Findings from a context specific accreditation assessment at 38 public midwifery education institutions in Bangladesh

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Findings

from

a

context

speci

ﬁc

accreditation

assessment

at

38 public

midwifery

education

institutions

in

Bangladesh

Malin

Bogren

a,

*,

Afroza

Banu

b

,

Shahnaj

Parvin

b

,

Merry

Chowdhury

c

,

Kerstin

Erlandsson

d,e

a

InstituteofHealthandCareSciences,SahlgrenskaAcademy,UniversityofGothenburg,ArvidWallgrensbacke1,41346Gothenburg,Sweden

b

DirectorateGeneralofNursing&Midwifery(DGNM),Sher-E-BanglaNagarNursingCollege(AcademicBuilding),Sher-E-BanglaNagar,Dhaka,1207, Bangladesh

c

ChattogramNursingCollege,57,K.B.FazlulKaderRoad,P.S.PanchlaishP.O.Chattogram-4203,Bangladesh

d_School_of_Education,_Health_and_Social_Studies,_Dalarna_University,_Falun,_Sweden e_Department_of_Women’s_and_Children’s_Health,_Karolinska_Institute,_Solna,_Sweden

ARTICLE INFO Articlehistory: Received29April2020

Receivedinrevisedform30May2020 Accepted25June2020 Availableonlinexxx Keywords: Midwiferyeducation Accreditation Qualityassessment Bangladesh SouthAsia ABSTRACT

Background:Inordertopromotesustainablemidwiferyeducation,itisimportanttounderstandwhatthe structuralshortcomingsare.Inthisstudyof38publicnursinginstitutionsinBangladesh,weaimto identifyanumberofstructuralshortcomingsandtodiscussstrategiesforlimitingthem.

Methods: Anevaluatedcontext-speciﬁcaccreditationassessmenttool consistingof37multi-choice closed-responsequestionsencompassing14educationalstandardsalignedwithinternationalstandards formidwiferyeducationprogramsandcompetencesformidwiferyeducatorswasusedtoassessall publicnursinginstitutionsinBangladesh(n=38),theresultsofwhicharepresentedinsimpledescriptive statistics;number(n),percentage(%),mean,SDandminimum-maximumvalue.

Results:ProvisionaroundclinicalpracticesitesisthekeystructuralshortcomingwithintheBangladeshi midwifery educational system. Twenty-five percentof theinstitutions provided no opportunityfor midwifery studentstopracticecomprehensivesexualandreproductivehealthcare.Twenty-nineper cent of the clinicalsiteswerenotawareofthecontentofmidwifery courses andsyllabi.Finally,onethirdofstudents achievingamidwiferyqualificationdidnotmeetthelearningoutcomestosupportwomeninbirth. Conclusions:Tomeasureprogresstowardsnationalandglobalmilestonestoensurestudentsareequipped withrequiredcompetenciesbeforegraduatingasregisteredmidwiveswillbedifficulttomeetunless shortcomingswithintheeducationalsystemareaddressed.Werecommend(i)theinclusionofclinical placementsitesinfutureassessments,(ii)theintroductionofanintegratedfeedback-appeal-response system,and(iii)thedevelopmentofasystemforimprovedcommunicationlinksbetweeneducational institutionsandclinicalplacementsites.

Statementofsigni_ﬁcance Problemorissue

There is an inconsistency globally in midwifery education programsintermsoftheeducationalrequirements,resources,

facilities, services, and assessment strategies needed to guaranteequalityinmidwiferyeducationalprograms. Whatisalreadyknown

In Bangladesh, midwifery education informed by global standardsexists,buttherewasnoeducationaccreditation systemforaf_ﬁrminghighqualitymidwiferyeducationuntila contextspeci_ﬁc accreditation assessment toolwas devel-opedandpilottestedin2017.

Whatthispaperadds

Acontext-speciﬁcaccreditationassessmenttoolcanbeused asabenchmarkfromwhichtomeasureprogresstowards

Abbreviations: BNMC, Bangladesh Nursingand Midwifery Council;DGNM, DirectorGeneralofNursingandMidwifery;ICM,InternationalConfederationof Midwives;SRH,SexualandReproductiveHealth;UNFPA,UnitedNationsPopulation Fund;WHO,WorldHealthOrganization.

* Correspondingauthor.

E-mailaddress:malin.bogren@gu.se(M.Bogren). http://dx.doi.org/10.1016/j.wombi.2020.06.009

xxx–xxx

ContentslistsavailableatScienceDirect

Women

and

Birth

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national and global milestones to ensure that students obtain required competences before graduating as regis-teredmidwives.

