Maternal Health Training Priorities for Nursing and Allied Health Workers in Colombia, Honduras, and Nicaragua

Pan American Journal Original research of Public Health

Maternal health training priorities for nursing and allied health workers in Colombia, Honduras, and Nicaragua

Amelia J. Brandt,1 Samantha Brown,1 Silvia Helena De Bortoli Cassiani,1 and Fernando Antonio Menezes da Silva1

Suggested citation Brandt AJ, Brown S, De Bortoli Cassiani SH, Menezes da Silva FA. Maternal health training priorities for nursing and allied health workers in Colombia, Honduras, and Nicaragua. Rev Panam Salud Publica. 2019;43:e7. https://doi.org/10.26633/RPSP.2019.7

ABSTRACT Objective. To assess maternal health training priorities for primary care human resources for health (HRH) in nursing and allied health workers in Colombia, Honduras, and Nicaragua, to inform maternal care HRH strategic planning efforts. Methods. This Washington, D.C.–based study utilized cross-sectional survey methodology to collect country-level data. From October 2016 to March 2017, a needs assessment tool was developed by the Pan American Health Organization/World Health Organization (PAHO/WHO) and PAHO/WHO Collaborating Centers. Data collection was completed by PAHO/WHO country offices, in collaboration with national health authorities and other high-level government personnel. The collected data included information on the composition, capacities, and training priorities of traditional birth attendants (TBAs), community health workers (CHWs), registered nurses (RNs), and auxiliary nurses in the three study countries; the findings were summarized in a report. Results. Data on the health workforce composition in the three countries indicated reliance on HRH with low levels of education and training, with limited integration of TBAs. In all three countries, management of obstetric emergencies was a training priority for RNs, and identification of danger signs was a priority for CHWs and TBAs. Training priorities for auxiliary nurses varied widely across the three countries and included health promotion, preconception and prenatal care, and obstetric emergencies. There was also a wide range in the total number of HRH across the three countries. Conclusions. Reliance on health workers with low levels of training is concerning but can be mitigated through in-service training. Training priorities are consistent with the major causes of maternal mortality, and Latin America and Caribbean region training programs show promise for improving quality of care. In the long term, planning for maternal care HRH should seek to increase the concentration of health professionals that are more highly skilled.

Keywords Human resources; maternal health services; primary health care; capacity building; strategic planning; Latin America; Caribbean region; Colombia; Honduras; Nicaragua.

1 Human Resources for Health Unit, Health Preventable pregnancy- or child- In addition, for each maternal death, Systems and Services Department, Pan American at least 30 women suffer complica- Health Organization, Washington, D.C., United birth-related complications kill 830 States of America. Send correspondence to: women daily, with 99% of these deaths tions with potential long-term conse- Amelia Brandt, [email protected] occurring in developing countries (1). quences (1).

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Rev Panam Salud Publica 43, 2019 1 Original research Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua

