Woods DL, Greenfield DH. Teaching in under-resourced hospitals: Experience from South Africa.
NeoReviews 2010; 11: 5-11.
TEACHING NEONATAL CARE IN UNDER-RESOURCED HOSPITALS: EXPERIENCE FROM SOUTH AFRICA
David L Woods MB ChB, MD, FRCP, DCH
David H Greenfield MB ChB, MPhil (MCH), DCH, DTM&H, DPH
Perinatal Education Trust, Cape Town, South Africa
Abstract
To decrease neonatal mortality in under-resourced countries, nurses and doctors providing primary health care need to be able to
manage their own continuing education as traditional methods of training are often not available to health care workers, especially
in rural areas. The Perinatal Education Programme has sucessfully provided learning opportunities to thousands of doctors and
nurses in South Africa who manage their own professional education without the need of formal tutors. Data from a prospective
study of nurses using a self-help learning course in newborn care from the Programme documents significant improvements in
knowledge, clinical skills and care practices. This cheap and innovative method brings the promise of lifelong learning to all health
care practitioners caring for mothers and infants.
Introduction
Each year approximately 4 million infants die worldwide in the first four weeks of life (1). The vast majority of these neonatal deaths
take place in under-resourced countries such as those in sub-Saharan Africa (2). Enormous disparities exist between rich and poor
countries with an estimated neonatal mortality rate of 44 per 1000 live births in Africa compared to 4 per 1000 live births in high
income countries (3). The fourth Millennium Development Goal calls for a two thirds reduction in child deaths under the age of 5 by
2015. In South Africa almost a third of these deaths occur in the neonatal period (4). Therefore, a substantial improvement in
neonatal mortality is needed to meet this challenge of improving childhood survival in low income countries.
Neonatal deaths in South Africa
The estimated neonatal mortality rate for South Africa is 21/1000 live births with two thirds of these deaths falling in the first week of
life (5). Of the approximately one million births annually in South Africa, more than half are recorded by the Perinatal Problem
Identification Programme (PPIP) which documents the probable causes and avoidable factors associated with both stillbirths and
early neonatal deaths occurring in state hospitals and clinics (6). The main causes of these early neonatal deaths are low birth
weight, intrapartum hypoxia, infections and congenital malformations (7). A review of avoidable factors identified inadequate
clinical assessment and management of newborn infants by health professionals as major contributors to preventable mortality.
In a three year study of perinatal mortality in the Western Cape Province of South Africa it was found that early neonatal mortality
rates varied widely between different districts and were highest in those districts furthest away from metropolitan areas (8). Some
rural areas with relatively few low birth weight infants had a higher than average perinatal mortality rate suggesting inadequate
health care services. Therefore, any attempts to reduce neonatal deaths, especially early neonatal deaths, would have to
concentrate on rural areas where living standards and the provision of health care services are often poor.
The challenge of improving newborn care
Neonatal care is largely dependent on adequate numbers of well trained midwives and neonatal nurses as they provide most of the
primary health care in South Africa. They should be supported by doctors and administrators who can optimize the service they
provide. In addition, easy community access to good health facilities, sufficient and appropriate equipment and medication, and an
integrated, regionalized system of planning, management, communication and transport are needed. But the most important
element is well trained, motivated and compassionate nurses. This demands both excellent basic training and an efficient system
of continuing education.
Tradition methods of in-service and continuing training rely on centralized teaching of small groups of health professionals in the
academic units of large city hospitals. Much of what is taught in these tertiary hospitals is not put into practice as it is inappropriate
to the needs in peripheral hospitals and clinics and may not be applicable due to a lack of the necessary equipment, medication
and support systems. Centralized courses are also expensive and need accommodation, depend on a scarce resource of
competent trainers, and require participants to travel long distances and leave their families and places of employment for variable
periods of time. Many health professionals are denied study leave due to staff shortages. While there is still a place for centralized
training in advanced courses, this does not meet the needs of most primary health care professionals in South Africa.
Many years back the provincial system of bringing nurses and doctors to regional hospitals for update courses was changed to
regular visits by teams of trainers to rural districts where one and two day update courses were conducted. Formal lectures were
given, discussion groups facilitated, audit sessions arranged and selected skills taught. Although this system of taking the teachers
to the rural areas was partially successful, it was limited by travel costs and excessive demands on a few teachers. Occasional
teaching sessions by visiting experts are no substitute for a well planned programme of ongoing education. The pernicious system
of rotating staff also prevents the retention of knowledge and skills within a paediatric unit.
Our experience with staff exchanges and a cascade approach to train-the trainers has been disappointing while computer-based
internet training is not practical in most under resourced areas where staff have very limited computer skills, electricity supplies are
often intermittent and theft of teaching equipment is a problem.
