Training of Trainers (TOT) Workshop on Essential...

In Collaboration With MOH and MOHE in Iraq and MOH in JordanAl- Bashir Hospital / Amman – Jordan

Training of Trainers (TOT) Workshop on

Essential New Born Care7th – 18th of January 2007

World Health Organization 2006@

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Joint WHO/UNICEF TOT Workshop, Amman 7-17 January 2007 2

WHO / UNICEF Training of Trainers (TOT) Workshop

On Essential New Born Care

In Collaboration

With MOH and MOHE in Iraq and MOH in Jordan

From the period 7th – 18th of January 2007 Al‐ Bashir Hospital / Amman – Jordan


The scope of the Course WHO and UNICEF organized jointly the first WHO TOT on Essential Newborn Care Course in Amman for the period 7‐18 January 2007 for 35 Iraqi professionals. It was part of the support that WHO Country Office Iraq is providing to strengthen Maternal and Child Care, co‐funded by UNICEF and organized in collaboration with the Ministry of Health and Ministry of High Education in Iraq and the Ministry of health in Jordan. The workshop was held at the Al Basher Hospital, a large public tertiary level hospital with around 10 000 deliveries per year and a training centre for postgraduate students. In view of the high neonatal mortality in Iraq, this course will assist the main training institutions to build capacity for neonatal care at the primary care level including routine care of the normal newborn and care for complications as well as transport of the sick neonate to referral institutions. These activities are part of the Maternal, Child and Reproductive Health Strategy 2005‐2008 in Iraq. Objectives To improve care and health of the newborn by health providers by:

o Introducing evidence based interventions (as described in the Pregnancy, Childbirth, Postpartum and Newborn Care‐PCPNC ,a guide for essential practice)

o Using a variety of teaching methods. o Hands on practice.

To build capacity of national facilitators.


Expected Outcome: • clinical skills on essential newborn care acquired • Case management skills of health professionals improved. • National facilitators on newborn care provided

Course description:

• The course is based on the newborn sections of Pregnancy, Childbirth and Newborn Care (PCPNC).

• Activities and teaching methods include lecture presentations, demonstrations, pair and group work, role play, clinical practices, discussions, practice reviews and study exercises (case studies).

• The course was held at the Al Basher Hospital, a large public tertiary level hospital with around 10 000 deliveries per year and a training centre for postgraduate students.and clinical practices take place in the delivery room and on the ward with real babies and mothers.

• The course material is in English. It is comprehensive and was distributed on a CD;

• The course was organized in two parts(2 weeks course): 1‐First week ( 8‐12 January): a 5 days TOT for ENCC for 15 highly qualified neonatologists, paediatricians and nurses from Medical and Nursing colleges working in teaching hospitals in six governorates(Baghdad, Mosul, Erbil, Kirkuk, Diwania and Basra) who were trained to be the future facilitators. The participants were nominated by MOHE and the training course was facilitated by WHO/HQ staff and consultants.

2‐ Second week (14‐ 18 January 2007): 5‐day course for the target audience – 7 (Nurses and Midwives,) and 9 (Doctors) ‐Total 16, from Maternity and Teaching Hospitals. 14 participants were not able to attend the course from other governorates due to various social and security reasons. This course was facilitated by national facilitators


from the first week TOT course under the supervision of WHO facilitators. Background of participants were Paediatricians and Nurses working in Maternity and paediatrics hospitals from Baghdad, Mosul, Erbil, Salah Aldeen, Karkuk, Babil and Dialah

• The facilitators were: ‐Ms. Sandra Lang, Lecturer at Institute of Child Health, UK who had developed the course contents

‐Dr. Ornella Lincetto, Paediatrician, WHO/HQ The workshop was also attended by 4 clinicians from Al Basher Hospital, 2 participants from UNICEF Iraq country program and Dr Faiza Majeed, Country Office Iraq who provided valuable programmatic and logistic support. The agenda and the list of participants are attached at (annex I and annex II respectively). Training methodology: The TOT in ENC is skilled‐based and conducted in line with the adult participatory learning techniques using a variety of teaching methods including demonstrations, presentations, clinical practice, role play and discussions. It covers the main areas of basic Neonatal care including care at birth, initiating and supporting early Breastfeeding, Thermal Control, Examination of the Normal Newborn, Neonatal Resuscitation, Kangaroo Mother Care, Communication Skills and Special Care for the Low Birth‐Weight Baby. It included the following methods: Reading sessions:

