{"paper_id":"37e08a6a-7d6a-43a2-bd46-eccdd880ddc2","body_text":"Stakeholders' insights and perceptions on nursing and midwifery care providers' pre-service education, training, and regulations in Senegal: a mixed-methods study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Stakeholders' insights and perceptions on nursing and midwifery care providers' pre-service education, training, and regulations in Senegal: a mixed-methods study Ann-Beth Moller, Moussa Sarr, Isabelle Moreira, Saly Amos Diatta, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7643871/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract Few countries in sub-Saharan Africa (SSA) are on track to meet the Sustainable Development Goals (SDG) related to maternal and neonatal mortality, despite widespread progress towards the SDG target for births assisted by skilled health personnel. The inconsistent quality of care provided by skilled health professionals (SHPs) also known as skilled birth attendants (SBAs) has been identified as one contributor of this disconnect. Senegal has made exemplary progress reducing maternal and neonatal mortality, making it a strong setting to explore the myriads of factors that contribute to quality of childbirth care. This research was conducted as part of a multi-country study to assess the quality of pre-service education of health professionals providing childbirth care and to enhance the measurement related to the coverage of SBAs and SHP. Twenty-five key informant interviews (KIIs) were conducted in Senegal with government bodies responsible for maternal and newborn health (MNH) at central and regional levels and MNH data collectors, training institutions, professional associations, as well as technical and financial partners. An online survey was carried out to assess the quality of pre-service education programs among 30 students and 15 program administrators, and SBAs pre-service training curricula were evaluated against international standards. Interviews suggested that the growing number of private training schools has led to insufficient oversight from government bodies and some schools not meeting national regulations or quality standards. Respondents shared that responsibilities for the regulation of pre-service education and training are split by three different government bodies, and the development of professional associations for nurses and midwives has been delayed. KIIs revealed that graduates can fail to pass the national licensing exam but may still be awarded a school diploma and recruited by health facilities. Additionally, respondents reported poor success rates on both annual school and licensing exams. The surveys also revealed quality gaps in pre-service education are due to lack of access to libraries, computers, equipment for skills labs, as well as the number of educators and their competencies at practical training sites. Amid commendable progress, this research reveals key gaps that continue to undermine the quality of care during childbirth in one of highest-performing countries in SSA. Recommendations include improving the regulation of SBAs pre-service education programs, introducing renewal process for licensing, developing professional orders, and ensuring continued training programs. Continuing to enhance pre-service education and in-service training programs in Senegal is crucial for sustainable improvements in the quality of MNH care. Health sciences/Health care/Public health/Epidemiology Health sciences/Health care/Health policy Figures Figure 1 Figure 2 Main Sustainable Development Goal (SDG) 3 of the 2030 Agenda focuses on ensuring healthy lives and promoting well-being for all. Specifically, SDG 3.1 aims to reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births and SDG 3.2 aims to reduce neonatal mortality rate (NMR) to at least as low as 12 deaths per 1000 live births by 2030. 1 Despite apparent global progress, maternal and neonatal mortality remains high in many countries, especially in sub-Saharan Africa (SSA). Recent estimates suggest that SSA accounted for nearly 70% of global maternal deaths and 46% of global neonatal deaths in 2023 2,3 . Current trends in MMR and NMR reduction globally will still fall short of meeting the SDG targets 2,3 . Over the past two decades, Senegal has been one of the best-performing countries in SSA at improving maternal and newborn health (MNH), beyond what could be expected when accounting for economic development. As a result of this progress, a program known as Exemplars in Global Health identified Senegal as an Exemplar (i.e. positive outlier) country in MMR and NMR reduction 4 , and documented the strategies to their success that others could learn from. These strategies include improving access to healthcare facilities, removing user fees for childbirth services, launching and tailoring a family planning action plan to improve contraceptive demand, and improving access and the availability of skills of healthcare workers 5 . Skilled birth attendants (SBAs) are essential to the health and survival of women and newborns. The extent to which SBAs are properly educated, competent and equipped is directly tied to MNH outcomes, as extensive global and sub-national studies have shown 6-9 , and the World Health Organization’s global strategy