In order to avoid these obstacles, what is needed is a simple, cheap, decentralized and effective means of learning which does not
depend on large numbers of formal tutors, avoids moving participants away from their homes and work stations, and provides
appropriate and applicable ways of improving knowledge, clinical skills, attitudes and service delivery. Every effort should be made
to encourage confidence and self-reliance rather than foster dependency and self-doubt.
The vision of self-empowered continuing education for primary health care workers
To address these many challenges in South Africa, the Perinatal Education Programme (PEP) was developed by a team of
midwives, neonatal nurses, obstetricians and neonatologists to empower both nursing and medical personnel to take responsibility
for their own continuing learning and professional growth. The Programme is based on the belief that health professionals can,
with support and encouragement, manage their own training programmes (Figure 1). Many of the principles used in writing the
education material were adapted from the very successful Perinatal Continuing Education Programme currently managed by the
American Academy of Pediatrics (9).
This very cost-effective community-based method of peer assisted learning used in PEP has many advantages and can rapidly be
rolled-out to large numbers of professional health care workers (Figure 2).
Structure of the Perinatal Education Programme
The PEP courses are written by members of a multidisciplinary editorial board and then review by invited experts in the field (10,
11). New developments in care practices and feedback from participants are used to regularly update the learning material.
The 15 most important topics in both maternal and newborn care are addressed in the basic programme which is used over 2
years. Each chapter covers the epidemiology, prevention, causes, presentation, danger signs and management relevant to that
topic. Using a simple question-and-answer format, the relevant content of each condition is presented in “bite sized chunks”. Each
answer leads the learner to the next question. In this stepwise fashion all the important information is mastered. Case studies at
the end of each chapter give clinical scenarios followed by further questions and answers. This pulls all the newly learned
knowledge together into “real life” situations. Flow diagrams summarize important diagnostic and management protocols.
Twenty multiple choice questions at the start of each chapter allow the participant to identify knowledge gaps while a post test
indicates what information has still not been learned. In this way, participants can monitor their own progress through the course
and be encouraged by the measured amount they have learned.
Most chapters have an attached skills workshop which uses clear instructions and simple line drawings to explain important clinical
skills to be learned (Figure 3).
The courses are presented as study books which are most practical for learning at home, at work or while travelling by bus or train.
The courses can also be done on the internet as an interactive programme. In addition, all the study material (without the multiple
choice questions) is available free on an open website.
A formal multiple choice examination is offered at the end of each course. The study group has to find a local invigilator (proctor) to
manage the examination and a mark of 80% is required to pass. Candidates using the internet-based programme can complete
the final examination on the website. Successful candidates are given a certificate of course completion.
Implementing the Perinatal Education Programme
PEP uses a system of peer tuition and co-operative learning where participants encourage and support each other in study groups
while learning most of the material on their own at a convenient time. These self-directed learning groups, which meet every few
weeks, should be supported by regional facilitators who can introduce the programme and encourage participation, obtain consent
from health managers, help to arrange a suitable venue and time for the meetings, order the study books, provide guidance in the
study method, assist with hands-on skills training, field queries and give support, and manage the final examination. It is important
that the facilitator does not take on the roll of teacher and control the process as this disempowers the participants and returns
them to the position of passive students. If a suitable facilitator is not available, the group appoints a member to co-ordinate the
course and invite an experienced doctor or nurse form the region to assist with each specific clinical skill, if needed.
Funding the Perinatal Education Programme
The development of PEP courses is funded through the not-for-profit Perinatal Education Trust. Participants pay for the study
books themselves at a minimal cost (approximately 20 US dollars for a one year course). There is no cost involved in managing
the courses at the hospitals or clinics as salaried trainers are not used. Successful candidates can apply through the trust for a
retrospective bursary from an outside funder to repay them the cost of the course book. The practice of participants paying for
courses themselves with the prospect of a refund is a positive incentive to successfully complete the course. This system of
rewarding success is appreciated by funders.
Assessing the impact of the Perinatal Education Programme
Initial field studies showed that groups of midwives and neonatal nurses, both in urban and rural hospitals, could significantly
increase their knowledge of perinatal care when using PEP in self-study groups(12). This was followed by a prospective, controlled
trial of the Maternal Care manual of PEP with midwives in a district hospital and local antenatal clinic in the Eastern Cape Province
of South Africa. Groups of participants who supported each other, without a formal trainer, significantly improved their knowledge
(13), clinical skills (14), attitudes (15) and quality of patient care (16) in the study district. There were no changes in the
neighbouring control district.