Maternal mortality (MM) in the Amer- achieve sustained and equitable health Paulo. The development of the instru- icas region has dropped by more than in the Americas (17). PAHO/WHO Res- ment was informed by a literature re- 40% in the past 20 years, but these ad- olution CSP29.R15 (Strategy on Human view on maternal health in the Americas vances do not affect all women equally Resources for Universal Access to region and existing tools (19, 20). (2). For example, for 2015, the estimated Health and Health Coverage), approved The Spanish-language instrument maternal mortality ratio (MMR) for the in September 2017 at the 29th Pan Amer- consisted of a 24-page written survey Americas is 52 deaths per 100 000 live ican Sanitary Conference, reaffirms divided into three sections (health care births, but in Latin America and the Ca- PAHO/WHO’s role in providing techni- personnel, training needs, and country ribbean (LAC) it is more than 30% higher cal support to member states to improve resources). The target population in- (68) (3). The estimated MMRs of Colom- capacity for strategic HRH planning cluded four categories of health work- bia, Honduras, and Nicaragua are also (18). This type of strategic planning re- ers providing maternal health care at high at 64 (2014), 129 (2010), and 150 quires the identification of HRH train- the primary care level in LAC countries: (2016) respectively (3). ing priorities in maternal health. traditional birth attendants (TBAs), The MMR varies by ethnicity, socio- In 2016 and 2017, as part of the community health workers (CHWs), economic status, and geography (1, 2). IHSLAC project (Integrated Health Sys- registered nurses (RNs), and auxiliary For example, the 2001 pregnancy-related tems in Latin America and the Caribbe- nurses. These categories were selected mortality ratio in Honduras ranged from an), funded by Global Affairs Canada, a based on consultations with maternal 177 to 277 across different regions of the survey tool was developed to conduct health experts and country offices on country and was higher in those with an assessment of maternal health train- the key nursing and allied health work- high poverty and low development (4). ing priorities for nursing and allied ers providing maternal health services The leading direct cause of MM in the health workers working in the first level in the three countries studied. The four Americas is hemorrhage, closely fol- of care in Colombia, Honduras, and groups were defined as follows using lowed by hypertension (5). The esti- Nicaragua. These three countries were internationally recognized criteria: mated proportion of deaths caused by selected for the study based on the ac- 1) TBA—person without formal educa- hemorrhage is 23.1% (13.3% during post- cessibility of country information, the tion who assists mothers through child- partum, 5.8% during prepartum, and MMR, and the level of interest of the birth using skills learned through 4.1% during intrapartum) (5). PAHO/WHO country offices and na- delivering babies herself or through an Increased access to skilled birth atten- tional health authorities. apprenticeship with other TBAs; 2) dance in low- and middle-income coun- The objective of the study was to assess CHW—community member selected by tries has not led to expected reductions in maternal health training priorities for pri- peers who works in the community to preventable MM and morbidity, possibly mary care HRH in nursing and allied provide care to support health care de- due to a lack of good-quality maternity health workers in Colombia, Honduras, livery and has no formal professional care (6–8). Low-quality services and disre- and Nicaragua, to guide maternal care certificate or degree; 3) RN—individual spectful care can harm women’s health HRH strategic planning efforts. The study who has graduated from a nursing pro- and well-being (9). Quality must be im- was designed to contribute to LAC coun- gram typically lasting three to four proved at all levels of care to continue try efforts to achieve universal access to years and has legal authority to practice progress in reducing MM and morbidity health, universal health coverage, and the as a nurse in his/her country based on (10–12). Highly skilled care does not nec- Sustainable Development Goals (SDGs).2 national regulations and licensing; and essarily lead to improved outcomes, even The assessment was limited to nursing 4) auxiliary nurse—individual with ba- in high-income countries. A review of 13 and allied health workers to match the sic nursing knowledge and, usually, randomized control trials in Australia, scope of the training efforts that will be high school–level training, who may Canada, Ireland, New Zealand, and the informed by the study results. have some on-the-job training but has United Kingdom found that women who no training in nursing decision-making. had midwife-led continuity models of MATERIALS AND METHODS The health care personnel section of care were less likely to experience region- the survey instrument covered in this al analgesia, episiotomy, and intrapartum This study used a cross-sectional report was designed to collect informa- analgesia/anesthesia compared to vari- quantitative survey methodology to col- tion on the general characteristics and ous combinations of care models focused lect country-level data on national ma- scopes of practice for each type of health on highly skilled care (13). ternal HRH needs. worker. The three country-level survey Interventions targeting human re- The survey instrument was devel- respondents were asked to answer cir- sources for health (HRH) in the areas of oped by PAHO/WHO’s Department of cle-response questions and describe, in management, education, and policy Health Systems and Services/Human writing, key capacities for each type of have been shown to improve HRH ca- Resources for Health Unit (HSS/HR) in provider and the scope of their practice pacity and maternal health outcomes collaboration with the following in the country. Both multiple-choice and (14), especially when there is an empha- PAHO/WHO Collaborating Centers: open-ended questions were used to elic- sis on strengthening primary health care University of Chile, University of Mi- it general descriptions related to the (PHC) (15, 16). ami, University of Michigan, University number, geographic distribution, edu- The Pan American Health Organiza- of Pennsylvania, and University of São cation requirements, community stand- tion/ World Health Organization ing, number of births attended, (PAHO/WHO) promotes increased ac- 2 This assessment focused on SDG Goals 3, 5, 10, regulation, payment, training, access to and 17. More details on the SDGs can be found at: cess to qualified health workers to http://www.un.org/sustainabledevelopment higher levels of care, and barriers of

