|Year : 2020 | Volume
| Issue : 2 | Page : 61-68
Training among in-service doctors in Manipur and their translation into practice
Mutum Vivekson, Brogen Singh Akoijam
Department of Community Medicine, RIMS, Imphal, Manipur, India
|Date of Submission||16-Oct-2017|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||25-Jan-2021|
Department of Community Medicine, RIMS, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Introduction: Manipur, the easternmost state of India, suffer from lack of specialist doctors at peripheral public health service points. Among MBBS doctors, many lack knowledge on maternal and child health, resulting in delay identifying high-risk cases, which contribute to increased morbidity and mortality. Under RMNCH + A strategy as a continuum to the previous program, to overcome the shortage of specialist doctors, multi-skilling of doctors in the public health system is being undertaken. Training need assessment, proper conduct of training, mentoring should be ensured so that these service providers gain confidence and are thus able to practice newly acquired skills.
Objectives: The aim is to determine the type and pattern of training among Medical Officers and to assess the level of translation of Basic Emergency Obstetric Care (BEmOC) training (knowledge and skills) into practice.
Materials and Methods: A cross-sectional study was done from June 2015 to October 2017. A questionnaire-guided interview was done among BEmOC trained in-service doctors. Data collected were analyzed using SPSS-version-21. Descriptive statistics such as percentage, mean, median, and standard deviation were used. Chi-square test and Fisher's exact test were used for testing the significance between the proportions. ANOVA and independent t-test were used for comparing means. A value of P < 0.05 was taken as significant.
Results: Out of 49 respondents, 82% responded and 61% were male. The mean knowledge score was 21 ± 2.8 with a range of 16–27 and the mean age was 33.2 ± 4.1. Gender, year of training, and performed manual removal of placenta were seen significantly associated with knowledge score. About 81.6% of the doctors conducted normal delivery in the past 6 months. Around 45% of the doctors reported performing manual vacuum aspiration (MVA) procedures in the past 6 months and were confident about it.
Conclusion: The mean knowledge score about BEmOC was more than two-third of the total score. After training, the knowledge score seems to decrease as time passes. Males had better knowledge than females. There was no association between age, place of posting, and years of experience with knowledge. Almost half of the participants performed the induction of labor and MVA procedure in the last 6 months.
Keywords: Basic Emergency Obstetric Care doctors, knowledge, practice
|How to cite this article:|
Vivekson M, Akoijam BS. Training among in-service doctors in Manipur and their translation into practice. J Med Soc 2020;34:61-8
| Introduction|| |
The urban population in India accounts for less than a third of its total population. Allopathic physicians are highly concentrated in urban areas compared to rural areas (13.3 and 3.3/10000 populations, respectively). Nurses and midwives are also similarly concentrated in urban areas (15.9 and 4.1/10000 populations). Out of the 660856 doctors registered in India, only 12% are in the public sector. According to the 2011 Census, 377 million Indians live in urban areas. The number of people not receiving treatment because of “financial problems” and “lack of medical facility” is higher in rural areas than in urban areas. Although rural areas house 68% of the Indian population, only 20% of the total hospital beds are located in rural area. An imbalance in the urban-rural distribution of specialists and perceived poor quality health care services in the rural areas result in almost two-third of the patients in urban hospitals coming from rural areas. As in all over India, the state of Manipur also suffers from a huge lack of specialist doctors at the periphery public service (rural). Many a time, due to lack of knowledge, there has been delay in identifying a high-risk case which contributes to morbidity and mortality. Early identification of high-risk cases is crucial for early referral to places where workforce and facilities are adequate for better management. Therefore to identify and manage such cases, training of the in-service doctors posted at the periphery is essential. The training will also provide a chance to update their knowledge.
Under RMNCH+A strategy as a continuum to previous program, to overcome the shortage of specialist doctors, multi-skilling of doctors in the public health system is being undertaken. This includes an eighteen week-long training program of MBBS qualified doctors in Life-Saving Anaesthetic Skills; a sixteen-week-long training program in Obstetric Management Skills including Caesarean section; a 10-day-long training for Medical Officers in Basic Emergency Obstetric Care (BEmOC) and a 3-week-long Skilled Birth Attendance training for ANMs/LHVs/Staff Nurses. Currently, the focus is on the placement of trained providers for postpartum IUCD (PPIUCD) insertion at district and sub-district hospital level only, considering the high institutional delivery load at these facilities. However, it would be essential to have PPIUCD trained providers at all those health facilities up to the sub centers, which are currently providing delivery services. Training of Medical Officers in “Minilap” for provision of Postpartum Sterilization in high caseload facilities is another such step in this direction. Other training programs provided are Navjaat Shishu Suraksha Karyakaram, Medical Termination of Pregnancy/Manual Vacuum Aspiration (MTP/MVA), Reproductive Tract Infection/Sexually Transmitted Infection, Skilled Birth Attendant, Infection Management and Environment Plan (IMEP), Rastriya Bal Suraksha Karyakaram, Laparoscopic Sterilization, Routine Immunization, Infant and Young Child Feeding, etc.
