The effect of the Maternal Care Manual of the Perinatal Education Programme on the Attitude of Mid wives towards their work

OBJECTIVE
In this study the changes in attitude of midwives towards their work following completion of the Maternal Care Manual of the Perinatal Education Programme (PEP), were determined.


METHOD
A prospective, controlled trial was performed in a study, and two control towns in a region where PEP had not previously been used. All midwives caring for pregnant women in the three towns were included in the study. First the attitude of these midwives was determined by means of a questionnaire. Subsequent to this, the Maternal Care Manual was introduced and studied by the midwives in the study town. Following the completion of the Manual after 12 months, the attitude of all midwives was again evaluated using the same questionnaire.


RESULTS
A total of 40 midwives in the study town and 53 in the two control towns were included in the study. There were no differences on comparing the ages of the midwives in the study town to those in the control towns. The attitude of the midwives in the study town improved significantly (p < 0.001). The mean result in the study town improved by 6.1 (24.4%) marks from 14.5 (58.0%) to 20.6 (82.4%). A significant shift also occurred in the range of the marks from 0-25 to 13-25. No changes were observed in the control towns.


CONCLUSION
Most studies that have evaluated educational programmes measured improvement in health services, and did not evaluate changes in attitude. This study found that the attitude of midwives improved significantly in the study town. This positive attitude of midwives towards their work and their ability to perform their daily tasks must be an important component of any programme to improve the quality of care rendered to women during pregnancy, labour and the puerperium.


M e th o d
A prospective, controlled trial was performed in a study, and two control towns in a region where PEP had not previously been used.All midwives caring for pregnant women in the three towns were included in the study.First the attitude of these midwives was determined by means of a questionnaire.Subsequent to this, the Maternal Care Manual was introduced and studied by the midwives in the study town.Following the completion of the Manual after 12 months, the attitude of all midwives was again evaluated using the same questionnaire.

R e su lts
A total of 40 midwives in the study town and 53 in the two control towns were included in the study.There were no dif ferences on comparing the ages of the midwives in the study town to those in the control towns.The attitude of the mid wives in the study town improved significantly (p<0,001).The mean result in the study town improved by 6,1 (24,4%) marks from 14,5 (58,0%) to 20,6 (82,4%).A significant shift also oc curred in the range of the marks from 0-25 to 13-25.No changes were observed in the control towns.

C on clu sion
Most studies that have evaluated educational programmes measured improvement in health services, and did not evalu ate changes in attitude.This study found that the attitude of midwives improved significantly in the study town.This posi tive attitude of midwives towards their work and their ability to perform their daily tasks must be an important component of any programme to improve the quality of care rendered to women during pregnancy, labour and the puerperium.

Intro duction
The philosophy of the Maternal Care Manual of the Perinatal Education Programme (PEP) is to enable midwives to provide effective primary obstetric care.A problem solving approach is followed and the emergency management of common ob stetric complications is described step-by-step.The neces sary information is provided to apply knowledge directly into clinical practice.
Previous studies have shown that midwives improved their cognitive knowledge and ability to interpret antenatal cards and partograms by studying the Maternal Care Manual of PEP (W oods and Theron 1995;85, Theron June 1998).The question as to whether changes in attitude towards work also occur is therefore relevant.This question had already been posed following the co m p le tio n of the first study, w hich had provided proof that midwives who stud ied PEP improved their cog nitive knowledge (Woods and Theron 1995;85).
In this study the changes in attitude of midwives following com pletion of the Maternal Care Manual of PER were de termined.
A prospective, controlled trial was performed in the Eastern Cape Province, a region where PEP had not previously been used.Three towns were chosen, one as the study town and the other two as control towns.All midwives caring for preg nant women in the three towns were included in the study.First, the attitude of these midwives was determined by means of a questionnaire.Subsequent to this, the Maternal Care manual was introduced and studied by the midwives in the study town.The midwives were divided into small groups for this purpose.A member of each group acted as the co ordinator for the group.The task of each co-ordinator was to distribute the manuals and to arrange and conduct discus sions for the group following the completion of each unit in the manual.The groups met every three to four weeks.One of the midwives in the study town acted as the regional co ordinator, to help local co-ordinators with problems encoun tered.Following the completion of the manual after 12 months, the attitude of all midwives was again evaluated using the same questionnaire.
The attitude of midwives towards their work was assessed using five questions.These questions had to be answered according to a Likert response format (Appendix A).The con tent of the questions covered the following aspects: training , knowledge, practical skills and self confidence.The last ques tion related to the level of job satisfaction experienced at that time.The maximum mark possible (25) would indicate total satisfaction.The questionnaire formed part of an multiple choice question examination and questions regarding the iden tification and interpretation of antenatal cards and partograms.
The means of the total marks allocated to all five questions in the study town were compared before and after completion of the manual, and to those of the control towns.Changes that occurred in individual questions were similarly compared.In addition a stratified analysis was performed on the magnitude of these changes scored for individual questions in the study town, by comparing antenatal care midwives to those work ing in the labour ward.The shift in the marks allocated to indi vidual midwives was also analysed with a method that distin guished between small random changes and more definite ones.
Consent for the study was obtained from the regional and lo cal health authorities.The study protocol was approved by the Ethics Committee of the Faculty of Medicine, Stellenbosch University.The data was loaded on Epi Info 6, Version 6.02 of O ctober 1994 and the statistical analysis was done using the same programme.Bartlett's test for ho mogeneity was used to determine whether the variance of two sam ples was homogeneous with 95% confidence.Homogeneous sam ples were compared using a two tailed S tudent's t-test and if the variances differed, medians were compared using the Kruskal-Wallis H test.

