PREPARATORY WORKSHOP FOR MIDWIFERY EDUCATION

A Brief Report On PREPARATORY WORKSHOP FOR MIDWIFERY EDUCATION and CADRE IN NEPAL Organized by Ministry of Health and Population with Support from UNFPA Venue: TRADE TOWER, THAPATHALI, Kathmandu, Nepal Date: 20-21 November 2014. MoHP/UNFPA midwifery workshop report November 20-21/2014 1

BACKGROUND: The Government of Nepal (GoN) is committed to reducing maternal and neonatal mortality and morbidity by ensuring the availability, access to and utilization of skilled care at every birth. The National Skilled Birth Attendants (SBA) policy (2006) specifically identifies the importance of skilled birth attendance at every birth and embodies the government s commitment for development of a new cadres of professional Midwives as a crucial human resource for safe motherhood, providing service and leadership in midwifery as a long term measure to be reached before 2017. Since 2010 MoHP is working with UNFPA and other partner agencies for the initiation of midwifery education and for the development of this professional cadre. However the progress has been slow and as of now Midwifery education as per ICM standard is yet to start in Nepal. However development of reference curriculum and the teaching /learning tools for the three years Bachelor in Midwifery and draft faculty development frame work for Midwifery Education for Nepal has been completed. A task force committee to advance Midwife cadre and Education has also been set up under the leadership of MoHP and the Midwifery association of Nepal (MIDSON) continues to advocate for midwifery education and cadre in the country. Apart from this, since early 2014, work on regulation is also being carried out through Nepal Nursing council (NNC) by developing Education standards and revision of current Nursing Act to include Midwives as a separate cadre of health professional. The feasibility study on professional midwives in Nepal conducted in collaboration with Family Health Division in early 2012 has recommended five potential universities, namely TUIOM; NAMS, Bir hospital; PAHS, BPKIHS, Nepalgunj Medical College affiliated to Kathmandu University that could initiate midwifery education. Hence in line with the above commitment of the Government of Nepal, to initiate midwifery education in the country this workshop was organized by MoHP with support from UNFPA in order to bring 6 universities_ one who have explicitly expressed its interest to start midwifery education (KU) and other five recommended by feasibility study, along with other relevant skate holders together to prepare a comprehensive action plan to initiate professional midwifery education in Nepal by identifying and analyzing the strength and gaps/needs of each of these universities to. ( Annex I- program agenda). Objectives of the workshop: 1. To prepare a comprehensive action plan for initiating professional midwifery education in Nepal. 2. To draft a plan for deployment of professional midwives. MoHP/UNFPA midwifery workshop report November 20-21/2014 2

DISCUSSION AND WORKSHOP ACTIVITIES Day 1 (20 th November, 2014) Opening Session The workshop started with welcome remarks by Dr. Guna Raj Lohani, Chief, Curative Division, MoHP. He highlighted the government strategy and referred to the SBA Policy 2006 especially its long term plan of developing separate cadre of Midwifery professionals to improve maternal and newborn health in Nepal. After the opening remark, Ms. Ishwari Devi Shrestha, Chief Nurse Administrator, MoHP presented achievements made on maternal and neonatal health situation by the country till now and the importance of having midwives as a long term solution to sustain or improve on the progress made so far. She also highlighted on the role of Stakeholders on initiating the education the education as well as for faculty preparation. Dr. Bimal Dhakal, Special Secretary, MoHP closed the opening session highlighting the importance of working together with different stakeholders and necessity and having Midwives in Nepal. He expressed his eagerness to see this cadre being developed soon and expressed MoHP s willingness to support the process as required. He articulated the need of qualified and skilled manpower in RH services, and further mentioned that midwives can play a vital role to save the lives of mother and neonates specially in remote places where access to quality service remain limited. MoHP/UNFPA midwifery workshop report November 20-21/2014 3