As every training program provided to the health-care provider is for proper mentoring and update of knowledge and skill, a careful observation of their retention of these knowledge and skill and their translation into practice is needed. Mentoring support and posttraining follow up should further be ensured so that these service providers gain confidence and are thus able to practice newly acquired skills. Obstetric care from a train provider/train professional is recognized as critical for the reduction of maternal and neonatal mortality. In-service training for medical officers is essential for imparting management skills and leadership qualities. The purpose of this study is to document the baseline functioning and practice of the trained in-service doctors in the health centers where they are posted after receiving training. This study will focus on the medical officers in Manipur state service who received training in BEmOC. No such study has been conducted in Manipur. This study information may be helpful for the health planners and policymakers of this state and our country for an effective and better planning in providing a more effective and better quality training program in the near future.
| Materials and Methods|| |
A cross-sectional study was conducted from June 2015 to October 2017 in Manipur. There were nine districts in Manipur with a small population of 28.5 lakhs (census 2011) at the time of data collection. There were 85 primary health centers, 17 community health centers in Manipur, 7 district hospitals, and 2 medical colleges (2012). For interview, there were a total of 49 eligible medical officers trained in BEmOC during 2011–2015 who were posted in Imphal West, Imphal East, Bishnupur, and Chandel districts of Manipur. Those who refused to participate and those who were not available even after three consecutive visits were excluded from the study. Data were collected using a questionnaire guided in-depth interview consisting of three sections. Section A: Socio-demographic characteristics, Section B: The knowledge assessment questionnaire which was taken from the BEmONC trainer's notebook. In this knowledge-based questions for BEmOC trained medical officers, there were 30 questions each carrying one mark. Therefore, maximum and minimum obtainable scores were 30 and 0, respectively, and Section C: In the practice-based questions, there were 35 questions to record skills performed in the past 6 months. These lists of questions were selected from the World Health Organization. For each question, participants were asked whether they have performed the said skill and how many times they have done and whether they were confident in performing the said skill.
- For the first objective, secondary data were collected from records provided by State Training Nodal officer, NHM office, Manipur
- For the second objective, primary data were collected using the in-depth interview.
For the first objective, records from state training nodal officer, NHM office, Manipur were used to get details at the time of posting, training of medical officers in various fields, and their place of posting. For the second objective an in-depth interview was conducted in a quiet and private place. Informed consents were taken from all the participants. The participants were reassured of their anonymity at the time of interview and the importance of an honest answer was stressed.
Interview was done using a structured questionnaire. Rapport building with informal talk and introduction was carried out. Names were not taken and if the medical officers could not be met on the 1st day of visit, a minimum of two visits were made. Collected data were checked for completeness and consistency before leaving the health center and necessary rectification was made.
Sociodemographic characteristics such as age, sex, religion, year of joining the state service, years of experience at work, current place of posting, year of training BEmOC, and place of posting when training was initiated were the independent variables.
Knowledge and practice of BEmOC among BEmOC trained medical officers were the outcome variables.
For analysis purpose participants will be categorized based on their obtained mean score as follows:
- Score > mean + 1 standard deviation (SD), as having good knowledge
- Score between mean and mean + 1SD, as having fair knowledge and
- Score < mean, as having poor knowledge.
The collected data were entered and analyzed in SPSS (IBM) version 21 (IBM Corp., Armonk, NY, USA). Summarization of data was carried out by using descriptive statistics such as mean, median, SD and percentages. Chi-square test, Fisher's exact test, ANOVA, and Independent t-test were employed to test the association between knowledge with variables of interest such as age, sex, year of joining the state service, years of experience at work, current place of posting, and year of training BEmOC. P < 0.05 was taken as statistically significant.