2 Rev Panam Salud Publica 43, 2019 Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua Original research each group of health worker. To identify collaborating government personnel were RESULTS scopes of practice, the instrument pro- selected by the PAHO/WHO country vided lists of skill sets for each group offices. Workforce composition and prompted respondents to select all Upon receipt of the completed sur- that were applicable and rank the three veys, the research team reviewed and The total number of CHWs, RNS, and most important. The question on rank- analyzed the data and summarized the TBAs in the nursing and allied health ing was open-ended. Figure 1 shows a findings in a report. The terminology personnel workforce varied consider- summary of the information collected used to identify health priorities was ably across the three countries studied, for this part of the survey. The other two standardized to allow for comparison ranging from almost 300 000 in Colom- sections of the survey (training needs across countries. The original and stan- bia, to 72 112 in Nicaragua, to 7 088 in and country resources) were not used in dardized terminology are available from Honduras (Table 1). this assessment, as it was designed to the corresponding author (AJB) upon re- There was also a wide range in the gather data on HRH training, so are not quest. The summary report was shared workforce composition across countries. described here in detail. The survey in- with each PAHO/WHO country office For example, auxiliary nurses comprised strument can be made available on re- for review and feedback. the majority of the workforce in Colom- quest to the corresponding author (AJB). bia and Honduras but only 5.4% in Nica- Data collection was completed between Ethics approval ragua. While CHWs made up the October 2016 and March 2017 by the majority of Nicaragua’s workforce, no PAHO/WHO country offices in the three The study protocol was submitted to data were provided on this group by re- countries studied in collaboration with the PAHO Ethics Review Committee, spondents from Colombia or Honduras. national health authorities. One survey which determined it exempt from review Honduras had the highest percentage of was completed for each country. The as it was not human subjects research. RNs, followed by Colombia. In contrast, RNs made up only 6.2% of Nicaragua’s FIGURE 1. Summary of information collected in the personnel section of the Pan workforce. American Health Organization (PAHO)/World Health Organization (WHO) human TBAs were not integrated into the for- resources for health (HRH) needs assessment survey mal health system in Honduras or Co- lombia. Therefore, the respondents from Survey instrument: personnel section Honduras did not provide any data for Professional General Scopes of Training this group and those from Colombia groups: characteristics: practice: priorities: provided only an unofficial estimate. In - Traditional birth - Number - List of skillsets - Open ended Nicaragua, TBAs made up 8.9% of the attendants - Geographic provided - Indicate and workforce, outnumbering auxiliary - Community distribution for each rank top three nurses and RNs. health workers - Educational professional training - Registered requirements group priorities nurses - Community - Select all - Auxiliary standing applicable Capacity requirements nurses - Births attended - Regulation Key capacities required for RNs in - Payment maternal health were similar in Colom- - Training - Higher levels bia, Honduras, and Nicaragua and in- of care: barriers cluded preconception, prenatal, and and access intrapartum care; delivery of uncomplicated pregnancy; management of Source: PAHO/WHO HRH needs assessment survey. preeclampsia and eclampsia; management of postpartum bleeding and hem- TABLE 1. Human resources for health (HRH) in nursing and allied personnel, based on the orrhage; recognition of symptoms of results of a country-level Pan American Health Organization/World Health Organization premature labor; management of pre- needs assessment survey, Colombia, Honduras, and Nicaragua, 2017 mature labor; suture of episiotomies; administration of blood transfusions; Colombia Honduras Nicaragua postpartum care; newborn care; family HRH No. % No. % No. % planning services; breastfeeding edu- Registered nurses (RNs) 55 256 18.6 2 088 29.4 4 448 6.2 cation; identification of complications Auxiliary nurses 241 621 81.4a 5 000 70.6 3 886 5.4b and timely referrals; medication administration; contraceptive counseling; Community health workers (CHWs) NDc ND 57 346 79.5 assistance with spontaneous abortion; Traditional birth attendants (TBAs) – d ND 6 432 8.9 <1.0 referral of complicated abortions; care Total 296 877 7 088 72 112 for postpartum depression; and HIV/ Source: Prepared by the authors based on the survey results. AIDS care. Manual removal of the pla- a Includes auxiliary nurses and medical technicians. centa was indicated as a necessary ca- b Includes only those working in the public sector. c ND: no data provided. pacity for nursing practice in Colombia d Unofficial estimate. and Nicaragua, but not Honduras.

