Ministry of Health Transitional Federal Government of Somalia and Ministry of Health Puntland State of Somalia In collaboration with UNFPA Somalia

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1 Ministry of Health Transitional Federal Government of Somalia and Ministry of Health Puntland State of Somalia In collaboration with UNFPA Somalia Office Post Basic Midwifery Curriculum 2012

2 Contents FORWORD... 4 ACRONYMS... 6 INTRODUCTION AND RATIONALE FOR THE POST-BASIC MIDWIFERY PROGRAMME... 7 CURRICULUM FOUNDATION Vision Programme aim Philosophy The Somalia and Puntland contexts PROGRAMME DESCRIPTION Achievements on completion PROGRAMME STANDARDS Organisation and administration Faculty and staff Learning and teaching Assessment strategies Programme of studies monitoring, evaluation and re-validation ACADEMIC REGULATIONS Student selection and admission criteria Student regulations Attendance and leave of absence Annual leave Disciplinary action Assessment regulations Assessment of theoretical knowledge Assessment of practice competence External examiner and Examination Board ORGANISING PRINCIPLES AND MODELS OF THE CURRICULUM Foundational principles Models of midwifery The international model for midwifery A Community Model of midwifery

3 PROGRAMME ORGANISATION AND STRUCTURE Programme duration Programme structure and themes Semester Semester Semester Module programmes Clinical experience RESOURCES Financial resources Human resources Physical resources and learning environments The learning schedule TEACHING AND LEARNING STRATEGIES Approaches to learning and teaching Methods of learning and teaching Lecture/discussions Role play and drama Reflective practice Clinical skills practice Records of assessment of midwifery clinical skills, case book and log of clinical experiences Community and MCH centre links ASSESSMENT STRATEGIES Formative Summative: Theoretical assessment methods Behaviour / attitudes assessment methods: Skills assessment methods The Case book and Log of experience REFERENCES MODULE AND UNIT OUTLINES Module PM 1 Orientation to Midwifery Module PM 2 Study and information technology skills Module PM 3 English Communication

4 Module PM 4a Nutrition science Module PM 4b Ethics in midwifery Module PM 4c Pharmacology applied to midwifery Module PM 4d Community and public health with epidemiology Module PM 4e Pathology applied to midwifery Module PM 4f Health promotion and education Module PM 5 Understanding and working with people Module PM 6 Anatomy and physiology, and changes in pregnancy Module PM 7 Mental health and illness Module PM 8 Antenatal Module PM 9 Labour Module PM 10 Postnatal Module PM 11 The newborn Module PM 12 Understanding research and evidence-based practice Module PM 13 Childbearing 2 complications Module PM 14 Newborn 2 (complications) Module PM 15a Child spacing Module PM 15b Sexually transmitted infections, HIV and AIDS Module PM 15c Gender-based violence including harmful traditional practices Module PM 15d Common gynaecological and breast disorders and issues Module PM 16 Principles of learning and teaching Module PM 17 Management and leadership Module PM 18 Consolidation workshops: Emergency skills and revision Module PM 19 Consolidation of practice ANNEXE 1 ICM Definition Of The Midwife ANNEXE 2: ICM Philosophy And Model Of Midwifery Care ANNEXE 3: Essential Competencies For Basic Midwifery Practice ANNEXE 4 MIDWIFERY LOG BOOK ANNEXE 5 RECORD OF ASSESSMENT OF CLINICAL MIDWIFERY SKILLS

5 FORWORD 4

6 5

7 ACRONYMS AIDS ARV BEMOC CEMOC CMW CPR FIGO FGM HIV ICM ICN IDP INGO IT MCH MDG MMR MoH MTCT(P) NGO OSCE GBV TBA UNICEF UNFPA WHO Auto-immune Deficiency Syndrome Anti-retroviral drugs Basic emergency obstetric care Comprehensive emergency obstetric care Community midwife Cardio-pulmonary resuscitation International Federation of Gynecologists and Obstetricians Female genital mutilation Human Immunodeficiency Virus International Confederation of Midwives International Council of Nursing Internally displaced persons International non-governmental organisation Information technology Maternal and Child Health Millennium Development Goals Maternal Mortality Ratio Ministry of Health Mother to Child Transmission (Prevention) of HIV Non-governmental organisation Objective structured clinical examination Gender-based violence Traditional birth attendant United Nations Children s Fund United Nations Population Fund World Health Organization 6

8 INTRODUCTION AND RATIONALE FOR THE POST-BASIC MIDWIFERY PROGRAMME A major challenge for any government is to maintain the health of the population. Poor health has an impact on individuals, families and indeed on the whole economic development of the country. Maternal and infant health continues to give great cause for concern in many countries but does so particularly in Somalia. With one of the highest rates of morbidity and mortality in the world this issue affects every community and family. Not only do women have the right to health and life when fulfilling their childbearing role, but families do poorly when the mother is lost, infants usually die and young children often do not survive either. As any country in the world, Somalia has an ancient history of midwifery including for nomadic peoples as many Somalis are. Older women had an important role helping women of the community give birth. They would wait until the baby was about to be born and would then make an episiotomy with an unsterile knife. Women suffered greatly in those days (and still do). In the mid-twentieth century Italian midwife educators began to train Somali midwives to assist women and reduce their suffering and continued for many years. Since the beginnings of professional midwifery in the region, midwifery has continued to change as circumstances change. Although nursing, midwifery and community health training were available in Mogadishu before the falling of the central government in 1991, midwifery training ceased because of conflict and insecurity from 1991 onwards. This means that women are served almost entirely by traditional birth attendants in the home, and untrained auxiliaries in hospitals and health centres. Some women have the benefit of nurses who have received some maternity training from the nursing schools that continue to function in Puntland and Somalia, and a few are supported by midwives who trained before the civil war or elsewhere. Now the intention has been expressed in Somalia including in Puntland to re-establish midwifery schools and training. For this reason this revised Post-basic curriculum was commissioned by the Ministries of Health (TFG and Puntland) with the support of UNFPA so qualified nurses could be upgraded. This intention is also supported by the nursing associations in Somalia. At the same time as upgrading qualified nurses in midwifery, it is acknowledged that there remains a place for less well-educated women from rural and inaccessible communities to train to become skilled birth attendants to serve their own communities. This is especially important in areas where hospital-based maternity care is difficult to access, and also where education of young women may have been severely limited by insecurity. For this reason, a companion curriculum for Community midwives has been commissioned by the Ministries of Health and developed. 7

9 The review is especially timely with the recent global emphasis on midwives who fulfil the revised Definition of the Midwife (ICM 2011) and international Essential Competencies 1 (ICM 2010a) as key players in reducing maternal and neonatal morbidity and death, 2 and with the publication for the first time of Global Standards for Midwifery Education (ICM 2010b).Somalia and Puntland aspire to meet the standards wherever possible, a process that will continue forward through the lives of these curricula. This curriculum lays out the learning experience and opportunities for Post-basic Midwives. The curriculum is intended to meet the midwifery education needs of women who have already successfully completed a three year nursing diploma programme. The programme of training is intended to enable these women to fulfil the Essential Competencies for Basic Midwifery Practice (ICM 2010 and Annexe 3) as far as is possible in the Somalia and Puntland contexts. The focus on practical aspects of midwifery is underpinned with the level of knowledge essential for understanding the needs of women and their families. Post-basic trained midwives must be able to work in any setting, within hospitals and referral centres, in homes and MCH centres. They become midwives who are able to lead and supervise others such as Community Midwives, auxiliaries and TBAs, and work independently in providing care for women in normal childbearing and detecting and managing complications, referring to medical care as appropriate. In this way they respond to the needs of women, babies, families and communities in urban and rural areas, hospitals, MCHs and (where appropriate) homes, and also take a role in developing midwifery practice in Somalia and Puntland. This Post-basic midwifery curriculum uses the same structure and principles as the Community midwifery programme although over a shorter time period and building on students nursing training, including maternity nursing training. Indeed many of the learning experiences need to be the same despite differences in scope of practice. These grades of midwife differ mainly in their level of knowledge and understanding of the theory and evidence that underpin midwifery practice. Postbasic midwives are prepared for a more advanced level of practice when dealing with complications and also being prepared for more analytical and critical thinking and independence as learners than are Community midwives. The socio-cultural and psychological context for practice, the global context, research appreciation, the evidence-base for practice, and clinical teaching are particular areas that Post-basic midwives consider in much greater depth. In order to achieve designation as skilled birth attendants (WHO undated), both must fulfil the ICM Definition of the Midwife (ICM 2011 and Annexe 1) and the Essential Competencies for Basic Midwifery Practice (ICM 2010a and 1 A competency is a combination and integration of knowledge, skills and attitudes, which result in effective performance. These essential competencies for basic midwifery practice 2010 are based on ICM s values, vision, strategies and actions and used by midwives who attend to the health needs of adolescents, women and childbearing families. Throughout this curriculum the term competencies is used to refer to both the broad statement heading each section, as well as the knowledge, skills and behaviours required of the midwife for safe practice in any setting. Ministry of Health Republic of South Sudan (2011) Diploma in Midwifery (draft.p.14). 2 UNFPA, JHPIEGO, WHO, Global Health Workforce Alliance, UNICEF, FIGO, ICM, World Bank (2010) The global call to action: strengthen midwifery to save lives and promote health of women and newborns ( ) available at posium_on_strengthening_midwifery_final_04jun2010.pdf 8

10 Annexe 3). The two Programmes thus present broadly similar content, to be addressed at different levels and from very different starting points. 9

11 CURRICULUM FOUNDATION The vision, mission and philosophy of the programme are described here so that the basis of curriculum decisions is clear. This is also required by the WHO (2009) and ICM (2010b). Vision The vision for the Post-basic Midwifery programme is that women previously trained as nurses serve them as midwives and meet the requirements of the 2011 International Definition of the Midwife (Annexe 1) and the 2010 Essential Competencies for Basic Midwifery practice (Annexe 3). They will also be able to provide essential care for children under five years and support the health of communities in which they work by virtue of their previous nursing education. Programme aim The aim is that qualified nurses will: become midwifery practitioners who provide safe, competent and timely care to women, their infants and families contribute to the reduction of maternal, neonatal and child morbidity and mortality act at all times with honesty, integrity and without discrimination to people whatever their ethnic group, faith, gender, nationality or culture work in collaboration with the community and with professional colleagues become lifelong learners who are able to reflect on and improve their practice and encourage and support others to do the same work toward the advancement of the profession of midwifery. Philosophy The curriculum is based on the following concepts and assumptions: Of the person A person has social, cultural, religious, psychological and physical needs that should be respected. A person has impact on, and is affected by, the socio-cultural, religious, psychological and physical environment. A person has rights of self-determination regarding what happens to him or her in health, disability and illness regardless of gender. A person takes responsibility for his or her own well-being to whatever extent possible and collaborates in positive ways to meet deficits. 10

12 Of midwifery Childbearing is a profound experience, which carries significant meaning to the woman, her family and the community. Birth is a normal physiological process. Midwives are the most appropriate care providers to attend women during pregnancy, labour, birth and the postnatal period. Midwifery care empowers women to assume responsibility for their health and for the health of their families. Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian. Midwifery care combines art and science. Midwifery care is holistic in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women and based upon the best available evidence. Midwives have confidence and trust in, and respect for women and their capabilities in childbirth. The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities. (ICM 2005 and Annexe 1) Of learning Learning is an active, continuous, sequential process with concepts, skills and values being constantly re-evaluated and reorganised for use. Learning is facilitated when it: o takes place in or near the real situation in which learners expect to work, or is related closely to the individual s own practice o is relevant to need and experience o takes account of individual needs, circumstance, abilities and learning styles o involves active participation by learners who are well-motivated and take responsibility for their own learning o encourages learners to seek information, evaluate and use it o helps learners to feel respected as independent adults. Students should be encouraged to evaluate their own needs and progress, and accept feedback on their strengths and weaknesses. Learning objectives and course content should be based on defined midwifery competencies, addressing the knowledge, skills and professional behaviours fundamental to professional midwifery. Learning needs to be life-long. Of teaching Teaching is a process of facilitating student learning and development. Teaching should encourage and support students toward self-direction. Learning strategies should encourage reflection on appropriate behaviours and attitudes. Teachers should prepare varied activities that encourage and enable students to seek, understand and analyse information, and apply it appropriately to their practice. Teachers should ensure no physical or psychological barriers prevent full student participation. 11

13 Strategies should be based on evidence-based education theory and practice. Of assessment The purpose of assessment is to determine student progress toward the achievement of course objectives and midwifery competencies. Decisions about assessment of learning are influenced by many factors including; o curriculum philosophical approaches o competencies and learning outcomes o purpose of the assessment (whether formative or summative) o content o level o practical issues e.g. class size, teaching and learning methods employed, assessment frequency and availability of resources. Assessment should: o be conducted fairly and without discrimination or favour o be focussed on the competencies and objectives in question o use various methods appropriate to the skills, knowledge and behaviours being assessed o involve students where possible in assessing their own achievements o incorporate client/patient and family feed-back where possible and appropriate o as feed-back, contribute to the identification of, and response to individual student or group needs. The Somalia and Puntland contexts Midwives work within a political, social, economic and health care environment that undoubtedly influences the nature, focus and direction of their practice (ICN 2003). This educational programme for qualified nurse to undergo midwifery training takes the environment and context into account so that successful candidates are fit for purpose on completion of the Programme. The Somalia and Puntland environment presents immense challenges to providing effective and high quality health care, many of them common within and outside the region but made even more difficult by insecurity, recurrent conflict and natural disasters. The country has experienced substantial change over several decades, from conflict, loss of infrastructure and professional workers, lack of resources, and with a very heavy and changing burden of ill-health especially among young children and childbearing women. Political and economic collapse has led to the disintegration of the health system and made responding to health emergencies almost impossible. The disrupted social and economic system and socio-cultural issues also impact on the health of the whole population and how needs care are met but this impact is experienced particularly powerfully by women and their children. Somalia and Puntland populations experience severe economic stress with often extremely low incomes or none. There is also significant quat and tobacco use primarily amongst men with consequences for both health, relationships and family income. Family structures can be unstable 12

14 with multiple marriages and divorce and many women experiencing repeated pregnancies, few having the decision-making power, knowledge or access to services to enable child spacing. Women have limited autonomy especially if illiterate as very high numbers are. They have little socioeconomic or political power, they may have no money of their own and their own health needs are often neglected. Services for women and families are anyway severely limited with many completely destroyed because of the political instability and security situation in major parts of the region. Women may be subject to sexual and gender-based violence and exploitation including rape even of girl children, made worse by the conflict and ongoing violence against communities. Early marriage is common with many marrying before 16 years and some under 14 with consequences for the safety of these adolescents when childbearing. 3 FGM continues to be practised 4 with immediate and long-term health and psychosocial impact on girl children and women including on maternal mortality. Very high maternal and perinatal mortality and morbidity rates continue, with an estimated 45 women dying every day (TFG Somalia 2010), and a maternal mortality ratio of at least 1044 per 100,000 live births (WHO-EMRO 2010) which equates to more than a 1 in 14 lifetime chance of dying of pregnancy and childbirth related problems. 5 Main causes of morbidity and death for women are obstructed labour, fistulae, infection, haemorrhage, eclampsia, unsafe or neglected abortion, all of which are very high. Children s death rates have improved slowly although 200 per 1000 still die before the age of 5 (UNICEF 2010a), many as neonates or under one year (52 and 108/1000) (UNICEF 2010b). 6 Birthrelated problems and tetanus are common cause of neonatal death, while diarrhoeal disease, respiratory infections and malnutrition are linked to many child deaths as is measles and its complications, susceptibility being compounded by the malnutrition. The very low rate of exclusive and prolonged breastfeeding contributes greatly to deaths and morbidity. Many women in countries that are poorly resourced lack access to maternity care for reasons of poverty, distance, poor roads and transport as well as experiencing often inadequate services on arrival and having limited social and economic control. In addition for Somali women, violence may make travel impossible especially at night. Many women arrive in the mornings at the remaining health facilities and die because night travel has been too dangerous to undertake. Added to that, Somalia is experiencing devastating hunger because of insecurity and natural disasters, at times being in a state of famine so that many, especially women and children, are severely malnourished. The large proportion of the population that is nomadic or semi-nomadic have even more difficulty in accessing services because of distance and poverty, and loss of livestock through drought is making their poverty worse. Public health and the provision of an adequate infrastructure is at least as difficult a challenge amongst rural and nomadic people as amongst overcrowded urban dwellers and is a key issue in camps for the 1.4 million internally displaced persons (UNICEF 2010a). HIV prevalence of 0.7% (UNICEF 2010) is fairly low but increasing incidence of tuberculosis has an impact on public health systems. Mental health services are almost non-existent as are those for people 3 Personal communication. 4 Most often pharaonic - type 3 (Population Reference Bureau 2010), and about 98% of females (UNICEF 2010). 5 MPIC (2007) makes the Puntland MMR much higher at 1600/100, Capacity to collect meaningful health information is severely impaired with fragmentation of health systems made worse by political insecurity and conflict. 13

15 with physical and mental disabilities. Childbearing women may then be doubly disadvantaged with such needs going unrecognised and unmet. A large unmet need for preventative and curative health care exists within communities and outside of the hospital context where most nursing services and training are currently focused. This unmet need is especially acute for childbearing women as there are extremely few fully-trained midwives able to fulfil the ICM/WHO Essential Competencies for Basic Midwifery Practice (2010) and ICM definition of the Midwife (2011). Nurses provide some maternity care but most women give birth with no skilled birth attendant, most with untrained auxiliaries, or even more with traditional midwives who are often untrained and unsupervised. Very few women receive antenatal care, with around 26% being seen once and 6% having the four recommended visits (UNICEF 2010). The almost total lack of availability and access to referral for EMONC is responsible for very many deaths of women and newborns when complications arise. Somali midwives and maternity nurses work with limited support or medical cover whether working in rural or urban areas, MCH centres, homes, hospitals or for NGOs, and manage the untrained and often illiterate and innumerate auxiliary workers who provide most care, including deliveries and coping with emergencies. This demands an education process that produces midwives fully competent to provide for the needs of childbearing women throughout pregnancy, labour and the postpartum period. This includes the ability to recognise deviations from the normal when they arise, respond appropriately and refer for medical care as necessary and available, possibly going beyond the normal scope of practice when no doctor is available. Drafting new midwifery curricula is an essential part of reinstating and upgrading services to meet women s needs and the challenges of the 21 st century. A key document that sets the context for the midwifery curricula is the Essential Package of Health Services (UNICEF 2009) and professional education and training is a significant part of this. The Somalia and Puntland contexts are inevitably linked with the changing global environment. Midwives are acknowledged worldwide to be essential for maternal and neonatal health, safety and wellbeing, and for achievement of the Millennium Development Goals 4 and 5. Public and global expectations of their education, competence and scope of practice have of necessity risen. These issues are articulated in several documents such as those from FIGO (2009) and many INGOs which specifically address the renewed emphasis on the importance of midwives, most recently the Global Call to Action. 7 Somalia and Puntland-educated midwives take their place as skilled birth attendants alongside their sisters from around the world. 7 UNFPA, JHPIEGO, WHO, Global Health Workforce Alliance, UNICEF, FIGO, ICM, World Bank (2010) The global call to action: strengthen midwifery to save lives and promote health of women and newborns ( ) available at posium_on_strengthening_midwifery_final_04jun2010.pdf 14

16 PROGRAMME DESCRIPTION Achievements on completion The WHO (2009) expects that newly qualified midwives will demonstrate: use of evidence in practice cultural competence the ability to practice in the global and local health care system and meet population needs critical and analytical thinking the ability to manage resources and practice safely and effectively the ability to be effective client advocates and professional partners with other disciplines in the health care system a community as well as hospital service orientation leadership ability and continual professional development. Although intended for university graduates, these expectations relate to some degree to all midwives practicing in Somalia and Puntland apart from perhaps less emphasis on leadership and skills of critical and analytical thinking than at university graduate level. The International Confederation of Midwives (ICM) expectation of qualified midwives is the demonstration of the Essential Competencies for Basic Midwifery Practice (ICM 2010) in order to qualify as a midwife who fulfils the International Definition of the Midwife (Annexe 1, ICM 2011). The complete Competencies may be seen in Annexe 3 but in outline, all midwives are expected to employ a variety of skills and spheres of knowledge to provide high quality, individualised, culturally relevant and sensitive care to childbearing women, newborns, their families and communities through pregnancy, birth and the postpartum period maximise their health, promote family life, planned pregnancies and positive parenting provide for early detection and treatment or referral for complications and care for women suffering pregnancy loss depending on applicable laws and regulations. 15

17 PROGRAMME STANDARDS In general, the standards required are those of the ICM Global Standards for Midwifery Education and the accompanying guidelines (ICM 2010b). These standards act as benchmarks to the achievement of a global norm for midwifery, help to define expectations of quality and integrity, foster trust in midwifery and its education, and allow for accountability to students, to the profession and to the woman and families of Somalia and Puntland. They also support quality improvement and the pursuit of lifelong learning. It is acknowledged that resource constraints will make some of these standards difficult to achieve in the short term but that barriers may gradually lift. Some key points are highlighted below. Organisation and administration The midwifery programme is headed by a qualified midwife teacher with experience in administration and management. The midwifery programme has a designated budget and budgetary control sufficient to meet programme needs. The midwifery programme is self-governing, where necessary under an overall School Director. Faculty and staff Midwife teachers and clinical instructors have formal preparation in midwifery, are currently licensed or legally recognised to practice and demonstrate competency, normally with a minimum of two years of clinical midwifery experience. Midwife teachers have formal preparation for teaching or are undergoing such preparation. Clinical instructors/preceptors have formal preparation for their role. Midwife teachers and clinical instructors maintain their competence and have their teaching and clinical performance assessed at intervals. Individuals from other disciplines who teach specialist topics are competent and current in their fields. Midwife teachers work in classroom and clinical sites, and collaborate with clinical staff and management to provide appropriate learning experiences and assessment. The ratio of teachers and clinical instructors to students is determined by the school and regulators. Learning and teaching Sufficient practice experiences in a variety of appropriate settings are available so that students can attain the Essential Competencies within the programme timeframe and become knowledgeable and autonomous practitioners. Students provide midwifery care primarily under the supervision of qualified midwives teachers and clinical instructors, to a level determined on an individual basis and normally reducing toward the final stages of the programme. 16

18 The midwife teacher has the ultimate responsibility for the quality of all learning experiences and the support of students. The theory practice ratio is minimum 40% theory and 50% practice (approximately 40/60 in this curriculum) Evidence-based approaches to learning and teaching are used so that students become independent and lifelong learners (see below). Adequate teaching and learning resources including books, teaching and clinical equipment and supplies are available for students to attain the competencies. Teaching facilities, services and clinical environments are clean, safe and secure. Assessment strategies Valid and reliable formative and summative assessment evaluation/assessment methods are used to measure student performance and progress in learning regarding o Knowledge o Behaviours / attitudes o Practice skills o Critical thinking, problem-solving and clinical decision-making o Interpersonal relationships and communication skills. Expectations of students and evaluation methods and criteria are written and available to students, as are strategies for identifying learning difficulties. Programme of studies monitoring, evaluation and re-validation Governance, monitoring and evaluation polices are in place and involve both staff and students. Student representation is ensured on committees. Student feed-back mechanisms concerning the Programme, curriculum, learning experiences and midwifery faculty are written and used. Midwifery faculty conduct regular evaluation of practice learning sites for their suitability in relation to learning outcomes. External review of the Programme curriculum takes place at intervals, normally of five years. The curriculum is not static. Regular Programme review is important and changes may be required in the interim when demonstrated to be necessary through feed-back and evaluation. The conduct of the Programme will be evaluated at least at three yearly intervals by internal and external midwifery education specialists in collaboration with clinical staff and any authority delegated such responsibilities e.g. a health professions council, on behalf of the Ministry of Health. Evaluation will include internal standards of quality, value and efficacy inputs, process and outputs of the Programme tracking of career pathways after qualification student and teacher evaluation of the conduct of the Programme stakeholder evaluation (clients/patients and their families, employers, NGOs). 17