Ethical approval was obtained from the Research Ethics Board, RIMS, Imphal before the beginning of the study. Written permission from the Director of Health Services, Manipur and Deputy Director of Training, Manipur was obtained.Written informed consent were taken from the participants and their participation was completely voluntary and right to refuse to participate in study was respected. A unique code number was given and no names were taken to maintain confidentiality. All the information collected for the study were utilized only for the purpose and not disclosed to anyone outside the research team.
| Results|| |
In total, 732 medical officers were trained during 2011–2015 in various short course training conducted by the state health department. As shown in [Table 1], maximum number of trainings was given for IMEP followed by postpartum intra uterine contraceptive device insertion and minimum for emergency obstetric care. Others were BEmOC, skill birth attendant, medical termination of pregnancy, and sexually transmitted disease. Maximum numbers of doctors given training were from Thoubal District and minimum from Churachandpur District. Out of this, 104 medical officers were trained in BEmOC. Among the medical officers trained in BEmOC, 49 of them were from the study districts. All 49 of them were approached for in-depth interview regarding knowledge of BEmOC and practice of BEmOC in the past 6 months. However two of them, when interviewed, denied of ever joining the training. And again out of 47, 9 of them were out of station. Therefore, only 38 of them were interviewed, giving a response rate of 82%. Males consisted of 61% of the interviewed participants. Maximum interviewees (29%) were from Bishnupur district and most of them were given training in the year 2011. The mean age of the participants was 33.2 ± 4.1.
|Table 1: Distribution of participants with Districts of Manipur and types of training (n=732)|
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The overall mean knowledge score was (21 ± 2.8.) 70% of the total score, but only 18.4% of them gave correct answer in MVA utilization and 42.1% gave the correct answer regarding vacuum extraction. A statement which says all instruments should be decontaminated with 0.5% chlorine for 30 min; only 34.2% gave correct answer. Other statements about delayed postpartum bleeding and the management of mild preeclampsia; in both the statements only 36.8% gave correct answer. Regarding breast pain and tenderness 3–5 days after childbirth only 42.1% of gave correct answer. Maximum (37%) participants scored poor which were followed by good (37%) and minimum (29%) by fair. As shown in [Table 2], there was no significant association between age of the participants and months of experience with knowledge score even though there was a slight increase among less experience group. Those who have served 5 years or less were found to have higher mean score than those who have served >5 years, but it was not significant. Males had significantly higher knowledge score than females [Table 3]. Those who had been trained in 2015 have a significant higher mean score than those trained in 2011. We can also see those who were trained recently in 2014 and 2015 had significantly higher mean score than those trained in 2011 and 2013 as shown in [Table 4]. There was no significant association between district of posting and knowledge score. Numbers of males were found to be more than females in managing a normal delivery in the past six months but it was not significant [Table 5]. Those doctors who did manual removal of placenta in the last six months were found to have significantly higher knowledge score than those who didn't [Table 6].
|Table 2: Association between age, sex, experience, and length of service with knowledge score among Basic Emergency Obstetric Care trained participants (n=38)|
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|Table 4: Association between year of training and knowledge among Basic Emergency Obstetric Care trained participants (n=38)|
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|Table 5: Association between sex and practice of delivery in the past 6 months (n=38)|
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|Table 6: Association between knowledge score by practice of manual removal of placenta (n=38)|
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When asked about the obstetric skills performed in the last 6 months from the date of interview 81.6% of the doctors have reported conducting normal vaginal delivery at their health center. One of the doctors in a CHC reported a maximum of 60 deliveries being done by him during the period [Table 7]. On an average, each doctor had conducted 8 deliveries in the past 6 months. Around 45% of the doctors performed induction of labor and 18% of the doctors performed ventous delivery in the past 6 months. None of them reported performing forceps delivery. Around 45% of the doctors reported performing MVA procedure in the past 6 months and were confident about it. Pre eclampsia cases were managed by 21% of the doctors and 23% of the doctors did a referral for eclampsia after initial management. Around 31% of the doctors perform IUCD insertion after delivery or abortion. Manual removal of placenta was reported being done by 37% of the doctors and 16% of the doctors repaired third-degree tear with episiotomy wound in the past 6 months and they were confident about it. For newborn resuscitation, 66% of the doctors reported performing in the past 6 months. Partograph was used successfully by only 37% of the doctors [Table 7].
|Table 7: Obstetric skills performed in the last 6 months at their health centers|
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Some of the procedures such as management of prolapsed umbilical cord, management of malaria during delivery, abdominal aortic compression, and manuevers for shoulder dystocia were not performed by any of the participants in the past 6 months.
| Discussion|| |
Most of the trainings undergone by medical officers were concerned about maternal and child health. This may be aligned to the objectives laid by the 11th 5 year plan National Rural Health Mission (NRHM) in reducing maternal mortality ratio and infant mortality rate (IMR). This can also be one of the major factors in having one of the least IMR of 11/1000 live birth (SRS-2016) among the Indian states. Out of 732 doctors who had in service training during 2011–2015, 38 medical officers who went for BEmOC training were selected for an in-depth interview from four districts regarding knowledge about BEmOC and their translation into practice.
