Characteristics of quantitative study participants
A total of 54 nurses and midwives completed the acceptability survey. The majority of participants were midwives (n=33). More than half were from Masaka district hospital (n = 30, 56%), the majority were female (n = 33, 61%), their average age was 33 years (SD = 7.1). The level of education was predominantly the advanced diploma (A1) in midwifery with 27 of 54 (50%) participants having advanced diploma (A1 level) in midwifery. The least represented level of education was the secondary school level (A2) in nursing with only one participant with A2 level in nursing. A detailed description of the survey respondents is provided in Table 1.
Table 1
Demographic characteristics of the acceptability survey respondents ( N=54)
|
|
n (%)
|
Hospital Affiliation
|
|
|
Masaka District Hospital
|
30 (55.6)
|
|
Nyamata District Hospital
|
24 (44.4)
|
Sex
|
|
|
Male
|
21 (38.9)
|
|
Female
|
33 (61.1)
|
Education Level
|
|
|
Midwife A0
|
6 (11.1)
|
|
Midwife A1
|
27 (50)
|
|
Nurse A0
|
5 (9.3)
|
|
Nurse A1
|
15 (27.8)
|
|
Nurse A2
|
1 (1.8)
|
Age, years, Mean (SD)
|
33 (7.12)
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Abbreviations: %: Weighted percent, A0 = bachelor’s degree, A1 = Advanced Diploma, A2 = Secondary school level.
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The nurses’ and midwives’ experiences of the SDA during the study implementation.
The utilization of the SDA by nurses and midwives
The majority of participants (n=31) reported using the SDA four to six times per week. Features of the SDA that were most consulted include; the action cards (n=15), my learning (n=14) and the drug list (n=10). A half of the participants used the SDA to revise their knowledge. Other participants used the SDA in emergency situations (n=14), in a normal work situation (n=5) and to discuss with co-workers (n=8). Nurses and midwives predominantly accessed the SDA on both their own smartphones and on the smartphones provided by the researcher (n=28). A large number of participants (n=35) often used the SDA with a co-worker. Participants reported having access to most of the equipments and drugs seen in the SDA (n=40). More details on the SDA use and evaluation by end-users are shown in Table 2.
Table 2
SDA access and evaluation by nurses and midwives ( N=54)
|
|
n (%)
|
Frequency of SDA use in a week
|
|
|
I used it almost every day
|
15 (27.8)
|
|
I used it 4-6 times
|
31 (57.4)
|
|
I used it 1-3 times
|
8 (14.8)
|
|
I didn’t use it at all
|
0 (0)
|
Features of the SDA most consulted
|
|
|
Videos
|
9 (16.7)
|
|
Action cards
|
15 (27.8)
|
|
Drug list
|
10 (18.5)
|
|
Procedures
|
6 (11.1)
|
|
My Learning
|
14 (25.9)
|
Most often quoted reasons for using the SDA
|
|
|
To revise my knowledge
|
27 (50)
|
|
During an emergency
|
14 (25.9)
|
|
In a normal work situation
|
5 (9.3)
|
|
To discuss with co-workers
|
8 (14.8)
|
The device often used to access the SDA
|
|
|
Own phone
|
7 (13)
|
|
The phone provided by the researcher
|
19 (35.2)
|
|
Both
|
28 (51.8)
|
With who do you often use the SDA?
|
|
|
By myself
|
19 (35.2)
|
|
With a co-worker
|
35 (64.8)
|
Access to the equipment and/or drugs seen in the SDA.
|
|
|
All
|
14 (25.9)
|
|
Most
|
40 (74.1)
|
|
None
|
0 (0)
|
Abbreviations: Wt.% : Weighted percent; SDA: Safe Delivery mHealth Application
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When rating their experiences of using the SDA particularly, half of respondents (n=27) indicated that it was very easy to the SDA, however one participant reported that it was very difficult to use a smartphone. SDA features that were most appreciated included: the action cards (33%), the drug list (22%), and my learning (19%). They also reported feeling more confident (53.7%) and becoming better (40.7%) at doing their jobs at work. Few participants (n=5) reported what they liked least about the SDA, three participants stated that they did not understand instructions, and the other two said that it was difficult to navigate the smartphone. More details on the experiences with the SDA and its added value are displayed in Table 3.
