This is the final episode of our mini-series, focusing on the programme Improving Quality of Maternal and Newborn Health in Kenya. This is an FCDO funded programme, the Foreign Commonwealth Development Office, and it is led by the Liverpool School of Tropical Medicine.

In each of the episodes we have been discussing the different ways that the programme has strengthened the capacities of health workers, mainly midwives and nurses, to deliver high quality care, to reduce maternal and newborn morbidity and mortality. In previous episodes, we have heard how data has been used in decision-making through the maternal and perinatal death surveillance and response approach.

We've also heard about pre-service training and teaching and how it has been improved so that nurses and midwives feel more competent and capable of step into their roles on the frontline. In this episode, we're going to be focused on in-service training.

We hear about real life examples where the programme’s revised approaches to mentorship and training have improved outcomes and saved lives, including an example from Dr. Shaban, who joined us straight out of theatre!

More about our guests:

Lucy Nyaga (Co-host) - Country Director, Liverpool School of Tropical Medicine, Kenya

Lucy is the Country Director, Liverpool School of Tropical medicine, in Kenya. She has a background in Medical Anthropology and Public Health with extensive experience in promoting implementation of research results into policy and practice with a special focus on maternal and neonatal health (MNH). With twenty years’ experience working in health programming, her experience and expertise in MNH has involved managing and implementing programmes that incorporate implementation research to inform effective programming and policy influence. Working with a range of organisations ranging from governments, academic and research institutions, UN agencies, and national & INGO, Lucy has led and contributed to key MNH research that has then led to policy influence in Eastern Africa.

Veronica Musiega - Advanced practice nurse (midwifery speciality), Vihiga County, Department of Health Services

Veronica is the County reproductive health coordinator for Vihiga county. She is a national trainer in EmONC as well as EmONC mentor. She facilitates training, mentorship, support supervision and co-ordination of EmONC activities in the county and at National level.

Veronica has trained MPDSR at National level and within Vihiga county and has planned, initiated and coordinated MPDSR activities at County, Subcounty, Facility and community level. Under her co-ordination, various fora and networks have been developed at sub county and county level to manage EmONC emergencies and address gaps in provision of EmONC services.

Veronica heads a team that performs county supportive supervision in EmONC, providing technical assistance and addressing gaps in service delivery; as well as developing work plans to improve on reproductive health.

She is the secretary to the county MPDSR committee and has led the team to compile Biannual MPDSR report which is disseminated at county level and contributes to the national MPDSR reports. In addition, Veronica has spearheaded the implementation of the MPDSR committee actions.

Sylvia Kimtai - Subcounty Reproductive Health Coordinator, Kapseret Subcounty, Department of Health Services, County Government of Uasin Gishu

Sylvia is a midwife, a national EmONC trainer and mentor, who has working in maternal and newborn health since 2008 to date. Currently, she coordinates reproductive health services in Kapseret subcounty.

She has facilitated over fifty EmONC and MPDSR training sessions in various parts of Kenya. She mentors a team of mentors across maternity units in the county who also mentor their colleagues with the health facilities. She manages a WhatsApp forum/platform where EmONC mentors within Uasin Gishu county actively interact, share best practices and address challenges faced.

Sylvia provides technical support to other EmONC mentors both virtually and through onsite support supervisory visits to their health facilities. She also conducts support supervision in health facilities on maternal and newborn care including conducting periodic EmONC functionality assessments on performance of EmONC signal functions to address gaps in availability of services.

She is the Secretary to Sub county MPDSR committee and also member of the facility MPDSR Committees.

Sylvia is the custodian of EmONC training equipment in her county and ensures mentors access the equipment during mentorship.

Dr. Nassir Shaban - Resident Obstetrician Gyanaecologist, Msambweni County referral hospital, Kwale County.

Dr. Nassir was trained by LSTM eight years ago and since then has been collaborating with LSTM on various capacity strengthening projects focusing at improving Maternal and Neonatal Health. He has facilitated training of midwives, medical officers and consultants OBGY on Emergency Obstetrics and Neonatal Care (EmONC) ; as well as Advanced comprehensive obstetric surgical and anaesthesia skills.

