Effect of midwife competence training in primary healthcare facilities on obstetric risk early detection

Abstract

Early detection of obstetric risk is the main competence of midwives to anticipate the mother’s inability to adapt during pregnancy. The early detection competence of midwives determines the success of obstetric risk management, preventing pain and even death of mothers and babies. This study aimed to analyze the effect of obstetric risk early detection training on improving the competence of midwives in basic health care facilities. The study employed a quasi-experimental pre-posttest design with a control group. The samples were selected based on inclusion criteria, encompassing independent practice midwives and public health center midwives. The study comprised 27 midwives in the treatment group and 27 in the control group. The determination of and control groups was conducted through simple random sampling. Data analysis involved the use of Mann-Whitney and T-tests. The results indicated a significant difference in the increase in midwife competence within the treatment group post-training (p-value <0.001), with a notable improvement of 34.5%, compared to a 14.53% rise in midwife competence within the control group after reading the training module. Although a slight decrease in competence was observed after 2-4 weeks of training, the posttest values remained considerably higher than the pretest values. These findings underscore the impact of training on midwife competence, emphasizing the continual need for midwives to enhance their skills to elevate the health outcomes for the mothers and children under their care.

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Healthcare in Low-resource Settings
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Zannah AN, Yuningsih Y, Sari AI, Septiyono EA. Effect of midwife competence training in primary healthcare facilities on obstetric
risk early detection. Healthc Low-resour S doi: 10.4081/hls.2024.11767
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Effect of midwife competence training in primary healthcare facilities on obstetric risk
early detection
Ai Nur Zannah,1 Yuningsih Yuningsih,1 Asri Iman Sari,1 Eka Afdi Septiyono2
1Department of Midwifery, Faculty of Health Science, Universitas Dr. Soebandi, Jember;
2Department of Maternity Nursing, Faculty of Nursing, Universitas Jember, Indonesia
Correspondence: Ai Nur Zannah, Department of Midwifery, Faculty of Health Science,
Universitas dr. Soebandi, Jember, Indonesia.
E-mail: ainz@uds.ac.id
Key words: competence, early detection, midwife, training.
Contributions: ANZ, conceptualization, data curation, formal analysis, methodology,
validation, visualization, writing – original draft, review and editing; YY, conceptualization,
investigation, methodology, validation, and writing – original draft, review and editing; AIS,
conceptualization, methodology, formal analysis, validation, and writing – original draft,
review and editing. All the authors have read and approved the final version of the
manuscript and agreed to be held accountable for all aspects of the work.
Conflict of interest: the authors declare no potential conflict of interest.
Ethics approval and consent to participate: the research has received ethical approval from
the Health Research Ethics Commission, Faculty of Health Science, Universitas dr. Soebandi,
based on ethical certificate No.244/KEPK/UDS/VI/2022. During the research, the researcher
pays attention to the ethical principles of information to consent, respect for human rights,
beneficence and non-maleficence.
Patient consent for publication: written informed consent was obtained for anonymized
patient information to be published in this article.
Availability of data and materials: all data generated or analyzed during this study are
included in this published article.

Funding: none.
Acknowledgements: the authors would like to thank Universitas Dr. Soebandi for their
valuable insights and contributions to this study.
Abstract
Early detection of obstetric risk is the main competence of midwives to anticipate the
mother’s inability to adapt during pregnancy. The early detection competence of midwives
determines the success of obstetric risk management, preventing pain and even death of
mothers and babies. This study aimed to analyze the effect of obstetric risk early detection
training on improving the competence of midwives in basic health care facilities. The study
employed a quasi-experimental pre-posttest design with a control group. The samples were
selected based on inclusion criteria, encompassing independent practice midwives and public
health center midwives. The study comprised 27 midwives in the treatment group and 27 in
the control group. The determination of and control groups was conducted through simple
random sampling. Data analysis involved the use of Mann-Whitney and T-tests. The results
indicated a significant difference in the increase in midwife competence within the treatment
group post-training (p-value <0.001), with a notable improvement of 34.5%, compared to a
14.53% rise in midwife competence within the control group after reading the training
module. Although a slight decrease in competence was observed after 2-4 weeks of training,
the posttest values remained considerably higher than the pretest values. These findings
underscore the impact of training on midwife competence, emphasizing the continual need
for midwives to enhance their skills to elevate the health outcomes for the mothers and
children under their care.
Introduction
Obstetric risk is psychological or physical abnormalities and pregnancy difficulties that may
worsen maternal and neonatal outcomes.1 The World Health Organization (WHO) defines
risk factors as traits or circumstances of an individual associated with a higher probability of