Rev Panam Salud Publica 43, 2019 3 Original research Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua

TABLE 2. Key capacities for auxiliary nurses, based on the results of a country-level Pan With some exceptions, capacities for American Health Organization/World Health Organization needs assessment survey on auxiliary nurses were relatively consis- human resources for health (HRH), Colombia, Honduras, and Nicaragua, 2017 tent across all three countries. Honduras was unique in that intrapartum care Key capacity Colombia Honduras Nicaragua was not a necessary capacity for auxilia- Preventive care against HIV, malaria, tetanus, STIs, etc. x x x ry nurses. Administering medication, Health promotion x x x fetal monitoring, and bimanual massage Breastfeeding education and evaluation x x x were indicated as necessary capacities Neonatal care x x x in Honduras and Nicaragua, but not Prenatal care x x x Colombia. Intrapartum care x x CHWs and TBAs, who work primar- Delivery of uncomplicated pregnancy x x x ily in the community, generally had Recognizing signs and symptoms of major complications during pregnancy x x x limited or no formal education and Family planning services xa x x therefore a limited scope of work. Administering medication x x Table 3 lists key CHW and TBA capaci- Fetal monitoring x x ties by country. Bimanual massage xb x Colombia required only three capacities for CHWs: 1) health promotion, 2) Source: Prepared by the authors based on the survey results. a Accompaniment and counseling only. recognizing signs and symptoms of b Prior to birth. complications during pregnancy, and 3) preventive care against infections. Both Honduras and Nicaragua required TABLE 3. Key capacities for community health workers (CHWs) and traditional birth CHWs to have those capacities in addi- attendants (TBAs), based on the results of a country-level Pan American Health tion to others, including the ability to Organization/World Health Organization needs assessment survey on human provide breastfeeding education and resources for health (HRH), Colombia, Honduras, and Nicaragua, 2017 evaluation. In Honduras, CHWs were also required to have the capacity to CHWs TBAs Key capacity provide family planning services and Colombia Honduras Nicaragua Colombia Nicaragua sexual education. In Nicaragua, CHWs Preventive care against HIV, malaria, tetanus, x x x were also required to have the capacity STIs, etc. to provide neonatal care; identify dan- Health promotion x x x ger signs during pregnancy, birth, post- Breastfeeding education and evaluation x x x x partum, and childhood; and carry out Neonatal care x x xa chronic and febrile illnesses prevention Prenatal care x activities. Intrapartum care x In both Colombia and Nicaragua, re- Delivery of uncomplicated pregnancy x x quired capacities for TBAs included Recognizing signs and symptoms of X x x x x breastfeeding education and evaluation, major complications during pregnancy delivery of uncomplicated pregnancy, Family planning services x xb xb accompaniment and counseling for fam- Administering medication ily planning services, and recognition of Fetal monitoring signs and symptoms of major complica- Bimanual massage tions during pregnancy. Bimanual mas- Source: Prepared by the authors based on the survey results. sage was only a required capacity in a In the home. Nicaragua. In Nicaragua and Colombia, b Accompaniment and counseling only. TBAs also needed to have multiple key capacities directly related to clinical care, In all three countries, auxiliary nurses of health workers. For example, key re- despite education limitations. For exam- had considerably less education and sponsibilities indicated for RNs but not ple, neonatal care and delivery of un- training than RNs, and their scope of auxiliary nurses included preeclampsia complicated pregnancy were identified practice was more limited. Key capaci- and eclampsia, postpartum bleeding and as necessary capacities for TBAs in both ties for auxiliary nurses by country are hemorrhage, premature labor, suturing countries. In Nicaragua, neonatal care shown in Table 2. episiotomies, blood transfusions, sponta- delivered by TBAs had to take place in Another characteristic common to all neous abortion, HIV/AIDS, and post- the home. Colombia identified prenatal three countries was that auxiliary nurses partum depression. Key responsibilities and intrapartum care as necessary capac- and RNs had similar key capacities, in- indicated for auxiliary nurses but not ities for TBAs. Nicaragua highlighted the cluding breastfeeding education, prena- RNs tended to focus on preventive and transport of children and mothers to tal and neonatal care, family planning administrative care such as infection pre- health facilities as a responsibility of services, and delivery of uncomplicated vention, health promotion, and recogni- TBAs, who were described as authorities pregnancy. However, other capacities tion of signs and symptoms of major in maternal and child health issues in were exclusive to one of the four groups complications during pregnancy. some indigenous communities.

