Nursing
87 Correlating Demographic Data with Preferred Learning Styles to Improve Neonatal Resuscitation Training for Guatemalan Lay Midwives
Ella Baker
Faculty Mentor: Lauri Linder (Nursing, University of Utah)
ABSTRACT
Midwives throughout the world practice in vastly different geographic areas, socioeconomic contexts, and with a variety of resources. Though midwives attend the majority of births across the globe, their role and educational opportunities are not standardized. Training in crucial skills, such as neonatal resuscitation, is often inadequate or inaccessible to midwives with limited literacy in developing countries, such as Guatemala. While the Guatemalan government has offered midwifery training since 1955, the training has failed to change midwife knowledge because they are taught with written materials in Spanish, even though many midwives have limited literacy and speak Mayan dialects. More information is needed about how midwives best learn. This project aims to explore the learning styles of midwives in the context of neonatal resuscitation training with a larger goal of ultimately decreasing neonatal mortality. The project was conducted at Refuge International Health Clinic in San Raymundo, Guatemala, which is a suburban area located approximately 30 kilometers from Guatemala City. The project included 12 midwives with 1 to 46 years of midwifery practice experience. Participants reported a range of literacy from none to an ability to read and write in Spanish, and education levels ranged from elementary school through university. By means of a select-all-that-apply question added to a general demographic survey, the preferred learning styles of the lay midwives were assessed. Response options to the question, “What methods best serve your learning?” included color drawings, black and white drawings, verbal instruction, demonstration, storytelling, written instruction, hands-on practice, verbally repeating what you learned to someone else, acting out what you learned, writing down what you learned, and/or watching a video. Participants could select all methods that applied. The work of this pilot study provided several insights into how this education can be better suited to learner needs. First, more color drawings should be included in distributed written materials. Color drawings were far preferred to black and white drawings by those included in the pilot study. Next, for indigenous participants whose first language is not Spanish, administrators should consider having Kaqchikel translators available, or avoid the use of complex medical terminology if translators are unavailable. From the findings of this study, it is clear that learning is a collaborative process. Program facilitators should regularly evaluate learner preferences and attempt to apply them as possible.
INTRODUCTION
Lay midwives are invaluable figures within maternal and infant health care, and especially so in developing countries. In fact, one study found that “Midwifery-led continuity of care is associated with superior outcomes for women and babies, relative to other models of care” (Hewitt et al., 2021). Despite being essential to the well-being of birthing people, many lay midwives have limited literacy and lack the educational resources that might improve the quality of their care. These birth attendants are highly skilled, but training is often inadequate or inaccessible to low-literacy midwives in developing countries. One notable educational deficit lies in neonatal resuscitation training for lay midwives. While neonatal resuscitation is only necessary in 5-10% of all births, success in lay midwives providing this intervention is not shown in data from developing countries (Wall et al., 2009). In fact, 98% of worldwide neonatal deaths occur in these nations (Carlo et al., 2010). A gaping divide unfortunately persists between desired, and frankly, achievable, neonatal outcomes and the current reality within these countries.
A notable demographic variation also is evident in this population of care providers. Midwives practice in vastly different geographic areas and socioeconomic contexts, and with a varying range of resources available to them. Though midwives practice worldwide, attending the majority of births throughout time and across the globe, their role and educational opportunities are not standardized. While more defined educational standards for midwives are becoming widespread in developing countries, inequities still remain in implementing these standards across nations (Castro Lopes et al., 2016). Quality improvement efforts are not universal, despite a pronounced need. Thus, tailoring the training programs to the unique needs of each group of lay midwives is important. Evaluating traditional teaching methods for lay midwives and revising these methods accordingly is critical to addressing infant and maternal health in developing countries. In turn, respecting diverse learning styles will maximize the educational hours of the trainees, trainers, and will improve the outcomes of such programs. Further emphasis should be placed on building a neonatal resuscitation curriculum that is both accessible and retainable.