Dr. Nassir’s biggest dream is to significantly contribute to reduction of maternal mortality and improve neonatal outcomes in his resource-constricted health institutions, something he works very hard to achieve through training and capacity strengthening amongst his colleagues and team players in health.

On matters of research, Dr. Nassir has a special interest. He has worked with LSTM towards publishing a couple of research papers on Maternal and Neonatal Health, latest one which will be featured in the upcoming Health Conference in South Africa in April 2023.

At the National level, Dr. Nassir has been involved in the revision of National EmONC training curriculum, development of EmONC mentorship package as well as development of the "Continuum of Care" package in collaboration with the Ministry of Health.

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Hello listeners, and welcome to the final episode of our mini-series where we have been focused on the programme

This is an FCDO funded programme, the Foreign Commonwealth Development Office, and it is led by the Liverpool School of Tropical Medicine.

In each of the episodes we have been discussing the different ways that the programme has strengthened the capacities of health

In previous episodes, we have heard how data has been used in decision-making through the maternal and

We've also heard about pre-service training and teaching and how it has been improved so that nurses and midwives feel more

In this episode, we're going to be focused on in-service training and as with the other three

She is the country director of the Liverpool School of Tropical Medicine in Kenya and is a medical anthropologist by background,

So Lucy, welcome back to the podcast in this final episode.

Lucy, why do we need in-service training on top of all the quality training that you have been

Good afternoon from Kenya and thank you very much Kim, to just give a background to

First, you know, previously the way the curriculum of the in-service was designed, it was not comprehensive and when nurses,

So when they went out to the field, the only way that we could cover that gap is then to be able to train them on

You know, as things change, as the world change, so does medicine, so does new health challenges come

Through continuous development and also through continuous, uh, medical education.

So that's why it's necessary.

However, we'll hear in the context of this programme, uh, that, uh, inservice training is

Through this programme, we've put systems in place that will ensure we have less and less of in-service training, reducing that impact

We have three guests who have been, beneficiaries of the training and mentorship that Liverpool School of Tropical Medicine, together

So our guests today, therefore, to highlight more on this, Dr.

Nassir Shaban, Dr.

Nassir Shaban is an obstetrician gynecologist working at the Msambweni County Referral Hospital, Kwale County at the coast of Kenya.

We also have Veronica Musiega a senior midwife working in Vihiga county as a county reproductive health coordinator.

Vihiga County in the Western, uh, part of Kenya and we have Sylvia Kimtai, a senior midwife, working in Uasin Gishu

Veronica, what is the scope of this programme that LSTM implemented and how was the in-service training received by the midwives in Kenya?

The in-service training, basically it is for healthcare providers, mainly the nurses, the

So normally they have gaps in issues or key resuscitation obstetric emergency areas.

These are the areas we sharpened their skills in and mainly we were identifying how our participants from the MNH departments, especially

That composes of about 32 participants.

After the training where we follow them map in their various facilities, just to ensure that uh,

So we follow it up and where we have gaps, we continue it with the mentorship.

Remember, the five day training, we were using the mannequins and the modules, but now when it comes to the actual clients, maybe

We follow them up in mentorship.

The mentorship, again, we can do it even on actual patients, the mannequins again, so that their skills are more

Yeah, so for Vihiga County from 2019, it was a cost sharing programme where the county chipped in with the part of the training

Thank you very much, Veronica, Sylvia, how was the in-service training received by the

Before the EmOC training, most midwives were not confident enough to manage mothers and babies and once they were

And also, after the training, most midwives now knew the kind of drugs or the kind of supplies that they might need in their maternity.

For example, before the training, most midwives did not know even how to use the simple vacuum extractor.

Most midwives did not even know how to use the manual vacuum aspiration set.

And also before then, most midwives said that they used to refer many clients to the next level, and most of the times

For example, they were not able to do simple procedures, like even the manual removal of the placenta or perform manual vacuum aspiration.

