Country case study
The ‘Making it Happen’ programme in India and Bangladesh
Dr B Utz, Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Emails Bettina.Utz@liv.ac.uk; firstname.lastname@example.org
Please cite this paper as: Raven J, Utz B, Roberts D, van den Broek N. The ‘Making it Happen’ programme in India and Bangladesh. BJOG 2011;118 (Suppl. 2):100–103.
A training package designed to train health care providers in the management of common obstetric and newborn complications using a competency based ‘skills and drills’ approach is used in Bangladesh and India as one of the interventions under the ‘Making it Happen’ programme. The programme was commenced in 2009 and aims to reduce maternal and newborn mortality and morbidity by improving health care providers’ capacity to deliver Essential (Emergency) Obstetric and Newborn Care (EOC&NC) thus increasing the availability and quality of these services.
Preliminary results indicate that the training package has improved knowledge and skills of trained health care providers and ensures more signal functions of EOC are provided.
A training package designed to train healthcare providers in the management of common obstetric and newborn complications, using a competency-based ‘skills and drills’ approach, is used in Bangladesh and India as one of the interventions under the ‘Making it Happen’ programme. The programme started in 2009 and aims to reduce maternal and newborn mortality and morbidity by improving the capacity of healthcare providers to deliver essential (emergency) obstetric and newborn care, thereby increasing the availability and quality of these services.
Preliminary results indicate that the training package has improved the knowledge and skills of trained healthcare providers, and ensures that more of the signal functions of emergency obstetric care are provided in targeted areas.
Overview of the ‘Making it Happen’ programme
A new training package, Life-Saving Skills—Essential Obstetric and Newborn Care (LSS–EOC&NC), was developed for use in developing countries by the Liverpool School of Tropical Medicine (LSTM), in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG), and in collaboration with the World Health Organization (WHO) and a wide group of experts from a multidisciplinary background, with extensive experience in teaching and practice in maternal and newborn health in resource-poor settings. The content of the training is based on the main causes of maternal deaths and the signal functions of EOC&NC (Table 1).1,2 The generic course content is adapted to suit a particular country’s needs and setting. All training courses are delivered by a team of international and national expert facilitators (or ‘master trainers’). Participants include the cadres of staff in each country that provide skilled birth attendance (SBA), and include nurses, midwives, doctors as well as obstetrician/gynaecologists. Effective and evidence-based management of obstetric complications such as haemorrhage, eclampsia, sepsis, obstructed labour and complications of abortion, as well as newborn resuscitation and early newborn care, are taught using a competency-based approach. Adult learning is encouraged through short lectures, scenario teaching and skills teaching, using mannequins, practical demonstrations and role play.
Table 1. Signal functions for EOC
|1. Parenteral antibiotics |
2. Parenteral oxytocic drugs
3. Parenteral anticonvulsants
4. Manual removal of placenta
5. Removal of retained products (e.g. by manual vacuum aspiration)
6. Assisted vaginal delivery (usually ventouse delivery)
7. Newborn resuscitation using bag and mask
|All those included in basic EOC (1–7) plus |
8. Caesarean section
9. Blood transfusion
India and Bangladesh carry a high burden of maternal and neonatal deaths. According to the WHO health statistics inter-agency estimates for 2008, the maternal mortality ratio (MMR) was 230/100 000 live births in India and 340/100 000 live births in Bangladesh.3
The ‘Making it Happen’ programme started in Bangladesh in 2009 and in India in 2010, working in close collaboration with the ministries of health in both countries, with UN partners and with professional associations.
‘Making it Happen’ in Bangladesh
The ‘Making it Happen’ programme in Bangladesh links closely with the UN Joint Maternal and Neonatal Health Initiative (MNHI). Training is delivered at primary and secondary healthcare level (from the level of upazilla health complexes upwards) in the four current UN MNHI target districts: Jamalpur, Moulvibazar, Narail and Thakurgoan. After an LSS–EOC&NC demonstration course and training of trainers, which was attended by obstetrician/gynaecologists from the Obstetrical and Gynaecological Society of Bangladesh (OGSB), obstetrician/gynaecologists and midwives from the Government Medical Colleges and private institutions, representatives from WHO, as well as staff from health facilities already supported under MNHI, consensus was reached on the content and mode of delivery of the training package. It was widely acknowledged that the 3-day LSTM–RCOG LSS–EOC&NC training package was much needed, and was complementary both to other existing short training packages, which are more theoretical and less competency based, and to the 6- and 12-month programmes supported by the UN Children’s Fund (UNICEF) and the UN Population Fund (UNFPA), which aim to train general medical officers to conduct caesarean sections and manage women with obstetric complications in settings where there is no fully trained obstetrician/gynaecologist. The content of the training package in Bangladesh covers all nine signal functions of comprehensive EOC and targets all healthcare providers, including nurse/midwives, general medical officers and obstetrician/gynaecologists. The ‘Making it Happen’ programme in Bangladesh is advised by a national advisory group with representatives from the Directorate General of Health Services, the Directorate General of Family Planning, the OGSB, the International Representative Committee of the RCOG in Bangladesh and UNFPA.