Table 3
Experiences with the SDA and its added value ( N=54)
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n (%)
|
Experience with the smartphone and the SDA
|
|
Very easy
|
27 (50)
|
Somewhat easy
|
23 (42.6)
|
Somewhat difficult
|
3 (5.6)
|
Very difficult
|
1 (1.8)
|
Features of the SDA most appreciated
|
|
Action cards
|
18 (33.3)
|
Videos
|
10 (18.5)
|
Drug list
|
5 (9.3)
|
Procedures
|
12 (22.2)
|
My Learning
|
9 (16.7)
|
Added value from the SDA
|
|
I have become better at doing my job.
|
22 (40.7)
|
I feel more confident at work.
|
29 (53.7)
|
Fewer mortalities/fatal cases
|
3 (5.6)
|
I did not notice any change.
|
0 (0)
|
What do you like least about the SDA?
|
|
I do not understand the instructions.
|
3 (5.6)
|
I think it is difficult to navigate the smartphone.
|
2 (3.7)
|
The app does not add to my existing knowledge.
|
0 (0)
|
None applicable.
|
49 (90.7)
|
Abbreviations: Wt.% : Weighted percent; SDA: Safe Delivery mHealth Application
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Acceptability of the SDA as rated by nurses and midwives.
Nurses and midwives were asked to rate their acceptance of the SDA in a Likert scale. They were asked whether they "strongly disagree", "disagree", were "undecided", "agree", or "strongly agree" to a series of statements relating to the SDA acceptability. Responses were assigned point values as follows; strongly disagree =1, disagree =2, undecided =3, agree =4, strongly agree =5. Likert scale survey results showed that the SDA was: well understood (Mean=4.00); easy (4.46) and comfortable (4.31) to use; an effective decision support (4.63) and training (4.65) tool; and useful in improving efficiency in BEmONC (4.59). Most participants reported that they intended to continue using the SDA in daily practices (4.68). On the other hand, a lower rating was given to using the SDA when seeing notifications (2.48), implying that most participants did not only use the SDA when they saw notifications. The notifications are push messages that appear occasionally on the phones of the SDA users to remind them to revisit the SDA. The messages mainly guide the users to interesting parts that they may want to explore in the SDA. Overall participants reported good acceptability of the SDA. Likert scale responses are highlighted in Table 4.
Table 4
Likert scale survey responses of nurses and midwives about SDA acceptance
Statement
|
N
|
Mean (SD) [Range]
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I have a good understanding of what the SDA is
|
54
|
4.00 (0.71) [3–5]
|
The SDA is easy to use
|
54
|
4.46 (0.50) [4–5]
|
I am comfortable using the SDA
|
54
|
4.31 (0.57) [4–5]
|
The SDA is an effective decision support tool for BEmONC
|
54
|
4.63 (0.69) [4–5]
|
The SDA is an effective training tool for BEmONC
|
54
|
4.65 (0.48) [4–5]
|
The SDA is useful in improving efficiency in BEmONC
|
54
|
4.59 (0.56) [3–5]
|
I intend to continue using the SDA in my daily practices
|
54
|
4.68 (0.50) [4–5]
|
I use the SDA when I see notifications
|
54
|
2.48 (0.40) [1–3]
|
Note: Likert scale response options were as follows: 1Strongly Disagree, 2Disagree, 3Neutral, 4Agree, and 5Strongly Agree
|
Perceptions about the usefulness and acceptability of the SDA
The results of the interviews with end-users of the SDA emerged into four main themes: (1) the perceived usefulness of the SDA; (2) professional growth acquired through the use of the SDA; (3) SDA, an empowering, intuitive and user-friendly technology; and (4) the desired SDA features and functions. The results of the interviews with key stakeholders revealed two main themes (1) benefits of the SDA as perceived by the key informants, and (2) future use of the SDA. These identified themes are shown in Figure 1. More details on the main themes and sub-themes are presented in the discussion of results, and are illustrated by verbatim quotations from the two FGDs and six KIIs.
Interviews with end-users of the SDA
Perceived usefulness of the SDA
Participants described the SDA as a useful, intuitive, empowering and practical tool that supported their daily practices. They described how it provided important information and guidelines on management of obstetric emergencies, and thus, increases their knowledge and skills on how to manage normal childbirth as well as birth complications.
“This application came as a golden opportunity for us …normally, it is very hard to go to a library all the time to read; but the library, I am hereby talking about is that SDA application we have received…It provides very useful information and guidelines that upgrade our knowledge and skills in delivery care”Midwife, FGD1.
In addition, nurses and midwives reported using the SDA both as a decision support tool while managing birth complications including PPH or NR, and as a debriefing tool for reflections on performed care to identify if essential procedures had been missed.