19 Monitoring will ensure the ongoing quality of the programme is maintained. Periodic evaluation will help to ensure the Programme remains fit-for-purpose and continues to produce the qualified midwives that the Somalia and Puntland populations need. A report will be produced and submitted to the appropriate authorities. 18

20 ACADEMIC REGULATIONS Student selection and admission criteria The selection process will be transparent and without prejudice, discrimination or favour and take account of any existing or future Somalia and Puntland maternity workforce plans (WHO 2009, ICM 2010b). Candidates will: hold general nurse registration hold a verifiable transcript of successfully completed general nursing training at Diploma level or above (see below regarding level of nursing knowledge and skills) normally have two years experience in a nursing or health-related position (newly qualified nurses may be admitted at the discretion of the School Director) where appropriate provide a verifiable reference from a recent nursing or health employer where appropriate provide a verifiable reference from the Director of the appropriate School of Nursing pass as fit in any examination of medical fitness deemed necessary by the School Director or Board of Management. Disability should not be a barrier provided the candidate is able to fulfil midwifery competencies. This will be at the discretion of the medical adviser and Director of the School of Midwifery have received all recommended immunisations, to be determined by the medical advisor. Selection will be by interview and entrance examination set by the institution, in collaboration with the Ministry of Health and other bodies as appropriate. Midwife student selection panels will include midwives and midwife teachers. The entrance examination and/or panel proceedings will include both spoken and written English, candidates achieving a level permitting communication and the ability to read text. A level of nursing knowledge and skills is assumed that is equivalent to that described in any national diploma in nursing curriculum. Supplementary learning experiences outside of the curriculum hours described in this document may need to be provided where candidates have undertaken a programme using a curriculum that has not been updated in the previous four years. (See the section Teaching and learning strategies / prior learning ). It is also noted that not all Somaliatrained nurses benefit from a maternity nursing component during training. It may be necessary to provide extra learning experiences for these candidates compared with those who have undergone the maternity nursing elective. 19

21 Student regulations Attendance and leave of absence 90% attendance is required during both theory and practice parts of the programme in order to gain the right to enter end of semester and programme examinations. Leave of absence: No unauthorized absence is accepted. Students needing sick leave must inform the Director of the School. Medical evidence in the form of a doctor s letter is required for absence of more than one week. Students who present an acceptable reason may request temporary leave of absence of up to one year from the School Director or Board of Management. The student granted temporary leave of absence should apply with a written request to continue from the place in the Programme at which she stopped. A certificate of fitness to return may be required if the leave has resulted from ill-health. Lesser or longer periods of absence will be dealt with on an individual basis with longer periods possibly requiring recommencement of the Programme. No guarantee can be given that students will be able to recommence after approved leave of absence in the event that a suitable Programme is not available at the time. Consideration may be given to transfer to another institution that is providing the Programme. Decisions of the Board of Management are final. Annual leave Annual leave may only be taken at the time notified by the Director of the School of Board of Management. Directors have the discretion to adjust the actual timing within the Programme timetable provided this does not interfere with any national assessment timetable. Disciplinary action School Directors or Boards of Management may take disciplinary action at their discretion, including dismissal from the Programme where appropriate, for any behaviour deemed inappropriate to the profession of midwifery or that contravenes professional regulations in place at the time. The External Examiner may be involved in such decisions where appropriate. Appeal and dismissal Students will have the right of appeal to the Board of Management of the School whose decision is final. Students must make such appeals personally. Cheating and plagiarism Plagiarism is the direct copying of the work of another student or published material (including unpublished material from the internet) without appropriate acknowledgement and referencing, usually in coursework. If a teacher suspects a student of plagiarism or cheating (such as copying the work of another or conferring during tests and examinations), the teacher will investigate the case. If no satisfactory explanation is provided by the student, then the teacher will refer the student to the School 20

22 Director, and if necessary to the External Examiner and/or Examination Board for a decision regarding disciplinary action. Assessment regulations Assessment of theoretical knowledge Students must pass all summative written tests and examinations. The pass mark is 60%. 8 One re-sit, to be attempted one month after summative examinations, is permitted for students who fail at grade D. Grade E does not give students the right to re-sit. Support should be made available to help students to improve their performance on re-sit. Students who fail a re-sit will be required to repeat that semester or module before attempting the assessment again. A further failure will normally lead to discontinuation. Marking of theory assessments Formative assessments will be returned to students complete with evaluative feed-back to assist students further development. Summative assessments will be cross-marked/moderated by another midwife teacher to provide evidence of fairness and transparency. This second marker should preferably be unaware of marks given by the primary marker. Where there is disagreement the lead teacher s judgment is taken. Where faculty numbers do not permit this, consideration should be given to the moderation of a selection of student work by teachers from other schools of midwifery. This is especially important with final examinations. Assessment of practice competence Students must pass all clinical examinations at a level of full competence. Competence is achieved at different rates by students so no particular timeframe is put on successful achievement to the level of fully competent independent practice. Students may make more than one attempt to achieve this level provided that the overall level of progress is satisfactory. Where experiences cannot be provided in the clinical setting, perhaps because the incidents are uncommon, student competence may be assessed in the skills lab. Skills which must be demonstrated using actual clients/patients are listed in the Assessment methods section. Marks have not been specified for practice assessment as the important issue is that students achieve a level of full competence in skills and are able to practice independently by the end of the programme. Marks system may be introduced at the discretion of Directors of Schools or a national authority. Assessment grading see over 8 This pass mark may be changed at discretion of the appropriate authorities. The pass mark needs to be reflected in the difficulty of the examination. So an examination with a pass mark of 60% will be more difficult that an examination the pass mark of which is 80%. Gradings would also need to be changed. 21

23 Assessment grading The following grades are commonly used. Teachers need to specify the requirements for each grade. Requirements may identify issues such as goals of the assessment, essential or expected knowledge, the ability to apply it to practice appropriately, intellectual level (description only for lower grade, analysis and critique for higher grades). Grade A Distinction more than 80% Grade B Merit 70-79% Grade C Pass 60-69% Grade D Fail, can re-sit 50-59% Grade E Fail, no re-sit 49% or below External examiner and Examination Board An Examination Board for Midwifery will be appointed by the Ministry of Health and/or an authority which has this power delegated to it such as a future Health professions council. This Board will include representatives from midwifery and midwifery teachers, MoH, each school of midwifery and the nursing and midwifery association where possible. Others such as international NGOs may be included if desired. Decisions made by the Examination Board will be final. An External Examiner or Examiners will be appointed by the Examination Board to oversee the fair conduct of summative examinations, act as an external reference person and adviser where necessary, and to ensure that the appropriate academic and clinical standards and rigour are maintained across the schools of midwifery in Somalia and Puntland. External examiners will be appointed from among midwife teachers who: are familiar with the curriculum and midwifery programme fulfil the Somalia and Puntland criteria for midwife teachers are familiar with contemporary education requirement and teaching, learning and assessment methods do not have current teaching contracts with schools for which they are acting as Examiners. 22

24 ORGANISING PRINCIPLES AND MODELS OF THE CURRICULUM The written curriculum and all the education experiences of the students, such as course content, learning, teaching and assessment are based on the principles described in the Curriculum Foundation and on models for midwifery. Models describe the characteristics of midwifery and the midwives on completion guide what is included in the curriculum ensure that what is included takes its rightful place in the curriculum provide an explanation for decisions taken. Foundational principles Students are capable of independence and self-determination in their learning with appropriate support from teachers The teaching role is to facilitate learning and help students to gain access to appropriate learning opportunities, and to ensure reliable and fair assessment takes place Teachers include academic and clinical staff who need to communicate and collaborate in planning, teaching and student support. These will mainly be midwives but include other health care professionals and, for example, language teachers where appropriate Maternity service users have a role in furthering student learning and contributing to their evaluation Students build on prior learning both continuously and at specific points in the programme; Midwifery and education practice is based where possible on contemporary evidence. Postbasic midwifery students learn to read and understand available research, how research is carried out and how it contributes to safe practice Student learning experiences take account of midwifery ethics and the diversity in circumstance, culture and belief of childbearing women and their families Student assessment reliably and fairly demonstrates achievement of the midwifery competencies, addressing attitudes, knowledge and skills, and the ability to apply theory to practice Midwifery practice takes place in both institutional and community settings and covers the provision of services for normal healthy childbearing and when complications occur as illustrated in Fig.1 A community model for midwifery practice. This and the changing context of health care described in the Foundation section means that students need to learn and to be assessed in both hospital and community settings. 23

25 Models of midwifery Models of midwifery help planners to determine the approach to designing the curriculum and teaching, learning and assessment strategies. They also assist designers to select appropriate content that enables students to achieve the required attributes and competencies, and become people who are able to meet the challenges of providing appropriate and evidence-based midwifery services to women, their newborns and families and support health in the wider community. Likewise, models have an important role in indicating to teachers and students the appropriate knowledge, skills and attitudes or behaviours required to fulfil this role. The international model for midwifery The ICM provides one such model in The Philosophy and Model of Midwifery Care (undated) (Annexe 2). This features the protection and support of women s reproductive rights and respect for diversity promotion and protection of the normality of birth and avoidance of unnecessary intervention building up of women s self-confidence in handling birth appropriate use of technology, flexible care and timely referral trust and respect between women and midwives promotion and protection of wellness of mother and baby. A model, the Community Model for midwifery, is featured below. A Community Model of midwifery The Community Model highlights the context for midwifery practice. It is imperative that midwives are able to understand the context of women s lives and the challenges they, their families, and the communities they live in, face. It is also vital that midwives are able to work in any setting where women need them including the home when necessary as can be seen in the Essential Competencies (ICM 2010a) and the WHO standards (2009). Fig. 1 illustrates this. Fig. 1 24

26 Community model of midwifery Maternal and neonatal health problems and emergencies Acute Public health & health promotion Pregnancy care Care during birth Community Maternal and infant care after birth Physical & learning disability Reproductive health & family planning Gillian Barber / THET with thanks to Faduma X. Abubaker and Marian Yusuf Fahiye Chronic disease management Mental health Family relationships Gender issues 18 PROGRAMME ORGANISATION AND STRUCTURE Programme duration The Post-basic Midwife programme is undertaken over 18 months. This is the length recommended for such programmes by the ICM (2010b). It is an increase on older Post-basic Midwife curricula response to changing demands on knowledge levels of midwives and the need for substantial practice hours in order to fulfil the Essential Competencies and practice often with minimal medical support. Practice experience must be gained throughout the 24 hours. The programme is made up of 3 semesters, each of 26 weeks. Theory weeks are 6 days in length, days are of 6 hours. Practice weeks are 6 days in length, days are of 7 hours Programme practice and theory weeks = 24 weeks per semester. 6 days x 6 hours (theory) = 36 hours per week 6 days x 7 hours (practice) = 42 hours per week Weeks will often actually be a mix of theory and practice, or blocks of theory and blocks of practice at the discretion of teachers. Annual leave of 2 weeks is taken at the end of semesters 1and 2. 1 week of revision and 1 week of final examinations are provided at the end of semester 3. Total practice and theory days Total practice and theory weeks = 432 days = 72 weeks Programme hours: 25

27 50% hours for practice at 42 hours per week (1404/42) = 33 programme weeks At 6 days per week = 198 programme days = 11 semester weeks = 66 semester days 50% hours for theory at 36 hours per week = 39 programme weeks At 6 days per week = 234 programme days = 13 semester weeks = 78 semester days Total estimated study hours for the programme: = 2808 hours Total actual = 2742 If an institution wishes to alter the student hours per day, then appropriate adjustments will need to be made to Semester length. Should national assessment be put in place, adjusting the commencement of the Programme appropriately will be required to ensure the final assessment dates are the same as for cohorts studying via the standard day lengths. Programme structure and themes In each of the three semesters student learning will focus on a theme. Learning modules include both theoretical content and practice skills needed to fulfil the Essential Competencies, building up from a foundation of normality to understanding and managing complications women and their newborns may encounter. Learning modules permit students to learn new material and, at the same time, revisit knowledge and skills developed in previous modules. Although all Modules address specific topics, students are encouraged throughout to develop their ability to think analytically, solve problems and make decisions based on evidence to hand such as assessment of clients and available resources. They are also encouraged throughout to develop independence as learners. Periods of supervised practice are provided during which students will have the opportunity to develop their practice skills and knowledge over the full range of Competencies. It is important that each student is given the opportunity to develop their skills in the full range of practice settings. The programme ends with other relevant topics and a period of consolidation of practice in hospital and community settings. Semesters focus on: Semester 1: Review of core topics and relationship to midwifery (see Table 1) normal pregnancy and labour including anatomy and physiology, mental and community health, psycho-social and cultural issues Semester 2: Normal postnatal period and newborn health, complications in pregnancy, labour, and postnatal period and of the newborn, research appreciation, Semester 3: Reproductive health, clinical teaching, management and leadership, and a period of consolidation. 26

28 Semester 1 Students are introduced to the role of the midwife, its global and local importance for both maternal and newborn health care and how it contributes to the general health and economic wellbeing of communities. They are also introduced to the historical and cultural background to the profession and review the concept of ethics and ethical practice usually first introduced in nursing education, here specifically applied to midwifery practice. The opportunity is given to review foundational knowledge and skills first developed during initial nursing education, specifically nutrition, ethics, pharmacology, community / public health and epidemiology, pathology, and health promotion and education. (Also see Student selection and admission criteria and Approaches to learning and teaching regarding the expected level of knowledge and skills). Students further develop their knowledge and skills about normal childbearing first learned during nursing training. Here their competencies are developed to the level appropriate for meeting international expectations (ICM 2010a). They also consider community health aspects of the midwife role. Public health, health promotion and education, communication and counselling, are studied in this Semester, practice experience continuing in placements throughout the Programme. Topics are often revisited later e.g. Counselling in 15b. Practice skills are learned first in the skills lab, then under supervision in clinical settings. Apart from focussed visits and supervised practice taken as part of class/theory time, 6weeks of supervised practice are undertaken. Further experience is gained in the following Semesters. Practice will be undertaken in a variety of clinical settings, hospital, MCH centres, and it is very important that experience is gained in homes and community environments. A community link system will assist students in grounding their newly developing knowledge and skills in the realities of women s lives. Also in Semester 1, students consider mental health and illness and normal labour and birth. English communication classes are commenced during this semester but should continue whenever students are based at the midwifery school in following semesters. The hours are specified in semester 1. For semesters 2 and 3 teachers will arrange these when convenient but they should continue at a minimum of two hours per week during those times. The ability to read and communicate in English is seen as essential to enable health care professionals to read and write technical documents, books, articles, reports and to use the internet. Students will also further develop their information technology and computer skills, and study and information retrieval skills. Computer skills and information retrieval from books, journals and the internet are seen as essential for midwifery practice now. These skills are given specific time in Semester 1 but support and skills development will continue as a thread throughout the programme. On the last week of this semester, summative assessment of students theoretical learning is carried out. Clinical skills are assessed on an ongoing basis during the semester using the Record of assessment of midwifery clinical skills (Annexe 5). The two week break follows although timing may be adjusted according to local need provided this does not have a negative impact on learning. 27

29 Semester 2 Semester 2 commences by considering the essentially healthy postnatal woman and her infant and looks at evidence based practice and the way it is developed in a research appreciation module. Midwives have a responsibility to base their practice on clear evidence (WHO 2009, ICM 2010a /Annexe 3) and may also be involved with collecting data for developing such evidence, so understanding research is an important component of this Semester. Midwives will then be able also to evaluate and understand the implications of published research papers and put them into practice. The focus of Semester 2 moves on to the woman and her newborn that are at particular risk or are encountering complications. Having some knowledge and skills gained in the Diploma of Nursing, students will deepen their understanding of the complications of pregnancy, labour and birth, the postpartum period and of the newborn. By the end of the Semester they will be able to identify the at-risk mother and fetus or infant, provide immediate care and support, refer them appropriately and continue to care for them under the direction of medical staff. They will continue to gain such experience alongside caring for healthy women and babies in the final Semester also. 13 weeks are made available in semester 2 for supervised practice, mainly in district hospitals and referral centres. As the emphasis is on women experiencing complicated childbearing, placements need to be selected accordingly. Other opportunities exist during the study weeks for skills lab simulation, focussed supervised practice as well as clinical and field visits. The semester ends with summative assessment of student theoretical learning. As with Semester 1, clinical skills are monitored and assessed on an ongoing basis. Two weeks of leave follow. Semester 3 The focus for the semester is on other topics relevant to the role of midwife which feature in the Essential Competencies (Annexe 3). This semester includes 13 weeks of supervised practice with the focus during clinical placements being on the topics featured in the semester. This will influence the selection of appropriate placements. Other relevant experience will continue to be developed. A brief review of gynaecology will reinforce learning from nursing education. The Child spacing module will also build on prior learning. Students will develop their knowledge and skills of sexually transmitted infections, HIV and AIDS. FGM is again given significant attention because of the influential role midwives have in advocacy and prevention in Somalia and Puntland and is embedded within a wider Module that considers various forms of violence against women and (particularly girl) children. Because of the known dangers to women and their children of giving birth very young and adolescents lack of real control over their own lives, adolescent pregnancy is given attention here. Also in this Semester students are encouraged to consider and debate the more difficult medical and ethical issues around childbearing. Midwives are also expected to support the learning of others so clinical teaching, commenced in the 2009 Diploma in Nursing and previous curricula, will be reviewed and developed with opportunities given for supporting the learning of more junior students and others such as TBAs. The principles will also contribute to health education practice. 28

30 Managing facilities and others, and to some extent leading, will be a key role of qualified midwives so a Management and Leadership module is provided. This includes attention to quality improvement, introducing standard setting and audit. Also provided is the opportunity to consider the future, looking at professional issues such as regulation and supervision, continuous professional development and lifelong learning. A continuous period of consolidation of practice is included in the Semester, the timing being negotiated by teachers with facility managers but with the aim in mind of enabling students to practice as a midwife under minimal supervision. The semester and the programme end with revision and emergency skills workshops, and then a week of final summative assessment of knowledge and skills through written examinations and OSCEs. The OSCEs supplement the continuous assessment of practice made during the semester. These semesters are detailed in Tables 1 and 2. Table 1 indicates the main content of each Semester, and Table 2 shows how the hours for theory and practice are distributed through each Semester. It must be emphasised that these are not timetables. No attempt is made to provide an actual timetable. Lead midwife teachers may choose to use the block system, day release, workshops or a mixture depending on circumstance. 29

31 Module programmes Table 1 Semester modules and units NB Modules for this curriculum carry the prefix PM (Post-basic Midwifery) to distinguish them from other current curricula. Semester 1 Code Module Unit /topics 1 Orientation to midwifery The origin and history of midwifery as a profession Millennium Development Goals and the global effort to reduce maternal and neonatal mortality and morbidity Maternal health services in Somalia and Puntland Evidence-based practice in midwifery (introduction) 2 Study and IT skills Study, information retrieval, and information technology skills 3 English English: continues through each Semester at teacher discretion communication 4a Review of 4b fundamentals of 4c practice and their 4d application to 4e midwifery 4f 5 Understanding and working with people 6 Anatomy and physiology of childbearing Nutrition sciences Ethics and introduction to ethical issues Pharmacology Community, public health and epidemiology Pathology and infection control Health promotion and education Psychology applied to midwifery Socio-cultural and faith issues in childbearing Communication and counselling skills Anatomy and physiology of childbearing including Review of female and male anatomy and physiology Sexual activity and conception Embryology and fetal development Fetal development Mental health and illness in childbearing women 7 Mental health and illness 8 Pregnancy 1 Preparing for pregnancy - pre-conception advice Normal pregnancy Antenatal care Health education in pregnancy 9 Labour 1 Physiology of labour and birth, processes and anatomical changes The woman and fetus Midwifery care and scope of practice Semester 2 see over 30

32 Semester 2 Code Module Topics 9 Continued (practice experience) 10 Postnatal 1 Postnatal changes Midwifery care including feeding Immediate contraception advice (also see Module 15a) Postnatal follow-up in the community 11 The newborn 1 Transition to extra-uterine life Immediate and ongoing care of the healthy newborn 12 Understanding research and evidence - based practice 13 Childbearing 2 (complications) 14 The newborn 2 (complications) English communication continues as 2 hours per week. Understanding research The research process Evaluating research Evidence-based practice: the concept and evidence for midwifery Pre-existing disorders Substance abuse, smoking and alcohol Complications and appropriate action in pregnancy, childbirth and postpartum including Emergency Obstetric Care Complications and appropriate action in the newborn including Emergency Neonatal Care Semester 3 Code Module Unit / topics 15a Reproductive and Child spacing 15b women s health Sexually transmitted and reproductive tract infections, HIV and AIDS 15c Gender-based violence including harmful traditional practices 15d Common gynaecological and breast disorders and issues 16 Principles of clinical learning and teaching The midwife s role as teacher Applying theories of adult learning Teaching in clinical practice issues 17 Management and leadership Applying management and leadership theories to midwifery Managing oneself and others Quality improvement and audit 18 Consolidation Emergency skills workshops Revision 19 Consolidation Being a midwife practicum Midwifery professional and ethical issues English communication continues as 2 hours per week. Table 2 see over 31

33 Table 2 Semester modules and unit time allocations Theory time is 36 hours per week. Practice time is 42 hours per week Theory time normally includes skills lab activities. Practice time is normally counted here as clinical settings, field visits etc. Semester 1 Code PM Module / unit Theory weeks/days/hours Practice weeks/days/hours Total weeks/days/hours 1 Orientation to midwifery Study and IT skills English communication Review of fundamentals and 4a midwifery application Nutrition science ½ ½ b Ethics ½ ½ c Pharmacology d Community, public health & 1½ ½ 9 54 epidemiology 4e Pathology ½ ½ f Health ½ ½ 9 60 promotion/education 5 Understanding and working with people 6 Anatomy and physiology of childbearing 7 Mental health and illness ½ ½ Pregnancy Labour Semester 1 totals Semester 2 see over 32

34 Semester 2 Code PM Module / unit Theory weeks/days/hours Practice weeks/days/hours Total weeks/days/hours 9 Labour 1 (continued ) cont. 10 Postnatal ½ ½ The newborn ½ ½ Understanding research and evidence-based practice 13 Childbearing (complications) 14 The newborn 2 (complications) Semester 2 totals Semester 3 Code Module / unit PM 15 Theory weeks/days/hours Practice weeks/days/hours Total weeks/days/hours 15a Reproductive & women s health Child spacing ½ ½ b STIs, HIV and AIDS ½ ½ c GBV and harmful traditional practices 15d Gynaecology and breast conditions 16 Principles of learning and teaching 17 Management and leadership 18 Consolidation workshops Consolidation of practice Semester totals PROGRAMME TOTALS Hours for core midwifery practice in clinical settings will normally be combined and taken in blocks and/or on days per week basis at the Programme Director s discretion. Hours for each separate element above e.g. normal antenatal care, are for information only. Hours for core midwifery practice learning i.e. pregnancy, labour and birth, postnatal and newborn care, including the consolidation period are shown in the Practice column below in Table 3. Table 3 see over 33

35 Table 3 Period Theory hours Practice hours Totals Pregnancy Labour Postnatal (Sub-total for uncomplicated (180) (399) (579) woman) Newborn Childbearing 2 (complications) Newborn 2 (complications) Consolidation of practice TOTAL midwifery practice in the curriculum excluding other topics 504 (35%) 966 (65%) 1470 hours Clinical experience Although competence is the main criteria for clinical practice assessment rather than the numbers of times a student has carried out a procedure, it is nevertheless helpful to have indicated the numbers to be achieved and main experiences to be covered. This is shown in Table 4. It should be noted that Post-basic students will have had experience of maternity care during initial nurse training. Where the number of procedures undertaken in nurse training can be proved, the number of procedures indicated below may be reduced individually at the discretion of a student s teacher in discussion with the lead teacher, provided the final level of competence achieved is satisfactory. Table 4 see over 34