4 Rev Panam Salud Publica 43, 2019 Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua Original research

Though both CHWs and TBAs work country, survey respondents identified In contrast, Colombia’s priorities reflect- directly in the community, they shared the three highest priorities for further ed an emphasis on prevention. few key capacities. The only key capaci- training for each. Honduras did not CHW training priorities were similar ty indicated for both categories in all identify training priorities for TBAs. across all three countries. Identifying dan- three countries was recognition of signs Table 4 presents training priorities by ger signs was the highest priority for and symptoms of major complications country and health worker group, with Honduras and Nicaragua and second pri- during pregnancy. In Nicaragua, TBAs “1” indicating the highest priority. ority for Colombia. Nicaragua also men- and CHWs shared additional capacities, Training priorities for RNs varied tioned the Three Delays Model3 (21) with including breastfeeding evaluation/ed- across the three countries but there were regard to this priority. Preventive care was ucation and neonatal care. Capacities some similarities. For example, manage- the third priority for all three countries. indicated for CHWs but not TBAs in ment of obstetric emergencies was in- In Colombia and Honduras, the focus all three countries included health pro- cluded as either a first or second priority was HIV, malaria, tetanus, and STIs, while motion and prevention of infectious for all countries. Some training priorities in Nicaragua it was chronic diseases. The diseases. listed by respondents were similar across remaining priorities varied by country. Recognizing signs and symptoms of countries but with a slight variation, Training priorities for TBAs in Colom- major complications during pregnancy such as identification of danger signs bia and Nicaragua were varied. Both was identified as vital for all groups of in Colombia, and referral and counter- countries prioritized training on identifi- health workers in all three countries. An- referral following identification of dan- cation of danger signs, but Colombia other characteristic common to all three ger signs in Nicaragua. Each country also limited this to pregnancy, while Nicara- countries was requiring provision of had some unique priorities, such as pre- gua included identification of these signs family planning services as a key capaci- conception and prenatal care in Colom- during birth and postpartum, and for ty for auxiliary nurses and RNs. In Hon- bia; management of preeclampsia and newborns. Other priorities were unique duras, this capacity was a required key eclampsia in Honduras; and nursing to each country’s context. In Honduras, capacity for all four health worker standards in Nicaragua. delivery of uncomplicated pregnancy groups. Breastfeeding education and Training priorities for auxiliary nurses was listed as a priority for auxiliary nurs- evaluation was another key capacity for varied widely across the three countries, es and RNs. In Colombia, breastfeeding all four groups of health workers in Nic- with no priority being listed by more education/evaluation was prioritized aragua and Honduras. than one country. The priorities identi- for auxiliary nurses and TBAs. fied by Nicaragua and Honduras indi- Training priorities cated a more active role for this group in DISCUSSION pregnancies, as illustrated by the inclu- In addition to identifying the capaci- sion of delivery of uncomplicated preg- Although the global community has ties/scope of work for each of the nancy in Honduras and management made significant strides in reducing MM, four groups of health workers in their of obstetric emergencies in Nicaragua. much progress remains to be made (1). While the estimated MMR for the Amer- icas for 2015 (52) was below the SDG tar- TABLE 4. Top three training priorities for registered nurses (RNs), auxiliary nurses, community health workers (CHWs), and traditional birth attendants (TBAs), based get (70 deaths per 100 000 live births), it on a country-level Pan American Health Organization/World Health Organization remained unacceptably high (3, 22). In needs assessment survey on human resources for health, Colombia, Honduras, and 2017, ministers and secretaries of health Nicaragua, 2017 in the region unanimously endorsed the Sustainable Health Agenda for 2017– RNs Auxiliary nurses CHWs TBAs 2030, which established a goal for reducing the MMR for the Americas to less than 30 (23). Training area Country case studies have shown that Colombia Colombia Colombia Colombia Honduras Honduras Honduras Nicaragua Nicaragua Nicaragua Nicaragua integrating PHC strategies into maternal, Priority level newborn, and child health (MNCH) programs has the potential to reduce mater- Breastfeeding education and evaluation 2 3 nal deaths by 20%–30% and strengthening Care and knowledge of newborn danger signs 3 MNCH programs at the primary level is Delivery of uncomplicated pregnancy 3 3 2 recommended to reduce MM (14). PHC Family planning services 2 2 requires a well-trained health workforce Health promotion 1 1 to reduce MM, and strategic planning is Identification of danger signs 3 3 2 1 1 1 2 vital to developing appropriate and ef- Managing preeclampsia and eclampsia 1 fective training. The results of this study Nursing standards 3 can be used to inform strategic planning Obstetric emergencies 1 2 2 1 for training HRH at both the national Preconception and prenatal care 2 1 level and for the Americas region. Prevention of infections and chronic diseases 3 3 3 3 3 The idea that MM is related to delays in 1) decid- Referral and counter-referral 1 2 2 1 ing to seek care; 2) reaching the health care facil- Source: Prepared by the authors based on the survey results. ity; and 3) receiving care.