“When you have an emergency case to manage, you don’t have difficulties figuring out how to handle it…all the steps are clearly outlined in this application and so well summarized that you immediately find what you need whenever you refer to it…The SDA support our clinical decisions in emergency situations…Sometimes, when I go home from a night duty, on the bus, I consult the SDA to see if I have performed well during the night” Nurse, FGD2.
Participants also described the SDA as a practical and easy to use tool that helps strengthen their theoretical knowledge. They articulated how the SDA helped them remember the management of rare clinical cases. Procedures for those rare cases are easy to forget as they rarely had to apply the theory learnt from school into practice.
“Before SDA, you could sometimes start wondering what management was appropriate for a case which is not so frequent after you had forgotten…Now, we refer to the SDA when there is a doubt about anything… With this new application, we have become all fresh and we can easily remember the essential procedures step by step as per international standards” Midwife, FGD1.
Other participants expressed appreciation of the SDA as a training tool, highlighting the ingenuity of the visuals when dealing with life threatening complications of mothers and their newborns. They considered the SDA to be a kind of simulated clinical training that continuously enhances their knowledge and practical skills, contributing to their professional growth. They also reported improved performance when managing childbirth complications. Such improvement was attributed to continuous learning, facilitated by the SDA and the fact that learning could take place anywhere.
This application has been an important learning tool…I consider it as a training manual with all clinical guidelines accompanied by video materials… we learn a lot from the SDA in addition to what we learned at school…You can learn from this application from anywhere: at the hospital, on the bus, at home or anywhere. So, having your telephone means being able to learn more anywhere.”Midwife, FGD2.
Then again, participants revealed that they used to consult other internet sources for learning like youtube. They found such sources not so easy to use, as it was hard to get concise updated information and guidance in a timely manner, the way the SDA does.
“We used to visit youtube to learn something about the services we deliver, but most materials in there are not so clear as in this app. When you consult the SDA, you find that everything is easy to understand. You quickly get information on which medication is good for which case…” Midwife, FGD1.
“Some of us are mentors in health centers and we have been consulting this application while preparing training materials” Midwife, FGD1.
Some found the SDA notifications useful as reminders for them to continue learning. The notifications that appeared intermittently on their phones, reminded them to revisit the SDA that also pointed them to other interesting parts of the SDA that they may want to explore.
“We have posters displayed in maternity telling us what to always bear in mind. Some of the information on them is “remember to close the door to keep the newborn warm” … I compare this with the SDA notifications that I frequently get on my smartphone…these are very nice reminders that I have to keep learning” Midwife, FGD2.
“I would come back to what a colleague said about SDA notifications. This is a way of alerting you and I like that… There exists a wrong belief that nurses don’t like reading. Maybe, it is true but this application is not too demanding. It doesn’t consume your time as if you go to a library… This app is a good source and we need to regularly use it” Nurse, FGD1.
Professional growth acquired through the use of the SDA
The perceived usefulness of the SDA described by the participants was associated with substantial improvements in their childbirth care practices. Nurses and midwives narrated experiencing an increase in their knowledge, skills, and confidence after using the SDA and how such professional growth has been reflected in the quality service they offer.
“The reason number one I like this app is that it upgrades my knowledge and skills, and makes me confident than before…it is a kind of continuous professional development…It is so good in a way that if you fail to understand the text when reading, you have an option to search for more explanation using videos. It is really very useful…” Nurse, FGD2.
“The biggest difference for me when I compare now and the past experience is service delivery which has so positively improved. The special aspect of the application is that the content therein has everything we theoretically studied at school” Midwife, FGD2.
The study participants indicated that the SDA has helped them to recollect and revise their skills, which have made them more capable at managing childbirth complications in accordance with the recommended essential procedures. One of the significant changes expressed by participants was that they had learned the lifesaving steps of how to stop a bleeding by applying bimanual compression.
“This application has been helping us refresh our memories and equipping us with techniques that we use to handle obstetric emergencies.… My colleagues have talked about bimanual compression…You may even not know anything about it … Then, when you try to familiarize with it on the SDA, you get to know about it and perform it correctly” Midwife, FGD1.
Other participants explained how the SDA supported them during practice. They described the before SDA childbirth care experience and compared it with after SDA experience by highlighting the specific instances in which the SDA supported them. Previously, in situations where nurses and midwives were struggling to assist a mother or a newborn, they would immediately call upon a medical doctor to come and help. And, sometimes the doctor assigned to maternity department was busy with caesarean surgery which would delay his assistance to attend to the complicated case. But, now with the support of the SDA, nurses and midwives have been able to provide essential assistance to mothers and newborns while waiting for the doctors.