Background

Healthy lives and quality education are two of the most importantAgenda2030sustainabledevelopmentgoals[1].This requiresatransformativeup-scalingofthemidwiferyeducation programinmanylow-andmiddleincome countriessothatthe quantityofalocalmidwivesisincreased,theirqualityisimproved and the country’s health system and its sexual, reproductive, maternal and newborn health outcomes are strengthened [2]. However,supportinganeducationalsystemthatcanproducehigh qualitymidwiferycareisaseriouschallengeformanycountries, especiallythosewhere economic andeducationalresourcesare scarce[3].

Since the start of the three-year direct entry midwifery educationprogrammeatdiplomalevelin2013,morethan3000 midwives have graduated in Bangladesh. These midwives are deployedatasecondarycarelevelandinhumanitariansettings, andareprovidingcareduringpregnancy,labourandbirthandthe periodafter [4]. Bangladesh,with acurrent maternalmortality ratioof173per100,000livebirthsandaneonatalmortalityratioof 17.1per1000livebirths[5],hashenceinrecentdecadesrapidly scaled up its midwifery education system [4,6], increased its midwifery educator capability [7–9], improved students’ job preparedness [10] and integrated midwives into the wider healthcaresystem[11]. Allof thiswas donetomeetthesexual and reproductive, maternal and newborn health needs of the countryandtoreachinternationalhealthgoalssetbytheUN.Asa further step in this development process, in 2017 Bangladesh introduced a context-speciﬁc accreditation tool for accrediting midwifery education programs that met international quality standards[12].

Acrosstheworld,midwiferyeducationprogramsvarywidelyin termsof theireducational requirements, facilities,services and assessment strategies [13–15]. A key quality marker for a midwiferyeducationprogramis itsadoptionof theICMGlobal StandardsforMidwiferyEducation[16]andtheWHO’sMidwifery Educator Core Competencies [17]. One strategy to ensure midwiferyeducation meets these international standards is to promotethe accreditationof midwifery programswhich adopt them.AdvicefromICMandWHOsuggestsusingthemomentum whichhasledtotheadoptionofanaccreditationsystemtopush forqualityimprovementsintheeducationalinstitutionsthatteach midwifery.Ideally,thisshouldbedonealongsidetheintroduction ofaccreditationguidelines[18–20].

Strongmidwiferyinstitutionsareessential.Theyneedtohave aneffectiveinfrastructurewhich cansupportqualitymidwifery teaching. Where such institutions are weak, or failing, they themselves need to be supported so they can improve the competenciesofstaff,increasestaffnumbers,reformadmissions criteria, and in general, strengthen students’ competencies througha revised and updated curriculum [19]. This is critical work:maternalhealthcaresystemsdependonproperlyeducated midwiveswiththe appropriate competencies who canprovide highstandardsofsafe,evidence-basedcare.

Inordertopromotequalityimprovementsinweakorstruggling midwiferyeducation institutions it is of critical importance to understandwhattheirstructuralshortcomingsareandhowthey canbestbeaddressed.Actiontoimproveperformanceshouldthen betaken,withanopportunityforre-assessmentafterasetperiod. Inthis studyof 38nursingcolleges/institutes inBangladesh, in

ordertosustainmidwiferyeducation,weaimtoidentifyanumber ofstructuralshortcomings thatareindicative oftheissuesthat manymidwiferyeducationinstitutionsinmanylow-andmiddle income countries face. We used an evaluated context-speciﬁc accreditation tool to measure the performance across several areas. This assessment took place during the development of nationalaccreditationstandardsandduringthedevelopmentof theICMaccreditationguidelines[19].

Method

Studydesignandsettings

Thisstudy wasconducted betweenMarchand June 2018.A cross-sectional assessment of nursing colleges/institutes where midwiferyeducationprograms aretaught, in each of theeight geographicaldivisionsinBangladesh,wascarriedoutusingdata takenfromanaccreditationquestionnairedevelopedaspartofa midwiferyaccreditationprogramintroducedin2017.Toensurefull coverageofeducationalprovisionacrossthecountry,allofthe38 publiceducationalinstitutionsinBangladeshwereincludedinthis study.Becausetheaccreditationquestionnaire(whichisdescribed elsewhere asan accreditation‘tool’)was designed accordingto international midwifery educational standards and educators’ competences[16,17]itformedaqualitybaselineagainstwhichthe Bangladeshi midwiferyeducationprogramscouldbemeasured. EthicalclearancewasobtainedfromtheEthicalReview Commit-tee:CentreforInjuryPreventionandResearch,Bangladesh,CIPRB/ ER/2018/12.

