final png report - Home | Charles Darwin University that most of the births in PNG are attended by...

PAPUA NEW GUINEA

MIDWIFERY EDUCATION REVIEW

FINAL REPORT

2006

Dr Sue Kruske

Charles Darwin University, Australia

For

WHO and National Department of Health

Papua New Guinea

PNG Midwifery Review Final Report ii

PNG Midwifery Review Final Report iii

Table of Contents

List of Tables ........................................................................................................vi

List of Tables ........................................................................................................vi

List of Figures..........................................................................................................vii

Acknowledgements...................................................................................................ix

Executive Summary...................................................................................................2

Overview................................................................................................................2

Stakeholders and Key Informants..........................................................................2

Midwifery Education Facilities..............................................................................3

Curriculum Analysis ..............................................................................................3

Health Services ......................................................................................................5

Regulation and Registration of Midwives .............................................................5

Recommendations..................................................................................................6

Section 1: Background.............................................................................................10

Midwifery in the International Context ...............................................................11

Papua New Guinea...............................................................................................12

Midwifery education in PNG...............................................................................15

Terms of Reference for a Review of Midwifery Education in PNG ...................16

Section 2. Methodology for Conducting the Review...............................................18

Methodology........................................................................................................18

Overview of Data Collection and Analysis .........................................................18

Data Collection Tools and Analysis ....................................................................18

Tool 1. Education Institution Assessment Tool...............................................19

Tool 2. Midwifery Teacher Questionnaire.......................................................20

Tool 3: Curriculum Evaluation Tool................................................................20

Tool 4: Student Midwife Assessment Tool .....................................................20

Tool 5. Health Facility Assessment Tool.........................................................20

Tool 6. Midwife Self Assessment Tool ...........................................................21

Focus Groups Discussions ...................................................................................21

Stakeholders and Key Informants........................................................................21

Desk Review ........................................................................................................21

Data Analysis .......................................................................................................22

PNG Midwifery Review Final Report iv

Section 3. Results.....................................................................................................23

Overview..............................................................................................................23

Site Visits .............................................................................................................23

Stakeholders and Key Informants........................................................................24

Key Findings of Stakeholders and Key Informants.............................................24

Section 4: Midwifery Education ..............................................................................26

Overview..............................................................................................................26

Midwifery Training in PNG.................................................................................26

Scope of Practice..................................................................................................27

International Definition of a Midwife..................................................................28

Educational Facility Assessment .........................................................................29

Recommendations for Midwifery Facilities ....................................................32

Teachers of the Midwifery Education Program...................................................32

Recommendations for Midwifery Teachers.....................................................35

Program Reviews.................................................................................................36

University Of Papua New Guinea....................................................................36

Pacific Adventist University ............................................................................38

Lutheran School of Nursing, Divine Word University, Madang.....................39

University of Goroka .......................................................................................42

Distance education...........................................................................................45

Curriculum Analyses ...........................................................................................45

Entry Criteria ...................................................................................................49

Approval by Regulatory Authority ..................................................................49

Educational Theories and Critical Thinking....................................................49

Midwifery Philosophy .....................................................................................50

Clinical Supervision.........................................................................................50

Ability to Practice Autonomously, in any Setting, with Life Saving Skills ....50

Clinical Assessors ............................................................................................51

Comparisons with PNG programs and International standards...........................51

Clinical Practice...................................................................................................53

Combining Midwifery with Paediatrics...........................................................57

Recommendations for Midwifery Programs........................................................58

Conclusion ...........................................................................................................60

Section 5. Student Midwives ...................................................................................61

PNG Midwifery Review Final Report v

Essential Midwifery Competencies Results.....................................................61

Focus Group Discussions.................................................................................64

Conclusion ...........................................................................................................67

Section 6. Health Services .......................................................................................69

Equipment ............................................................................................................69

Workforce ............................................................................................................70

Fee for service payment .......................................................................................71

Maternal Complications and Life threatening emergencies ................................71

Post Partum Haemorrhage ...............................................................................71

Pre-eclampsia and Eclampsia ..........................................................................74

HIV ..................................................................................................................76

Resuscitation of the Newborn..........................................................................77

Clinical Midwives................................................................................................77

Results of the Midwifery Self Assessment ......................................................79

Recommendations for Health Services................................................................81

Section 7: Regulation of Midwives..........................................................................83

Overview..............................................................................................................83

Recommendations for Nursing Regulation and Accreditation ............................85

Conclusion ...........................................................................................................85

Section 8: Conclusion ..............................................................................................86

References................................................................................................................88

Appendix 1: Education Institution Quality Assessment Tool..................................90

Appendix 2: Midwife Teacher Questionnaire..........................................................98

Appendix 3: WHO Framework for Evaluating Curriculum..................................106

Appendix 4: Student Midwives Surveys................................................................108

Appendix 5: Health Facility Assessment Tool ......................................................112

Appendix 6: Midwife Self-Assessment Tool.........................................................116

Appendix 7: List of Stakeholders and Key Informants.........................................123

PNG Midwifery Review Final Report vi

List of Tables

Table 1: Site visits........................................................................................................23

Table 2: Education Facility Assessment ......................................................................30

Table 3: Educational qualifications of midwife teachers.............................................34

Table 4: Theoretical Subjects at UPNG.......................................................................37

Table 5: Theoretical Subjects at PAU..........................................................................38

Table 6: Theoretical Subjects at Lutheran School of Nursing.....................................40

Table 7: Theoretical subjects in UOG program...........................................................44

Table 8: Curriculum Evaluation...................................................................................47

Table 9: Comparisons between the four curricula and WHO International Standards52

Table 10: Student Midwives Surveyed from 2005 and 2006 programs ......................61

Table 11: Range and average of key skills in midwifery.............................................66

Table 12: Summary of demographic data on clinical midwives..................................79

PNG Midwifery Review Final Report vii

List of Figures

Figure 1: Student confidence in normal pregnancy and birth......................................62

Figure 2: Student confidence in managing maternal emergencies ..............................62

Figure 3: Confidence of midwives in normal pregnancy and birth .............................80

Figure 4: Confidence of midwives in maternity emergencies .....................................81

PNG Midwifery Review Final Report viii

PNG Midwifery Review Final Report ix

Acknowledgements

The consultant (Sue Kruske) would like to thank all those who participated in the

Midwifery Education Review, particularly Estelle Jojoga from University of Papua

New Guinea, Julie Aengari from Pacific Adventist University, Elizabeth Natera from

the Lutheran School in Madang and Lilian Sewi from University of Goroka for

extending themselves to accommodate us on our visits to their facilities. Not only did

they facilitate access to university processes, they ensured our comfort and safety

whilst visiting their towns and arranged transport to rural health facilities and villages.

This ensured a comprehensive ‘snapshot’ of the lives of PNG families.

She would also like to acknowledge the other members of the review team, Ms

Sulpain Passingan from the Department of Health and Mr Geoff Clark from WHO.

Extended thanks also to the support and assistance from Department of Health

personnel, WHO personnel, health practitioners, and education staff.

It is not the intention of this review to diminish or discredit the hard work done by

many individuals across education, policy and clinical services. Most individuals are

doing the best they can possibly do in a system that is challenging and poorly

resourced. It is hoped that the recommendations in this report can assist these

individuals in strengthening maternity services in this country to achieve what all

participants are striving for: a reduction in the devastating loss of life in women and

children in PNG from conditions that are mostly preventable.

This Review was made possible by funding from WHO.

PNG Midwifery Review Final Report 1


Executive Summary

Overview

The quality of education provided for the preparation of midwives has a major

influence on the ability of health services to provide skilled care for women in

pregnancy, childbirth and the postnatal period. A review of midwifery education was

undertaken in November and December 2006, made possible through funding by the

World Health Organisation.

The National Department of Health in Papua New Guinea (NDoH) is to be

congratulated on its efforts to develop strategies to reduce maternal and childhood

mortality and morbidity. In particular, their success in prioritising attention on the

issue of midwifery, as the key to achieving such reductions, is exemplary, especially

in a country facing so many other urgent health issues.

A comprehensive review of the four education facilities currently providing

midwifery education in PNG was undertaken. These included the University of Papua

New Guinea (UPNG), the Pacific Adventist University (PAU), the University of

Goroka (UOG) and the Lutheran School of Nursing, Divine Word University. In

addition interviews were undertaken with 68 stakeholders and key informants

including health policy officers, clinical service workers and Nursing Council

representatives.

Stakeholders and Key Informants

It was acknowledged that there are currently insufficient midwives in PNG and that

the numbers of midwives currently being trained will not address these workforce

shortages. Poor maintenance of health facilities is affecting the ability to attract and

maintain staff and to provide high quality and safe care. In addition essential medical

supplies and equipment are often not available even though the central warehouse has

supplies available.

Many women are not seeking health services for care during pregnancy and

childbirth, largely due to the demographic and geographical challenges of PNG


populations, although health service fees and staff attitudes were also thought to affect

access.

Midwifery Education Facilities

Midwifery education in PNG was once considered the best in the West Pacific Region

but is no longer producing the same calibre of midwife. The transfer of education to

the tertiary sector occurred in 2002 and reduced the number of students being

educated in midwifery. Strategies to increase the number of midwives due to a

government pledge to have a midwife in every health centre in the country led to the

introduction of midwifery programs in three other institutions in the last few years.

Most of the education institutions were well equipped and had qualified teachers,

some of them with Master qualifications. Deficiencies included a lack of written and

electronic resources in some of the institutions including inadequate computers and

information technology access for teachers and students. Lacks of teaching models

were also noted in most of the facilities to enable students to develop skills on

mannequins prior to clinical placement.

Teachers of the programs were mostly registered midwives although some lacked

recent clinical experienced that limited their capacity to be effective in the clinical

setting. Stakeholders and students also reported inadequate support of university staff

in the clinical area. Midwife teachers did not appear to be up to date on many of the

latest evidence regarding the treatment or management of many of the life threatening

conditions women face in PNG.

Curriculum Analysis

Three of the four institutions reviewed provide midwifery education in a combined

‘maternal and child health’ format. The time of the programs varied between 40

weeks in the UPNG, PAU and Lutheran programs and 52 weeks in Goroka.

Whilst the overlap of midwifery and child health is recognised, it is unlikely that

competence in either discipline would be gained in the current time frame and

curriculum format of 40-52 weeks. Many of the stakeholders and key informants

supported the concept of the combined program, particularly for those staff working


in the rural areas. However, some informants recognised the clear shortcomings of the

current structure and supported the reestablishment of two distinct programs.

The theoretical component was considered stronger in the midwifery-only program

(offered through the Lutheran School of Nursing in Madang) compared with the other

programs due to its focus on midwifery only and the development of all subjects

within a midwifery context. The other three programs provide a range of generic

subjects shared with other post basic courses.

It is believed that all courses require more attention to the complications of pregnancy

and childbirth, particularly those conditions that contribute to the high rates of

maternal mortality (PPH, pre-eclampsia, puerperal sepsis etc) as the response from

students, educators and clinical midwives demonstrated lack of in-depth

understanding of these events, particularly pre-eclampsia.

The review found that overall there is insufficient clinical experience offered to

students across the four programs in the area of midwifery, particularly exposure to

labour ward. Some students spent as little as one week in labour ward, though the

average was 3-4 weeks. The only exception to this was the midwifery-only Lutheran

program which included 14 weeks in labour ward. More time is required in the key

maternity areas of labour ward and antenatal clinic, in line with WHO

recommendations. The exposure to key clinical skills necessary to reduce the maternal

and infant mortality, such as management of pre-eclampsia and resuscitation of the

newborn was also limited.

None of the four institutions provided students with a specified number of clinical

procedures. Even when a number was provided (for example, 10 normal births), many

students did not achieve this and were still permitted to graduate. A minimum number

of procedures should be applied across all institutions in line with WHO

recommendations (see page 52) and the students must achieve these requirements

prior to graduation.

Given that most of the births in PNG are attended by Community Health Workers

(CHWs), the role of the midwife needs to be strengthened as an educator within their


local health structure with a responsibility to supervise, mentor and teach the other

cadres of health personnel currently providing services.

The University of Goroka included an innovative aspect of their program that aimed

to provide local volunteer training, at the same time as placing students within the

volunteers’ villages for a period of eight weeks. This was to assist the student learn

about the issues facing families at the village level as well the opportunity to carry out

health assessments on every household, in partnership with the village volunteer. This

aspect of the program appeared to provide many benefits for both village members

and students of the program. However the time allocated to this aspect of the program

(16 weeks) sacrificed important clinical practice time for students to develop

midwifery (particularly emergency) skills.

Health Services

Government health services appeared less resourced than Church-sponsored health

services. Essential equipment was not available in many of the facilities visited with

staff carrying their own supplies of needles for suturing and buying their own soap.

Some of the smaller facilities did not have sphygmomanometers to monitor blood

pressures, and even when they were available women may not have their blood

pressure recorded. All facilities reported running out of essential medicines such as

Syntocinon, required for the prevention and management of post partum

haemorrhage. Clinical skills in the management of life threatening conditions were

also limited in some staff at the health facilities.

Regulation and Registration of Midwives

Although it is a requirement for all midwifery and nursing programs in PNG to be

approved by the regulatory authority, the Nursing Council, the UPNG curriculum has

not been submitted for approval by the Nursing Council. It was difficult to ascertain if

formal approval had been given to the three other programs. It is believed that this

approval has not been formalised for these three institutions, though the curriculum

documents had been submitted. UOG submitted their curriculum over twelve months

ago but have not received formal approval to provide the program and Lutheran

responded to a number of Council enquiries regarding their program, but have also

not received subsequent communication.


It was noted that no graduate from any nursing or midwifery program, including

undergraduate nursing programs (not included in this review) has been registered

since 2004. Whilst these students continue to be employed in both Church and

Government health facilities, there is significant concern amongst graduate students,

health clinicians and educators regarding this issue and this is a key area for policy

makers and leaders to address.

The Nursing Council could assist in the improvement of the quality of midwifery

graduates by developing a set of minimum clinical skills (including a predetermined

number of clinical procedures to attain those skills) that each student must attain prior

to graduation. This minimum number could be based on the WHO international

midwifery curriculum.

Recommendations

The midwifery training institutions can be strengthened by:

1. Increasing the amount of mannequin (models) for practical training, particularly

for life saving skills such as manual removal of the placenta, PPH and neonatal

resuscitation.

2. Ensuring the appointment of midwifery teachers who are both academically and

clinically competent midwives.

3. Ensuring computer and internet access for staff and students.

4. The use of powerpoint to be available for teaching within the facilities.

Increasing the capacity of the midwifery teachers can be achieved through:

5. Ensuring teachers are up to date in both theory and clinical practice Upskilling in

these areas could be achieved through a one week Regional Credentialling

Program (available through WHO).

6. Increasing time spent by teachers in the clinical areas providing clinical

supervision.

7. Utilising electronic resources and international literature more effectively.

8. Ensure teachers are also expert clinicians with continuous access to clinical

practice through student supervision (providing opportunities to upskill for those

who are not currently clinically competent). This requires all teachers offering

clinical supervision to be registered midwives.


Education programs in midwifery can be strengthened by:

9. Basing PNG programs on the WHO international curriculum, modified to meet

the contextual needs of this country.

10. Increasing the length of the program to 12 months (52 weeks) for midwifery only

with a 6 month additional component for child health/paediatrics.

11. A minimum number of clinical procedures be included in all curricula. For

example, increase the number of manual removal of placentas that students must

achieve to a minimum of five.

12. Comprehensive clinical logbooks be developed for students to record the minimal

number of clinical skills, for example, space be provided to document 100

antenatal assessments, 40 normal births, 5 breech births, 5 vacuum extractions etc.

Competencies can then be signed off by a competent supervisor once for each

skill.

13. Ensure that each student achieves all minimum clinical requirements before

allowing them to graduate.

14. Improve access to clinical skill development through rostering of students on all

shifts including night-duty and weekends, and also other hospitals in PNG.

15. All programs should develop a midwifery specific curriculum and not embed the

program within nursing.

16. Subjects should be midwifery specific where possible.

17. The entry criteria be revised and standardised to incorporate international

recommendations that accept registered nurses with hospital based certificates.

18. More attention be devoted throughout the program to develop life saving skills,

particularly management of pre-eclampsia, eclampsia, and resuscitation of the

newborn.

19. More attention be devoted throughout the programs to develop critical thinking

and reflective practice through the use of role plays, case studies, case reviews,

reflection on critical incidents etc.

20. All curricula include information on evidence based practice using A Guide to

Effective Care in Pregnancy and Childbirth and WHO literature such as the

Reproductive Health Library.

21. Extend the capacity to train midwives through distance learning.


Health services can be strengthened by:

22. NDoH develop and disseminate a standardised policy for all education and health

facilities, outlining the appropriate management of third stage and the

management of PPH. This should include:

• Minimising the stimulation of the uterus prior to expulsion of the placenta.

• Accurate physiological management in the absence of oxytocics.

• Routine administration of syntocinon rather than syntometrine for the active

management of third stage.

The availability and appropriate administration of misoprostol (800 – 1000

micrograms inserted rectally) in the management of PPH.

23. NDoH develop and disseminate a policy to all education and health facilities,

outlining the appropriate identification and management of pre-eclampsia and

eclampsia. This should include:

• The availability of testing for proteinuria at the clinical level.

• Clear definitions and classifications of hypertensive disorders in pregnancy.

• Contemporary evidence around signs and symptoms of the disorder.

• Current evidence around management of the disorder including appropriate

use of antihypertensives and magnesium sulphate for the prevention and

management of eclamptic seizures.

24. Improvement of working conditions by ensuring:

• Adequate drugs and single use items where required to increase quality and

safety of care.

• Facilities provide appropriate means for ensuring infection control procedures

can be followed at all times (especially hand washing hardware: running

water, soap and towel).

25. Funding to be secured to provide an upskilling workshop on maternity

emergencies for senior clinical (midwifery and obstetric) and education staff in

PNG.

26. NDoH recommence preceptor training for clinicians working with students and

junior staff in the clinical areas.

Regulation of midwives can be strengthened by:


27. Process the registration for all students who have graduated from nursing and

midwifery programs since 2004. This must be attended to as a matter of urgency.

For graduates from the UPNG program that has not received formal approval to

offer the existing program, these students should not be penalised by withholding

registration. Whilst it is recommended that the UPNG program restructure their

program in line with the recommendations of this report, it is not believed the

graduates from the UPNG program are significantly less competent than the other

programs. Therefore to withhold registration to these students on the basis that the

program was not approved would not be useful, particularly when representatives

of the Nursing Council were included in the curriculum development.

28. Develop a set of minimum standards of clinical skills that each institution must

incorporate into their curricula. These should be based on WHO recommendations

documented in their international curriculum.

29. Conduct a review of the registration procedures required by Council in order to

improve the efficiency and reduce the workload required by the Council to assess

each graduate individually.

30. Set standards for minimum requirements for entry into the profession that should

include registered nurses with hospital based certificates.


