{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T03:44:51Z","timestamp":1774583091638,"version":"3.50.1"},"reference-count":31,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2014,7,24]]},"published-print":{"date-parts":[[2014,8]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>The \u2018enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa\u2019 (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A mixed methods process evaluation with the predominate methodology being qualitative.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>54 EmONC NPCs with 3\u2005years\u2019 plus experience.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Intervention<\/jats:title>\n                    <jats:p>Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2014-005751","type":"journal-article","created":{"date-parts":[[2014,8,13]],"date-time":"2014-08-13T09:52:53Z","timestamp":1407923573000},"page":"e005751","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":18,"title":["Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation"],"prefix":"10.1136","volume":"4","author":[{"given":"David R","family":"Ellard","sequence":"first","affiliation":[{"name":"Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wanangwa","family":"Chimwaza","sequence":"additional","affiliation":[{"name":"College of Medicine, Malawi University, Blantyre, Malawi"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Davies","sequence":"additional","affiliation":[{"name":"Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joseph Paul","family":"O'Hare","sequence":"additional","affiliation":[{"name":"Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Francis","family":"Kamwendo","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynaecology Department, Malawi University, College of Medicine, Blantyre, Malawi"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Siobhan","family":"Quenby","sequence":"additional","affiliation":[{"name":"Division of Reproductive Health, Warwick Medical School, The University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frances","family":"Griffiths","sequence":"additional","affiliation":[{"name":"Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2014,8,12]]},"reference":[{"key":"2025121605243985000_4.8.e005751.1","unstructured":"WHO. The World Health Report: working together for health . Geneva: World Health Organisation, 2006."},{"key":"2025121605243985000_4.8.e005751.2","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph2007040002"},{"key":"2025121605243985000_4.8.e005751.3","unstructured":"UNICEF. State of the world's children. New York: United Nations Children and Education Fund, 2009."},{"key":"2025121605243985000_4.8.e005751.4","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(06)69380-X"},{"issue":"(Suppl 1)","key":"2025121605243985000_4.8.e005751.5","doi-asserted-by":"crossref","first-page":"S123","DOI":"10.1016\/j.ijgo.2009.07.021","article-title":"Reducing intrapartum-related deaths and disability: can the health system deliver?","volume":"107","author":"Lawn","year":"2009","journal-title":"Int J Gynaecol Obstet"},{"key":"2025121605243985000_4.8.e005751.6","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1111\/j.1471-0528.2005.00719.x","article-title":"Who will do the caesareans when there is no doctor? Finding creative solutions to the human resource crisis","volume":"112","author":"Bergstrom","year":"2005","journal-title":"BJOG"},{"key":"2025121605243985000_4.8.e005751.7","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4491-5-17"},{"key":"2025121605243985000_4.8.e005751.8","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.28.5.w876"},{"key":"2025121605243985000_4.8.e005751.9","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)60785-5"},{"key":"2025121605243985000_4.8.e005751.10","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1111\/j.1471-0528.1996.tb09797.x","article-title":"A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique","volume":"103","author":"Pereira","year":"1996","journal-title":"Br J Obstet Gynaecol"},{"key":"2025121605243985000_4.8.e005751.11","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2007.01489.x"},{"key":"2025121605243985000_4.8.e005751.12","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.d2600"},{"key":"2025121605243985000_4.8.e005751.13","doi-asserted-by":"publisher","DOI":"10.1258\/td.2009.090068"},{"key":"2025121605243985000_4.8.e005751.14","doi-asserted-by":"publisher","DOI":"10.1258\/td.2010.100272"},{"key":"2025121605243985000_4.8.e005751.15","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4491-7-14"},{"key":"2025121605243985000_4.8.e005751.16","doi-asserted-by":"crossref","unstructured":"McAuliffe E Bowie C Manafa O . Measuring and managing the work environment of the mid-level provider\u2014the neglected human resource. Hum Resour Health 2009;7:13.","DOI":"10.1186\/1478-4491-7-13"},{"key":"2025121605243985000_4.8.e005751.17","unstructured":"WHO. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: World Health Organisation, 2012."},{"key":"2025121605243985000_4.8.e005751.18","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1186\/1471-2393-12-116","article-title":"The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project","volume":"12","author":"Ellard","year":"2012","journal-title":"BMC Pregnancy Childbirth"},{"key":"2025121605243985000_4.8.e005751.19","doi-asserted-by":"crossref","unstructured":"Ellard D Parsons S . Process evaluation: understanding how and why interventions work. In: Thorogood M Coombes Y , eds. Evaluating health promotion practice and methods. 3rd edn. Oxford: Oxford University Press, 2010:87 104.","DOI":"10.1093\/acprof:oso\/9780199569298.003.0007"},{"key":"2025121605243985000_4.8.e005751.20","unstructured":"Brennan A-M . ETATMBA: Enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa. Secondary ETATMBA: Enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa. [Web Pages] 20 Nov. 2013. http:\/\/www2.warwick.ac.uk\/fac\/med\/about\/global\/etatmba\/about\/"},{"key":"2025121605243985000_4.8.e005751.21","unstructured":"Ministry of Health. Malawi 2010 EmONC needs assessment final report . Republic of Malawi Ministry of Health, 2011."},{"key":"2025121605243985000_4.8.e005751.22","unstructured":"Steckler A Linnan L , eds. Process evaluation for public health interventions and research. San Francisco: Jossey-Bass, 2002."},{"key":"2025121605243985000_4.8.e005751.23","doi-asserted-by":"crossref","first-page":"18","DOI":"10.3109\/01443615.2010.533218","article-title":"Improving essential obstetric and newborn care in resource-poor countries","volume":"31","author":"Grady","year":"2011","journal-title":"J Obstet Gynaecol"},{"key":"2025121605243985000_4.8.e005751.24","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-10-339"},{"key":"2025121605243985000_4.8.e005751.25","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1055\/s-0031-1291446","article-title":"Gastrointestinal endoscopy in a low budget context: delegating EGD to non-physician clinicians in Malawi can be feasible and safe","volume":"44","author":"Wilhelm","year":"2012","journal-title":"Endoscopy"},{"key":"2025121605243985000_4.8.e005751.26","doi-asserted-by":"publisher","DOI":"10.1093\/inthealth\/iht011"},{"key":"2025121605243985000_4.8.e005751.27","unstructured":"Colbourn T Nambiar B Costello A . Final evaluation report. The impact of quality improvement at health facilities and community mobilisation by women's groups on birth outcomes: an effectiveness study in three districts of Malawi. 2013. http:\/\/www.health.org.uk\/publications\/maikhanda\/ (accessed 09\/07\/2014)."},{"key":"2025121605243985000_4.8.e005751.28","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1186\/1748-5908-7-66","article-title":"Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial","volume":"7","author":"Georgeu","year":"2012","journal-title":"Implement Sci"},{"key":"2025121605243985000_4.8.e005751.29","doi-asserted-by":"publisher","DOI":"10.1093\/her\/cyp054"},{"key":"2025121605243985000_4.8.e005751.30","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1186\/1472-6963-9-89","article-title":"A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa)","volume":"9","author":"Ridde","year":"2009","journal-title":"BMC Health Serv Res"},{"key":"2025121605243985000_4.8.e005751.31","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-3156.2003.01111.x"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2014-005751","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T13:24:52Z","timestamp":1765891492000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2014-005751"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2014,8]]},"references-count":31,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2014,8,12]]},"published-print":{"date-parts":[[2014,8]]}},"alternative-id":["10.1136\/bmjopen-2014-005751"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2014-005751","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2014,8]]}}}