“I agree that BEmONC services were also delivered before we started using SDA but the situation was not the same. For example, when there was a complication with a patient, the only thing we would do was to ask a colleague or to call a medical doctor. This was time consuming and would delay service delivery and could complicate the situation even cause maternal deaths... However, when there is a problem nowadays, you just take your phone, go to the application and get a quick solution. As a result, our patients get quick and more efficient service” Midwife, FGD2.
Both nurses and midwives revealed that they used to fear occurrence of birth complications, because of the limited skills and experience on how to manage such events. They noted that the SDA had reduced this fear and had led them to have more confidence in their work.
“In using this app, you are always aware of what might happen in a given case. So, when you have a real case, you don’t panic much…For instance, when it comes to PPH management, with the SDA you can easily figure out the steps to follow” Nurse, FGD1.
“This application can help you when you are stressed. You may have had a lot of cases to manage in a day and end up in confusion somewhere. When this happens, you take your phone and see what should be done to handle a particular case with confidence.” Midwife, FGD2.
Some participants described how solving problems using the SDA motivated and enabled them to be more efficient in providing care at work.
“when you have a problem and you find a way to solve it, that is self-explanatory; you feel motivated automatically. As we get support from the application, our job becomes easier and more efficient” Midwife, FGD1.
Further, nurses and midwives explained that they used the SDA either at home to update knowledge or while they were at work, either before a delivery when the woman is in labor or when complication arises in the course of a delivery. Some participants described using the SDA to guide co-workers when they work in pairs in order to follow the necessary steps during a delivery. In emergency situations, the SDA was often used as a decision support tool to see how to manage e.g. PPH and neonatal resuscitation or as a reminder of drug dosages and administration. Participants also acknowledged having access to most of the equipments and drugs seen in the SDA.
“We have most of the materials we need to perform well. But, the SDA has been there to support us in upgrading our knowledge wherever we are - at home, before assisting a delivery or during an emergency…You may forget something like medication dosage, even though you learned it at school… but since we got this app, it helps us to remember the dosages in emergencies, we use it as a job aid in a simple way” Nurse, FGD2.
SDA an empowering, intuitive and user friendly technology
The study participants also voiced that the SDA is easy to use, intuitive, user friendly, and enabled them to provide first aid to patients before calling upon doctors.
This application is special in that it is so focused and shows you clear sequences…For example, you can easily find what specifically refers to steps for removing a retained placenta when you have such a case. We really like it because it is easy to use” Midwife, FGD2.
“I would say something additional. With this application, we have learnt how at least one can provide first aid for a mother or do resuscitation for a newborn… That is so important because you don’t need to call upon a doctor for everything” Midwife, FGD2.
Likewise, participants indicated that the SDA has helped them to get a common understanding with medical doctors about managing birth complications. They explained on how consulting the SDA helped them to have informed recommendations and they were happy to contribute with confidence to care plans and sometimes supporting doctors.
“I would say that when I have a special case, I first consult the application, see how I can myself manage it before I talk to a medical doctor. Even when I have to talk to the doctor, at least I provide an informed suggestion and contribute to further treatment steps. We are supporting our doctors much more.” Midwife, FGD1.
Then again, nurses and midwives described how the SDA has helped them to get updated information and to have a common understanding among themselves during practice.
“I can easily remember what I studied in school and when I tell my colleague X, he sometimes tells me a different story. This is due to the fact that he studied so recently, let’s say three years ago, while I studied the similar subject 12 years ago…There is a need for all of us to have the same updates. This application is a solution because it keeps getting updated” Nurse, FGD1.
When asked if they will continue using the SDA in their future practice. Both nurses and midwives stated that due to the SDA benefits, it is their own advantage to continue using it in their routine practice for efficient provision of care.
“I would say that we have been lucky to be the champions of this application. I agree that we have a lot of work to do in maternity but we can’t forget that we also need updates in our career…We will always need to refer to the app in our routine practices and find some time to learn new things from the SDA. We shall keep using it and it is for our own interest” Midwife, FGD2.
“This application is user friendly, affordable, covers a lot of areas, and does not take your internet megabytes when using… It is not like a book or a computer that would be heavy for you to carry…It is in a mobile phone that you always carry in your hands…You can check up anything, anywhere and anytime.… Unless something unexpected happens, I don’t see how people can stop using the SDA” Midwife, FGD1.