Section 1: Background

Midwives are recognised in most countries where they exist as the front-line care-

givers in pregnancy and childbirth. As such they are often described as the linchpins

of safe motherhood and have a special role and responsibility to promote reproductive

health. The role of the midwife is clearly expressed in the definition formulated by

International Confederations of Midwives (ICM) in 1972 and amended in 1990 and

2005. The definition is approved and adopted by key international agencies including

the International Federation of Gynaecologists and Obstetricians (FIGO) and WHO.

Critical components of a strategic approach to reducing maternal mortality and

morbidity, as well as to promoting women’s health throughout their reproductive life

include:

• Updating educational programs to respond to community needs

• Setting clear standards for practice to identify essential competencies for

clinical practitioners and educators, as well as for the health system needed to

support the functioning of a midwife, and finally

• Establishing an enabling legislative and policy framework for practice

(WHO, 2006b).

To meet the challenge of providing quality care to women and their newborns, both

initial and continuing midwifery education must be improved. Improvements must

include:

• Technical competencies, including life-saving skills

• Skills in communication, counselling and health education to assist the

midwife in developing good relationships and working with the community

• Introduction to all aspects of the concept of reproductive health

• Access to all the equipment, supplies and drugs needed to give quality care

and manage life-threatening conditions in the woman and newborn

• Regular, continuing education to maintain and extend midwives’ skills and

encourage accountability

• Support from supervisors and regular, constructive performance appraisals.

(WHO, 2006b)


In addition to their clinical role, midwives need to be politically astute and capable of

taking appropriate and skilful action to promote reproductive health and the rights and

well-being of women. Each midwife must also be able to function effectively as a

fully accountable member in a multi-professional team and develop collaborative

working relationships with other members of the maternity services team, other health

care providers and with community workers such as traditional birth attendants

(TBAs) both trained and empirical, where they exist (WHO, 2006b).

Midwifery in the International Context

There is a trend towards more community based maternity health services utilising

primary health care principles, a recognition of the importance of inter-disciplinary

collaboration and the promotion of social support for childbearing women. The

current wave of change occurring in maternity health services is characterised by

escalating costs; crises in the recruitment and retention of both midwives and medical

practitioners, particularly in rural areas; the closure of rural units; shorter hospital

stays; and increasingly sophisticated information technology and biotechnology.

Midwives need a strong scientific knowledge base and the ability to learn and make

independent enquiry at a high level in the face of complex maternity health services

where the increased availability of knowledge requires ‘rethinking, rediscovering and

reforming practice’ (Page 2000:xi).

At the second WHO Ministerial conference on nursing and midwifery in Europe, in

The Munich Declaration (WHO, 2000), Ministers of Health stated their belief that:

Nurses and midwives have key and increasingly important roles to play in

society’s efforts to tackle the public health challenges of our time, as well as in

ensuring the provision of high quality, address people’s rights and changing

needs (WHO, 2000).

In the Munich Declaration which was issued by ministers at the conference (WHO,

2000), all relevant authorities were urged to ‘step up their action’ in order to

strengthen nursing and midwifery by:

• Ensuring a nursing and midwifery contribution to decision-making at all levels

of policy development and implementation;


• Addressing the obstacles, in particular recruitment policies, gender and status

issues, and medical dominance;

• Providing financial incentives and opportunities for career advancement;

• Improving initial and continuing education and access to higher nursing and

midwifery education;

• Creating opportunities for nurses, midwives and physicians to learn together at

undergraduate and postgraduate levels, to ensure more cooperative and

interdisciplinary working in the interests of better patient care;

• Supporting research and dissemination of information to develop the

knowledge and evidence base for practice in nursing and midwifery;

• Seeking opportunities to establish and support family-focused community

nursing and midwifery programs and services, including, where appropriate,

the Family Health Nurse;

• Enhancing the roles of nurses and midwives in public health, health promotion

and community development. (WHO, 2000)

Papua New Guinea

Papua New Guinea is the largest developing country in the Pacific. Covering 2.2

million square kilometres, its main landmass, 85% of its total, is shared between

Papua New Guinea and Papua Province of Indonesia. The remaining 15% is spread

over 600 islands.

It has a population of 6.0 million (estimated 2005), with a population growth rate of

2.7 %. It remains a primarily rural society with 87% of the population living in rural

areas. Around 800 languages are spoken, and each language group has a distinct

culture. There are large socio-cultural differences between and within provinces.

Official languages are English, Pidgin and Motu.

Access to the widely scattered rural communities is often difficult, slow, and

expensive. Only 3% of the country’s roads are sealed. Many villages can only be

reached on foot. Much travel between the provinces is by air. There is a persistent and

serious law and order problem, which involves a combination of serious

‘conventional’ crime and public disorder, and tribal warfare. This, together with the


poor road infrastructure and rugged terrain, pose formidable challenges to effective

health services delivery nation-wide.

Health status, the lowest in the Pacific region, once steadily improving during the

1980’s has progressively declined over the last ten years. Life expectancy (2000) is

estimated to be 52.5 for men, and 53.6 years for women, with Healthy Life

Expectancy of 45.5 years (WHO 2006a). It is estimated that about 15% of a woman’s

life span to be affected by some form of disability or morbidity. The estimations of

mortality and morbidity patterns in the population are very approximate, as data are

almost entirely facility based and laboratory confirmation of clinical diagnoses is rare.

Maternal mortality estimates are amongst the worst in the world at 370 per 100 000

live births (2000 figures). Causes of maternal deaths include postpartum haemorrhage,

puerperal sepsis, antepartum haemorrhage, eclampsia and anaemia. Only 40% of

women are cared for by trained health personnel. The infant mortality rate is 64 per

1000 live births very high compared to 38 for the other lower middle-income

countries.

Chronic malnutrition is a serious problem, particularly among rural women and

children, and is closely related to poverty. Overall 27% of children are considered

moderately to severely malnourished and 43% of children aged 0-5 have stunted

growth. Again there are marked regional variations (WHO, 2006a).

Health services across the country is provided by both the government through the

National Department of Health (NDoH) and a number of Church Organisations. The

Churches work in close partnership with the government and provide approximately

50% of both health services and education of the health workforce. These Churches

are multi denominational and are collectively represented by the Churches Medical

Services with administrative offices located within the NDoH.

Papua New Guinea is divided into four regions. Within these regions there are 19

provinces and within the provinces, 89 districts. Each region has a regional hospital

with smaller district hospitals in each of the districts. Smaller communities are

serviced by ‘Health Centres’ with some of the smaller villages having an ‘aid post’.


The numbers of Aid Posts have rapidly reduced over the past 10 years, leaving some

villages with no health service at all. Infrastructure at the Health Centre level is

minimal with the majority having no electricity or running water.

Birthing services are available at most of these facilities (not Aid Posts) though many

are without a midwife or doctor (see below). The number of births at each facility was

difficult to ascertain but range from several per month in the smaller Health Centres to

approximately 1,000 per month at the Port Moresby General Hospital.

The nurse to population ratio is 6.52 per 100,000. An additional 1000 nurses and 100

midwives are estimated to be needed to fill vacant posts, and current production rates

are insufficient to fill this gap (WHO, 2006a). The NDoH released its National Health

Plan 2000-2010 in the late 1990s where it was recognised the health of PNG people

had not improved and in some indicators such as maternal and child health had

actually deteriorated. The government announced a commitment to address this and

one of the goals was to have a midwife in every health service by 2010. However at

the beginning of 2007, many recognise that this goal is not possible to fulfil with most

of the births across the country being unsupervised by a skilled health attendant.

The majority of women giving birth in rural health centres are cared for by

Community Health Workers (CHWs). These workers undertake a two year education

program that is based on health promotion and disease prevention. Within their roles

the CHW are supposed to monitor women during pregnancy and refer them to a

midwife for birthing services.

Another category of worker, not recognised as qualified health personnel is the

Village Health Volunteer (VHV). This program was commenced in 2002 and is

generic volunteer program run over four weeks and incorporates five training modules

including:

• Being a better volunteer

• Self help health care (first aid)

• Safe motherhood

• Healthy children


• Learning about health (nutrition, hygiene and diseases)

Members are chosen by the community to undertake the program. More than half of

the volunteers are men and an evaluation of the program was undertaken in 2006

though the results were not released at the time this review was undertaken.

The delivery of health services to people with such a large percentage living in rural

and remote areas, often in geographically isolated areas, have been challenging.

Health infrastructure has been insufficient and poor maintenance of buildings and

inadequate resources has resulted in over 50% of rural health centres closing over the

past twenty years despite the population almost doubling from 3 to 6 million people

(WHO, 2006a).

The NDoH have developed a ‘Minimum Standards for Health Facilities’ document

that outlines the minimum equipment and staffing levels for each category of facility.

However the majority of the services, including the largest health facility, the Port

Moresby General Hospital are not able to implement these standards due to workforce

and funding shortages.

Midwifery education in PNG

Like many countries, midwifery education was traditionally conducted through

apprentice-style training based in hospitals where registered nurses received

additional education in the specialist field of midwifery. In the late 1990s midwifery

education was transferred to the tertiary sector and was initially offered as an

advanced diploma before becoming a bachelor degree in 2002. The move to the

tertiary sector resulted in a dramatic decrease in new midwives being produced as

initially only University of Papua New Guinea (UPNG) was offering a tertiary based

midwifery program. Three other institutions have developed midwifery programs

since 2002 and there are now four programs being offered across the country, two in

Port Moresby UPNG and Pacific Adventist University (PAU), one in Goroka

(University of Goroka) and one in Madang (the Lutheran School of Nursing, Divine

Word University).


Terms of Reference for a Review of Midwifery Education in PNG

This review was undertaken under the following terms of reference

A: In collaboration with the Director, HRM branch, National Department of Health,

the Nursing Council of Papua New Guinea, the School of Nursing, University of

Papua New Guinea (UPNG), the Obstetric Division, Port Moresby General Hospital

(PMGH), the Lutheran School of Nursing, Divine Word University, the University of

Goroka and the Pacific Adventist University and the Papua New Guinea Midwifery

Society to:

1. Review the current curricula in use for midwifery education, including clinical

training and teaching, at the School of Nursing, the Lutheran School of Nursing,

Divine Word University, the University of Goroka and the Pacific Adventist

University, in terms of it’s appropriateness for preparing midwives in the context of

practice in Papua

2. Develop a tool for the conduct of a comprehensive review of the outcome of

graduates of the School of Nursing, University of Papua New Guinea, the Lutheran

School of Nursing, Divine Word University, the University of Goroka and the Pacific

Adventist University.

3. Develop a list of stakeholders to be consulted in the review including, but not

limited to, tutoring staff of the 4 schools, graduates of the program, employers,

clinical facilitators, and midwifery and obstetric colleagues.

4. Conduct a comprehensive review with stakeholders of the outcome of graduates of

the School of Nursing, University of Papua New Guinea (UPNG), the Obstetric

Division, Port Moresby General Hospital (PMGH), the Lutheran School of Nursing,

Divine Word University, the University of Goroka and the Pacific Adventist

University.

B: Submit a detailed report, with any appropriate recommendations, at the end of the

assignment.


This work therefore involved close consultation and collaboration with key

stakeholders and partners including education and health service providers.


Section 2. Methodology for Conducting the Review

Methodology

The WHO has developed a set of guidelines that can be used for establishing or

reviewing midwifery programs according to a country’s needs and priorities. They

cover the following aspects of midwifery education and practice:

Legislation and Regulation: Making Safe Motherhood Possible.

• Guidelines for the Development of Midwifery Education Programs.

• Competencies for Midwifery Practice.

• Guidelines for the Development of Standards for Midwifery Practice.

• Guidelines for the Development of Programs for the Education of Midwife

Teachers.

(WHO, 2006b)

These guidelines were used to guide this review.

Overview of Data Collection and Analysis

In view of the complex nature of health services in PNG and the limited time

available to complete the task, a rapid appraisal approach was utilised. Key concepts

of the rapid appraisal approach are taking a systems approach, triangulation of data

and iterative data collection and analysis (Beebe, 1995). The systems approach

utilises the insiders understanding of the situation, considers all aspects that may be

affecting the functioning of the system but moves on to focus on the most important

aspects to that particular context (Beebe, 1995). Triangulation of data is the second

key concept in the rapid appraisal approach and involves consciously choosing

different research methods, different team members and different individuals for

interview to provide different perspectives. The third key concept of rapid appraisal is

iterative data collection and analysis which is used to clarify uncertainties and may

uncover unexpected details (Beebe, 1995).

Data Collection Tools and Analysis

A number of specific tools were developed for the review, based on tools used in

similar assessments conducted in other countries. These tools included


• Educational Institution Assessment

• Midwife Teacher Assessment

• Curriculum Assessment

• Student Midwife Assessment

• Health Facility Assessment

• Midwife Self Assessment

A copy of all tools is provided in the appendices of this document.

The tools that listed key skills and competencies (the midwife teacher tool, the student

midwife tool and the clinical midwife tool) were developed and tested in a previous

review of midwifery in Cambodia and Mongolia, where the validity of the tool was

tested and shown to have a good correlation with observed and tested competencies

(Sherratt et al., 2006). They were based on the ‘Essential Core Competencies of a

Midwife’ developed by the International Confederation of Midwives (ICM). The ICM

is the only professional association that solely represents the voice of midwifery

globally, having over 89 member Associations in 86 countries, and is a member of the

new global Partnership for Maternal, Newborn and Child Health. The ICM core

competencies were developed through a rigorous Delphi study, that included

representatives from both member and non-member countries, many of which were

from developing countries. In addition, the ICM competencies are in-line with the

essential competencies required of any skilled attendant, as agreed by international

consensus and published by the World Health Organisation.

Tool 1. Education Institution Assessment Tool

The education and training facility assessment tool was used in a ‘walk through’

assessment of the educational establishments that were visited. This was used to

assess the training and education facilities available for midwifery training, the

resources available for the midwifery teachers and the students, dormitory facilities,

models and equipment, library facilities and information technology infrastructure.

See Appendix 1 for a copy of this tool.


Tool 2. Midwifery Teacher Questionnaire

A simplified education audit tool was used to gather data on midwifery teachers’

experiences and competencies. All midwifery teachers in the four institutions were

asked to complete a self reporting questionnaire that sought details on their

educational qualifications, clinical experience as a midwife and identified barriers to

work performance. They were also asked to address a range of educational and

clinical competencies required to practice all clinical midwifery skills to mastery

level. See Appendix 2 for a copy of this tool.

Tool 3: Curriculum Evaluation Tool

This tool provides a framework to comprehensively assess programs of education for

the preparation of midwives to become competent to practise to an agreed, or

understood, scope of practice. The tool compares programs against a generic

curriculum and includes information regarding the process in which the curriculum is

developed, entry requirements, student teacher ratios, regulatory requirements,

educational theories used, teacher requirements, quality of graduate attributes and

quality assurance procedures. See Appendix 3 for a copy of this tool.

Tool 4: Student Midwife Assessment Tool

A self reporting questionnaire was given to as many students as possible to gain their

experiences of their midwifery training, including their experience of clinical

exposure and supervision. The tool also measured their level of confidence in over 45

clinical skills in the area of midwifery and child health. See Appendix 4 for a copy of

this tool.

Tool 5. Health Facility Assessment Tool

The health system environment in which health personnel work is known to affect

their performance. A simplified ‘walk-through’ assessment was made of all facilities

visited. The purpose of this ‘walk-through’ assessment was to identify major

challenges to the performance of the midwives. The walk through assessment was a

simple checklist which focused on identification of key equipment, resources required

for practice, general cleanliness and hygiene of the facility, water and sanitation

facilities, infection control and waste management practices. See Appendix 5 for a

copy of this tool.


Tool 6. Midwife Self Assessment Tool

A tool was also developed for clinical midwives to determine their level of skill and

confidence in a number of areas. It was considered necessary to attempt to ascertain if

clinical midwives were competent in key areas necessary to provide safe, high quality

care to women and their families as this workforce is often the most influential in the

learning of midwifery students and new graduates. Over forty essential midwifery

competencies, from the list of core competencies developed by the ICM were chosen

for assessment. Respondents were given five answer options, which included whether

or not they had learned the skill and if they felt confident or not to practice the skill.

The competencies included in the tool focused on those most needed to reduce

maternal and infant mortality and morbidity. See Appendix 6 for a copy of this tool.

Focus Groups Discussions

To compliment the information gained from the self assessment tools, Focus Groups

Discussions were employed to obtain further qualitative data on the experiences and

perceptions of the different groups involved in midwifery education and health

services. Wherever possible midwives, students and educators were interviewed in

individual groups and asked questions particular to their area of expertise and

experience.


Meetings were held with as many stakeholders and key informants that the NDoH and

WHO partners could identify and, could be accommodated within the time frame

available for data collection. Semi-structured interviews were conducted with key

informants around their impressions of maternity services and midwifery in PNG, the

difficulties and challenges that currently exist for maternity services including the

recruitment of midwives, the quality of midwifery graduates, clinical supervision for

students and how they believed midwifery could be strengthened.

Desk Review

A review of pertinent reports and curriculum documents was conducted. This

included: the National Health Plan 2000-2010; the Strategic Plan for the PNG Health

Sector 2006-2008; the Minimum Standards for Health Facilities document; the

National Framework for the Accreditation, Monitoring and Evaluation of Nursing and


Midwifery Programs; and the curriculum documents in all four institutions that

provide midwifery education in PNG.

Data Analysis

The limited time of the review and the number of tools did not permit sophisticated

statistical calculations. The statistical package (SPSS) was used for data analysis of

the midwife, student midwife and midwifery teacher self-assessment tools. Thematic

analysis of discussions with key stakeholders and the focus group members was

performed.


Section 3. Results

Overview

The major results of the review have been presented under the following sections:

• Stakeholder and Key Informants responses

• Midwifery Education: facilities, teachers, curriculum

• Midwifery Students

• Health services

• Regulation and accreditation of midwives and midwifery programs

Site Visits

A list of the health facilities and the educational facilities that were visited are listed

in the table below.

Table 1: Site visits

Education Institutions

Location Institutions/organizations

Port Moresby University of Papua New Guinea

Pacific Adventist University

Madang Lutheran School of Nursing, Divine Word University

Goroka University Of Goroka

Health Facilites

Port Moresby Port Moresby General Hospital

Six Mile Urban Health Centre

Mandang Modilon General Hospital

Madang Town Clinic

Yagaum Rural Health Centre

Mugil Rural Health Centre

Nobonob Aide Post

Goroka Goroka Base Hospital

Asaro Health Centre

Village in Asaro District



A total of 68 people were interviewed as stakeholders and key informants who had

been nominated by NDoH and WHO as important to the review. The list of these

individuals can be found in Appendix 7.

Key Findings of Stakeholders and Key Informants

Results around questions specific to the participants’ area of expertise in relation to

the Terms of Reference are documented further in the relevant sections of this report.

This section reports on overall impressions of stakeholders and other key informants

around the following prompt questions:

• What were their impressions of maternity services and midwifery in PNG;

• The difficulties and challenges that currently exist for maternity services;

• What were the key issues around:

• The recruitment of midwives;

• The quality of midwifery graduates;

• Clinical supervision for students, and;

• How they believed midwifery could be strengthened.

