Issues in enhancing continuing professional development for midwives in clinical practice in Mongolia

Summary

Midwives are professionals who fulfill maternal and child health needs. In Mongolia, midwives were unable to transfer their knowledge and skills to the next generation midwives last few decades. The details of their experiences and the comprehensive aspects of continuing professional development (CPD) are still unclear. This study aimed to assess the current status of midwives in clinical practice through an online symposium. Relevant information was collected from presentations, question-and-answer sessions, and questionnaires. It was found that CPD has unclear training plans, no specialized training, and with them having little experience with CPD. Newly graduated midwives do not have an educational program. As of the current status, midwifery services are not provided at the clinical site in the scope of midwifery job descriptions. This study also discusses the situation of low status and salary in midwifery. Strengthening the system of midwifery CPD like development of the educational program is needed.

Introduction

Sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) is an essential component of achieving Sustainable Development Goals. According to the State of the World's Midwifery 2021 report (1), midwives can fulfill 90% of the needs for SRMNAH services if they are fully educated, licensed, and integrated with an interdisciplinary team.

As a policy of the Mongolian government, primary medical services such as prenatal checkups are provided at primary healthcare facilities, and care during childbirth or for pregnant women with complications is provided at referral-level hospitals (2,3). In Mongolia, the National Program, "Maternal, Child, and Reproductive Health" (4) was adopted in 2017. Implementation of the policies reduced maternal and child deaths. These programs have resulted in 99.7% of all pregnant women giving birth in a hospital by 2020 (5). As for midwives, the Center for Health Development (CHD) has been issuing midwifery licenses since 1999, and the midwifery job description was declared as a decree of the Minister of Health in 2017 (6). In Mongolia, 1,119 people were working as midwives by 2020 (4).

Midwives faced various difficulties in their pursuance of their education and roles. According to the materials of "Core Competency of Midwives" by the Mongolian National University of Medical Sciences in 2018 (7), there was a period when midwifery education for midwives was suspended from 1993 to 2003 and midwifery as a practice was suspended from 2000 to 2017. During this period of suspended midwifery education and work, it was not possible to transfer knowledge and skills from midwives to midwives. Thus, there are no data on the comprehensive aspects of continuing professional development (CPD) or the details of midwives' experiences. This study aimed to assess the current situation of midwives in clinical practice through an online symposium aimed at strengthening CPD for midwives in Mongolia.

Online symposium

The online symposium was organized by the Mongolian Midwives Association, the Mongolian National University of Medical Sciences, the Ministry of Health, and the Japan International Cooperation Agency's project for strengthening post-graduate training for medical doctors and nurses to discuss the current situation of midwives in clinical practice on December 16, 2021.

Midwives of eight out of all 37 hospitals in Mongolia that handled childbirth, presented their current situation of ⅰ) CPD, ⅱ) education for newly graduated midwives, and ⅲ) to what extent the job description for midwives adhered to in clinical practice. These eight hospitals were chosen as the main maternal hospitals that handle approximately 60% of the births in Mongolia.

After the presentations, a question-and-answer session was conducted for 20 minutes. The organizers shared the questionnaire with the participants. For ethical considerations, the questionnaires (Table 1) were filled out anonymously by the participants of the online symposium who agreed to participate in the study and completed the investigation using Google forms.

Table 1. Questions of questionnaire by google forms.

Participant characteristics

○What is your position?

○How many years of experience do you have?

Satisfaction of online symposium

○How satisfied are you with the online symposium? Choose from 5 levels.

○What is the reason for your satisfaction rating?

Experience in CPD

○What CPD have you attended in the past?

Midwifery service and job description

○How consistent are job descriptions with clinical practice?

Let us know if there are any themes you would like to have in online symposiums

Information for this study was collected from the presentations, question-and-answer sessions, and questionnaires at an online symposium.

