Identifying needs for optimizing the health workforce in Ethiopia: with focus on sexual, reproductive, maternal and newborn health services providers

Background: Midwifery support and care led by midwives is the most appropriate strategy to improve maternal and newborn health. The Government of Ethiopia has recently improved the availability of midwives by scaling up pre-service education. However, the extent to which graduating students acquire core competencies for safe and effective practice is not known. The purpose of this study was to evaluate the quality of midwifery education by assessing the competence of graduating midwifery students. Methods: We conducted a cross-sectional study to assess the competence of students who completed basic midwifery education in Ethiopia in 2013. We interviewed students to obtain their perceptions of the sufficiency and quality of teachers and educational resources and processes. We assessed achievement of essential midwifery competencies through direct observation, using a 10-station Objective Structured Clinical Examination (OSCE). We calculated average percentage scores of performance for each station and an average summary score for all stations. Chi-square test, independent sample t test, and linear regression analysis were used to assess the statistical significance of differences and associations. Results: We assessed 484 graduating students from 25 public training institutions. Majority of students rated the learning environment unfavorably on 8 out of 10 questions. Only 32 % of students managed 20 or more births during training, and just 6 % managed 40 or more births. Students’ overall average competence score was 51.8 %; scores ranged from 32.2 % for manual vacuum aspiration to 69.4 % for active management of the third stage of labor. Male gender, reporting sufficient clinical experience, and managing greater numbers of births during training were significant predictors of higher competence scores. Conclusions: The quality of pre-service midwifery education needs to be improved, including strengthening of the learning environment and quality assurance systems. In-service training and mentoring to fill competence gaps of new graduates is also essential. * Correspondence: tegbar.yigzaw@jhpiego.org Jhpiego, Addis Ababa, Ethiopia Full list of author information is available at the end of the article © 2015 Yigzaw et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. 23 Yigzaw et al. BMC Medical Education (2015) 15:130 Page2of10 Background Ethiopia has made impressive progress towards Millennium Development Goal 4: it is one of seven high mortality countries that have reduced under-five mortality by twothirds or more before the 2015 deadline [1]. However, absolute levels of maternal and newborn mortality remain high. The 2011 Ethiopia Demographic and Health Survey reported a maternal mortality ratio (MMR) of 676 deaths per 100,000 live births and a neonatal mortality rate (NMR) of 37 deaths per 1000 live births [2]. Now more than ever there is a global consensus regarding the contribution of midwifery care and midwives to reduce maternal and newborn mortality. Competent midwives can provide 87 % of essential care needed for women and newborns and universal coverage with quality midwifery care can prevent more than 80 % of maternal and newborn deaths [3–5]. However, skilled care coverage in Ethiopia is low with only 10 % of births assisted by a doctor, nurse, or midwife [2], which is extremely low even by the standards of subSaharan Africa [6]. A shortage of midwives has been an important bottleneck to increasing skilled midwifery care and, consequently, to improving maternal and newborn health outcomes in Ethiopia. In fact, the midwifery workforce including midwives is estimated to meet only 32 % of the need for maternal and newborn health care in Ethiopia, leaving the needs of the vast majority of women and their children unaddressed [5]. Ethiopia had only 0.3 doctors, nurses and midwives per 1000 population when the World Health Organization identified a workforce threshold of 2.3 per 1000 population to achieve high coverage with essential interventions, including those necessary to meet health millennium development goals in 2006 [7]. Since then the Government of Ethiopia has invested in pre-service education to increase availability of the midwifery workforce. It expanded direct entry diploma and degree programs and in 2011 launched an accelerated midwifery training initiative that provided a one-year post-basic training program for diploma-level nurses. As a result of the rapid scale-up of pre-service education, the number of midwives in Ethiopia has increased markedly in recent years, rising from 1275 in 2008 [8] to 6925 in 2014 [5]. But availability of midwives may not translate into improved maternal and newborn health outcomes unless we ensure midwives master the essential knowledge, skills, and attitudes during their pre-service education [3]. This is potentially a challenge in Ethiopia, given high student enrollment, a shortage of qualified faculty, resource constraints, and low caseloads and questionable quality of care at clinical training sites [9–11]. The objective of this study is to generate evidence on the quality of midwifery education by assessing competence of students at the point of graduation. Research on the competence of graduating midwifery students contributes to 24 the much needed evidence base on midwifery workforce development in Africa. It is particularly important for local training institutions to review and improve the quality of pre-service education. The Ethiopian Ministry of Health and Midwifery Association can also use it to identify priority health workforce strengthening strategies. Methods Study design and sample This paper reports baseline information on the competence of midwifery students at the point of graduation from public training institutions. It is part of a larger evaluation study that will employ a pre-post design to assess changes in competence levels as a result of technical assistance by the USAID-funded Strengthening Human Resources for Health Project to increase availability of competent midwives. At the time of this baseline study, 20 public universities and 22 public TVET (technical and vocational education and training) colleges offered pre-service education for midwives. All 22 TVET colleges and 8 (out of 20) universities had a graduating class in 2013. Eight universities and 17 TVET colleges were included in this study. Five TVET colleges were excluded because of inaccessibility, inadequate information on graduation status or decision to shut down the program. A total of 2340 midwifery students (1988 from TVET colleges and 352 from universities) were expected to graduate from these 25 training institutions in 2013. Separate representative samples were calculated for university (185) and TVET (326) programs with assumptions of 95 % level of confidence, 80 % statistical power, 44 % competence level (adopted from a 2008 national emergency obstetric and newborn care survey [11] that reported knowledge score of midwives in maternal care and we selected the score that yielded the largest sample size), 10 % expected increment, and design effect of 1. We randomly selected 20 students per TVET college and 24 students per university from the registrar lists to participate in the study. Of these 532 students, 484 students (336 from TVET colleges and 148 from universities) participated in the study. The average number of participants at each institution was 18.5 (range: 7–24) for universities and 19.7 (range: 18–20) for TVET colleges. The main reasons for relatively lower participation from universities were the inability to recall students after they completed their exams and the overlap of the data collection schedule with student preparations for graduation. Data collection Data were collected in June/July 2013 from students who completed their education through interview and direct observation of performance. Data collectors interviewed Yigzaw et al. BMC Medical Education (2015) 15:130 Page3of10 students privately to obtain information on their background characteristics and perceptions of whether instructors, resources, and infrastructure were adequate and effective using a three-point scale (yes, partially, no). Students were also asked to report how many births they attended during training. After the interview, the competence of students was assessed using an Objective Structured Clinical Examination (OSCE), a testing format widely believed to generate valid and reliable conclusions [12–15]. The content of the OSCE was drawn from the essential competencies for basic midwifery practice defined by the International Confederation of Midwives (ICM), which serve as expected outcomes of pre-service education [16]. Three additional competencies (3, 5 and 10 tasks below) were tested based on national needs. We mapped out 10 OSCE stations, or tasks, from these competencies. Each task consisted of 5 to 13 skills steps. The 10 OSCE stations were: 1) assisting normal delivery, 2) active management of the third stage of labor, 3) vacuum-assisted delivery, 4) history taking in providing focused antenatal care, 5) manual vacuum aspiration, 6) newborn resuscitation, 7) partograph interpretation, 8) postpartum counseling, 9) applying medical eligibility criteria for family planning provision, and 10) integrated management of childhood illness (IMCI). At each manned OSCE station, the assessor explained the assessment process to the student,