developing or going through a serious condition likely to result in mortality.2 Midwives, one
of the key players in fundamental maternal health services, especially obstetric care services,
must have promotional and preventive competencies that also involve family members, the
community, and advocacy to increase appropriate referrals and prevent delays that lead to
Maternal Mortality Rate (MMR).3 This is in addition to foster visits by trained Community
Health Workers (CHWs) to the mother’s home.4,5
Every year, an additional 10,000 pregnant women at high risk for complications are born, and
the primary complications (postpartum hemorrhage, infections, pre-eclampsia, and
eclampsia) contribute to approximately 75% of all maternal deaths.6 Despite addressing a
broader spectrum of issues in Indonesia, the rates of maternal morbidity and mortality have
not seen a proportional decrease. The Maternal Mortality Rate in Indonesia has not yet
reached the target of 183 per 100,000 live birth by 2024; currently, it stands at 305 per
100,000 live births.7-10 This situation is purportedly due to limitations in the knowledge,
attitudes, and skills of health professionals, particularly midwives, in managing early dangers
for pregnant women at risk of obstetrics, including early detection.11-13
Early detection is a proactive process that utilizes screening instruments such as the Poedji
Rochjati Score Card (KSPR) and the Pregnancy Assessment Monitoring System (PRAMS).
Currently, the Maternal and Child Health (MCH) handbook is also employed to identify risk
factors that may not have manifested symptoms or complaints. This process involves the
active participation of pregnant women, their husbands, families, as well as trained health and
non-health workers, including traffickers, cadres, and cadets. The early detection operations
are conducted meticulously, methodically, and repeatedly until reaching the delivery
stage.14,15
There is a need for efforts to enhance the competence of midwives, and one effective avenue
is through training. Training represents a systematic effort to enhance knowledge, skills, and
work attitudes through a structured learning process, with evaluations measuring progress
towards the expected changes in performance behavior.16-18 This study aimed to analyze the
effect of early detection training on the risk of obstetrics on improving the competence
(knowledge and skills in early obstetric risk detection) of midwives in primary health care
facilities.
Materials and Methods
This study used a quasi-experimental design pretest–posttest with a control group. The
assessment was conducted thrice, utilizing the observational method and questionnaire

completion throughout 2022. The pretest was administered at the commencement of the
intervention, posttest 1 immediately followed the conclusion of the intervention, and posttest
2 was conducted four weeks after posttest 1. The study included 27 midwives in both the
treatment and control groups. The control group consisted of respondents who read and
recalled the guidebook or training module attended, focusing on obstetrics, such as normal
delivery care training, midwifery update, and Obstetric and Neonatal Emergency First Aid
Training. The selection of midwives in both groups was accomplished through simple
random sampling from those working in healthcare facilities meeting specific inclusion
criteria: possessing a minimum midwifery with diploma degree, holding a valid license to
practice as a midwife, having three years of work experience, and demonstrating the capacity
to assist with five births per month.
The data were initially analyzed using primary data collected through knowledge surveys and
skill observations in early obstetric risk detection conducted over four weeks as part of
midwives’ competency tests for obstetric risk early detection.11 The assessment of the data
involved utilizing statistical methods such as the Mann-Whitney test, T-test, and Wilcoxon
test. The Jember District Health Office granted approval for the study to proceed, ensuring
adherence to research ethics principles. The Faculty of Health Sciences, Universitas Dr.
Soebandi, issued a research permit after completion of the review by the health research
ethics committee (No. 244/KEPK/UDS/VI/2022). Throughout the research process, the
researcher maintained a commitment to ethical principles, including informed consent,
respect for human rights, and considerations of beneficence and non-maleficence.
Results
The research respondents comprised individuals with varying characteristics, including age
(67% aged ≥35 years), education (52% with a D4 degree), and work experience (74% with
≥10 years of experience). Regarding midwife competence, which involved knowledge and
skills in early obstetric risk detection, there was no significant difference observed between
the treatment and control groups (p-value >0.05), allowing for a meaningful comparison of
all respondents. Table 1 served as an illustrative example of this.
Table 2 indicates that there was a significant improvement (p-value <0.001) in the knowledge
and skills of midwives in the early detection of obstetric risk within the treatment group, with
a much higher increase (34.59%) compared to the control group (4.46%). This midwife
competency posttest measurement represents the final posttest (posttest 2, measured 2-4