An unpublished study of neonatal nurses using the Newborn Care manual of PEP in a district hospital and satellite clinic in the
same province showed similar results. In this study the knowledge, skills and care practices of 24 nurses were evaluated before
and after they managed their own learning course over a year period using the Newborn Care manual of PEP (17).
A multiple choice test of 74 questions plus 5 case studies with a further 35 questions was used to determine their cognitive
knowledge of newborn care. Without prior warning, the same evaluation was used at the end of the study. There was a highly
significant improvement of knowledge from a mean pretest score of 55% to a mean post test score of 88% (Table 1).
An objective structured clinical evaluation (OSCE) was used to assess five practical skills before and after the course in 22 nurses.
The skills, chosen from the skills workshops in the course, were the physical examination of an infant, scoring gestational age with
the Ballard method, endotracheal intubation of a manikin, inserting a venous catheter into a segment of umbilical cord to simulate
umbilical vein catherization, and the measurement of blood glucose concentration with a reagent strip. The maximum possible
score was 123. There was a highly significant increase from 45% to 83% in the mean total score. There was also a highly
significant improvement for each skill tested (Table 2). The Student t test was used to assess improvement in both knowledge and
skills.
Finally patient care practices were assessed by chart reviews of clinical records over a period of 6 months before and after the
course. Records of infants weighing less than 2000 g or 4200 g or more at birth were chosen as were infants with an Apgar score
below 7 at 1 minute plus any other newborn infant admitted to the special care nursery. In addition, the record of a normal infant
was selected for every four infants selected for each of these high risk categories. The 4 criteria assessed in each record were
observations made on the infant, quality of notes written, identification of problems, and management given. One hundred and
ninety one records were evaluated before and 201 after the course. Criteria were scored at less than 12 hours and then again at
12 to 72 hours. The Mann-Whitney test for non parametric data was used. There was a highly significant improvement in both the
individual categories and the total scores (Table 3).
This systematic evaluation documented that a group of nurses, without formal tuition, could successfully use the Newborn Care
manual of PEP to improve their knowledge, skills and provision of newborn care.
The promise of self-help learning for all health professionals
It is now possible for all nurses and medical officers providing primary healthcare for pregnant women and their newborn infants to
access on-site continuing education courses. Most of the previous obstacles of traditional training have been removed. The
promise of this self-help method is that maternal and perinatal care will improve and morbidity and mortality will fall. This education
opportunity must be incorporated as an integral part of a wider programme to address the needs of primary health care in South
Africa. A well structured network of regional facilitators to assist with group education should greatly enhance the implementation.
The Perinatal Education Programme has been used by over 60 000 nurses, doctors and under graduate students in South Africa in
the past 15 years. Common learning material for nurses and doctors, in both basic and in-service training, has helped to correct
the previous fragmentation between health professionals in training and practice.
An additional 7 short courses address important maternal and newborn tpoics such as primary newborn care (clinic based), mother
and baby friendly care, maternal and perinatal audit, perinatal HIV, and birth defects (18). Recently this series of self-help learning
courses in maternal and newborn care for health professionals has been extended into the fields of child health as well as adult and
childhood HIV. The content of the learning material used in these courses is available on an open website (19).
This cheap and successful method of self-empowered learning could be used to address the training needs of many other aspects
of healthcare, not only in under-resourced countries but poor, inner city areas of many industrialized countries (Figure 4).
1.
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Zupan J, Aahman E. Perinatal mortality for the year 2000: estimates developed by WHO. Geneva: World Health
Organization, 2005.
State of the World’s Newborns. A report from Saving Newborn Lives. Washington DC. Save the Children. 2001.
Lawn JE, Zupan J, Begkoyian G and Knippenberg R 2006. “Newborn Survival”. In Disease Priorities in Developing
Countries, 2nd ed, ed. DT Jamison, JG Breman, AR Measham, G Alleyne, M Claeson, DB Evans, and others, 531-550. New
York. Oxford University Press.
Tracking Progress in Maternal, Newborn and Child Survival: The 2008 Report. UNICEF. 2008
Lawn JE, Kerber K eds. Opportunities for Africa’s Newborns: practical data, policy and programmatic support for newborn
care in Africa. Cape Town. PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO; 2006.
Saving babies 2006-7: Sixth Report on Perinatal Care in South Africa. Ed RC Pattinson. Tshepesa Press, Pretoria, 2009.
Pattinson R, Woods D, Greenfield D, Velaphi S. Improving survival rates of newborn infants in South Africa. Reproductive
Health 2005; 2:4
Louw HH, Khan MBM, Woods DL, Power M, Thompson MC. Perinatal mortality in the Cape Province: 1989-1991. S Afr
Med J. 1995; 85: 352-355.