Relevant Literature
According to the literature, quality improvement is becoming a greater focus for midwives across the world (Markaki et al., 2019). Midwives are crucial figures in this quality improvement process, as they are strategically situated to make measurable change within the field of women’s and neonatal health. Within Guatemala, lay midwives are present at approximately 80% of indigenous births, and are poised to provide a distinct perspective of the reality within these settings (Lang & Elkin, 1997). Also, many of the births attended by midwives are outside of a hospital, as a recent study found that only half of indigenous women in Guatemala birthed at a designated healthcare facility (Juarez et al., 2020).
Despite their strong presence at most indigenous births, the majority of Guatemalan midwives’ training is through apprenticeships administered by more seasoned lay midwives (Juarez et al., 2020). Unfortunately, more formal trainings offered to Guatemalan lay midwives by the government are written and in Spanish, despite the low-literacy level of many members of this population (Garcia et al., 2018). Little improvement in maternal or infant health outcomes has been shown by these trainings, which have been held monthly by the Guatemalan Ministry of Health since 1955 (Lang & Elkin, 1997). Within other developing countries, neonatal resuscitation curriculum is also shown to be inadequate. One study assessed the efficacy of the World Health Organization (WHO) Essential Newborn Care Course (ENCC) across six developing countries including Guatemala. Of the 62,366 infants included in the trial, no significant decrease in neonatal mortality from baseline was reported after the birth attendants received the WHO ENCC training (Carlo et al., 2010).
Consulting midwives is essential when evaluating the efficacy of administered training, especially in developing countries. One qualitative, narrative inquiry of thirteen Tanzanian midwives regarding reducing incidents of birth asphyxia concluded that “Midwives’ stories are key to understanding their experience, and engagement, listening, interpretation, and understanding can lead to a dialectical relationship between the researcher and research subject” (Becker et al., 2022). A conclusion that can be drawn from this statement is that both researchers and learners should adopt a growth mindset and work collaboratively to change the content of such curriculums for the better.
This idea reflects an anthropological concept from Madeleine Leininger’s Theory of Transcultural Nursing, which is employed to promote cultural awareness and sensitivity (Murphy, 2006). According to the theory, emic knowledge is derived from the local culture, and is generally preferred over etic knowledge, which encompasses the researcher’s perspectives and external ideas (Murphy, 2006). Understanding lay midwives and their history, before bringing in outside concepts, stands to improve the way neonatal resuscitation is taught.
No universal approach exists to address this community of practitioners, which is why demographic information and data on learning styles are key to adjusting the curriculum. In fact, organizations such as the Ministry of Health concur that midwifery education must be adjusted to fit the needs of each individual developing country to best enhance infant and maternal outcomes (Markaki et al., 2019). In these countries, midwives may be the only figures that stand between optimal and catastrophic outcomes. Within nations like Guatemala, midwives are trusted and revered, and in many instances, they are a woman’s primary contact for pregnancy-related complications (Glei et al., 2003). The time to comprehend their unique needs is now.
Purpose
This project aims to address why neonatal resuscitation training is not always translated into practice and decreasing neonatal mortality by communicating directly with a group of lay midwives with limited literacy in Guatemala during their own training on neonatal resuscitation techniques. By means of a select-all-that-apply question added to a general demographic survey, the preferred learning styles of the birth attendants themselves will be assessed. The optimal outcome would be to utilize this information to revise neonatal resuscitation programs in the future to make the training more effective and engaging, and improve retention of the learners. The specific aim of this thesis is to examine which educational methods Guatemalan lay midwives with limited literacy prefer. By delving into the response to the learning styles question, the neonatal resuscitation curriculum could be revised to better accommodate learner needs moving forward. With the proper teaching methods, the birth attendants could improve neonatal outcomes and pass on what they learn to midwives who did not have the opportunity to directly receive the training.
METHODS
Ethics Statement
The University of Utah’s Institutional Review Board granted the study an exempt status and an expedited review (IRB_00154182). Verbal consent, rather than written, informed consent, was obtained from participants due to the limited literacy skills of the participants. This pilot study was part of a larger, quantitative, exploratory study involving a single group to generate descriptive statistics. The larger study examined change in knowledge regarding neonatal resuscitation after a culturally sensitive teaching on the topic. Demographic data were collected for the larger study on only one occasion from a group of twelve lay midwives and the survey administered included a question on preferred learning styles.