The following points summarise the key findings from discussions from stakeholders

and key informants

• There are currently insufficient midwives in PNG.

• The numbers of midwives currently being trained will not address workforce

shortages.

• Poor maintenance of health facilities is affecting the ability to attract and

maintain staff and to provide high quality and safe care.

• Essential medical supplies and equipment are often not available even though

the central warehouse has supplies available.

• Many women are not seeking health services for care during pregnancy and

childbirth.

• Midwifery education in PNG was once considered the best in the West Pacific

Region but is no longer producing the same calibre of midwife.


• The current education programs preparing midwives do not provide enough

time in the clinical area.

• The supervision of student midwives in the clinical area was insufficient.

• That some of the midwifery teachers were not clinically competent.

• Some stakeholders believed that the midwifery and paediatric strands should

be separated.

Further findings from stakeholder and key informant interviews will be included in

the relevant sections of the report.


Section 4: Midwifery Education

Overview

Integral to the midwifery workforce is the training and education of midwives. The

review explored the current capacity of the educational institutions to produce an

adequate and sustained supply of midwives with the ability to offer quality midwifery

care. Midwives must have necessary skills for saving the lives of mothers and babies.

The review identified a number of gaps and areas for potential action to increase

capacity of the midwifery workforce.

Midwifery Training in PNG

Post basic certificate programs for Registered Nurses were established in the early

1960s. The College of Allied Health Science, under the auspices of the National

Department of Health controlled these programs from 1969 until the late 1990s. The

Diploma of Advanced Clinical Practice commenced in 1995 through CAHS.

Following affiliation between CAHS and UNPG the Bachelor of Clinical Nursing

specialising in Midwifery first commenced in 2002.

At the time the Government pledged ‘a midwife in every health facility by 2010’,

only 20 midwifery graduates are year were being produced through UPNG. This

pledge led to the development of midwifery programs in several other institutions. As

a result, programs are now being offered by the four institutions being reviewed in

this report (University of PNG, Pacific Adventist University, University of Goroka

and Divine Word University in Madang). A fifth program was planned to be re-

established at St Mary’s school of nursing in Vunapope but no significant progress

appears to have been made.

The care of women in pregnancy and birth is part of the core training for general

nurses in PNG and many nurses continue to provide this care to women. Therefore

many students (though not all) enter the midwifery program with significant

experience in normal birth and care in pregnancy. Hence, in PNG, midwifery has

always been seen as an extension of the role of the Registered Nurse. Internationally

there is a trend towards establishing a distinction between the nursing and midwifery


professions. This is because midwifery is often seen as unique and separate to nursing

with a philosophy of working with women in a social model of health that recognises

pregnancy and birth as a normal physiological event that should be kept separate to

the medical model of illness that dominates medical and nursing services. To this end

many countries have commenced a three year ‘direct entry’ education program for

midwives that is seen as a shorter route into midwifery undertaking nursing first and

then midwifery.

However, this is not so for all countries. In PNG the health centres in rural and remote

areas require a broader scope of practice than only midwifery. As 85% of PNG people

live in rural areas, it is unlikely that a direct entry midwifery program will be

considered for some time.

Post-registration education in Paediatrics has also been a long standing program in

PNG due to the high population numbers in this age group and the high levels of

childhood morbidity and mortality. Other specialty nursing programs apart from

Midwifery and Paediatrics include Acute Care Nursing, Nurse Education and Mental

Health. Midwifery and Child Health are recognised as important continuum and this

led to the two courses being formally combined two years ago in three of the four

institutions and are now offered as a Bachelors degree as a ‘double major’. Essentially

this resulted in two, one year programs being merged into one, one year program. As

the one year programs are offered within an academic year, the time spent is actually

only 40 weeks (although UOG run their program in 52 weeks). Three of the four

universities in PNG that offer midwifery now provide this ‘double major’ with only

the Lutheran School of Nursing at Madang maintaining a ‘midwifery only’ program.

Scope of Practice

Within the health care professions, a scope of practice generally refers to what health

care professionals are able to do. In PNG, there is a general acceptability on the

midwives scope of practice though it is not clearly documented. However, other

health workers such as Registered Nurses and Community Health Workers are

currently providing maternity care to pregnant and birthing women. Although the

scope of practice of these cadres of health workers was not reviewed, there was some


concern that they are working outside their scope of practice, particularly the CHWs.

Having clearly articulated scope of practice for all heath workers can:

• Provide guidance to practitioners and employers about what they can and

cannot expect of a practitioner;

• Form part of the regulatory framework;

• Be used to legally protect certain acts thereby limiting competition and

protecting professional interests;

• Inform the educational requirements and content of educational programs;

• Inform the way groups of health workers work; and,

• Assist policy makers and workforce planners in relation to models of service

delivery, workforce development and the allocating of health and educational

resources.

(WHO 2006)

Developing clarity about the scope of practice can also assist in identifying when

practice falls outside the traditional or accepted boundaries. Research undertaken in

the United Kingdom in relation to the scope of professional practice identified the

positive role that a defined scope of practice has to play in the nursing, midwifery and

visiting health professions (UKCC, 2000). The research identified that a scope of

practice provides a framework within which practitioners can justify what they are

able to do and identify what they are not in a position to do, due to a lack of skills or

knowledge, and how this may be remedied. The International Definition of the

Midwife has been used to guide the definition of the role and scope of practice

development and accreditation of education standards and registration or licensing in

many countries.

International Definition of a Midwife

The internationally accepted definition of a midwife is:

A midwife is a person who, having been regularly admitted to a midwifery

educational program, duly recognised in the country in which it is located, has

successfully completed the prescribed course of studies in midwifery and has

acquired the requisite qualifications to be registered and/or legally licensed to


practise midwifery. The midwife is recognised as a responsible and accountable

professional who works in partnership with women to give the necessary support,

care and advice during pregnancy, labour and the postpartum period, to conduct

births on the midwife’s own responsibility and to provide care for the newborn

and the infant. This care includes preventative measures, the promotion of

normal birth, the detection of complications in mother and child, the accessing of

medical care or other appropriate assistance and the carrying out of emergency

measures. The midwife has an important task in health counselling and

education, not only for the woman, but also within the family and the community.

This work should involve antenatal education and preparation for parenthood

and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals,

clinics or health units (ICM, 2005).

The PNG midwife appears to work within this definition, although the international

definition does not appear in any of the documentation reviewed. To assist in the

formal recognition of the role of the midwife and to strengthen the education

programs to prepare midwives, adopting the International Definition of a Midwife is

recommended.

Educational Facility Assessment

The environment where student-learning takes place plays an important role in the

effectiveness of education programs. For that reason, an ‘Education Facility

Assessment Tool’ (adapted from the WHO Midwifery Toolkit and provided in

Appendix 1) was used in a ‘walk through’ assessment of the educational

establishments that were visited. The tool was used to assess the training and

education facilities available for midwifery training, the resources available for the

midwifery teachers and the students, dormitory facilities, models and equipment,

library facilities and information technology infrastructure.

Findings across the four institutions are summarised in the table below.


Table 2: Education Facility Assessment

Criteria UPNG PAU LUTHERA

N UOG

Graduates produced in 2006 33 8 22 11

Offices for midwife teachers Yes Yes Yes NO

Computers for teachers Yes Yes Yes NO

Teachers experienced midwives with specialist

teaching preparation Yes Yes Yes Not all

Internet access for teachers Yes Yes NO NO

Adequate Classroom facilities Yes Yes Yes NO

Adequate IT facilities for students NO Yes Yes NO

Internet access for students Yes Yes NO NO

Adequate practice labs Yes Yes NO NO

Clinical laboratory with models available and

equipment NO Some Some NO

Accommodation for students Yes Yes Yes Yes

Formal Curriculum Committee Yes Yes Yes Yes

Adequate written information regarding course

given to students Yes Yes Yes NO

Multiple educational methods used Yes Yes Yes Yes

Formal mechanism for student complaints Yes Yes Yes Yes

Adequate library facilities Yes Yes Yes NO

Adequate access to midwifery texts NO Yes Yes NO

Clinical supervisors for all areas Yes Yes Yes Yes

Formal preparation for clinical supervisors Yes Yes Yes Yes

Adequate time spent with students in the

clinical area NO NO NO NO

Adequate security for students and staff Yes Yes Yes Yes

The education institutions were well equipped and 50% of midwifery teachers had

education and Masters Qualifications. Lutheran and PAU have computer facilities for

students, and UPNG will soon have their computers installed. UOG had poor

computer access for both students and staff. Internet access both for teachers and

students was available in PAU and UPNG. At the Lutheran School of Nursing, staff


and students were required to travel to the Divine Word University and pay for

internet access. UOG students had no internet access and had to pay for private word

processing for typing their assignments.

Classrooms were of adequate size and well ventilated though lacked the necessary

equipment to provide lectures using ‘powerpoint’ presentations, relying instead of

overhead projectors and paper based handouts. To encourage regular updating of

materials and suitable medium for guest lecturers (usually doctors) the use of

‘powerpoint’ is recommended and will save the institutions time and money in

resource production.

Library facilities appeared adequate, with the exception of UOG, although many of

the text books were older than 10 years. Electronic resources did not appear to be

utilised effectively in any of the institutions visited. There are now a number of

databases and electronic resources available free of charge to resource-poor countries

such as PNG. Library and education staff should be encouraged to access these

services. Band Width is poor in PNG resulting in slow download time but many

resources are also available on CD Rom and could be uploaded to university servers

and networked to staff and student computers, negating the need for high-speed

technology.

The need for more training aids and mannequins was recognised with some

universities (UPNG and UOG) having no training models and others not utlising the

models they had effectively. Lack of airconditioning in some of the rooms led to rapid

deterioration of some of the models.

The resources available for the maternal and child health program at UOG were

significantly less than other institutions. Although the facilities at UOG appeared

satisfactory, the teachers of the maternal child health program are situated off campus

in converted rooms within the accommodation dormitories at the Goroka Hospital.

The facilities here included a small office, inadequate to house the three teachers

allocated to use it, a small storeroom and a classroom with the capacity to

accommodate approximately 15 people and insufficient for the 24 students currently

enrolled. These rooms had no power for several months this year, is poorly ventilated


and not an ideal environment for either teaching or learning. The staff reported,

however, that next year they will be relocating to the main UOG campus and this

situation should be remedied.

Recommendations for Midwifery Facilities

The midwifery training institutions can be strengthened by:

1. Increasing the amount of mannequin (models) for practical training, particularly

for life saving skills such as manual removal of the placenta, PPH and neonatal

resuscitation.

2. Ensuring the appointment of midwifery teachers who are both academically and

clinically competent midwives.

3. Ensuring computer and internet access for staff and students.

4. The use of powerpoint to be available for teaching within the facilities.

Teachers of the Midwifery Education Program

High quality midwifery education can only be achieved by having sufficient well-

prepared midwife teachers. It is essential that midwifery teachers not only have good

academic ability, but are also experienced and competent clinical midwives. In order

to maintain their clinical skills they should spend regular and frequent periods

working with and supervising students in clinical practice.

Midwife teachers require an in-depth knowledge of evidence-based midwifery, both

theory and practice, and should also ideally be capable of conducting their own

research. The midwife teachers also need a good knowledge of the principles and

practice of education and to be comfortable with, and committed to, modern,

participative approaches to adult education, because it is widely accepted that these

are most effective. Broadly this means adopting a student-centred, rather than a

teacher-centred approach to education and using a range of teaching and learning

methods which encourage students to be actively involved in their own learning.

Midwife teachers also need opportunities for ongoing professional development on a

regular basis to enable them to keep up-to-date in both midwifery and education if

they are to maximise their effectiveness and maintain their interest and enthusiasm.

Teachers should also be aware of international initiatives, guidelines, education


documents and resolutions related to maternal child health and reproductive health

issues.

Overall the academic quality of the midwifery teachers in the four institutions

reviewed was high with approximately half of the teachers holding masters level

awards. It was noted that UOG utilised teaching staff who were not midwives (only

one of the three core teachers used on the program had some experience as a midwife

and she did not commence employment until 8 months into the first program). Whilst

most of the other institutions used experienced midwives with clinical experience,

some had not practiced for some years and were not considered clinically competent

by some of the key informants in the health services area (see also Stakeholder

results, Section 3 and Student midwives, Section 5).

Furthermore there was lack of evidence to reassure the review team that the midwife

teachers were up to date on many of the latest evidence regarding the treatment or

management of many of the life threatening conditions women face in PNG. It was

noted in the subject outlines (when provided) and by verbal reports from education

staff, that doctors were used to deliver lectures around complications of pregnancy

and labour, such as pre-eclampsia. Whilst the use of doctors to provide midwifery

lectures is at times appropriate, midwife teachers should also be competent to teach

these subjects.

The World Health Organization prepares a large quantity of literature related to

reproductive health that is very helpful for teaching and learning purposes. Education

materials produced which are suitable for midwives include: The Midwifery Toolkit,

The Safe Motherhood Initiative, WHO’s Making Pregnancy Safer Initiative, The

Millennium Declaration and the Millennium Development Goals (MDGs), WHO’s

`The Mother-Baby Package’, WHO `Midwifery Education Modules for Safe

Motherhood’, various international declarations and commitments especially those

produced by the International Confederation of Midwives (ICM) and many others.

All teachers of midwifery programs across the four institutions were asked to

complete a ‘Midwife Teacher Questionnaire’, (see Appendix 2) that was based on the

Midwifery Toolkit questionnaire, developed and validated in similar countries.


The teachers were asked to provide information on their: age; qualifications, previous

experience, reasons for being a midwife and a midwifery teacher; if they believe

midwives should conduct clinical midwifery; and three things that would assist them

to be more effective in their positions.

A total of 13 teachers completed the questionnaire from a total pool of 16 teachers.

Results showed the mean age of the midwifery teachers throughout the four

institutions was 44 years old with an age range of 30-58 years. Approximately 50% of

the teachers surveyed had post graduate teaching qualifications and were also

prepared at Masters level. Most of the teachers were registered midwives (81%). A

summary of the educational qualifications of the midwife teachers is provided in the

table below.

Table 3: Educational qualifications of midwife teachers

Institution Total surveyed Midwife Education

qualifications Masters level

UPNG 6/6 5/6 4/6 4/6

PAU 3/5 3/3 1/3 1/3

Lutheran 2/2 2/2 2/2 2/2

UOG 2/3 1/2 0/2 0/2

Total 13/16 (81%) 11/13 (85%) 7/13 (54%) 7/13 (54%)

All respondents believed it was essential for midwifery educators to conduct clinical

practice and most planned to still be teaching in five years if they had not retired. Self

identified strategies to enhance their effectiveness as teachers in midwifery included:

• More staff or resources (including midwifery text books)

• More time in the clinical areas

• Closer relationships with clinical staff

• More opportunities for professional development

• More opportunities to do research

• IT support such as powerpoint presentations and internet access

• Separate midwifery and paediatric streams


• Improved communications with Nursing Council to ensure rapid registration

of graduates.

The teachers were also asked to identify if they considered themselves experienced in

a number of skills and knowledge necessary to effectively prepare students for

practice. A full list is provided in Appendix 2 and covered the skills to effectively

teach designed under the following headings: clinical practice, research, teaching

methodologies, assessment, documentation; computer and internet skills to access

information; management; communication; and, intercultural competence.

Of the 13 midwifery teachers who completed the questionnaire, the respondents

indicated that they were experienced in most of the 29 indicators. Some of the areas

that were reported as being ‘unsure’ included: managing birth in a home setting;

national legislation on record keeping; educational management theories, curriculum

evaluation, vacuum extraction; listening techniques; and, cultural taboos and customs

in different communities or countries.

However, the review team found limited evidence to support this self-reported high

level of knowledge in some areas, particularly in maternity and neonatal emergencies.

Recommendations for Midwifery Teachers

Increasing the capacity of the midwifery teachers can be achieved through:

1. Ensuring teachers are up to date in both theory and clinical practice Upskilling in

these areas could be achieved through a one week Regional Credentialling

Program (available through WHO).

2. Increasing time spent by teachers in the clinical areas providing clinical

supervision.

3. Utilising electronic resources and international literature more effectively.

4. Ensure teachers are also expert clinicians with continuous access to clinical

practice through student supervision (providing opportunities to upskill for those

who are not currently clinically competent). This requires all teachers offering

clinical supervision to be registered midwives.

Each midwifery program will now be discussed individually.


Program Reviews

University Of Papua New Guinea

UPNG commenced tertiary based midwifery education in 2002 with the combined

‘double major’ in midwifery and paediatrics commencing in 2005. Documents

produced for the review comprised the curriculum for the 2002 program with a course

timetable and subject outlines provided for each of the units provided in the new

course.

The UPNG curriculum is situated within a document that encompasses all other post-

registration courses offered by the school including Acute Care Nursing and Mental

Health. It therefore lacks any specific attention to the philosophy of midwifery or

context in which midwifery services are offered to women and their families within

PNG.

Although each subject outline is reasonably comprehensive and provides aims,

objectives, contents, semester timetable, assessment details and clinical competencies

where relevant, the overarching framework of the curriculum is limited. It includes an

overall aim of the Bachelor of Clinical Practice (encompassing the specialist streams

of midwifery/paediatrics, mental health and acute care nursing), but does not include

an educational philosophy, program aims or other key program information.

The theoretical component is comprised of eight, seven week subjects of six hours per

subject per week. Subjects are listed in the table below:


Table 4: Theoretical Subjects at UPNG

Semester One Semester Two

Applied Research in Nursing (Core*)

Nursing Ethics and Legal Aspects (Core*)

Nursing Management and Leadership Skills

(Core*)

Community Assessment and Rural Health

Field Practice (Specialist^)

Antenatal Care and Reproductive Health

(Specialist^)

Paediatric and Neonatal Nursing (Specialist^)

Child Health (Specialist^)

Labour management and Postpartum Care

(Specialist^)

*Core subjects indicate subjects shared by other specialist strands and are not specific to

midwifery. ^ Specialist subjects indicate those speciality subjects unique to the midwifery

program.

Given that three of the eight units are generic subjects, the theoretical time dedicated

to midwifery is reduced to 210 hours. This is equivalent to 6 weeks at 35 hours per

week. The WHO curriculum recommends 8 units or modules that cover the life-cycle

of the woman and includes care of the child up to five years of age. Whilst the

importance of topics such as research and ethics are not discounted, these aspects

would be more useful if embedded within midwifery subjects as provided in the

WHO modules.

The practical component of the program consisted of 20 weeks (35 hours per week): 5

weeks in a rural facility and 15 weeks in a hospital or urban health facility. This

results in a theory/clinical ratio of 50:50. However students on the program reported

that many of them did not have this much time in the clinical area but the review team

were unable to determine the reasons some students appeared to get more clinical

time than others. Furthermore, due to the merger of the paediatric and midwifery

programs, much of the clinical time was spent in paediatric areas such as Children’s

Outpatients department and the Children’s Ward (see Student midwives, Section 5)

which restricted the available time they had to spend in midwifery areas.