36 Table 4 Midwifery procedure or experience Number Full initial antenatal examination including history taking, physical examination, 10 phlebotomy, tests and advice Follow-up antenatal examination 40 (AN total 50) Health education session in pregnancy (both group and individual) 20 Vaginal examination 40 Opening scar tissue of infibulated woman 15 Medio-lateral episiotomy including perineal infiltration where possible 20 (see note 1) Normal delivery including third stage OBSERVED 5 Normal delivery including third stage PERFORMED Full care of woman through first, second and third stages of normal labour Full care of woman (as above) and of the newborn of total 5 of total (note 2) Multiple birth 5 (see note 3) Breech birth 5 (see note 3) Manual vacuum aspiration of retained products of conception(observation and Maximum conduct) possible Manual removal of retained placenta (observation and conduct) Maximum possible Immediate care of the newborn 40 Immediate care of newborn (having conducted the delivery also 5 of total) Repair of perineum (1 st and 2 nd. degree, 3 rd. where appropriate, and episiotomy) 15 Full examination of the newborn 50 Immunisation of the newborn 50 Supporting woman with breastfeeding 50 Postnatal examination (first 24 hours) 50 Postnatal examination (before transfer home) including child spacing advice 20 6 week postnatal follow-up examinations including child spacing advice 20 Child spacing advice in clinics 20 Note: 1. The episiotomy number is a guide only as it is imperative that women only undergo episiotomy for essential reasons in view of the evidence (from non-fgm women) that episiotomy is only advantageous for severe fetal compromise. It is understood that this may be different for women with type 3 FGM if they have extensive vaginal and/or perineal scar tissue. 2. It is expected that students care for the women in labour whose babies they then deliver wherever possible. Students MUST provide complete care for a minimum of 10 women, 5 of them to include caring themselves for the newborn. Experience should be gained in all settings. 3. These are a guide. It is understood that breech and multiple birth numbers may not be achieved. 35

37 RESOURCES The following resources are required: Financial resources Sufficient resources for managing the programme and providing necessary learning experiences are held by the lead midwifery teacher (ICM 2010b). Human resources The ratio of teachers and clinical instructors to students will be set preferably by the Ministry of Health, delegated where appropriate to any health professions authority. One such model 9 is: Classroom: 1 teacher to 50 students maximum Small group discussion: 1 teacher for 12 students Simulated practice / skills lab: 1 teacher to 12 students Clinical practice: 1 teacher or clinical instructor for 4 students The qualifications and experience required is described in the section Programme standards above. In-service training is important for teaching staff so that they can maintain and develop their abilities in facilitating student learning, and in counselling and support. Teachers need to have current, evidence-based knowledge and skills, be familiar with information retrieval, be able to model the Essential Competencies and act as inspirational role models in their attitudes and behaviours. They also need to be approachable and available to students at reasonable and advertised times, by appointment if necessary and non-urgent. Physical resources and learning environments Classrooms, skills laboratory/practical room, libraries, student computer rooms that are: o conducive to teaching and learning (size, structure, comfort, lighting, ventilation, and appearance) o equipped with appropriate and functional technologies computers, internet access audio-visual equipment including facilities for viewing educational DVDs, CD- ROMs and videos o equipped with clinical equipment and anatomical models, posters, audio-visual aids, DVDs, CD-ROMs etc. o supplied with library holdings sufficient in number, scope, and quality for Post-basic midwife student use and for use by their teachers. These may be books, articles and other resources. Offices and meeting rooms are available and suitable 9 With thanks to Ministry of Public Health, Afghanistan (2009) Institute of Health Sciences, Afghanistan (2009), Curriculum for Community Midwifery Education, 3 rd. edn. 36

38 Toilets facilities are adequate to numbers and gender sensitive School utilities are available and functioning including access to refreshments Clinical placements, community links and experiences : o provide appropriate learning opportunities, both in mix and numbers of patients or clients o are sufficient for numbers of students o the multidisciplinary student load does not detract from student midwife learning experiences o make available adequate support, supervision and clinical teaching to students, supplied by clinical instructors and midwife teachers as well as permanent staff o have the necessary equipment, drugs and consumables to enable students to learn o are accessible to students, with transport provided where necessary o are audited for quality of care and available experience. It is desirable that selection standards and audit systems be devised for clinical settings (ICM 2010b). Arrangements will be made by the Director of the midwifery school where necessary for access to clinical and classroom learning and teaching environments and field visits outside of the direct school jurisdiction. The learning schedule In this curriculum the Modules and learning units include the time to be dedicated to topics (written as weeks/days/hours). They do not specify the actual learning schedule which should be devised to suit the local situation. A written schedule should be made available by semester to students and staff. Schedules will include dates, timings, place, transport arrangements and the responsible staff member and specify when class room sessions are planned periods for simulated learning in the skills lab (or clinical environment) clinical practice sessions clinical placements and the objectives for these Assessments. 37

39 TEACHING AND LEARNING STRATEGIES Approaches to learning and teaching The Programme will be evidence-based and will be delivered using a variety of teaching and learning approaches which emphasise teacher facilitation and active, participatory, student-centred learning and are consistent with the Programme philosophy. They will allow learners to develop their knowledge, skills, and appropriate attitudes and behaviours including respect for clients, patients and each other. The Post-basic midwife students will have had experience of varying approaches to learning in their nursing education. Some may have engaged in learning at a higher level. This means that their needs will vary. Some may need substantial support if their experience has been mainly didactic and teacher-centred. Students having higher levels of prior learning may need to be challenged to stretch them and avoid complacency. As autonomy and independence as practitioners and learners are important for midwives, approaches to learning and teaching are required that promote and support this independence. To become thinking practitioners, students should be encouraged to develop skills of analysis, critical thinking and problem-solving. A problem-based learning (PBL) approach 10 is commonly used in many countries to help develop this independence and critical thinking among health care professionals. Although PBL may be too demanding, at least at first, other related approaches will be appropriate with Post-basic midwife students. Approaches such as problem-solving 11, case studies and scenariobased learning where they look at actual, anonymous, or likely situations and cases will help students to develop confidence in their decision-making abilities. A decision-making model is provided below to act as a framework. Midwives will themselves be responsible for teaching and supervising others such as TBAs, auxiliary staff, supervising student midwives in future, and of course have a substantial role in health education. This means that good role modelling by teaching and clinical staff in class and practice settings is very important so that students witness and experience good teaching as well as clinical practice. Theory and practice integration 10 Problem-based learning in its most pure form means that an entire curriculum is approached by the setting of problems (or giving of wider topics) and the discovery by students of the knowledge and skills they need to solve the problem. They must find out who holds that knowledge and/or what resources they need. Confident and non-directive support by trained facilitators is essential. A mix of PBL and more traditional forms of teaching such as lectures is a common compromise. 11 Problem solving is more often used alongside other teaching and learning approaches and is very like scenario-based learning. Students are set problems or given scenarios and they work out how to solve them, for example making plans of care. 38

40 Students will be assisted by teachers to integrate theoretical and practical learning throughout the Programme. Theory/practice integration will also be encouraged at any opportunity in the classroom and practice placements such as in discussions about patient care and doctors rounds, and specifically through case studies and projects, and a final year project which will be assessed. Prior learning Post-Basic student midwives are drawn from a background of qualification as registered nurses, so a level of knowledge and skills is assumed that is equivalent to a diploma (not degree) in nursing. Where Post-basic students have undertaken a programme at a lower level, or the programme is not very up-to-date (say revised in the previous four years), supplementary learning experiences may need to be provided. Such learning opportunities will be outside of the Post-basic Midwifery programme hours unless teachers find themselves able to make up this deficit during Module time. Particular topics that may need such augmentation include Ethics and ethical issues Understanding and using research as evidence for practice Contemporary ways of providing maternal and neonatal health care Learning and teaching in clinical practice Socio-cultural aspects Psychology and mental health Management and leadership Critical care Women s rights Information technology Epidemiology and statistics Methods of learning and teaching Learning and teaching activities will be varied and student-centred with an element of self-directed learning to increase independence as discussed above. Both direct (small group discussions, faceface interaction) and indirect teaching strategies (library use, and use of internet sources, problemsolving etc.) will be used to stimulate learning as students become more experienced and gain confidence. Examples of methods that may be used within different learning environments are summarised in Table 5 and explored in more depth below. Table 5 Methods used within different learning and teaching environments Clinical and community Clinical and classroom Classroom and skills lab Direct client care under supervision in all settings Simulations Case / log book Management of facilities Field trips Community links/visits Health education sessions Case studies Discussion of case / log book Mini teaching sessions Reflective discussion Peer-group learning Scenario-based learning and critical incident analysis Problem-based learning if Lectures and discussions Seminars Enquiry-based learning Multi-media Skills Lab simulations Group work Practice OSCEs Role play 39

41 Immunisations campaigns appropriate Drama Lecture/discussions Learning is more effective when students are involved and able to take responsibility. Part of this responsibility is to prepare for classes by reading material advised by teachers beforehand and to find other relevant material themselves. They should also be encouraged to attend class with readyprepared questions about their reading and issues for discussion. This gives students confidence and enables them to contribute and take part in class more usefully. Questions should be encouraged during lectures and it is the responsibility of teachers to ensure this happens. Students should also be encouraged to prepare and lead discussions and, later, mini-lectures. Role play and drama Drama can bring situations to life for those taking part and observing as well as raising important issues that initiate discussion and questions. It can help students to practice communication skills, and preparing for the drama can assist in thinking through ideas, issues and actions. Drama is normally planned carefully and has an audience. It is often used as a health education tool for example to encourage birth preparedness and complication awareness in a community. As such it can be used for assisting the learning of both those taking part and those observing. Role play is more spontaneous than drama. Those taking part put themselves in the place of the people depicted, and act and react naturally as the situation unfolds. It can help to develop communication and interpersonal skills. It can also raise issues and help those taking part (and observers) to understand emotions and the experiences of others. For this reason it can have a negative impact on those taking part as well when emotions become too powerful or raise personal issues or memories. It should be used with care and, at the end, those taking part should deliberately return to their normal selves and should have the opportunity to debrief or talk about the experience privately. Role play can be used just within the actual participants and without observers. Sometimes this is desirable if very personal. Typical examples of role play might be a counselling session prior to HIV testing, discussing breastfeeding with a newly delivered woman, talking to parents of a newborn girl about FGM, and talking to a pregnant woman who you suspect is experiencing domestic violence. Both these activities need to be facilitated and supervised by teachers to ensure learning opportunities are maximised and no harm results. Reflective practice Students should be encouraged to reflect on their practice and on incidents occurring in the clinical setting. The case book may be used as a journal in this way (also see below). The reflective cycle of Gibbs is probably the easiest to use. 12 Clinical skills practice 13 Before undertaking skills sessions, teachers need to 12 Many sources exist for this 1988 model and for others e.g Adapted from Ministry of Public Health Afghanistan (2009). 40

42 be confident in the procedure or skill have necessary resources and equipment prepared ensure the space is available, client ready and agreeing to be involved, clinical staff permission obtained. During sessions, teachers or clinical instructors: explain the purpose and outline of the session review the steps that make up the procedure demonstrate the procedure using checklists if available observe students carrying out the steps in pairs or groups provide guidance as necessary determine the readiness of students to carry out the procedure or activity with clients/patients. Simulation may be used as a preliminary to clinical practice or when experiences are uncommon or very complex. Planned realistic situations are provided in which students can apply their knowledge and skills as a learning exercise, and try out their decision-making skills with no risk to actual clients. Feed-back may come from teachers / clinical instructors or other students. Examples might be responding to post-partum haemorrhage, shoulder dystocia, or a woman with severe pre-eclampsia who has a convulsion. Simulations can be used repeatedly until students are confident in their actions. A useful alternative label for these is skills drills wherein a set of predetermined actions must be followed. Records of assessment of midwifery clinical skills, case book and log of clinical experiences Students will be provided with: a Log book in which they will record the numbers of specific experiences (Annexe 4). a Record of assessment of midwifery clinical skills (Annexe 5). Teachers and clinical instructors will use these with students to ensure procedures are demonstrated, performed under supervision and students progress to competence. a blank case book in which students will record and reflect on the care of women and neonates throughout the Programme. These documents may be printed off or photocopied from the Annexes on the Programme CD-ROM, except for the Case book for which an A4 notebook or journal may be used. Teachers will review the Case book and Log with the students at intervals and provide feed-back. The Case book and Log must be submitted completed to the satisfaction of the teacher and with the requisite number of experiences achieved (see Table 4), in order for a student to present herself for the final assessment at the end of Semester 3. A recommended framework for writing the case studies is adapted from the cyclical midwifery decision-making framework (ICM 2002) as follows in Table 6. This is similar to a problem-solving model. Table 6 see over 41

43 Table 6 Step 1 Step 2 Step 3 Step 4 Step 5 Collect information from the woman, from the woman's and the infant's records, and from physical examination and laboratory tests in a systematic way for a complete assessment. Identify actual or potential problems based on the correct interpretation of the information gathered in Step 1. Develop a comprehensive plan of care with the woman and her family based on the woman's or infant's needs and supported by the data collected. Carry out and continually update the plan of care within an appropriate time frame. Evaluate the effectiveness of care given with the woman and her family, consider alternatives if unsuccessful, returning to STEP 1 to collect more data and/or develop a new plan. Community and MCH centre links Students enrolled on midwifery programmes need to learn and understand the reality of the lives of childbearing women and their families. There is great benefit in ensuring students gain this experience, by linking to communities and community level activities. This will include: Linking with, and being given placements in MCHs Taking part in government and NGO community level programmes and campaigns Community experience in environments such as schools, prisons and IDP camps where this can be arranged. Linking with specific communities preferably for the duration of the programme. These communities may be rural or urban, nomadic or settled and will be primarily groups who have limited access to resources. (see below). The community links present a valuable learning opportunity for midwifery students. With tutorial support they develop relationships with families in that community through regular visits and develop their understanding of the realities of people s lives and the impact on health. Students should be introduced as early as possible, if possible within the first semester, with the links continuing through the Programme. The communities can be used for a variety of learning experiences during different Modules where possible and appropriate. These might be individual or group activities e.g. visits accompanied by teachers related to health promotion, nutrition, midwifery care provision, child health, child spacing, collecting epidemiological data. to perform an assessment of the health of women in a community and devise an action plan using the link community with whom they have built a relationship rather than such an activity being carried out where students are unknown. provide health promotion after discussing the needs with the lead midwife at the MCH centre and their teachers talk to women, their families and community leaders about childbirth preparedness and support the development of family and community plans. 42

44 It is understood that student safety must be the primary consideration when attempting to arrange these experiences, and that it may not always be possible to achieve for this reason. Objectives are described in Table 7 Objectives for practice experiences. These provide an overview for these settings and are not exclusive. Table 7 Objectives for practice experiences Placement By the end of the Programme students will be able to: Community services / provide midwifery services in the community, applying midwifery principles, detecting complications and responding in a timely and appropriate manner MCHs and links discuss the implications for maternal health in the community of the Three delays model of Thaddeus and Maine (1994) describe and analyse the availability of local referral mechanisms for women, infants and children under 5 needing emergency or other medical care and arrange referrals when needed demonstrate understanding of how cultural, religious and social aspects of family and community life relate to maternal and infant health explain the challenges childbearing women and their families meet in maintaining physical and mental health and how midwives can assist describe the role of government and local and international NGOs in helping people to maintain the best possible health demonstrate communication skills appropriate to the settings develop opportunities for health promotion and education manage a MCH work with local care providers (e.g. Community midwives, CHWs, TBAs, NGOs) and community civil and religious leaders to improve health of residents analyse needs and contribute to service development, taking the lead where appropriate. Hospital As above and provide woman-centred and baby-friendly evidence-based clinical care to women experiencing both normal and complicated childbearing and to both healthy, preterm and sick newborns recognise and use opportunities for health promotion with women receiving hospital care provide midwifery care independently to healthy women and newborns work with other healthcare team members, reporting to medical and senior midwifery staff when complications and emergencies arise provide emergency and ongoing care once under medical direction analyse needs and contribute to service development, taking the lead where appropriate Field trips understand how water supply and sanitation services are provided and the impact of deficiency on women and their families, taking supportive measures to make improvements describe the role of midwives in providing services in specific settings such as prisons and IDP camps, developing services where appropriate take part in campaigns such as community health, child immunisation, FGM advocacy and fistula prevention and lead where appropriate. 43

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46 ASSESSMENT STRATEGIES Student evaluation/assessment will measure achievement of specific, relevant knowledge, behavioural and skills competencies. Assessment will also assist with diagnosing students strengths and weaknesses and aid their progress and development. It will reflect the context of practice and the methods used for teaching and learning. Although theory and practice are often assessed separately, an emphasis on integration of both is always expected. Assessment of both clinical and theoretical progress will be: Formative: Formative assessment throughout the Programme provides feedback to learners and teachers about their progress in meeting the objectives, competencies and attributes. Students are given grades to indicate progress in theoretical work but these do not count towards the final Module or Programme assessment. Academic marks or grades are not given for the assessment of clinical practice which is aimed at progress toward achievement of the Essential Competencies. Competence is either achieved, or not achieved. Summative: Summative assessment takes place at the end of the learning process, or on a periodic basis and is designed to determine what the student has learned and to put a value on it. Summative assessment is used to determine final Semester and Programme grades achieved and to indicate the level of achievement of the Essential Competencies. Assessment is a key role of the Director of the Midwifery school and teaching team. The teacher s obligation is to evaluate students work objectively and without favour or discrimination. It is also essential that assessment is focussed on the specified criteria, objectives and competencies and that these are known and understood by both teachers and students. As the midwifery role is so personcentred, feedback is desirable also from clients with whom, and communities with which, students have worked. Opportunities for students to demonstrate learning and achievement of competencies include: Theoretical assessment methods: Formative tests during Semesters. End of Semester or Programme summative assessment, unseen written and/or oral examinations, examinations being set and administered by the programme teaching team. If it is so decided, the end of programme assessment may be nationally organised. Coursework projects (prepared and submitted by students, not under examination conditions) may be assessed for formative and/or summative feed-back 45

47 Unseen written tests / examinations will test knowledge and consist mainly of structured/objective examinations, short answer questions and, as the student gains more experience, essay questions. Behaviour / attitudes assessment methods: The Record of assessment of midwifery clinical skills (Annexe 5) includes a personal conduct section to assist in assessing professional behaviours and attitudes. Other methods such as role play and clinical simulations can also help the teacher monitor the development of appropriate professional behaviours and, of course, observation of the student in practice settings and feed-back from clients and staff. Skills assessment methods: Skills assessment will focus on regular working of midwife teachers and clinical instructors with students in various practice settings, and skills laboratory where appropriate e.g. for assessing the teaching of life-saving procedures and other procedures that are not normally encountered in the practice setting. The Record of assessment of midwifery clinical skills (Annexe 5) will be used for summative as well as formative assessment. A final skills assessment is carried out if possible as an OSCE. The student case book and log book can form the basis of discussion around practice for formative assessment, The Case book and Log of experience While the Case book and Log of experience are not summatively marked, they must be submitted before the students may present themselves for final assessment in Semester 3. They must have been completed to the satisfaction of the teacher who will have reviewed them with the student at regular intervals throughout the programme. They should demonstrate accuracy and reflection using a specified model, as well as integration of knowledge and professional attitudes. Record of assessment of midwifery clinical skills (Annexe 5). Skills should be assessed using actual clients/patients where possible but normally only once competence is achieved in simulated settings and the student has had the opportunity to carry out the activity with clients under supervision. Skills checklists are scored as: Procedure demonstrated Performs under close supervision Minimal supervision needed Performs independently. Where actual clinical experience is not available, assessment may be made in simulated settings and with models. It is expected that this will be for less common complications only. Examples are Management of prolapsed cord Shoulder dystocia Breech delivery 46

48 Twin delivery Vacuum extraction Management of postpartum haemorrhage by bimanual or aortic compression Manual removal of placenta. Assessment methods used are summarised in Table 8. Table 8 Assessment methods Theory/knowledge Checklists, rating scales, multiple-choice, multiple response, true/false, multiple choice tests: used to test recall of factual knowledge. Students whose performance is unsatisfactory should be given assistance to develop their knowledge further as needed before re-sits and final assessments are reached. Short answer papers are used to assess understanding as well as factual recall Essays can provide evidence of a student s ability to assemble knowledge needed to respond to a particular question or problem, to prioritise and organise the knowledge, and apply it to practice in an analytical way. Group projects can assess teamwork, problem-solving, understanding and decision-making as well as knowledge Case books help in monitoring the development of decision-making skills. Used as the basis of class/group discussions, they could also help monitor attitudes and knowledge. Poster presentations and talks such as healthy eating in pregnancy Viva voce e.g. of 15 minutes can accompany Practice assessment to test knowledge and understanding. Practice/skills Observation of clinical practice by teachers, clinical supervisors and staff Skills laboratory or clinical setting including OSCEs Case book and log Clinical documentation Record of assessment of midwifery clinical skills used for achievement of competencies. Poster presentations and talks Feedback from clients/patients and families Attitudes / professional behaviours Observation by teachers, clinical supervisors and staff of clinical practice Role play and simulations, need to be observed by teachers Feedback from clients/patient s and families. 47

49 REFERENCES Department for International Development (UK) Somalia fact sheet, (2008). International Confederation of Midwives (1999 revision) International Code of Ethics for Midwives International Confederation of Midwives (2002) International Confederation of Midwives Essential Competencies for Basic Midwifery Practice (no longer available) International Confederation of Midwives (2010a) International Confederation of Midwives Essential Competencies for Basic Midwifery Practice International Confederation of Midwives (2010b) International Confederation of Midwives Global Standards for Midwifery Education International Confederation of Midwives (2011) ICM Definition of the Midwife International Confederation of Midwives (undated) The philosophy and model of midwifery care, International Council of Nursing (2003) An implementation model for the ICN framework of competencies for the Generalist Nurse, Geneva: ICN Ministry of Planning and International Cooperation, Puntland State of Somalia (2007) Puntland Facts and Figures 2006, and-figures-mopic- MPIC: Ministry of Public Health, Afghanistan (2009) Institute of Health Sciences, Curriculum for Community Midwifery Education, 3rd. edn. Population Reference Bureau (2010) Female genital mutilation/cutting: data and trends, Update 2010 Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context, Social Science and Medicine, 38: UNICEF (2009) Essential Package of Health Services Somalia 2009 UNICEF (2010a) Somalia Annual report, UNICEF (2010b) Somalia statistics, WHA (2007) World health statistics, Geneva: WHO WHO (1994) Making pregnancy safer: the critical role of the skilled birth attendant: a joint statement by WHO, ICM and FIGO, Geneva: WHO WHO (2002) Strategic directions for strengthening nursing and midwifery services, , Geneva: WHO WHO (2006) Strengthening nursing and midwifery, Resolution WHA59.23, Rapid scaling up of health workforce production, in Fifty-ninth World Health Assembly, Geneva, May 2006, Resolutions and decisions, Geneva: WHO WHO (2009) Global standards for the initial education of professional nurses and midwives, Geneva: WHO 48

50 WHO EMRO (2010) Somalia Country Profile ALSO SEE OVER WHO (undated) Skilled birth attendants Factsheet, 49

51 MODULE AND UNIT OUTLINES Code Module and unit name PB 1 Orientation to midwifery The origin and history of the profession of midwifery Millennium Development Goals and the global effort to reduce maternal and neonatal mortality and morbidity Maternal health services in Somalia and Puntland Evidence-based practice in midwifery (introduction) 2 Study, information retrieval, and information technology skills 3 English communication 4 Review of fundamentals of practice and their application to midwifery 4a Nutrition for childbearing and the neonate 4b Ethics and introduction to ethical issues 4c Pharmacology 4d Epidemiology 4e Pathology and infection control 4f Community and public health 4g Health promotion and education 5 Understanding and working with people 5a Psychology applied to midwifery 5b Socio-cultural and faith issues in childbearing 5c Communication and counselling skills 6 Anatomy and physiology of childbearing including embryology and fetal development 7 Mental health and illness in childbearing 8 Antenatal 1 9 Labour 1 10 Postnatal 1 11 Newborn 1 12 Understanding research and evidence-based practice 13 Childbearing 2 (complications) 14 The newborn 2 (complications) 15 Reproductive and women s health 15a Child spacing 15b Sexually transmitted and reproductive tract infections, HIV and AIDS 15c Gender-based violence including harmful traditional practices 15d Common gynaecological and breast disorders and issues 16 Principles of learning and teaching 17 Management and leadership 18 Consolidation: emergency skills and revision 19 Consolidation Consolidation of practice Midwifery professional and ethical issues 50