Neonatal Resuscitation Training Design
The study was conducted at Refuge International Health Clinic in San Raymundo, Guatemala, which is a suburban area located approximately thirty kilometers from Guatemala City. This project was conducted in partnership with the local Ministry of Health and the nonprofit organization, Refuge International. Refuge International has a local board and has maintained three clinics in Guatemala for twenty years. For recruitment purposes, nurses from the Ministry of Health who hold monthly educational sessions with local lay midwives informed the attendees about the details of this neonatal resuscitation training.
The inclusion criterion for the study was anyone who identified as a midwife. The exclusion criterion for the study was the inability to speak either Spanish, English, or the indigenous language, Kaqchikel. No other exclusion criteria were applied due to the unique learning opportunity provided and the long distance the twelve lay midwives traveled to attend.
Upon arrival at the clinic, coffee and sweet bread were served while the Principal Investigator (PI) explained the purpose of the study. Consent was verbally obtained after program facilitators gave a brief description of the study and participants were told they could leave at any time. Participants were informed that their participation in the training would be regarded as giving consent. No written consent was obtained due to the low-literacy level of many of the study participants.
Next, the participants filled out a demographic survey. The data were collected in the form of a brief, written survey administered by program facilitators. The facilitators assisted participants with low-literacy in providing their responses. The demographic data collected included age, ethnicity (Hispanic or Indigenous), preferred language (Spanish, English, or Kaqchikel), years of midwifery experience, literacy, education level (none, Primary School, Secondary School, High School, College), and whether or not they have had neonatal resuscitation training in the past, and a question on learning styles that was structured as follows:
“What methods best serve your learning? Select all that apply.
- color drawings
- black and white drawings
- verbal instruction
- demonstration
- storytelling
- written instruction
- hands-on practice
- verbally repeating what you learned to someone else
- acting out what you learned
- writing down what you learned
- watching a video
After the demographic survey was completed, a pre-test evaluating prior knowledge of neonatal resuscitation was administered. Then, a twenty-nine minute focus group was conducted to explore what the participants already knew about neonatal resuscitation and needs they may have regarding the topic. The focus group was employed to collect pre-existing, emic knowledge before program facilitators provided outside information about neonatal resuscitation.
Next, an evidence-based, verbal training was given by expert faculty from the University of Utah’s College of Nursing with frequent practice and repetition, for the duration of two hours. After the training, a post-test was given with three questions designed to assess curriculum usability, feasibility, and satisfaction with the neonatal resuscitation content.
To thank them for their participation, each participant received a backpack with neonatal resuscitation and birth supplies. Participants also received a laminated reminder card with colorful images to remind them of neonatal resuscitation priorities along with written steps on the back of the card to reinforce knowledge retention. After the completion of the day’s training, participants and program administrators enjoyed lunch together.
Data Management and Analysis
The Principal Investigator (PI), Dr. Kimberly Garcia, who speaks Spanish and has been working with Guatemalan lay midwives since 2009, translated the surveys and provided information to me. The PI analyzed the demographic data, calculating the percentage of answers regarding learning styles.
RESULTS
Participants
The study sample was twelve, Spanish-speaking lay midwives in Guatemala. They each identified as either Hispanic or Indigenous, had different literacy levels, varying years of schooling and midwifery experience, and had a wide array of ages. Table 1 details the various demographic characteristics of the study population. The mean age of participants was 50.75 (range = 31-72 years). The mean number of years of experience as a lay midwife was 15 (range = 1-46 years). Of the participants, approximately thirty-three percent (four out of twelve participants) reported limited literacy (range = no formal education to elementary education) and approximately sixty-seven percent (eight out of twelve participants) reported they could both read and write (range = elementary education to university level). Of the participants, approximately forty-two percent (five out of twelve participants) reported Indigenous as their ethnicity, and approximately fifty-eight percent (seven out of twelve participants) reported Hispanic as their ethnicity.
