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Introduction: Quality midwifery education is central to improving midwifery service delivery and maternal and newborn health outcomes. In many settings, midwifery educators insufficiently prepared for their teaching role and deficient curriculum compared to international standards affect the quality of healthcare provided by the midwifery graduates. This study assessed the effectiveness of an EmONC enhanced midwifery curriculum delivered by trained and mentored midwifery educators on the quality of education and student performance in Kenya., Methods: A cluster randomised controlled trial in 20 midwifery colleges (12 intervention, 8 control colleges). Educators in both arms received training in teaching/EmONC skills to deliver the updated national midwifery curriculum. The intervention arm received additional 3-monthly post-training mentoring for 12 months. Educators' knowledge and confidence in EmONC/teaching skills was assessed before and after training and at 3, 6, 9 and 12 months. Teaching skills observations at baseline and endline in both study arms were also assessed. Knowledge, self-rated confidence and three OSCE in EmONC practical skills among final year midwifery students were assessed. Linear mixed effects models were used to evaluate the effect of intervention on educators and students., Results: Seventy four educators and 146 students participated. Training significantly improved educators' mean knowledge (61.3%-73.3%) and confidence to teach EmONC (3.1-4.2 out of 5). Observed teaching skills mean scores of educators in the intervention arm were significantly higher compared to those of controls at endline (89.4%-vs-72.2%, mean difference 17.2 [95%CI, 3.2-29.8]). Mean scores for students in the intervention arm were significantly higher than those in controls for knowledge (59.6%-vs-51.3%, mean difference 8.3 [95%CI, 1.6-15.0]) and the three skills assessed (means; mean difference (95%CI): shoulder dystocia (64.5%-vs-42.7%; 21.8 (10.8-33.9); newborn resuscitation (43.9% vs 26.1%; 17.8 (2.0-33.9); and maternal shock resuscitation (56.5%-vs-39.2%; 17.3 (8.0-26.0) and combined average skills scores (55.0%-vs-36.0; 19.0 (8.7-29.5)., Conclusion: Training and supportive mentoring improved the quality of educators' teaching pedagogy and EmONC skills and enhanced students' learning. Overall performance in EmONC knowledge and skills was significantly higher for students who were taught by trained and mentored educators compared to those who received training alone. Thus, a local mentoring system is effective to enhance learning and effectiveness of an EmONC-updated midwifery curriculum., Competing Interests: Declarations. Ethics approval and consent to participate: The study was reviewed and approved by Liverpool School of Tropical Medicine’s Research and Ethics Committee (REC 20–050), Moi University/Moi Teaching and Referral Hospital Institutional Research and Ethics Committee (IREC) (IREC FAN: 0003764), Kenya Medical Training College (KMTC/ADM/74/Vol VI) and the National Commission for Science, Technology and Innovation (License No: NACOSTI/P/21/8931). Consent was received at various levels. Details about the study were communicated by the KMTC Headquarters to all the participating colleges’ administration for institutional entry and required support. Study participants (educators) received an electronic detailed study information booklet containing all information about the study (including recording of teaching sessions as appropriate) and consent form two weeks before the commencement of the study. Secondly, a print copy of the same participant information sheet was issued to each participant and a written informed consent was obtained at the start of the face-to-face training sessions. A written informed consent was obtained from the students who participated in the study. Participation was strictly voluntary with an explicit option to withdraw at any time with no consequences. Those who opted not to participate in the study were not denied the training. Confidentiality was maintained throughout the study using the anonymous identity codes assigned to the study participants (educators and students). The study carried no risk to the participants as their identity was concealed throughout, study results (knowledge or skills scores) were not shared with the administration and participation in the study did not form part of their performance appraisal. Assessments, interview discussions and debrief meetings were conducted in a designated private space within the colleges. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: To achieve quality midwifery education, understanding the experiences of midwifery educators and students in implementing a competency-based pre-service curriculum is critical. This study explored the experiences of and barriers to implementing a pre-service curriculum updated with emergency obstetric and newborn care (EmONC) skills by midwifery educators, students and mentors in Kenya., Methods: This was a nested qualitative study within the cluster randomised controlled trial investigating the effectiveness of an EmONC enhanced midwifery curriculum delivered by trained and mentored midwifery educators on the quality of education and student performance in 20 colleges in Kenya. Following the pre-service midwifery curriculum EmONC update, capacity strengthening of educators through training (in both study arms) and additional mentoring of intervention-arm educators was undertaken. Focus group discussions were used to explore the experiences of and barriers to implementing the EmONC-enhanced curriculum by 20 educators and eight mentors. Debrief/feedback sessions with 6-9 students from each of the 20 colleges were conducted and field notes were taken. Data were analysed thematically using Braun and Clarke's six step criteria., Results: Themes identified related to experiences were: (i) relevancy of updated EmONC-enhanced curriculum to improve practice, (ii) training and mentoring valued as continuous professional development opportunities for midwifery educators, (iii) effective teaching and learning strategies acquired - peer teaching (teacher-teacher and student-student), simulation/scenario teaching and effective feedback techniques for effective learning and, (iv) effective collaborations between school/academic institution and hospital/clinical staff promoted effective training/learning. Barriers identified were (i) midwifery faculty shortage and heavy workload vs. high student population, (ii) infrastructure gaps in simulation teaching - inadequate space for simulation and lack of equipment inventory audits for replenishment (iii) inadequate clinical support for students due to inadequate clinical sites for experience, ineffective supervision and mentoring support, lack/shortage of clinical mentors and untrained hospital/clinical staff in EmONC and (iv) limited resources to support effective learning., Conclusion: Findings reveal an overwhelmed midwifery faculty and an urgent demand for students support in clinical settings to acquire EmONC competencies for enhanced practice. For quality midwifery education, adequate resources and regulatory/policy directives are needed in midwifery faculty staffing and development. A continuous professional development specific for educators is needed for effective student teaching and learning of a competency-based pre-service curriculum., (© 2024. The Author(s).)

Background: Midwifery education is under-invested in developing countries with limited opportunities for midwifery educators to improve/maintain their core professional competencies. To improve the quality of midwifery education and capacity for educators to update their competencies, a blended midwifery educator-specific continuous professional development (CPD) programme was designed with key stakeholders. This study evaluated the feasibility of this programme in Kenya and Nigeria., Methods: This was a mixed methods intervention study using a concurrent nested design. 120 randomly selected midwifery educators from 81 pre-service training institutions were recruited. Educators completed four self-directed online learning (SDL) modules and three-day practical training of the blended CPD programme on teaching methods (theory and clinical skills), assessments, effective feedback and digital innovations in teaching and learning. Pre- and post-training knowledge using multiple choice questions in SDL; confidence (on a 0-4 Likert scale) and practical skills in preparing a teaching a plan and microteaching (against a checklist) were measured. Differences in knowledge, confidence and skills were analysed. Participants' reaction to the programme (relevance and satisfaction assessed on a 0-4 Likert scale, what they liked and challenges) were collected. Key informant interviews with nursing and midwifery councils and institutions' managers were conducted. Thematic framework analysis was conducted for qualitative data., Results: 116 (96.7%) and 108 (90%) educators completed the SDL and practical components respectively. Mean knowledge scores in SDL modules improved from 52.4% (± 10.4) to 80.4% (± 8.1), preparing teaching plan median scores improved from 63.6% (IQR 45.5) to 81.8% (IQR 27.3), and confidence in applying selected pedagogy skills improved from 2.7 to 3.7, p < 0.001. Participants rated the SDL and practical components of the programme high for relevance and satisfaction (median, 4 out of 4 for both). After training, 51.4% and 57.9% of the participants scored 75% or higher in preparing teaching plans and microteaching assessments. Country, training institution type or educator characteristics had no significant associations with overall competence in preparing teaching plans and microteaching (p > 0.05). Qualitatively, educators found the programme educative, flexible, convenient, motivating, and interactive for learning. Internet connectivity, computer technology, costs and time constraints were potential challenges to completing the programme., Conclusion: The programme was feasible and effective in improving the knowledge and skills of educators for effective teaching/learning. For successful roll-out, policy framework for mandatory midwifery educator specific CPD programme is needed., (© 2024. The Author(s).)