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53 Module PM 1 Orientation to Midwifery Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hours 1/6/36 Module aim To introduce students to the Programme, to midwifery practice and the role of the midwife. Some of the issues such as ethics and rights will be raised again elsewhere and in the consolidation module Learning and teaching methods Discussion/ interactive lectures, guest speakers from clinical staff to share their values and experiences, role play, scenario-based learning, group work Learning outcomes. On successful completion of the module students will be able to 1. list the main components of the Post-basic midwifery Programme 2. discuss the development of the midwifery profession in global history including in Islam and Christianity, and in Somalia and Puntland 3. describe the roles and relationships of midwives with other members of the Somalia and Puntland health care team and with clients, families and communities, and the difference from nursing 4. discuss the role of midwives in maintaining birth as a normal process and maintaining safety 5. discuss and demonstrate appropriate behaviours of midwives and respect for dignity and diversity 6. briefly describe how the key principles of ethics apply to midwifery 7. briefly discuss the purpose of ICM and any local codes of ethics and how they affect practice 8. briefly explain the duty of care, and patients /clients rights applied to midwifery 9. discuss issues around childbearing and parenting that affect women with disabilities 10. explore the midwifery role as advocate for woman and families 11. discuss Millennium Development Goals 4 and 5 and Somalia and Puntland s maternal and infant morbidity and mortality status 12. describe the key global and local causes of maternal and infant morbidity and mortality 13. discuss maternal health services in Somalia and Puntland and issues of accessibility for women. Module content Topics Midwifery and the health care team Ethics, human rights, standards of behaviour Outline of content Development of midwifery in the world and in Somalia and Puntland Faith-based origins and contemporary Islamic and Christian views of caring ICM definition and role of the Midwife Midwifery and safeguarding normality of pregnancy and birth Accountability and professionalism in midwifery Somalia and Puntland and International Confederation of Midwives Codes of Ethics, practice and standards Review of key principles of ethics and human rights-based behaviours and 52

54 The role of nurses and midwives Maternal and neonatal morbidity and mortality Evidence-based practice attitudes Fairness Doing good and doing no harm Respect for individual freedom and autonomy, confidentiality, dignity Promoting wellbeing Sincerity and integrity Confidentiality and the communication of essential information Issues of consent and the right to refuse Discrimination, judgemental behaviours and their avoidance Supporting diversity: ethnic, religious, social status, and women living with disabilities The International definition of the midwife Role descriptions and approaches to care The specific role of the Somalia and Puntland midwife, Post-basic and Community Working with women, families and communities MDGs 4 and 5 and their relevance to the health of women and babies Global, Somalia and Puntland causes of maternal and neonatal morbidity and mortality Global and local strategies for safer motherhood Introduction to barriers to access and the Three Delays model of Thaddeus and Maine Introduction to the concept of BEMOC and CEMOC The concept of evidence-based practice in midwifery Introduction to key evidence (Relates to all modules and also see Module 12) Assessment type Formative / summative Essential Competencies assessed Quizzes, class tests Formative ICM Competency 1 End of semester examination question Summative Recommended resources for teachers and students Beauchamp T, Childress J (2008) Principles of biomedical ethics, 5 th edn. Oxford University Press USA Black R, Cousens S, Johnson H, Lawn J, Rudan I, Bassani D, Jha P, Campbell H, Walker C, Cibulskis R, Eiseles T, Liu L. Maters C (2010) Global, regional and national causes of child mortality in 2008: a systematic analysis, The Lancet, 375: June 5 pp www. thelancet.com Bhutta Z, Chopra M, Axelson H, Berman P, Bryce J, Bustreo F, Cavagnero E, Cornetto G, Daelmans B, de Francisco A, Fogstad H, Gupta N, Laski L, Lwn J, Maliqi B, Mason E, Pitt C, Requejo J, Starrs A, Victoa C, Wardlaw T (2020) Countdown to 2015 decade report ( ): taking stock of maternal, newborn and child survival. The Lancet, 375, June 5, pp Brayford D, Chambers R, Boath E, Rogers D (2008) Evidence-based care for midwives: clinical effectiveness made easy, Radcliffe Publishing Bryant N ed. (2003) Women in nursing in Islamic societies, Oxford: Oxford University Press Foster I (2010) Professional ethics in midwifery, Jones and Bartlett Fraser D, Cooper M eds. (2009) Myles Textbook for Midwives 15 th. edn, Churchill Livingstone Frith L, Draper H (2003) Ethics and midwifery: issues in contemporary practice, Books for 53

55 Midwives Huband S, Hamilton-Brown P, Barber G (2006) Nursing and Midwifery: a practical approach, Basingstoke: Macmillan/TALC. ch. 3 International Confederation of Midwives Code of Ethics available at International Council of Nurses (2002) International Code of Ethics for Nurses, International Confederation of Midwives (2011) ICM Definition of the midwife Jones S (2000) Ethics in midwifery, Mosby Nicol M, Brooker C, Meyer J (2003) Adult nursing: setting the scene, ch.1 in Brooker C, Nicol M eds. Nursing Adults: the practice of caring, Mosby Office of the High Commissioner for Human Rights Sachedina A (2009) Islamic biomedical ethics: principles and applications, Oxford University Press Taylor C, Liilis C, LeMone P, Lynn P (2005) Fundamentals of Nursing: the art and science of nursing care, Lippincott, Williams and Wilkins. ch.6 Thompson F (2003) Mothers and midwives: the ethical journey, Books for Midwives Press 54

56 Module PM 2 Study and information technology skills Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1/6/36 Module aim Students will gain maximum benefit from learning opportunities offered and further develop their independence for lifelong learning, locating and using appropriate resources and information technology. The module is the beginning of an ongoing process supported by teachers. Learning and teaching methods Group and individual study skills and IT exercises with teacher support, use of library and internet Learning outcomes On successful completion of the module and Programme students will be able to 1. Plan and organise their own study activities including revision 2. Become aware of their personal learning preferences 3. Make good use of resources available 4. Find and select appropriate information from printed and online sources 5. Make effective use of sources in writing coursework and written assessments of all types 6. Avoid plagiarism in producing written work 7. Write accurate records and reports 8. Use computers for word processing and preparing presentations 9. Maintain their reflective case and log books including guarding client/patient confidentiality 10. Develop skills of problem-solving, critical analysis and reflection 11. Work independently and in groups 12. Present their work to colleagues 13. Plan for their own continuing professional development on qualification Module content Topics Organising learning Resources Writing skills Outline of content Study time management Reflection on personal learning styles Organising case and log books Revising for tests Using learning opportunities effectively including developing skills of problem-solving, critical analysis and reflection Effective use of libraries, books and teacher-prepared materials Taking and organising notes Using computers and the internet (if available) Selecting appropriate materials Using multi-media Record-keeping applied to midwifery Writing case studies Word processing Planning and preparing coursework assignments and projects 55

57 Lifelong professional learning Referencing The aim of continuing professional development (CPD) Strategies for CPD Keeping a personal professional portfolio Assessment type Formative / summative Essential Competencies assessed Case and log book review Formative ICM Competency 1 Exercises in information retrieval and Formative writing Supervised task in information retrieval on a given topic including preparing an accurately referenced topic report Summative Recommended resources for teachers and students Bolton G (2005/2010) Reflective practice: writing and professional development, 2 nd. / 3 rd. edn., London: Sage * Cottrell S (2005) Critical thinking skills, Basingstoke, Palgrave Macmillan Cottrell S (2008) The study skills handbook, 3 rd. edn. Basingstoke, Palgrave Macmillan Gimenez J (2007) Writing for nursing and midwifery students, Basingstoke, Palgrave Macmillan Greetham B (2008) How to write better essays, Basingstoke: Palgrave Macmillan Moore S, Neville C, Murphy M, Connolly C (2010) The ultimate study skills handbook, Open University Press Price B, Harrington A (2010) Critical thinking and writing for nursing students, Learning Matters Scullion P, Guest D (2007) Study skills for nursing and midwifery students, Maidenhead: Open University Press and McGraw-Hill. 56

58 Module PM 3 English Communication Theory/ wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1/6/36 This module is organised as 2 hours/week while students are classroom-based, more if it can be arranged. The English classes continue through the three Semesters on this basis. Module aim Students will develop their ability to communicate in spoken and written English building on any experience of English provided in school. This will enable them to make use of midwifery and related literature and be an investment for their future personal and professional lives. Learning and teaching methods Small group and class activities, drama, discussions, audio-visual media, visits from native English speakers for conversation where possible. English will be used for all teaching because of the importance of fluency for using texts. Learning outcomes On successful completion of the module students will be able to 1. Converse in English to Oxford Headway or equivalent at least to intermediate level 2. Use appropriate everyday spoken and written social and medical/midwifery vocabulary and explain the meaning 3. Make use of English grammatical construction at least to intermediate level 4. Explain the meaning of passages in midwifery learning materials and texts 5. Explain back the content of texts journal articles, online resources and teaching sessions in English 6. Ask and answer questions in English and take part in discussions 7. Give class presentations in English 8. Take all assessments in English. Module content Topics Outline of content Conversation, grammatical construction, reading and writing English using Oxford Headway course or similar. Medical and midwifery terminology and text comprehension Assessment type Formative / summative Essential Competencies assessed Assessment is formative and ongoing in that assessment will be in English and must be passed. In order to pass students must also have understood and benefited from teaching and learning materials written in English. Recommended resources for teachers and students OUP Oxford Headway English course or similar, interactive if possible Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, (a text written in Macmillan plain English style). 57

59 Module PM 4a Nutrition science Theory wks/days/hrs ½ /3/18 Practice wks/days/hrs 0/0/0 Total wks/days/hrs ½ /3/18 Module aim Students will revise their knowledge of nutrition needed later for assessing the nutritional status of childbearing women, and for providing advice to childbearing women and their families. Nutrition for pregnancy and childbearing, and feeding the newborn are reconsidered in later modules. Learning and teaching methods Lecture/discussions, questioning in class, quizzes, audio-visual media, questioning family members about food practices and beliefs, group preparation of nutrition education session Learning outcomes On successful completion of the module students will be able to 1. Apply their knowledge of food categories, nutritional value of macro and micro-nutrients to healthy childbearing and infancy 2. Describe local food sources including for neonates, and explain their value as nutrition for childbearing and for infancy 3. Discuss foods and tradition, taboos and rules in Somalia and Puntland including fasting and the impact on the pregnant woman and her fetus 4. Discuss the nutrition needs of adolescents and the link between poor nutrition and pelvic deformity 5. Discuss the importance of good nutrition prior to pregnancy, in labour, for childbearing and lactation 6. Discuss common barriers to achieving good nutrition in adolescence, prior to and during pregnancy. postnatal and breastfeeding periods 7. Assess the nutritional status of individual pregnant women 8. Provide nutrition information and advice to women and their families 9. Discuss strategies for helping women to achieve good nutrition for childbearing and lactation. Module content Topics Nutrition science Socio-cultural issues Nutrition for childbearing women Outline of content Food categories, composition and nutritional values, macro and micro-nutrients and their importance for childbearing Local foods and their nutritional values Maintaining a healthy diet in Somalia and Puntland during childbearing and lactation Food and tradition, culture, nutrition beliefs, taboos, fasting, local infant initial and ongoing feeding and weaning practices Changing needs in pregnancy and lactation Assessing and monitoring nutritional status Special dietary needs e.g. with anaemia, heart disease, obesity, diabetes Mal-nutrition in pregnancy and lactation 58

60 Macro-nutrients e.g. protein or carbohydrate deficiency Micro-nutrients e.g. vitamin and mineral deficiency Obesity, impact on pregnancy and labour, eating disorders (bulimia, anorexia) Neonatal nutrition See Modules 11 and 14 Assessment type Formative / summative Essential Competencies assessed Quizzes, group activities Formative ICM Competency 1, contributes Test questions / project e.g. report of nutrition patterns in Somalia and Puntland and the impact on childbearing women Summative to others Recommended resources for teachers and students Bender D (2007) Introduction to Nutrition and Metabolism, 4th.edn. CRC Press Burgess A, Bijlsma M, Ismael C (2009) Community Nutrition: a handbook for health and development workers, Basingstoke: Macmillan (TALC) Carter I (2003) Healthy Eating, Tearfund Langley-Evans S (2009) Nutrition: a lifespan approach, Chichester: Wiley-Blackwell Martyn K (2003) Nutrition, ch.11 in Brooker C, Nicol M eds. Nursing Adults: the practice of caring, Edinburgh: Mosby Savage King F, Burgess A (1993) Nutrition for Developing Countries, 2nd. edn. Oxford: Oxford University Press (available from TALC) Truswell AS (2003) ABC of Nutrition, 4th. edn. London: Bookpower with BMJ Books (available from TALC) UNICEF / TALC (2006) Community Nutrition, free TALC CD-ROM 59

61 Module PM 4b Ethics in midwifery Theory wks/days/hrs ½ /3/18 Practice wks/days/hrs 0/0/0 Total wks/days/hours ½ /3/18 Module aim Midwives have the requisite knowledge from ethics to provide high quality and dignified services to childbearing women and their newborns. Learning and teaching methods Discussion/ interactive lectures, guest speakers from clinical staff to share their values and experiences, role play, drama, scenario-based learning, group work. Learning outcomes. On successful completion of the module students will be able to 1. describe how the key principles of ethics apply to midwifery 2. discuss the purpose of ICM and local codes of ethics and how they affect practice 3. explain the duty of care 4. discuss the impact of human rights and their violation on the health of childbearing women and their babies 5. discuss issues around childbearing and parenting that affect women with disabilities 6. explore the midwifery role as advocate for woman and families and how they may be empowered 7. support women s rights to make informed choices about their care and that of their babies. Module content Topics Human rights Ethics, human rights, standards of behaviour Professional ethics Key issues Outline of content Human rights conventions including Rights of the Child Review of key principles of ethics and human rights-based behaviours and attitudes Fairness Doing good and doing no harm Respect for individual freedom and autonomy, confidentiality, dignity Promoting wellbeing Sincerity and integrity Deontology Local and International Confederation of Midwives Codes of Ethics, practice and standards Confidentiality in midwifery Discrimination and its avoidance Supporting diversity in ethnicity, religion, social status Supporting and avoiding discrimination for women living with disabilities Introduction to key ethical issues in midwifery and obstetrics Choice, consent and refusal Ethical policy-making 60

62 Thinking and decisionmaking Reproductive choice and society and religious norms Issues of life and death in childbearing and babyhood including truth telling Equity of service access and treatment Research on human subjects MORAL model Make a thorough enquiry into the issues Outline the options Review the alternatives Act Look back and evaluate Assessment type Formative / summative Essential Competencies assessed Quizzes, class tests Formative ICM Competency 1 End of semester examination question OR assessed group project Summative Recommended resources for teachers and students Beauchamp T, Childress J (2008) Principles of biomedical ethics, 5 th edn. Oxford University Press USA Bryant N ed. (2003) Women in nursing in Islamic societies, Oxford: Oxford University Press Foster I (2010) Professional ethics in midwifery, Jones and Bartlett Fraser D, Cooper M eds. (2009) Myles Textbook for Midwives 15 th. edn, Churchill Livingstone Frith L, Draper H (2003) Ethics and midwifery: issues in contemporary practice, Books for Midwives Huband S, Hamilton-Brown P, Barber G (2006) Nursing and Midwifery: a practical approach, Basingstoke: Macmillan/TALC. ch. 3 International Confederation of Midwives Code of Ethics available at International Council of Nurses (2002) International Code of Ethics for Nurses, Jones S (2000) Ethics in midwifery, Mosby Nicol M, Brooker C, Meyer J (2003) Adult nursing: setting the scene, ch.1 in Brooker C, Nicol M eds. Nursing Adults: the practice of caring, Mosby Office of the High Commissioner for Human Rights Sachedina A (2009) Islamic biomedical ethics: principles and applications, Oxford University Press Taylor C, Liilis C, LeMone P, Lynn P (2005) Fundamentals of Nursing: the art and science of nursing care, Lippincott, Williams and Wilkins. ch.6 Thompson F (2003) Mothers and midwives: the ethical journey, Books for Midwives Press 61

63 Module PM 4c Pharmacology applied to midwifery Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1/6/36 Module aim Midwives will be able to use knowledge of pharmacology to administer medicines and other therapeutic substances safely and effectively to childbearing women and newborns. This will be according to local protocols regarding whether medical prescription is required or for drugs and substances recognised in Somalia and Puntland for prescription by midwives. Learning and teaching methods Demonstrations, lectures, calculation activities, skills lab activities, pharmacy visits, supervised practice, case books, log books. Learning outcomes On successful completion of the module students will be able to 1. Describe the main classes of drugs and their uses including those specific to childbearing women 2. Describe the basic actions of common drugs and how the body processes them during the childbearing period 3. Describe possible side-effects of the most common medications 4. Demonstrate the safe administration of drugs and therapeutic substances such as intravenous fluids to childbearing women and newborns, including accurate calculations 5. Describe available local protocols and legal frameworks regarding therapeutic substances 6. Demonstrate knowledge of where to find information about medications. Module content Topics Main classes Storage and use review Outline of content Main classes of medicines and other therapeutic substances Pharmacokinetics in childbearing: what happens to drugs in the body (LADMA) Liberation Absorption Distribution Metabolism Excretion Pharmacodynamics: the effect of drugs on the body, how they work Common side effects, adverse drug reactions and interactions Traditional medicines in Somalia and Puntland, uses, effectiveness, dangers, interactions Drugs used in midwifery and obstetrics Safe storage and disposal in all settings Reading and interpreting prescriptions Drug calculation skills including dilutions and IV administration rates Safe administration by various routes (including Five rights of 62

64 Drugs for the newborn Education of clients Legal and policy issues medicine administration ). Records Unsafe practices including use and disposal of sharps Main drugs used Safe administration to newborns including routes Side effects Traditional medicines and substances: types, uses, effectiveness, dangers, interactions Advising childbearing women about medicine use including storage, expiry dates, completing courses, over-the-counter purchases, selfmedication Advising women about drugs for newborns and infants National legal and policy frameworks The WHO Model lists of essential medicines Assessment type Formative / summative Essential Competencies assessed Quizzes and tests Formative ICM Essential Competencies 1-7 Observation of skills lab activities Drug calculation skills tests Clinical skills assessments /OSCEs Summative Recommended resources for teachers and students Bavin C, Cronin P, Rawlings-Anderson K, Nicol M (2008) Essential nursing skills, 3rd. edn. Edinburgh: Mosby (or recent) Deglin J, Vallerand A (2009) Davis s drug guide for nurses, 11th. edn. F.A. Davis Company (or recent) Gatford J, Philips N (2006) Nursing calculations, 7th. edn. Churchill Livingstone Jordan S (2010) Pharmacology for midwives: the evidence base for safe practice, 2 nd. edn. Basingstoke: Palgrave Macmillan (or 2002) Joint Formulary Committee (2011) British National Formulary, Pharmaceutical Press (and BNF for Children) (or latest available) McGavock H (2005) How drugs Work: basic pharmacology for health care professionals, 2 nd. edn. Radcliffe Publishing Taylor C, Liilis C, LeMone P, Lynn P (2005) Fundamentals of Nursing: the art and science of nursing care, Lippincott, Williams and Wilkins PATH, the World Health Organization, and the United Nations Population Fund (2006) Essential medicines for reproductive health: guiding principles for their inclusion on national medicines Lists. Seattle: PATH WHO (2011) WHO Model list of essential medicines (Adult) 17th. edn. WHO (2011) WHO Model list of essential medicines for children (Child) 3rd.edn. 63

65 Module PM 4d Community and public health with epidemiology Theory wks/days/hrs 1½/9/54 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1½/9/54 Module aim Midwives will support health improvements in the community related to maternal and infant health working with community members, leaders and other healthcare team members and collect data as required. Managing this process is addressed further in Module 17. Learning and teaching methods Community visits, lecture/discussions, audiovisual media, role play, scenarios, take part in data collection activities if opportunities arise, log books. Activity: In groups, students may conduct interviews and/or focus group discussions in their link community to assess and plan for major health needs of childbearing women and infants, prepare and present the results to fellow students. Where possible they should involve civil and religious leaders, TBAs, CHWs, traditional healers as well as residents. This may be used as summative assessment) see below). Learning outcomes On successful completion of the module students will be able to 1. Explain public health principles applied to midwifery 2. Explain the principles of primary health care and community health and their application to midwifery 3. Discuss the midwifery role in relation to other members of the public and community health teams 4. Relate communicable disease issues to midwifery 5. Apply the principles of epidemiology and data collection to maternal and newborn health care 6. Describe factors that influence the health of childbearing women and their infants within community settings 7. Assess the needs of childbearing women and their infants Module content Topics History and principles of primary health care, public and community health Review of Influences on health (health determinants) and application to childbearing women and infants Outline of content Primary health care history and international declarations Definitions and principles of primary health care, public and community health The midwifery role within public and primary health/community health teams Review infrastructure issues and relate them to maternal and infant health Water supply safety including well design Sewage disposal including latrine design Design of dwellings and ventilation Planning residential areas for health Pollution of the environment 64

66 Action for health Epidemiology Refuse collection and toxic waste Atmospheric pollution including open cooking fires in homes Substance abuse and the impact on families and communities Pest control Lifestyle (e.g. diet, exercise, exposure to tobacco smoke, qat) The role of public service and resource constraints in disease The role of inequality, gender, poverty, unemployment, urbanisation in maternal and newborn health Breastfeeding as a public health measure Communicable disease and the impact on childbearing women and babies Public health of vulnerable groups e.g. IDPs, refugees, homeless families, women living with disabilities Assessing community health and planning activities to support health improvements Participatory learning and action cycle (see Badas et al 2011 below) The role of government and NGOs in public and community health Review of principles and application to the midwifery role Public health surveillance, health information, Review data collection methods Data collection in maternal and newborn health National statistics and how they are gathered and analysed Issues limiting gathering of statistical data Maternal and neonatal death audit, Near Miss audit Assessment type Formative / summative Essential Competencies assessed Quizzes, tests Formative ICM Essential Competencies 1, 2 Group community assessment Unseen examination question Summative Recommended resources for teachers and students BADAS, Ekjut, Women and Children First (UK) (2011) Community mobilisation through women s groups to improve the health of mothers and babies: Good practice guide, Booth B, Martin K, Lankester T (2001) Urban health and development: a practical manual for use in developing countries, Basingstoke: Macmillan Carr S, Unwin N, Pless-Mulloli T (2007) An introduction to public health and epidemiology, 2 nd. edn. Open University Press Coles L, Porter E (2008) Public health skills: A practical guide for nurses and public health practitioners, Wiley Blackwell Conant J, Fadem P(2008) A Community guide to environmental health, Hesperian Edwards G, Byrom S (2007) Essential midwifery practice: public health, Wiley-Blackwell Farmer R, Lawrenson R (2004) Epidemiology and public health medicine, 5 th. edn. Malden. Mass: Blackwell Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 24 Medecins Sans Frontiers (undated) Rapid health assessment of refugee or displaced persons 65