TheBangladeshmidwiferyeducationsystemiscentralizedand fallsundertheauthorityoftheDirectorateGeneralofNursingand Midwifery(DGNM)and theBangladesh Nursingand Midwifery Council(BNMC).TheDGNMisresponsiblefortherecruitmentand deploymentofeducatorsandstudentswhiletheCouncildevelops and approves teaching curricula for midwifery programs. The Council alsovalidatespublicand private colleges/nursing insti-tutes and provides for the registration, licensing and licensing renewal of midwives.Nursing colleges in Bangladesh generally offera three-yearmidwiferyeducationprogram thatleadstoa diploma inmidwifery.These collegesarelocatedatthedistrict levelandareusuallyattachedtotertiaryhospitalsthatreceivea highlevelofreferralsfromtheprimarylevel.Anursinginstituteis situatedatthedistrictlevelandisafﬁliatedwithgeneralhospitals. Theterminstitutionreferstobothnursingcollegesandnursing institutes.Thenumberofeducationalinstitutionsandgraduatesin Bangladeshhasgrownrapidlyinthepastdecadeandthereisnowa large midwifery education sector. The educational institutions, with their increasing number of residential students, act as economicalhubsofferingdeploymentopportunitiestothefuture midwives[21].

Thecontext-speciﬁcaccreditationassessmenttool

Usingaparticipatoryconsensus-buildingapproach,aworking groupofsenior government of_ﬁcials,national andinternational academicsandtheBangladeshMidwiferySociety,developedaset of 14 accreditation standards for midwifery education in Bangladeshaimedatimprovingthequalityofmidwifery educa-tion. These standards, along with an assessment tool for the accreditation of midwifery institutions and programs, were endorsedandapprovedforusein2018bytheDGNMandBNMC. TheaccreditationassessmenttoolwasdevelopedusingtheICM Global Standardsfor Midwifery Education [16] and the WHO’s MidwiferyEducatorcorecompetencies[17]andcontextualizedfor theBangladeshisetting.Thetoolcomprisesastructured question-naire with37 multiple-choice closed-response questions struc-turedintoﬁveareas:organizationandadministration;midwifery

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faculty; student body; assessment strategies; and, curriculum. Institutionsareexpectedtoachieveaminimumstandardineach areain order to gain ofﬁcial accreditation for their midwifery program.Thedevelopment,contentand piloting ofthis assess-menttoolhasbeendescribedindetailelsewhere[12].

Datacollectionandparticipants

In2018,twonon-Bangladeshimidwivesandresearcherswith advancedknowledgeandexperienceofthemidwiferyeducation systeminBangladeshtrained10Bangladeshimidwiferyeducators intheuseofthecontext-speci_ﬁcaccreditationtool.Thetraining consistedofanorientationsessionandinstructioninone-daydata collectionmethodsandprocesses.Alloftheeducatorshadbeen part of the accreditation tool’s development process, so were familiarwithitsobjectivesandcontent.Duringthetrainingthese educators were able to discuss issues, practice interview and assessmenttechniques,acquiredatacollectionskillsandreceive feedback ontheirperformance. Once completed,theeducators weregroupedintoﬁveassessmentteams,eachcomprisingtwo’ assessors’.Eachassessmentteamwasgivenaweeklyscheduleof assessments that needed to be completed over a three-month period.

Thedata collectionwas approvedbythe DGNM, BNMCand Principals at all institutions.All participantswere given verbal informationaboutthestudyandtheirrights,suchastherightto refrain from answering a question or to discontinue without explanationatanytime.

Datawerecollectedatall(n=38)publicmidwiferyeducational institutionsthatofferedthe3-yearmidwiferyeducationprogram betweenFebruaryandJuly2018.Theassessmentteamvisitedeach institutionontheirlistand, duringaface tofacemeeting with representativesfromtheinstitutions,completedtheaccreditation questionnaire.Theserepresentativesusuallycomprisedagroupof 4–10midwiferyeducatorsandclinicalpreceptors.Itwas consid-eredpreferabletoadoptthisgroupsurveyapproach,ratherthan completingthequestionnairewithanindividualcollegemember, in order to avoid the possibility of missing or conﬂicting informationfromwithinthesameinstitution.Theanswerswere completedinEnglish,butdiscussionsaroundthesewereheldin thelocallanguage.Theassessmentvisitendedwithatourofthe midwifery institution. Characteristics of the participants are illustratedinTable1.

Dataanalysis

Descriptive analyses were computed for the background variables relating to age, designation, degree and number. Descriptive statistics werenumber (n=), percentage (%), mean, SD, and minimum and maximum value. Other variables were relatedtotheﬁvecompetenceareaswithpossibleresponsesasYes or No with two lines for opentext entries.The analyses were carriedoutusingExcelsoftwareTM_._All_the_data_were_entered_and

storedinapassword-protecteddatabasetofacilitatecon ﬁdential-ityandconsistentanalysisbytheﬁrstandlastauthors.