Technical session The technical session was divided in to two sections. Initially presentations were made by the MOHP, UNFPA, NHTC,NNC and MIDSON. During the second session group works were done following a structured format to develop faculty development plan, ( by the various universities), and Midwifery workforce deployment and career development plan ( by MoHP, MoE, NNC, MIDSON, WHO, GIZ & UNFPA). The following presentations were made and each was followed by discussions: Requirement of Professional Midwives in Nepal: Ms. Catherine Breen Kamkong, Deputy Representative at UNFPA Nepal presented on the global ICM/WHO Standards for midwifery education. As the Global standards provide framework for designing, implementing, and evaluating the quality of midwifery programmes she emphasized on the importance of adherence to ICM/WHO Global standards for Midwifery education. She also emphasized the importance of strengthening all three pillars of midwifery that is Education, regulation, and association. Midwifery workforce, deployment and career strategy development: Mr. Kedar Bahadur Adhikari, from HR Division, at MoHP, highlighted the need to carefully plan entry criteria for midwifery education and prospects for future midwifery graduates in Nepal. He also focused on the challenges for midwifery education such as core infrastructure of universities/institutions, creating position in government institution, deployment and issues regarding retention of midwives in the rural areas once they graduate. He emphasized on the need to develop the following documents, through general consensus for midwifery education and cadre: Finalize the course for different levels of Midwives: Bachelor level, upgrading of ANMs etc. Define the number of intake for the course Work plan for selection of candidate: Quota for ANMs and staff nurses in public serves. What proportion of students in each batch will be from Government services and as direct entrees? Selection of institutions for Midwifery education and their plan for sustainability. Partnership with academic institutions and other stakeholders for initiation of midwifery education. MoHP/UNFPA midwifery workshop report November 20-21/2014 4

Preparation of a good HR deployment Plan. History of SBA training and progress made so far: Mr. Mahendra Prasad Shrestha, Director, NHTC highlighted on the progress made so far in regards to SBA training. Introduction to Global standards in Midwifery Education: Ms. Kiran Bajracharya, President, MIDSON highlighted on the Requirement of Professional Midwives in Nepal based on the lesson learned from other countries. She also shared about the need for professional midwives as the current nurses do not have adequate competencies as per ICM standard to be recognized as professional midwives. Current nursing curriculums were assessed in 2011 to identify Gaps in Midwifery competence as compared with ICM standards which are as follows: ANM- 37 Competencies PCL- 28 Competencies B.Sc. Nursing 16 Competencies BN- 23 Competencies Regulatory framework for Midwifery education: Mrs Daya Laxmi Joshi, President, NNC highlighted on the work NNC is undertaking in regards to Midwifery education. She also highlighted on the issues regarding inclusion of midwifery in the present act, and process related to curriculum development, accreditation and sustainability of Midwifery education. Later the participations were divided into various groups according to the need and expertise: Group Work Group 1: Midwifery workforce deployment and career strategy Group members: MoHP, MoE, WHO, GIZ, NNC, MIDSON, UNFPA Group 2: Faculty development plans including curriculum, HR and facilities required to initiate midwifery education Group members: BPKIHS, KU, TU, IOM, Nepalgunj Medical College in separate groups. MoHP/UNFPA midwifery workshop report November 20-21/2014 5

Each group had team representative who facilitated the group discussion, and team leader who made the presentations based on the group discussions. Group 1 made their presentations on Day1 of workshop while the others did so on the second day: Group 1: Midwifery workforce deployment and career strategy Issues identified in terms of Midwifery workforce deployment and career strategy:- - - - - - - MoE is drafting higher education policy and an integrated Education Act, this will govern all education standards, operational plan and curriculum including Midwifery. - Coordination amongst various ministries needs to be strengthened for forecasting of HR needs, employment and deployment allocating resources- ( MoE, MoHP, MoGA, MoF, NPC) There is a need to have a separate health workforce policy for professional Midwifery either upgrade/ revise (rename) the current SBA long term policy or develop a new one (in reference to the new health policy and NHSPiii). Review the career ladder for all nursing professions and to recommend where midwives would fit in their placement in the HR structure and at which level of health institution as well as their role (supervisory only, supervisory and service provision both, others). Need to develop a strategy/ framework for retention (rotation) midwives in rural remote areas. ( remote area allowances)- Scholarship provision linked with deployment in remote area service for a certain period of time (plan to implement). More work needed on licensing and registration (Role of NNC) MoHP/UNFPA midwifery workshop report November 20-21/2014 6