67 O Luanaigh P, Carlson C eds. (2009 (or 2005) Midwifery and public health: future directions and new opportunities, 2 nd. edn. Churchill-Livingstone Stockman D (1994) Community assessment, Intermediate Technical Publications, available from e-talc.org.uk Walley J, Wright J eds. (2009) Public health - an action guide to improving health in developing countries, Oxford: Oxford University Press Online resources Medecins Sans Frontieres e.g. Public health pdf., refugee camp virtual tour, slideshows, videos WHO Alma-Ata Declaration on Primary Health Care WHO Declaration on Occupational Health for All WHO materials on: primary health care, environmental health and pollution, health impact assessment, disabilities and rehabilitation, school and adolescent health, refugees, travel, poverty, substance abuse, tobacco, alcohol. 66

68 Module PM 4e Pathology applied to midwifery Theory wks/days/hrs ½/3/18 Practice wks/days/hrs 0/0/0 Total wks/days/hrs ½/3/18 Module aim Midwives will apply knowledge of pathology in providing midwifery services to women and babies Learning and teaching methods Skills room demonstrations, exercises and simulations, lecture/discussions, audio-visual media and learning packages, visits to wards and departments e.g. central sterile supply, path lab, supervised practice, log books Learning outcomes On successful completion of the module students will be able to 1. Describe ways of maintaining their own personal safety and that of patients/clients, their families, and colleagues from infection 2. Use existing knowledge of microbiology in preventing and treating infection in childbearing women and babies 3. Use existing knowledge of haematology and biochemistry in providing midwifery services 4. Use local guidelines and protocols in providing midwifery care. Module content (These topics will be revisited and applied in later modules e.g. 13) Topics Outline of content Microbiology and infection Personal hygiene control review Appropriate clothing and footwear for clinical practice Review of microbiology including infectious agents and their affects infection transmission and hosts principles of sepsis and asepsis applied to midwifery Infection prevention and control hospital acquired (nosocomial) infection and the impact on childbearing g women and babies universal precautions in midwifery basic hand washing and skin cleansing techniques hand washing and appropriate use of clean and sterile gloves and gowns, masks and goggle for midwifery and neonatal procedures maintaining a clean or sterile field revision of hazardous waste and safe disposal applying infection prevention and control principles to the home, community and small facility environment Haematology Review of haematology Haematology applied to childbearing and the neonate Blood groups and their application to midwifery Safe transfusion of blood and blood products Biochemistry review Biochemistry review 67

69 Service guidelines Biochemistry and the childbearing woman Guidelines and protocols Assessment type Formative / summative Quizzes and tests Formative and summative Observed skills lab and Formative clinical setting activities Semester examinations Summative OSCEs Essential Competencies assessed ICM Competency 1 but relevant to all competencies Recommended resources for teachers and students Baston H, Hall J, Henley-Einon A (2009) Midwifery essentials, vol. 1, Basics, Churchill Livingstone Bavin C, Cronin P, Rawlings-Anderson K, Nicol M (2008) Essential Nursing Skills, 3rd. edn. Edinburgh: Mosby (or 2002 edn.), Brooker C, Nicol M eds. (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby ch. 13 Fraser DM, Cooper MA eds. (2009) Myles Textbook for Midwives 15 th. edn, Churchill Livingstone Gould D, Brooker C (2000) Applied Microbiology for Nurses, Edinburgh: Churchill Livingstone Higgins C (2007) Understanding laboratory investigations for nurses and health professionals, 2 nd. edn. Wiley-Blackwell Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, ch. 6 and midwifery chapters JHPEIGO (2003) Infection prevention guidelines for health care facilities with limited resources, Johnson R, Taylor W (2000 or later) Skills for midwifery practice, Edinburgh: Churchill Livingstone Provan D, Singer F (2009) Oxford handbook of clinical haematology, 3 rd. edn. Oxford: Oxford University Press Springhouse (2008) Diagnostic Tests Made Incredibly Eay, 2 nd. edn. Lippincott, Williams and Wilkins Waugh A, Grant A (2006) Ross and Wilson Anatomy and Physiology in Health and Illness, 10 th. edn. Edinburgh: Elsevier Churchill Livingstone (or 2001 edition). See ch. 15. Includes online resource for students: 68

70 Module PM 4f Health promotion and education Theory wks/days/hrs ½/3/18 Practice wks/days/hrs 1/6/42 Total wks/days/hrs 1½ /9/60 Module aim Midwives will develop the knowledge and skills to promote health with individuals and communities, and to provide health education sessions to childbearing women and their families. Learning and teaching methods Observation in practice settings, lecture-discussions, micro-teaching in peer groups, role play and drama, making visual aids, using audio-visual media in health education sessions, log books, preparing, presenting and evaluating health education sessions to women and their families. This Module content will be revisited in later Semesters. Learning outcomes On successful completion of the module students will be able to 1. Discuss the application of the principles of health promotion and education to midwifery 2. Assess the needs for health promotion and education of individual women and groups 3. Use and develop health promotion and education opportunities with individuals and groups 4. Devise a plan for promoting maternal and neonatal health and providing appropriate education 5. Prepare and present a health education session for a group e.g. drama, demonstration, talk 6. Make effective use of available health promotion and education resources 7. Produce health education materials e.g. e.g. posters, recordings, models from locally available materials 8. Apply the principles of educating adults to health education of childbearing women and families 9. Evaluate and discuss the success of the plan and the health education session 10. Respond appropriately to self-assessment and feedback from others. Module content Topics Health promotion Review of psychology of health promotion and education Different needs Outline of content Review the concept of health, definitions, constructions and beliefs Review principles and models of health promotion Partnerships in health promotion, working with NGOs, government and other health professionals, TBAs and CHWs Attitude and behaviour change theories what works? Resistance and positive behaviours Influences on health-related behaviours Communicating and collaborating Principles of educating adults Promoting health of: adolescents, childbearing and lactating women, infants e.g. nutrition, prevention of STIs and HIV, FGM childbearing women living with HIV, diabetes, STI prevention, malnutrition complication awareness and emergency readiness for labour in 69

71 Health education communities including transport, funds, communication, knowledge of facility availability Health promotion re. breastfeeding, mental health, child spacing, GBV and harmful traditional practices e.g. FGM and early marriage Promoting health in vulnerable groups e.g. IDPs and refugees, learning disabled women Profiling and assessing need in individuals and communities Planning interventions Preparing talks, audio-visual aids, dramas Skills in using common audio-visual equipment and other resources Demonstrating skills to adults Providing health education talks and demonstrations Evaluating plans and sessions Assessment type Formative / summative Essential Competencies assessed Make and use a visual aid Quizzes and tests Formative Formative ICM Essential Competencies 1, 2, 3, 5, 6, 7 Prepare, present and evaluate the success of a health education session. The plans form part of the assessment. Summative Recommended resources for teachers and students Bensley R, Fisher J (2002) Community health education methods: a practical guide. 2 nd.. edn., Sudbury Mass: Jones and Bartlett (in SLNMA library) Blaxter M (2010) Health Key concepts, 2 nd. edn. Polity Press Bowden J, Manning V (2006) Health promotion in Midwifery: principles and practice, Hodder Arnold Dunkley-Bent J (2000) Health promotion in midwifery practice: a resource for health professionals, Edinburgh: Bailliere Tindall Ewles L, Simnett I (2003) Promoting health: a practical guide, Edinburgh: Bailliere Tindall Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery: a practical approach, Basingstoke: Macmillan/TALC (chapter 50) Naidoo J, Wills J (2009) Foundations for health promotion, Edinburgh: Bailliere Tindall WHO (2009) Milestones in health promotion: statements from global conferences, Online sites Eldis Family Health International John Hopkins Center for Communication Programs and search for health promotion Use then search box for specific topics 70

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73 Module PM 5 Theory wks/days/hrs 3/18/108 Understanding and working with people Practice wks /days/hrs 0/0/0 Total wks/days/hrs 3/18/108 Module aim Midwives will use knowledge from psychology and socio- cultural studies to understand people s lives and behaviours and interact and communicate more effectively with them. They will also be able to provide basic counselling. Learning and teaching methods Interactive lectures, role play, case studies and scenarios, supervised practice, reflective writing in case books Learning outcomes On successful completion of the module students will be able to 1. Discuss the application of psychological principles to childbearing, parenthood and to midwifery 2. Discuss socio-cultural and faith issues and how these impact on lives and communities 3. Discuss principles from socio-cultural studies 4. Describe influencing socio-cultural and faith factors on the health and wellbeing of childbearing women and their families 5. Discuss how types of communication are used in practice 6. Discuss how effective communication skills can assist midwives to provide services to childbearing women and their families 7. Demonstrate appropriate counselling techniques 8. Provide basic counselling services relevant to the role e.g. in child spacing or HIV testing 9. List facilities for referral for counselling 10. Use this knowledge in writing reflective case studies for the case book. 11. Maintain confidentiality at all times. Module content Topics Review of principles of psychology and application to midwifery Communication with individuals and groups Review of socio-cultural Outline of content Review psychological principles including human development and socialisation human need how groups act the influence of childbearing on family dynamics Making contact Factors affecting communication Skills for communication Dealing with bad news Dealing with prejudice Boundaries in the client-professional relationship in midwifery and how to maintain them Review of ideas from sociology / how society works 72

74 issues Power relationships and inequality in families, how power differentials impact on women, relationship between power and GBV (also see Module 15c) Gender and society, health, education Stigma and discrimination Views of women, representation of female bodies How people live in contemporary Somalia and Puntland (including the family) Socialisation and the role of the family Tradition and rites of passage (childhood, adolescence, marriage, childbearing, death) The expectant family, parenting, reactions to motherhood and fatherhood, relationships Culture and religion and their impact on maternal and infant health The faith-based outlook on health, care and on childbearing of the diversity of ethnic and faith groups in Somalia and Puntland Social impact of using addictive / harmful substances: tobacco, qat Human rights including of women and children Disrupted lives and health e.g. family breakdown, refugees, IDPs, natural and man-made emergencies Implications of socio-cultural and faith issues for midwifery practice. The issue of reproductive rights Assessment Assessment type Formative / summative Essential Competencies assessed Case studies in case book Short answer tests Formative ICM Competency 1 and relevant to 2-7 Unseen essay examination OR reflective case presentation Summative Recommended resources for teachers and students Barry AM, Yuill C (2008) Understanding the sociology of health and illness: an introduction, London: Sage Bryant n (2003) Women in nursing in Islamic societies, Oxford: Oxford University Press Davis-Floyd R, Barclay L, Daviss B, Tritten J, eds. (2009) Birth models that work, Berkeley: University of California Press Doyal L (1995) What makes women sick: gender and the political economy of health, Palgrave- Macmillan Giddens A (2009) Sociology, 6 th. edn. Polity Press Helman C (2007) Culture, health and illness, 5 th. edn. Hodder Arnold Henley A, Schott J (1996) Culture, religion and childbearing in a multi-racial society, Books for Midwives Press Hunt S, Symonds A (1995) The social meaning of midwifery, Basingstoke: Macmillan Hunt S, Martin A (2000) Pregnant women, violent men: what midwives need to know, Books for Midwives Press ICM, FIGO and WHO (2005) Definition of the midwife, Kent J (2000) Social perspectives on pregnancy and childbirth for midwives, nurses and the caring professions, Buckingham: Open University Press 73

75 Kirkham M (2006) Exploring the dirty side of women's health, Routledge Maclachlan M (2006) Culture and health: a critical perspective towards global health, 2 nd. edn. Wiley-Blackwell McCabe C, Timmins F (2006) Communication skills for nursing Practice, Palgrave Macmillan Nettleton S (2006) The sociology of health and illness, 2 nd. edn. Cambridge: Polity Oakley A (2005) The Ann Oakley reader: gender, women and social science, Policy Press Raynor M, England C (2010) Psychology for midwives: pregnancy, childbirth & the puerperium, Milton Keynes, Open University Press Stewart M (2003) Pregnancy, birth and maternity care: feminist perspectives, 2 nd. edn. Books for Midwives Press Sully P (2003) Communication in adult nursing, ch. 3 in Brooker C, Nicol M eds. Nursing Adults: the practice of caring, Mosby Taylor S, Field D eds. (2007) Sociology of health and health care, 4 th. edn. Wiley-Blackwell Web resources and CD-ROMS Multiple sources available by searching human rights and women or maternal e.g. Women and Children First WHO Publications of the Gender, Women and Health Network , CD-ROM and multiple resources 74

76 Module PM 6 Anatomy and physiology, and changes in pregnancy Theory wks/days/hrs 3/18/108 Practice wks /days/hrs 0/0/0 Total wks/days/hrs 3/18/108 Module aim The module enables midwives to understand the body structures and natural processes underlying childbearing, including the changes and normal discomforts experienced by women. This forms the foundation for later Modules on childbearing and for safe and effective practice. Fetal and neonatal anatomy and physiology is addressed in Modules 8 and 11. Learning and teaching methods Lecture-demonstrations, use of anatomical models and charts, audio-visual media, handouts, group activities Learning outcomes On successful completion of the module students will be able to 1. Explain basic biochemistry principles and their application to childbearing 2. Describe the structure and functions of cells and tissues including changes through childbearing 3. Outline the role of hormones on pregnancy, labour, birth, the puerperium and lactation 4. Describe changes in homeostasis experienced in pregnancy 5. Describe the impact of pregnancy on body systems 6. Outline human reproductive from the production of gametes to fertilisation 7. Describe the development of the embryo and fetus 8. Outline the physiological process of the onset of labour through to postpartum and lactation. Module content Topics Review of basic biochemistry Body organisation Homeostasis Body systems and the impact of pregnancy Reproduction review Basic pathology of fetal and neonatal disorders Outline of content Principles and their application to childbearing Body tissues and structures and changes during childbearing Impact of pregnancy on homeostasis The immune system in pregnancy Hormones and control Cardiovascular system and blood Respiratory system Metabolism, the digestive and urinary systems, elimination Minor discomforts and their relationship to pregnancy changes Female and male reproductive anatomy and physiology Puberty, menarche, menstruation and menopause Development of eggs and sperm Sexual intercourse, fertilisation and implantation Development of the embryo and fetus Introduction to basic principles of genetics Introduction to the causes of disorders in the fetus and neonate Pathological agents and processes e.g. genetic/inherited problems, 75

77 toxins, pathogens, radiation, trauma, oxygen and nutrient deficiencies Assessment type Formative / summative Essential Competencies assessed Quizzes and tests Formative ICM Competency 1 but needed for Module or Semester examination Summative 2-7 also Recommended resources fir teachers and students Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, various chapters Springhouse (2007) Fluids and electrolytes made incredibly easy, 4th. edn. Springhouse Publishing Springhouse (2008) Anatomy and physiology made Incredibly easy, 3rd. edn. Lippincott Williams and Wilkins Stables D, Rankin S (2004 or 2010) Physiology in childbearing with anatomy and related biosciences, 2 nd. edn., Bailliere Tindall Tortora G, Derrickson (2011) Principles of anatomy and physiology, 13 th edn. John Wiley (includes online access) (or Tortora G, Grabowski S, earlier editions) Watson R (2005) Anatomy and physiology for nurses, 12th.edn. Edinburgh: Elsevier (or earlier ) Waugh A, Grant A (2006) Ross and Wilson Anatomy and physiology in health and illness, 10th. edn. Edinburgh: Elsevier Churchill Livingstone (or 2001 edn). 10 th. edn. includes access to online resource for students: 76

78 Module PM 7 Mental health and illness Theory wks/days/hrs ½/3/18 Practice wks/days/hrs 0/0/0 Total wks/days/hrs ½/3/18 Module aim Midwives will provide high quality care to childbearing women that takes account of mental health needs and issues Learning and teaching methods Lectures and discussion, role play, scenarios, case book reviews, supervised practice and clinical visits if available NB. Practice hours are not included for this Module because of the virtual absence of mental health services. However every effort should be made to provide some experience for students. At least their experiences of mental health issues amongst the childbearing women they encounter can be drawn on and their awareness be developed. Learning outcomes On successful completion of the module students will be able to 1. Describe the issues that impact on women s mental health 2. Describe the way women adapt psychologically to childbearing 3. Describe the main mental illnesses that childbearing women and their families may experience 4. Describe the main features of mental illness arising in pregnancy and postpartum 5. Provide immediate and ongoing support and refer appropriately 6. Describe the possible impact of mental illness and stress on attachment and child development and ways of helping 7. List the key issues for childbearing women using psychiatric drug therapy 8. Provide information on any available support services and support women s access to them Module content Topics Concept of mental health and illness Review of influences on mental health Review of mental health issues and disorders and their management Outline of content Review of concepts of mental health and illness, cultural, faith-based, medical Stress, bereavement Gender-based violence and the impact of pregnancy Physical health issues Adaptation to pregnancy and parenthood Main features, identification, and management of disorders of Perception: psychotic disorders, schizophrenia Mood; bipolar disorder Anxiety Eating Personality Coping Issues affecting mental health and causing stress Vulnerable people: displaced persons and refugees, homelessness, poverty, unemployment, substance abuse, trauma, abused women and children, people living with disability 77

79 Pregnancy-related disorders Mental health services and support Psychosocial abuse and abusive relationships Self-harm and suicide Unexplained somatic complaints and their link with psychosocial stress and abuse Organic causes of disorders Mental health assessment in childbearing women Psychotropic drugs during pregnancy and lactation Management of psychiatric emergencies within the community Personal safety of staff Main features, management and referral for Antenatal and postnatal mild and severe depression Postpartum psychosis Service availability and referral facilities in Somalia and Puntland and the potential for development Mental health and illness Violence against women and children Mental health promotion Community support and issues of stigma Health care professional responses to mental illness How the midwife can help women and families Prevention of mental illness in subsequent pregnancies Assessment type Formative / summative Essential Competencies assessed Class tests Observation of role plays and Formative ICM Essential Competencies 3, 4, 5 simulations Review of case books Examination questions Summative Recommended resources for teachers and students Barker P (2008) Psychiatric and mental health nursing, 2 nd. edn. Hodder Arnold Brooker C, Nicol M (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby. ch. 30 ( ) Callaghan P, Waldock A eds. (2006) Oxford Handbook of Mental Health Nursing, Oxford: Blackwell Hanley V (2009) Perinatal mental health: a guide for health professionals and users, Wiley Blackwell Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapters 8, 49 Patel V (2003) Where There is No Psychiatrist: a mental health care manual, London: Royal College of Psychiatrists Price S (2007) Mental health in pregnancy and childbearing, Edinburgh: Churchill Livingstone Raynor M, England C (2010) Psychology for midwives: pregnancy, childbirth & the puerperium, Milton Keynes, Open University Press WHO (2008) Mental health aspects of women s reproductive health, Geneva: WHO Wrycraft N (2009) An introduction to mental health nursing, Open University Press Extensive resources from UK based support organisation 78

80 Module PM 8 Antenatal 1 Theory wks/days/hrs 2/12/72 Practice wks/days/hrs 4/24/168 Total wks/days/hrs 6/36/240 Practice hours are supplemented during the Consolidation period Module aim Midwives provide high quality antenatal care to maximise women s health during pregnancy. Midwives also provide advice pre-conception. The early detection and treatment or referral of complications is considered in Module 13. Learning and teaching methods Skills lab activities, visits to clinics and communities, lectures, role play, simulations, supervised practice, case books, log books. Throughout this Module contemporary research-based evidence will influence what is taught. Possible activity: present records of a full antenatal assessment of a woman with a plan of care devised with the woman. Learning outcomes On successful completion of the module students will be able to 1. Describe Millennium Development Goal 5 and the main causes of maternal morbidity and mortality in Somalia and Puntland 2. Discuss local traditions and practices used in pregnancy and their implications for women s health 3. Use knowledge of anatomy and physiology and reproductive biology including the growth and development of the fetus to underpin antenatal care 4. Advise women on preconception measures to prepare for healthy pregnancy 5. Confirm pregnancy, assess gestation and estimate the date of birth 6. Take a comprehensive health and obstetric history and a focussed antenatal examination taking account of the woman s mental health and home circumstances as well as physical wellbeing 7. Arrange or carry out basic screening tests in the antenatal period and take appropriate action 8. Provide preventive measures as required e.g. folic acid, iron, malaria prophylaxis, tetanus immunisation, ARVs 9. Advise woman and their partners about health maintenance in pregnancy including nutrition, hygiene, use of over-the-counter and traditional medicines, sexuality, work inside and outside the home, use of treated bed nets in malarial areas, preventing STIs and HIV infection. 10. Advise women on common discomforts and how to relieve them 11. Assess the progression of pregnancy and growth and condition of the fetus 12. Describe actions of drugs in pregnancy including traditional medicines and cures 13. Educate women and their families and communities about danger signs and symptoms in pregnancy, emergency preparedness, and the onset of labour 14. Support women in making decisions about their care, place of birth and preparing for the newborn 15. Provide information about Somalia and Puntland maternity services and the role of skilled birth attendants 16. Discuss the importance of exclusive breastfeeding. 17. Overview of principle complications (to be continued in Module 13) 79

81 Module content Topics Midwifery role Local traditions Review of female and male reproductive anatomy and physiology Preparing for pregnancy Understanding pregnancy: anatomy and physiology Normal pregnancy and development of the embryo and fetus Focussed antenatal care and midwifery support Outline of content Overview of midwife s role prior to and during pregnancy Local traditions and practices used in pregnancy and expectations of women and their implications for women s health Female reproductive anatomy and physiology including menstruation Male reproductive anatomy and physiology including spermatogenesis and ejaculation Intercourse, fertilisation and conception Preparation for healthy pregnancy and fetus e.g. nutrition and the importance of micronutrients, avoiding obesity, smoking, secondary exposure to tobacco smoke, qat, other drugs, preventing malaria, treating STIs and HIV (also see Module 15b) Anatomy and function of the female pelvis Pelvic changes in pregnancy Variation in the shape of the female pelvis and its significance Landmarks of the pelvis and their importance External genitalia and the pelvic floor, soft tissues of the pelvis, and changes in pregnancy Changes in the cervix and uterus Development of the placenta, cord, decidua, amniotic membranes and fluid Hormonal changes Fetal development Basic development of the fertilised ovum, embryo and fetus Impact of teratogens e.g. drugs and toxins Impact of chromosome abnormalities and the main conditions Fetal circulation basics including difference between fetal and adult Basics of genetics and genetic counselling (inc. availability) Pregnancy Signs and symptoms of pregnancy Impact of pregnancy hormones on the woman o physiological and psychological changes o discomforts of pregnancy and measures to alleviate them Overview of common complications (to be continued Module 13) Examinations and tests used to confirm pregnancy Estimating gestation and calculating dates for birth Taking a health and obstetric history Basic screening tests and appropriate action on results Identifying and referring women experiencing violence Identifying and referring women with obstetric fistulae and repairs Preventive measures as required e.g. folic acid, iron, malaria prophylaxis, tetanus immunisation, ARVs Monitoring progress Initial and follow-up antenatal examination taking account of the woman s mental health, home circumstances, physical wellbeing Blood pressure measurement, urine testing and weighing Abdominal examination and other measures for estimating fetal 80

82 growth, presentation, position and engagement Fetal auscultation Detection of complications and appropriate action (overview to be continued Module 13). The wider midwifery role: social support, advocacy, counselling, health promotion and education Health education What to expect in pregnancy, birth and after and ways women may help themselves Smoking, drugs and traditional medicines Preventing STIs and HIV infection Sexual activity and the impact of pregnancy Alleviating discomforts of pregnancy Danger signs and symptoms in pregnancy, emergency preparedness, and signs of the onset of labour Planning for place of birth and carer including who/what/where/how, transport, funds, cleaning and equipment needed for home birth, items needed for hospital / MCH birth Local maternity services and the importance of skilled birth attendants The role of the father and family Complications overview Overview of principle complications (to be continued Module 13) Early pregnancy loss, haemorrhage, infection, pre-eclampsia, premature rupture of membranes, labour complications Assessment type Formative / summative Essential Competencies assessed Quizzes, tests, skills lab activities, Formative ICM Essential Competency 3 supervised practice, case and log books, plan of care (see methods) Antenatal care plan (see methods) Skills assessments including end of Programme OSCEs Examination questions Summative Recommended resources for teachers and students Baston H, Hall J (2009) Midwifery essentials, vol. 2 Antenatal, Churchill Livingstone / Elsevier Baston H, Hall J, Henley-Einon A (2009) Midwifery essentials, vol. 1 Basics, Churchill Livingstone / Elsevier Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 34. Institute of Child Health (2001) How to make maternal health services more women-friendly, Institute of Child Health Johnson R, Taylor W (2008) Skills for midwifery practice, 2 nd. edn. Churchill Livingstone Medforth J, Battersby S, Evans P, Marsh B, Weller A, eds. (2011) Oxford Handbook of Midwifery, OUP UNDP Millennium Development Goals 81

