The Critical Role of Supervision in Retaining Staff in Obstetric Services: A Three Country Study

Abstract

Millennium Development Goal (MDG) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015. In order to reach these goals, greater access to basic emergency obstetric care (EmOC) as well as comprehensive EmOC which includes safe Caesarean section, is needed.. The limited capacity of health systems to meet demand for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers. Although this does provide greater capacity for service delivery, concern about the performance and motivation of these workers is emerging. We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally. To investigate this, we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers (health workers trained for shorter periods to perform specific tasks e.g. clinical officers) delivering obstetric care in Malawi, Tanzania, and Mozambique. Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace. In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave. We find no evidence that facility level factors modify the link between supervisory methods and key outcomes. We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision. This will promote better job satisfaction and improve the retention and performance of obstetric care workers, something which has the potential to improve maternal and neonatal outcomes in the countdown to 2015.

Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers

“…Consistent with findings from other studies, we found that clinical mentoring strengthens HCWs’ self-reported knowledge, perceptions and confidence [32-34], enables orientation of less experienced HCWs [35], promotes staff satisfaction and retention [36,37], and reinforces implementation of IMCI quality of care in rural and limited-resource settings [38-40]. Furthermore, mentorship skills in active listening, humility, and non-judgmental feedback created mentor-mentee relationships that contributed to effective teaching and coaching of HCWs with low levels of education and minimal experience in IMCI.…”

Support and performance improvement for primary health care workers in low- and middle-income countries: a scoping review of intervention design and methods

“…The positive associations of supervision on HCW motivation have also been repeated in multi-country studies (McAuliffe et al 2013, Willis-Shattuck et al 2008, Ahmed et al 1993). Lack of supervision or poor quality supervision has been shown in India (Mohan et al 2011) and South Africa (Suri et al 2007) to be associated with poorer performance, inferior fidelity to protocols, and even treatment failure and poor patient outcomes, respectively.…”

Healthcare workers’ behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review

“…A third of the responded were aware of the fundal massage as a component of the AMTSL protocol.Kimberly et al (2010)/ Zambia [34]Nonphysician obstetric care workers ( n  = 21)Observational studyKnowledge and skills (use) of maternal ultrasound Clinical decision-makingPaired OSCE scores showed a slight overall improvement in the midwives ability to scan at 2 months of 10.0/14, SD 3.9 (71%) and at 6 months of 11.6/14, SD 1.8 (83%). Paired t -test showed no significant difference between OSCE 1 and OSCE II with p  = 0.15McAuliffe et al (2013)/ Malawi, Tanzania, Mozambique [35]Nonphysician obstetric care workers ( n  = 1561)Cross-sectional studyIntention to leave obstetric services (job satisfaction)Not receiving any supervision appeared to be most strongly linked to decrements in intentions to leave and job satisfaction. In particular, intentions to leave were substantially increased when no supervision system was in place in Malawi (b = 1.09, SE = 0.31, t = 3.52, p  < 0.01), Tanzania (b = 0.82, SE = 0.3, t = 2.73, p  < 0.01), and Mozambique (b = 1.04, SE = 0.39, t = 2.67, p  < 0.01).…”