Rev Panam Salud Publica 43, 2019 5 Original research Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua

Workforce composition personnel workforce. The results of this the materials. However, for some of the study highlight the discrepancies be- nursing and allied health workers, such Appropriate planning for training re- tween the capacity of auxiliary nurses as auxiliary nurses, the priorities were so quires a clear understanding of HRH and their scope of work, likely due to varied that consensus-building would be composition, especially for in-service resource shortages. Although increased required to carry out training across programs (24). The lack of data in this training of auxiliary nurses can improve LAC. In contrast, training priorities were area indicates the need to improve HRH the provision of basic preventive or relatively consistent across the three monitoring for nursing and allied health primary care services (28), HRH plan- countries for CHWs. Given that Nicara- workers. For example, in this assess- ning must address the need for equita- gua was the only country where TBAs ment, the number of CHWs in Honduras ble access to highly skilled personnel had a formalized role, a regional training and Colombia could not be determined. (18, 29, 30). approach would not be appropriate. In addition, a large percentage of the At the community level, for all coun- When planning training based on na- nursing and allied health workforce in tries studied, CHWs were a more inte- tional interests, the national training pri- the three sample countries included gral part of the workforce than TBAs. orities for various categories of health health workers with limited or no formal The only country of the three where workers emerging within countries health education, such as auxiliary TBAs had a formalized role was Nicara- should be considered. For the three coun- nurses, CHWs, and TBAs. While this gua, and even there, they comprised a tries and four groups of health workers limits HRH capacity, in-service training smaller part of the workforce than assessed in this study, these would in- can be an effective tool for improving the CHWs. Although Colombia and Hondu- clude referral and counter-referral in skills of these three groups of health ras did not provide data on CHWs, it Nicaragua, recognition of complications workers (25, 26). In line with PAHO’s seems likely that both countries have a during pregnancy and breastfeeding ed- Strategy on Human Resources for Uni- large CHW workforce, given the large ucation in Colombia, and delivery of un- versal Access to Health and Universal number of CHWs in Nicaragua. In addi- complicated pregnancy in Honduras. Health Coverage (18), national health au- tion, both Colombia and Honduras pro- Training should also focus on hemor- thorities, universities, and professional vided information about CHW scope of rhage and hypertension, the two leading associations should play a significant practice and training priorities, indicat- causes of MM in the LAC region (5). role in the provision of ongoing training ing that although numerical data were Based on the survey results, in all three and professional development opportu- missing for this assessment, CHWs are countries studied, identification of dan- nities, as well as regular assessment of considered part of the workforce. ger signs was a top training priority for the training needs of nursing and allied at least one of the four categories of health workers, through studies similar Training priorities health worker, and obstetric emergencies to the one reported here. was a priority for RNs. These findings Training efforts designed for the Despite HRH similarities in all three are promising with regard to maternal Americas region as a whole contribute to countries, there was significant variation health progress, as improving these two the streamlining of the development of in training priorities. While priority-set- capacities alone could significantly re- MNCH training materials and facilitate ting is complex and multifaceted, some duce maternal deaths due to hemorrhage resource- and knowledge-sharing across hypotheses can be developed. For exam- and hypertension (31, 32). However, pre- countries (27). However, it is important ple, Colombia was the only country that natal care was only indicated as a train- to consider the consistency of health identified breastfeeding education as a ing priority for auxiliary nurses in worker roles across countries and to take priority, and it had higher exclusive Honduras, and for RNs in Colombia. country contexts and training priorities breastfeeding rates than the other two Complete prenatal care significantly re- into account, given the findings reported countries, possibly indicating a focus on duces mortality in pregnant women with here, which highlight variation in the this area (3). Similarly, Nicaragua, the hypertensive disorders (33), so its em- key capacities of these health workers only country identifying care and knowl- phasis in training would likely contrib- across countries. edge of newborn danger signs as a prior- ute to reduction of MM at the primary ity, had lower neonatal mortality than care level. Task shifting is also a key Capacity requirements Honduras (3). Nicaragua was also the strategy to improve access to health care. only country that identified obstetric WHO recognizes task shifting as an im- Capacity requirements for RNs were emergencies as a priority for auxiliary portant tool to increase accessibility of remarkably consistent for Colombia, nurses, which seems logical, as it has the basic health services in low-resource set- Honduras, and Nicaragua. This is prom- widest scope of work for this group of tings (34, 35). This supports increased ising as it may indicate coordination professionals of all three countries. Fam- investment in training of nondoctor per- across LAC in the development of the ily planning services were identified as a sonnel who are influential in the realm of profession. Auxiliary nurses also have a priority in Honduras only, which may be maternal health, including CHWs, auxil- similar role in each of the three countries, due to its low use of modern contracep- iary nurses, RNs, and TBAs. although there was more variation com- tion and high unmet need compared to pared to RNs. The role of auxiliary nurses Colombia and Nicaragua (3). Limitations in Colombia was more limited than in Training priority variation for nurses Nicaragua or Honduras, even though, in could be addressed by developing train- This study had some limitations. First, all three countries, this group comprised ing materials for each identified area and much of the health workforce composi- most of the nursing and allied health allowing countries to select and adapt tion data were missing or estimated.