Kattwinkel J, Cook LJ, Nowacek GA, Ivey HH, Short JG. Improved perinatal knowledge and care in the community hospital
through a program of self-instruction. Pediatrics 1979; 64: 451-458.
Woods DL. An innovative programme for training in maternal and newborn care. Semin Neonatology 1999; 4: 209-216.
Woods DL, Theron GB. A distance learning Programme in Maternal and Newborn Care. Perinatology 2000; 2 (6): 283-285.
Woods DL, Theron GB. The Impact of the Perinatal Education Programme on cognitive knowledge in midwives. S Afr Med
J 1995; 85: 150-153.
Theron GB. Improved cognitive knowledge of midwives practicing in the Eastern Cape Province of the Republic of South
Africa through study of a self education manual. Midwifery 1999; 15: 66-71.
Theron GB. Improved practical skills of midwives practicing in the Eastern Cape Province of the Republic of South Africa
through study of a self education manual. J Perinatology 2003; 3: 184-188.
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Theron GB. The effect of the maternal care manual of the Perinatal Education Programme on the attitude of midwives
towards their work. Curationis 2000; 22: 63-68.
Theron GB. The effect of the maternal care manual of the Perinatal Education Programme on the quality of antenatal care
and intrapartum care rendered by midwives. S Afr Med J 1999; 89: 336-342.
Greenfield DH. Evaluation of the use of the neonatal manual of the Perinatal Education Programme in Proceedings of the
18th Conference on Priorities in Perinatal Care in South Africa 1999. pp 1-14.
www.pepcourse.co.za
www.EBWhealthcare.com
Figure1: Basic structure of the Perinatal Education Programme.
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Clear learning objectives emphasize the most important lessons to be learned
Theoretical knowledge is presented in an easy, problem-solving way
Step-by-step guides through definitions, causes, prevention, clinical presentation, diagnosis, dangers and management.
Case studies in story-form help to apply new knowledge and solve common problems
Line algorithms for diagnosis and management
Skills lessons to learn the clinical skills required
Multiple-choice questions to monitor progress through the course
Figure 2: Advantages of the Perinatal Education Programme.
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Participants can study at their own pace at a time and place that suits them
The Programme is book-based so does not require any electronic equipment or internet access
The Programme is cheap and does not require a tutor
The Programme encourages participants to identify and solve clinical problems in a compassionate and caring way
The Programme enables participants to manage their own education with little outside support
The emphasis is on learning rather than teaching
The Programme content addresses real needs and provides practical answers to common and important clinical problems
Table 1. Assessment of cognitive knowledge (maximum possible score = 119)
n
24
Before the course
mean
SD
65.0
11.8
After the course
n
mean
24
105.1
SD
11.1
t = 13.59
p < 0.001
Table 2: Assessment of clinical skills (maximum total score = 123)
Before the course
After the course
n
mean
SD
n
mean
SD
t
p
Infant examination
22
15.0
16.3
22
21.7
10.6
6.65 <0.001
Gestational scoring
22
9.9
7.9
22
26.3
6.0
29.39 <0.001
Endotracheal intubation 22
11.3
27.3
22
21.8
10.9
6.80 <0.001
Umbilical vein catheter
22
11.0
12.0
22
19.5
10.2
11.12 <0.001
Blood glucose
22
8.9
19.5
22
12.7
11.1
7.09 <0.001
Total score
22
55.5
27.7
22
102.0 10.9
20.15 <0.001
Table 3: Assessment of clinical practice. (Scores given in percentages while n = number of records assessed)
Before the course
After the course
Before 12 hours:
n
mean
SD
n
mean
SD
t
p
Observations
192
53.3
18.0
203
62.2
16.8
5.06 <0.001
Documentation
192
44.0
15.9
203
52.4
17.8
4.89 <0.001
Problem identification
192
16.2
29.4
203
44.8
31.4
10.0 <0.001
Management
192
54.9
18.0
203
66.5
15.4
6.9 <0.001
Total score
192
43.5
14.4
203
58.4
13.8
10.5 <0.001
n
mean
SD
n
mean
Observations
155
58.7
23.7
169
77.8
21.6
7.8 <0.001
Documentation
155
49.3
13.9
169
55.9
13.0
4.4 <0.001
Problem identification
155
28.2
37.0
169
69.1
32.6
10.6 <0.001
Management
155
43.4
24.2
169
49.7
20.0
2.6
Total score
155
44.6
16.6
169
61.7
13.7
10.2 <0 001
12 to 72 hours:
SD
t
p
0.011