Pacific Adventist University

PAU has offered a four year Bachelor in Health Sciences since 2004 with the

Maternal and Child Health Nursing stream being first offered 2005. The first three

years are offered as a Diploma of Nursing as undergraduate preparation for general

nurses with the fourth year offering specialist streams in Maternal and Child Health

Nursing, Rural and Community Health, and Acute Care Nursing. As with the UPNG

program, midwifery is offered in a ‘double major’ format with a combination of

midwifery and paediatric streams. Registered Nurses are admitted to the fourth year

of the bachelor if they have a existing diploma or degree. This excludes nurses who

were educated in the hospital system, unlike the other three institutions who accepts

these applicants. Although PAU has the capacity to admit 15 students in the Maternal

Child Health Stream they have only been able to attract 7 students in 2005 and 8

students in 2006. The criteria for applicants to hold a existing diploma may limit the

numbers of students PAU can attract to their midwifery program.

Students are required to complete 10 subjects including two relevant electives drawn

from fourth year nursing subjects or acceptable subjects from other disciplines of the

University. The subjects of the Maternal Child Health stream are presented in the

Table 6 below.

Table 5: Theoretical Subjects at PAU


Advanced Paediatrics I (Specialist) Advanced Paediatrics II (Specialist)

Advanced Obstetrics I (Specialist) Advanced Obstetrics II (Specialist)

Theories of Nursing (Core) Health Care Management and Organisation

(Core)

Parish Nursing (Core) Family Health Nursing (Core)

Elective Elective

As in the UPNG program, much of the theoretical component of the program is not

specific to midwifery or child health. A breakdown of the theoretical hours per subject

was not provided. Total theory as recorded in the curriculum document is 569 hours,

equivalent to 16 weeks (in 35 hour weeks) over the two semester program. This


includes lectures and tutorials. An additional 682 hours (equivalent to 18.5 weeks of

37 hour weeks) is spent in the specialty clinical areas of midwifery and child health

and 74 hours (2 weeks) in management.

Practical experience is obtained 2 days per week in the academic semester and a

further 8 week clinical block between semester one and two and 4 weeks at the end of

semester two. The program takes a total of 40 weeks to complete. This calculates to a

theory clinical ratio of 50:50.

The PAU midwifery curriculum is embedded within the four year bachelor degree

comprised of the three year undergraduate diploma and the fourth year of speciality

streams. It is therefore difficult to identify a specific midwifery philosophy or context.

Lutheran School of Nursing, Divine Word University, Madang

The Lutheran School of Nursing developed a midwifery course in 2003 and have just

completed their third year of the midwifery program producing approximately 20-22

graduates per year since 2004. The 40 week program runs over one academic year but

unlike the other three midwifery programs in PNG, this one does not combine

paediatrics and is only focused on maternal and newborn care.

Temporary approval to run the program was granted from the Nursing Council.

However, further clarification regarding some aspects of the curriculum were

delivered to the Lutheran School. The School addressed each of these issues in a reply

to the Council. However, further response has not been forthcoming despite frequent

requests by the School including making appointments with the Council when visiting

Port Moresby.

Staff at the Lutheran school reported significant concerns over the inability to achieve

registration by the Nursing Council for graduates of both the three year diploma

nursing program and the midwifery program. Despite attempts to determine the

requirements of the Nursing Council to achieve registration for its graduates, and the

development of materials specific to these requirements (such as a ‘clinical portfolio

for each student), no graduate has been registered from either program since 2004.


Overall the Lutheran School curriculum is more contemporary that the others

reviewed. Although it does not state to support the international definition of a

midwife, it clearly articulates a comprehensive model of midwifery care that

incorporates women’s centred care, working in partnership with women and working

under the principles of primary health care. It also incorporated contemporary

teaching and learning styles such as the use of case studies and research activities in

the area of maternal and child health.

Furthermore, unlike the other programs reviewed, this course offers each subject that

is situated within a midwifery context. The subjects in the midwifery program are

listed below in table 5.

Table 6: Theoretical Subjects at Lutheran School of Nursing


Foundation Studies Promoting Health through education and

research

Christian and socio-cultural factors and their

impact on health Clinical leadership and management

Foundations in midwifery Advanced Midwifery

The neonate Community midwifery and women’s health

issues

The only additional subject area that would compliment the Lutheran program and

assist the new graduates provide more effective care to women and children in PNG

would be to incorporate some topic areas that address growth and development and

common childhood illnesses for children up to five years of age. The incorporation of

some child health that is community focused (not hospital) is supported by the WHO

curriculum.

Clinical experience is gained over 20 weeks, delivered in two 10 week blocks in the

latter part of each semester. A total of 14 weeks of this time is spent in labour ward,

unlike the small amounts of time other students receive from other institutions. Unlike

the PAU and UPNG students, Lutheran students are not required to spend time in


rural health centres. The rationale given for this was that the students were mostly

from rural health centres and had extensive experience in this context. It was believed

that it was more important for the students to gain clinical experience in hospitals

under the supervision and expertise of senior midwifery and medical staff.

Students are provided with a detailed logbook to record their clinical activities.

Although the students are only required to sign off up to five episodes of many of the

competencies, staff encouraged them to achieve many more. The competencies were

well linked to the Midwifery Competencies released by the Nursing Council in 2003.

The Lutheran School currently support two fulltime midwifery teachers. These

teachers visit the students on a daily basis in the clinical areas, however did not work

continually with these students at this time, relying on staff in the clinical areas to

provide this. Students are placed in a number of hospitals around the area in an

attempt to more adequately spread the placement of student midwives across the area

and decrease the demands the students would place on midwifery staff in the Modilon

Hospital in Madang.

The entry criteria for entrance into the midwifery program was as a Registered Nurse

licensed with the Nursing Council and a 1000 word essay outlining why they wanted

to become a midwife and also demonstrating adequate writing skills.

Lutheran School staff spoke highly of their program and believed it produced high

quality graduates. Whilst the amount of time in clinical practice was considered better

than most of the other programs in PNG, they reported that they were considering

increasing the time of the program to 18 months to further consolidate clinical skills.

They discussed increasing the student numbers to 40 from the 22 they currently

accepted and believed they had the accommodation and classroom infrastructure to

support this increase. However they believed they would require additional teaching

staff, particularly in the area of clinical supervision. This would result in one intake

every two years with the students completing after 18 months and the next six months

of the calendar year being spent on material revision and development.


The facilities of the School were adequate with a large classroom and adequate library

resources for a country with limited resources. A computer laboratory of 25

computers provided student with good computer access. However these computers

were not connected to the internet and students and staff were required to visit the

Divine Word University in Madang to access Internet facilities at a cost of K15 per

hour of use.

University of Goroka

In 2004 UOG began to develop an 18 month ‘double major’ in maternal child health

as a post graduate diploma. However this required applicants to hold an existing

bachelor’s degree and when it became apparent that there would be insufficient

numbers with such a qualification the program was altered to become a 12 month

Bachelor in Clinical Maternal and Child Health. This would allow hospital trained

nurses to be eligible to apply and thus increase student numbers.

The 12 month Bachelor in Clinical Maternal and Child Health was first offered in

September 2005, with the first intake of 11 students completing the program in

September 2006. In addition, a further 24 students commenced a second program in

July 2006 and a third intake is expected to commence in January 2007.

A copy of the curriculum document was sent to the Nursing Council in December

2005 but as yet (December 2006) no further correspondence has been received from

the Nursing Council. Therefore formal approval to run the course has not been given;

however, NDoH instructed GOH to proceed with the program.

The UOG program is a 52 week program, providing significantly more time than the

other ‘one year’ programs that are in fact only 40 weeks. However a total of 16 weeks

of the UOG program consists of the training of village volunteers in child health (8

weeks) and maternal health (8 weeks). At the beginning of the program, each student

is appointed a village volunteer who comes into Goroka and undertakes training, by

the student (who is prepared for this teaching role prior to them coming) in both

maternal and child health. Each student then spends two, four week clinical blocks in

the volunteers’ village where they work in partnership with the volunteer. The student

undertakes a situational analysis of the village and attends community development


activities to strengthen community functioning. Students, volunteers and university

staff visit each family in the home and undertake a full assessment. However they do

not have access to any resources or medical supplies such as blood pressure machines

or drugs. They therefore refer any resident to the nearest health facility should they

detect a problem requiring further care. This component of the UOG program

provides a much stronger focus on community and primary health care than the other

training institutions in midwifery. However, their effectiveness could be strengthened

if they were given access to basic medical equipment and supplies. Regardless of this

the students gain a much greater insight into some of the causes of ill health as well as

the community benefiting from health assessment, education and promotion. UOG is

commended for developing this innovative model and it is recommended that it be

considered by other institutions. However this placement is provided at a cost of

reduced clinical time in the hospital.

Many of the first intake of students were hospital-based, and were experienced

clinicians in their relevant specialist field (midwifery or paediatrics). This could have

been a strategy to upgrade hospital staff initially to provide appropriate levels of

leadership for subsequent student intakes. It appears the subsequent intakes of

students will comprise a higher percentage of rural nurses.

The theoretical component of the program offers twelve subjects summarised in the

table below. Of these 12 subjects only four of these subjects are specific to midwifery

and the theoretical hours allocated to each subject was not provided.


Table 7: Theoretical subjects in UOG program


Foundations in Child Health Foundations in Maternal Health

Advanced Child Health Advanced Maternal Health

Professional Issues in health care Health Research

English for post vocational training Academic Writing

Communication in health care Community/Rural/Urban maternal health

issues

Community/Rural/Urban child health issues Neonatal

Clinical time in the hospital consists of two weeks of clinical placement every month,

except when the students are placed in the rural village for a total of eight weeks. The

clinical time in the hospital is divided between labour ward, postnatal ward, antenatal

clinic, special care nursery, family planning clinic, HIV ward, childrens’ outpatients,

and children’s ward. The child health placements are provided in the first semester

with the maternal health ones occurring in the second semester. A clinical timetable

was provided to the review team and it was calculated that each student receives

approximately only three weeks in labour ward. The staff reported that depending on

the needs of the students, this timetable is flexible and students can be moved to areas

where more experience is required. It still appears the amount of time in labour ward

remains inadequate. Improved exposure to labour ward could be achieved by

decreasing the time spent in other areas, such as SCN, children’s outpatients, and

children’s wards.

It was also suggested to staff that given that most maternal and childhood mortality

occurs in pregnancy, birth or within the first 28 days, that the maternity component of

the program extend longer than 6 months by reducing the total time in paediatrics or

increasing the overall length of the program. Similarly, whilst the village volunteer

training and residential component is considered to be an innovative and important

component of the program, the time allocated to these activities could be reduced

from 16 to 8 weeks and would still retain its usefulness.


At the time of the review, the current intake of 24 students were only halfway through

their program and there is an additional intake of up to 40 students commencing in

January. There is significant concern that there are insufficient resources provided in

the program to adequately support this large number of students, particularly for

clinical and village placement. Clinical placement is currently only provided through

the Goroka Base Hospital and with the large increase in student numbers anticipated,

other hospitals will need to be approached to provide clinical placement, though this

will be reliant on appropriate clinical supervision being available.

Distance education

Currently UPNG is developing a midwifery program that is appropriate for distance

mode of delivery. This would result in students in rural areas being able to undertake

the midwifery program with access to local hospitals for clinical supervision.

However for such a model to be successful, local hospitals must have the capacity to

support students in the clinical area, including specific preparation for clinicians to

support students. This could be possible through the preceptor program currently

available through NDoH. It is also recommended that if distance programs are to be

available, that students travel to the university offering the program for a minimum of

one week intensive block in each semester of study.

Curriculum Analyses

The program of education for midwives must prepare midwives who are competent to

practise to an agreed, or understood, scope of practice. The Midwifery Toolkit

developed by WHO includes a generic curriculum which translates the international

definition of a midwife into an education program which can be adapted for use in

any country. A number of other documents underpin this curriculum including the

WHO Mother-Baby Package (WHO), the ICM core competencies (ICM, 1999a), the

ICM Code of Ethics for Midwives (ICM, 1999b) and the other documents in the

Strengthening Midwifery Toolkit. The curriculum outlined in the Toolkit identifies

the essential bases for practice, irrespective of how midwifery education is offered in

a country’s educational system: whether as direct entry, as part of a nursing program,

or post-basic program following nursing (WHO, 2006b).


The WHO curriculum has clear minimum requirements for clinical experience in

midwifery programs. This is considered one of the most important aspects of

midwifery education to ensure that the students develop into competent practitioners

on completion of the program.

An analysis of the four midwifery curricula was undertaken. Comparisons were made

with the curriculum that is outlined in the Midwifery Toolkit: Developing a

Midwifery Curriculum for Safe Motherhood (WHO 2006).

A summary of the curricula for all four institutions providing midwifery education is

provided in the table below


Table 8: Curriculum Evaluation

Criteria UPNG PAU LUTHERAN UOG

The curriculum has been reviewed and revised in

the last five years Yes Yes Yes Yes

Minimum entry requirement (for post registration)

courses) is: Registration or Licence to practice

nursing, good health, commitment to women’s

health

Yes NO Yes Yes

Teacher student ratio has been agreed and conform

to national norms Yes Yes Yes Yes

The curriculum is approved by the Midwifery

Regulatory Authority NO Yes Yes

Not

form

al

The curriculum is delivered in, or has the approval

of an appropriate educational body/institution Yes Yes Yes Yes

The curriculum is at the educational level

equivalent to the curriculum of other health care

practitioners

Yes Yes Yes Yes

The curriculum is based on sound educational

theories of adult learning that fosters the critical

thinking and problem solving of students

?? ?? Yes Yes

The curriculum has a clear philosophy of

midwifery that values midwives working with

women in a partnership and recognising that

childbirth is a natural life event for most women

NO NO Yes Yes

The curriculum is organised to ensure students can

link theory to practice. Practice placements allow

them to practice what they have been taught in the

classroom

Yes Yes Yes Yes

The curriculum is lead by an experienced midwife

teacher who has a background in midwifery and

has been trained as a teacher

Yes Yes Yes NO

Teaching and learning resources are adequate and

expose students to recent research findings Yes Yes Yes NO


Students have opportunities to practice in the

clinical area under the direct supervision of an

experienced midwife and have their practice

assessed

Not consistently – students often attend

normal births unsupervised

On completion of the education program midwives

are able to practice as autonomous/self directing

practitioners (able to practice as outline in the

International definition of a midwife)

NO NO Yes NO


are able to practice as a fully participating member

of a multi-disciplinary team

Yes Yes Yes Yes


are able to provide midwifery care in any setting,

community, clinic, health facility hospital or home

NO NO Yes NO


are able to provide all essential life saving skills to

both women and the newborn

NO NO NO NO

All assessments are clearly identified in the

curriculum and assessment points are known to the

students

Yes Yes Yes NO

Clear criteria has been set for all theory and clinical

assessments Yes Yes Yes Yes

All assessors, including clinical assessors have

been specially prepared for their role

Clinical midwives are often used to assess

students and most have not undertaken

preceptor training.

The curriculum has a clear and transparent Quality

Assurance mechanisms, students able to give

feedback to teachers

Yes Yes Yes Yes

Student records ensure that individual progress can

be tracked throughout the program. Yes Yes Yes Yes

* required but approval by the Nursing Council has not been obtained

Discrepancies against any of the items listed in the above table will now be further

elaborated.


Entry Criteria

The entry criteria for admission to the midwifery programs was not consistent over

the four institutions. PAU required nurses with hospital based certificates to upgrade

to a diploma level prior to admission and the other three accepted hospital trained

nurses but required 2-3 years experience as a registered nurse, some with experience

in the specialty area. This is not supported by international recommendations which

state that registered nurses need only be in good health and demonstrate a

commitment to the area of women’s health.

Approval by Regulatory Authority

Although it is a requirement for all midwifery and nursing programs in PNG to be

approved by the regulatory authority, the Nursing Council, the UPNG curriculum has

not been submitted for approval by the Nursing Council. UOG submitted their

curriculum over twelve months ago but have not received formal approval to provide

the program. There appears to be considerable tension between UPNG and the

Nursing Council with the UPNG staff reporting that the Council was involved in all

advisory bodies overseeing the curriculum development, and the Council reporting

that UPNG has failed to answer numerous written requests for document submission.

The other institutions claim that they have attempted to provide the necessary

information to the Nursing Council to facilitate the process of their students receiving

registration, but claim lack of communication from the Council and ongoing problems

with their students receiving registration. The consequences of this communication

breakdown is that graduates from all midwifery programs over the past several years

(the exact number was unable to be determined) are currently practicing without

registration. These issues will be further discussed in Section 7 on Regulation.

Educational Theories and Critical Thinking

Although all of the curricula reviewed documented a range of teaching and learning

strategies and principles of adult learning and problem based learning, it was difficult

to establish how effective these strategies were to develop critical thinking and

reflective practice. On discussions with clinical midwives and graduates of the

programs, clinical practise appears to remain task oriented. Stakeholders reported that

early identification of complications were often not optimal. Critical thinking allows

clinicians to more appropriately identify risk factors and early deviations of normality


and can be promoted in education programs through the use of case studies, role

plays, case review and case management.

Midwifery Philosophy

Two of the four curricula reviewed (UPNG and PAU) situated their midwifery

programs within general nursing curricula. This fails to specify the unique role of

midwives in line with the international definition of the midwife. Fundamental to

midwifery practice is the relationship the midwife has with the woman, which should

be based on partnership, to ensure the well being of the childbearing woman and her

baby. To do this, midwives must believe in the woman’s ability to assume

responsibility for her health and that of her families and through partnership become

more empowered. This professional ethos is often seen separate to nursing

philosophies, which is often situated within an ill-health model of curative care.

Clinical Supervision

Although all institutions reported sending their teachers to the clinical field to

supervise students, this appeared to be in an ‘adhoc’ manner in most placements,

although PAU appeared the most formalised. It is acknowledged that at some

institutions there are insufficient numbers of education staff to be with all students at

all times. However there was a concern that most of the normal births the students

were conducting, were done so unsupervised by any staff, clinical midwife or

education staff.

Ability to Practice Autonomously, in any Setting, with Life Saving Skills

With 85% of people in PNG living in the rural areas, many graduates will return to

work in these areas, often as the most senior clinician in maternity. Many of the

students were proficient at normal pregnancy and birth prior to entry to these

programs. The greatest need of the programs is to prepare the students to deal with the

complications that may arise, and the review team felt this was not achieved

consistently across the four institutions, particularly the combined midwifery and

paediatric programs.


Clinical Assessors

Student midwives rely on clinical midwives to assist in supervision, teaching and

assessment. The NDoH has developed a training package on Preceptor training and

ran a number of courses in 2005. Some of the staff working in the facilities had

undergone this training, though most had not. There appeared to be some problems

with accrediting this program and hence no training was offered in 2006. It is believed

that approval has now been given to run the program and it is hoped that it will

recommence training in 2007 which will assist health staff in clinical teaching,

mentoring and assessment.