• Reading • Individual feedback • Role play


• Video sessions • Demonstration • Group discussions

Clinical sessions:

Inpatient sessions Outpatient sessions

Brief summary on the course

On the first day, participants were introduced to the content and structure of the course in plenary and then were divided into two groups, one facilitated by Sandra Lang and the second facilitated by Ornella Lincetto. The first day focused on course administration, teaching materials and methodology, including a thorough presentation on how to use WHO guidelines ‐ Pregnancy, Childbirth, Postpartum and Newborn Care.


During the next four days participants had the opportunity of

practising various teaching methods and leading clinical practices. This ensured a hands‐on training for the participants who would eventually train health providers at the country level. International facilitators provided guidance on the course to participants and

additional inputs in particular in relation to the evidence base of WHO recommendations and the options for replicating the course in the country.

During the TOT the participants were made aware of the importance and the evidence base of the key interventions needed to improve neonatal survival. While some of them were initially expecting a course on advanced technology, all agreed at the end of the week on the importance of strengthening essential care as a basis to ensure care for all newborn babies at primary level and to improve quality of care at referral level.

The role of facilitators was to provide support and strengthen their capacity to conduct the course in an efficient and interesting manner as well as to organize future courses on their own.

The organizing team at Al Basher Hospital provided excellent support for the course, providing facilities and clinicians to facilitate the training.

The comparison between WHO recommendations and the observed practices in the hospital offered an opportunity to discuss more in depth the scientific evidence and the expected outcomes from the implementation of the recommendations of the ENC.

The second week TOT course was facilitated by Ms Sandra lang and Dr. Faiza Majeed

Despite the availability of high technology for newborn care in the hospital, the clinical practices related to maternal and newborn care at delivery and in the postpartum period both for routine and special care, were not of good quality and differed from those recommended in the ENC course.

The results of the evaluation forms that were distributed to the participants is as per attached (Annex III)

The closing session was attended by key officials from MoH, MOHE and Director of Al basher hospital.


The ToT course was followed by a two days meeting 19‐20 January

2007 with the key facilitators from all governorates with the following objectives and recommendations:

Objectives ‐ Situation Analysis including:

o Current practices to obtain baseline data. o Expected interventions to improve the current practices and

outcomes. ‐ Plan of Action for 2007. (See Annex IV)

Conclusions and Recommendations of the meeting

Coordination of implementation of Plan of action for the essential

newborn care with the existing MCH/RH scientific committee at MoH. Orientation workshops for all stakeholders at central and governorate

level. To conduct situation analysis to obtain baseline data at institutional

and community level. Introduction of the essential Newborn care training package into

medical and nursing pre‐service and post graduate training to encourage research work in the area of newborn care.

Introduction of the essential Newborn care training package for all post graduate health professionals caring for mothers and babies from birth and during in first days after delivery.(This should include health care providers of maternity services in the community which covers Skilled birth attendants ,TBAs and Midwives)

Review the Arabic version of PCPNC guide with the second English version of PCPNC.

Implementation of the MCH/RH plan of action 2005‐2008 which includes the activities and interventions regarding Newborn care services.

Implementation of the components of Infant and Young child Feeding strategy(IYCFS) which support the essential newborn care practices (i.e. BFHI and further community support for mother during Antenatal and post natal care.


Improve care for babies with weight between 1500‐ 2500 gm with

WHO technical support. Adoption of Kangaroo mother practice in Iraqi health facilities with

WHO technical support. Provision of training materials, supplies and equipments. Conduct the second Training of Trainers (TOT) workshop on essential

Newborn care in Erbil for 24 Iraqi participants from all governorates by the 13 Master trainers during 2007.

To conduct consultation meeting in July 2007 with the Iraqi Master trainers with WHO technical support to review the situation analysis report, second TOT workshop and the implemented activities during the previous six month and discuss the future plans and activities for the coming six months at governorate level

Formulation of the central Consultation committee newborn care Recommendations for improving the course

Recommendations related to the materials of the TOT in ENC. Correct reference pages on the CD Rom according to the new version of the PCPNC. Add Cochrane Reviews and additional sources of evidence to the reference materials. Improve and expand video and photo material. Use colour coding for separating modules or parts of the course which have different functions (e.g. clinical practices, training modules, etc.).