Background: International Confederation of Midwives and World Health Organization recommend core competencies for midwifery educators for effective theory and practical teaching and practice. Deficient curricula and lack of skilled midwifery educators are important factors affecting the quality of graduates from midwifery programmes. The objective of the study was to assess the capacity of university midwifery educators to deliver the updated competency-based curriculum after the capacity strengthening workshop in Kenya., Methods: The study used a quasi-experimental (pre-post) design. A four-day training to strengthen the capacity of educators to deliver emergency obstetrics and newborn care (EmONC) within the updated curriculum was conducted for 30 midwifery educators from 27 universities in Kenya. Before-after training assessments in knowledge, two EmONC skills and self-perceived confidence in using different teaching methodologies to deliver the competency-based curricula were conducted. Wilcoxon signed-rank test was used to compare the before-after knowledge and skills mean scores. McNemar test was used to compare differences in the proportion of educators' self-reported confidence in applying the different teaching pedagogies. P-values < 0.05 were considered statistically significant., Findings: Thirty educators (7 males and 23 females) participated, of whom only 11 (37%) had participated in a previous hands-on basic EmONC training - with 10 (91%) having had the training over two years beforehand. Performance mean scores increased significantly for knowledge (60.3% - 88. %), shoulder dystocia management (51.4 - 88.3%), newborn resuscitation (37.9 - 89.1%), and overall skill score (44.7 - 88.7%), p < 0.0001. The proportion of educators with confidence in using different stimulatory participatory teaching methods increased significantly for simulation (36.7 - 70%, p = 0.006), scenarios (53.3 - 80%, p = 0.039) and peer teaching and support (33.3 - 63.3%, p = 0.022). There was improvement in use of lecture method (80 - 90%, p = 0.289), small group discussions (73.3 - 86.7%, p = 0.344) and giving effective feedback (60 - 80%, p = 0.146), although this was not statistically significant., Conclusion: Training improved midwifery educators' knowledge, skills and confidence to deliver the updated EmONC-enhanced curriculum. To ensure that midwifery educators maintain their competence, there is need for structured regular mentoring and continuous professional development. Besides, there is need to cascade the capacity strengthening to reach more midwifery educators for a competent midwifery workforce., (© 2022. The Author(s).)

Background: Community health workers (CHWs) have been identified as a critical bridge to reaching many communities with essential health services based on their social and geographical proximity to community residents. However, various challenges limit their performance, especially in low-and middle-income countries. With the view to guiding global and local stakeholders on how best to support CHWs, this study explored common challenges of different CHW cadres in various contexts., Methods: We conducted 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria. The study covered 10 CHW cadres grouped into Level 1 and Level 2 health paraprofessionals based on education and training duration, with the latter having a longer engagement. Data were analysed using thematic analysis., Results: We identified three critical challenges of CHWs. First, inadequate knowledge affected service delivery and raised questions about the quality of CHW services. CHWs' insufficient knowledge was partly explained by inadequate training opportunities and the inability to apply new knowledge due to equipment unavailability. Second, their capacity for service coverage was limited by a low level of infrastructural support, including lack of accommodation for Level 2 paraprofessional CHWs, inadequate supplies, and lack of transportation facilities to convey women in labour. Third, the social dimension relating to the acceptance of CHWs' services was not guaranteed due to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs' health activities and community members' daily routines., Conclusion: To optimise the performance of CHWs in LMICs, pertinent stakeholders, including from the public and third sectors, require a holistic approach that addresses health system challenges relating to training and structural support while meaningfully engaging the community to implement social interventions that enhance acceptance of CHWs and their services., Competing Interests: The authors have declared that no competing interests exist.

As key stakeholders continue to affirm the relevance of community health workers (CHWs) in universal health coverage, there is a need for a commensurate focus on their motivation and job satisfaction especially in low- and middle-income countries (LMICs) where they play prominent roles. Despite the wealth of literature on motivation and job satisfaction, many studies draw on research conducted in high-income settings. This study explored factors influencing motivation and satisfaction among CHWs in LMICs. Thirty-two focus group discussions and 116 key informant interviews were conducted with CHWs, programme staff, health professionals and community leaders in Bangladesh, India, Kenya, Malawi and Nigeria. Data were analysed using thematic analysis. Overall, CHWs desired: (1) CHW programmes with manageable workload; work schedules that address concerns of female CHWs on work-life balance; clear career pathway; and a timely, regular and sustainable remuneration. However, no remuneration type guaranteed satisfaction because of an insatiable quest for additional financial reward. (2) Relationship with stakeholders that enhances their reputation. This was more important for unsalaried CHWs. (3) Opportunities to support community members. This was popular among all cadres as it resonated with their altruistic values. This study provides insights for developing a 'comprehensive motivation package' for CHWs., (© 2021 John Wiley & Sons Ltd.)