Gaining increased knowledge and skills motivates.

Motivation was high among the participants to take part in the three-pillar training programme as it provided them with updated knowledge and skills for daily practice, which could contribute to healthy and positive childbirth.

Most of the participating healthcare professionals had not received any formal in-service training since their professional education, and the three-pillar training programme provided them with new knowledge. At two facilities they typically arranged training themselves in areas where care was not optimally conducted, for example in how to resuscitate a newborn. At one facility, the church sometimes organised training, and those who had participated shared their new knowledge with colleagues:

There is a lack of in-service training. We get nothing. Sometimes we’re invited to seminars organised by the private health sector, but no such seminars are organised by the government health zone; they just give some random information. (FGD 1, Healthcare Facility 7)

Most of us have not gotten any formal in-clinic training since we completed our pre-service professional education. We try to solve this through organising our own in-service trainings using our doctors, who have been at the university. But they only have their own notes, and would have needed to have PowerPoints and other educational materials. (FGD 1, Healthcare Facility 4)

All participants, except for at one healthcare facility, expressed an awareness that they did not have the latest scientific evidence-based knowledge and accordingly were not practising optimally. They were primarily motivated to learn in several areas such as promoting normal physiologic birth and correctly managing complications like postpartum haemorrhage. The materials they were provided–birthing balls and Rebozo sheets for use during labour, and penguins and a ventilation mask for aspirating the newborn in need–added to their motivation and their possibility to practise the skills they had learned:

We don’t have an ambulance that we can use to transport the women who need a C-section, and the ambulance from the reference hospital often comes much too late. The training we’ve gotten helps us support a normal birth and lets us handle acute conditions like bleeding. (FGD 2, Healthcare Facility 6)

There was a positive attitude regarding sharing knowledge between the different healthcare facilities within the same health zone. The three-pillar training was regarded as such a knowledge exchange programme both within an individual healthcare facility as well as between the different facilities. There was a desire to develop such knowledge sharing even further, as the healthcare facilities had the same type of patients with similar backgrounds and health conditions. The master trainers, in turn, acknowledged that the training programme had given them a mandate to have access to and connect with the other facilities within the zone.

Women’s utilisation of the healthcare facilities motivates.

Another motivating factor for the healthcare professionals to participate in the training programme was when they noticed that their changed care routines had influenced how women informed their peers about their positive experiences of being cared for at the healthcare facilities, which in turn positively influenced other women’s decisions to seek care at the facilities. It had also been noticed that several women arrived earlier when their labour had started, which in turn influenced the outcome:

The training was fantastic, both for us as staff at the clinic and for the women who come in and give birth. At one of the clinics, many more women giving birth are coming in. Now, when a woman in labour comes, the staff are close to the woman and massage her. When the woman goes home she tells others where she lives about her positive experience. (FGD 2 with master trainers)

It was acknowledged that caring for an extremely poor, and often low-educated, population was challenging. Women commonly feared having a C-section. With the newly trained care routines that promoted a normal physiologic birth, there was a belief among the healthcare professionals that their increased knowledge and skills in turn would increase the prevalence of vaginal, non-instrumental births, which in turn would motivate women to give birth at the facility:

The population is very poor and has a low education level; this makes it difficult to motivate the patients for different decisions about care. (FGD 1, Healthcare Facility 4)

The pregnant women are afraid of having repeated C-sections. There are different reasons; one can be that the family force her to give birth normally in order to be considered a real woman. Another reason for rejecting a C-section is the cost; they therefore reject having a C-section. (FGD 1, Healthcare Facility 5)

Monetary incentives for participating are expected.

Another strong, motivating factor for participating in the training programme was the expectation of monetary incentives. This expectation was the same for master trainers, facilitators, and the healthcare professionals at the facilities, and was based on the fact that monetary incentives were commonly provided by other projects they had participated in. As this training project had no such monitoring incentive system in place for the weekly participation in training, it made participants at the healthcare facilities hesitant to attend the sessions:

You know how it is with Africans: they don’t come if they don’t get any sugar [compensation]. You need something to motivate them; money’s needed as motivation. // We, as trained [facilitators], don’t get any sugar [compensation] for the training we hold [at the healthcare facilities], and we didn’t get any compensation when we took part in the training to become facilitators. (FGD 2 with facilitators)

The healthcare professionals at each facility followed work schedules covering 24 hours, seven days a week, which made it difficult for them to attend every scheduled training activity. Activities that were part of the Pillar 1 and 2 trainings were often practised in the morning, which made it challenging for those who had been working the night shift. The importance of being reimbursed as motivation to participate in the training was stressed, at least being reimbursed for transportation costs if the training activities were undertaken when someone was off duty:

It can be hard to convince the staff to take part in the different training steps. What’s hard is motivating the staff to stay and train after the end of their workday, as well as motivating staff to come in on their day off to train. Sometimes they refuse to come in because they’re not paid for the transportation. (FGD 2 with facilitators)

The master trainers stressed that the provision of incentives would increase their motivation to conduct the scheduled training activities. This, as being a master trainer and a facilitator was regarded as having dual work responsibilities–both their ordinary work as well as this training–which therefore required sufficient monetary incentives. The lack of monetary incentives to facilitators and the insufficient incentives to master trainers contributed to a lack of motivation:

We’d like to get paid when we train the others; we only get a transportation allowance. When we had our master training in April and May, we didn’t get any compensation. (FGD 2 with master trainers)

Because facilitators don’t get paid, they’re not motivated to train their colleagues. (FGD 2 with master trainers)

Authorities from the health zone need to be included.