Recommendations related to the dissemination of the ENCC.

For future TOT with more than 8 trainees ensure the participation of two facilitators to provide supervision and support for the second TOT week.

The need of WHO technical assistance for conducting sub national training courses in Iraq.

Develop a monitoring and evaluation system to follow‐up and to

document changes in practices.


Additional support from WHO will be beneficial to create the visibility

and support needed to effectively replicate the course and in particular to introduce changes in practices.

In relation to the course materials,

More work is needed to improve the CD Rom, Improve some of the videos Consider to add pictures to describe less common situations that cannot be observed in clinical practice,

Ensure that all links work properly Explore the possibility of colour coding sections for separating modules or parts of the course which have different functions, expand the list with sources of evidence.

Finally, given the amount of photocopying that each course is

requiring, it could be useful to discuss alternative options for the dissemination of the course in the future and their related cost.


Annex 1 Suggested timetable 1 – Preparation week for the Training of Trainers Course Joint WHO/UNICEF Training of Trainers (TOT) workshop on essential New Born

Care In Collaboration with

MOH and MOHE in Iraq and MOH in Jordan From the period 7 – 17 January 2007 Al‐ Bashir Hospital/ Amman – Jordan

Day 1

Administration issues

Day 2 ENCC training day 1

Day 3 ENCC training day 2

Day 4 ENCC Training day 3

Day 5 ENCC Training day 4

Review of Day 1 (10 mins)



08.30 Welcome and introduction (30 mins) WHO representative and UN health Cluster Manager

3 Care of the newborn baby at the time of birth

7 Examination of the newborn baby

10 Breastfeeding the newborn baby: overcoming difficulties

12 The small baby

09.30 Introduction to course materials and methods

Session discussion

Examination recording form

9 Routine care of the baby

11 Alternative methods of feeding

10.30 Break 4 Keeping the baby warm

Clinical practice discussion

Clinical practice (60 mins) 3

11.00 1 Intro to PCPNC (60 mins)

Practice review (30 mins

14 Kangaroo mother care

Demonstration of teaching styles (60 mins) Teaching plan for trainees during the preparation week

Clinical Practice (60 mins) 1

Clinical Practice (40 mins) 2 Practice review (30 mins)

Clinical practice checklists (30 mins)

Clinical practice (60 mins) 4

12.00

30 (mins) Practice review (30

13.00 Lunch


Visit to the clinical area (30 mins)

Session discussion (30mins)

6 Communication skills

8 Resuscitation ‐ Theory

Preparation for teaching Discussion of second week

Teaching plan for second week

14.00

Discussion of clinical practice organisation(60 min) Breastfeeding observation form 1

5 Breastfeeding and the newborn baby: Ensuring a good start Breastfeeding Observation form 2

Resuscitation – Practical

Preparation for week 2

15.30 Break Practice review (30 mins)

Teaching review Action plans & practice review (40 mins)

15.45 16.45

Preparation for teaching (60 mins)

Teaching review (30 mins)

Review of progress (60 mins)

Teaching review (30 mins)


Annex 2

Joint WHO/UNICEF Training of Trainers (TOT) workshop on essential New Born Care

In Collaboration with MOH and MOHE in Iraq and MOH in Jordan

From the period 7 – 17 January 2007 Al‐ Bashir Hospital/ Amman – Jordan

Day 1: Sunday 14 January 2007

WHO facilitators: Ms. Sandra Lang Dr. Faiza A. Majeed

National Facilitators Time Session Group 1 Group 2

08.30 Welcome and opening ceremony ‐ UN health Cluster Coordinator - MoHE/MoH Iraq Representative‐ Introduction to

the course - Ministry of Health/Jordan - UNICEF Representative

WR. Dr. Naeema Al gasseer Dr. Mahjob Al Nadawi Dr. Mohammed Al Rawabda Dr. Alex Malyavin

