for Midwifery Education and World Health Organization’s 7-step action plan framework for improving the quality of midwifery education with a focus on programme governance, faculty development, students, curriculum, institutional resources and quality improvement in low- and middle-income countries (LMICs). Liverpool School of Tropical Medicine’s Emergency Obstetric and Quality of Care Unit supports implementation of pre-service interventions anchored on WHO’s actions 2, 4, 5, 6 and 7 of the framework to improving midwifery education. The actions focus on preparing pre-service educational institutions, updating curricula and strengthening faculty to teach the updated curricula and enhancing theory and practical teaching, learning and assessment for students, conducting implementation research that includes effectiveness of interventions and evaluation of systems and processes, actively learning, knowledge co-production and dissemination in Kenya. To date these have been achieved through support from FCDO Kenya, Johnson and Johnson Foundation, and in collaboration with the Alliance for Improving Midwifery Education led by UNFPA Sexual and Reproductive Health Branch, Technical Division. However, there are still gaps and emerging issues around practice settings and clinical mentors, retention of clinical skills for effective teaching and practice, linked to policy and strengthened leadership for the sustainability of our 

impact to date. A multi-pronged approach is required to strengthen the enabling environment, including the quality of pre-service midwifery education. This is critical to fully achieve the potential of midwifery for the acceleration of maternal and newborn health SDG 3 targets, especially in low resource settings.

Knowledge management and learning

The final of four Knowledge Management and Learning (KML) events in the final year of the FCDO Kenya MNH programme, was hosted by the national Ministry of Health (MoH) in Nairobi on 6^th and 7^th March, 2023. The event brought together stakeholders from the Ministry of Health, development partners (UNFPA, UNICEF, USAID among others), nursing and midwifery training regulator – Nursing Council of Kenya (NCK), Kenya Medical Training College (KMTC), Midwives Association of Kenya, Clinical Officers Council, midwifery training universities, Council of Governors, implementing and neighbouring counties, and implementing partners in Kenya. The aim of the event was to share lessons learnt in the implementation of the MNH programme with a view of enhancing sustainability measures that will be adopted for implementation beyond the programme. For the pre-service component of the programme, progress achieved, lessons learned, transition plans and emerging issues for future consideration and implementation were disseminated.

Pre-service workstream programme achievements

Programme outputs were achieved under the stewardship of the MoH-led Pre-service Taskforce whose membership was composed of the MoH – Department of Family Health; Division of Reproductive & Maternal Health (chair); training regulators – Nursing Council of Kenya & Clinical Officers Council; teaching & training institutions – mid-level KMTC & universities; development partners – FCDO, UNFPA, WHO and Johnson & Johnson Foundation; midwifery and obstetrics and gynaecological associations; counties and training hospitals and LSTM (secretariat). Progress of implementation was reviewed through biannual meetings chaired by the MoH. Key programme achievements are summarised in the box below.

Pre-service workstream achievements (2019 – 2023) 

1. Reviewed and updated the pre-service nursing and midwifery and clinical medicine (reproductive health) core curricula integrating emergency obstetrics and newborn care (EmONC).

2. Four mid-level training institutions were mapped and strengthened with EmONC training equipment as training hubs for pre-service educators.

3. 50 master trainers from nursing and midwifery and clinical medicine were trained to teach EmONC within the updated pre-service curriculum (including facilitating online/virtual teaching).

4. 383 from a target of 382 (100.1% achievement) of faculty trained and have the capacity to teach EmONC within the pre-service curriculum.

5. 129 training institutions (56 KMTCs, 46 private & faith-based mid-level medical training colleges & 27 universities) from a target of 50 (258% achievement) have the faculty and capacity to teach EmONC within the updated curriculum.

6. 20 regionally representative KMTCs participated in the post-training follow-up to evaluate whether training and mentoring of faculty improves the quality of teaching and students’ performance.

7. Implementation research: Evidence generated and disseminated from the faculty capacity strengthening interventions has improved the knowledge, skills and confidence of educators at mid-level training colleges and universities in teaching the updated nursing and midwifery curriculum integrated with EmONC for skilled health personnel.

Emerging issues

Despite the achievements, gaps still exist as emerging issues to improve the quality of pre-service midwifery education and training in Kenya. Evidence has shown that there is low retention of in-service EmONC-trained skilled health personnel in relevant maternity departments for impact in reduction of preventable maternal and newborn mortalities and morbidities. Therefore, this calls for the need to re-evaluate the approach to capacity building, deployment and retention. Another issue is the quality of bedside training for midwives. The inadequate numbers and capacity of educators to provide quality bedside clinical teaching and support mentoring is a barrier to quality pre-service nursing and midwifery education and training. Other issues and several leadership and policy interventions that could potentially address these emerging issues include the following:

• Expand the training and orientation of nursing and midwifery lecturers together with the clinical instructors via the designated hubs. This is to saturate the training institutions and ensure that the faculty involved in clinical teaching is up to date with the current clinical teaching and practice in the clinical settings. This should be supported with mentorship for midwifery educators as a continuous process for skill retention. Modalities should be in place for educators to support students within the clinical environments (maternity units) through mentoring and support supervision to enhance learning and skills retention.
• One-off trainings alone are not sufficient to strengthen the capacity of the educators’ teaching and clinical skills.  The midwifery educator CPD programme to enhance teaching and clinical skills has been developed by multiple pre-service stakeholders. However, there is a need to establish a policy for mandatory access and training of nursing and midwifery educators in CPD through both self-directed learning and practical skills components to update their knowledge and skills in teaching (including digital innovations in teaching and learning), students’ assessments, effective feedback and mentoring of students for quality nursing and midwifery graduates and workforce.
• Training equipment are key in practical skills training. Training institutions should plan within their annual workplans modalities for ensuring the regular maintenance of skills lab equipment through regular inventory audits and functionality checks and repairs/replenishment as applicable. In addition, the budgetary allocations should consider the consumable supplies to maintain good storage and functionality of the equipment for longer term use.
• Maintaining clinical competencies of the nursing and midwifery faculty as per the ICM’s essential competencies for midwifery practice is relevant. Importantly, ICM recommends that at least 50% of midwifery education and training should be practical based with opportunities for clinical experience. However, evidence suggests that pre-service faculty are more confident in theoretical classroom teaching compared to practical skills teaching with lack of opportunities for clinical practice. As a result, there is need for systems and opportunities for pre-service faculty to enhance their clinical practice skills and competencies that are core in their clinical supervision and mentoring of students during their clinical placements.
• Research considerations. Although the feasibility of the midwifery educator CPD programme will be tested to improve the design, relevance and accessibility of the modules in sub-Saharan Africa, there is need to understand how CPD is implemented in high-income countries and conduct a context analysis of what is currently practiced in LMICs as CPD and compare with the high-income countries to identify opportunities for strengthening the practice of CPD.

Conclusion

Overall, the programme investments strengthened the capacity of over 380 nursing and midwifery and clinical medicine (reproductive health) educators in over 120 training institutions to deliver EmONC within the pre-service curriculum in Kenya. However, challenges still exist to improve the quality of skilled health personnel training. To improve the quality of pre-service midwifery education and training, more investments are needed. Resources are needed to strengthen investments in the training curriculum (all cadre of maternity care providers), institutions, faculty and students for quality graduates and skilled health personnel workforce to meet the universal health coverage agenda and contribute to the attainment of Kenya Vision 2030.