S no Action required Responsible organization/person Time Frame Remarks 1 Amendment of Nursing and Midwifery Act and Regulation, drafting of Midwifery Education standard. 2 Registration process(licensing ); Relicensing guidelines 3 Coordination with Ministry of Education for Education Standard for Midwifery in reference to the in- progress integrated Education Act 4. Create baseline on # of professional Midwives workforce, assess skills and identify HR need in professional Midwifery. (Operation and Management survey) 5. Support to update /revise/rename the SBA long term policy to include Midwifery (Including drafting of implementation plan to align with NHSP III and costing) Preparation of Midwifery workforce deployment 6. plan recruitment, retention and development including creating supporting working environment ( Focusing on QoC) 7. Preparation of scholarship guidelines for Midwifery NNC ( preparation of Act, Regulation, Education Standard) MoHP ( Endorsement and approval through Secretary, Minister and Parliament/Cabinet) NNC- ( drafting re- licensing guidelines) MoHP ( endorsement and approval) In- progress, drafting to be completed by Dec 2014 To be endorsed by July 2015. In- process ( end of 2015) UNFPA supported UNFPA to support MoE, MoHP, NNC On- going NNC to support MoHP, MIDSON Still under preparation, by end of Feb 2015 MoHP, FHD By July 2015 MoHP, MoF, MoGA Feb 2015. EDP MoHP, MoF, MoGA Dec 2014 EDP UNFPA supported, WHO will also explore additional support. MoHP/UNFPA midwifery workshop report November 20-21/2014 7

Group 2: faculty development plans including curriculum, HR and facilities required to initiate midwifery education Kathmandu University, Dhulikhel Action Plan Standards What we have Gap Action to address these gaps 1. Midwifery faculty M.Sc Mid- 2 WHD- 3 B.Sc Mid with experience- 2 (All SBA trained) 3 - Refreshment courses for existing faculties - Faculty Development (Masters in Midwifery) Need to add Responsible person/organizations Nursing Director, Associate Dean, Dean of KUSMS Timelin e Feb 2017 Remarks - Enough for initiation. - Planning to enroll 15-20 students in the beginning 2. Facilities - Classroom including skill - Clinical placement sites 1 1.Dhulikhel Hospital, 2.17 Outreach centres (all are recognized birthing centre) 2 Will submit very soon Nursing Director, Associate Dean Dean of KUSMS Donor organizations (UNFPA, GTZ, etc) 2016 Requested MoHP and UNFPA 3. Curriculum On the process of finalization submission to Academic Council of KU and NNC Bachelor level Nursing Subject Committee, Academic Council of KU NNC April 2015 - Referred ICM global standard draft curriculum and international curriculum (Danish, Austria, USA- Seattle) MoHP/UNFPA midwifery workshop report November 20-21/2014 8

4. Resources 1. Midwifery Lab (Room) with equipment enough for CL and B.Sc nursing such as One Non pregnant model (Susie), 3 Pelvic half model with fetus and placenta, neonatal resuscitation set etc. Main gap in resources 1.Pregnant simulator model 2. Condom model on base 3.Vacuum set 4. IUD insertion set 5. Implant insertion &removal set 6. Manual Vacuum Aspirator etc - - Dean, associate Dean, Nursing Director - Donor organization(unfpa, MoHP, GIZ etc.) July 2015 - Need help for main resources from donor agencies - We will manage other resources as per guidelines. 5. Education can be started by? - August 2015 MoHP/UNFPA midwifery workshop report November 20-21/2014 9

Tribhuvan University, Institute of Medicine Action Plan Standards Gap Action to address these gaps Responsible person/organizations Timeline Remarks 1.Midwifery 1. Midwifery teachers with master degree in women health and development but not registered midwife Orientation workshop /meeting with authorities of TU,IOM Dean, Assist Dean, Campus chief, Assit Campus chief, HODs,Midwifery Faculty One month by December 21, 2014 Support from MOHP, UNFPA, GIZ 2.Facilities - Classroom including skill lab - Clinical placement sites Has skill lab No adequate human resources 3.Curriculu m No formal midwifery curriculum 4.Resources No sufficient resources 5.By when can you start the education? By july, September, 2015,TU IOM MoHP/UNFPA midwifery workshop report November 20-21/2014 10

B.P.Koirala Institute of health Sciences, Dharan Action Plan Standards Existing Gap Action to address these gaps Responsible person/organizations Timeline Remarks 1.Midwifery faculty Existing= 3 faculties 1= 4 teacher 2=4 teacher 3= 3 teacher Total = 11 Recruit /prepare for the same purpose BPKIHS/MOHP, EDPs If 4 teacher provided, it can be started immediately. 2.Facilities - Classroom including skill lab - Clinical placement sites - Class room & skill Lab Available - Hostel Not available - Total 150 bedded MCH hospital with 4 LT - 1200 to 1500 Delivery per month 3.Curriculum - After conducting Workshop Curriculum can be approved from Academic committee MoHP/UNFPA midwifery workshop report November 20-21/2014 11

