Novel on-site follow-up and enhancement program (FEP) improves knowledge, clinical skills and enabling environment of skilled birth attendants in Nepal

PLoS One. 2023 Aug 22;18(8):e0285653. doi: 10.1371/journal.pone.0285653. eCollection 2023.

Abstract

Introduction: Although great strides have been made in maternal and newborn health in Nepal, the maternal mortality ratio (MMR) is still high at 186 per 100,000 births. Many maternal deaths are preventable if there is access to a skilled birth attendant (SBA). The Ministry of Health and Population of Nepal launched the in-service SBA training program in 2007 and has trained over 10,000 SBAs to date. Evidence shows that one episode of training is not enough to retain skills. Therefore, the Nick Simons Institute (NSI) in collaboration with National Health Training Center (NHTC) devised a Follow-Up and Enhancement Program (FEP) in 2011 where the knowledge, clinical skills, and working environment of SBA graduates were assessed directly at their worksites. FEP allows on-site coaching and feedback so that graduates may continue to improve upon any gaps in their knowledge, skills, and working environment. This study aims to assess the effectiveness of FEP.

Methods: We used a mixed-methods research design. A total of 73 SBAs who had a pre-FEP assessment in 2016 were followed up for a post-FEP assessment in 2017. We also collected data from 3 additional districts (115 SBAs) that had not previously had FEP, to compare SBAs in FEP versus non-FEP districts. Qualitative data was collected from 16 health facilities on the perceptions, motivation, and satisfaction of stakeholders.

Results: Of the total 188 SBAs that were sampled, a one-time FEP increased knowledge scores by 9%, clinical skills scores by 29%, and enabling environment scores by 7%. The number of deliveries conducted improved with a one-time FEP, although this increase was not statistically significant. We found a trickle-down effect of working in a facility that has had prior FEP, with SBAs that have never had FEP improving their clinical skills. FEP was found to be a highly accepted program and is beneficial to SBAs, trainers, and the Hospital Management Committee (HFOMC). However, a one-time FEP is not sufficient in retaining clinical skills and knowledge.

Conclusion: FEP is a highly effective program by both quantitative and qualitative evaluation. Our study suggests that FEP should be frequent and continuous to retain the knowledge and clinical skills of SBAs, motivate them through on-site coaching, and improve their working environment through direct feedback to the Ministry of Health and Population.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Academies and Institutes*
  • Clinical Competence*
  • Data Accuracy
  • Female
  • Follow-Up Studies
  • Humans
  • Infant, Newborn
  • Nepal

Grants and funding

Funding for the Follow-up and Enhancement Program, which carried out the data collection for the study in conjunction with the National Health Training Center (NHTC) of the Ministry of Health and Population of Nepal, came entirely from the Nick Simons Institute (http://www.nsi.edu.np/en), a charitable organization that works to train and support healthcare workers in rural Nepal (www.nsi.edu.np). The Nick Simons Institute initiated this study as part of its mission to continually improve care delivery in rural Nepal. Accordingly, it will use the study results to both raise awareness and lobby for changes in skilled birth attendant training, recruitment, and follow-up in Nepal and internationally. Neither the Nick Simons Institute nor the authors stand to receive material gain from the publication of this study.