on human resources for health (Workforce 2030) continues to reinforce 10 . Growing evidence, including new research provided in this series, point to the fact that merely having an SBA present during childbirth is insufficient to realize the complete health benefits required to meet positive health outcomes and SDGs 3.1 and 3.2 - health professionals must also have adequate competencies and an enabling environment to succeed. Recent data from the 2023 Demographic and Health Surveys (DHS) suggests that 93.5% of births in Senegal are assisted by SBAs. The 2023 DHS defines SBAs as doctors, midwives, nurses, nursing assistants, and heads of health posts, though the heads of health posts are not always considered SBAs in other contexts and data systems in Senegal 11 . Published decomposition analyses indicate that the majority of maternal and newborn lives saved come from healthcare interventions, health services, and medical products largely delivered by SBAs 12 . Despite positive health outcomes and progress in Senegal, challenges remain with the availability, distribution, access and quality of the health workforce in relation to MNH. Density of nurses and midwives in Senegal in 2023 was 4.2 per 10 000 population, below what is recommended to meet universal health coverage 13 . Substantial variation exists in these cadres’ training and education 11 . Senegal had 103 training institutions for midwives, nurses and assistant nurses registered in 2023 14 . Of these institutions, nine were public and 94 were private. Dakar and Thiès regions now have the largest number of private pre-service education programs. This growth of nursing and midwifery schools in Senegal emerged post-2000s to address increasing healthcare demands, rapid population growth, and need for additional education programs across regions. Private schools came as a complement to the previously existing public education system, which was 100% state-managed and mostly centralized in the capital city of Dakar. Furthermore, an evolving global landscape may present new challenges for countries like Senegal to sustain exemplary progress. If international funding for health programs and data declines, countries will need to prioritize activities that address the most critical remaining barriers, as well as rely on domestic, low-cost data and indicators to monitor their progress 15 . In order for countries to improve MNH, scale up human resources for health, and meet the SDGs, it will be imperative to understand the barriers and contributors to quality of childbirth care provided by SBAs, in exemplary settings such as Senegal. To inform effective interventions, it is essential to examine both the drivers of improved care quality and the reasons it remains insufficient in some circumstances. To date, there have been limited systematic efforts to evaluate the quality, theoretical and practical competencies of SBAs in Senegal, despite evidence of apparent gaps in managing childbirth care 16 . To address these health workforce challenges and support the improvement of MNH outcomes in Senegal and elsewhere, this study aimed at addressing and evaluating strengths and weaknesses in nursing and midwifery pre-service training programs related to care during childbirth focusing on the concept related to “standard of practice”, which includes training, education and regulation 17 . Methods Setting and study design This research was conducted as part of a multi-country, mixed-methods study to enhance the understanding of how the coverage of SBAs and SHP could be more reliably measured, including developing a valid metric and including all the concepts of the 2018 SHP definition 17 (Box 1). This project was conducted in Nepal, Senegal and Zambia, three countries involved in a program known as Exemplars in Global Health (EGH). EGH is a partnership dedicated to learning from countries that have demonstrated exceptional progress in a range of health areas, such as MNH 18 . This project included cross-country quantitative research as well as qualitative research components in all three study countries. This article specifically focuses on three components of that study in Senegal: qualitative research from key informant interviews, a quantitative component of surveying students and administrative staff from the nursing and midwifery training institutions, and an assessment of SBAs pre-service curricula comparing to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice framework, 2019 update 19 . A protocol was developed outlining the study approach and was adapted to the Senegalese context. A Technical Working Group composed of key government and international partners in Senegal was established to provide technical support for the project (Supplementary Fig. 1). Box 1. The 2018 definition of skilled health personnel (competent health care professionals) 20 Skilled health personnel, as referenced by SDG indicator 3.1.2, are competent maternal and newborn health (MNH) professionals educated, trained and regulated to national and international standards. They are competent to: (i) provide and promote evidence-based, human-rights- based, quality, socio-cultural sensitive and dignified care to women and newborns; (ii) facilitate physiological processes during labour and delivery to ensure a clean and positive childbirth experience; and (iii) identify and manage or refer women and/or newborns with complications. In addition, as part of an integrated team of MNH professionals (including midwives, nurses, obstetricians, paediatricians and anaesthetists), they perform all signal functions of emergency maternal and newborn care to optimize the health and well-being of women and newborns. Within an enabling environment, midwives trained to International Confederation of Midwives (ICM) standards can provide nearly all of the essential care needed for women and newborns.