Results
A total of 40 midwives in the study tow n and 53 in the tw o control towns were included into the study.
The number of midwives rendering antenatal care and those working in the labour wards, as well as their age distributions are shown in Table 1.There were no differ ences in the mean and median ages or age distributions, when comparing the study to the control towns.
Experience of the midwives was assessed by comparing the number of working years in their towns and by the number of years in their posts at the time of the study (Table 2).The study and control towns were homogeneous with regard to the number of working years in the towns.There was how ever a tendency towards fewer years in their present posts (p=0,097) in the study town (5,3 vs. 7,3), when comparing the mean values.None of the midwives in the study town, and only one labour ward midwife in a control town, had under gone advanced midwifery training.
In the study town, 31 midwives completed the manual and were prepared to participate in the post-test evaluation.The reasons given by the 9 (22,5%) midwives that did not com plete the manual were: three resignations, two transfers, one retirement and three who cited loss of interest.In the control towns, 11 (20,8%) midwives were not available for post-testing.Reasons here included: illness, maternity leave, transfers and resignations.
Table 3 shows the means, medians and range of the marks allocated to the five questions regarding attitude during the pre-and post-testing in the study and control towns.A signifi cant (p<0,001) improvement occurred in the study town.The mean result in the study improved by 6,1 (24,4%) marks, from 14,5% (58,0%) to 20,6 (82,4%).A significant shift occurred in the range of the marks from 0-25 to 13-25.No changes were observed in the control towns.
The pre-test marks did not differ (p=0,21) between the study and control towns (Table 3).However, the post-testing marks were signifi cantly (p<0,001) higher in the study town.A significant (p=0,001) im provement occured for each indi vidual question in the study town, w hereas th ere w ere o n ly s lig h t changes in the control towns (Ta ble 4).This analysis was only per fo rm e d on m id w iv e s fo r w hom paired values were available.The difference between pre-and post test results for individual questions in the study town were larger for midwives working in the antenatal clinics than those working in the la b ou r w ard (Table 5).However, these differences were not statisti cally different, except for a tendency towards being significantly better in question 1.By accepting a > 4 mark (> 16%) improvement as a substan tial shift, the majority of midwives in the study town improved, whereas most in the control town remained unchanged (Ta ble 6).

Discussion
Few studies regarding the attitude of health workers towards their work and especially changes in attitude following inter vention, are to be found in the medical literature.Attitudes of midwives towards midwife obstetric units have been tested and Turnbull and co-workers included a control group in their study (Turnbull and co-workers 1995;11).Renfrew reviewed the literature regarding shared care compared to care by mid wives only in the Cochran data base (Renfrew August 1992).
In general studies that have evaluated educational p ro grammes aimed at improving health services have not evalu ate changes in attitude (Engel and co-workers 1992;26, Ndeki    Program m e (PCEP) evaluated, a m o ng st o the r aspects, changes in attitude following the completion of their educa tional manual (Kattwinkel and co-workers 1979;64, Kattwinkel and co-workers 1978;12).This manual focused mainly on neonatal care.Attitude was evaluated in one of the studies with a pre-and post-study questionnaire (Kattwinkel and co workers 1979;64).A significant improvement in attitude of be tween 16% and 23% was achieved.The improved attitude related to specific aspects of the task health workers needed to perform.In contrast, the index study evaluated changes in attitude of midwives with regards to their perception of how well they felt equipped to perform the task expected from them (Appendix A).A direct comparison of the two studies is there fore not appropriate.Another study by Kattwinkel and co workers found that health workers had a fatalistic attitude that could be detrimental to the ideal of optimal care (Kattwinkel and co-workers 1978;12).Provisional results of that study found that this attitude could be significantly improved follow ing the com pletion of PCEP No figures to quantify these changes were provided, neither were control hospitals used in either of their two studies.

