A Swiss-Malagasy partnership

Adapting an ESTHER partnership in response to COVID-19

In February 2020, just as the Coronavirus disease was setting out on its trip around the world, representatives of Geneva University Hospital (HUG) and Ambanja Referral District Hospital in Madagascar were finishing their application for a CHF 99,677 partnership grant from ESTHER Switzerland. In a section on Risks and Mitigation, applicants were asked to list the probability of “natural disasters or the outbreak of epidemics which could delay the implementation of activities”.

“We never thought about an outbreak,” says Project Leader Caroline Benski of HUG. “It was absolutely not on our minds.”

Published: 07. April 2021, Author: Jeannie Wurz

The new partnership—”Integrated obstetric simulation training to improve respectful maternity and newborn care in Madagascar”—was designed to address the high rate of maternal mortality in the country, where there are 353 deaths/100,000 live births, and 6 out of 10 births occur at home.

An assessment of the hospital’s needs had identified lack of training, poor compliance with guidelines, an unsafe and unsupportive work environment, lack of motivation, and healthcare providers’ negative attitudes toward mothers and families.

In addition, there was a clear need for improved communication, such as who to call during an emergency, what information to communicate to the women, and what procedures to follow when communicating with each other, the midwife, the doctor, the anaesthetist (if there is one) and the lab.

Change of plans

The partnership had originally consisted of three parts: on-site training of 35 healthcare providers of basic emergency obstetric and neonatal care and 10 providers of comprehensive emergency obstetric and neonatal care in the Ambanja District Hospital, on-site support and supervision, and small-group simulations using mannequins. “We initially planned to implement the training on respectful care as a component of onsite training provided by HUG,” says Dr. Cecilia Capello of Enfants du Monde (EdM), a Geneva-based NGO and partner institution. “When the first COVID wave hit the world, the partners realised a mission would probably be impossible. We changed our strategy from an on-site course to a distance learning course.”

As COVID-19 continued to spread, however, it became clear that many other aspects of the project would have to be reorganized. Instead of high-fidelity mannequins Mama Nathalie and Baby Nathalie, low-fidelity mannequins consisting of only a uterus, a placenta and a baby were ordered. Instead of four project members traveling from Geneva to Ambanja to conduct simulation trainings, eight trainers were recruited from the area around the country’s capital using virtual interviews, and remote oversight of training was organised via HUG in Switzerland. The number of participants was reduced from 40 to 14.

While HUG trained the team of local trainers and made the necessary adjustments to start the obstetric simulation training in 2021, Enfants du Monde produced an e-learning course consisting of four modules on respectful maternal and newborn care. This was created in 60 days and translated into Malgache—the country’s second official language. It began with a newly created module on COVID-19, designed for 30 healthcare providers working in maternal and newborn health.

Expanding to handle the COVID crisis

Although the focus of the ESTHER partnership was on maternal and newborn health, the partners also served as a source of information about COVID-19.

The partners produced two posters and a video for healthcare workers who were uncertain how to help their patients.  This included an explanation of simple barrier protection to avoid the spread of infection: how to wear a mask, how to use gloves, how to separate women at risk from women not at risk.

“They will not have personal protective equipment for sure, in the northwest of Madagascar where they don’t have water or electricity, says Benski. “But if they have masks and gloves and can use them properly, it can help a lot.”

Members of the partnership appreciated the information. “Even though we thought we already knew everything about [COVID], this training has given us new knowledge,” says Dr. Paulin R. Manjary, Clinical Mentor for the Ambanja District Hospital. “For example, that to protect ourselves against the virus responsible for COVID-19 we should not touch the mask when we are wearing it.”

Challenges of remote learning

Distance learning still has handicaps for the transmission of know-how, says REJELA NELLY Evella Fréchette of the Madagascar Ministry of Public Health. “Online trainers here in the country need to become familiar with the technology and foster communication, collaboration and interaction between distance trainers,” she says. “In order to implement the teaching and evaluation methods, they need to acquire distance facilitation skills and learn to use telecommunication tools which are not necessarily available in Madagascar.”

Lessons learned

Overall, however, the partners were able to function in spite of the restrictions created by COVID, says Vonimboahangy Rachel ANDRIANARISOA, head of the department Maternity Without Risks in Madagascar’s Ministry of Public Health in Antananarivo. “Despite the fact that the health situation does not allow for physical presence, the team was always able to communicate with each other, in small doses, but very frequently, for the preparation of the activity to be implemented.” The partnership led to a new way of working, including “the habit of checking emails and not waiting to be overwhelmed by events,” she says.

Likewise, Cecilia Capello feels that so far the partnership “has been a great learning platform”, giving its participants an opportunity to grow and adapt. “We have developed the skill of adjusting rapidly to a changing context, strategically, pedagogically, and operationally,” she says. “And we have developed strong links with the local hospital team, learning to fully rely on them in implementing every step of the project.”

For Caroline Benski as well, the partnership has been a positive experience. She is happy with the way the members have responded to the pandemic. “How we tried to change, and innovated. The way we structured the project. The way we involved our partners. The way we interacted among ourselves.”

Future collaboration

There were both pro’s and cons in the new situation, according to Vonimboahangy Rachel ANDRIANARISOA. The costs of distance learning were lower than the costs of in-person learning, but “we missed the personal contact. Face-to-face discussions are more enriching and more human.”

In the end, however, she feels that “there are always benefits to be gained from a collaboration. “The combined efforts of [all parties] contribute to the achievement of the goal.”

Cecilia Capello: The Lesson Plan
We produced the training materials in two months, from mid-September to mid-November. This included adaptation of the online material to the Malgache context, translation of the entire contents into Malgache, development of the Storylines by a consultant, creating the platform and uploading the final content to it, development of guides for the local facilitators and for the participants, and development of a quiz. During this time, a local team helped us enormously, facilitating the training at the local level and helping us during the Zoom.