Improving the Ghanaian Safe Motherhood Programme

Executive Summary

In 1995, the Ghana Health Services (GHS) of the Ministry of Health (MOH) launched the National Safe Motherhood (SM) Programme, the focus of which is to reduce the high levels of maternal mortality and morbidity through improving the quality and coverage of maternal health services, and to increase awareness about maternal health issues in communities.

Since 1998, PRIME II, a global project funded by USAID and managed by IntraHealth International for the training and support of primary reproductive health providers, has provided assistance to strengthen the training, supervision and referral capacity of the MOH’s Regional Resource Teams (RRT). Training in safe motherhood knowledge and skills was initially provided through a combination of theoretical and practical work during a 3-week residential course.

An assessment of this training approach raised several concerns, notably, that trainees were away from their facilities for a substantial amount of time, thus restricting access to services, and that many trainees were not able to complete their practical training due to low client caseloads and the high number of trainees at the training sites at one time.

Scaling up of the SM programme to the three northern regions began in 2000 with a Performance Needs Assessment (PNA), which measured the current performance levels of the RRTs against a desired status determined by national standards, identified causes of the gaps found, and proposed interventions for eliminating or reducing these gaps.

Consequently, the GHS and PRIME II reviewed and revised the existing interventions to include a competency-based Life Saving Skills (LSS) training to minimise existing implementation gaps and to increase the impact of such interventions on provider and clinic performance. In addition, PRIME II had successfully tested an innovative approach to in-service training, a modular Self-Paced Learning (SPL) approach, combined with an extensive learner support system, for trainee-midwives of the private sector Ghana Registered Midwives Association (GRMA), and this experience suggested that this SPL approach may be relevant when scaling up the SM programme.

With the level of investment needed for expanding the SM programme, it was felt important to assess whether the SPL training approach would be at least or more cost-effective than the existing 3-week residential approach. Support was requested from the Population Council’s USAID-funded Frontiers in Reproductive Health programme to assist PRIME II and the GHS to undertake an operations research study to prospectively evaluate and compare the cost-effectiveness of these two training approaches and other performance improvement interventions.

The study measured and compared changes in provider knowledge and skills and the costs of implementing the three-week residential and the SPL approaches using a non-randomised pre-intervention post-intervention comparison group design. Data were collected through:

• inventories of equipment and supplies at each service delivery site;
• compilation of service statistics for the previous 12 months;
• interviews and practical assessments of all trained service providers to gauge their knowledge of safe motherhood services and procedures;
• observations of client-provider interactions during antenatal visits and exit interviews with the clients;
• compilation of financial expenditures for all activities during implementation of each approach and estimation of the opportunity costs for staff time.

After the training, only providers in the SPL group exhibited improvements in their group mean summary scores for indicators of knowledge, with statistically significant improvements of 24 and 46 percent. In relation to indicators of provider performance, both approaches registered improvements across all three areas evaluated (i.e., routine ANC, managing obstetric and other complications, and PAC), but the only increase that was statistically significant was for skills in managing obstetric and other complications among the SPL group. Both groups performed well in labour and delivery skills; however, there was a statistically significant difference in the average score across the four skills of 70 percent in the intervention group compared to 74 percent in the comparison group.

The SPL approach costs more per trainer than the traditional residential approach, both in financial costs alone and when opportunity costs are added. A cost-effectiveness analysis showed that for improving provider knowledge, the SPL approach was clearly more cost-effective because the traditional residential approach was not effective. When financial costs only were considered, there was no difference between the two approaches for improving routine ANC or PAC performance, but for EOC performance the SPL approach was more cost-effective.

When opportunity costs were included, however, the residential approach was more cost-effective than the SPL approach across all three performance indicators.
A dissemination meeting held with stakeholders agreed that the SPL and residential approaches are not mutually exclusive – both approaches have their strengths and weaknesses. Training for safe motherhood should be developed based on the strengths of the two approaches.