Results

Characteristicsofinstitutionsdeliveringmidwiferyeducation programs

Thirty-eightinstitutions participatedin thesurvey:27 (71%) werenursinginstituteswhilenursingcollegesare11(29%).Taken together,theseinstitutionshadacombinedstudentbodyof8544, giving each institution on average 224.8 students. The total numberofstudentsstudyingmidwiferywas2849,oranaverageof 75studentsperinstitution.Thetotalnumberofeducatorsteaching midwiferycourseswas387,givinganaverageof11.7midwifery teachersateachinstitutionat33reportinginstitutions.

Assessmentﬁndings

Theﬁndingsfromtheassessmentarepresentedusingthesix midwiferyeducatorcompetencydomainsasdeﬁnedbytheWHO [17](Fig.1).

1.Ethicalandlegalprinciplesofmidwifery

Competencydomain1:Midwiferyeducatorsincorporateandpromoteethical andlegalaspectsofmidwiferycareinteaching/learningactivitiesandby consideringrolemodeling.

Area1)organizationandadministration

The ethical and legal principles of midwifery and the role modelingofthesewasanimportantfeatureintheorganization and administration of the majority of Bangladeshi midwifery institutions. All 38 institutions (100%) stated that they imple-mented these principles, from their recruitment of students, throughtheirretentionanddeploymentprocessesandthroughout theiroverall approach.Twenty-ﬁve(66%)of the38 institutions reported that those involved in the admissions process had receivedsometraininginrecruitmentandselection.Ofthese25 institutions a further 14 (56%) reported that their midwifery educatorshadreceivedtrainingin:

-planningforrecruitmentandselection

-assessinganddeterminingshortlistingandselectioncriteriaand -monitoringtheeffectivenessofselectionprocesses.

Fortheremaining11(44%)institutions,educatorshadreceived traininginoneortwoofthethreeprocedures.

Theprincipaland/ornursinginstructorscarriedoutselection processes.Thirteen(34%)institutionshadaclearadmissionspolicy and six (16%) had clear entry guidelines that outlined linked employmentopportunitiesupongraduation.Twenty-three(61%) institutionsrequiredprospectivestudentstowriteatextinEnglish and12(32%)institutionsatextinBangla.Amajorityofinstitutions (23,or61%)madeitclearonentrythatmidwiferystudentshada governmentemploymentaftertheirgraduation.

Table1 Characteristicsofparticipants(n=256)n(%). Gender Female 255 (996%) Male 1(0,4%) Age Range 35 59 Mean 50

Designation NursingInstructor/Educator 165 (64%) NursingInstructorincharge 11(4%)

Principal 8(3%)

SeniorStaffNurse 49(19%)

NursingSupervisor 11(4%)

NursingSuperintendent 12(5%)

Academicqualiﬁcation PhD 1(0,4%)

Masters’degreeinPublic Health/Sexual,Reproductive andPerinatalHealth/Nursingand Midwifery

205 (80%)

BachelordegreeNursing/PublicHealth 29(11%) DiplomainNursingandMidwifery 21(8%) Numberofworking

experience

Range,year 0–38

Mean,year 246

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Educatorsat25institutes(71%)outof35reportedtheywere abletooffertheadviceand guidancenecessarytodevelopsafe women-centered practice that enabled students to become effectivemidwives.Ten (29%)institutions statedthey werenot abletoofferthisadvice.

2.Midwiferypractice

Competencydomain2:Midwiferyeducatorsmaintaincurrentknowledgeand skillsinmidwiferytheoryandpracticebasedonthebestevidenceavailable. Area2a)midwiferyfaculty

Bangladesh has, since the inception of midwifery as a profession in 2010, provided a 6 month training course in midwiferyfor nursingeducators[4]. Atthe time this datawas collected70(16.7%)outofareported418educatorstaughtonthe midwiferyprogramand51(12.2%)hadmaster_’sdegreesinsexual andreproductiveandperinatalhealth.Twohundredandsixty-two (62.7%)hadmaster’sdegreesinotherareassuchasreproductive and children’s health, public health, health promotion and educationandhospitalmanagement.Afewhadamaster’sdegree fromtheHighlySkilledMigrantprogram.Fifteen(3.2%)hadPhDs inhealthscience,healthandmedicinescience,nursing, adminis-trationoradultmedicineandsurgery.

Outofatotalof418educators,only53(12.7%)ofthosewitha master’sdegreetaughtonlymidwifery.Onlythirty-three(7.9%)of thenursing educators who had received additional training in midwiferyeducationtaughtexclusivelyonamidwiferyprogram. Mosteducatorsteachingonthemidwiferyprogramweretoagreat extentinvolvedinthenursingprogram.

