Training needs of registered midwives in two Comprehensive Emergency Obstetrics and Neonatal Care facilities in Eswatini

A cross-sectional study of 202 midwives in Eswatini identified significant training needs across all measured categories, with research/audit and newborn resuscitation emerging as the highest priorities to inform targeted emergency obstetrics and neonatal care programs.

The Gist

Imagine the healthcare system in Eswatini as a massive, high-stakes rescue operation. Every day, midwives are the first responders on the front lines, rushing to save mothers and babies during dangerous emergencies. But even the best firefighters need their gear checked and their skills sharpened regularly. If they haven't practiced a specific rescue technique in a while, their reflexes might get a little rusty.

This paper is essentially a "Gear Check and Skill Audit" for 202 midwives working in two major hospitals in Eswatini. The researchers wanted to answer one simple question: "What specific tools and training do these heroes need right now to do their jobs even better?"

Here is the breakdown of their findings, using some everyday analogies:

1. The Problem: The "Rusty Tool" Effect

The study starts by noting that despite having skilled staff, many mothers and babies are still dying. Why? Sometimes, skills fade away if they aren't used often (a phenomenon called "skills decay"). It's like a musician who hasn't played their instrument in years; they know the notes, but their fingers aren't as fast as they used to be. The researchers realized that to fix this, they couldn't just guess what training was needed. They had to ask the midwives directly.

2. The Method: The "Self-Reported Menu"

The researchers handed out a questionnaire (a digital or paper menu) to the midwives. They asked them to rate two things for 37 different tasks:

• How important is this task? (Is it a life-or-death situation?)
• How well do I currently perform it? (Do I feel confident, or am I struggling?)

If a task was marked as "Super Important" but the midwife felt they were only "Okay" at it, that gap represented a Training Need.

3. The Results: What the Midwives Said They Needed

The findings were like a map showing exactly where the potholes were in the road.

• The Biggest Gap: Research and Auditing (The "Map Makers")
  Surprisingly, the highest need wasn't just about delivering babies; it was about Research. The midwives felt they needed better training on how to study their own work, analyze data, and audit their results.

  • Analogy: Imagine a chef who is amazing at cooking but doesn't know how to taste-test their own dishes or read a nutrition label to improve the recipe. They need to learn how to be their own critics to get better.

• The Runner-Up: Clinical Skills (The "Hands-On Heroes")
  This was the second biggest need. These are the actual medical procedures: stopping bleeding, delivering babies in tricky positions, and resuscitating newborns.

  • Analogy: This is like a mechanic realizing they need a refresher course on the newest engine models. They know the basics, but they need to practice the specific, high-pressure repairs.

• The Other Needs:

  • Administration: Learning how to manage paperwork and use computers (the "Office Manager" skills).
  • Communication: Learning how to talk to patients and work as a team without friction (the "Team Huddle" skills).
  • Supervision: Learning how to lead and manage others (the "Coach" skills).

4. The Specific "Must-Haves"

When asked for the single most important thing they needed to learn, the midwives voted overwhelmingly for Newborn Resuscitation (saving a baby who isn't breathing).

• Analogy: If the hospital is a lifeboat, this is the skill of knowing exactly how to pump the air back into a person who has stopped. It is the most critical, immediate skill on the list.

5. The Conclusion: Tailoring the Training

The researchers concluded that you can't just give everyone a generic "First Aid" course. It's like trying to teach a pilot how to fly a helicopter using a manual for a boat.

The training needs to be custom-made.

• If the midwives are struggling with research, send them to a research workshop.
• If they are shaky on newborn resuscitation, run intensive simulation drills for that specific skill.

Why This Matters

By identifying exactly where the gaps are, the Ministry of Health can stop wasting money on training that isn't needed and start pouring resources into the areas that will actually save lives. It's about making sure that when the emergency alarm rings, every midwife has the right tools, the sharpest skills, and the confidence to handle whatever comes their way.

In short: This paper is a call to action to stop guessing and start listening, ensuring that the people who save lives are given the specific training they need to keep saving them.

Technical Summary

1. Problem Statement

Despite high rates of institutional delivery (92.7%) and skilled birth attendance (93.4%) in Eswatini, the country continues to face critical challenges in maternal and neonatal mortality. The Maternal Mortality Ratio (MMR) stands at 452 per 100,000 live births, and the Neonatal Mortality Ratio is 21 per 1,000 live births. While the Sexual and Reproductive Health Unit (SRHU) provides training, mortality rates remain high, suggesting a gap between current training programs and actual performance needs.

The core problem identified is the lack of evidence-based training programs informed by a systematic Training Needs Analysis (TNA). Existing training often lacks specificity regarding the actual knowledge and skills gaps of midwives, particularly in Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) facilities. Furthermore, previous TNA studies in the region often relied on convenience sampling (limiting generalizability) or were conducted in high-income countries, making their findings less applicable to the Eswatini context.

2. Methodology

The study employed a quantitative, descriptive, cross-sectional study design to assess the training needs of registered midwives.

