Development and testing of a tool to assess health workers' clinical confidence to provide perinatal bereavement care in Sub-Saharan Africa

Background to the research: The death of a baby before, during, or soon after birth, termed stillbirth or neonatal death, is amongst the most traumatic of life events for parents. The overwhelming majority of stillbirths and neonatal deaths happen in low- and middle-income countries, with sub-Saharan Africa and South Asia accounting for around 75% of the world total. The death of a baby has long-lasting impacts on parents, greatly increasing the risk of poor mental and physical health and family breakdown, which have negative effects on wider society. Across the world, most women give birth in hospitals. We know that when a baby dies, having good care and support from health workers in the hours and days surrounding the death has a positive effect in helping mothers and fathers cope, and adjust to the loss. However, in many countries, including African countries, parents do not get good enough care or support after their baby dies. Health workers tell us that they find this part of their work difficult and do not always know what they should do to support parents, they need more education and help from facilities to give better care. Having appropriate methods (such as questionnaires) to assess health workers' abilities, identify areas for development, and test the effectiveness of strategies such as training packages, is crucial to demonstrate and maintain improvement. Tools to assess bereavement care need to reflect the local environment and culture. Currently, there are very few tools designed to assess health workers' knowledge and confidence in providing care after the death of a baby, and none have been developed with African health workers or parents.

Aim: The aim of this research is to develop and test a tool to assess the confidence of health workers to provide bereavement care after stillbirth or neonatal death in sub-Saharan Africa.

Research plan: A team of midwives, psychologists, and statisticians from the UK, Malawi, and Zimbabwe will work with local health workers, managers, policymakers, and parents, with previous experience of the death of a baby. In phase 1, the tool will be developed, using previous research, experiences of local health workers in providing care, and behaviour change theories. The whole team will be involved in decisions surrounding the choice of topics and questions to be included and methods for response e.g. scales. Once the tool is agreed it will be tested with a small number of health workers in Malawi and Zimbabwe to ensure it is clear, acceptable, and easy to complete. Consistency will be also tested. Revisions will be made as necessary, based on the results. In phase 2 the tool will be tested with up to 300 health workers
across Malawi, Zimbabwe, Kenya, Tanzania, Uganda, and Zambia, to assess whether it is reliable and measures what is intended.
The tool is likely to be useful in other low- and middle-income countries and for related situations e.g. care following a miscarriage. It could also be used with other professional groups, such as community health workers and counsellors.

Capacity strengthening: During this research, the local researchers will have the opportunity to gain skills in developing and testing tools. Inexperienced researchers will be supported by senior researchers (UK and Africa) to develop leadership and management experience which will contribute to increasing the capacity of local universities, particularly in Malawi and Zimbabwe, to conduct midwifery research and improve the health of mothers and babies. UK researchers will gain additional experience in global health research.

Background: The overwhelming majority of global perinatal deaths occur in LMICs, with sub-Saharan Africa and South Asia accounting for 75% of the 4.5million annual total. Stillbirth and neonatal death are amongst the most traumatic life events, increasing the risk of prolonged psychological distress and adverse social consequences for parents and wider communities. In LMICs, many women do not receive compassionate support from health workers in facilities after the baby's death, a key protective factor against poor outcomes. Currently, there are no validated tools to assess health workers' confidence in providing bereavement care in sub-Saharan Africa. Such tools are key in defining needs and assessing the impact of interventions to improve their capacity to deliver optimal care.
Aim: To develop and validate a context-appropriate tool to assess health worker confidence to provide perinatal bereavement support in sub-Saharan Africa.
Methods: A two-phase mixed methods study. During phase 1, a systematic literature review and qualitative exploration of health worker experiences in Malawi and Zimbabwe will be undertaken, to define the construct of 'clinical confidence' and generate items. Following this, the tool will be co-constructed with input from stakeholders and informed by behavioural models and theory. Pilot-testing to assess clarity and test-retest reliability with 50 health workers, will allow the tool will be finalised. Wider testing with 300 health workers in Kenya, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe in Phase 2, will assess internal consistency and psychometric properties, contributing to the evaluation of validity and reliability. The study will generate a context-appropriate self-report tool for use in research and clinical practice. A parallel programme of capacity strengthening will develop sustainable methodological and research leadership capacity in local midwifery research teams across the study sites.