Midwifery educators maintain their current knowledge and practice-basedskills throughongoingprofessionaldevelopment andwhensupervisingstudentsinclinicalplacement.Thirty(86%) out of35 reportinginstitutionsreportedtheyhad formalskills trainingopportunitiesformidwiferyeducators.Twenty-_ﬁve(74%) out of 34 institutions reported that the educators had the competence to lecture simulation-based sessions. Thirty (86%) outof35reportedthattheymaintainedthecompetencyoftheir midwifery educators through more general staff development events.

3.Theoreticallearning

Competencydomain3:Midwiferyeducatorscreateanenvironmentthat facilitateslearning.

Area2b)midwiferyfaculty

Midwiferyeducatorscreatedapositivelearningenvironment thatatmanyeducationalinstitutions.Forinstance,theskillslab wasorganizedaroundICMmidwiferycompetencesat30(86%)out of 35 reportinginstitutions.Educatorsfrom25 (71%)of the35 reportinginstitutions(35)statedtheyofferedappropriatelearning opportunitiesfortheirmidwiferystudents.Skillslabs,librariesand computerlabsweremostfrequentlymentionedasthemethods usedtoenablestudentstogainhands-onpractice.Educatorsat26 (74%)outof35institutionsclaimedtheyhadtheresources(mobile phone,computer,internetaccess)theyneededtosupportstudents oncampusandwhileontheirclinicalplacements.However,allof the institutions reported that there was nobudget for clinical preceptorsattheclinicalsites.Thirteenoutof38(34%)institutions

Fig.1.Midwiferyeducator’scompetencydomains. xxx–xxx

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thereforestatedthattheyregularlyspenttimesupportingstudents onclinicalplacement.Thissuggeststhat25(66%)providednosuch support.

4.Learningintheclinicalarea

Competencydomain4:Midwiferyeducatorscreateanenvironmentfor effectiveclinicalteachingofmidwiferycare.

Area3)studentbody

Table2showsthatthemajorityofmidwiferyeducatorsprovide clinicallearningopportunitiesacrossthespectrumofreproductive healthcarebyarrangingclinicalplacementsforstudentsinvarious hospital wards. The number of midwifery students in clinical education at the time for the assessment was reported to be between3to75midwiferystudents(meanvalue23.4,SD24.9).

Table3showsthatthemajorityofinstitutions_’provideteaching acrossawiderangeofclinicalareas.

5.Assessmentandevaluationofstudentsandprograms

Competencydomain5:Midwiferyeducatorsareresponsibleforconducting regularmonitoring,evaluationandassessmentofprogramsandstudents. Area4)assessmentstrategies

Tables4and5showhowinstitutionsreportedtheassessment andevaluationoftheirstudentsandtheirclinicalperformance.

Recordsofhowstudents hadperformedacademicallybefore goingoutonplacementwassharedby28(78%)ofthemidwifery institutions with the healthcare professionals at their clinical partner sites. Thirteen institutions (36%) reported that their midwiferyeducatorscontactedclinicalpartnersitestafftocheck students’performanceonadaily(0,or0%),weekly(8,or22%)or monthly (13, or 36%) basis (n=36). Seven (19%) out of 37 institutions acknowledged that assessments required by the curriculum and course syllabi to prove eligibility for a ﬁnal qualiﬁcationwerenotalwayscompleted.

6.Organization,managementandleadership

Competencydomain6:Organization,managementandleadership Area5)curriculum

Allinstitutions(38)reportedthattheircurriculumwasaligned withnationalhealthpoliciesattheorganizational,management andleadershiplevel.Thirty-seven(97%)oftheinstitutionsstated they had been part of developing the national curriculum. Midwiferyeducatorshad participated in formulatingthepolicy andprogramoutcomesandindesigningandimplementationthe curricula.

AsTable6shows,themajorityofinstitutionsensuredthattheir studentshadfulﬁlledalloftherequiredclinicalcomponentsprior tograduation.Thatsaid,10institutionsacknowledgedthattheir studentshad notmettherequirementsfornormalbirthsanda further8failedtorespondtothisquestionatall.

Itisthemidwiferyeducatorswhoareresponsibleforinforming thehealthcareprofessionalsattheclinicalpartnersitesaboutthe contentoftheirtrainingprograms,includingcurriculumstructure, coursecontentandlearningoutcomes.Twenty-seven(71%)of38 reporting institutions declared that theyshared their learning outcomes withtheir clinicalpartners at thebeginning of each semester.

Discussion

This study of 38 public institutions shows the structural shortcomings of midwiferyeducation programs in Bangladesh. Theseshortcomingsweremadeevidentthroughtheintroduction

Table2

Midwiferyeducator’sarrangementsforstudents’learningwithinthespecialist areasofreproductivehealthreportedfrom36institutions.