Since the initial demonstration course and stakeholder meetings, training has been conducted in all four MNHI target districts, and by April 2011 a total of 363 maternal and newborn healthcare providers, as well as 60 master trainers, had been trained in Bangladesh.
‘Making it Happen’ in India
Following extensive consultation with the Ministry of Health and Family Welfare (MOHFW), the Government of India (GOI) requested the training package to be adapted to include mainly signal functions of basic EOC as well as to re-emphasize key components of SBA. The target cadres of staff particularly in need of training were identified to be the MBBS doctors, staff nurses and auxiliary nurse midwives. The course was adapted to reflect the current practice areas of these cadres, where most do not conduct caesarean section or assisted delivery (by ventouse or forceps), and it was felt that the other components could be covered in 2 days, thus saving teaching resources and time. After reviewing the content of the existing 3-day generic package for LSS–EOC&NC training, a 2-day training package was developed focusing on SBA, basic EOC and early NC, including a revised manual and facilitator guide. This is called the ‘Foundation Course for Re-orientation in Basic Emergency (Essential) Obstetric Care’.4 In 2010 and 2011 this new 2-day training package was piloted in India and included five signal functions: antibiotics, oxytocics, anticonvulsants, the manual removal of the placenta and newborn resuscitation. There is a separate and complementary training package available for MBBS doctors to learn how to conduct manual vacuum aspiration (MVA) in India. In January 2010 the content of the training package and method of its delivery was finalised, and from June to August 2010 a total of 462 healthcare providers, from seven high-focus states in India (Orissa, Bihar, Chattisgarh, Jharkhand, Madhya Pradesh, Uttar Pradesh and Rajasthan), were trained in Delhi. In addition, a core group of 48 ‘master trainers’ were trained and had the opportunity to co-facilitate training alongside experienced international volunteer master trainers. In November 2010 all target states identified four districts within each state and three high-volume facilities in each of these districts where all healthcare providers involved in maternal and newborn health care will receive the 2-day training from the Indian master trainers. The mannequins and training materials required have been sent to all target states by LSTM and the National Institute of Health and Family Welfare (NIHFW).
Monitoring and evaluation
A comprehensive monitoring and evaluation framework is applied in both country settings to measure project performance and impact at individual health care provider as well as facility level and to evaluate the effect on maternal and newborn health outcomes. Data are collected before and after training using both quantitative and qualitative research methods.
The monitoring and evaluation framework is based on the four key levels of learning according to the Kirkpatrick model, incorporating the UN process indicators for maternal and newborn health. The levels assessed are: the reaction of participants to the training; the improvement in the knowledge and skills of participants; the change in behaviour of participants (clinical practice); the functionality of the facility; and maternal and newborn health outcomes.
Preliminary results show an enthusiastic response from participants, with a statistically significant improvement in their knowledge and skills measured before and after training.5 At follow-up visits to health facilities and from discussions with healthcare providers who have been trained, it is clear that such new knowledge and skills are generally put to good use.
In India, a mixed team from the GOI and LSTM visited two target states, Rajasthan and Orissa, in September 2010 to follow-up healthcare providers who had been trained between June and August 2010. In-depth interviews and focus group discussions were conducted. The consensus was that the training is very practical and relevant, and there was evidence of improved quality of the delivery of care to women and their newborn babies. General agreement indicated that more healthcare providers should be trained in each facility. Most participants felt that the training had given them a much-needed boost in confidence and enthusiasm to deal with the many obstetric and newborn emergencies that they encountered daily at their facility. Quotes from trained healthcare providers in India are provided in Box 1.