4.Resource Gap 5.By when education can be started. Books, journals, LCDs, computers. - no birthing center, Require coordination with Medical teams for clinical practice If Human Resource (Teachers), SBA Training and Clinical Placement coordination arranged it can start immediately. MoHP/UNFPA midwifery workshop report November 20-21/2014 12

Lord Buddha Education Academy, Nepalgunj Action Plan Standards Gap Action to address these gaps Responsible person/organizati ons Timeline Remarks Midwifery faculty No faculty member with Master s degree in Midwifery/maternal nursing/women health and development Recruitment and training of faculty members Managing Director, LBEA Once we get program ( probably 2015) We do not have any Bachelor Nursing programme Facilities Classroom including skill lab Clinical placement sites Teaching learning materials like, books, manuals, videos are lacking Coordination with Government for use of their facilities for training site Arrange for these Use of Government facilities for clinical training Curriculum No curriculum Take approval from NNC and KU for starting the Bachelor Midwifery education Managing Director, LBEA KU, NNC, LBEA 2015 2015 Classroom available, fully equipped skill lab. Resource Gap NA Use curriculum finalized by KU and approved by NNC By when education can be start If approved by MoHP, NNC, KU education can be started in 2015 MoHP/UNFPA midwifery workshop report November 20-21/2014 13

Day 2 (21 st November) Presentation was made by universities on their prepared action plan. Kathmandu University stated that they are ready to start midwifery education from next year and has already drafted the curriculum. Under the Bachelor in Nursing Science programme that they are currently running, Midwifery would be one of the three stream including Oncology nursing and ICU/CCU. All the participants raised the concern that there should be a separate programme for Midwifery to meet the International standards and not midwifery as one of the subjects to be taught 9as already existing at many universities).bpkihs is ready to start the education once they receive formal letter from MoHP with their commitments. However, they shared that the major challenges are lack of trained faculty members, inadequate hostel, No Birthing center at present, limited co- ordination with Obs/Gynae team; and issues related to provision for scholarship for the government sponsored candidate. Nepalgunj also committed to start the midwifery education as soon as possible. TU IOM was unable to commit due to absence of designated authorities in the workshop. Things to be prepared by the Universities/ Institution based on the discussion: Faculty Preparation Clinical Setting preparation. Also select additional clinical training sites in addition to the hospital facility connected with the university. These sites need to be able to teach students midwifery care skills and so may need to be strengthened according to the required standards. Education standards and curriculum for submission to the nursing council for review and endorsement to initiate the Bachelor in midwifery course. Projection of human resource requirements including whether they feel it is possible to recruit and find qualified faculty members according to ICM standards or whether they need support from external development partners to provide qualified trainings to their faculty members. Curriculum as per the guidelines developed. Budget. Recommendations from participants in terms of preparation for Midwifery education: 1. Curriculum should be uniform across all the universities. 2. MoHP should be clear and commit ted to develop the deployment policy for the midwives. MoHP/UNFPA midwifery workshop report November 20-21/2014 14

3. MoHP should provide funding for faculty development (especially for curriculum development, recruitment of additional teaching staff and class room facilities). 4. The universities that attended (BPKIHS and KU Dhulikhel) are ready to start the program. They only need formal official approval and the allocated budget from the MoHP. 5. Nepalgunj Nursing campus expressed their eagerness to start the midwifery education program if MoHP approves as they do not have any existing bachelor program yet. Follow up action plan to contribute further to the workshop objectives. It was agreed that a follow up visit to the universities will be carried by a team of experts from MoHP, UNFPA, WHO, NNC and MIDSON. The objective of these visits will be to assess the capacity of the institutions (clinical sites, faculty, and pre- service requirement) as per the ICM /WHO standard and to identify areas for further support. Assessment tools for clinical sites, Skills lab and Pre service requirements have been developed by UNFPA as per WHO/ ICM standard. Note: the check list for this visit has been shared with the institutions representatives and a copy of each was provided to them during the workshop. Action: MoHP will finalize the tentative dates for visit to each university and inform the team. Conclusion The overall workshop had been fruitful. It met the expectation of the participants and the hosting agency. We were able to (to some extent) analyze the existing framework, gaps identified and current capacity and needs for support of the faculties of at least 3 universities and one medical college affiliated with one of the universities to start midwifery education. This will be further refined during the upcoming field visit by the team of MoHP, UNFPA, WHO and NNC. Although they said that they were ready to start the midwifery education, all universities (who attended the workshop) expressed a great need to recruiting additional human resources,, especially the qualified midwife teachers and the clinical preceptors to ensure quality education for the midwives. It was also realized that to find a teacher as per the ICM /WHO standard within the existing HR Pool in Nepal. It may be quite challenging and thus may need additional support from the Ministry of Health and Population and the EDPs. MoHP/UNFPA midwifery workshop report November 20-21/2014 15