Comparisons with PNG programs and International standards

A further summary of the four programs, measured against international standards is

provided in the table below.


Table 9: Comparisons between the four curricula and WHO International Standards

Criteria International

Standard UPNG PAU

Lutheran School of Nursing,

Madang University of Goroka

Length of

program (post

registration)

Minimum of

18 months or

78 weeks

40 weeks with 3

weeks holiday

(double major)

40 weeks with one

weeks holiday

(double major)

40 weeks with two weeks holiday

(midwifery only)

52 weeks with 3 weeks holiday (double

major)

Ratio Theory :

Practice 40% : 60% 50% : 50% 50% : 50% 50% : 50% 40% : 60%

Curriculum

model

Competency-

based,

evidence based

practice, with

foundation in

Primary Health

Care

Competency-

based, philosophy

not stated

Competency-based,

nursing philosophy,

Christian values

Competency-based, midwifery

philosophy, primary health care,

health promotion

Competency-based, primary health care,

health promotion

Minimum no.

births 20 (ideal 40 +)

Verbally told 10

but space for 3

assessments in

clinical logbook

Space to record six

in clinical logbook

5 minimum though space to

record 45 in clinical logbook. Not provided to review team


Clinical Practice

Although all four programs report using competencies to assess students’ clinical

skills, specific information regarding what competencies were required varied. No

program reflected a comprehensive list of all essential skills and knowledge required

to provide safe, high quality care to women and their families.

The International Confederation of Midwives in partnership with WHO have prepared

recommended midwifery competencies and the skills needed to achieve these

competencies. These competencies articulate the skills and knowledge that midwives

require in order to provide safe, effective care in pregnancy, childbirth and the

postnatal period for care of mothers and newborns, and include the knowledge and

skills necessary to achieve them. The skills have been divided into basic and the

essential life-saving skills which are essential if the midwife is to make a difference to

the outcome of pregnancy and childbirth to promote Safe Motherhood and make

pregnancy and childbirth safer.

These essential competencies also provide useful guidelines for those responsible for

the education and training of midwives/midwifery practitioners. They also provide

information for those in government and other policy arenas who need a deeper

understanding of exactly what a midwife does and the education and training required

to enable midwives fulfil their role.

The competencies, which form the basis for good practice, are grounded in current

research, where it is available. They are generic and need to be adapted within

countries or regions to meet local realities and to correspond with new evidence as it

emerges.

Clinical assessments in the four institutions are based on the PNG Midwifery

Competencies. With the exception of the Lutheran School of Nursing, the competency

checklists and performance criteria are relatively reductionist, with little evidence of

integrating the competencies into practice-based skills or performance cues. Three of

the four institutions did not provide their students with a comprehensive clinical

logbook. The Lutheran School of Nursing was the exception and provided a good

example of a clinical logbook with useful cues or examples listed against the broader


midwifery competency statements. Although the Lutheran School was the most

useful, and could be used as a template for all institutions, the overall numbers of

most clinical requirements also need increasing in line with WHO recommendations.

Adequate time in the clinical area is essential if student midwives are able to practice

effectively following completion of their education program. Although the time

allocated for clinical practice was between 50 and 60% of the overall program, the

time is spent across paediatrics and midwifery and is generally insufficient. There

were no minimum time requirements for each area of practice and some students

spent only one week in labour ward over the entire program (see Section 5 for more

information). Curriculum documents provided by the four institutions failed to

provide detailed information regarding the amount of time spent in individual clinical

areas. However it was determined that time spent in key areas such as labour ward

was inadequate.

It is most important that students become competent in life-saving skills. Ensuring the

students are competent in these skills is critical for all midwifery graduates but

particularly those who will return to practice in district hospitals and rural health

centres. Overall the development of skills in complications and maternity and

newborn emergencies was grossly insufficient. More information on clinical

competence is provided in Sections 5 and 6.

WHO have developed an outline on the minimal amount of clinical experience

students should gain throughout the program. Some of these include:

• A minimum of 100 antenatal examinations.

• A minimum of 40 normal deliveries.

• Assist at 3 breech deliveries.

• Conduct a minimum of 3 vacuum extractions, under supervision.

• Perform at least one medio-lateral episiotomy.

• Perineal suturing on at least 3 women.

• Assess the condition of the newborn at birth and resuscitate, as required.


• Examine 100 newborn babies, noting any abnormal conditions, and take

appropriate and timely action.

• A minimum of 100 postnatal examinations, identify any abnormal signs or

symptoms and take appropriate and timely action.

• Care for at least 100 postnatal women and their newborn infants, giving

appropriate health education and advice, and providing the support, midwifery

care and prophylactic treatments which are required.

• Assist mothers with breast feeding, as appropriate, and give correct advice and

care to women who develop breast problems.

• Give emergency care, under supervision, to women with obstetric and

gynaecological problems, eg abortion, ectopic pregnancy, ante and postpartum

haemorrhage, prolonged, pre-labour rupture of the membranes, obstructed

labour, retained placenta, eclamptic fits, puerperal sepsis.

• Management of shock.

• Cardio-pulmonary resuscitation on a model.

• Resuscitation of the newborn, first observation, then assistance and finally

practice, under supervision.

• Liaise with the community in order to have an effective system to ensure that

rapid referral is possible when complications occur and to make arrangements

for referral, when required.

• Liaise with the community to give information about the health services which

are available and devise and implement strategies to increase the uptake of

care by a skilled attendant.

• Provide health education in the community and first level health facilities to

pregnant women, families and to adolescents, with emphasis on good

nutrition, healthy life-styles, immunizations, the avoidance of harmful

practices, the prevention of sexually transmitted diseases and unwanted

pregnancies.

• Liaise with schools, churches, mosques, women’s groups and places of

employment to provide appropriate health education.

• Provide information and counselling on safe sex and contraceptives at family

planning clinics and provide women with the method of their choice and

follow-up care.


• Perform appropriate screening tests and give appropriate prophylactic

treatments and/or immunizations, as required, e.g. for STIs, tetanus toxoid,

anti-malarials, mebendazole, vitamin A if in deficient areas, iron/folate.

• Liaise with other health care professionals in the community to monitor the

health and well being of mothers and their infants, the uptake of care and

devise strategies together to further improve the quality and uptake of care and

health facilities.

• Liaise with traditional birth attendants, spiritual healers and other untrained

personnel in the community who are involved in care before, during or after

childbirth in order to encourage safe practices, the acceptance of training

opportunities where they exist, information on the early recognition of

complications and the promotion of early referral when complications arise.

It is clear that a number of these skills are not provided in the PNG programs. This

outline should only be used as a guide, but should include the minimum where

numbers are stipulated. In skills such as breech or vacuum, PNG may consider

increasing these numbers as many midwives will work in facilities where they will be

the most skilled provider of maternity services and higher level skills in complications

such as breech, manual removal and vacuum are required.

Some of the staff and students who participated in this review stated that it was

difficult for students to access large numbers of births, particularly those with

complications. However, the rostering of students in clinical areas often did not

include night duty or weekends, though some students did make themselves available

at these times. Improved access to the development of essential skills in maternity

emergencies could be enhanced by more creative placement of students that included

all shifts, including weekends and nights, and accessing other hospitals throughout

PNG.

Once the minimum number of births is determined, they should be included in

Nursing Council guidelines and students who fail to meet these requirements will not

be permitted to graduate until all skills are attained to the level of competent practice.

A record of these skills needs to be included in each student’s clinical logbook.


Combining Midwifery with Paediatrics

As seen in this review, PNG has seen a recent trend to combine midwifery training

with paediatrics. Whilst the overlap of these two areas is recognised, it is unlikely that

competence would be gained in either area in the current time frame of 40-52 weeks.

Many of the stakeholders and key informants supported the notion of the combined

program, particularly for those staff working in the rural areas. However, some

informants recognised the clear shortcomings of the current structure and supported

the reestablishment of two distinct programs.

A significant number of students in the combined paediatrics and midwifery

programs, particularly in the UPNG and UOG programs, were hospital based

paediatric nurses. As such many had minimal experience as a registered nurse in

maternity services. Their motivation to do the programs was not to become midwives,

but rather to advance their skills in paediatrics. These students appeared much less

competent to perform as midwives on completion of the program, though they no

doubt increased their capacity as paediatric nurses. These nurses mostly returned to

the paediatric areas in the hospital. Therefore targeting this part of the workforce to do

the programs will do little to address the midwifery shortage in PNG.

The WHO recommends that midwifery curriculum includes a child health component

with the following subject headings

• Monitor nutritional status, growth and development

• Screening and developmental tests

• Nutrition of the young child, including weaning and food supplements

• Failure to thrive

• Signs of infection or illness

• Immunizations and other prophylactic treatments recommended for child 0to 5

years

• Advice given to mothers on the care of their child

• Serious conditions which require referral for expert consultation or treatment

• Organisation of referral to an appropriate referral centre where there is expert

paediatric help.


It should be recognised that these components of child health are aimed to prepare

midwives to care for children in the community setting and relies on specialist

medical care for those children requiring transfer to hospital. Much of the paediatric

components offered in the ‘double majors’ in PNG appear to be focused on hospital-

based care with nurses being taught to do high order acute care skills such as lumbar

punctures. It was beyond the scope of this review to determine if these skills are

required in midwives in PNG, although many rural facilities do not have the

laboratory facilities to deal with lumbar puncture specimens, which negates the need

for nurses or midwives working in these areas to be competent in this skill.

Recommendations for Midwifery Programs

The results of the review found that there is a wide range of clinical experience

offered to students across the four programs in the area of midwifery, particularly

exposure to labour ward. The theoretical component was considered stronger in the

midwifery-only program (offered through the Lutheran School of Nursing in Madang)

than the other programs due to it’s focus on midwifery only and the development of

all subjects within a midwifery context. The other three programs share a range or

generic subjects shared with other post basic courses.

It is believed that all courses require more attention to the complications of pregnancy

and childbirth, particularly those conditions that contribute to the high rates of

maternal mortality (PPH, pre-eclampsia, puerperal sepsis etc) as the response from

those students, educators and clinical midwives failed to demonstrate an indepth

understanding of these events, particularly pre-eclampsia (See Sections 5 and 6).

Apart from the Lutheran School program in Madang, the clinical components of the

programs are significantly inadequate. More time is required in the key maternity

areas of labour ward and antenatal clinic. A minimum number of procedures should

be recommended across all institutions in line with WHO recommendations.

Given that most of the births in PNG are attended by CHWs, the role of the midwife

needs to be strengthened as an educator within their local health structure with a

responsibility to supervise, mentor and teach the other cadres of health personnel

currently providing services.


In summary, education programs in midwifery can be strengthened by:

1. Basing PNG programs on the WHO international curriculum, modified to meet

the contextual needs of this country.

2. Increasing the length of the program to 12 months (52 weeks) for midwifery only

with a 6 month additional component for child health/paediatrics.

3. A minimum number of clinical procedures be included in all curricula. For

example, increase the number of manual removal of placentas that students must

achieve to a minimum of five.

4. Comprehensive clinical logbooks be developed for students to record the minimal

number of clinical skills, for example, space be provided to document 100

antenatal assessments, 40 normal births, 5 breech births, 5 vacuum extractions etc.

Competencies can then be signed off by a competent supervisor once for each

skill.

5. Ensure that each student achieves all minimum clinical requirements before

allowing them to graduate.

6. Improve access to clinical skill development through rostering of students on all

shifts including night-duty and weekends, and also other hospitals in PNG.

7. All programs should develop a midwifery specific curriculum and not embed the

program within nursing.

8. Subjects should be midwifery specific where possible.

9. The entry criteria be revised and standardised to incorporate international

recommendations that accept registered nurses with hospital based certificates.

10. More attention be devoted throughout the program to develop life saving skills,

particularly management of pre-eclampsia, eclampsia, and resuscitation of the

newborn.

11. More attention be devoted throughout the programs to develop critical thinking

and reflective practice through the use of role plays, case studies, case reviews,

reflection on critical incidents etc.

12. All curricula include information on evidence based practice using A Guide to

Effective Care in Pregnancy and Childbirth and WHO literature such as the

Reproductive Health Library.

13. Extend capacity to train midwives through distance learning.


Conclusion

Findings presented in this section suggest significant restructuring of midwifery

education is essential to ensure graduates are suitably equipped to provide effective

high quality care to women in PNG. There are many guidelines and materials

available through WHO to assist in this process.


Section 5. Student Midwives

Midwives who had recently completed their educational program were considered

important sources of information regarding the quality and appropriateness of their

training. Student midwives in the hospitals and educational facilities visited by the

review team were asked to complete a ‘student-midwife self assessment tool’ (see

Appendix 4). It was considered necessary to attempt to ascertain if these new

graduates were competent in key areas necessary to provide safe high quality care to

women and their families.

Forty six essential midwifery competencies, from the list of core competencies

developed by the ICM were chosen for assessment (see Appendix 4). Respondents

were asked to indicate if they felt confident in each of the skills listed. The tool was

introduced by members of the review team and was completed anonymously.

Due to the timing the review was undertaken (November-December 2006) many of

the students had completed their program requirements and were not available for

interview or assessment. For that reason graduates from both the 2005 and 2006

programs were included in the sample. The number of graduates from the four

programs is summarised below:

Table 10: Student Midwives Surveyed from 2005 and 2006 programs

Institution Number of graduates

UPNG 6

PAU 4

Lutheran 2

Goroka 9

Total 21

Essential Midwifery Competencies Results

Of the 46 essential competencies listed, the students were asked to indicate if they felt

confident in each area by marking a tick next to each skill. Most of the students ticked

‘confident’ next to most of the normal skills. It can be seen by the figures below that

the students surveyed reported high levels of confidence in most indicators in the


management of normal pregnancy and birth. The main exception was around HIV

counselling, screening and management of HIV where only 14% of students indicated

confidence. Of the other five indicators, there were some students who were not

confident in basic midwifery skills such as antenatal examination, screening and

management of sexually transmitted infections, active management of third stage and

examination of the newborn.

Figure 1: Student confidence in normal pregnancy and birth

Normal Birth

0

20

40

60

80

100

120

antentatal sti hiv counselling normal birth activemanagement

examinationnewborn

per

cen

t

confident not confident

There was a much lower level in the confidence of students around the management

of emergency skills, such as breech, cord prolapse, cannulation, manual removal of

the placenta, resuscitation of the newborn and the management of eclampsia. These

are seen in Figure 2 below.

Figure 2: Student confidence in managing maternal emergencies

Maternity emergencies

0

20

40

60

80

100

120

cannulation breech cordprolapse

newbornresus

eclampsia pph mrop

per

cen

t



In addition to the assessment of competencies, the following data were also collected.

• Facility where they undertook midwifery education

• Work Experience prior to midwifery education

• Why they chose to train as a midwife

• If they were living away from their family to study

• Amount of clinical experience during the training program

• Did they have adequate supervision in the clinical area

• Did they have adequate support in the university

• If they thought the teachers at the university were up to date in midwifery

• Where they intended to work on completion of their training

• If they felt ready to care for women as autonomous practitioners

All of the midwifery graduates were registered general nurses prior to undertaking

their midwifery education. They had been taught about pregnancy and normal birth in

their general nursing program. Many were experienced in antenatal care and normal

birth, having been required to carry out these duties as a registered nurse, particularly

in the rural areas. Their motivation to do midwifery was to develop skills and

knowledge in the complications in pregnancy and childbirth and to reduce the

maternal mortality and morbidity rates.

Approximately half the students moved away from their families to undertake their

midwifery training. Only PAU provided accommodation for married couples and

families, and actually only accepted married students if their families were prepared

to move to the Port Moresby campus with their spouses for the duration of the

program.

The amount of reported clinical practice time varied greatly amongst the students and

often did not support the amount of time reported by the institution, though this may

have been a misinterpretation of the question. The total documented clinical time

ranged from 6 to 18 weeks with an average of 13 weeks, with Lutheran students

reporting the most time in labour ward. Approximately 75% of the students believed

they had not received adequate supervision in clinical practice and this was supported

in the focus group discussions (see below).


With the exception of UOG students most other respondents reported that they felt

adequately supported by the university and that they believed their midwifery teachers

were up to date on relevant midwifery issues. UOG students unanimously identified

inadequate support from both the university and in the clinical areas. Although they

spoke highly of the paediatric component of the program, UOG students had no

midwifery educator until the last four months of their program. They were particularly

disadvantaged in the amount of midwifery education they received, including both

theoretical and practical. UOG students also had very poor support from the

university in terms of computer and internet access, library facilities and midwifery

text books.

All students reported unanimously that they felt capable of caring for women as

autonomous practitioners but some stated they required ‘more practice’ in

complications.

Focus Group Discussions

Whist the results of the self reported student midwife assessment suggests high levels

of confidence in most of the essential skills required to work effectively as a midwife,

this was not supported by the information these students gave through the focus group

discussions. It was believed that the students were reluctant to offer criticism of the

program on paper (with the exception of UOG students) but were more likely to

express their opinions verbally. Consequently students’ experiences were also elicited

through focus group discussions.

Overall the students did not believe they had adequate experience in the clinical area.

Many of the students had experience in the provision of midwifery care, including

birth, and expressed confidence in normal birth. However, they did not feel confident

in their skills to deal with maternity emergencies. This is of particular concern for the

students who were returning to rural and remote areas where some of them would be

the only clinician with midwifery education.

The poor level of supervision was evident in the amount of time some of the students

spent in the birthing environment, the low number of births they attended, and the

high percentage of births they did attend unsupervised by either a university


supervisor or a midwife. Many of the students who undertook clinical placement at

PMGH reported competition for births with medical students and large numbers of

midwifery and undergraduate students often being on the labour ward at once.

However, it appeared the students usually only worked in daylight hours during

Monday to Friday. Some students recognised that they would benefit from coming to

the labour ward out of these hours and PAU students in particular spoke of working

night duty. With approximately 1,000 births per month at PMGH, it seems

inconceivable that students would have problems accessing adequate birth numbers

and rostering of students should include all shifts including weekends and nights.

The amount of time the students spent in labour ward also varied considerably with

Lutheran students reporting up to 50 births and most UPNG, UOG and PAU students

reporting 5-15 births. One UPNG student reported spending only one week in labour

ward throughout her program. This student had no prior experience in caring for

birthing women. The rural experience was also varied with many UPNG students

being sent to run down health centres where no births occurred in the 4-6 weeks they

were stationed there.

The range and average of normal births and three essential life saving skills are

provided in the table below. Competence in these skills is considered essential for

students returning to rural areas with no other colleagues who had midwifery or

obstetric training. Although Lutheran students reported much higher numbers of

normal births, their experience in complications was similar to other institutions.

However, it should be noted that only two Lutheran students were available for

interview, due to the timing of the review.