Study Sample Characteristics
Table 1. Overview of Demographics and Preferred Learning Styles of Pilot Study Participants
|
Age |
Ethnicity |
Years of Experience |
Can Read and Write |
Education Level |
Survey Response To Preferred Learning Styles Question |
|
70 |
Indigenous |
40 |
No |
Elementary |
color drawings |
|
57 |
Indigenous |
40 |
No |
Elementary |
color drawings, demonstration |
|
31 |
Indigenous |
13 |
Yes |
Elementary |
color drawings |
|
54 |
Indigenous |
17 |
Yes |
Elementary |
color drawings |
|
38 |
Indigenous |
22 |
Yes |
High |
color drawings |
|
70 |
Hispanic |
42 |
No |
None |
color drawings, verbal instruction, demonstration, hands-on practice, verbally repeating what you learned to someone else, acting out what you learned |
|
40 |
Hispanic |
5 |
No |
Elementary |
color drawings, verbal instruction, demonstration, storytelling, hands-on practice, verbally repeating what you learned to someone else, acting out what you learned, watching a video |
|
72 |
Hispanic |
46 |
Yes |
Middle |
verbal instruction, writing down what you learned |
|
60 |
Hispanic |
10 |
Yes |
High |
verbal instruction, written instruction |
|
37 |
Hispanic |
12 |
Yes |
High |
color drawings, verbal instruction, hands-on practice, watching a video |
|
37 |
Hispanic |
1 |
Yes |
University |
verbal instruction |
|
43 |
Hispanic |
4 |
Yes |
University |
color drawings, black and white drawings, verbal instruction, demonstration, storytelling, hands-on practice, watching a video |
Table 2. Ethnicity, Literacy, and Preferred Learning Styles: Frequency and Percentages (*See key below table)
|
Ethnicity |
Can Read and Write |
A. |
B. |
C. |
D. |
E. |
F. |
G. |
H. |
I. |
J. |
K. |
|
Indigenous |
No |
2 (100%) |
0 |
0 |
1 (50%) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Indigenous |
Yes |
3 (100%) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Hispanic |
No |
2 (100%) |
0 |
2 (100%) |
2 (100%) |
1 (50%) |
0 |
2 (100%) |
2 (100%) |
2 (100%) |
0 |
1 (50%) |
|
Hispanic |
Yes |
2 (40%) |
1 (20%) |
5 (100%) |
1 (20%) |
1 (20%) |
1 (20%) |
2 (40%) |
0 |
0 |
1 (20%) |
2 (40%) |
* Table 2 Key
What methods best serve your learning? Select all that apply.
A. color drawings
B. black and white drawings
C. verbal instruction
D. demonstration
E. storytelling
F. written instruction
G. hands-on practice
H. verbally repeating what you learned to someone else
I. acting out what you learned
J. writing down what you learned
K. watching a video
Table 3. Top Three Overall Answers for the Twelve Participants
|
|
|
DISCUSSION
From the data, several conclusions can be drawn. The first notable finding was that all indigenous participants selected color drawings as a preferred learning style. Of all of the participants, 75% selected color drawings as a preferred learning style. Only one (Hispanic) participant selected black and white drawings as a preferred learning style, and that participant also selected color drawings as a preferred learning style. The clear preference for color drawings within the sample is notable, especially in regard to indigenous participants. Of note, many of the educational resources typically provided to Guatemalan lay midwives by the Ministry of Health only include black and white drawings.
It is important to note that studies on multimedia have indicated that images with color may help to improve attention and memory (Dzulkifli & Mustafar, 2013). This indicates that this seemingly arbitrary detail may have a larger impact than expected on learner retention. While cultural considerations such as preferences for color are often disregarded by educational administrators, the simple inclusion of color in teaching materials may appeal to both indigenous and Hispanic participants and improve their retention.
The next finding illuminated by the results of this study was that while all Hispanic participants selected verbal instruction as a preferred learning style, none of the indigenous participants selected this option. This is significant because, though all Kaqchikel-speaking, indigenous participants reported they were fluent in Spanish, verbal instruction in Spanish may not be most suitable for their learning. In one study regarding Ministry of Health-led midwifery training, “Nearly all participants endorsed Kaqchikel-Spanish language barriers as a major determiner of the quality of the training sessions they attended” (Chary et al., 2013).