When asked how they perceive the SDA sustainability in district hospitals in Rwanda, all nurses and midwives indicated that the SDA will be likely sustained.
“This application will be maintained because it is an important tool for us to deliver good service to the patients. When you use it properly, you deal with various cases with confidence and you perform your duties with success” Midwife, FGD1.
“I am also confident that SDA will be sustained for two main reasons. The first reason is that it is easy to use and provides text content accompanied by video materials. Secondly, SDA is so relevant in that it is equipped with modules that reflect our day to day clinical practices” Midwife, FGD2.
Furthermore, participants requested the SDA scalability to the whole country of Rwanda in consideration of the present country’s agenda to support the adoption of technology in healthcare service delivery.
“Personally, I would say that this is the most appealing application on my phone…When we are discussing with colleagues on social media (WhatsApp), there may be some questions raised in relation to our career. When there is a confusion, I immediately take my phone, get reliable information from the SDA and in a fast way I share with them… Is it possible to implement this app in all hospitals in Rwanda? …Since most people have smartphones, this should not be a problem, also our country is currently promoting application of technology in healthcare. I think this would make a lot of difference”Midwife, FGD1.
“I have to tell you that this is a very good application, those using the application have already started seeing the benefits and they gain a lot from it. I wish it could have been shared with other hospitals too. It should be scaled up to national level. I wish to see all midwives in Rwanda using this app… It is easy to use, once you have it installed, you don’t need much guidance on how to use it, then we will be able to save more maternal and newborn lives” Midwife, FGD2.
“I remember I was in Musanze some time back and when I talked about this application to my friends, they were surprised. They started asking me how they can access it too. I just showed them and they became very interested. I am inviting everyone to have this spirit of sharing so that it reaches more people” Nurse, FGD1.
Other participants recommended that the SDA should be part of learning materials used at University.
“Ever since I started using the SDA, there has been no single case that I have failed to get information about in this application. I think this application should be part of tools that midwifery students use at University before they graduate. If this is done, using it at workplace would be easier. I am confident that if you once saw something at school and you need to use it in your job, it becomes easily implementable” Midwife, FGD1.
Desired SDA features and functions
The study participants were asked if there might be any other information or functionalities they would want to be added to the SDA for improving the application. Most participants stated that the SDA is useful as it is. However, some participants suggested features and functions they wish to be added to the SDA. Firstly, participants requested if the SDA could have a version for desktop and laptop computers so that it could be installed in computers available at their respective hospitals or if they could access the SDA using a desktop/laptop browser.
“I wonder if this application can’t be installed in our office computers because sometimes one’s phone might not be available maybe because it is not charged, it is stolen or broken or the owner simply doesn’t have it with him/her. Having the application available in various devices would be much better and accessing it might be easier for everyone” Midwife, FGD1.
Other participants expressed their need for locally appropriate clinical decision support tools and emphasized their wish to have a version of the SDA available in the local language ‘Kinyarwanda’.
“I would like to add that it would be great to have this application in Kinyarwanda like I saw it having other language versions including Swahili, Hindi…. I guess this is a process, but we will be grateful if this is expedited. That will really be helpful. Thanks” Nurse, FGD2.
In addition, nurses and midwives requested additional animated videos to be added to the SDA. These include; videos on antenatal care in line with the new WHO antenatal care models with a minimum of eight contacts as well as guidance on the identification of risk factors for birth complications before delivery.
‘‘I think this application can be very helpful if they add some videos on antenatal care or how one could identify a woman in labor who would probably get a complication” Midwife, FGD2.
Also important was the suggestion that the SDA application could have a discussion forum window or platform for the users across different hospitals and countries to share experiences about managing obstetric emergencies.
“I wish that this application can have a kind of worldwide discussion forum where we can put comments and share experiences and views. For example, a midwife from X hospital in Rwanda can discuss and share her experience with midwives in other hospitals across multiple countries…Sharing like this can upgrade levels of knowledge for everyone. I think this would be very beneficial” Midwife, FGD1.
Interviews with key stakeholders
The analysis revealed two main themes: (1) benefits of the SDA as perceived by the key informants, and (2) future use of the SDA. These identified themes are shown in Figure 1. The details on the main themes and sub-themes are presented, and are illustrated by quotations from the six KIIs.