Table 11: Range and average of key skills in midwifery

Institution Normal Births Breech Vacuum MROP

UPNG (6) 5-20 (ave 12) 0-5 (ave 2) 0-5 (ave 2) 0-5 (ave 2)

PAU (4) 12-20 (ave 15) 2-4 (ave 3) 3-5 (ave 4) 3-5 (ave 4)

Lutheran (2) 30-50 (ave 40) 2-4 (ave 3) 2-3 (ave 2) 3 (ave 3)

Goroka (9) 10-20 (ave 15) 0-2 (ave 1) 0-2 (ave 1) 0-1 (ave 0)

The confidence of students in the university lecturers who supervised the students in

the clinical area also varied. UPNG staff did not spend as much time with students in

the clinical area as other institutions, although many students reported the lecturers

tended to ‘drop by’ rather than spend any time with the students. This was supported

by clinical staff in the Port Moresby General Hospital. Some students reported a lack

confidence in the clinical skills of the university staff, preferring to refer to the

clinical midwife on duty. Others however, believed their midwife lecturers were

clinically up to date. UOG students had the most limited midwifery support, largely

due to the access of only one midwife teacher, who did not take up her position until 8

months into the program. Other UOG lecturers provided support in the clinical areas

of midwifery but these lecturers were not midwives and the capacity to teach students

in this speciality area was therefore limited. All students reported that some of the

clinical midwives were very approachable and supportive whereas others were not

supportive and the students felt reluctant to ask questions or seek support.

Attitudes from health staff to women and their families is known to be an important

factor in the provision of health services and has been identified as a problem within

health services in PNG (Larsen et al., 2004, Garner et al., 1996). Attitudes to women

were difficult to assess using the tools employed in this review. However, it was

apparent that the UOG students were significantly more influenced in this area than

other programs and it was believed this was due to the community development

activity of volunteer training and residential placement within the volunteers’ village.

UOG students reported this aspect of their education to be particularly beneficial with

many students recognising they are now much more aware of some of the influencing

factors of poor health and access to health services. Furthermore they believed they


were now much more empathetic to the situation of the woman which resulted in

more sensitive and appropriate care.

The students were questioned on their management of a number of clinical scenarios

known to be essential for the provision of safe practice, particularly in the rural areas

in the absence of more senior medical or midwifery staff. Responses from the

participants revealed significant concerns in the level of competence in these key

areas. The students were questioned on their knowledge around active management of

third stage and the management of preeclampsia. On the topic of management of third

stage, the students were unable to describe the difference between active and

physiological management though on closer questioning it appeared they had been

taught the mechanisms of active management. However there was some concern over

the practice of stimulating the uterus before expulsion of the placenta. This practice

was also confirmed in discussions with both educational and clinical staff and is

discussed further in Section 6.

When asked about the signs and management of preeclampsia, many of the students

were not able to report that it was a multi-system disorder that could present in a

number of ways. They recognised high blood pressure was a sign and that they should

check the urine for protein but did not appear to recognise the other more dangerous

signs of hyper-reflexivity or other neurological or multi-system indicators.

The biggest concern held by ALL students was the issue of their registration. No

student from any program in 2005 and 2006 had received registration at the time the

review was undertaken. This caused significant distress in most of the students

interviewed. Interviews with the review team appeared to increase this distress as

some feared that if the review determined that the courses were inadequate they

would never become registered. Issues around registration is further discussed in

Section 7

Conclusion

Information obtained from the students supported the findings in other components of

this review. The clinical component is currently inadequate in the courses, particularly

the combined midwifery/paediatrics programs. Although the students all considered


themselves capable of caring for women in pregnancy and childbirth, verbal responses

to key questions around maternity emergencies did not support this.


Section 6. Health Services

For graduate midwives to effectively provide high quality care to women and their

families, they must be supported by a well functioning health service. Two decades of

economic and structural reform have capped expenditure, restricted public budgets

and resulted in generalised depletion of the health care workforce and the

environments in which they provide care.

Three hospitals, three rural health centres and one Aide Post were visited as part of

this review (for full list see Table One in Section 3 of this report). Whilst a

comprehensive review of health services was not included in the Terms of Reference

a walk-through assessment was undertaken and some of the deficiencies identified

that would influence the ability of midwives to reduce the high levels of maternal and

child health morbidity and mortality.

The facility assessment tool (Appendix 5) was used as a guide to assess the general

condition and hygiene of the facility, water and sanitation facilities and infection

control and waste management practices.

Equipment

Many key informants reported that the essential equipment and medical supplies were

often not available and influenced the quality of care they were able to offer. Birthing

bundles frequently ran out requiring staff to soak instruments in antiseptic solution for

reuse on birthing women. Suture material was often not available and led to clinical

midwives keeping their own supply of needles soaked in solution for use on perineal

repair. Sphygmomanometers were often broken in labour wards and antenatal clinics

resulting in the inability to monitor women’s blood pressure, essential in the

appropriate management of preeclampsia. Syntocinon and other oxytocics frequently

were unavailable that would result in increasing rates of post partum haemorrhage and

difficulties in managing haemorrhages when they occurred.

The current system relies on the pharmacy to replenish supplies. It appears there is an

urgent need to address the process.


Minimum standards developed by NDoH are not enforced and most health services do

not have the resources or funding to implement the standards.

Workforce

Much of the maternity care for women in PNG is provided by non-midwives, namely

registered nurses and Community Health Workers. This includes all hospitals,

included the Port Moresby General Hospital, although a larger percentage of non-

midwifery care can be found in smaller hospitals and rural health centres. In the

smaller rural health facilities visited by the review team CHWs provided all care to

women and only when complications arose was a nurse or a midwife summonsed.

Although the CHWs are acknowledged as having a wealth of experience and indeed,

are the backbone of health services, serious concerns were raised on the quality of

care women received when complications occurred. The opportunity to interview

CHWs were limited as the review team were usually met by senior staff and when

CHWs sat in on focus group discussions, they rarely spoke of their experiences or

opinions of the service. On several occasions, more senior staff were not available and

CHWs were questioned on the type of care they provided to women in childbirth.

Although the numbers of interviewees was small, it was clearly apparent that the

CHWs had limited knowledge on the causes or management of women with

complications. If PNG is to address the high levels of maternal and perinatal mortality

and morbidity, CHWs require closer supervision and more education on the early

detection and referral of maternal complications.

At each facility, the review team requested to see case notes for any labouring or

postnatal women at the facility. Documentation was minimal and the level of care was

of concern, particularly in the rural facilities. Observations were taken on each woman

on admission to labour ward and included maternal temperature and pulse, fetal heart

rate, strength and frequency of contractions and a vaginal examination. Often these

were the only observations recorded for the duration of labour. Many of the women in

rural facilities did not have a recorded blood pressure and the intramuscular

administration of ergometrine was routine for management of third stage and each

woman was placed on oral ergometrine three times a day for several days post


delivery. The administration of ergometrine is contraindicated in the presence of

elevated blood pressure.

In the larger hospitals, observations included blood pressure and appeared to be

conducted more frequently than once on admission.

Fee for service payment

According to National Health Policy and the National Health Plan, all maternity

services (antenatal, birth and postnatal) are supposed to be provided free of charge.

However, as the National Department of Health has no authority over the provinces

(due to the Organic Law) the Hospitals, Health Clinics and Aid Posts ignore the

National Health Policy and set fees for these services. The fees vary though usually

involve K10-20 for admission and K2-5 for outpatients appointments including

antenatal clinics. In addition, some women were charged an extra fee for blood tests

(K2). Although the fees appear minimal, they are likely to be unaffordable for many

women in PNG and would act as a deterrent to access services.

Maternal Complications and Life threatening emergencies

In order to determine the appropriate response to and management of maternal

obstetric emergencies educators, clinical staff and students were asked their opinion

and management of two common maternal emergencies: PPH and pre-eclampsia.

These two conditions were chosen as they are two of the most common causes of

maternal mortality and both can be dramatically reduced with early recognition and

prompt and appropriate management.

Post Partum Haemorrhage

Active management of the third stage of labour (delivery of the placenta) is known to

significantly decrease the amount of blood lost during childbirth and is recommended

by leading international agencies to be offered to women as part of routine

management by skilled attendants in childbirth (ICM and FIGO, 2004).

Active Management of the Third Stage involves the routine administration of a

uterotonic agent following the birth of the anterior shoulder or immediately following

the birth of the child. Signs of placental separation are then observed for (lengthening


of the cord and a small gush of blood) and the placenta is removed using controlled

cord traction (Lalonde et al., 2006).

The uterotonic agent of choice in PNG is syntometrine, which involves mixing of two

solutions from two ampoules – 5 units of syntocinon with 0.5milligrams of

ergometrine, neither of which are refrigerated. The routine administration of

syntometrine has been discontinued in many countries due to the higher side effects of

ergometrine (nausea, vomiting and increase in blood pressure), contraindications for

use with women with elevated blood pressure, and the need to store ergometrine

between 2 and 8 degrees Celsius (requiring refrigeration). Oxytocin (syntocinon),

however, can be stored between 15 and 30 degrees Celsius for up to three months

(Hogerzeil et al., 1993). For these reasons, international agencies therefore

recommend the use of oxytocin (syntocinon) as the drug of choice for active

management of third stage (Lalonde et al., 2006).

Furthermore, a recent Cochrane review found no advantage of ergometrine over

syntocinon in the prevention of post partum haemorrhage of over 1000mls

(McDonald et al., 2005) though a small though statistically significant difference with

blood loss of between 500ml and 1000ml was found. With the current practice in

PNG requiring the use of two ampoules, that the ergometrine is not stored according

to international recommendations, and that some women do not have their blood

pressure checked on admission to labour ward, it appears reasonable that the routine

use of syntocinon only is considered.

All educators, clinical staff and students were asked to describe their management of

third stage. Most respondents were able to describe the steps of administration of

syntometrine and controlled cord traction; although several students were unaware

this was termed ‘active management’. However some respondents (educators,

clinicians and students) discussed feeling for (or stimulating) the uterus to contract

before delivering the placenta. At one of the institutions (UPNG) the clinical

‘checklist’ to measure competence included a list of ‘performance indicators’ for

management of third stage. The first performance indicator is recorded as directing

the student to ‘rub the fundus to contract’, prior to administration of an oxytocic or

delivery of the placenta. This practice is not recommended and is actually harmful as


it can cause excessive blood loss resulting in a postpartum haemorrhage and for it to

be formally taught to new students requires urgent attention.

The frequency of practice of stimulating the uterus prior to expulsion of the placenta

in the clinical area was difficult to determine. The review team, however, believe it is

relatively common practice and should be discouraged through dissemination of an

memo, development of a policy or whatever other action the NDoH believes will

reach the maximum number of providers, including CHWs.

When active management is not possible due to the lack of availability of uterotonic

agents, physiological (or expectant) management of third stage is recommended. In

focus groups with some of the new graduates, the students were asked what they

would do if oxytocics were not available. They responded that they should continue to

apply controlled cord traction to remove the placenta. This practice should be

discouraged as physiological management of the third stage relies on no interference

by the attendant other than putting the baby to the breast and ensuring the woman is

an upright position to facilitate the expulsion of the placenta by the mother using

physiological means. By continuing to apply controlled cord traction, the woman is at

increased risk of PPH, particularly in the absence of available oxytocics that are also

required in the management of PPH (ICM and FIGO 2004).

Management of post partum haemorrhage commonly involves intravenous

administration of an oxytocic infusion. When clinical staff and students were asked

about the dose of syntocinon used in the infusion, hospital staff reported using 20

units per 1000 mls.

Misoprostol is another drug available for the management of PPH and has proven to

be very effective in stimulating a sustained contraction in a previously atonic uterus.

Misoprostol is currently available in some health facilities in PNG though is primarily

used for induction of labour. Although it is a ‘Category A’ drug which can be ordered

by all health care workers (PNG NDoH, 2002), current practice in PNG makes it

unavailable for use by health staff other than doctors. In PMGH it is kept in the

locked drug cupboard and requires the authorisation of a medical officer prior to

administration. It is thought the restricted access of the drug is due to the risk of it


being used inappropriately for the termination of pregnancy. Misoprostol is quite

affordable (similar to oxytocics), does not require refrigeration or IV access (given

per rectum) and could have a significant impact on the prevalence rates of PPH if

more widely available.

Stakeholders also reported that retained placenta appeared to be a significant issue in

the rural areas, often requiring expensive referral in the absence of a midwife or

doctor, or worse, death by haemorrhage for the woman. Students’ access to

performing manual removal of the placenta varied amongst the students with some

students reporting no opportunity to learn this skill and others doing 2 or 3 throughout

their practical experience. If new graduates are returning to rural areas with no other

specialist support it is essential that they are competent to manually remove a placenta

and this requires more exposure to the procedure within their midwifery program. It

should also be noted that the high rates of retained placenta may in part be associated

with the inappropriate management of third stage and if this was corrected, less

women should experience the complication.

Pre-eclampsia and Eclampsia

Pre-eclampsia is a multi-system disorder of pregnancy and a common cause of

maternal death in PNG and internationally. The most common presentation of pre-

eclampsia is an elevated blood pressure (international definition being two readings of

140 systolic AND/OR 90 diastolic at least 30 minutes apart). However to meet the

criteria of pre-eclampsia (and distinguish between conditions such as ‘hypertension in

pregnancy’ or pre-existing essential hypertension, the elevated blood pressure should

be accompanied by at least one other manifestation. Usually this is proteinuria, due to

renal impairment. Other signs of worsening pre-eclampsia include neurological signs:

vision changes, frontal headache, and hyper-reflexia, liver involvement including a

palpable, or tender liver, abnormal liver function tests, and blood dyscrasias indicating

coagulopathies or haemolysis. Whilst generalised oedema can be a sign of pre-

eclampsia, this is considered to be an unreliable sign, particularly given the fairly

common presentation of lower limb oedema in normal healthy women.

The staff of each facility was asked how often they saw women with pre-eclampsia

and the review team was told it was seldom seen. Yet the available statistics state that


severe pre-eclampsia and eclampsia is one of the most common causes of maternal

mortality.

It was apparent that many of the graduating students and experienced clinicians had

very little knowledge around signs of severe pre-eclampsia and the impression gained

from the review team was that life threatening conditions did not receive adequate

attention throughout the education programs, nor in the clinical areas. When asked

what were the signs of pre-eclampsia, most staff and students reported an elevated

blood pressure, though on closer questioning many could not provide clear definitions

of what constituted an ‘elevated’ blood pressure. When other signs were not provided,

the students and clinicians were questions further. The question appeared to perplex

most respondents and they almost universally could only suggest that oedema (some

even stating ‘lower limb oedema’) was the only other sign they could provide.

Clinicians providing antenatal or intrapartum care throughout PNG do not have the

capacity to test urine at the clinic level, which is currently only available at the

laboratory level. However, the testing for proteinuria can be done simply at the

clinical level by a dipstick. Whilst the application of urine testing may not be

justifiable in terms of resource allocation in PNG, the availability of these dipsticks

for women presenting with other signs of pre-eclampsia would be useful to

distinguish those women who require urgent referral or more aggressive management.

It is acknowledged that sophisticated blood analysis is unrealistic for many health

facilities in PNG, however educating the current and future workforce on some of the

other clinical signs of severe pre-eclampsia would lead to earlier diagnosis and more

appropriate management of this potentially life threatening disorder.

The management of severe pre-eclampsia is the administration of antihypertensives

(usually hydralazine) to lower the blood pressure with intravenous magnesium

sulphate to prevent or control eclamptic seizures. The use of diazepam in the

management of eclamptic seizures has not been recommended for some time.

However, it was listed as the first drug of choice in the laminated ‘wall charts’ found

in many of the labour wards.


Throughout the review, most respondents were aware of magnesium sulphate, though

many did not know why it was used, or how, and seemed to rely on the medical staff

to have this information. In a major obstetric unit such as PMGH this may be

understandable (though not acceptable). However in the rural areas, where medical

staff are often not available, the lack of appropriate knowledge of the staff providing

the care to women is of serious concern.

NDoH staff informed the review team that magnesium sulphate should be available at

all hospitals and health centres. However it appears the drug was not available at

many of the rural centres, nor did staff know how to use it.

To address the high levels of maternal mortality of pre-eclampsia and eclampsia, the

knowledge and skills of all staff providing care to pregnant women must include the

appropriate identification and management of this disorder.

HIV

Papua New Guinea was declared to have a generalized epidemic of HIV/AIDS in

2003. HIV prevalence among antenatal attendees is over 1.3 per cent in Port Moresby

and 3.7 percent in some other areas. There has been significant resources provided to

improve the rates of HIV screening and treatment in antenatal women. However the

review team failed to observe any routine screening procedures offered to women in

most of the facilities we visited. In the notes reviewed for inpatient obstetric patients,

only the Haemoglobin and VDRL were recorded. When staff were questioned on the

availability of HIV screening, most respondents replied that they did not have the

facilities to screen women, or that when pre-test counselling was introduced that

many of the women refused testing. This has led to the introduction of opt-out testing

where pre-test counselling is given as a group but post-test counselling is done

individually. This is an internationally recognised model, recommended by WHO as a

means to ensuring maximum access to screening and treatment. However in the health

facilities visited as part of this review, most women were not being counselled or

screened for HIV. Testing kits, anti-retroviral medication and training are all available

through the NDoH and donor agencies and health staff should be encouraged to

screen more widely where these resources are available.


Resuscitation of the Newborn

It is generally accepted that approximately 10% of infants internationally will require

some degree of assistance to breathe at birth (ILCOR, 2005). The vast majority of

these infants will successfully establish respirations following some assistance with

positive pressure ventilation, usually delivered via a self-inflating bag and mask.

During the walk through of each facility, the review team requested to look at the

equipment available to resuscitate infants, should they require it. Whilst the larger

facilities of PMGH and Goroka base hospital had an infant resuscitation cot and a bag

and mask located within labour ward, on the two occasions we visited it was either

not connected to oxygen or the oxygen bottle was empty. In other facilities such as the

Modilon Hospital in Madang, the resuscitation equipment was located in the nursery,

and in the smaller facilities, the staff could not locate the bag and mask though

insisted they had one ‘somewhere’. When clinicians and students were questioned

about the frequency and type of resuscitation administered to sick newborns, the

review team were not reassured that this skill was highly developed amongst the staff.

Most of the respondents reported they initiated ‘frog breathing’, even when a bag and

mask was available. There is currently no evidence on the efficacy of frog breathing,

but given that the appropriate equipment for effective resuscitation is available in the

larger health facilities, adequate preparation of both students and staff is essential and

will no doubt have a positive impact on neonatal morbidity and mortality.

Clinical Midwives

Reliable data on the midwifery workforce is currently not available. The PNG

Nursing Council currently estimates midwifery numbers to be 567 although many of

these midwives are no longer working in clinical positions. As already mentioned, it

appears that graduates from midwifery courses over the past few years have not yet

been registered (see Section 7 for more information). The National Department of

Health, assisted by WHO, have developed a database that will provide accurate

information on the nursing and midwifery workforce and will enable health planners

to identify workforce shortages, particularly in the rural and remote areas.

Operationalisation of this database, including the entry of labour-force data, must be

given priority.