* (In different countries, these competencies are held by professionals with varying occupational titles.) *The state of the world’s midwifery 2014: a universal pathway: a woman’s right to health. New York (NY): United Nations Population Fund; 2014 (www.unfpa.org/sow my). Sampling Key informants were chosen through purposive sampling in collaboration with the Ministry of Health and Social Action and the Technical Working Group. The following pertinent stakeholders were considered throughout the country based on professional profile, experience and degree of involvement in aspects related to the training and provision of childbirth care providers. MNH government managers (national and regional levels), heads of training institutions for doctors, midwives and nurses, those responsible for collection and usage of data related coverage of SBAs and other childbirth related indicators, and members of professional organizations were selected. For the online survey out of the 103 schools providing midwifery and nursing training at the time of the study, 38 schools were selected based on stratified random sampling to ensure acceptable representation by region, private versus public, and school size. Email addresses were obtained after telephone contact with the training schools using the directory of registered schools. Data collection and tools In-depth interviews In-depth interview guides were piloted with two people before being used with stakeholders. The key informant interviews were conducted from August to October 2023 applying an in-depth interview guide (Supplementary Fig. 2). Data were collected from 25 key informants by S.A.D and I.M and conducted in French and English according to the interviewee's preferred language. Twenty-one interviews were conducted online and four were conducted face-to-face based on the interviewee’s preference. Interview participants were informed of the voluntary nature of the study through an explanatory document shared, and all signed the consent before the interviews were conducted (Supplementary Fig. 3). Survey An anonymized online survey was administered between August and October 2023 to address the quantitative perspective of the study (Supplementary Fig. 4). A context-adapted survey was developed by the team for educational settings to primarily assess the following key dimensions: i) staff competence and evaluation, ii) availability of learning materials, infrastructure and practical training, and iii) program administration, governance, and success. Two versions of the survey were developed – one survey for administrators (29 questions), and another survey for students (29 questions). Eighteen questions were the same in both the student survey and the administrator survey, with the remaining eleven questions unique to students and to administrators. The survey was hosted on Google Forms, with data collected in Google Sheets, and was sent via email to students and administrators. The full surveys are included in Supplementary Fig. 4. The online survey was pre-tested with members of the team. Coverage of competencies related to childbirth care in pre-service training curricula An extraction form in Microsoft Excel was developed to map the pre-service training curricula to the ICM framework. The 2019 ICM Essential Competencies for Midwifery Practice consists of four main categories: i) general competencies, ii) pre-pregnancy and antenatal care, iii) care during labour and birth, and iv) ongoing care of women and newborns. For this study we only focused on the third category “care during labour and birth”, consisting of 54 competencies with 19 knowledge indicators and 35 skills and behaviours indicators 19 . For all components of the study, research files, recordings and transcriptions were stored, password protected and kept on a secure drive on Institut de Recherche en Santé, de Surveillance Épidémiologique et de Formation (IRESSEF) systems. Data analysis In-depth interviews Audio files of the interviews were transcribed verbatim. Quality checks were performed by transcribers and members of the research team to ensure the conformity of the audio files and transcripts. These transcripts were combined with detailed notes and uploaded into NVivo software version 12 for analysis by members of the team. The coding was guided by preset themes and sub-themes that were in the interview guides and protocol. For the analysis the following steps were used: i) data familiarization and generating notes of prevalent topics, ii) systematic data coding, iii) generating initial themes from coded and collated data, iv) developing and reviewing themes, v) refining, defining, and naming themes. Survey Microsoft Excel was used to clean and tabulate