Thoubal district had the maximum number of doctors trained in various short-course training programs during the year 2011–2015 followed by other valley districts. This may be due to the population size in Thoubal district (422168), which was the fourth largest after Senapati district (479148), having more demand for MCH care. In other high population districts such as Imphal east (4561134) and Imphal west (517992), most of them seek the two tertiary hospitals in both districts. Moreover, Thoubal district was a politically favored district during these periods. On the other hand, the hill districts had lower number of trained doctors with Churachandpur district having the lowest. This may be due to the fact that the number of doctors posted in the hill districts is comparatively lower than the valley districts more over the posting preference away from disturbed area by the doctors may be also a factor, which may explain for lower number of in service trained doctors in Senapati district.
The mean knowledge score obtained was 70% of the total score and 47% of the doctors scored more than the mean score. All of the participants scored >50% of the total score which reflects the standard of their knowledge level which is much better than a study in Pakistan where only 6% of the medical officers scored >70% and only 30 per cent of MO managed to score above the minimum competency level of 50%. However, similar findings were seen in a study in Somalia where 64.2% scored more than the mean score. In the present study, the knowledge score seems to decrease with time from the year of training, i.e., the score was found to be better among those who were trained BEmOC recently when compared with those trained earlier (P = 0.004), similarly another study showed the knowledge gained from ALSO training was retained by 87% for up to 9 months but practical skills deteriorated. This may be due to the fact that with time and their lack of regular exposure to this field, they tend to forget about these. Therefore, the study finding has shown the importance of regular and repeated training in reinforcing the knowledge. Males were found to have significantly higher mean score than female participants (P = 0.036). It is possible that men have better insight through personal experience, as they were found to perform certain procedures more than female medical officers.
Preeclampsia is a multi-system disorder of unknown etiology seen after the 20th week of pregnancy in a previously normotensive and non proteinuric patient, characterized by hypertension of 140/90 mm Hg or more, proteinuria, and edema. A study in Malawi showed only 39% of the participants giving the correct answer to the treatment of eclampsia with MgSO4 when compared with the current study, where 65.8% correctly rejected sedatives and tranquilizer as the treatment of pre-eclampsia. This may be due to the fact that in the current study only 21% reported of managing a case of pre-eclampsia in the past 6 months. Others may not have encountered such case frequently which can affect their knowledge. Similar findings were seen in a study in Jamaica, where the mean score was 69.2% regarding pregnancy induced hypertension. Similarly, a cross-sectional study by Bayley et al. showed that only 56% identified correct management of eclampsia and preeclampsia.
Partograph is a simple, inexpensive managerial tool for the prevention of prolonged labor. It monitors the fetal condition, maternal condition, progress of labor, and the intervention. In this study, 68.4% gave the correct answer in identifying unsatisfactory progress of labor in partograph, but 71.1% gave the wrong answer in deciding to go ahead with caesarean if active phase of labor is prolonged. This may be because of less exposure and utilization, i.e., only 36% of the doctors used partograph at their center to check progress of labor. Similarly, it was seen in a study conducted by Zelellw et al. in northwest Ethiopia, where more than half of the obstetric caregivers had good knowledge about partograph.
Active management of third stage of labor (AMTSL) is a standard practice for all deliveries and a widely accepted maneuver of reducing the rate of postpartum hemorrhage. AMTSL involves the administration of oxytocin and controlled cord traction along with uterine massage. In the present study, 78.9% gave the correct answer regarding AMTSL but only 52.6% correctly dismissed ergometrine as the drug of choice for AMTSL. This may be due to lack of exposure, where around 20% of the participants did not conduct a normal delivery at their centers in the past 6 months. However, it was better than a study conducted in Jamaica where only 40.2% gave correct answer regarding AMTSL. Similarly, in Hawassa city of Ethiopia, a study has demonstrated 33.3% of obstetric care providers were knowledgeable about AMTSL. Another study in Rwanda showed only 23.3% of the participants had adequate and 9% had excellent knowledge regarding AMTSL. Poor knowledge was demonstrated by a study in Pakistan where most of the participants answered ergometrine rather than oxytocin to initiate AMTSL.