6 Rev Panam Salud Publica 43, 2019 Brandt et al. • Training priorities for maternal care in nursing/allied health: Colombia, Honduras, and Nicaragua Original research

Other limitations included the use of educated professionals. However, it is of Health of these countries in complet- open-ended questions in the survey also essential to provide high-quality ing the needs assessment tool and as- section on training priorities, to allow in-service education to the existing sisting in the interpretation of results. for flexibility in responses, which re- workforce, in order to meet immediate They also thank the PAHO/WHO Col- quired conversion to standardized ter- needs, and to continue to assess capaci- laborating Centers (University of Chile, minology to allow for inter-country ties and training needs. University of Miami, University of analysis. Strategic planning is vital to ensure na- Michigan, University of Pennsylvania, tional and regional training programs and University of São Paulo) for their Conclusions meet training needs and have high im- contributions in preparing the needs as- pact. This assessment provides key infor- sessment tool. The importance of HRH at the primary mation for planning training to build level for improving maternal health is HRH capacity for maternal health in Co- Funding. This research was funded by well-established. However, low-quality lombia, Honduras, Nicaragua, and in the Global Affairs Canada through the Inte- services impede and may jeopardize LAC region overall. The results from the grated Health Systems in Latin America maternal health progress. HRH training study are currently being used by and the Caribbean grant. can increase the quality of existing ser- PAHO/WHO and national health au- vices and improve maternal health across thorities to develop training for national Conflicts of interest. None. the LAC region. The current nursing and trainers in maternal health. allied health personnel workforce in Disclaimer. Authors hold sole respon Colombia, Honduras, and Nicaragua is Acknowledgments. The authors sibility for the views expressed in the composed primarily of lower-educated would like to acknowledge the contri- manuscript, which may not necessarily health workers. To build capacity, it is butions of colleagues at the PAHO/ reflect the opinion or policy of the RPSP/ important to strategically plan to in- WHO offices in Colombia, Honduras, PAJPH or the Pan American Health crease the number of more highly and Nicaragua as well as the Ministries Organization (PAHO).