Getting the local health zone authority involved was critical for successful implementation, and obtaining this authority’s approval was perceived as a requirement for conducting the three-pillar training programme. Involving the local health authority in the training could therefore support and encourage the healthcare facilities to include the training activities within their daily routines. The authorities from the health zone were informed about the training action and had granted permission to conduct it; but to support the project further, according to the master trainers, the health inspectors would need to be incentivised, and it was suggested that the project consider budgeting for this:

The health inspectors from the health zone are included to some degree, but they’re not motivated to support the project. They want to be a part of this project. They want to be there when we master trainers go to the clinics, but they don’t want to be trainers. If they were included more they’d be able to motivate the staff to participate in the project during their regular visits to the healthcare facilities. … The inspectors have expressed that if they’re paid, like they are in other projects, they can encourage the healthcare facilities to take part in the training. (FGD 2 with master trainers)

The healthcare facilities’ management needs to be involved.

Involving the healthcare management at each healthcare facility was stressed to be of critical importance, as they make all the decisions concerning care and care routines. And if the training programme was to gain sustainability and continue beyond its scheduled time, creating ownership among the local management was acknowledged as crucial:

We have a culture in which the responsible parties are higher in rank than us; we others feel lower than them. So if this training is to continue, you have to involve more of those at management level at the healthcare facilities. That would increase the ownership. Then, management will take greater responsibility, they’ll increase our motivation, create an ownership. (FGD 2, Healthcare Facility 1)

Being involved entailed not only being informed about and influencing the training strategy, which was a part of the project; it also included receiving monetary incentives. If not, this could act as an obstacle to the training programme. This was especially clear at the tertiary-level facility. These leaders hindered the programme in various ways, for example by not taking part in the training and even stating that they had never heard about it:

If people with management responsibility aren’t directly involved in the project, they’ll turn the responsibility over to those who are running the project. You have to bring in the boss, make him part of the project. When the boss talks everybody listens; I can’t ask the boss to do various things, I can’t give the boss orders. So the boss has to participate and have a mandate. And that means that the boss needs money from the project. It’s not a salary; it’s a motivation. If the boss is motivated, we can get everybody to do what we want in the project. If he doesn’t get paid he’s not going to participate himself and he’s going to work against it. The other healthcare facilities are small; this is a gigantic clinic, and the boss has to be involved. (FGD 2with master trainers)

Inadequate physical space and electricity.

According to the participants and our own observations all seven facilities, and specifically their maternity units, had inadequate physical space to meet the needs. Hence, this contradicted the training. One challenge that negatively influenced the training using mannequins was that the mannequins were packed in bags and stored, and were only picked up for each training session. According to the participants this was due to a lack of space, and the fact that there was no separate table for the mannequins. This resulted in the training not always being conducted as they had learned during their training. Another reason for storing the training products was a fear that the material would be stolen:

At the labour ward there’s no place; we’ve notified the staff that they can use the material on the day. We have no room to store it openly and guard it. We have many interns, the African culture–the material can be stolen. (FGD 2 with master trainers)

No access to, or insufficient availability of, electricity was another challenge that limited the possibilities to conduct care during labour and birth based on the staff’s new knowledge. Often, electricity was only available for six to eight hours or even less, but there could also be two days with no electricity at all. This led to ambiguity about using electric equipment, as it was almost impossible to rely on equipment like the blood refrigerator, resuscitation equipment, and heating lamps for newborns, which depended on electricity. Solar panels were commonly used, but were often insufficient. At one facility, the blood refrigerator used all the electric capacity. Thus, it was motivating to take part in this training programme and use the assigned equipment that did not require electricity:

Electricity comes and goes; we cannot say how often. We have solar cells but they’re not strong enough to drive medical equipment, as it needs electricity. (FGD 1, Healthcare Facility 6)

Lack of equipment to promote physiologic birth.

Unanimously, all participants mentioned the lack of childbirth care equipment at the healthcare facilities as very limiting to the provision of high-quality maternal and newborn healthcare. There was especially a lack of equipment for promoting normal physiologic birth. Thus, the birthing balls and a specially designed sheet for the use of Rebozo techniques were specifically valued, as this made it possible to offer alternative pain relief and positions during labour and birth.

The material provided through the project was used often, and all participants stressed a need for additional birthing balls and Rebozo sheets. At some facilities, the balls and sheets had been used so often they were now broken/torn, while other facilities were in need of extra equipment so that it could be used if several births were taking place at the same time. The importance of cleaning the equipment between women also created a need for extra balls and sheets:

I participated in a one-week course last autumn and learned about alternative pain relief such as Rebozo and birthing balls, but couldn’t practise it as we didn’t a ball like that. (FGD 1, Healthcare Facility 2)

If we have two women at the same time we can’t offer both women a birthing ball. We want to have a ball for all women giving birth; we have about three deliveries a day. We also need more Rebozo sheets. We’d like to have three Rebozos. (FGD 2, Healthcare Facility 4)