T ab le 2 : Previous e x p erie n c e o f m idw ives
The index study found that the attitude of midwives towards their work improved significantly in the study town (Table I).
No differences were found between the study and control towns with pre-testing and no changes occurred in the con trol towns.The five questions included the most important com ponents of attitude tow ards work (Appendix A).The changes that occurred in the study town therefore indicate that a favourable attitude can be achieved by studying PER The im provem ent achieved in the study town was evenly spread amongst the 5 questions (Table 3).Only slight varia tions occurred in the control towns.Larger changes were observed with midwives working in the antenatal clinics com pared to those in the labour ward (Table 4).Although not sig nificantly different, the findings correspond to the larger im provement achieved by antenatal care midwives with regard to the application of knowledge (tested by antenatal cards), compared to labour ward midwives (tested by partograms) (Theron March 1996).Small random changes could have been expected between pre-and post-tests performed following an interval of 12 months.If a change of > 4 (>16%) marks is regarded as substantial, a favourable change occurred in 17 (65,4%) midwives in the study town (Table 5), whereas 22 (61,1%) in the control towns showed no substantial changes.
The median age of midwives in the study town was 42 years with an age distribution that ranged from 23 to 60 years (Table 1).The mean ages of the midwives in the study and control towns did not differ (p=0,27).The median time spent in the study town was 8 years with a range from one to 30 years.Three years before the study, the hospital antenatal clinic to gether with it's staff was amalgamated with clinics under the local authority.This resulted in the differences in time spent by the midwives in their present posts when comparing the study and control towns at the commencement of the study.
The study town is larger than other towns in the region.There fore two control towns were chosen, to match the study town, also with regard to the number of practicing midwives (Table I).With regard to medical care, these towns represent the prevailing health care situation in most rural South African towns.
M ost studies evaluating attitude, have used a qualitative method (Turnbull and co-workers 1995;11).Although this kind of feedback was not formally obtained, comments regarding the programme volunteered by the midwives during post-test ing, was w ithout exception favourable.Chief professional nurses praised the uniform approach to patient care within the services, that resulted from studying the manual.They were unanimous in their view that the quality of care had im proved.
Midwives who studied the Maternal Care Manual of PEP ex perienced a significantly improved attitude towards their work.
The improved cognitive knowledge and ability to apply knowl edge was also personally experienced, resulting in an increase in self confidence and job satisfaction.This positive attitude of midwives toward their work and their ability to perform their daily tasks is an important component of any programme to improve the quality of care rendered to women during preg nancy, labour and the puerperium.

A ckn o w led g em en ts
The author wishes to acknowledge support from grants by the South African Medical Research Council and the Univer sity of Stellenbosch.I am indebted to the efforts of mrs JS Snyman who was the regional coordinator and mrs PM Smith who performed the data analysis.I would also like to thank Professor H.J. Odendaal who was the promotor of the doc toral thesis from which this matrial is taken and Professors D.L. Woods and J. Kattwinkel who were responsible for the conception of the idea to do the study.

Table 1 : N um bers and ages of p artic ip atin g m idw ives Study town Control towns Total
# Student's t-test SD = standard deviation M

Table 6 : T h e shift in m arks of individual m idw ives for w hom paired observations w e re availab le
andco-workers 1995; 16, Taylor 1992;38).However, the pa per of Maclean and Tickner regarding the Safe Motherhood Initiative Educational Project reported possible changes in at titude as determined with a check list (Maclean and Tickner 1992;8), but no information regarding the result of the analy sis appears in this publication.Two of the studies done in the United States by Kattwinkel and co-workers regarding the Perinatal Continuing Education