MVA is an alternative to the standard electrical vacuum curettage and can be performed under local anesthesia. In this study, the knowledge score was poor in understanding MVA utilization, i.e., only 18.4% gave the correct answer. Regarding vacuum assisted delivery 42.1% gave the correct answer for timely intervention of ventous to assist a delivery. Only 34.2% gave correct answer regarding decontamination of instruments. In case of delayed postpartum bleeding and mild pre-eclampsia, only 36.8% gave correct answer. Regarding breast pain and tenderness after childbirth only 42.1% of them knew it. Most of them failed to give correct answers which may be due to their lack of exposure to that particular case or less number of cases.
In the present study, knowledge of newborn care was good, with a mean of 94% answered correctly where as in a study conducted in Pakistan, their mean percentage score among the medical officer was 52.7% about newborn care and in a study in Jamaica, their mean score in immediate newborn care was 62.4% and in Rwanda the mean percentage knowledge score of 43.8% about newborn care. Another study in Malawi showed the knowledge of neonatal care low with an average of only 58% correct answer overall. Therefore, knowledge for newborn care in the present study showed a much better score than other studies. This can be in line with the states IMR report of being one of the least in India.
Self-reporting of practices by providers is not an ideal approach in understanding what providers actually do when seeing patients. One may expect there to be an overstatement of what care is truly being provided. Self-reporting was the approach adopted to gather at least preliminary information of the type of care being provided. When asked about the obstetric skills performed in the past 6 months from the date of interview 81.6% of the participants reported conducting normal vaginal delivery at their health center. On an average, each doctor has conducted 8 (2–60) deliveries in the past 6 months. Institutional delivery at public hospital accounts for 45.7% in Manipur (National Family Health Survey-4) and birth rate is 14.9/1000 population. Therefore, conducting 8 deliveries at an average by each participant during the past 6 months at their respective health centers is quite acceptable. Around 45% and 18% of the doctors performed induction of labor and ventous delivery in their health center, respectively. Around 45% of the doctors have reported performing MVA procedure and were confident about it. Pre-eclampsia cases were managed by only 21% of the doctors as compared to a study in River state, Nigeria which showed in urban 48.5% respondents and in rural 29.4% of respondents did management of pregnancy induced hypertension and 23% of the doctors in the current study did a referral for eclampsia after initial management. This reduced number of practice may be due to lack of cases or may be due to the fact that only 23.5% of the health center had magnesium sulfate. Around 31% of the doctors perform IUCD insertion after delivery or abortion. Manual removal of placenta was reported being done by 37% of the doctors and 16% of the doctors repaired third-degree tear with episiotomy wound in the past 6 months and they were confident about it. For newborn resuscitation, 66% of the doctors reported performing in the past 6 months. Routine use of partograph for monitoring of active phase of labor was reported low by only 37% of the doctors as compared to a study conducted in River state, Nigeria which showed in urban, 74.8% compared to rural, 56.6% respondents reported routine use of partograph for active management of labor. This low level may be due to the unavailability of partograph at their health centers or it was not made mandatory by the center incharge. In spite of the reporting, the level of use is still very low because every labor is supposed to be monitored with a partograph to aid detection and prompt decision making in the event of prolonged obstructed labor. Obstructed labor has been implicated in 8% of all direct obstetric deaths. It therefore implies that a considerable percentage of this life threatening complication is not detected early, thereby increasing the level of preventable deaths in these settings. Some of the procedures such as forceps delivery, management of prolapsed umbilical cord, management of malaria during delivery, abdominal aortic compression, and manuevers for shoulder dystocia were not performed by any of the participants in the last 6 months. This may be because these cases are rare and didnot come at their centers during the said period.
| Conclusion|| |
As a training policy, in-service doctors were given training focused on maternal and child health by the state during the year 2011–2015. They were widely spread all over the health centers with more concentration toward the valley region which corresponds to the population size. The mean knowledge score about BEmOC was more than two-third of the total score. After training, the knowledge score seems to decrease as time passes. Males had better knowledge than females. There was no association between age, place of posting and years of experience with knowledge. Around 4/5th of the medical officers reported of performing a normal delivery in the past 6 months with confidence. Almost half of the participants performed induction of labor and MVA procedure. Moreover, only 1/5th of the participants performed ventous delivery but none of them did forceps delivery. Around 1/3rd of the participants performed manual removal of placenta and used partograph to monitor labor. Almost 1/3rd of the participants did IUCD insertion after delivery or abortion.
Regular training of the medical officers will ensure knowledge update and quality management of the obstetric cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]