weeks after training), following the earlier completion of posttest 1 (measured shortly after
training) between the treatment and control groups, as illustrated in Table 3.
Table 3 demonstrated a decrease in midwife competence in measurements taken 4 weeks
after training in both the treatment and control groups, with insignificant differences (p-value
>0.005). This decline can be attributed to the passage of time, reflecting changes in the
behavior of some individual midwives regarding the competencies learned during training
and their application in the workplace (beyond the classroom setting).
Discussion
The results revealed a significant improvement in midwife competence before and after
training, indicating an increase of 34.59%. Competence, encompassing cognitive/knowledge,
affective/attitude, and psychomotor/skill abilities, is a trait possessed by individuals within
their respective professions.19 Training emerges as one of the most effective strategies for
enhancing competence, with 40% of these acquired competencies being applied in the
workplace, 25% lasting for six months, and only 15% enduring for up to a year.20 In this
study, competence was derived from a combination of knowledge and skills acquired in the
early detection of obstetric risk.
Midwives’ knowledge in the early detection of obstetric risk exhibited a significant difference
before and after training, with a percentage increase of 31%. Similarly, in the control group,
who read the module and recalled the training that had been conducted, there was an increase
in knowledge by 14.5%. Knowledge, a cognitive dimension of competence, involves
understanding theories comprising facts or procedures related to intellectual abilities such as
memory and problem-solving. This dimension can influence the mindset and understanding
of the information received.21,22 Midwives can enhance their knowledge through the
educational process, participation in training, conferences, and seminars, as well as reading
and studying journals, materials, books, and explanations from other professionals.
Skill assessment is conducted through direct observation when midwives perform services,
particularly in the early detection of obstetric risk. The results indicated a notable increase of
34.6% in midwife skills after training within the treatment group, contrasting with the control
group, which experienced a 4.5% rise. The study’s findings, indicating an enhancement in
competence post-training, align with previous research. Brief training in health services,
including obstetrics, has proven effective in increasing knowledge and skills among
healthcare providers working in maternity wards in sub-Saharan Africa and Asia.23 Public
health center midwives, village midwives, and independent practice midwives, who