Most of the times they would refer clients who are still bleeding to the next facility and that would actually

So in a way, after the training, they gained the confidence and in a way also it led to reduction

Also as a county, we were able to improve in terms of finances, because remember, as a country we have,

The reduction in um, the referrals means that these women delivered in their facilities and in turn, the resources were

Wow, that is really interesting and, uh, really impactful.

With the trainings that we have had in the county, I must say that there really is great improvement in the

Earlier on an emergency, like let's say prolapse, you would find that the midwife would come along with the mother as

So you actually wonder what is the problem, the mother is already walking and having the head press onto the cord.

But, uh, as we speak now for the last like, uh, four cord prolapse that were pulsating, that were referred, the midwives from the

Even, as we do supervision in our facilities, we realise that these emergencies are clearly displayed in the labour wards so that any

They've put the emergency kit in place so that they will even and orient somebody who is new.

In every subcounty, we will realise that we have mentors in every subcounty.

We also have even facilities that have mentors.

Basically everybody is sharpened and even at management level, even up to the governor's desk, they are always scared of a maternal death.

Nobody wants to record a maternal death, and that is why everybody wants to know how to avert and be able

Dr.Nassir, in terms of what this adverse obstetric course is about and what it has done to you personally as a practitioner?

The advanced obstetric and anaesthetic and neonatal care is a slightly different type of

In this type of a package, it encompasses the anaesthetic part and a lot of surgical part.

When we were training all the medical officers, the consultants and the nurses and the clinical officers in Kenya, it was thought that

People also felt like the consultants are rarely on the ground, the consultants and the medical officers were spending most

Just an example, for breach most of them will be sectioning them, but the essence of theatre and

So actually the package on advanced surgical obstetric and anesthetic care came on time and it

So for instance, we go deep on how to manage difficult cesarean sections.

What are the challenges we anticipate when we have, let's say for example, low lying placenta, the accreta and all those things.

So we go very deep on the surgical skills in such a way that once one, uh, graduates from such courses and training, they tend to be updated

I can share a small experience.

I was delayed a little because of, I delayed in theatre and what happened to me today, I was sectioning a woman and one

Okay.

I ended up with a little bit of tear, which led me to, uh, spend more time than what I anticipated to spend in theatre,

So those are areas which the medical officers, the consultants, were lacking before this training came.

Another one advantage, which I can say openly is for any person who is a registrar in this country, in our country,

In fact, I can comfortably say that had had, had it not been for the skills and the trainings I was going through, I feel

I can say at least 50%, 50% of the exam in part two exam in our universities come from the

This is really interesting because, you know, one of the things that we are trying to do as a Liverpool

It's saving life, it's actually practical, but for Sylvia and for Veronica, because I know one of the things you mentioned is that this

What difference in this approach has led to assistance change at your county level?

I think I will start with Uasin Gishu County.

One of the things that was introduced by LSTM, was the introduction of the human resource dashboard.

Before then we would train, uh, uh, midwives within a couple of weeks, a couple of months, the midwives are rotated and

With the introduction of the human resource dashboard, we've seen the management committing to ensure that

That has really improved on the quality of care that we've been giving.

Also with the introduction of the EmOC functionality assessment, the feedback was shared with the county, we

For example, if we don't have the emergency drugs, facilities do not have the manual vacuum aspiration

Sharing this data with management really helped them to see where to focus when they want to buy supplies

Remember we said when we were doing the trainings, we also looked for the trainer of trainers or trainer

Like before, we used to have a pool of mentors either at subcounty level or a county level, and the mentors

Now with this introduction from LSTM of having mentors attached to facilities or mentors being part of the maternity staff

The last thing is something on communication.

Eh, For me, the management has really picked up the communication tool and that has really improved referrals

For me, I think Uasin Gishu is one of the counties that has really benefited from this concept from LSTM.

There's so many really good points coming out, but what I also pick is there's a human bit which in terms of people enjoying

I think during the training there is, uh, a module that really cover issues of respectful care and, that is what is

That basically started in maternity, where we expected that privacy issues, of confidentiality must be strengthened, that maternity

From a different perspective from Dr.Nassir, kindly talk about some best practices in terms of the human bit of the training.

First of all, I, I appreciated the importance of patients in everything we do.