Benefits of the SDA as perceived by the key informants
The key informants described the SDA as a useful tool and recommended its implementation in routine practices, specifically for the purpose of continuous learning without interrupting health services. Such benefit was depicted as fitting for the work environment in the context of Rwanda where numbers of healthcare providers were insufficient. Clinical staff require periodic training to stay on track with the knowledge and skills necessary for their practice. For their annual practice licence renewal, they need evidence of continuous professional development in addition to corresponding academic credits. SDA was therefore seen as a valuable solution as it offers on-the-job learning opportunities, assessment strategies, and possibilities of getting certificates.
“This application is useful as it allows on-job continuous learning. We have been facing challenges for getting continuous learning opportunities for all staffs, now the SDA comes with this advantage. I recommend that it should be incorporated in routine practices” Respondent, KII 3.
While the SDA was recommended for staff, because it captures the essential topics for BEmONC, key informants felt that this should in addition to the other sources of information including formal books and Ministry of Health guidelines that gives a broader view of obstetric care.
“The SDA is good particularly for BEmONC but the SDA alone cannot solve all maternity care problems. Our staff need to use this application together with other sources of reliable information like the guidelines from the Ministry of Health”Respondent, KII 1.
Another benefit highlighted was that the SDA is applicable in clinical practices by providing guidance on essential procedures that are needed to save maternal and newborn lives.
“…We need safety in all we do, so this application is welcomed. I was happy to note that it provides concise information that will help nurses and midwives to take good decisions when dealing with childbirth complications” Respondent, KII 6.
Future use of the SDA
When KII participants were asked their opinions about the SDA cost, scalability, and sustainability, opinions on the future use of the SDA in Rwanda were apparent, along with the aspect of technology application in healthcare and its support in continuous learning. Participants perceived the estimated cost of piloting the SDA as affordable compared to physical training opportunities or online learning resources. They recommended the SDA implementation in consideration of its benefits, particularly the mLearning opportunity.
“The cost is reasonable compared to other online learning tools…Also physical training has a double cost of time and resources. This application can train many people at the same time depending on individuals’ needs…I think this mLearning approach should be promoted in Rwanda as the country is looking to making healthcare services electronic-based…This application will be one of the solutions” Respondent, KII 5.
One participant was concerned about the technology cost. But, he indicated that this cost could be alleviated by the fact that many healthcare providers own a smartphone. He suggested that they could use their own smartphone for future use of the SDA.
“The technology cost is a bit high but as many people have smartphones and access to good internet, this might not be a problem. They could download the SDA on their own smartphones” Respondent, KII 6.
In addition, participants expressed their wish to see the SDA implemented at a large scale, in all hospitals in Rwanda. However, they recommended that the SDA scalability needs to be preceded by a proper assessment and approvals by all required bodies.
“Technology is in everything we do in healthcare and this application is useful…For future implementation, you need more sensitization and to involve all key stakeholders like MOH (Ministry of Health), RAM (Rwanda association of midwives), association of gynecologists and pediatricians…” Respondent, KII 2.
“I think after in-depth assessment and approval by MOH (Ministry of Health), the whole country (all hospitals) could use this application and it could help us to promote continuous learning while at work” Respondent, KII 3.
Another participant highlighted the need for possible monitoring and follow-up programs to evaluate if the acquired knowledge and skills are translated into real clinical practices. He also suggested that the monitoring programs could be connected with the existing annual performance contracts and evaluation.
“…Some mechanisms of monitoring could be put in place to assess if what has been learnt in the SDA is being practiced…Why not link this monitoring with imihigo (performance contracts)? People should think about it” Respondent, KII 4.
Then again, participants indicated that the SDA could benefit a large variety of healthcare cadres like medical doctors.
“…Not only nurses and midwives would benefit from the application, medical doctors can use it …Everyone needs to know how it works and its importance. Respondent, KII 2.
Moreover, KII participants perceived the SDA as an easy to use tool with well explained topics. They indicated that the SDA could be sustained because it supports healthcare providers to manage childbirth complications. They also acknowledged the fact that the SDA provides useful information needed in routine clinical practices.
“I think this application will be sustained…When you see the topics and how they are explained…This information is what our staff need every day for managing birth complications” Respondent, KII 1.
Furthermore, participants suggested additional topics other than topics of BEmONC that could be added to the SDA to make it more useful and sustainable.
“We have seen some additional topic like COVID 19 and infection prevention in this application. Other topics that are generally relevant for healthcare providers could be added…I am thinking of topics like: medical bio safety and bio security, patient centered care and quality improvement, ethics in clinical practice…all these topics could be tied to maternity care” Respondent, KII 3.