83 WHO (2006) Pregnancy, birth and newborn care: a guide for essential practice, Geneva, 82

84 Module PM 9 Labour 1 Theory wks/days/hrs 2/12/72 Practice wks/days/hrs 4/24/168 Total wks/days/hrs 6/36/240 Practice hours are supplemented during the Consolidation period Module aim Midwives provide high quality, culturally sensitive care during labour, conduct a clean and safe birth and provide immediate care for the newborn. For care related to complicated birth and multiple birth see Module 13. Learning and teaching methods Skills lab demonstrations and practice, skills drills, visits to MCH birth centres and hospitals, supervised practice, lectures, role plays, scenarios and simulations, audio-visual media, case book, log book. Contemporary research-based evidence will influence what is taught throughout. Learning outcomes On successful completion of the module students will be able to 1. Describe the anatomy of the uterus, cervix, vagina, perineum, female pelvis and the main variations, soft tissues and the fetal skull 2. Describe the normal processes of birth including uterine action, hormones and the passage of the fetus through the pelvis through all stages of labour 3. Identify the physical and psychological changes expected at all stages of labour in the woman and fetus and act to ensure labour progresses without hindrance 4. Prepare any necessary environment for labour and birth 5. Provide support that takes account of relevant psychological and socio-cultural issues including providing women with information on their progress throughout labour and supporting choice 6. Support women in mobilising and using positions that encourage physiological processes 7. Provide for the prevention and relief of pain using psychological, comfort/practical and pharmacological methods, understanding their impact on the progress of labour 8. Assist the women to maintain hydration and nutrition in labour 9. Monitor, record and report maternal and fetal condition and progress through labour and birth 10. Take measures to prevent infection of the woman and fetus, and protect self and others 11. Identify the second/expulsive stage of labour, providing holistic support, helping her to maintain physiologically appropriate positions and/or mobility 12. Protect the perineum where possible and take appropriate action depending on circumstances 13. Deliver the infant safely to immediate skin-to-skin contact, mother and baby wrapped together 14. Manage the third stage of labour actively, or support physiological/expectant third stage if oxytocins are unavailable or refused 15. Assess the infant, ensuring warmth and that the adaptation to extra-uterine life occurs without hindrance, and cord ligature/clamp is secure (also see Module 11) 16. Ensure early breastfeeding occurs at least within one hour of birth unless refused 17. Repair perineal and/or vaginal/vulval lacerations, opened scar tissue and/or episiotomy 18. Monitor maternal condition and blood loss ensuring that the uterus remains contracted 19. Monitor infant condition 20. Provide early interventions as local protocols e.g. screening, vitamin K 21. Support the woman in care of herself and the infant in the first hours after birth 83

85 22. Take account of issues of maternal consent to midwifery and medical actions 23. Detect the principle complications and seek midwife help (to be continued in Module 13 and 14) Module content Topics Outline of content Understanding normal childbirth Ethical issues in labour Infection prevention Personal care and support Monitoring, recording and reporting progress, and condition of woman and fetus Local practices and traditions and their implications for women including role of fathers and expectations of women s behaviour Anatomy and physiology review from Module 9 e.g. presentations and positions the uterus, cervix, vagina normal female (gynaecoid) pelvis and soft tissues o changes in labour o brief overview of variations and abnormal pelves (revisit Module 13) the fetus o fetal skull structure and landmarks normal mechanisms / passage of fetus through the pelvis stages of labour and normal progress o overview of hormonal changes in labour o indicators of latent and active phases of first stage o physical and psychological changes at the onset of the expulsive / second stage of labour o physiology of third stage of labour Maintaining women s rights, providing information, supporting choice Maternal consent to midwifery and medical actions Maintenance of dignity and supporting diversity Maintenance of hygiene by the woman at all stages of labour Infection prevention in labour including any environment (home, MCH, hospital, emergency settings) Universal precautions and their purpose Preparing the environment for labour and birth (home, MCH, hospital) Hydration and nutrition in labour Urinary bladder care, bowels if required Psychological and socio-cultural issues including providing information on progress to women Mobilising and using positions that encourage physiological processes Prevention and relief of pain experience of pain and physiology / pathophysiology of pain, pain perception psychological, comfort/practical methods e.g. position, massage, relaxation, breathing, reducing anxiety pharmacological methods, indications, side-effects, impact on the progress of labour o oral, injections, regional anaesthesia (overview) Monitoring of maternal and fetal condition and progress through labour and birth physical and abdominal examination in labour normal and abnormal fetal heart patterns using the Pinard s and binaural stethoscope using ultrasound where available (as addition to use of Pinard s) abdominal examination for fetal presentation, position and descent 84

86 vaginal examination for membranes, cord, fetal position and descent, dilatation of the cervical os maternal vital signs fluid intake and output Recording and reporting including use of the partograph Expulsive / second stage Physical and psychological changes expected at the onset of the of labour expulsive / second stage of labour including signs of full dilatation of the cervical os Ensuring the physiology of the expulsive stage is not hindered (e.g. position, stress, environment, privacy, dignity) Care of the perineum ways of maintaining an intact perineum when possible surgical opening of an infibulated woman in the second stage infiltration of the perineum with local anaesthetic episiotomy: evidence re. the use of episiotomy, and performance Safe delivery of the infant Immediate and unhindered mother-infant skin-to-skin contact Third stage of labour Physical changes during the third stage of labour Active management of the third stage of labour Physiological/expectant management of the third stage (when oxytocins are unavailable) (Must be practised by simulation if no opportunity arises in clinical practice). Examination of the placenta, membranes and cord, and safe disposal Repair of perineal and/or vaginal lacerations and/or episiotomy Inspection for and referral for cervical and third degree lacerations Monitoring maternal blood loss and uterine contraction Urinary bladder care The newborn Review main changes in the circulation after birth Assessing the condition of the newborn (e.g. APGAR scoring) and maintenance of warmth without interfering with the maternal-fetal bonding process Clear airway, basic resuscitation (revisited Module 11, 14) Positions that encourage early initiation of breastfeeding Early breastfeeding at least within one hour Early postnatal care and Monitoring of maternal and infant s condition in the first few hours monitoring (continued Breastfeeding or substitute feeding support Modules 11, 13) Supporting early self-care and infant care Routine care according to local protocols: screening tests and vitamin K where available, birth registration Complications overview Principle complications overview (continued Module 13) Assessment type Formative / summative Essential Competencies assessed Simulated and clinical practice Formative ICM Essential Competency 4 Tests and quizzes Log and case books Clinical skills assessments / OSCEs Observation of practice Examination questions Summative 85

87 Recommended resources for teachers and students Baston H, Hall J (2009) Midwifery essentials, vol. 3 Labour, Churchill Livingstone / Elsevier. Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapters 6, 7, 37, 41 Johnson R, Taylor W (2008) Skills for midwifery practice, 2 nd. edn. Churchill Livingstone Medforth J, Battersby S, Evans P, Marsh B, Weller A, eds. (2011) Oxford Handbook of Midwifery, OUP WHO (undated) Safe birth techniques, videos and WHO Reproductive Health Library CD-ROMs WHO (2006) Pregnancy, birth and newborn care: a guide for essential practice, Geneva, WHO (2010) WHO Partograph E-Learning Tool, CD-ROM 86

88 Module PM 10 Postnatal 1 Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 1½/9/63 Total wks/days/hrs 2½/15/99 Practice hours are supplemented during the Consolidation period Module aim Midwives will provide comprehensive, high quality, culturally sensitive postpartum care for women. It may be useful to teach this Module alongside Module 11. Learning and teaching methods Skills lab demonstrations and practice, community and MCH visits, supervised practice, lectures, role plays, scenarios and simulations, audio-visual media, case book, log book. Activity: examine a woman and baby before discharge, discuss her home situation, provide advice and information and record findings and actions in the case book. (Also see Module 11). Where available, contemporary research-based evidence will influence what is taught. Learning outcomes On successful completion of the module students will be able to 1. Discuss local postnatal practices and the implications for women s health 2. Describe the normal physiology of the puerperium including involution and lactation 3. Describe the physical and emotional changes experienced by women 4. Discuss the importance of early and exclusive breastfeeding to the infant and woman 5. Use understanding of the physiology and process of lactation and breastfeeding and common variations to support and educate women and partners to achieve exclusive breastfeeding 6. Teach women and families about safer substitute feeding where breastfeeding is not used 7. Support and teach women to ensure rest and appropriate activity, good nutrition, hygiene and care of physiological needs throughout the first six postnatal weeks 8. Support parent-infant bonding /attachment, transition to parenthood including education 9. Provide initial child spacing and sexual activity advice before discharge from care 10. Provide community and clinic-based follow-up services 11. Provide support to women with special needs 12. Detect the principle complications and seek midwife help. Module content Topics Postnatal changes Traditions and practices Midwifery care including Outline of content Physical and emotional changes hormonal changes and their effects blood volume and haemoglobin changes urinary system and bowels involution and lochia perineal /vulval / vaginal wound healing lactation and breastfeeding physiology and common variations hormones, life change, tiredness and influences on emotions Local practice and tradition in the postnatal period and their impact on women s health Physical examination including assessment for deviations from 87

89 feeding normal breasts and nipples uterine involution and lochia healing of perineal / vulval / vaginal lacerations and repairs urination and bowels blood tests for anaemia Dealing with perineal or after pains Supporting through the blues Maternal personal care and prevention of infection hygiene, achieving rest, mobility to prevent embolism bowel and bladder perineal care nutritional needs of postpartum and lactating women Lactation, feeding and related evidence the concept of Baby-Friendly Hospitals the importance of exclusive breast feeding and WHO guidance baby-led feeding UNICEF 10 steps to successful breastfeeding infant position, latching and suckling common variations including engorgement, reduced or excess milk supply, nipple inversion substitute feeding, quantities, practical and safety issues (Also see Module 11) Education of mother on care of self and infant, including signs and symptoms of complications and when and how to seek help Supporting the transition to parenthood Child spacing (also see Child spacing in the postnatal period (also see Module 15a) Module 15a) Overview of child spacing services Advising about child spacing and sexual activity Provision of contraceptive supplies and referral to clinic Postnatal follow-up in the Continuing advice re. personal and infant care, parent/infant community / clinic attachment, feeding Postnatal service facilities in Somalia and Puntland and the midwife role in their development Special needs support Social and psychological support of adolescents, single women, women with physical or learning disabilities, pre-existing physical or mental conditions Complications overview Common complications overview (continued Module 14) Assessment type Formative / summative Essential Competencies assessed Simulated practice in skills lab Formative ICM Essential Competency 5 Tests and quizzes Clinical skills assessments including OSCEs Examination questions Summative Activity in Methods section may be used for formative or summative assessment Recommended resources for teachers and students 88

90 Baston H, Hall J (2009) Midwifery essentials, vol. 4 Postnatal, Churchill Livingstone / Elsevier. Bick D, MacArthur C (2009) Postnatal care: Evidence and guidelines for management, 2 nd. edn. Churchill Livingstone Elsevier (teacher resource) Boyle M (2006) Wound healing in midwifery, Oxford: Radcliffe Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapters 6, 7, 40 Johnson R, Taylor W (2008) Skills for midwifery practice, 2 nd. edn. Churchill Livingstone Medforth J, Battersby S, Evans P, Marsh B, Weller A, eds. (2011) Oxford Handbook of Midwifery, OUP UNICEF Baby-friendly Hospital Initiative UNICEF Ten steps to successful breastfeeding WHO (2006) Pregnancy, birth and newborn care: a guide for essential practice, Geneva, 89

91 Module PM 11 The newborn 1 Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 1½ /9/63 Practice hours are supplemented during the Consolidation period Total wks/days/hrs 2½/15/99 Module aim Midwives provide high quality comprehensive care for the essentially healthy infant from birth to two months of age. It may be useful to teach this module alongside Module 10. Learning and teaching methods Skills lab demonstrations and practice, skills drills, visits, supervised practice, lectures, role plays, scenarios and simulations, audio-visual media, case books, log books. Activity: examine a (woman and) baby before discharge, discuss the home situation, provide advice and information and record in the case book. (Also see Module 10). Where available contemporary research-based evidence will influence what is taught. Learning outcomes On successful completion of the module students will be able to 1. Discuss issues around newborn health, morbidity and mortality including MDGs 2. Discuss the implications for newborn health of common local traditions 3. Apply knowledge of the main physiological changes in the newborn s adaptation to extra-uterine to care at birth 4. Describe the characteristics (appearance and behaviours) of the healthy newborn 5. Identify common variations in the newborn e.g. caput and moulding, skin appearance 6. Assess the newborn condition at birth including gestational age and act appropriately 7. Provide immediate care to newborns ensuring needs for a clear airway, skin-to-skin contact, and nutrition are quickly met while assessing condition and guarding the infant s warmth 8. Discuss advantages of kangaroo method of newborn warming and care 9. Identify the infant securely according to local protocols 10. Provide ongoing newborn care 11. Provide support and education re. exclusive breastfeeding 12. Provide support and education re. breastmilk substitutes where appropriate including safe preparation of formula, types of milk, quantities 13. Educate the parents about ongoing care including cord and umbilicus care, infant warmth, nutrition, safety, hygiene and attachment needs including danger signs 14. Inform the parents of any available local / community resources including MCH facilities and when to use them 15. Describe the needs, risks and benefits of newborn immunisation 16. Provide newborn immunisation according to national protocols 17. Advise parents about birth registration 18. Educate parents about normal growth and development of the newborn 19. Promote newborn health in communities 20. Identify and report common newborn complications 90

92 Module content Topics Newborn health, morbidity and mortality Adaptation to extra-uterine life The newborn baby General care of the newborn Feeding (Also see Module 10). Outline of content Health maintenance, morbidity and mortality Local traditions affecting newborn infants Millennium Development Goals Current statistics for Somalia and Puntland and issues for data collection Newborn health programmes in Somalia and Puntland Anatomy and physiology of fetal circulation Main physiological changes after birth Appearance and behaviour including neurological characteristics Thermoregulation Patterns of elimination and feeding (see below also) Common variations e.g. caput, moulding, cephalhaematoma, skin appearance, physiological jaundice Minor conditions and disorders and their management e.g. sore buttocks, skin rashes, minor eye infections Review immediate after-birth care of newborn Prompt attention to clear airway, APGAR score, skin-to-skin contact, secure identification, nutrition while guarding the infant s warmth The importance of skin-to-skin contact at birth and after Review initial birth assessment including gestational age Full assessment, physical examination and screening Daily care Cord / umbilicus care Skin hygiene Bowels and micturition Eyes Warmth, nutrition and growth Importance of promoting and maintaining normal newborn body temperature through covering, environment, skin-skin contact and feeding o Link between warmth, food and oxygen for meeting energy needs for growth and health o kangaroo method of newborn warming including physiological advantages to baby and to lactation Infection prevention general care and hygiene immunisation, and national protocols and programmes malaria prevention feeding safety especially with substitutes see below Other newborn prophylaxis e.g. screening tests, Vitamin K administration where available Composition of breast milk at different stages of lactation, and of substitutes The importance of colostrum to babies Early feeding patterns of breast and substitute-fed babies Normal weight-gain in breast and substitute-fed babies 91

93 o WHO 2006 growth standards and charts Local customs around infant feeding Prevention of mother to child transmission of HIV, WHO guidance, understanding stigma Breastfeeding Review the basic physiology of lactation and breastfeeding The advantages of breastfeeding Importance of exclusive breastfeeding o WHO guidance for women living with HIV o dangers of mixed feeding UNICEF Baby-Friendly Hospital Initiative UNICEF Ten steps to successful breastfeeding Educating mother, partner and family Latching and positioning for efficient suckling Baby-led feeding Feeding twins and triplets (also see Module 14) Supporting the woman with difficulties e.g. engorgement, sore/cracked nipples, thrush, mastitis Expression of breastmilk and cup and spoon feeding Supplementary and complementary feeding: uses and disadvantages Substitute feeding Supporting and advising the mother who is not breastfeeding Dangers of mixed feeding Dangers of substitute feeding in resource-poor environments Safe preparation of feeding equipment and substitute feeds Substitute feeds, types, quantities, feeding frequency Parent support and Supporting parents education Supporting the woman with disabilities Education of parents and families Importance of exclusive breastfeeding Safety including o feeding hygiene o general infection prevention o home accident prevention o dangers of exposure to tobacco smoke e.g. Sudden Infant Death, respiratory disease) Daily care needs Attachment / bonding Normal growth and development Harmful traditional practices including FGM Danger signs and when to seek medical help Sources of support including MCHs and health professionals Birth registration the local situation and its importance Health promotion Promoting good health in communities (also see Module 4f) Complications overview (to Brief introduction to common congenital and acquired newborn be continued Module 14) complications and referral. 92

94 Assessment type Formative/summative Essential Competencies assessed Observation of skills lab simulation Formative ICM Essential Competency 6 and supervised practice Class tests Skills assessments including OSCEs Examination questions Summative If the activity (see Methods) was not used for assessment in Module 10, it could be used here for formative or summative assessment Recommended resources for teachers and students Bill and Melinda Gates Foundation, Kangaroo Mother Care multimedia resource Davies L, McDonald S (2008) Examination of the newborn and neonatal health, Edinburgh: Churchill Livingstone Elsevier Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Edinburgh: Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 41 Johnson R, Taylor W (2008 or 2000) Skills for midwifery practice, Edinburgh: Churchill Livingstone Johnston P, Flood K, Spink K (2003) The newborn child, 9 th. edn. Edinburgh: Churchill Livingstone Moore J, McDermott J (undated) Every newborn s health: recommendations for care for all newborns, Saving Newborn Lives, available from Savage-King F (1992) Helping women to breastfeed, AMREF The Lancet (2005) Newborn health: a key to child survival (Neonatal survival series) ml UNDP Millennium Development Goals UNICEF site: multiple resources UNICEF Baby-Friendly Hospitals Initiative UNICEF Ten steps to successful breastfeeding World Health Assembly resolution May 2010, Infant and child nutrition, (multiple resources) WHO (2006) Child Growth Standards WHO (2006) Pregnancy, birth and newborn care: a guide for essential practice, Geneva, WHO (2010) Guidelines on HIV and infant feeding, WHO (2011) Kesho Bora study: preventing mother to child transmission of HIV during breastfeeding 93

95 Module PM 12 Understanding research and evidence-based practice Practice wks/days/hrs 2/12/72 Theory wks/days/hrs 0/0/0 Total wks/days/hrs 2/12/72 Practice hours are supplemented during the Consolidation period Module aim Midwives understand how research is carried out and apply findings to practice providing high quality, comprehensive care that is based on sound evidence Learning and teaching methods Discussions, lectures, class activities, independent and peer group learning, basic research article analysis exercises, basic statistics exercises (based on learning from nursing education) Learning outcomes On successful completion of the module students will be able to 1. Explain the concept of evidence-based practice 2. Apply valid and reliable evidence to their practice 3. Outline the research process 4. Explain the concepts of quantitative and qualitative research 5. Outline the way data is collected for quantitative and qualitative research 6. Evaluate the quality and importance of straightforward research articles 7. Take part in the research process where possible 8. Develop a proposal for a small descriptive or qualitative research project Module content Topics Midwifery knowledge development Review of the research process Data collection methods review Basic statistics Outline of content How midwifery knowledge is developed Types of knowledge underpinning practice: theoretical, practical, interpersonal, intuitive, empirical, experiential, ritual Research as evidence for practice and policy, protocol and guideline development Midwifery research / medical research and the midwifery role Concepts of validity, reliability and bias Question/problem formulation Analysing results Literature review Presenting results Choosing the method Coming to a conclusion Collecting information Reporting the results Qualitative / interpretive Interviewing, structured, semi-structured, unstructured Observation, participant and non-participant Triangulation for ensuring reliability and validity Quantitative Experimental Randomised controlled and blind trials Surveys Basic statistics for understanding research 94

96 Literature searching Research ethics Midwifery evidence Defining the topic Doing a literature search Evaluating search results and critical reading Ethical issues re. researching on human subjects Research ethics committees Putting evidence into practice Key evidence for practice e.g. Post maturity of the fetus ad induction of labour Nutrition and hydration in labour Mobility and positioning for labour Shaving and enemas Positions for birth The expulsive stage Perineal care Skin-to-skin contact Kangaroo mother care Breastfeeding and baby-led feeding Exclusive breastfeeding or substitutes and PMTCT of HIV Assessment type Formative / summative Essential Competencies assessed Class and individual exercises Formative ICM Essential Competency 1 Group project Short literature review and evaluation of a key article OR Proposal for small research project Summative Recommended resources for teachers and students Brayford D, Chambers R, Boath E, Rogers D (2008) Evidence-based care for midwives: clinical effectiveness made easy, Radcliffe Publishing Brooker C, Nicol M (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby ch. 30 Cluett E, Bluff R (2006) Principles and practice of research in midwifery 2 nd. edn., Edinburgh: Churchill Livingstone Downe S (2008) Normal childbirth: evidence and debate, 2 nd. edn. Edinburgh: Churchill Livingstone Fraser D, Cooper M eds. (2009) Myles Textbook for Midwives 15 th. edn, Edinburgh: Churchill Livingstone Gerrish K, Lacey A (2010) The research process in nursing, 6 th. edn. Wiley Hicks C (1996) Undertaking midwifery research: a basic guide to design and analysis, Edinburgh: Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and Midwifery: a practical approach, Basingstoke: Macmillan/TALC ch. 49. Lavender T, Edwards G, Alfirevic Z (2004) Demystifying qualitative research in pregnancy and childbirth, Quay Books Parahoo K (2006) Nursing research: principles, process and issues, 2 nd. edn. Palgrave Macmillan Polit D (2009) Essentials of Nursing research: appraising evidence for nursing practice, 7 th. edn (or recent), Lippincott, Williams, Wilkins Proctor S (2000) Linking research and practice in midwifery: a guide to evidence based practice, Edinburgh: Bailliere Tindall 95

97 Rees C (2003) An introduction to research for midwives, Books for Midwives Press Schneider Z, Whitehead D, Elliot D, LoBiondo-Wood G (2008) Nursing and midwifery research: methods and critical appraisal for evidence-based practice, 3 rd. edn. Mosby Rowntree D (1981) Statistics without tears: a primer for non-mathematicians, London: Penguin Spiby H, Munro J (2009) Evidence-based midwifery: applications in context, Wiley Walsh D (2007) Evidence-based care for normal labour & birth, Routledge (or 2011 edn.) Wickam S (2002) Midwifery best practice vol.1, Books for Midwives Press Wickam S (2004) Midwifery best practice vol.2, Books for Midwives Press Wickam S (2005) Midwifery best practice vol.3, Books for Midwives Press Wickam S (2006) Midwifery best practice vol.4, Books for Midwives Press Wickam S (2008) Midwifery best practice vol.5, Books for Midwives Press Wickam S (2008), Appraising research into childbirth: an interactive workbook, Books for Midwives Press. 96