implement basic health service facilities, are required to be skilled in delivering midwifery
care as per their authority.
Midwives are considered competent when their knowledge scores reach 80 or above, and
clinical skill scores are at 100. The competence of the control group increased by 7% when it
read the module but did not participate in training at that time. Respondents retained what
they learned from the module and remembered the training they had received.24 Additionally,
respondents had consistently applied this competency since the beginning, and prior research
has indicated that frequent use enhances a person’s competence. The training, which covers
Normal Delivery Care (APN), Contraceptive Technology Up to Date (CTU), and Midwifery
Update (MU), is mandatory for midwives to carry out midwifery services.
Competence in the early detection of obstetric risks is not only the procedure of upbringing
during early detection of risk but also knowledge, communication, and skills before and after
the early detection. The results of observations of communication and clinical skills of
midwives in the early detection of obstetric risks before training are still not following
Standard Operating Procedures (SOPs). There is no preparation of counseling/communication
information materials at the beginning and end of care related to screening/early detection of
red flags, lack of maintaining client privacy and principles of infection prevention during
care, skills to explore problems and complaints in anamnesis, as well as active listening and
helping clients make informed decisions.25,26 However, the lack of such skills after training
improves according to SOPs.
The results also showed that some midwives’ competence declined after 2-4 weeks,
particularly in knowledge from both the treatment and control groups, with no discernible
differences. The deterioration is brought on by time, modifications in certain midwives’
behavior, and the competencies they picked up outside of the classroom while training.24
Additionally, where there is no compensation, both positive and negative consequences, from
professional organizations, the health service, and where midwives work for the
professionalism of midwives, a decrease in competence can also be brought on by a lack of
motivational reinforcement.
Researchers proposed several elements to support the recruitment, retention, and motivation
of health workers and enhance the quality of their work: high-quality health facilities,
providing adequate training either during their education or after they start working,
continuous education, paid vacations, allowances for overtime, proper evaluations of their
work, and incentives27. However, because researchers and enumerators directly observe skills

when midwives provide care to pregnant women, birth mothers, and postpartum mothers,
there is a potential for bias in the conducted research.
Conclusions
Midwives demonstrate increased capability in identifying obstetric risks early, with
competencies showing the most significant improvement. Within 4 weeks following training,
there was a slight drop; however, it was not statistically significant. Consequently, continual
education is required to maintain midwives’ competence, involving training in obstetrics and
communication, which can contribute to enhancing motivation and character.
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Table 1. Midwives’ competence (knowledge and skills) in identifying obstetric risk before
training.
Variable
Midwife Competence
Category
p-value
Treatment
Control
Knowledge
𝑥" (SD)
Median
Range
67,83 (10,5)
70
40-85
65,5 (11,7)
65
45-85
0,419**
Skills
𝑥" (SD)
Median
Range
73,17 (6,2)
76
57-81
73,33 (5,5)
71
62-86
0,458*
*Mann Whitney test; **unpaired t test

Table 2. Midwives’ competence (knowledge and skills) in identifying obstetric risk before-
after training.
Variable
Midwife Competence
Category
p-value
Treatment
Control
Pretest
Posttest
Pretest
Posttest
Knowledge
𝑥" (SD)
Median
Range
67,83 (10,5)
70
40-85
86,83 (4,2)
85
80-95
65,5 (11,7)
65
45-85
73,83 (8,6)
70
55-90
<0,001*
Increase (%)
31,06
14,53
<0,001*
Skills
𝑥" (SD)
Median
Range
73,17 (6,2)
76
57-81
97,78 (3,9)
100
86-100
73,33(5,5)
71
62-86
76,67 (9,8)
71
67-100
<0,001*
Increase (%)
34,59
4,46
<0,001*
*Mann Whitney test

Table 3. Early detection of obstetric risks and changes in midwives’ competency (knowledge
and skills) before and after training.
Variable
Midwife
Competence
Category
Treatment
Control
Pretest
Posttest 1
Posttest 2
Pretest
Posttest 1
Posttest 2
a. Knowledge
𝑥" (SD)
Median
Range
p-value
67,83(10,5)
70
40-85
88,17 (4,8)
90
80-95
<0,001**
86,83 (4,2)
85
80-95
65,5(11,7)
65
45-85
74,67 (8,9)
70
55-90
<0,001**
73,83 (8,6)
70
55-90
0,011**
0,096*
b. Skills
𝑥" (SD)
Median
Range
p-value
73,17 (6,2)
76
57-81
97,62 (4,1)
100
86-100
<0,001**
97,78 (3,9)
100
86-100
73,33(5,5)
71
62-86
76,83 (9,7)
74
67-100
0,017*
76,67 (9,8)
71
67-100
0,803**
0,792*
*Paired t test **Wilcoxon test
Submitted: 11 September 2023
Accepted: 20 december 2023
Early access: 30 January 2024