YES NO

Antenatalcare 36(100%) 0(0%)

Maternitytriage 22(61%) 14(39%)

Maternitywardincludinglaborward 36(100%) 0(0%)

Postnatalward 36(100%) 0(0%)

NewbornandnewbornICUdepartment 30(83%) 6(17%)

Operationtheatre 35(97%) 1(3%)

Gynae/cervicalandbreastcancerscreening 27(75%) 9(25%) Manualvacuumaspiration/menstrualregulation 21(58%) 15(42%)

Familyplanning 30(83%) 6(17%)

UpazilaHealthComplex(secondarylevelofcare) 11(31%) 25(69%) Communityunionorclinic(primarylevelofcare) 3(8%) 33(92%)

Table3

Institutions’provisionofclinicalcomponentsofmidwiferystudents’learning(n =36).

YES NO

Activeﬁrststagemanagementofbirth 27(75%) 9(25%) Initiation,establishmentandmaintenanceof

breastfeeding 31(86%) 5(14%) Partographinterpretation 24(67%) 12(33%) Newbornresuscitation 29(81%) 7(19%) Intrapartumcare 30(83%) 6(17%) Familyplanning 28(78%) 8(22%)

Careofnewbornswithspecialneeds 29(81%) 7(19%) Assessmentofwomen6weekspostpartum 19(53%) 17(47%) Managementofnewbornillness 29(81%) 7(19%)

Table4

Evidenceoftheassessmentandevaluationofstudents’achievementsinthemidwiferyprogram.

YES NO

Midwiferyeducatorsmonitorandfollowupstudents’recordsofclinicalexperienceasperlog-booksandchecklists (responsefrom37institutions)

31(84%) 6(16%)

Midwiferyeducatorsgradestudents’recordsofclinicalexperienceinlogbooksaccordingtochecklistsrequiring examinationof30full-termnewborns,100antenatalandpostnatalepisodesandatleast30normaland10assisted births(responsefrom35institutions)

27(77%) 8(23%)

Thesign-offclinicianforstudents’clinicalachievementsisaclinicallypracticingnurse/midwife/doctor(responsefrom 36institutions)

31(86%) 5(14%)

Assessmentstrategiesusedtoassessstudents’knowledge,practicalskillsandattitudesinclude:

–Writtenexaminations(responsefrom36institutions) 36(100%) 0(0%)

–Vivavoceexamination(responsefrom37institutions) 37(100%) 0(0%)

–Roleplay(responsefrom37institutions) 35(95%) 2(5%)

–ObjectiveStructuredClinicalAssessment/Examination(OSCA/OSCE)(responsefrom36institutions) 32(89%) 4(11%) Students’complainaboutfacultybeingunfairandbiasedinassessinglearning(responsefrom36institutions) 6(17%) 30(83%)

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ofacontext-speciﬁcaccreditationassessmenttool[22]whichwas basedontheICM’sGlobalMidwiferyEducationsStandards[16] andtheWHO’smidwiferyeducatorcorecompetencies[17].The toolrevealedthatthemainproblemwithmidwiferyeducationin Bangladeshwastherelationshipbetweenthemidwifery educa-tionalinstitutions and theirclinical placement sites.The study showedthat29%oftheclinicalpreceptorswerenotawareofthe expectedlearningoutcomesforthemidwiferystudents’clinical practice.Forexample,few of themrealized that students were requiredtohavehands on 40births in ordertograduate.This explainswhystudentsat33%ofthemidwiferyinstitutionsdidnot meettheclinicalrequirementsforsupportingbirths.Bestpractice clinicalmidwiferysupervisionmodelstoachieveclinical require-mentsis a global challenge [23]. This needs tobe particularly addressedinBangladesh,asone-thirdofBangladeshimidwifery studentswillsuccessfullygraduatewithoutachievingthe compe-tenciesdeemedbyinternationalstandardsandlocalregulationsto be an effective and well-educated midwife [24]. One solution might be to establish formal communication links between educators at the institutions and preceptors at the clinical placementssites.Thiscouldincludescheduledmeetingsbetween student,clinicalpreceptorandeducatortodiscussthestudents’ learning progress towards set learning outcomes. This would reducethenearly30%ofinstitutionsreportingthattheireducators hadnocontactwiththeirclinicalplacementsites.Inarecentstudy of the implementation of the context-speciﬁc accreditation assessmenttoolinBangladesh[25],midwiferyeducatorsreported thattheintroductionoftheaccreditationprocesshadencouraged them to visit their clinical sites more frequently and that the communication between the clinical sites and the educational institutions had improved as a result. This can perhaps be explainedbythefactthatsince2016theUnitedNationsPopulation Fund (UNFPA) and the Bangladesh government supported the development of the national midwifery educational program throughpartnershipagreementswithnationalandinternational organizationssuchasSavetheChildrenandUCEPinBangladesh, theRoyalCollegeof Midwivesin theUnited Kingdom, andthe DalarnaUniversity, Sweden. To improve learning outcomes for midwiferystudents,localphysicianshavebeenfundedtosupport selectedclinicalplacementsitesacrossthecountryandanonline mentorshipprogram,availabletoall38educationalinstitutions, hasbeendeveloped incooperationwithUNFPABangladeshand DalarnaUniversitytoencouragemidwiferyeducatorsto imple-ment the national curriculum [9]. Despite these efforts, 9