Information from the presentations

The issues identified in the eight hospital presentations were common. It was found that the CPD has problems like unclear training plans, no specialized training for midwives, no textbooks, and poor training environment, and lack of support for CPD. The CPD was necessary to strengthen the capabilities of clinical midwives. They also opined that ultrasound and family planning training are necessary. Regarding the education for newly graduated midwives, there were no educational programs and no trainers for newly graduated midwives at the clinical site. Regarding the midwifery service and job description, they explained that midwives at the clinical site could not follow their job descriptions. Because the most of the other health professionals such as medical doctors and nurses are not familiar with midwifery job description, there is a lack of an environment in which midwives can work according to the job description, like performing a pelvic exam to diagnose labor progress.

Other issues identified by the midwives in clinical sites were that other health professionals do not understand the value of the midwifery profession, the need to clarify the division of roles between doctors and midwives in obstetric care, and low salaries for midwives.

Information from the question-and-answer session

Various issues, like low social awareness of midwives and low salaries, were discussed in the question-and-answer session. Moreover, two specialists from the Ministry of Health shared that specialized training for midwives just started to develop in 2021, and that measures regarding salaries are now being considered.

Information from questionnaire

The online symposium was accessed one hundred and fifteen, and 44 (38.2%) responded to the questionnaire on the Google Forms (Table 2).

Table 2. Characteristics and answer of survey (n = 44).

Characteristics and answers	n (%)
Position
Midwife	35 (79.5)
Midwife and Associate Doctor	4 (9.1)
Director of Nursing Department	2 (4.5)
Head Midwife	2 (4.5)
Deputy Director of Nursing Department	1 (2.3)
Years of clinical experience
0–4 years	9 (20.5)
5–9 years	7 (15.9)
10–14 years	11 (25.0)
15–19years	1 (2.3)
20–24 years	4 (9.1)
25–29 years	7 (15.9)
30 and more	5 (11.4)
Experience in CPD
Advanced training of one month	7 (15.9%)
Neonatal Cardio-Pulmonary Resuscitation	5 (11.4%)
Training of Trainer	2 (4.5%)
Intensive care	1 (2.3%)
Procedure of IUD	1 (2.3%)
Others (written as credit training and is not specified)	13 (29.5%)
None	15 (34.1%)
Satisfaction of online symposium
Very satisfied	39 (88.6)
Satisfied	3 (6.8)
Neither	1 (2.3)
Unsatisfied	1 (2.3)
Very unsatisfied	0 (0)

Participant characteristics

It was found that of the total participants, there were 35 midwives (79.5%), four "midwife and associate doctor" (9.1%), two head midwives (4.5%), two directors of the nursing department (4.5%), and a deputy director of the nursing department (2.3%). The years of clinical experience of the participants ranged from one year to 34 years.

Experience in CPD

Of the total participants, seven participants (15.9%) had advanced training, five (11.4%) had training in neonatal cardiopulmonary resuscitation, and 15 (34.1%) never had a chance to attend any training. The participants added comments like, "There is no information for CPD for midwives", and "Midwives have too many tasks. Because of the shortage of midwives, we cannot have time to have training".

Satisfaction of online symposium

Regarding satisfaction with the online symposium, 42 participants (95.4%) reacted to this event as "very satisfied" and "satisfied". Most of them commented that the themes were facing serious issues for midwives, such as CPD or job descriptions. One respondent (2.3%) who indicated "neither" satisfaction commented that she was unable to attend the entire online symposium. One unsatisfied respondent (2.3%) commented on dissatisfaction with the work environment, including communication problems in the workplace, lack of courtesy, and the need for inter-organizational coordination to strengthen CPD.

Education for newly graduated midwives

The participants added comments like "There is no manual or educational program for newly graduated midwives", and "Newly graduated midwives need clinical trainers". The participants opined that it is necessary to educate newly graduated midwives at clinical sites.

Midwifery service and job description

To the question, "to what extent are midwives' job descriptions adhered to in clinical practice at each hospital?", 27 participants (61.4%) answered that they had observed severe discrepancies, and seven (15.9%) faced a moderate amount of discrepancies. They further commented, "We can deliver midwifery service, but doctors do not allow us to do so", "Only midwives who work in rural prefectures, can follow the job description".

