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Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in SubSaharan Africa (ETATMBA)

Ellard, D., Davies, D., Griffiths, F., Kandala, N., Mazuguni, F., Shemdoe, A., Chimwaza, W., Chiwandira, C., Mbaruku, G., Bergström, S., Kamwendo, F., Mhango, C., Peile, E., Quenby, S., Simkiss, D. and O’Hare, J. (2014) Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in SubSaharan Africa (ETATMBA). Technical Report. ETATMBA.

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There is a chronic shortage of medical doctors in many Sub-Saharan African countries and indeed many of these countries have very little to spend on healthcare. As a consequence levels of maternal and neonatal mortality still very high and many are struggling to meet the WHO Millennium development goals. Many African countries like Malawi have a cadre of health workers called Non Physician Clinicians (NPCs) who are trained by the Ministry of Health and are often the most experienced health worker in hospitals and health centres across the country. Some of these NPCs specialize in emergency obstetric and neonatal care (EmONC) and are in the frontline providing care for mothers and babies. The value of NPCs cannot be understated, it will take many more years before countries like Malawi have enough doctors, and dedicated, hardworking and loyal NPCs are providing an essential and valuable service. Enhancing Training and Appropriate Technologies for Mothers and Babies in Africa (ETATMBA) was an EC funded (FP7) project managed by The University of Warwick Medical School (WMS) and was being delivered in Tanzania and Malawi. Project partners include the Karolinska Institute (Sweden), The Ministry of Health (Malawi), the College of Medicine (Malawi) and Ifakara Health Institute (Tanzania). The purpose of the project was to train non-physician clinicians (assistant medical officers (AMOs) in Tanzania) as advanced leaders providing them with skills and knowledge in advanced neonatal and obstetric care. Training it is hoped that they would cascade to their colleagues (other NPCs, midwives, nurses). We chose to trial effectiveness of this sort of education on NPCs because they tend not to emigrate and so it was possible to do longer term project work with more durable impact in these countries. The aim of the project was to try and address the high levels of maternal and neonatal mortality. This report is the result of the impact and process evaluation of the ETATMBA project in both Tanzania and Malawi. In both Tanzania and Malawi we carried out an evaluation of impact and a process evaluation. In Tanzania we used a before and after design looking at health indicators in the health facilities where the trainees were to be based for the period leading up to the start of the training and approximately a year after the training. The choice of training areas and centres was determined by the national plan to upgrade remote rural health centres to provide emergency obstetric care. In Malawi we were delivering the intervention in the northern and central regions which contained 14 districts. We chose to randomize the design putting selected trainees in half of the districts. Outcomes were health indicators like in Tanzania. The primary outcome was perinatal mortality (specified as fresh stillbirth plus neonatal death before discharge from the health facility), with secondary outcomes of maternal mortality, obstetric complications and birth complications. In addition, in Tanzania we looked at infrastructure and availability of key items (e.g. electricity, running water, specific equipment and appropriate drugs). In both Tanzania and Malawi we carried out a qualitative process evaluation. Interviews explored perceptions of the training, trainees where we required to provide real evidence that they were implementing their new skills and knowledge into practice. We also interviewed cascadees (colleagues who may have received training from one of our trainees) district medical officers and a number of the trainers involved with the trainees. In both Tanzania and Malawi the training was successfully implemented. In Malawi 54 trainees started and by the end we had 46. In Tanzania, we had dyads of trainees that is an AMO and a nurse or a nurse iv midwife (the plan was to train the nurse in anaesthesia). There were 54 trained and 36 evaluated. Of the 36 at the start (18 of each group) one passed away and two moved into other areas so we ended with 33 trainees. An ongoing initiative in Tanzania suggested that after being trained the trainee dyads would return to updated facilities (e.g. an operating theatre) that allowed them to use the new skills and knowledge. Training in Tanzania was an intensive period away working with the tutors and doctors whilst in Malawi it was more modular with clinical mentors visiting trainees in their own facilities: socalled “on-the-job” training. Both training courses included leadership training. Whilst we were very successful at carrying out an evaluation in both countries problems with data do make us cautious about interpreting the results we have. In Malawi for the primary outcome of neonatal and perinatal mortality we did not demonstrate any difference. In Tanzania we found that it is not routine practice to record neonatal mortality at the facilities making it impossible to calculate perinatal mortality. However, in terms of maternal mortality there is a decline in maternal mortality in Tanzania and may be a trend in Malawi but this needs further statistical modelling to account for confounders. In Malawi the lack of any change in intervention districts compared to control may also reflect the fact that to achieve the BSc, NPCs’ training continued to 2014 and a longer time may be needed to see the effect. In Malawi there is some indication that in intervention districts there are more obstetric complications but this is apparent at baseline. The qualitative data strongly supports that in Malawi the trainees applied new skills such as vacuum extraction and breech delivery, but baseline differences in the quantitative data between groups make it difficult for this to be clear. In Tanzania there is evidence that patients are aware of the new skills with people turning up at facilities that trainees are working in. Similarly, birth complications in Malawi appear to rise but differences at baseline make this difficult to interpret and again this may be a recording issue in the intervention group following training. For example, reported cases of asphyxia at birth have risen in both intervention and control districts. It is possible that training has influenced this; in ETATMBA we did extensive teaching on neonatal resuscitation but an important confounder has been a countrywide initiative called ‘Helping Babies Breathe’ that could have impacted on asphyxia rates in control districts. In both countries it is clear that resources and infrastructure have a huge impact on the ability of health workers, at times, to carry out their work. Basic no expensive drugs are often unavailable equipment is poorly maintained and running (clean) water and electricity are not guaranteed. Roads and vehicles for patient transfer or emergencies again are at times note available or so poorly maintained they are a major barrier to access to emergency obstetric care. Trainees across the study note that they would welcome ongoing support and mentorship as our project closes. Trainers are maintaining some contact but face-to-face is difficult. In Tanzania the pattern of shortages of medical doctors is different to Malawi (where the shortage is urban as well as rural). In Tanzania you can find doctors in major centres but as you get into remote areas there are considerably less of them. The trainees note that often they are the only health professional available in these areas yet they are poorly supported with very poor housing and little or no recognition. There were similar feelings of isolation in Malawi with trainees feeling they lack a clear career path. The training and the setting up of a BSc for NPCs has given them some hope. There is evidence from our qualitative study that due to the leadership training trainees in both countries are engaging with local communities and officials and working with the teams and management in the facilities to try and bring about clinical service improvements. This study has demonstrated that up-skilling non-physician clinicians with skills and knowledge in obstetrics, neonatal care and leadership is possible in sub-Saharan Africa. Not only is it possible it can v have a real impact on lives. The project highlights a number of the challenges of working in sub-Saharan Africa. This work provides strong evidence that this cadre are an important and integral part of the future of healthcare in sub-Saharan Africa and more should be done to encourage a future well-educated and supported generation who will have the health of nations in their hands and provide a sustainable solution for many countries in sub-Saharan Africa for the future.

Item Type: Report (Technical Report)
Keywords: Human Resources Enhancing, Maternal and Perinatal Survival, ETATMBA, Non Physician Clinicians, Health Workers, Tanzania and Malawi
Subjects: Health Systems > Human Resources
Divisions: Ifakara Health Institute > Health Systems
Depositing User: Mr Joseph Madata
Date Deposited: 07 Jan 2016 09:11
Last Modified: 07 Jan 2016 09:11

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