09.30 Introduction to PCPNC All groups Dr. Ziyad

10.30 Break 11.00 Universal precautions All groups

Dr. Thanoon 11.30 Keeping the baby warm (alternative session outline) in

clinical area/deliveries Dr. Ziyad Dr. Nazar

13.00 Lunch 14.00 Care of the newborn baby at the time of delivery Dr. Abbas

Dr. Lamia Dr. Layla Dr. Suhad

15.00 Break 15.30 Care of the baby at the time of delivery Dr. Abbas

Dr. Lamia Dr. Layla Dr. Suhad

16.00 Facilitators/trainers meeting All groups

Day 2 Monday 15 January 2007

08.30 Review of Day 1 09.00 Communication skills Dr. Lamia Dr. Rajaa

Dr. Aliaa 10.30 Break 11.00 Clinical practice 1 Deliveries Dr. Fakir

Dr. Awaz Dr. Layla Dr. Suhad


13.00 Lunch 14.00 Practice review Dr. Fakir

Dr. Awaz Dr. Layla Dr. Suhad

15.00 Break 15.30 Breastfeeding and the newborn baby: ensuring a good

start Dr. Awaz Dr. Aliaa

Dr. Salwa 16.30 Facilitators/trainers meeting All groups

Day 3 Tuesda16 January 2007

08.30 Review of day 2 09.00 Examination of the newborn baby Dr. Nahla Dr. Mahjob

Dr. Rahman 10.30 Break 11.00 Clinical practice 2 Dr. Nahla

Dr. Thanoon Dr. Nazar Dr. Rajaa

12.30 Practice review Dr. Nahla Dr. Thanoon

Dr. Nazar Dr. Rajaa

13.00 Lunch 14.00 Resuscitation Dr. Nahla

Dr. Ali Dr. Rajaa Dr. Aliaa

15.00 Break 15.30 Resuscitation Dr. Nahla

Dr. Ali Dr. Rajaa Dr. Aliaa

16.30 Facilitators/trainers meeting All groups

Day 4 Wednesday 17 January 2007

08.30 Review of day 3 09.00 Routine care of the newborn baby Dr. Abbas

Dr. Ziyad Dr. Mahjob Dr. Layla

10.30 Break 11.00 Clinical practice 3 Dr. Abbas

Dr. Lamia Dr. Rahman Dr. Aliaa

13.00 Lunch All groups 14.00 Practice review 15.00 Break All groups 15.30 Breastfeeding and the newborn baby: Overcoming

difficulties Dr. Awaz Dr. Suhad

16.30 Facilitators/trainers meeting


Day 5 Thursday 18 January 2007

08.30 Review of day 4 08.45 The small baby Dr. Lamia Dr. Rahman

09.45 Kangaroo mother care+ Alternative methods of feeding Dr. Nahla

Dr. Lamia Dr. Salwa Dr. Nazar

10.45 Break 11.15 Clinical practice 4 Dr.Mahjob

Dr. Salwa Dr. Ziyad Dr. Ali

13.00 Lunch 14.00 Practice review and action plans All groups 15.00 Break 15.30 Certificate and closing ceremony 16.30 Facilitators/trainers meeting


Annex 3 Joint WHO/UNICEF Training of Trainers (TOT) workshop on essential New Born



PLAN OF ACTION ON ESSENTIAL NEWBORN CARE SERVICES 2007 Activities/Interventions Expected

Outcome Timetable Executors Estimated

cost US$ Remarks

Formulation of the central committee at MOH, MCH committee

‐orientation of all stakeholders and compilation of data ‐monitoring and Supervision

January 2007

MoH MOHE

‐‐‐‐‐‐

Formulation of Peripheral committees at Governorate level(DOH)

Follow up the implementation of Plan of action including situation analysis data collection by prepared qaustionar

January 2007

MoH and MOHE

‐‐‐‐‐‐‐‐ 3‐4 persons from each governorate including the nominated focal point

Identification of focal point at institutional and PHC Sectors at governorate level

Plan of action followed and implemented in coordination with the peripheral committees

January 2007

MoH and MOHE

‐‐‐‐‐‐‐‐‐

Data Collection (Rapid assessment of health facilities)

situation analysis on Newborn care service at institutional and community level obtained

February –March 2007

MoH and MOHE WHO UNICEF

5,000

‐From Hospital registry ‐ Questionnaire

‐Training of Trainers(TOT)Workshop on Essential Newborn care for physicians and nurses from MoH and MoHE in Erbil

‐Two Master trainers at each Governorate(Total 36) ‐

End March‐Early April 2007

MoH/MoHE WHO UNICEF

40,000 Two training of trainers Workshop


Introduction of the essential Newborn care guidelines to clinical session of medical college Curriculum