98 Module PM 13 Childbearing 2 complications Theory wks/days/hrs 5/30/180 wks/days/hrs 4/24/168 Total wks/days/hrs 9/54/348 Practice hours are supplemented during the Consolidation period Module aim Midwives identify and react appropriately to deviations from the normal in pregnancy, labour and the postnatal period Learning and teaching methods Skills lab demonstrations and practice, skills drills, visits, supervised practice, lectures, role plays, scenarios and simulations, audio-visual media, case books, log books. It is strongly recommended that the free-to-download WHO/ICM and/or JHPIEGO learning resources be used (see reference list, resources identified as*) Notes This Module integrates problems encountered during these periods as many either have similar or the same causes, or are conditions that affect women at any stage e.g. pre-eclampsia. Conditions unique to a period are considered separately. The module links with Module 18 Consolidation: Emergency skills Childbearing is used to denote any stage of pregnancy, labour, birth and postpartum. Learning outcomes On successful completion of the module students will be able to 1. List the main causes of maternal morbidity and mortality in Somalia and Puntland 2. Outline the reasons why maternal morbidity and mortality are high in Somalia and Puntland 3. Identify pre-existing conditions that affect maternal condition and care and refer appropriately 4. Provide care under medical direction for childbearing women with pre-existing conditions 5. Identify common complications in childbearing women 6. Provide initial care, life support and BEMOC as facilities allow 7. Refer and transfer women appropriately 8. Provide midwifery care and CEMOC under direction of doctor if working in CEMOC facility 9. Provide emotional support and guidance to women and families during emergencies and after intra-uterine death, stillbirth or illness or abnormality in the newborn 10. Describe the basic issues around medication for childbearing women Module content (see over) 97

99 Module content Topics Maternal mortality and morbidity Pre-existing conditions and management (See Module 15b for STIs) Complications Outline of content National statistics as available Causes of morbidity and mortality in Somalia and Puntland Underlying socio-economic and service provision factors including barriers to accessing care. Why did Mrs. X die? (see WHO/ICM 2007 in resource list) The concept of BEMOC and CEMOC and the Signal Functions Three delays model of Thaddeus and Maine Review of conditions and the impact of childbearing Anaemia Hypertensive disorders Diabetes type 1 and 2 Cardiac disorders Respiratory disorders Mental health disorders Digestive system disorders Renal disease Hepatitis Tuberculosis Malaria Sexually transmitted infections Understanding complications: overview of the patho-physiology of individual complications Complications are listed here. Signs and symptoms, initial management, referral, BEMOC and CEMOC Signal Functions should be included as appropriate. Basic midwifery care, emotional and psychological support should also be included. Complications occurring at any time in childbearing and their management: Anaemia Bleeding and pain from the reproductive tract Early pregnancy loss, ectopic pregnancy, spontaneous and induced abortion and Post-abortion care (PAC) Placenta and vasa praevia Placental abruption Primary and secondary postpartum haemorrhage (see below) Fever and infection Urinary tract infection Vaginal bacterial and fungal infection Uterine / liquor amnii and puerperal infection Pneumonia Opportunistic infections (with HIV and AIDS) Infectious diseases affecting the fetus as well as mother especially rubella, cytomegalovirus, toxoplasmosis, chlamydia, malaria, gonorrhoea, syphilis Pregnancy-induced hypertension Gestational hypertension (no proteinuria) Pre-eclampsia and eclampsia HELLP syndrome and DIC Amniotic fluid and air embolism 98

100 Multiple pregnancy (NB. Although multiple pregnancy is a normal occurrence it is included here because of the extra management requirements) Types of multiple conception The process of multiple birth Risks and complications Care in pregnancy including assessment, support, nutrition, iron supplementation Dealing with discomforts of multiple pregnancy Management of labour and birth and complications of labouring with multiples Pregnancy specific complications and management (also see above) Ectopic pregnancy Incarcerated uterus Molar pregnancy Hyperemesis gravidarum Gestational diabetes Blood incompatibilities Abnormal lie, presentation and position of the fetus External cephalic version for breech Polyhydramnios and oligohydramnios and their implications Fetal growth retardation Fetal iso-immunisation Placenta and vasa praevia Reduced fetal movements Abnormal heart rate / patterns Intra-uterine fetal death Premature rupture of membranes Premature onset of labour Post term pregnancy Antenatal depression Labour and birth specific complications and management (also see above) Pre-term labour Induction of labour Trial of labour Scarred or over-distended uterus, polyhydramnios Unsatisfactory progress in labour and augmentation Cephalo-pelvic disproportion and obstructed labour o Abnormal / contracted pelvis (including review of types of pelvis) o Fetal macrosomia o Abnormal lie, presentation and position of the fetus, mechanisms, complications and management 1. breech 2. transverse lie and shoulder presentation 3. occipito-posterior position, face / brow, deep transverse arrest 4. compound presentation Fetal distress / abnormal heart rate and patterns Cord compression, fetal skull compression 99

101 Cord presentation and prolapse Intrauterine fetal death Uterine rupture Inversion of the uterus Placenta accreta EMOC Signal functions and core emergency skills Other skills Postpartum specific complications and management Sub-involution (also see above) Mastitis and breast abscess Perineal wound breakdown Deep vein thrombosis Pulmonary embolism Severe mental depression Psychosis Obstetric fistulae Maternal tetanus Carrying out BEMOC Signal Other skills: functions and/or care of woman: Treatment of shock Parenteral antibiotics Cannulation Parenteral oxytocin Blood specimen collection Parenteral anti-convulsants Fluid replacement and anti-hypertensives Oxygen therapy Manual removal placenta Cardio-pulmonary resuscitation Removal of retained products Destructive operations /care of (MVA) the woman Assisted vaginal delivery Cord prolapse management CEMOC signal functions Shoulder dystocia management Blood transfusion Bimanual compression of the Caesarean section uterus Support for bereaved women and families after pregnancy loss, intrauterine death, stillbirth, neonatal death or congenital abnormality Prevention of mother to child transmission of HIV, tuberculosis, hepatitis Vaccination Assessment type Formative / summative Essential Competencies Demonstrations and skills lab activities, supervised practice, log and Formative ICM Essential Competencies 3, 4, 5 case books Quizzes and tests Supervised practice, skills assessments, OSCEs Examination questions Summative Recommended resources for teachers and students Baston H, Hall J (2009) Midwifery essentials, vol. 1-4, Churchill Livingstone / Elsevier Bates K, Young N (2004) Managing childbirth emergencies in community settings, Palgrave Macmillan Boyle M ed. (2011) Emergencies around childbirth: a handbook for midwives, Radcliffe Publishing 100

102 Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15th. edn, Churchill Livingstone Gruenberg B (2008) Birth emergency skills training: manual for out-of-hospital midwives, Birth Muse Press Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, Chapters 35, , 39, 40, 49 ICM/FIGO (2006) Joint Statement. Prevention and treatment of post-partum haemorrhage: New advances for low-resourced settings, ICM_Statement_November2006_Final.pdf Johnson R, Taylor W (2008 or 2000) Skills for midwifery practice, Edinburgh: Churchill Livingstone Medforth J, Battersby S, Evans P, Marsh B, Weller A, eds. (2011) Oxford Handbook of Midwifery, OUP Thaddeus S, Maine D. (1994) Too far to walk: maternal mortality in context, Social Science and Medicine, 38: *WHO, UNFPA, UNICEF, World Bank (2003 or later) Managing complications in pregnancy and childbirth: a guide for midwives and doctors, (NB Large download) %20Complications%20of%20pregnancy%20and%20childbirth_midwives%20and%20doctors.pdf * JHPIEGO (2003) Managing complications in pregnancy and childbirth: Learning resource package: Guide for teachers, UNFPA (2007) UNFPA Maternal mortality update Expectation and delivery: investing in midwives and others with midwifery skills, +in+midwives.pdf UNICEF, UNFP, WHO, World Bank (2010) Package of interventions for family planning, safe abortion, care, maternal, newborn and child health, Geneva: WHO WHO (2005) Emergency Triage, assessment and treatment (ETAT), Facilitator guide WHO (2005) Emergency Triage, assessment and treatment (ETAT), Participant manual *WHO (2006) Pregnancy, birth and newborn care: a guide for essential practice, Geneva, *WHO/ International Confederation of Midwives, 2nd. edn. (2007) Midwifery Education modules, education for safe motherhood, CD-ROM and online at WHO (2010) WHO technical consultation on postpartum and postnatal care, 101

103 Module PM 14 Newborn 2 (complications) Theory wks/days/hrs 2/12/72 Practice wks/days/hrs 3/18/84 Total wks/days/hrs 5/24/156 Practice hours are supplemented during the Consolidation period Module aim Midwives provide high quality, comprehensive care for the newborn infant experiencing complications in any setting necessary Learning and teaching methods Skills lab demonstrations and practice, skills drills, visits, supervised practice, lectures, scenarios and simulations, audio-visual media, case books, log books Activity suggestion: Record in the case book the midwifery and medical care of a newborn baby experiencing complications, and evaluate the success of the care. Present this to colleagues for discussion. Learning outcomes On successful completion of the module students will be able to 1. Identify and provide immediate care to newborns experiencing complications at birth 2. Identify complications arising during the neonatal period 3. Demonstrate basic life support skills 4. Refer and transfer sick or preterm neonates appropriately 5. Adapt care strategies to low as well as well resourced settings 6. Manage complications in the neonatal period under medical direction where appropriate 7. Support mothers and family members of sick, low birth weight neonates or those born with congenital defects 8. Provide support in bereavement following stillbirth or neonatal death 9. Provide follow-up care to neonates who have been sick or born prematurely Module content Topics General management and core skills Outline of content Facilities for special care: in resource-poor environments and in the special nursery Monitoring vital signs Newborn cardio-pulmonary resuscitation Oxygen therapy including dangers (e.g. visual defects) Prevention and management of hypothermia including Kangaroo care and skin-to-skin contact emergency care in community, home and hospital settings ongoing care the link between hypothermia, hypoglycaemia and poor oxygenation (review, also see Module 11) Feeding sick or low birth weight babies basic principles of fluid and calorie intake in sick newborn breastfeeding and the importance of colostrum and breast milk expressed breast milk feeding 102

104 Main signs of illness Common problems cup feeding, bottle feeding nasogastric tube feeding micronutrient supplementation Administration of fluids Neonatal medications Referral and transport facilities in Somalia and Puntland General indicators of illness and danger signs Respiratory distress Pallor, poor perfusion, cyanosis, low blood oxygen levels Lethargy Hypoglycaemia Thermoregulation: hypothermia and hyperthermia / fever Nervous system abnormalities Poor feeding Weight loss or poor weight gain Jaundice Diarrhoea, vomiting, abdominal distension, dehydration Renal signs Signs, care and management, referral where necessary Adverse moulding of the skull Birth asphyxia Respiratory distress syndrome Apnoea attacks Seizures, irritability, abnormal cry or body position The jaundiced infant Infant of the diabetic mother Anaemia Blood group incompatibility/ rhesus isoimmunisation Infection o cord, eyes, skin o bacteraemia o pneumonia o meningitis o tetanus o HIV (also see Module 15b) o congenital syphilis Low birth weight and its complications o pre-term birth including poor respiratory effort and/or lung expansion, cerebral haemorrhage, necrotising enterocolitis o small for gestational age / intrauterine growth-retarded babies Birth injuries o facial and Erb s palsy o cephalhaematoma o cerebral irritation o fractures, dislocations, lacerations, bruising Congenital abnormalities Hip dysplasia Hydrocephaly, anencephaly, meningocele / spina bifida Congenital heart disease Cleft lip and palate 103

105 Multiple birth Ongoing care Gastro-intestinal malformations: imperforate anus, omphalocele Genitourinary and reproductive abnormalities: undescended testes, imperforate vagina, indeterminate sex Talipes Extra/missing digits or foreshortened limbs Management / care of twins and more Referral of at-risk twins and more Feeding twins and more Managing breastfeeding Managing substitute feeding General care of twins and more Maternal and family support, professional / community systems Community support systems Follow-up and monitoring growth Parent education about the needs of newborns who have experienced complications Death notification in Somalia and Puntland Bereavement support following stillbirth, neonatal death or the birth of infants with congenital defects Support for parents separated from infants Assessment type Formative / summative Essential Competencies assessed Skills lab simulation Formative ICM Essential Competency 6 Supervised practice Quizzes and tests Supervised practice Skills assessments and OSCEs Examination questions Summative Coursework activities e.g. see methods section, may be used for formative or summative assessment Recommended resources for teachers and students See Module 11, also: Advanced Life Support Group (2004) Emergency paediatric care CD-ROM, Blackwell Beck D, Ganges F, Goldman S, Long P (2004) Care of the newborn reference manual, Save the Children Federation, or download at Crisp S, Rainbow J (2007) Emergencies in paediatrics and neonatology, Oxford University Press Drew D (2000) Resuscitation of the newborn: a practical approach, Books for Midwives Government of Kenya (2010) Basic Paediatric protocols (rev), Hallsworth (2009) Nursing the neonate, Wiley Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, Chapter 42 Levene M, Tudehope D (2008) Essential Neonatal Medicine, 4th. edn. Oxford: Blackwell Publishing Maguire W, Fowlie P (2005) ABC of preterm birth, Wiley Multiple Births Foundation (2011) Guidance for health professional s on feeding twins, triplets 104

106 and higher order multiples, (written for UK but still useful - also other resources at Tinker A, Parker R, Lord D, Grear K (2010) Advancing newborn lives: the Saving Newborn Lives network, Global Public Health, 5:1, or download %20Health_%20SNL.pdf UNICEF, UNFP, WHO, World Bank (2010) Package of interventions for family planning, safe abortion, care, maternal, newborn and child health, Geneva: WHO Wall S, Lee A, Niermeyer S, English M, Keenan W, Carlo W, Bhutta Z, Bang A, Ariawan I, Lawn J (2009) Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up? International Journal of Gynecology and Obstetrics, 107:S47-S64 WHO Dept. of Reproductive Health and Research (2003) Managing newborn problems: a guide for doctors, nurses and midwives, Geneva: WHO WHO (2010) Guidelines on HIV and infant feeding, WHO (2011) Kesho Bora study: preventing mother to child transmission of HIV during breastfeeding WHO/UNICEF (2009) Home visits for the newborn child: a strategy to improve survival, WHO/ UNICEF Joint statement, available online at for adult and paediatric life support guidelines and algorithms 105

107 Module PM 15a Theory wks/days/hrs 1/6/36 Child spacing Practice wks/days/hrs 2½ /15/87 Total wks/days/hrs 3½/21/123 Module aim Midwives provide high quality, culturally sensitive child spacing advice and services to women and couples Learning and teaching methods Skills lab activities, simulations, role play, visits and supervised practice in clinics and MCH centres, lecture/discussions, group work, audio-visual media, case book, log book Activity: present to colleagues an anonymous report of the assessment, counselling and advice given to one woman or couple, the choices made and products provided Learning outcomes On successful completion of the module students will be able to 1. Discuss how child spacing contributes to the achievement of MDGs 4 and Use understanding of socio-cultural and faith issues around child spacing in providing services 3. Use knowledge of female and male reproductive anatomy and physiology including conception in providing services 4. Discuss the impact on child spacing service uptake of sexual and relationship problems, and issues of gender and control 5. Use basic knowledge of the way contraceptive drugs and devices work in providing services 6. Make assessment of health, family and reproductive history of male and female clients 7. Arrange laboratory and screening tests as available 8. Assess physical health and potential for healthy pregnancy 9. Provide basic counselling for decision-making around child spacing 10. Understand locally available natural methods of child spacing 11. Explain and dispense contemporary child spacing methods according to national protocols 12. Discuss the issue of HIV transmission 13. Provide pre-conception advice where appropriate Module content Topics Review of child spacing issues Outline of content The cultural and faith context for child spacing in Somalia and Puntland Faith-based views of child spacing and methods Traditional methods of limiting families, beliefs and local practices The concept of kalakoriye and the contribution of child spacing to achieving MDGs 4 and 5. Behaviours in contraception and decision-making Issues that arise in families, negotiation and decision-making for family size and child spacing, do women have choice? Achieving dual protection against pregnancy, STIs and HIV 106

108 Review of anatomy and physiology Natural child spacing methods Review of contemporary child spacing methods Education and counselling Management and clinical skills Adolescents and the risks of early intercourse and pregnancy Local services and national policies Access to services and barriers to uptake Unsafe abortion in Somalia and Puntland (also see Module 15d) Emergency contraception and induced abortion awareness Review of female and male reproductive anatomy and physiology Methods and advice, advantages and disadvantages lactation amenorrhoea (LAM) fertility awareness, calendar, cervical secretion sympto-thermal method (and Billings and basal body temperature) coitus-interruptus / withdrawal Methods and advice, advantages and disadvantages, provision of supplies in the Somalia and Puntland context Barrier methods o male and female condoms o diaphragm and cervical cap Spermicides Intra-uterine contraceptive device (IUCD) o copper releasing o hormone releasing (where available) Hormonal contraception o IUCD (as above) o Oral contraception (combined and progestin only) o injectable contraceptives and implants o hormone patches o vaginal ring Permanent methods (tubal ligation, vasectomy (awareness and discussion of local context) Health education and counselling techniques for child spacing For each individual/couple and method: Effectiveness Advantages Contra-indications, side-effects, disadvantages Advising on how to use each method Identifying the best method Supporting personal decision-making and choice Follow-up Pre-conception advice Management of contraceptive supplies and clinics Health assessment and monitoring Assessing for use of diaphragm and cervical cap Fitting of IUCDs Assessment type Formative / summative Essential Competencies assessed Skills lab activities e.g. role play Supervised practice Test and quizzes Formative ICM Essential Competency 2 107

109 Supervised practice Skills assessments Examination question OR assessment of the case activity (see Methods) Summative Recommended resources for teachers and students Fraser DM, Cooper MA eds. (2009) Myles Textbook for Midwives 15th. edn, Edinburgh: Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 29 INFO Project (2007) Family Planning: a Global Handbook for Providers: WHO, John Hopkins Bloomberg School of Public Health Centre for Communications INFO Project, USAID available as CD-ROM and online at International Planned Parenthood federation, Resource bank CD-ROM and McVeigh E, Hornburg R, Guillebaud J (2008) Oxford Handbook of Reproductive Medicine and Family Planning, Oxford: Oxford University Press Population Council resources available online at UNFPA sources online at WHO resources including Fact sheets 108

110 Module PM 15b Sexually transmitted infections, HIV and AIDS Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 2½/15/87 Total wks/days/hrs 3½ /21/123 Module aim Midwives will provide high quality, culturally sensitive HIV and STI services to individuals and health promotion to groups and communities. Further specialised learning may be required after qualification. Learning and teaching methods Observation, clinic visits and supervised practice, role play, lectures and discussion, audio-visual media, case book Learning outcomes On successful completion of the module students will be able to 1. Describe MDG 6 and its importance in midwifery practice 2. List the main sexually transmitted infections (STIs) and the transmission, signs, symptoms and natural course of these diseases 3. Explain the link between STIs and HIV infection, and with sexual assault 4. Explain non-sexual transmission of HIV and take preventive measures (universal precautions) 5. Discuss the psycho-social impact of infection and the issue of stigma 6. Describe common barriers to service uptake in Somalia and Puntland take action to reduce them where possible 7. Provide syndromic management of STIs 8. Discuss the common side effects of STI and ante-retroviral drugs 9. Discuss the WHO recommended ways of preventing maternal to child transmission of HIV 10. Advise or refer people who are or HIV positive for treatment or treatment review 11. Provide health promotion and education around STIs and HIV 12. Discuss STI and HIV service provision in Somalia and Puntland 13. Manage a clinic that provides basic STI and HIV services Module content Topics Introduction and review Psycho-social and cultural issues Outline of content MDG 6 and the global challenge of HIV, AIDS and hepatitis Review of STIs, HIV and AIDS, reproductive tract infections, and the link between STIs and HIV Women and STIs and HIV why are they more vulnerable than men? Other vulnerable groups: the young, displaced persons, victims of war and conflict Somalia and Puntland STI and HIV services, government and agencies Ethical issues including consent and confidentiality Local beliefs, traditions and treatments in Somalia and Puntland Barriers to service uptake in Somalia and Puntland The impact on individuals of positive diagnoses for STIs and HIV including stigma, discrimination and exclusion 109

111 Diseases overview Syndromic management overview HIV and AIDS basics review The impact on families including relationship breakdown and domestic violence The link between STIs and HIV, and STIs/HIV and sexual assault Diseases, transmission, clinical presentation, diagnostic tests and treatments for Trichomoniasis Candidiasis/thrush/monilia with Genital herpes symptoms (is STI in men, is Syphilis normal vaginal flora in women) Genital warts /human Bacterial vaginosis and other papilloma virus (HPV) agents causing abnormal Gonorrhoea discharge Chlamydia Differential diagnosis of cervical Hepatitis B and lower vaginal discharges HIV Common complications and associated conditions Vertical transmission to fetus: syphilis, HIV Transmission to infant: gonorrhoeal eye infection, HIV Pelvic inflammatory disease, endometritis, salpingitis, infertility, ectopic pregnancy (also see Module 15d) Epididymitis, prostatitis, urethral strictures Candidiasis in immuno-compromised people e.g. AIDS Genital and cervical cancer in women (HPV) Liver disease (hepatitis B) Universal precautions for prevention of HIV and hepatitis B transmission in healthcare settings Post-exposure prophylaxis (Rape, STIs and HIV risk) and legal factors STI syndromes for syndromic management: Men and women Men o Genital ulceration o Scrotal swelling o Urethral discharge Women o Swollen lymph o Vaginal discharge glands/inguinal bubo o Lower abdominal pain Presence of neonatal conjunctivitis Management overview Sexual history Physical examination Assessment and treatment of syndromes Prevention and control Education and counselling / health promotion Follow-up and partner tracing and treatment Record-keeping including recording of STIs 3 Cs of treatment Consent Confidentiality Counselling Transmission (vertical and horizontal) and resistance Prevention of transmission: sexual, blood-borne, trauma, universal precautions Review of how immunity works The impact of HIV on the body, early and ongoing symptoms and course of the disease 110

112 STIs and HIV in childbearing women Health promotion AIDS symptoms and disorders Opportunistic infections e.g. o Kaposi s sarcoma and lymphoma o Gastro-intestinal complications Treatment, care and support basics Voluntary counselling and testing (VCT) Local testing algorithms Overview of prevention and treatment programmes Consequences of STI or HIV infection for childbearing women and their infants including neonatal conjunctivitis Treatment in childbearing women Prevention of mother to child transmission of HIV including WHO 2011 Guidance on therapies and feeding Promoting sexual health STI and HIV health education Working with individuals, families and communities Counselling skills (also see Module 5) Assessment type Formative / summative Essential Competencies assessed Observed role play Supervised practice Formative ICM Essential Competencies 2, 3, 4, 5, 6 Tests and quizzes Exam question or coursework project Supervised practice Summative Recommended resources for teachers and students Cotton M, Jones M, Stegall M (2003) Nursing patients with sexual and reproductive health problems, ch. 25 in Brooker C, Nicol M eds. (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapters 31, 32 INFO Project (2007) Family Planning: a Global Handbook for Providers: WHO, John Hopkins Bloomberg School of Public Health Centre for Communications INFO Project, USAID available as CD-ROM and online at International Planned Parenthood federation, Resource bank CD-ROM and Fraser DM, Cooper MA eds. (2009) Myles Textbook for Midwives 15th. edn, Churchill Livingstone JHPIEGO McVeigh E, Hornburg R, Guillebaud J (2008) Oxford Handbook of Reproductive Medicine and Family Planning, Oxford: Oxford University Press Pathfinder International Population Council resources available online at UNFPA sources on HIV and AIDS available online at UN Millennium Development Goals WHO (2007) Training modules for the syndromic management of sexually transmitted infections, Geneva: WHO 111

113 WHO (2011) Kesho Bora study: preventing mother to child transmission of HIV during breastfeeding WHO resources e.g. Fact Sheet WHO resources 112