• Study Setting: Two CEmONC hospitals in Eswatini:
  • Site A: Hlathikulu Government Hospital (Regional referral, Manzini).
  • Site B: Mbabane Government Hospital (National referral, Mbabane; includes a NICU).
• Population & Sampling:
  • Target: Registered midwives working at both sites.
  • Sample Size: $N=202$ midwives.
  • Sampling Technique: Simple random probability sampling was used to select respondents from scheduling timetables to ensure homogeneity and reduce bias.
• Data Collection Instrument:
  • An adapted Hennessy Hicks Training Needs Questionnaire.
  • The original tool (30 items, 5 categories) was adapted by adding 7 items specific to Maternal and Newborn Health (MNH) based on literature and expert consultation, resulting in 37 items.
  • Categories: Research/Audit, Communication/Teamwork, Clinical Tasks, Administration, and Supervisory/Management.
  • Indicators: Respondents rated items on a 7-point Likert scale for Perceived Task Importance (A) and Perceived Task Performance (B). Training need was calculated as the difference ($A - B$).
• Data Analysis:
  • Data were analyzed using SPSS version 29.
  • Descriptive statistics (means, standard deviations) were calculated.
  • Paired sample t-tests were used to determine the statistical significance of the differences between task importance and performance for each category ($p < .05$).
  • A criterion of Standard Deviation (SD) > 1.5 was applied to identify the "highest" training needs.
• Ethical Considerations: Approval was obtained from the University of Johannesburg and the Eswatini Health and Human Research Review Board (EHHRRB). Informed consent was secured, and data were anonymized.

3. Key Contributions

• Context-Specific TNA: This is one of the first studies to conduct a rigorous, random-sampled TNA specifically for midwives in Eswatini's highest-level referral facilities, moving beyond convenience sampling.
• Tool Adaptation: The study successfully adapted the validated Hennessy Hicks tool for the Eswatini context, incorporating specific MNH items (e.g., newborn resuscitation, PPH management) without compromising psychometric validity.
• Holistic Scope: Unlike many studies focusing solely on clinical skills, this research evaluates needs across five distinct domains: research, clinical, administrative, communication, and supervisory tasks.
• Evidence for Policy: The findings provide empirical data to guide the Ministry of Health in Eswatini to allocate resources toward specific, high-impact training areas rather than generic programs.

4. Key Results

• Demographics: The mean age of respondents was 38.06 years. The majority (26.2%) were aged 40–44, and 37.1% had 5–9 years of work experience. 75.2% held a Bachelor's degree in nursing with a midwifery option.
• Overall Training Needs: All 37 measured items indicated a training need (Performance scores were lower than Importance scores).
• Category Rankings (Mean Difference Scores):
  1. Research/Audit: Highest need ($M=2.23 \pm 1.05$).
  2. Clinical Tasks: Second highest ($M=1.94 \pm 0.55$).
  3. Administration: ($M=1.70 \pm 1.00$).
  4. Communication: ($M=1.57 \pm 0.79$).
  5. Supervisory/Management: Lowest need ($M=1.14 \pm 0.76$).
  • Statistical Significance: All category pairs showed statistically significant differences between importance and performance ($p < .001$).
• Specific High-Priority Needs:
  • Top Specific Item: Critically evaluating research ($M=3.02$).
  • Top Clinical Skill: Newborn Resuscitation was identified as the single highest specific training need by 30.2% of respondents.
  • Other Critical Needs: Maternal CPR (24.3%), Vaginal Breech Delivery (11.9%), Shoulder Dystocia (9.9%), and Management of Postpartum Hemorrhage (8.9%).
  • Open-Ended Responses: Reinforced the need for training in puerperal sepsis, obstructed labor, APH (Antepartum Hemorrhage), and respectful maternity care.

5. Significance and Recommendations

• Addressing Skills Decay: The study highlights that infrequent use of clinical skills (e.g., resuscitation, breech delivery) leads to skills decay, necessitating targeted refresher training.
• Research Capacity: The high rating for research/audit needs suggests a gap in midwives' ability to conduct and utilize research for evidence-based practice, which is crucial for improving clinical outcomes.
• Tailored Training Programs: The authors recommend that the Ministry of Health and training institutions move away from generic training. Instead, programs must be tailored to address the specific gaps identified:
  • Prioritizing Newborn Resuscitation and Maternal CPR.
  • Integrating Research and Audit skills into continuing professional development.
  • Strengthening Administrative and Communication skills to improve team collaboration and patient safety.
• Impact on Mortality: By aligning training with these specific needs, the study posits that Eswatini can improve the competency of midwives in managing obstetric emergencies, thereby directly contributing to the reduction of maternal and neonatal mortality rates in line with Sustainable Development Goals (SDGs).

Limitations: The study was limited to two urban CEmONC facilities, excluding rural and private sectors, which may present different training needs. Additionally, the use of self-reported data introduces the potential for recall bias.