For example, suturing the uterus, it was all about patients.

This idea of rushing was actually something we were trying to avoid, so that you give the best to the mother so patience was everywhere.

The way you work with your people way, the way you work with your team, the way you work with the patient, everything needed patience.

That is number one.

Number two was teamwork.

I really appreciated teamwork, both on the team, which we were working with; the mentors, the mentees, and what we

You need to have a team.

You need to be coordinating from one another, one person to another.

You needed that being together for a common goal, and the goal is to give the best of the patient and to have the best outcome.

Something as I also learned was, uh, the importance of following protocols.

That there are a lot of things which are in our facilities.

For example, we've been talking about the muse charts.

We've been talking about, uh, the theatre checklist.

All these things are in our facilities, but we are not implementing them.

We were not following them.

We are having a lot of near misses.

We are having a lot of mortalities and morbidities simply because we were too lazy to follow the protocols.

It's actually the feeling of doing things on a shortcut.

You just want to do something and leave so the issue of following protocols, following order, came

Were we following the SOPs?

Were we following the protocols?

Will have saved a lot of our mothers, will have saved a lot of babies.

We have saved a lot of, uh, resources from our facilities because everything is there, the protocols

The last thing or the second last thing was sacrifice.

We realised, everything need a sacrifice.

Even holding these, uh, trainings, it needed a lot of sacrifices.

Sometimes you can be reporting, especially when our dear Dr.

Helen is around.

Sometimes we meet very early in the morning.

We meet at 7.30 and by the time we finish around six, we have our meetings for one one hour.

Sometimes we leave the training hall at around 7.30 or even 8.00 you need a lot of sacrifices.

But there's that feeling in your heart that I've given my best, I've transferred this knowledge to the people who

The participants also, staying on a, uh, in a training from eight to around 5.30 or 6 without even touching your

The last thing which I can mention is flexibility.

Someone can call you and maybe you are not on duty or you are doing your part-time thing and then you're called by your junior or

Remember when we were doing, uh, our trainings during Covid time, we, we had planned to do everything in

Now we all had to come to Mumbasa.

The issue of flexibility, sacrifice, following protocols, being patient and teamwork were the major, aspects of

It's the human aspect that really matters.

It doesn't matter how much training you have, but as long as you can, you know, transfer that to yourself and to your patients.

I think then that kind of brings out that aspect of best practice in medicine.

Do you feel that, having gone through this training has made any difference If you compare previously

I can say, in places where we've trained, the outcomes are very clear.

The results are seen.

The only problem we have is we need to train more and more and more.

I'm speaking on behalf of doctor of doctors so if you go to Nairobi University, for example, you go to Moi university and the small

So my parting shot is we need to train more.

Sylvia one parting short in terms of how you judge your patients.

We've done some client exit interviews in a couple of maternity, uh, facilities and the

And one of the things that came out clearly is that they're now being handled in a respectful way and I think

Thank you, Veronica, some parting shot.

I think the trainings have really helped us have behaviour change among our providers

I remember the last week I was just I found in labor ward they had just conducted a delivery and were

So I helped them and the baby actually came up and cried very well, and the mother was so happy and she actually

So this was like a precious baby and the mother was so excited and she was happy with that.

And that followed actually the skills that we had trained.

Thank you very much.

I think I'll stop there.

This is not the end of our conversation, we'll continue to disseminate.

This is a four year programme that we are trying to feed into 20 minutes of recording, uh, but I appreciate

Just a minute away changes when Dr.Nassir has just saved a baby in theatre.

Uh, the day before yesterday when Veronica saved a baby in theatre.

This is really impactful.

I mean, saved a newborn baby, made a a mother happy, made a family happy.

May God bless you for your good work, and we are really glad and we shall continue, you know, to engage more.

Thank you very much, Lucy.

It's really struck me, the impact of this programme is phenomenal and those real life experiences help to show how important it

So thank you to our guests.

Thank you, Lucy.

Wonderful host there, and this is the end of our mini-series.

So thank you for listening.

If you haven't already, please go back and listen to the previous episodes, which cover different

Thank you very much and bye for now.