Despite the lack of data, it was generally accepted by all stakeholders and key

informants that there are currently inadequate numbers of midwives in PNG and that

the current production of new midwives through education programs will not address

this shortfall. Increasing the number of the midwifery workforce could be achieved

by:

• Increasing the number of intakes from two to one intakes per year

• Establishing a part-time option for students

• Supporting other institutions such a Vunapope to develop and offer midwifery

education

• Support the development of distance education programs in midwifery

providing appropriate clinical supervision is available.

Clinical midwives in the hospitals visited by the review team were asked to complete

a ‘midwifery self assessment tool’. It was considered necessary to attempt to ascertain

if clinical midwives were competent in key areas necessary to provide safe high

quality care to women and their families as this workforce is often the most influential

in the learning of midwifery students and new graduates. Forty six essential

midwifery competencies, from the list of core competencies developed by the ICM

were chosen for assessment (see Appendix 6). Respondents were given five answer

options, which included whether or not they had learned the skill and if they felt

confident or not to practice the skill. The competencies included in the tool focused

on those most needed to reduce maternal and infant mortality and morbidity. The tool

was introduced by members of the review team and was completed anonymously. In

addition to the assessment of competencies, the following data were also collected.

• Age.

• Site of practice (facility).

• Year Graduated.

• Year started work.

• How many years have you been a midwife?

• Where do you want to be working in five years time?

• Have you attended any postgraduate training since you finished you midwifery

training? Please list some examples.

• Births attended in last 12 months.


Results of the Midwifery Self Assessment

The table below illustrates the results from the demographic data collected on 16

midwives from across the three hospitals visited. These included PMGH (6), Modilon

Hospital (6), and Goroka Base Hospital (4). Although ideally rural midwives would

also have been included in this survey, there were no midwives rostered on duty in the

rural areas at the time of the review teams visit. As can be seen below the sample

represented a wide range of ages and experience though the mean years of experience

was 9 years, indicating that the sample was well experienced. Most (62%) indicated

they planned to be in the same facility in five years time with the other 37% reporting

a variety of things they wanted to be doing in five years time, from retirement, to

education, rural practice, or private health practice.

Table 12: Summary of demographic data on clinical midwives

Number of midwives surveyed 16

Age Range 26-52

Mean age 39.5

Rural 0

Urban 100%

Range of experience (in years) 1-26

Mean years of experience 9

Working 5 years from now in same institution 62%

The self assessment consisted of 46 midwifery competencies, and apart from the few

listed in the figures below, the midwives reported self confidence in all other

competencies. The core midwifery competencies reported below were chosen as they

have been identified to directly reduce maternal and infant mortality and morbidity

and should be an essential part of midwifery education, both pre-service and as

continuing education, to ensure midwives remain current with evidence based practice

in these areas.

Midwives reported high levels of confidence in most of the ‘normal’ aspects of

maternity care. The exception to this was in both STI and HIV counselling, screening

and treatment. It is assumed that practicing midwives are not exposed to these


practices in their workplace and therefore lack confidence. Screening for syphilis was

the only STI testing done routinely in the facilities visited by the review team.

Figure 3: Confidence of midwives in normal pregnancy and birth

Normal Birth

0

20

40

60

80

100

120

ante

ntat

alca

re

sti s

cree

ning

,tr

eatm

ent

hiv

coun

selli

ng,

teat

men

t

man

age

norm

al b

irth

activ

em

anag

emen

t

exam

ine

new

born

per

cen

t

not confident

confident

The other reported responses included how the midwives perceived their confidence

in a number of key maternity emergencies, including the main causes of maternal

mortality in PNG. The levels of confidence in these competencies were significantly

lower than those in normal care of women in birth. All midwives reported confidence

in their ability to manage post partum haemorrhage, but less confidence was reported

in the management of breech birth (81%), cord prolapse (91%), newborn resuscitation

(89%), management of eclampsia (including administration of magnesium sulphate)

(56%), manual removal of the placenta (81%), and maternal sepsis (93%). All

midwives should be competent in these areas to practice in any setting in PNG.

Results of this survey indicates that not only are these skills important to be included

in midwifery education, it also supports the need for ongoing professional

development for practicing midwives.


Figure 4: Confidence of midwives in maternity emergencies

Maternity emergencies

0

20

40

60

80

100

120

breech cordprolapse

newbornresus

eclampsia pph mrop maternalsepsis

per

cen

t


Recommendations for Health Services

Health services can be strengthened by:

1. NDoH develop and disseminate a standardised policy for all education and health

facilities, outlining the appropriate management of third stage and the

management of PPH. This should include:

• Minimising the stimulation of the uterus prior to expulsion of the placenta

• Accurate physiological management in the absence of oxytocics.

• Routine administration of syntocinon rather than syntometrine for the active

management of third stage.

• The availability and appropriate administration of misoprostol (800 – 1000

micrograms inserted rectally) in the management of PPH.

2. NDoH develop and disseminate a policy to all education and health facilities,

outlining the appropriate identification and management of pre-eclampsia and

eclampsia. This should include:

• The availability of testing for proteinuria at the clinical level

• Clear definitions and classifications of hypertensive disorders in pregnancy

• Contemporary evidence around signs and symptoms of the disorder

• Current evidence around management of the disorder including appropriate

use of antihypertensives and magnesium sulphate for the prevention and

management of eclamptic seizures.

3. Improvement of working conditions by ensuring:


• Adequate drugs and single use items where required to increase quality and

safety of care

• Facilities provide appropriate means for ensuring infection control procedures

can be followed at all times (especially hand washing hardware: running

water, soap and towel).

4. Funding to be secured to provide an upskilling workshop on maternity

emergencies for senior clinical (midwifery and obstetric) and education staff in

PNG.

5. NDoH recommence preceptor training for clinicians working with students and

junior staff in the clinical areas.


Section 7: Regulation of Midwives

Overview

In order to reduce maternal and infant maternal mortality in PNG, midwives and other

health professionals need a clear legal and regulatory framework which permit them

to practise the essential interventions that will save lives and promote good health.

The main functions of a professional regulatory system are to:

• Set standards for entry into the profession

• Ensure maintenance of standards

• Provide a mechanism to deal with professional misconduct

• Maintain an effective register of all those eligible to practise

The PNG Nursing Council functions under the Medical Act, 1980 though this Act is

currently under revision with a new Health Practitioners Act expecting to be presented

to Parliament in 2007. This new Act will provide a more robust platform to guide

Nursing Council activities.

The Nursing Council appears to have been inefficient for a number of years and have

recently improved their performance though a staff restructure and the support of the

PNG WHO office. Of the four midwifery programs currently operating across the

country, three of the four have submitted curriculum documents for approval by the

Council. The review team were unable to determine if full approval had been granted

to these programs. The PAU team believed they had received approval, yet the

Council staff informed the team that whilst it had been approved by the education

committee, it had not formally gone before the board. Lutheran staff told the review

team after submission of their documents they received some points from the Council

that required clarification. The Lutheran staff claim they addressed each of these

points formally and in writing but had yet to receive further correspondence. The

UOG team claimed they had forwarded documentation in December 2005 and had yet

to receive a response 12 months later. The UNPG program had definitely not been

approved because Council representatives claim the UNPG have failed to forward

their Curriculum documents for review, despite a number of letters being sent to the

university over the last few years.


A National Framework for the Accreditation, Monitoring and Evaluation of Nursing

and Midwifery Programs is available though the ability to apply the document has

been limited due to a lack of documented criteria on which to evaluate and monitor

programs. For example, under Standard 5 of the Framework document, the institution

is required to demonstrate the students have gained appropriate knowledge and skills

to meet the community requirements and National Competency Standards. However,

it does not state specific skills to be attained, nor the minimum number of procedures

students must have achieved.

The capacity of the Nursing Council to accredit the midwifery programs has also been

restricted by a long backlog of nursing and midwifery graduates waiting to be

registered. The Nursing Council is currently concentrating on registering graduates

from undergraduate nursing programs from 2004 and it is expected that it will be

some months before they can attend to the midwifery programs and graduates. This

lagtime has resulted in no graduates from any program in midwifery being granted

Registration to practice for a number of years. This has resulted in significant stress

with both education staff and students with some education staff reporting the

boycotting of classes by students and increasing agitation for the schools to fulfil their

requirements in order for the students to receive registration. Although the graduates

are mostly in secure employment without registration, the staff and many of the

students are aware of the legal and ethical implications of this and seek a swift

resolution to this longstanding problem.

The process for granting Registration for both undergraduate nursing and

postgraduate nursing and midwifery programs appear hampered by a laborious

process where the Nursing Council is requesting the academic transcript, full

assessment record book, skill logbook and evidence portfolio for each student that

graduates from all 7 undergraduate institutions and 4 postgraduate institutions across

the country. If adequate mechanisms were in place for the development of curricula,

based on minimum standards, this process would not be required. This is because the

educational institutions would be delegated the responsibility of recommending

Registration based on a program developed using Nursing Council criteria that had

been approved by the Council. The quality of these programs could then be monitored

by sample audits undertaken by the Nursing Council, using the National Framework


for the Accreditation, Monitoring and Evaluation of Nursing and Midwifery Programs

document.

Recommendations for Nursing Regulation and Accreditation

1. Process the registration for all students who have graduated from nursing and

midwifery programs since 2004. This must be attended to as a matter of urgency.

For graduates from the UPNG program that has not received formal approval to

offer the existing program, these students should not be penalised by withholding

registration. Whilst it is recommended that the UPNG program restructure their

program in line with the recommendations of this report, it is not believed the

graduates from the UPNG program are significantly less competent than the other

programs. Therefore to withhold registration to these students on the basis that the

program was not approved would not be useful, particularly when representatives

of the Nursing Council were included in the curriculum development.

2. Develop a set of minimum standards of clinical skills that each institution must

incorporate into their curricula. These should be based on WHO recommendations

documented in their international curriculum.

3. Conduct a review of the registration procedures required by Council in order to

improve the efficiency and reduce the workload required by the Council to assess

each graduate individually.

4. Set standards for minimum requirements for entry into the profession that should

include registered nurses with hospital based certificates.

Conclusion

PNG already has many of the structures and processes in place to provide a strong

regulatory framework for their health and educational institutions. This framework

however, requires urgent attention to address the lack of registration being given to

graduates of both nursing and midwifery programs, as well as clarifying and reducing

the processes required for registration. It also requires prompt attention to the

accreditation of existing courses and the development of specific requirements for

clinical skills in future programs.


Section 8: Conclusion

Midwifery has gained increasing recognition in the last 10-20 years with the WHO

recommending that midwives are the most appropriate practitioner to care for women

in pregnancy, labour, birth and the postnatal period when no risk factors have been

identified. This has occurred alongside increasing international effort to reduce

maternal and newborn mortality by ensuring that every woman has access to a skilled

provider.

Overall the current preparation of midwives in PNG is not adequate to effectively

reduce the high maternal and childhood mortality and morbidity rates. However,

midwifery in this country has strong foundations and there are many competent and

experienced midwives working in maternity services across the country.

By increasing the amount of time in clinical practice, determining minimal numbers

of procedures that must be completed prior to graduation, upskilling key education

and clinical stall in maternity emergencies, and the provision of leadership on many of

these issues by the Nursing Council, PNG could easily produce a highly competent

workforce.

Limitations of this review include:

• The time available to conduct the review was a total of five weeks with 3

weeks in country

• The timing of the fieldwork was in late November and December, at the

academic year. Consequently many of the students were not available for

interview.

It is not the intention of this review to diminish or discredit the hard work done by

many individuals across education, policy and clinical services. Most individuals are

doing the best the can possibly do in a system that is challenging and poorly

resourced. It is hoped that the recommendations in this report can assist these

individuals in strengthening maternity services in this country to achieve what all


participants are striving for: a reduction in the devastating loss of life in women and

children in PNG from conditions that are mostly preventable.


References

Beebe, J. (1995) Basic concepts and techniques of rapid appraisal, Human

Organization, 54 (1) 42-51.

Garner, P., Heywood, P., Baea, M., Lai, D. and Smith, T. (1996) Infant mortality in a

deprived area of Papua New Guinea: priorities for antenatal services and health

education, PNG Medical Journal, 39 6-11.

Hogerzeil, H., Walker, G. and de Goeje, M. (1993) Stability of injectable oxytocics in

tropical climates: Results of field surveys and simulation studies on ergometrine,

methylergometrine, and oxytocin, World Health Organization: WHO Publication No.

WHO/DPA/93.6, Geneva: Action Programme on Essential Drugs and Vaccines

ICM (1999a), Vol. 2006 International Confederation of Midwives (ICM), The

Netherlands.

ICM (1999b) International Code of Ethics for Midwives, International Confederation

of Midwives (ICM), London

ICM (2005), Vol. 2006 International Confederation of Midwives (ICM), Brisbane.

ICM and FIGO (2004) Joint Statement Management of the Third Stage of Labour to

Prevent Post Partum Haemorrhage, International Congress of Midwives and

International Federation of Gynaecologists and Obstetricians

ILCOR (2005) Neonatal Resuscitation Guidelines, International Liaison Committee

on Resuscitation

Lalonde, A., Daviss, B., Acosta, A. and Herschderfer, K. (2006) Postpartum

hemorrhage today: ICM/FIGO

initiative 2004—2006, International Journal of Gynecology and Obstetrics, 94 243—

253.

Larsen, G., Lupiwa, S., Kave, H., Gillieatt, S. and Alpers, M. (2004) Antenatal care in

Goroka: issues and perceptions, PNG Medical Journal, 47 202-214.

McDonald, S., Abbott, J. and Higgins, S. (2005) Prophylactic ergometrine-oxytocin

versus oxytocin for the third stage of labour (Cochrane Review), The Reproductive

Health Library, Issue 8 (Oxford) Update Software Ltd. Available from

http://www.rhlibrary.com.

PNG NDoH (2002) Medical and Dental Catologue. 9th Edition, National Department

of Health, Port Moresby


Sherratt, D., White, P. and Chhuong, C. (2006) Comprehensive Midwifery Review,

Draft Final Report, Ministry of Health and WHO, Cambodia

UKCC (2000) Perceptions of the scope of professional practice, United Kingdom

Central Council for Nursing, Midwifery and Health Visiting (UKCC), London

WHO Mother-Baby Package: Implementing Safe Motherhood in Countries,

Department of Reproductive Health and Research, World Health Organisation,

Geneva

WHO (2000) Nurses and Midwives: A Force for Health, World Health Organisation,

Copenhagen

WHO (2006a) Country Co-operation Strategy, World Health Organization, Port

Moresby

WHO (2006b) Strengthening Midwifery Toolkit: Guidelines for Policy Maker and

Planners to Strengthen the Regulation, Accreditation and Education of Midwives,

Final Draft, World Health Organisation, Geneva

Appendix 1: Education Institution Quality Assessment 90

Appendix 1: Education Institution Quality Assessment Tool

1. Name & Address of Institution

3. Year Established: Year

commenced midwifery programme(s):

(if after 1990)

4. Type of Midwifery Program offered (give details - length of course, funding by, as

well as average number of participants per course and # course per year

5. Other healthcare trainings offered: (list name and length of course)

i.

ii.

iii.

iv.

6. # Midwife Teachers posts: #

Vacant midwife posts:

Identifier


7 Qualification of Midwife Teacher(s): (identify if full-time teaching midwifery, or

undertaking other roles and responsibilities in addition to teaching)

i.

ii.

iii.

iv.

v.

8. # Midwifery students per intake: # Intakes per year:

9. # Class Rooms: #. Seats per classroom:

9. # Offices for midwife teachers

10. Hostel Accommodation for available? Y / N

i. If yes, total # bedrooms #beds per bedroom.

(average)

ii. Total #beds available for midwifery students


iii.Total # of midwifery students in hostel at current time?

11. Running water available in all bathroom & toilets ? Y/ N

If no describe situation (how get water, if any problems of getting sufficient

water etc)

Please complete the following and supply additional information on a separate sheet

Ite

m

Criteria Yes No

1 Staff Development/institutional capacity building

The institution has been assessed within last five years to see that all

teaching materials required in curriculum etc are present and in good

order

All new teachers are required to have undertaken specialist

preparation for teaching course prior to taking up post

The institution has a written orientation programme for all new

teachers

The institution has had external support in last five years to upgrade

the facilities and / or

faculty

(Give name of funder and type of support provided )

Midwifery teachers have access to computers

Midwifery teachers have access to the Internet

2 The Curriculum

The institution has a formal committee for monitoring the curriculum

that consist of both academic, clinical staff and student representatives

The institution gives all students a manual outlining the curriculum,

expected competencies at end of training, schedule of classes, times

of assessments, etc., at commencement of the course


The institution has formal written guidelines for assessing students

3 Educational Processes

Teachers use multiple education methods to facilitate learning,

including small group work

Teachers use problem-based approach to learning to encourage

independent and autonomous practice

Teachers use Competency-based methodology and checklists for

development of clinical skills

4 Support to Students

The institution has a formal mechanism to investigate student

grievances

The institution has a formal student teacher committee to resolve

student complainants

The institution has a formal mechanism to support and counselling

students who have personal problems

5 Learning Materials

The institution has a well-stocked library to support midwifery

students (has more than 1 copy of up to date midwifery text books,

reports and journals) *please list on separate sheet all midwifery and

nurse-midwifery Journals available and dates of latest issues. Also any

relevant midwifery related textbooks and reports etc in local language)

Students are able to borrow books and other materials from the library

outside class times

Photocopy facilities are available for students to use (give cost per

sheet students have to pay)

The library is open after official class times


Other midwifery study books are available for use by students

(available from Midwife teachers). ( Comment on name and # of

books available language and if in good order)

Computer facilities are available for its use by students

Students have access to the Internet

6 Clinical Support

There are clinical supervisors in all areas where students go for

clinical practice including for

Community placement

Home births

ANC (HC and community etc)

PNC (HC and community etc)

Facility normal births

Facility management of obstetrical and neonatal complications

All clinical supervisors must undergoing a formal preparation

programme (in-service course) provided by institution

Teachers spend time working with and supporting students in the

clinical areas (when the students are on clinical placement)

A formal mechanism is operating to prepare clinical sites (to ensure

quality of care provided)

7 Facilities

Sufficient student accommodation is available on campus (or close

by) - comments on any shortages, number of rooms, occupants per


room and bathrooms)

Safe hygienic facilities (area) is available on site for preparing food

A separate room is available for students to use in off-duty time for

study

Clinical / skills development laboratory is available with sufficient

working models, equipment etc (comment on models and equipment

available if teachers have any deficiencies according to curriculum

needs - including any that are available but not in good working

order)

Auditorium (or large room) is available for graduations, large

meetings, seminars, workshops etc., with PA system

Each classroom is fully equipped with teaching aids, e.g.:

Blackboard/white board,

Flip chart stand

Each classroom is fully equipped with desks and chairs sufficient for

number of students

Each classroom has working fan or Air conditioning unit or good

ventilation (comment on if rooms appear well ventilated? and means

of ventilation and temperature control)

Over Head Projector is available and in working order and used by

midwife teachers


TV and video are available and in working order for use by midwife

teachers (comment on videos available/ regularly used by midwife

teachers)

Single sex toilets available and in good order (clean and well

ventilated)

If accommodation is attached to institution:

Recreational facilities are available for students (list facilities

available for students use)

TV is available for students use

Security is available (comment on security systems e.g. how they

ensure security of female students).