Medical jargon, complex enough in Kaqchikel, proved even more difficult to understand in Spanish, the indigenous participants’ second language (Chary et al., 2013). As none of the participants in this thesis’ pilot study cited verbal instruction as a preferred learning modality, it could be worthwhile to explore developing a neonatal resuscitation curriculum in Kaqchikel. If this is not possible, perhaps learning objectives could be explained in more common terms, and through physical demonstration. As much of indigenous lay midwives’ training is completed through apprenticeship, convoluted medical terminology in their second language is likely not appropriate for the best learning outcomes.
The median number of preferred learning styles selected by Hispanic participants was four, whereas the median number of selections for indigenous participants was only one. This finding may further suggest the intimate relationship between language and teaching styles. With current teaching methods, it is difficult to separate the two, so alternative solutions to verbal instruction in Spanish should be sought. The results of this thesis seem to confirm the conclusions of much of the previous literature on Guatemalan lay midwives and their education. Cultural considerations and language barriers matter. It is time to account for them and propose solutions such as including more color drawings and content in Kaqchikel using common terminology and demonstration as principal educational modalities.
Limitations
The key limitation of this study was the small sample size of participants. Only twelve lay midwives attended the training. This is a very minimal representation of the nation’s midwifery workforce as the Guatemalan government recognizes over 22,000 traditional midwives (Janetsky, 2022). To provide a more comprehensive sample, more midwives from different areas in Guatemala should be included in the study.
Also, only a single instance of data collection occurred, at the beginning of the training, and the next opportunity for reassessment is nearly a year from the time of the original pilot study. Since the data were collected before the training was completed, the midwives may have had different opinions on what learning style works best for them after they received the training.
Implications for Nursing
A central principle of quality nursing practice is patient-centered care. In the same way that knowing a patient’s unique needs and preferences, then incorporating them into the treatment plan is key to best practice, the same principle should be applied to learners. The results of this pilot study illuminate the necessity of treating lay midwives as individuals, rather than following a prescriptive and dated approach to educational training. These findings reaffirm the necessity of cultural humility and a solid understanding of the importance of health literacy while educating lay midwives across the globe. Accounting for language barriers and cultural preferences has already been proven to empower patients. The same principle could be translated into educational strategies for those who care for patients. Furthermore, it has been proven that monthly governmental training is not meeting the educational needs of lay midwives. More global health grants that incorporate research targeted at understanding how to fortify traditional birth attendants’ skills should be proposed.
Directions for Future Research
The most immediate follow-up study for this project would be to re-evaluate the retention levels of neonatal resuscitation protocol during the PI’s next visit to Guatemala. The original participants could also revisit their original answers to the survey question on learning styles, to see what change has occurred over the course of a year. On a larger scale, future research into this topic may include a broader study of lay midwives across several developing countries with high rates of neonatal mortality. More participants should also be recruited to provide a more comprehensive portrait of traditional birth attendants across the globe and how they best learn.
Implications for Policy
An implication for policy that may be proposed as a result of this project is to include more accommodations within Guatemalan governmental training for traditional birth attendants with limited literacy. Color drawings should be a mandatory component of any written material the lay midwives receive during their monthly training with the Ministry of Health. Furthermore, Kaqchikel translators should be, at the very least, readily available to answer lay midwife questions during these training sessions. It could also be worthwhile to explore developing a neonatal resuscitation curriculum in Kaqchikel.
Conclusion
Education for lay midwives in developing countries on neonatal resuscitation can be further optimized to improve outcomes and learner retention of the curriculum. In countries like Guatemala, where the neonatal mortality rate is already high, teaching those who can intervene and apply neonatal resuscitation techniques is vital. The work of this pilot study provided several insights into how this education can be better suited to learner needs. First, more color drawings should be included in distributed written materials. Color drawings were far preferred to black and white drawings by those included in the pilot study. Next, for indigenous participants whose first language is not Spanish, administrators should consider having Kaqchikel translators available, or avoid the use of complex medical terminology if translators are unavailable. From the findings of this study, it is clear that learning is a collaborative process. Program facilitators should regularly evaluate learner preferences and attempt to apply them as possible.