ANNEXES ANNEX I Preparatory Workshop for Midwifery Education and Cadre in Nepal. 20-21 November 2014 Venue: Trade Tower, Nepal, Thapathali, Kathmandu, Nepal. OBJECTIVE: The Objectives of this two days workshop is: 1. To prepare a comprehensive action plan for professional midwifery education in Nepal. 2. To draft plan for deployment of professional Midwives. Day I: 20/11/2014 TIME TOPIC Facilitator Comments 9-9:30 Registration and tea 9: 30-9:45:hrs - Welcome remark - Introduction of participants. - Objective of the workshop, - Presentation on Midwifery Education and Cadre in Nepal. MoHP 9:45-10:15 1. Introduction to : a) Global standards in Midwifery Education b) Elements of Faculty development Plan c) UNFPA s work at the global level in advancing Midwifery education. 10:15-10:30 Midwifery workforce, deployment and career strategy development Catherine Breen Kamkong (UNFPA) Kedar Adhikari (MoHP) 10:30-10:45 History of SBA training and progress made so far. Mahendra Shrestha (NHTC) 10:45-11:00 Requirement of Professional Midwives in Nepal Kiran Bajracharya 11:00-11: 15 Tea Break 11:15-12;00 1. Standard of Midwifery curriculum (Global) 2. Mechanism of curriculum approval and University accreditation, 3. Human resource requirement for midwifery education. 12: 00-13:00 Group work on: Group: 1 Midwifery workforce deployment and career strategy development. Daya Laxmi Joshi (NNC) Group 1: Facilitated by Kedar Adhikari (MoHP)/ Latika Maskey (UNFPA) Parallel group work in two groups(action Plan format) : Group: 1 NHTC,FHD,HR section MoHP, Ministry of MoHP/UNFPA midwifery workshop report November 20-21/2014 16

Group: 2, Universities to work on faculty development plans including curriculum, HR and facilities required to initiate midwifery education.* Group 2: Facilitated by Catherine Breem Kamkong, Dr Shilu Adhikari,Neera Thakur, Sitara Khatiwada (UNFPA) Finance, NNC, UNFPA,NHTC,DoHS, Nursing Association, GIZ, NSI, MoE, Group 2: Universities (BPKIHS, KU, PAHS, TU, NAMS, Nepalgunj Medical college), WHO, MIDSON, GIZ,UNFPA 13:00-14:00 Lunch 14:00-15:OO Continue Group work 15:00 16:00 Group1: Presentation on Midwifery workforce deployment and Group 1 career strategy development. 16:00-16:10 Wrap up/ Closing MoHP *Universities are expected to prepare in advance and bring information which can be presented in the workshop Day II: 21/11/2014 TIME TOPIC Facilitator Comments 9-9:30: hrs Registration /Tea 9:30-11:00 Group 2: Presentation of Universities on faculty development plans. Group 2 11: 00-12:30 Plenary discussion on roles and responsibilities. MoHP/ NNC Agree on next step 12:30-12:45 Closing remarks MoHP 12:45-13:45 Lunch (10 mins for each presentation, 5 mins for discussion) MoHP/UNFPA midwifery workshop report November 20-21/2014 17

ANNEX II List of Participants MoHP/UNFPA midwifery workshop report November 20-21/2014 18

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Annex III List of teaching/training/ materials used as reference materials to facilitate the group work and to take away as handouts. 1. Faculty Development, Framework for Midwifery Education For Nepal, Jointly prepared by UNFPA and MoHP, October 2014. 2. Draft Curriculum, Developed by UNFPA, Nepal. 3. ICM Global Standard for Midwifery Education (2010). 4. Midwifery Brochure- Sept 2013. 5. Feasibility study on Human Resource in Maternal health. 6. SoWMY 2014 report. 7. Strategic direction for professional midwives. 8. ICM Curriculum concordance 9. Teaching and learning guide. 10. Check list for : a) Pre- service Midwifery program education, capacity assessment tool b) Assessment tool for midwifery services in Nepal. c) composite list for skill lab. All based on ICM standard. MoHP/UNFPA midwifery workshop report November 20-21/2014 23