Needs of themes of next online symposiums or study sessions

Eleven participants (25%) requested training to hone the professional skills of midwives, five (11.4%) requested specialized training, three (6.8%) needed training in obstetric emergency and neonatal resuscitation, and two (4.5%) needed ultrasound training.

Free comment

These were other free comments, "The reality is difficult to become midwives of international standard level", "There are many people who do not know the profession of midwives", "Low status and low salary", "We do not want to be like an assistant for doctors. We could deliver midwifery services for women and infants", "We do not have enough midwives. One midwife is doing the work of two or three midwives".

Social background and expectations for midwife

There is no formal documentation of the social background and factors behind the suspension of midwifery education and practice in Mongolia. As for how the situation of midwives has changed and improved, there were needs for midwives from clinical sites, and midwifery education has been resumed in 2003 and work has started in 2017. In addition, expectations for midwives increased due to their active role in the coronavirus disease 2019 (COVID-19) pandemic. Therefore, the Minister of Health decree mandated the development of specialized training course for midwives in 2021 (8) and started to strengthen post-graduate education for midwives.

Analysis of current situation by analytical framework

The analytical framework of a house model was used to assess the current situation of the midwives. The National Center for Global Health and Medicine, Japan, has developed the house model as a comprehensive and visible framework for human resource systems (9,10). The house model can be comprehensively analyzed using eleven components, like available human resources, legal framework, finance, protection, deployment, and retention, to build a health system. It was developed by comparing the health system with the house. Just as one cannot build a stable house if any part of the house is weak - the pillars, roof, or soil - health systems need a holistic view to be more resilient.

The house model was used for the analysis of information from the online symposium, their presentations, their discussions, and the result of the questionnaire. Challenges were found in the retention and deployment parts. Retention includes continuous education and deployment includes recruitment.

Retention includes continuous education

Through the symposium, it was clear that CPD was not systematically implemented, and that there were no specific programs or training the trainers required to train newly graduated midwives. One-third of the midwives had never had a chance to attend relevant training. It is thus, necessary to complete the minimum number of credits required to renew a midwifery license every five years. There are no educational programs available for newly graduated midwives. In Mongolia, a newly graduated midwife normally follows an experienced midwife as a pair to learn how to care for patients and infants. There is an obvious dearth of strategic programs for CPD of midwives (11). For better midwifery care, strengthening the CPD system is crucial for stabilizing the roof and addressing health needs in the house model.

Deployment includes the recruitment

Deployment of proper training in midwifery is also a challenge in Mongolia. Thus, the shortage of midwives is a serious problem. Some participants said that they were working in understaffed departments, with one midwife doing the work of two or three. Unforeseen emergencies may occur during the childbirth, and personnel allocation is important for ensuring the safety and quality of medical care.

Recommendation for strengthening CPD of midwife

The CPD is explained in detail in a variety of scopes around the world; for example, CPD is related to professional licensing systems for renewing licenses (12), it is linked to regulations (13), and lifelong professional motivation and improvement of knowledge and skills (12,14). Furthermore, to strengthen CPD as a system, it is recommended that related organizations at all levels work together to secure sustainable costs, establish a system to confirm regulations and curricula to ensure quality, and support CPD attendance in the workplace (15).

In Mongolia, licensing systems for midwives and license renewal systems have been developed since 1999. The CPD plays a major role in providing the safe and comfortable midwifery services to meet the needs of women and society. To implement training for improving and updating the capabilities of midwives, it is necessary to prepare a workplace environment in which they can attend training and gain a budget. Moreover, creating a system that ensures training quality is crucial.

Thus, this study revealed midwives at clinical sites have little experience with CPD. Better midwifery care could lead to a better life for pregnant women, fetuses, newborns, women, children, and all family members. To strengthen CPD including developing an educational program for newly graduated midwives, and to establish the environment for midwives such as understanding of their professionals, status, welfare, etc., are needed.

This study has several limitations. This is not representative of midwife population as a whole in Mongolia, as midwives interested in the topic may have attended and responded to the online symposiums. In future, it is, thus, necessary to conduct a complete survey to grasp the current situation of midwives to establish a relevant CPD system and implementing relevant policies.