114 Module PM 15c Gender-based violence including harmful traditional practices Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1/6/36 Module aim Midwives will provide high quality, sensitive care to women and children exposed to, or at risk of violence and of harmful traditional practices especially FGM Learning and teaching methods Classroom simulations and role play, lectures and discussion, audio-visual media, case book. Enquiry-based learning, coursework projects. NB. This module does not include practice hours but students are likely to encounter women who have experienced FGM or violence and may be aware of risks to girl children. These should be recorded in their case books. They may also have traumatic personal experience. Learning outcomes On successful completion of the module students will be able to 1. Discuss the socio-cultural issues behind violence against women and girls and specific harmful practices, particularly FGM 2. Discuss Islamic views about violence against women and harmful traditional practices 3. Identify women and children who may be subject to violence and abuse 4. Act appropriately on suspicion or identification of violence including initial support and referral 5. Discuss ethical issues for midwives, nurses and doctors including human rights 6. Discuss the application of MDGs 3, 4 and 5 to midwifery practice 7. Identify global regions where FGM is practiced and examples of countries where it is illegal 8. Describe the WHO classifications of FGM 9. Describe the prevalence rates for FGM in Somalia and Puntland and the types, age commonly performed, how and by whom 10. List complications of FGM 11. Safely manage the consequences of FGM for birth including opening scar tissue and safe delivery 12. Work as advocates, health promoters and educators with families, communities and leaders Module content Topics Introduction Outline of content The concepts and definitions of gender-based violence (GBV), abuse and abusive relationships, sexual assault and rape Categories of violence against women and girls Sexual Psychosocial Physical Harmful traditional practices Economic Causes, contributing factors and the consequences of GBV including GBV used as a weapon of war and risk in emergencies MDG 3, 4 and 5 and their relevance Types of traditional practice existing in Somalia and Puntland including amongst non-somali communities 113

115 Early marriage and childbearing Other harmful practices Physical and psychosocial violence (FGM see below) Female genital mutilation Health promotion and advocacy The concept of harmful practice and non-harmful The view of Islam about violence against women and girls, and harmful traditional practices Socio-cultural and historical aspects including why such practices exist e.g. rites of passage for FGM, concepts of purity, cleanliness, chastity, being a woman The role of government and NGOs Legislation and its uses and disadvantages UN Conventions on the rights of women and girl children The midwifery role (see below, and Module 15d for sexual assault) The consequences of early intercourse and childbearing Supporting adolescent girls at risk of early marriage Supporting pregnant adolescents Forced marriage Wife inheritance Harmful food taboos and practices Identification of abused women and children Who is at risk and when? Indicators of physical violence Consequences of physical and sexual violence Immediate care and referral for physical violence (sexual assault Module 15d) Support for psychosocial abuse WHO classifications of FGM Countries where FGM is practised Countries currently legislating FGM amongst returning Somali residents of countries where FGM is illegal National statistics and issues that affect their availability How FGM is performed, where and by whom Review of the anatomy of female genitalia Complications of FGM Immediate physical Short-term physical Long-term physical Psychosocial and sexual Specific complications in pregnancy and childbirth including potential impact on the fetus and consequences for newborn FGM and first intercourse: traditional and contemporary practices FGM and childbirth: safe conduct of deliveries including opening scar tissue Perineal repair and after-care Care of girl children and women with complications of FGM Care of women undergoing reversal /opening Before first intercourse In pregnancy where available In labour The midwife role as advocate against GBV including FGM and other harmful practices Support services and NGOs The role of medical and police services, and social services where available Strategies for bringing about change Collaboration with communities, civic and religious leaders Replacement rites of passage 114

116 Debates about cessation of FGM or reduction in the extent of cutting Child protection issues Ethical issues e.g. medicalisation of FGM, postpartum re-infibulation by midwives and doctors Educating about the harmful effects of FGM Communicating with childbearing women, partners and families to discourage postnatal re-infibulation and FGM in daughters Assessment type Formative / summative Essential Competencies assessed Observation of role play Tests and quizzes Formative ICM Essential Competencies 1, 2, 3, 4, Essay questions Summative Coursework assignments/projects may be used for summative or formative assessment Recommended resources for teachers and students Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 28 Lewis G, de Bernis L eds. (2006) Obstetric fistula: guiding principles for clinical management and programme development, WHO Dept. of Making Pregnancy Safer Momoh C (ed.) (2005) Female genital mutilation, Oxford: Radcliffe Publishing Population Council multi-media and other resources available online at Population Council (2011) Addressing sexual violence and HIV risk among married adolescents in rural Nyanza, Kenya, Policy Brief 19 WHO (2001) Female Genital Mutilation: integrating the prevention and management of the health complications into the curricula of nursing and midwifery; a student s manual, Geneva: WHO Available online at WHO (2001) Female Genital Mutilation: integrating the prevention and management of the health complications into the curricula of nursing and midwifery; a teacher s manual, Geneva: WHO Available online at WHO GBV resources WHO (2005) Addressing violence against women and achieving the Millennium Development Goals, WHO (2011) Violence against women Fact Sheet 115

117 Module PM 15d Common gynaecological and breast disorders and issues Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 1/6/36 Module aim Midwives use a knowledge of gynaecology and women s health to provide services to women in all settings Learning and teaching methods Skills lab demonstrations and activities, use of anatomical models, visits and supervised practice, lectures and discussion. NB Supervised practice hours are not included but students should record relevant experiences gained during training in their case books. Learning outcomes On successful completion of the module students will be able to 1. Discuss factors affecting women s health and the midwifery role in prevention and care 2. List common gynaecological conditions and disorders of the female breast 3. Carry out health assessment including breast and pelvic examination 4. Provide basic emergency services and referral for women with gynaecological and breast conditions 5. Provide emergency (EMOC) services and referral or treatment for women with incomplete abortion 6. Support women with common discomforts and disorders of the menopause 7. Use knowledge of the causes of fistula and its prevention to provide safe care 8. Act as advocates for, and refer women with fistula to repair centres 9. Identify and refer couples with infertility issues appropriately 10. Provide care to women with common breast disorders and refer appropriately 11. Discuss issues of gender-based violence and sexual assault 12. Act appropriately on suspicion or identification of violence including initial support and referral 13. Provide support to women reporting sexual assault 14. Provide immediate care to women and girl children when sexual assault or rape is reported and refer appropriately. 15. Provide health education Module content Topics Anatomy and physiology review Women s health issues Outline of content Review of basic anatomy and physiology of the breast and female (and male) reproductive tract Healthy menopause Review determinants of women s health such as Socio-cultural, power, gender and faith-based issues Poor nutrition Infection Pregnancy too early, too often, too frequent, too complicated Carry out health assessment including breast, abdominal and pelvic 116

118 Disorders of the breast and basic management and referral Review of gynaecological disorders, management and referral Subfertility GBV and sexual assault examination, specimen collection Review normal cyclical and menopausal changes in women Review common conditions Benign breast pain Infection: mastitis and abscess Breast lumps: benign and malignant (male included) Recurrent breast cancer and metastatic spread Lymphodema Menstrual disorders, hormonal, uterine fibroids, polyps, endometriosis Pre-menstrual syndrome Female reproductive tract abnormalities Defects of uterus, vagina, Fallopian tubes, ovaries, vulva Review of early pregnancy problems (see Module 13) Signs and symptoms of sub-involution of the uterus or incomplete abortion Post-abortion care / Emergency treatment following incomplete accidental or unsafe/illegal abortion including Manual Vacuum Aspiration / care of women Emergency resuscitation and stabilisation including fluid/blood replacement Emergency contraception Antibiotics Follow-up child spacing counselling Somalia and Puntland beliefs and traditions regarding pregnancy termination Uterine prolapse, stress incontinence Obstetric fistula Cervical erosions and cysts Malignancy: vulval, cervical, endometrial, ovarian Pelvic inflammatory disease(pid) and its consequences (see 15d) Sexual dysfunction Healthy sexual responses, female and male Sexuality in pregnancy and postpartum Variations in sexual behaviour Local traditions, attitudes and myths Common types and causes of dysfunction Available referral mechanisms The impact of subfertility and childlessness in Somali society Main causes of male and female subfertility Primary and secondary infertility The role of infection e.g. STIs and PID Available female and male investigations Basic assessment and counselling Referral facilities available in Somalia and Puntland Overview of therapies available in high-resourced environments Providing support to childless couples and after pregnancy loss Socio-cultural issues around GBV, sexual assault and rape Childbearing and GBV Services in Somalia and Puntland 117

119 Health promotion The midwife role as support and advocate Immediate care, management and referral following rape Medical assessment including forensic evidence collection Post-exposure prophylaxis for HIV and STIs Emergency contraception Referral and referral facilities Psychosocial support and prevention strategies Agencies involved in sexual assault and the role of law Breast and normal body awareness, breast self-examination Advocacy for child spacing Healthy menopause Warning signs of serious disease Gender-based violence advocacy and referral Assessment type Formative / summative Essential Competencies assessed Observed role play Formative ICM Essential Competencies 1, 2, 7 Quizzes Case book review Examination or coursework Summative Recommended resources for teachers and students Barlow H (2003) Breast disorders, ch. 26 in Brooker C, Nicol M eds. (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby Cotton M, Jones M, Stegall M (2003) Nursing patients with sexual and reproductive health problems, ch. 25 in Brooker C, Nicol M eds. (2003) Nursing Adults: the practice of caring, Edinburgh: Mosby Engender Health / The Acquire Project (2006), Traumatic Gynecologic Fistula: A Consequence of Sexual Violence in Conflict Settings Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapters 22, 27, 30, 35 Post-Abortion Care Consortium (PAC) resources available online at 118

120 Module PM 16 Principles of learning and teaching Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 1/6/42 Total wks/days/hrs 2/12/78 Module aim Midwives use understanding of the principles of learning and teaching in supporting more junior students and staff in clinical settings and in providing health education (also see Module 4f) Learning and teaching methods Lectures and discussions, group-work, micro-teaching and presentations to peers, role play, discussing scenarios, supervised clinical teaching and health education, case books. Students should gain experience of small-group and individual teaching in clinical areas and health education. Coursework suggestions Plan and conduct a clinical teaching session, evaluating its success with those taught and with the clinical or classroom supervisor and preparing a report Investigate learning needs in a clinical area and develop a learning resource/package to meet this need. Learning outcomes On successful completion of the Module students will be able to 1. Describe key theories of adult learning and their importance for clinical and small group teaching and for health education 2. Use active learning methods for clinical and small group teaching and for health education 3. Use the buddy /befriending system to support the learning of more junior students 4. Assist with the clinical assessment of more junior students 5. Discuss the importance of mentoring students and the newly qualified for clinical learning 6. Provide health education to individual and groups of clients Module content Topics Review of principles Review of effective teaching and facilitating learning Review of practical teaching skills Outline of content Principles of how adults learn Principles of active learning Principles of behaviour change The role of midwives as clinical teachers and assessors What is a good learning environment? What is a good teacher? Learning and teaching styles and approaches Barriers to learning and how to overcome them From novice to expert a learning journey Using equipment and resources Making and using visual aids Making learning resources/packages for clinical areas Demonstrating Listening and questioning Buddying / befriending / mentoring/supervision 119

121 Assessment type Formative / summative Essential Competencies assessed Supervised clinical teaching and role plays Formative ICM Essential Competency 1 and relevant to others Supervised clinical teaching Coursework project / report Summative Recommended resources for teachers and students Bastable S (2007) Nurse as educator: principles of teaching and learning for nursing practice. 3 rd. edn., Sudbury Mass: Jones and Bartlett Butterworth T, Faugier J, Burnard P (1998) Clinical Supervision and Mentorship in Nursing, 2 nd. edn., London: Nelson Thornes Gopee N (2008) Mentoring and Supervision in Health Care, Sage Hays S (2006) Teaching and learning in clinical settings, Radcliffe Publishing Hinchliffe S (2009) The practitioner as teacher, 4 th. edn. Churchill Livingstone Morton-Cooper A, Palmer A (1999) Mentoring and preceptorship: a guide to support roles in clinical practice, 2 nd. edn., Oxford: Blackwell O'Connor A, (2006) Clinical instruction and evaluation: a teaching resource, 2 nd. edn.. Sudbury Mass., Jones and Bartlett Publishers Stuart C (2003) Assessment, supervision & support in clinical practice: a guide for nurses, midwives and other health professionals, Harlow: Churchill Livingstone 120

122 Module PM 17 Management and leadership Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 1/6/42 Total wks/days/hrs 2/12/78 Module aim Midwives use understanding of management, quality assurance and leadership principles to organise and lead health activities and manage and lead facilities and staff Learning and teaching methods Lectures and discussions, independent study, group work, role play, discussing scenarios and case studies, visits, supervised management practice, case book records of management activities. Coursework projects as group or individual. e.g. analyse a work environment and plan a small change. NB: Students have the opportunity to manage a department and/or MCH centre with which they are familiar, first under close supervision, then with minimal supervision for a period of e.g. two days. Learning outcomes On successful completion of the Module students will be able to 1. Manage their own time and activities 2. Discuss the Somalia and Puntland health system and potential development of maternal health services 3. Discuss how management and leadership theories can be applied to midwifery practice 4. Collaborate in collecting data for maternal and child morbidity and mortality audit 5. Collaborate in collecting data for audit of quality and standards 6. Take measures for improving service quality 7. Facilitate access of pregnant women to skilled care, and access of midwives to women in collaboration with colleagues and communities 8. Collaborate with medical and paramedical colleagues in service development 9. Collaborate with CMWs, TBAs and CHWs to organise and lead health outreach activities 10. Support the work and development of team members such as CMWs, auxiliaries, CHWs, volunteers and TBAs 11. Manage a MCH centre and/or hospital department Module content Topics Introduction and review of prior knowledge Management ideas review Managing change Outline of content The midwife role in management and leadership Leadership, management and administration: what is the difference? Personal prioritisation and time management Accountability Somalia and Puntland health system Key management and leadership theories and models Management and leadership styles Power issues and dynamics in teams Common strategies Problem-solving 121

123 Managing a clinical setting or service Quality improvement and audit Leadership Collaboration Workplace assessment The assessing, programme planning, implementing and evaluation cycle Effective communication with staff Managing relationships and negotiating Managing conflict and stress Safety and risk assessment Administration and record keeping Budgeting Rota planning Cold chain management Ordering drugs and supplies, secure storage, distribution and record keeping Organising and running clinics: e.g. antenatal and postnatal, child health and immunisation, well-woman and well-man, child spacing Organising home-based and community visits where appropriate Quality of care principles for improving service uptake (IPPF see resources) Information and choice Accessible services Privacy and confidentiality Safety Dignity and comfort Record keeping Continuity of service Working to standards Managing the environment, cleanliness, maintenance and repairs of building and facilities Setting SMART goals and standards (Specific, Measurable, Achievable, Relevant, Timebound) Barriers to achievement Auditing achievement of standards Client satisfaction, feed-back and dealing with complaints Staff supervision, performance appraisal and development Reporting Leadership theories and models Characteristics of an effective leader Team building Motivation Conflict and negotiation Working with others: Medical and paramedical staff, CMWs, CHWs, TBAs, campaigns e.g. FGM or immunisation, working with NGOs and INGOs Assessing local needs Collaborating with community leaders for change Assessment type Formative / summative Essential Competencies assessed Supervised management practice Observed discussions Formative ICM Essential Competency 1 and relevant to others Supervised management practice Examination questions or coursework assignment Summative 122

124 Recommended resources for teachers and students Carroll P (2006) Nursing leadership and management: a practical guide, Delmar Cangage Learning Finkelman J (2005) Leadership and management in nursing, Prentice Hall. See also online study guide Hyde J, Cook M eds. (2004) Managing and supporting people in health care, Edinburgh: Bailliere Tindall and Royal College of Nursing International Planned Parenthood Federation 10 Rights of the Client Jasper M, Jumaa M (2005) Effective health care leadership, Wiley-Blackwell Jones R (2007) Nursing leadership and management: theories, processes and practice, Philadelphia: S.A Davis Company Whitehead DK, Weiss SA, Tappen RM (2006) Essentials of nursing leadership and management, 4 th. edn., Philadelphia: FA Davis Company WHO, UNICEF, AMDD (2009) Monitoring emergency obstetric care: a handbook, Geneva: WHO k.pdf 123

125 Module PM 18 Consolidation workshops: Emergency skills and revision Theory wks/days/hrs 4/24/144 Practice wks/days/hrs 0/0/0 Total wks/days/hrs 4/24/144 Module aim This module provides the opportunity for students to consolidate their learning and gain confidence in emergency skills. Learning and teaching methods Demonstration and emergency skills drills, lectures, discussions, group work, multi-media, OSCEs Although this module is designated as theory, much activity will take place in the skills lab. Learning outcomes On successful completion of the Module students will be able to 1. Demonstrate understanding of their learning from the Programme 2. Outline key evidence that underpins midwifery practice 3. Provide emergency life support for neonates, infants and children 4. Provide emergency life support to adults 5. Transfer appropriately for medical care when possible Module content Topics Revision Outline of content Content to be negotiated with students Doing your best in OSCEs and examinations Emergency skills Review of key evidence that underpins practice (see Module 12) Adult life support workshop Triage Airway Breathing Circulation Defibrillation if available BEMOC and CEMOC skills review ETAT Neonate and child emergencies workshop or similar Triage Airway Breathing Coma and convulsion Dehydration Cold stress and low blood sugar Assessment see over 124

126 Assessment type Formative / summative Essential Competencies assessed Practice OSCEs Practice tests and exam questions Formative Contributes to all ICM Essential Competencies ETAT or other tests at end of emergency skills workshop OSCEs at end of Programme Skills assessments Examinations Summative Recommended resources for teachers and students See previous modules and Baston H, Hall J, Henley-Einon A (2009) Midwifery essentials, vols. 1-4, Churchill Livingstone / Elsevier Davies L, McDonald S (2008) Examination of the newborn and neonatal health, Edinburgh: Churchill Livingstone Elsevier Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Edinburgh: Churchill Livingstone Gruenberg B (2008) Birth emergency skills training: manual for out-of-hospital midwives, Birth Muse Press Huband S, Hamilton-Brown P, Barber G (2006) Nursing and midwifery, a practical approach, Basingstoke: Macmillan/TALC, chapter 11 Johnson R, Taylor W (2008 or 2000) Skills for midwifery practice, Edinburgh: Churchill Livingstone Medforth J, Battersby S, Evans P, Marsh B, Weller A, eds. (2011) Oxford Handbook of Midwifery, OUP St. John Ambulance Association / British Red Cross (2009) First Aid Manual, 9 th. edn. (or latest possible), London: Dorling Kindersley WHO Dept. of Reproductive Health and Research (2003) Managing newborn problems: a guide for doctors, nurses and midwives, Geneva: WHO WHO (2005) Emergency triage assessment and treatment: Participants manual, WHO (2005) Emergency triage assessment and treatment: Facilitator guide, WHO (2010) Guidelines on HIV and infant feeding, 125

127 Module PM 19 Consolidation of practice Theory wks/days/hrs 1/6/36 Practice wks/days/hrs 6/36/252 Total wks/days/hrs 7/42/288 Module aim Students will have the opportunity to reflect on the role and aspects of care and practice, and spend substantial time practising as midwives with minimal supervision Learning and teaching methods Minimally supervised practice, discussion and reflection, case book and log book. Teachers may wish to split the class days either side of the placement to permit briefing and debriefing. Every effort should be made to provide this experience in a continuous period to prepare the students for independent practice. At the same time account needs to be taken of individual student needs such as clinical settings where their experience e may be lacking. Learning outcomes On successful completion of the Module students will be able to 1. Discuss the midwife role and scope of practice 2. Discuss ethical issues in practice 3. Describe the purposes of registration and supervision 4. Discuss the importance of CPD and their own initial plans 5. Discuss the work of professional associations 6. Make a plan for identifying an informal mentor Module content Topics Professional issues Rural placement Outline of content Role and scope of practice of midwives Review of ethics and ethical issues in midwifery, ethical codes The future: Registration and supervision Lifelong learning and continuing professional development (CPD) Identifying an informal mentor Why professional associations? Why be a member? The national association and the International Confederation of Midwives. Briefing and de-briefing Expectations of the placement Setting personal objectives for the placement Review of case-books Assessment type Formative / summative Essential Competencies assessed Minimally supervised practice Summative ICM Essential Competencies: Skills assessments contributes to all Resources see over 126

128 Recommended resources for teachers and students Foster I (2010) Professional ethics in midwifery, Jones and Bartlett Fraser DM, Cooper MA eds. (2009) Myles textbook for midwives 15 th. edn, Churchill Livingstone Huband S, Hamilton-Brown P, Barber G (2006) Nursing and Midwifery: a practical approach, Basingstoke: Macmillan/TALC. ch. 3 International Confederation of Midwives website www. internationalmidwives.org International Confederation of Midwives Code of Ethics available at Jones S (2000) Ethics in midwifery, Mosby 127

129 ANNEXE 1 ICM Definition Of The Midwife 128

130 ANNEXE 2: ICM Philosophy And Model Of Midwifery Care The Philosophy and Model of Midwifery Care (2005) BACKGROUND A midwife is a person who, having been regularly admitted to a midwifery educational programme, 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 International Confederation of Midwives believes that a midwife offers care based on a philosophy, which influences the model of care. This document outlines the philosophy and describes the model of midwifery care. STATEMENT OF BELIEF As midwives we believe that 1. Childbearing is a profound experience, which carries significant meaning to the woman, her family and the community. 2. Birth is a normal physiological process. 3. Midwives are the most appropriate care providers to attend women during pregnancy, labour, birth and the postnatal period. 4. Midwifery care empowers women to assume responsibility for their health and for the health of their families. 5. Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian. 6. Midwifery care combines art and science. Midwifery care is holistic in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women and based upon the best available evidence. 7. Midwives have confidence and trust in, and respect for women and their capabilities in childbirth. 8. The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities. As a result: 129

131 1. Midwifery care promotes, protects and supports women's reproductive rights and respects ethnic and cultural diversity 2. Midwifery practice promotes and advocates for non-intervention in normal childbirth 3. Midwifery practice builds women's self confidence in handling childbirth 4. Midwives use technology appropriately and effect referral in a timely manner when problems arise 5. Midwives offer anticipatory and flexible care 6. Midwives provide women with appropriate information and advice in a way that promotes participation and facilitates informed decision making 7. Midwifery care maintains trust and mutual respect between the midwife and the woman 8. Midwifery care actively promotes and protects women s wellness and enhances the health status of the baby. GUIDING STATEMENT TO MEMBER ASSOCIATIONS Member associations can use this document as a guide in the education of midwives, organisation of midwifery care, supportive supervision of midwives and evaluation of care. It can also be used to guide the relationship between the midwife and the client. Member associations can share the statement with other health professions and governments during the development of regulations and legislation of midwifery practice. RELEVANT ICM DOCUMENTS ICM Definition of the Midwife (2005) ICM Vision Statement (1999) ICM Essential Competencies for Basic Midwifery Practice (2002) ICM International Code of Ethics for Midwives (2002). OTHER RELEVANT DOCUMENTS American College of Nurse-Midwives (ACNM), USA. Hallmarks of Midwifery Practice, in: Core Competencies for Basic Midwifery Practice (2002) ACNM. Philosophy of the American College of Nurse-Midwives (2004) Australian College of Midwives Inc. Theoretical and Philosophical Frameworks and Models of Maternity Care (2000) Citizens for Midwifery, USA. Midwives' Model of Care (1996) Certified Professional Midwives, USA. Providing the Midwives' Model of Care (2000) College of Midwives of Ontario, Canada. Philosophy of Midwifery Care in Ontario (1994) Homer C, Brodie P, Leap N. Establishing Models of Continuity of Midwifery Care in Australia: A resource for Midwives and Managers (2001) New Zealand College of Midwives. Midwifery Model of Care (2000) New Zealand College of Midwives. Philosophy of Midwifery (2000) Royal College of Midwives, UK. Midwifery Model of Care (2000) Royal College of Midwives, UK. A Philosophy of Midwifery (1992) Thompson JE. Human rights framework for midwifery care. Journal of Midwifery and Women's Health (2004). 130

132 International Confederation of Midwives La Confédération internationale des sages-femmes Confederación Internacional de Matronas Laan van Meerdervoort AN The Hague The Netherlands Tel: Fax: info@internationalmidwives.org Website: 131

133 ANNEXE 3: Essential Competencies For Basic Midwifery Practice 132

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