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RESUMEN Objetivo. Evaluar las prioridades de capacitación en el ámbito de la salud materna de los recursos humanos de enfermería y otros trabajadores de atención primaria en Colombia, Honduras y Nicaragua, y fundamentar los esfuerzos de planificación Prioridades de capacitación estratégica de los recursos humanos para la salud dedicados a la atención materna. en el ámbito de la salud Métodos. En este estudio, con sede en Washington, D. C., se empleó una metodología de encuesta transversal para recopilar datos a nivel de país. Entre los meses de octubre del materna para el personal de 2016 y marzo del 2017, la Organización Panamericana de la Salud/Organización Mundial enfermería y otros de la Salud (OPS/OMS) y sus centros colaboradores elaboraron una herramienta para la trabajadores de salud en evaluación de las necesidades. Las representaciones de la OPS/OMS, en colaboración con las autoridades nacionales de salud y otros funcionarios gubernamentales de alto nivel, Colombia, Honduras y realizaron la recopilación de datos. Los datos reunidos incluyeron información sobre la Nicaragua composición, las aptitudes y las prioridades de capacitación de las parteras tradicionales, los agentes comunitarios de salud, las enfermeras tituladas y las enfermeras auxiliares en los tres países del estudio. Los resultados se resumieron en un informe. Resultados. Los datos sobre la composición del personal de salud en los tres países indicaron que se depende de recursos humanos para la salud que presentan escasos niveles de educación y formación, y que la integración de las parteras tradicionales es limitada. En los tres países, el tratamiento de las urgencias obstétricas constituyó una prioridad de capacitación para las enfermeras tituladas, y la detección de los signos de peligro fue una prioridad en el caso de los agentes comunitarios de salud y las parteras tradicionales. Las prioridades de formación para las enfermeras auxiliares variaron sustancialmente entre los tres países y entrañaron la promoción de la salud, la atención pregestacional y prenatal, y las urgencias obstétricas. Asimismo, el número total de recursos humanos para la salud varió considerablemente entre los países. Conclusiones. Depender de personal de salud de escaso nivel formativo es motivo de preocupación, si bien la capacitación en el servicio puede mitigar este problema. Las prio ridades de capacitación están en consonancia con las principales causas de mortalidad materna y los programas formativos de América Latina y el Caribe resultan prometedores para mejorar la calidad de la atención. A largo plazo, la planificación de los recursos humanos para la salud dedicados a la atención materna deberá procurar aumentar la con- centración de profesionales de salud más capacitados.

Palabras clave Recursos humanos; servicios de salud maternal; atención primaria de salud; creación de capacidad; planificación estratégica; América Latina; región del Caribe; Colombia; Honduras; Nicaragua.

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RESUMO Objetivo. Avaliar as prioridades de formação em saúde materna dos recursos humanos na área de atenção primária à saúde entre profissionais de enfermagem e outros profissionais da saúde na Colômbia, Honduras e Nicarágua, a fim de subsidiar Prioridades em formação os esforços de planejamento estratégico de recursos humanos para saúde materna. em saúde materna para Métodos. Foi conduzido um estudo transversal, sediado em Washington, D.C., para coletar dados ao nível nacional. Uma ferramenta de avaliação das necessidades foi profissionais de desenvolvida, de outubro de 2016 a março de 2017, pela Organização Pan-Americana enfermagem e outros da Saúde/Organização Mundial da Saúde (OPAS/OMS) e Centros Colaboradores da profissionais da saúde na OPAS/OMS. A coleta de dados foi concluída pelas representações da OPAS/OMS nos países, em colaboração com autoridades sanitárias nacionais e pessoal de alto escalão Colômbia, Honduras e do governo. Foram coletados dados sobre a composição, as competências e as priori- Nicarágua dades de formação de parteiras tradicionais, agentes comunitários de saúde, enfermeiros licenciados e assistentes de enfermagem nos três países de estudo. Os resultados foram compilados em um relatório. Resultados. Os dados relativos à composição da força de trabalho em saúde nos três países indicaram que eles contam com pessoal com baixo nível de instrução e for- mação, com integração limitada das parteiras tradicionais. Observou-se, nos três países, que a atuação em emergências obstétricas era uma prioridade de formação para enfermeiros licenciados e a identificação de sinais de perigo era uma prioridade para agentes comunitários de saúde e parteiras tradicionais. As prioridades de for- mação para os assistentes de enfermagem foram bastante distintas entre os países: promoção da saúde, cuidados pré-concepcionais e assistência pré-natal e emergências obstétricas. O número total de recursos humanos para a saúde também variou nos três países. Conclusões. É motivo de preocupação ter de contar com profissionais da saúde com baixo nível de formação, porém este problema pode ser reduzido com a capacitação no próprio serviço. As prioridades de formação nos países estudados são condizentes com as principais causas de mortalidade materna e os programas de formação profis- sional da Região da América Latina e Caribe têm potencial para melhorar a qualidade da atenção. O planejamento dos recursos humanos para saúde materna deve visar a longo prazo aumentar a concentração de profissionais que são mais capacitados.

Palavras-chave Recursos humanos; serviços de saúde materna; atenção primária à saúde; fortaleci- mento institucional; planejamento estratégico; América Latina; região do Caribe; Colombia; Honduras; Nicaragua.

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