institutions (25%) in this study indicated that there was no opportunityfortheirmidwiferystudentstopractice comprehen-sivesexualandreproductivehealthcare,five(14%)reportedthat theirstudents couldonlyobservereproductive healthpractices andthattherewaslittleopportunityforthemtoassistorpractice midwiferyinclinicalplacementsites.Theissuesregardingthelack ofclinicalexperienceinmidwiferyeducationaslackof relation-shipsbetweentheeducationinstitutes,arechallengesalsoinother countriesandidentifiedintherecentWHOStrengtheningQuality MidwiferyEducationframeworkforaction[2].Supportivereview fromothercountriesonthisissue[23],wouldclearlybenefitthe wayforwardinBangladesh.

Thisstudyalsofoundthat14%oftheinstitutionsdidnothavea simulationlaborganizedtoenablelearninginformedbytheICM competencies,26%oftheeducatorsdidnothavetheprofessional competencenecessary todeliver simulation-basedtraining and 11%didnotuseOSCEexamstopreparetheirmidwiferystudents priortotheirclinicalplacement.Evenwhenmidwiferyeducators inBangladeshwereequippedwiththestrategiestoimprovethe quality of their graduates, this proved difficult to implement. Although more teachers now had master’sdegrees, had them-selves learned about women’s sexual and reproductive health rightsandwereencouragedtoempowertheirstudentsinasimilar way,theystruggledwithinaneducationalsystemwhichmadeit dif_ficultforthemtoteachwhattheyhadbeentaughtthemselves [7].GiventhatmostofthemidwiferyeducatorsinBangladeshare notmidwivesaccordingtointernationalstandards[4],arigorous educationalsystemthatsupportstheseeducatorsisnecessaryin ordertoensuretheproductionofhigh-qualitymidwivesfromeach of thediploma,bachelorand master’s degreelevels[7]. Thisis essentialforasustainableeducationalenvironment.Moreover,in ordertoclosetheknowledgegapbetweeneducatorsandclinical preceptors,thisstudyhighlightstheneedtobuildthecapacityof clinical preceptors so they can work together with midwifery educatorsonassessmentstrategies.Onesuchstrategycouldbeto enrollpreceptorsonin-servicetraining coursesorother educa-tionalprograms.Suchastrategycouldresultinmoremidwifery students ful_filling the required learning outcomes [12]. It is anticipatedthatthefigureswillhaveimprovedbythetimeofthe follow up assessment, given that ongoing interventions are continuing.It isimportant that accreditationis not a one-time event but rather the start of a consistent quality assessment process with regular follow-ups encouraging and providing opportunitiesforimprovement[21].

Table5

Institutionalassessmentandevaluationofclinicalpracticesites(reportsfrom38institutions).

YES NO

Regularauditsofclinicalpracticesitesarebeingperformedtoensuresufﬁcientopportunityformidwiferystudentsto gainmidwiferyexperiences

25(66%) 13(34%)

Commitmentfromhealthcareprofessionalsattheclinicalsites(doctors,nurses,supportstaffandmanagers)to collaboratecloselywiththeinstitute/collegeinordertofacilitatesupportformidwiferystudents

37(97%) 1(3%)

Asystemisinplacetoidentifyandappointclinicalmentorstofacilitatesupportivesupervisionofmidwiferystudents 24(63%) 14(37%) Awrittenpolicywithminimumcriteriahasbeendevelopedtoensurestudents’safetyandwellbeingintheclinicaland

learningenvironment

34(89%) 4(11%)

Table6

Extenttowhichmidwiferyeducatorsensurethatstudentsfulﬁlltheclinicalcomponentsoutlinedinthenationalcurriculumbeforegraduation.