Additional Notes

Appendix 2: Midwife Teacher Questionnaire 97


Appendix 2: Midwife Teacher Questionnaire

1. Title of post (if any)

2. Age:

3a. Length in current post:……..

3b. What did you do immediately before being posted as midwife teacher

4. Qualifications: Certificate/Diploma or degree

(midwife, nurse):……… ….

Place of training:……………………………………….

Year when training completed :………………………..

5. Other training: (give year, title of training and length, list in order of most recent first)

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

6. Reasons for becoming a midwife?

Code:


7. Reasons for becoming a midwife teacher?

8. What does the community think about midwives (is it a good job?)

� YES � NO (give reason for answer).

9. What job would you like to be doing;

next year?

in 5 years?

Give reasons for your answer

10. Do you think midwife teachers should conduct hands on midwifery practice?

� YES � NO

(If yes, how do you think this should be organized? If no, why not?)

11. What 3 things would make your current job easier?


(list in rank order)

1.

2.

3.


Midwife Teacher Competence

Skill Yes No Unsure

Do you consider yourself to have updated

knowledge of;

Biological and social sciences underpinning

midwifery

Midwifery subjects (for example

management of post partum haemorrhage

and resuscitation of a newborn)

Application of research findings in practice

(have research findings made any change to

how or what you teach your students?)

Attitude

Can you in a short sentence describe your view on what it means to be a

professional practitioner?

……………………………………………………………………………

Has experience (after graduation) of; Yes No

1. Providing pregnancy (ANC) care

2. Managing normal birth in a facility

3. Managing normal birth in home setting

4. Using a partograph

5. Managing third stage of labour using active

management of 3rd stage

1. Experience and

ability to practice

all clinical

midwifery skills to

mastery level

6. Managing third stage of labour using

physiological management of 3rd stage


7. Undertake the manual removal of the

placenta

8. Deliver a baby using vacuum extraction

7. Resuscitating newborns

8. Proving postnatal care to mothers and

babies

9. Providing health education and counselling

to women and families on health for

pregnancy (healthy diet, healthy life styles,

etc)

10. Assisting women and their families make

a birth and emergency preparedness plan

11. Providing counselling on birth spacing

12. Assisting women breastfeed successfully

13. Managing cases of eclampsia

14. Managing cases of PPH (in first 24 hours)

15. Managing cases of severe infection after

birth in mothers

2. Ability to

conduct or use

simple research

using qualitative

and quantitative

methodologies


knowledge of;

Basic epidemiology

Basic statistics

Analytical framework

Research resources

Yes No Unsure


3. Ability to apply

teaching

methodologies

effectively


knowledge of;

Learning styles (differences in students

ability to learn, including learning by doing,

and length of time each student needs to

develop skills)

Teaching and training methodologies

- Classroom (different adult learning

techniques)

- Clinical teaching (important aspects of

supporting students in the clinical area)

4. Ability to assess

students fairly


knowledge of;

Assessment strategies formative and

summative assessments)

Different assessment tools (different ways to

assess students clinical competence)

5. Ability to make

clear, accurate,

concise reports and

records


knowledge of;

Report writing

National legislation on record keeping


6. Ability to search

for up to date

information


knowledge of;

Using a computer

Using the Internet

Searching for current research

6. Management

skills


knowledge of;

Educational management theories what

makes a good working environment for an

educational institution)

Timetabling and scheduling (how to organize

students placements in clinical areas so that

all students have opportunity for maximum

hands on practice)

Curriculum design and development

(experience of involvement in developing a

new curriculum)

Curriculum monitoring (how to ensure

effective monitoring of a curriculum)

Curriculum evaluation (methods to evaluate

a curriculum)


7. Communication


knowledge of;

Communication techniques (factors that

enhance or hinder effective communication)

Presentational methodologies (what makes a

good presentation)

Listening techniques (what is required for

effective listening)

Counselling techniques (what is meant by

counselling and the counselling process)

8. Inter-cultural

competence


knowledge of;

Cultural taboos and customs in different

countries or communities (related to childbirth)

Cultural identity (what factors help to

develop a persons sense of individual

identity)

Additional Notes:

Appendix 3: Framework for Evaluating Curriculum 106

Appendix 3: WHO Framework for Evaluating Curriculum

YES NO Not

Know

n

The Curriculum has been reviewed and revised in the last five (5)

years

Minimum entry requirement is; 12 years school, or 10 years plus

entry test and/or successfully completing a foundation course, or

Registration or Licence to Practice Nursing

Teacher student ratio have been agreed and conform to national

norms

The curriculum requires approval by the Midwifery Regulatory

Authority (the body established by the government to oversee

midwifery and grant the right to practice)

The curriculum is delivered in, or has the approval of, an appropriate

educational body/institution

The curriculum is at the educational level equivalent to the

curriculum of other health care practitioners

The curriculum is based on sound educational theories of adult

learning that fosters the critical thinking and problem solving skills

of students

The curriculum has a clear philosophy of midwifery that values

midwives working with women in a partnership and recognizing

pregnancy and childbirth as a natural life event for most women

The curriculum is organized to ensure students can link theory to

practice, practice placements allow them to practice what they have

been taught in the classroom

The curriculum is lead by an experienced midwife teacher who has a

background in midwifery and has been trained as a teacher

Appendix 3: Framework for Evaluating Curriculum 107

Teaching and learning resources are adequate and expose students to

recent research findings

Students have opportunities to practice in the clinical area under the

direct supervision of an experienced midwife and have their practice

assessed

On completion of the education programme midwives are able to

practice as autonomous/self-directing practitioners, (able to practice

as outline in the International Definition of a Midwife)


practice as a fully participating member of a multi-disciplinary team


provide midwifery care in any setting, community, clinic, health

facility, hospital or clients own home.


provide all essential life-saving skills to both women and newborn

All assessments are clearly identified in the curriculum and

assessment points are known to the students

Clear criteria has been set for all theory and clinical assessments

All assessors, including clinical assessors have been specially

prepared for their role

The curriculum has a clear and transparent Quality Assurance

mechanisms, students able to give feedback to teachers

All assessment tools have been tested for validity and reliability

Student records ensure that individual progress can be tracked

throughout the programme

Appendix 4: Student midwives Survey 108

Appendix 4: Student Midwives Surveys

Facility you are studying at? Date

started_________ completed_______

What experience did you have before your training?

Why did you choose to train as a midwife?

Are you living away from your family to study?

What does a midwife do?

How much clinical practice do you have during your training?

Do you have adequate supervision in the clinical area?

Do you have adequate support in the university?

Code:

Appendix 4: Student midwives Survey 109

Are the teachers at the university up to date in midwifery?

Where do you want to work after midwifery training? (name village or town and the level

of facility)

Do you feel ready to care for women by yourself?

Appendix 4: Student-Midwives Survey 110

TICK IF YOU ARE CONFIDENT TO DO THESE CLINICAL SKILLS

Clinical skill Inspection of placenta and membranes

Taking an antenatal history Perform manual removal of placenta

Idenitify STIs Suture perineum

Treat STIs Assess Apgar scores

Council for HIV screening Rescuscitate a newborn with bag and mask

Screen for HIV Assist in immediate breastfeeding

Manage HIV positive women Examine newborn

Venipuncture Diagnose postpartum hemorrhage

Cannulate Manage postpartum hemorrhage

Counsel on birth and emergency plan Diagnose infection in the newborn and give appropriate

immediate care for newborn as per national protocols

Record findings using home based and

clinical records

Diagnose sepsis in postpartum women and give immediate care

according to national protocols

Measurement of uterine size Recognize women with eclamptic fits

Calculating EDC Manage eclamptic fits including giving magnesium sulfate

Identify onset of labor Provide information on fertility regulation and contraception

methods

Determination of fetal position by Effectively support the breastfeeding woman

Appendix 4: Student-Midwives Survey 111

abdominal examination

Identify the second stage of labor Effectively support the woman who cannot breastfeed

Manage second stage of labor Effectively monitor the growth and development of children up

to five years of age

Manage a normal birth Recognise and manage malnutrition in children

Perform episiotomy Recognise and manage common childhood illnesses

Manage a breech birth Knowledge of immunisation schedule

Manage a cord prolapse Administer immunisations to women

Physiological management of 3rd stage

Appendix 5: Health Facility Assessment Tool 112

Appendix 5: Health Facility Assessment Tool

1. Name & Address of Facility:

2. General Details

Year Established: # in-patient beds # births per

year

Service level: *For Referral Facility # C sections per month

(average)

# ANC sessions per week # ANC attendees per

session (average)

4. Staffing:

# Midwife posts: # Vacant midwife posts:

# staff with midwifery training not currently working in clinical maternity area

(comment on type of work they are currently doing)

Code:


FACILITY AUDIT

Item All Facilities Yes No

1.

Meets all the criteria in terms of equipment and drugs for service level

(check with NDoH standard)

2. Has the facility experienced any ‘stock-out’ of drugs within the last 12

months? Comment on which drugs and how long

3. Has the facility experienced any period of electricity (black-out) in

the last 12 months?

if so add comment about average

# of periods of LESS than 15 minutes

# of periods between 15 and 30 minutes

# of periods 1-2 hours

# of periods more than 2 hours

4 Toilet and bathroom is available for women in labour

5 Patient toilets are clean, well ventilated and have water (mention if

running water or containers)

6. Sink with running water is available in room for conducting births?

(if not, comment if facility is available in room for washing hands)

7 Soap and means for drying hands are available in all patient care

areas, including room for births?

(if some area deficient mention which)

8. Light is available in room for conducting births

9 Table or a flat surface is available in or just outside room for birth that

can be used for resuscitation of newborn, if required?

(ask them to say what they do if they have a newborn who needs

resuscitation)


10 Room for birth is warm and well ventilated, and has means for

protecting newborn for heat loss?

11 Equipment for decontamination is available, plus means of sterilizing

equipment? (Comment on sterilizing procedure)

(comment on how they clean and store equipment for birth after use)

12 Facility is clean? (Especially birthing room)

(comment on level of cleanliness)

13 All in-patient admissions and births entered into General Admissions

Register? (ask to see and check number of births)

14. Partograph is available for all women in labour? (ask to see)

15. Partographs is always used for all women in labour?

(If any women in labour or new postnatal ask to see)

16. Each patient/client has a record card for recording treatments and

nursing/midwifery care? (ask to see)

17 Safe facility for disposal of placenta is available?(comment on how

they dispose of placenta)

18 Telephone (or other communication system) is available for calling

for assistance in an emergency and is in good working order?

19 Has there been any maternal death in last 12 months?

(If yes, ask what was the cause and how is it recorded)

21 Has there been any newborn death in last 12 months?

(If yes, ask what was the cause and how is it recorded)

22 Are the protocol and procedure manuals with current information

available in all areas? (Do they use WHO IMPAC)

Additional Notes and comments on deficiencies and general condition

of building:

For Referral Hospital only

A midwife is always available for all 24 hours

(comment if staff shortage prevents safe operating of facility – has


there been any time when a midwife was not available in last 3

months, etc?, if so what was reason for this)

A doctor with EmOC skills is always available 24 hours

Appendix 6: Midwife Self Assessment Tool 116

Appendix 6: Midwife Self-Assessment Tool

District: Date: Age:

Years working in this facility

Site of practice: Clinical area:

Year Graduated

How many years have you been a midwife?

Where do you want to be working in five years time?

Have you attended any postgraduate training since you finished your midwifery

education. Please list some examples….

Births attended in last 12 months: <10 10-20 >20

Do you practice clinically outside this facility? YES NO How many hours per week?

Which services do you provide?

Antenatal care Y/N Attend births Y/N If yes, how many births per month? ___

Birth spacing Y/N Abortions Y/N Diagnosis and treatment of STIs Y/N

Other

TWO TICKS REQUIRED ON EACH LINE:

Tick one of the four options on learning, and one of the two options on how confident

you currently feel to perform the skill.

Code:


Clinical skill 1.

This skill was included in

my midwifery

educational program, and

I felt confident to

perform this skill at the

end of my program

2.

This skill was included in

my midwifery

educational program, but

I did not feel confident to

perform this skill at the

end of my program

3.

I learned this skill

after my midwifery

educational program

(via on the job

training or in-service

training)

4.

I have never

learned this

skill

1.

I do not

feel

confident

to

perform

this skill

2.

I feel

confident

to

perform

this skill

Taking an antenatal

history

Idenitify STIs

Treat STIs

Council for HIV

screening

Screen for HIV

Manage HIV positive

women

Venipuncture

Cannulate


Counsel on birth and

emergency plan

Record findings using

home based and

clinical records

Measurement of

uterine size

Calculating EDC

Identify onset of labor

Determination of fetal

position by abdominal

examination

Identify the second

stage of labor

Manage second stage

of labor

Manage a normal birth

Manage a breech birth

Manage a cord


prolapse

Active management of

3rd stage

Physiological

management of 3rd

stage

Inspection of placenta

and membranes

Perform manual

removal of placenta

Perform episiotomy

Suture perineum

Assess Apgar scores

Rescuscitate a

newborn with bag and

mask

Assist in immediate

breastfeeding

Perform newborn eye

care


Recognize uterus is

well contracted

immediately

postpartum

Examine newborn

Diagnose postpartum

hemorrhage

Manage postpartum

hemorrhage

Diagnose infection in

the newborn and give

appropriate immediate

care for newborn as

per national protocols

Diagnose sepsis in

postpartum women

and give immediate

care according to

national protocols

Recognize women

with eclamptic fits

Manage eclamptic fits


including giving

magnesium sulfate

Provide information

on fertility regulation

and contraception

methods

Effectively support the

breastfeeding woman

Effectively support the

woman who cannot

breastfeed

Effectively monitor

the growth and

development of

children up to five

years of age

Recognise and manage

malnutrition in

children

Recognise and manage

common childhood

illnesses


Knowledge of

immunisation schedule

Administer

immunisations to

women

Administer

immunisations to

women

Appendix 7: List of Stakeholders and Key Informants 123

Appendix 7: List of Stakeholders and Key Informants

STAKEHOLDERS

Name Title Institution

Mrs Mary Roroi A/Director HRM Branch National Department of Health

Dr Dagam, Director Curative Health Services National Department of Health

Dr Polume, Principle Advisor, Family Health National Department of Health

Simon Lugabai Principle Advisor, HR Training National Department of Health

Vincent Micheals Coordinator Church Medical Services

Prof Sir Isi Kevau Executive Dean, SoM&HS University of PNG

Mrs E Jojoga, Chair, Nursing Division, SoM&HS University of PNG

Dr A Tay CEO Port Moresby General Hospital

Dr John Vince Deputy Dean SoM&HS, UPNG University of PNG

Loa Babona Director of Nursing Port Moresby General Hospital

Laitte Moses Registrar Nursing Council

Julie Aengari Dean, School of Nursing, Pacific Adventist University

Glen Mola Professor of Obstetrics, SoM&HS University of PNG/PMGH

Micheal Iwaiz Provincial Health Adviser, Central Province Health Division

Norah Changei Acting Director of Nursing NCD Urban Health Services

Nira Micheal Principal, School of Nursing Lutheran School of Nursing

Judy Alingou Midwife and Nurse in Charge Madang Town Clinic

Dr Razafiarijaona Medical Officer/Director Yagaum Rural Hospital

Galug Sual Acting Director Of Nursing Modilon Hospital

Dr Geita Obstetrician Modilon Hospital

Marcus Kachau Provincial Health Adviser Madang Province Health Division

Fr Jan Csuba President Divine Word University

Dr Michael Mel A/VC and A/PVC Academic Dev. University of Goroka

Dr Jerry Semos A/PVC Administration University of Goroka

Lilian Siwi Section Head, Health Programs University of Goroka

Dr Joseph Appa CEO Goroka Base Hospital

Sonia Vano Korowi Director of Nursing Goroka Base Hospital

Kiddron Gimiseve Deputy Director of Nursing Goroka Base Hospital


KEY INFORMANTS

Gebo Nanu Lecturer paediatrics UPNG

Martha Haluni Midwife and tutor in Midwifery, UPNG

Nancy Buasi Midwife and Lecturer in Midwifery UPNG

Dorothy Kaputin Midwife and lecturer in

Administration and Education, UPNG

Rebecca Evia Midwife and lecturer in Community

Health Nursing UPNG

Agnes Willyman Deputy Director PMGH

Bonita Andrew Unit Manager, Antenatal Clinic PMGH

Hellen Hukula Unit Manager PMGH

Alice Baira Unit Manager PMGH

Lisi Jainana Inservice Tutor PMGH

Susan Kasai O&G Clinical Supervisor PMGH

Jenifer Pyakalyia O&G Unit Supervisor PMGH

Vigini Ure Coordinator Inservice, PMGH

Gebo Tahu Paediatric Unit Supervisor PMGH

Martha Semin Unit Manager, Paediatrics PMGH

Salin Paediatrics PMGH

Delker Margis O&G Clinical Supervisor PMGH

Susan Haroi, Chairperson PNG Nursing Council

Effrie Pereri Asigau Chairperson Registration PNG Nursing Council

Mai Arua Deputy Registrar PNG Nursing Council

Cecilia Palke Education Officer PNG Nursing Council

Martha Madogi Midwife and Lecturer, School of

Nursing Pacific Adventist University

Hettie Asugeni Midwifer and Associate Lecturer,

School of Nursing, Pacific Adventist University

Lester Asugeni Midwife and Lecturer, School of

Nursing, Pacific Adventist University

Dianne Kono Midwife and Associate Lecturer,

School of Nursing Pacific Adventist University


Evelyn Walkai Midwife and Health Promotion

Office Central Province Health Division

Pana Rim, Provincial Disease Control Officer Central Province Health Division

Singat Biels Midwife and Family Health

Coordinator Central Province Health Division

Micheal Masket Health Extension Officer Central Province Health Division

Nrisai Abraham Health Extension Officer Central Province Health Division

Ine Raempom Inservice Coordinator NCD Urban Health Services

Jullienna Haiara Midwife NCD Urban Health Services

Jenny Pyander Midwife NCD Urban Health Services

Mavis Namis Midwife NCD Urban Health Services

Linda Wazami Registered Nurse Madang Town Clinic

Shiela Romany Registered Nurse Madang Town Clinic

Mary Kililo Midwife and Midwifery Lecturer Lutheran School of Nursing

Elizabeth Natera Midwife and midwifery coordinator Lutheran School of Nursing

Julie Kep Strand Leader, Maternal Health University of Goroka

Alice Kauba Strand Leader, Paediatrics University of Goroka

Aiva Pikuri Midwife and Labour Ward Manager Goroka Base Hospital

Date post:	14-Jun-2018
Category:	Documents
Upload:	vuongdien
View:	214 times
Download:	0 times