Students of Medical and nursing colleges trained on Essential Newborn care guidelines

2006‐2007 MoHE WHO

Development of Educational Materials

IEC leaflets and posters developed

April‐May 2007

MoH/MoHE WHO UNICEF

15,000

Provision of Training Material

‐ Dolls, ‐ Mannequin ;and ‐ Training modules

February 2007

WHO UNICEF

100,000

‐One set(Manikin and ambo bag for each governorate) Total: 16 set WHO provided four for the training course ‐ Printing of Training modules

Follow up trainers by the central committee Monitoring and evalution

‐Impact of implementation

During 2007

MoH DOH

30,000

‐Conducted 4‐6 weeks after each training ‐Cost includes transportation and residence

Quarterly meeting of the Central committee and master trainers

Assessment of the implementation process and progress made

Q1‐Q2 2007

MoH,MOHE DOH

National Training activities at each governorate

Health professional at maternity and neonatal wards trained on essential newborn care

June‐december 2007

MoH,MOHE WHO UNICEF

5,000 /each course X19 Total cost US$95,000

Grand Total US$ 285,000


Annex 2

Joint WHO/UNICEF Training of Trainers (TOT) workshop on essential New Born



41 PARTICIPANTS

IRAQ 29 participants from Iraq – MOH, Nursing and Medical Colleges and Hospitals

JORDAN

4 from Jordan‐ MOH ,

3 from UNICEF

5 from WHO


Evaluation of TOT Essential Newborn Care A‐Evaluation of the Training sessions For each session listed in the left column, the following remarks were registered from the evaluation Questionnaire as mentioned by the participants. Title of session Very useful Useful Not

useful Remarks

Introduction to PCPNC 8(47%) 9(53%) Universal precautions

8(47%) 8(47%) 1(6%)

Care of the newborn baby at the time of birth

14(82.3%) 3(17.7%)

Keeping the baby warm

14(82.3%) 3(17.7%)

Breastfeeding the newborn baby: ensuring a good start

16(94%) 1(6%)

communication skills

7(41.2%) 10(58.8%)

Examination of the baby

15(88.2%) 2(11.8%)

Resuscitation of the newborn baby/practice

13(76.4%) 3(17.6%) 1(6%) More clinical practice needed in the wards

Routine care of the newborn baby

13(76.4%) 3(17.6%) 1(6%)

Breastfeeding and the newborn baby: overcoming difficulties

13(76.4%) 3(17.6%) 1(6%)

Alternative methods of feeding a baby

7(41.2%) 10(58.8%)


The small baby

14(82.3%) 2(11.7%) 1(6%)

Kangaroo‐mother care

8(47%) 5(29.5%) 4(23.5%) Difficult to apply in our country

Clinical Practice tasks

12(70.6%) 5(29.4)

5 Practice review

11(64.7%) 5(29.4) 1(6%)

5 Daily review

11(64.7%) 5(29.4) 1(6%)


B‐ Questions in the evaluation form 1‐ What did you think of the overall level of the course? Was it:

• Difficult (2) • Easy (11) • About right (4) Any other comments? • Highly concentrated course • Not enough time. Need for a longer duration • Some participants had difficulty in understanding English • Difficulties in following the PCPNC guidelines

2‐ Did you find the trainers easy to understand?

• Yes (16) • No (1)

3‐ Did you find the sessions were in a logical order? • Yes (11) • No (6)

4‐ What additional support, if any, do you think you may need after this training course to enable you to improve the newborn care in your own facility?

• Training of Doctors and nurses to improve their skills on Essential Newborn Care

• A need to an advanced course on Newborn care.

• Provision of training materials.

• Financial support for National Training Activities.

• Provision of supplies in such as thermometers for room temperature and ambo bags.

• Use of audio visual channels to raise awareness in the community on newborn care.


5‐ a) what were the best parts of the course? And why?

• Care for the Newborn and resuscitation, new way of training • Breast feeding. It is important for the nurses and midwives in labor

wards. • Clinical sessions are very important • Good discussions during the presentations by facilitators • Immediate care for the newborn after delivery will lead to reduction

in mortality rate. b) What were the worst parts of the course? And why?

• Long daily working schedule. • Kangaroo Method is difficult to apply in our community

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