REFERENCES
Becker, J., Becker, C., Oprescu, F., Wu, C. J., Moir, J., Shimwela, M., & Gray, M. (2022). Silent voices of the midwives: factors that influence midwives’ achievement of successful neonatal resuscitation in sub-Saharan Africa: a narrative inquiry. BMC pregnancy and childbirth, 22(1), 39. https://doi.org/10.1186/s12884-021-04339-7
Carlo, W. A., Goudar, S. S., Jehan, I., Chomba, E., Tshefu, A., Garces, A., Sailajanandan, P., Althabe, F., McClure, E. M., Derman, R. J., Goldenberg, R. L., Bose, C., Krebs, N. F., Panigrahi, P., Buekens, P., Chakraborty, H., Hartwell, T. D., & Wright, L. L. (2010). Newborn-care training and perinatal mortality in developing countries. New England Journal of Medicine, 362(7), 614–623. https://doi.org/10.1056/nejmsa0806033
Castro Lopes, S., Nove, A., ten Hoope-Bender, P., de Bernis, L., Bokosi, M., Moyo, N. T., & Homer, C. S. (2016). A descriptive analysis of midwifery education, regulation and association in 73 countries: The baseline for a post-2015 pathway. Human Resources for Health, 14(1). https://doi.org/10.1186/s12960-016-0134-7
Chary, A., Díaz, A. K., Henderson, B., & Rohloff, P. (2013). The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis. Midwifery, 29(8), 852–858. https://doi.org/10.1016/j.midw.2012.08.011
Dzulkifli, M. A., & Mustafar, M. F. (2013). The influence of colour on memory performance: a review. The Malaysian journal of medical sciences : MJMS, 20(2), 3–9.
Garcia, K., Dowling, D., & Mettler, G. (2018). Teaching Guatemalan traditional birth attendants about obstetrical emergencies. Midwifery, 61, 36–38. https://doi.org/10.1016/j.midw.2018.02.012
Glei, D. A., Goldman, N., & Rodrı́guez Germán. (2003). Utilization of care during pregnancy in rural Guatemala: Does obstetrical need matter? Social Science & Medicine, 57(12), 2447–2463. https://doi.org/10.1016/s0277-9536(03)00140-0
Hewitt, L., Dahlen, H. G., Hartz, D. L., & Dadich, A. (2021). Leadership and management in midwifery-led continuity of care models: A thematic and lexical analysis of a scoping review. Midwifery, 98, 102986. https://doi.org/10.1016/j.midw.2021.102986
Janetsky, M. (2022, March 29). To save lives, midwives mix Mayan heritage with Western medicine. National Geographic. Retrieved January 2, 2023, from https://www.nationalgeographic.com/culture/article/to-save-lives-midwives-mix-mayan-heritage-with-western-medicine
Juarez, M., Juarez, Y., Coyote, E., Nguyen, T., Shaw, C., Hall-Clifford, R., Clifford, G., & Rohloff, P. (2020). Working with lay midwives to improve the detection of neonatal complications in rural Guatemala. BMJ Open Quality, 9(1), e000775. https://doi.org/10.1136/bmjoq-2019-000775
Lang, J., & Elkin, E. (1997). A study of the beliefs and birthing practices traditional midwives in rural Guatemala. Journal of Nurse-Midwifery, 42(1), 25–31. https://doi.org/10.1016/s0091-2182(96)00069-9
Markaki, A., Moss, J., Shorten, A., Selleck, C., Loan, L., McLain, R., Miltner, R., Patrician, P., Theus, L., Ferrer, L., Góes, F., Valenzuela-Mujica, M. T., Zarate-Grajales, R., Cassiani, S., & Harper, D. (2019). Strengthening universal health: development of a nursing and midwifery education quality improvement toolkit. Revista latino-americana de enfermagem, 27, e3188. https://doi.org/10.1590/1518-8345.3229.3188
Murphy S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association : JMLA, 94(2 Suppl), E143–E151.
Wall, S. N., Lee, A. C., Niermeyer, S., English, M., Keenan, W. J., Carlo, W., Bhutta, Z. A., Bang, A., Narayanan, I., Ariawan, I., & Lawn, J. E. (2009). Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up?. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 107 Suppl 1(Suppl 1), S47–S64. https://doi.org/10.1016/j.ijgo.2009.07.013