Table Box 1.. Quotes from trained healthcare providers in India
|Our whole impetus has changed, it has boosted morale and changed attitude—this is a mindset change|
|Recently we had a case of shoulder dystocia, they used to panic, now the staff nurse can at least do the initial manoeuvres, we managed to deliver her safely|
|Now the nurses are starting the resuscitation if the baby needs it, drying the baby, putting on the bag and mask, before we come|
|A pregnant woman came in. After the first delivery we discovered there was another baby that we had not known about. We learned about how to detect and deliver the second twin in the course. Previously the doctor would come, but now we managed on our own|
|Now we work much better together. The nurses know what we know so the doctors don’t need to tell the nurses what to do or not do. The coordination and communication is better|
To assess the functionality of facilities, a baseline assessment was conducted in Bangladesh in all target facilities of Jamalpur, Moulvibazar, Narail and Thakurgaon.6
In each district all government health facilities providing basic and comprehensive EOC were identified and included in the baseline survey. During the baseline assessment, a total of 25 facilities were visited, including four district hospitals, four maternal and child welfare centres (MCWCs) and 17 upazilla health complexes (UHCs). Data were collected by: discussions with healthcare staff; direct observation of the facility, including the labour or delivery rooms, general maternity wards, operating theatres and laboratories; and extraction of data from facility registers.
At baseline, there were only four out of 25 facilities in the four districts that provided all nine signal functions of comprehensive EOC, and facilities aiming to provide basic EOC were generally not able to provide all seven signal functions. In all target districts evaluation is planned at 3, 6 and 12 months after the training of healthcare providers. In two districts, monitoring and evaluation has shown that three out of 12 target facilities continue to provide the required number of comprehensive EOC signal functions, and one facility has demonstrated a decrease from the provision of seven down to four signal functions; in all eight facilities aiming to provide basic EOC, the number of signal functions has increased by up to four signal functions.7
Compared with other emergency obstetric care courses requiring the attendance of healthcare providers for 1–7 weeks, attendants of the LSS–EOC&NC are only away from their workplaces for a few days. When taking into account the shortage of staff in most of the settings with high maternal and newborn mortality, a shortened intensive programme is strengthening deprived healthcare systems in two ways: firstly, healthcare providers acquire a large volume of knowledge and skills in a short period of time, but will not be away from their health facilities for more than 2 or 3 days; secondly, in Bangladesh and India, the majority of training is carried out at the district level and by local master trainers or facilitators, thus reducing the time spent on transport as well as overhead costs of accommodation and allowances. Another visible strength of the programme is the marked increase in the skills of the healthcare providers after training. Healthcare providers have reported that since receiving training, they have more confidence and ability to manage complications: for example, nurses initiate treatment for women with complications before the arrival of the doctor, resulting in fewer women being referred. There is clear evidence of the ‘up-skilling’ of mid-cadre staff in both countries, with emerging evidence that this leads to an increased availability of EOC signal functions.7
Most of the training material presented is in English. Although there are plans to translate the books into local languages, this has not yet been achieved. Results of knowledge assessments requiring the participants to understand the questions might therefore also underestimate the true knowledge of the healthcare providers.
Another weakness is that the training relies on the availability of mannequins and good training materials that are not generally available in these countries, particularly not at the district level. Such materials often need to be imported and are expensive. The speed of distribution depends on local customs regulations, and this can be difficult. Finally, this type of competency-based training is very labour intensive, and relies on maintaining the expertise and enthusiasm of a core group of master trainers or facilitators in each country. These are generally actively practicing obstetricians and midwives who give their time largely free of charge.
The course offers an opportunity for different cadres of healthcare workers to build/rebuild teams and lasting working relationships through genuine dialogue. Hierarchical structures can be overcome by training that is both fun and aims to engage the different cadres together to deliver improved services. A mixture of international (e.g. UK-based) clinicians teaching hand-in-hand with national and district-level colleagues also enables reciprocal learning, and creates a platform for exchanging experience and updating knowledge.
A dependency on donor funding in some countries may pose a threat to the continuity and scaling-up of the LSS–EOC&NC training both nationally and regionally. The practice of frequently rotating trained staff to other facilities and other areas of health care (not maternity or newborn care) is a challenge, and makes it difficult to sustain the delivery of the newly acquired skills and the continued availability of all of the EOC signal functions.
Preliminary results of the ‘Making it Happen’ programme in India and Bangladesh show that healthcare providers enthusiastically embrace the new training package, that knowledge and skills are increased, and that healthcare workers of all levels are able to translate their new knowledge and skills into improved healthcare practice.
Disclosure of interests
None to declare.
Contribution to authorship
B Utz and JR drafted the first version, NvdB and DR edited and redrafted the final version.
Details of ethics approval
The ‘Making it Happen’ programme in India and Bangladesh is funded by a grant from the UK’s Department for International Development. Equipment for training in India was part funded by Bupa.