Yes No

40births,whereof30normal(reportsfrom30institutions) 20(67%) 10(33%)

100antenatalassessments(reportsfrom31institutions) 29(94%) 2(6%)

100postnatalassessments(reportsfrom31institutions) 29(94%) 2(6%)

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Thisstudyalsofoundthat25%ofthemidwiferyinstitutionsdid not havethecapacity to provideclinicalpreceptors who could supportstudents’trainingintheactivemanagementofﬁrststage labor,33%didnotsupportstudents’trainingintheinterpretation ofpartograph,and47%didnotsupportstudents’traininginthe assessmentofwomensixweekspostpartum.Giventhatmostof thefactorslinkedtomaternalmortalityandmorbidityarerelated tohemorrhageandobstructivelabor,manyofthefuturemidwives in Bangladesh are still not fully prepared to manage life-threatening conditions for women during and after childbirth. Basedonourﬁndings,and thefactthat qualitymidwiferycare provided by midwiveseducated and regulated to international standards [16] can prevent over 80% of all maternal deaths, stillbirthsand neonataldeaths when integratedintothehealth system[26],westresstheimportanceofimprovingtheintegration betweentheoreticalknowledgeas taught inthe classroomand whatthestudentsexperienceinclinicalsettings.

By building partnerships between government, academia, professionalbodies,non-governmentalorganizationsanddonors, Bangladesh has made significant progress towards developing midwifery education and improving sexual and reproductive healthandrightsforwomenandnewborns[6].Withthisinmind, it is imperative that Bangladesh is supported to address the continuingstructuralshortcomingswithinitseducationalsystem witha feedback-appeal-response system that will enable mid-wifery institutionsto haveweaknesses identified and begiven timeandsupporttorectifythese.ForBangladeshtorespond to theseidentifiedshortcomings,wesuggestthatanactionplanfor eachindividualeducationinstitutionbedeveloped.Thenextstep, whichisalsosuggestedbyLuybenetal.[27],istouseanexternal reviewprocessandself-evaluationtoidentifyareasfor improve-mentandhowtheycanbeimproved.Theaccreditationassessment processshouldbeamendedtoincludetheclinicalplacementsites sothatclinicaleducationismoreintegratedwithinthenational midwiferycurriculum.Thisinternalaccreditationprocess,would prepare Bangladesh for the external ICM global Midwifery EducationAccreditationProgramme[19].

Strengthandlimitations

ThekeystrengthoftheBangladeshiaccreditationprocesshas beenitsparticipatoryapproach.Datacollectorsweregovernment ofﬁcials responsible for midwifery education and services in Bangladesh [12]. Their status, however, could be seen as a weaknessintheaccreditationsystem,puttingasitdoespressure oninstitutionstodeliverpositiveresultsandbelesstransparent abouttheirweaknesses.Theselectionofassessorstrustedwithin thesectoristhereforecrucial[28].Theaccreditationtoolisitself limited.Ithasnotbeensubjectedtoanyreliabilitytests,althoughit wasdevelopedwithinspirationfromglobaltoolsand culturally adjusted to the Bangladesh setting [12] which strengthens its credibility.Intermsoftransferability,theﬁndingsfromthisstudy can be transferred to similar settings with some caution [29]. Institutions sometimes chose not to answer certain questions, affectingthevalidityofthisdescriptivestudy.

Conclusions

This study can be used as a benchmark against which to measure progress towards national and global milestones to ensurethatmidwiferystudentsinBangladeshachievetherequired core competencies before graduating as registered midwives. Thereareseveralshortcomingsthatareneededtobeaddressed before this happens more widely. Right now one third of the midwiferystudentsinBangladeshdonotmeetthedeﬁnedclinical learning outcomes for supporting a woman during birth. We

suggest an accreditationassessment system that integrates the clinical placement sites, builds in a feedback-appeal-response system and develops a system for improved communication betweentheeducationalinstitutionsandtheclinicalplacement sites.Thiswillensurethefullimplementationofthemidwifery curriculumandthusproducemidwiveswhocandeliverthefull scopeofsexualandreproductivehealthservices.

Conﬂictofinterest Nonedeclared. Financialsupport

The accreditation assessment was conducted with ﬁnancial supportfromtheSwedishInternationalDevelopmentCooperation AgencyfundedprojectinBangladesh,administratedbytheUnited NationsPopulationFund(UNFPA)Bangladesh.Thefundingbodies playednopartindesigningthestudy,conductingtheanalysisor writingthemanuscript.

Ethicalstatement

Ethical clearance was obtained from the Ethical Review Committee: Centre for Injury Prevention and Research, Bangladesh,CIPRB/ER/2018/12.

Acknowledgements

Wewould liketoexpress oursincereappreciationtoallthe participantswhocontributedtothisstudy.Wewouldalsoliketo thankMrPappuNoorIslamforenteringallthedataintheexcel sheets,andAssociateProfessorMargaretaPerssonfortakingpart intheanalysisandcompilingtheresultsintableformats.

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