Pillar Two

Countries in sub-Saharan Africa (SSA) remain with some of the highest maternal and child mortality rates in the world. Specifically, Sierra Leone, West Africa has the world's highest incidence of infant mortality and the third highest incidence of maternal mortality. Although midwives can be educated and equipped with the knowledge and skills to be primary care providers to mothers and children, there remains a shortage of highly qualified practitioners. The greatest shortage is in SSA, where Seed Global Health’s (an international non-government organization) work is focused. To address the shortage and increase coverage of midwife-delivered interventions, the United Nations Population Fund (UNPF), World Health Organization (WHO), and International Confederation of Midwives (ICM), call for bold investments in midwifery education and training on the global and local scale.

Between 2020-2022 Dr. van de Water and Julie Mann, Associate Director of Midwifery at Seed Global Health developed, in collaboration with colleagues, a comprehensive Midwifery Preceptor Program (MPP) to train practicing midwives to confidently and competently precept students. They also adapted this program to pediatrics with support from Seed colleagues, specifically, Dr. Kelsey Renning, a pediatric nurse educator with Seed in Blantyre, Malawi.  This Preceptor Program consists of four steps with multiple activities per step: (1) partnership building and program development, (2) a clinical preceptor course, (3) training of trainers, and (4) program sustainability. Step 1 includes partnership development with Seed, preparation of schools, clinical site(s), and students, and program administration and communication logistics. Step 2 involves Seed-sponsored educators to work closely with preceptors to strengthen evidence-based, clinical knowledge and skills and expand competence and confidence in precepting students in the clinical setting through a mixture of low-dose, high frequency didactic, simulation, and discussion-based modules and modeling of precepting over the course of 40 weeks.   

Implementation science aims to improve the quality and effectiveness of health services.  Therefore, this study aims to use the well-known implementation science RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance)  to assess the readiness for implementation and early implementation of this MPP in Sierra Leone. Specifically, we aim to:   

1. Evaluate the organizational readiness to implement and maintain a comprehensive midwifery preceptor program within four Sierra Leonean midwifery institutions using process mapping and the organizational readiness for implementation change (ORIC) survey.

2. Determine the effectiveness of a midwifery preceptor program on preceptors competence and confidence after the intensive phase of the program through pre- and post- objective structured clinical examination (OSCE) and validated confidence scales.

3. Assess the early adoption and reach of the Seed midwifery preceptor program by Sierra Leone midwifery institutions through qualitative focus groups and in-depth interviews with institutional leaders, preceptors, and students affected by the MPP in Sierra Leone.   

As of September 2025, we have graduated 1 cohort in Malawi and 1 cohort in Sierra Leone, with cohort 2 set to graduate in the next few months in each country.   There have been 55 midwifery preceptors trained in Sierra Leone and 40 pediatric preceptors trained in Malawi thus far. The third cohort is being recruited and will begin their program soon.  We have published the readiness of organizations to implement this program, undertaken process mapping, and recently published qualitative findings from each country, the effectiveness of the pediatric preceptor program, and have the effectiveness of the midwifery program currently under review. Overall, this Seed Preceptor Program has been very well received and has been shown to be highly effective at increasing preceptor clinical and precepting competence and confidence.  

This was a project initiated due to the PI’s involvement in the International Council of Nursing’s (ICN) Global Nurse Leadership Institute (GNLI) program.  Along with colleagues in the Pan American Health Organization (PAHO) region, she led a study to investigate factors influencing investment in nursing from Brazilian interest holders.  With colleagues from Brazilian nursing universities, they found that investing in nursing across education, employment, leadership, and service delivery is worthwhile for a country’s health and economy. Specifically, educational opportunities translate into job opportunities only if governments invest in all levels of nursing and if a country can absorb well-trained and qualified nurses into the healthcare system. The team presented these findings at the ICN Congress in Montreal, Canada in 2023 and these findings have been accepted for publication in International Nursing Review as of September 2025.