data, calculate descriptive statistics for frequency and proportion. Responses were analyzed separately for all questions in each of the two surveys. Additionally, results were aggregated for questions that were the same in the students and administrators survey. Coverage of competencies related to childbirth care in pre-service training curricula Our team obtained five pre-service training curricula through literature review and conversations with stakeholders: public midwifery, private midwifery, nurses, assistant nurses, and medical doctors. Data extraction was performed by two members of the team (I.M. and S.A.D.) and each curriculum was read and reviewed several times to determine the content related to the third category “labour and birth care” inclusion the curricula. The 54 indicators (19 knowledge and 35 skills and behaviours) were considered equally important. The content of the curriculum was considered to have met the ICM frameworks third category competencies if the 54 indicators (maximum score) were included in the curriculum or in other words 100% alignment with the ICM framework. For each curriculum a summary score was calculated. Results In-depth interviews A total of 25 key informant interviews with details about their area of responsibility described in Table 1. This section is structured by findings about 1) quality of pre-service education, 2) regulation and legislation, and 3) in-service training and provision. Additional quotes supporting all themes are included in Supplementary Fig. 5. Quality of pre-service education Positive aspects of pre-service education for childbirth care, according to the key informants, included alignment between the curriculum and international guidelines; educational programs for senior nursing and midwifery in development; and continuous quality improvement projects receiving support from external funders. Barriers to quality training included low availability and insufficient experience of educators and supervisors and insufficient practical training due to infrastructure and material constraints. Respondents suggested that these challenges contribute to lower skill levels in graduates and low national exam success rates. Curriculum has been aligned with international guidelines Across both public and private nursing and midwifery schools, key informants suggested that their schools’ curricula for childbirth care providers had been recently adapted to be aligned with the training curriculum from the West African Health Organization 21 . Development of programs for more senior nursing and midwifery positions Several master’s and doctoral-level programs have been set up at École Nationale de Développement Sanitaire et Social (ENDSS), Université Gaston Berger and other universities for midwives and nurses to develop their skills. Over time, these programs can help to increase the number of nursing and midwifery educators in Senegal. Ongoing initiatives to monitor and improve quality of pre-service education Senegal continues to work with development partners to strengthen pre-service education. For example, United Nations Population Fund (UNFPA) has been involved in evaluations of curriculum, training approaches, and infrastructure at the national public school, ENDSS. UNFPA also partners with other universities to train students on new evidence-based guidelines in MNH care. The Japanese International Cooperation Agency (JICA) has supported the AQSIS (Amélioration de la Qualité des Stages des Infirmiers et des Sage-femmes) project to strengthen student supervision during practical training, and facilitate coordination between schools, health facilities and medical region/district managers. Takeda Pharmaceuticals has also been supporting the development of four public and private training schools. Educators and supervisors at some schools do not have sufficient experience to effectively teach students Several respondents shared that it was challenging to find and employ qualified teachers to teach at training schools. Additional quotes and details about requirements are in Supplementary Fig. 5. Respondents suggested that the combination of a shortage of teachers and their limited qualifications contributes to poorer learning outcomes at some educational institutions. A respondent from a government regional health training centre shared: “There is a glaring deficit in human resources. And when we don't have teachers, we can't provide quality training…there are many institutes where the quality and skill level [of teachers] pose a problem.” Another national-level government stakeholder shared: “We cannot have [so many] private health schools in Senegal and on the other hand you do not have the human resources to train them. Who will provide that training?” Insufficient practical training due to infrastructure and material constraints One common challenge discussed by respondents was insufficient practical training, either through limited skills laboratory infrastructure, a shortage of internship sites, or inadequate materials and supervision in these environments. These gaps may contribute to graduates lacking practical training when they enter the workforce. A reproductive health coordinator shared: “There are some schools that have training materials, but there are others that do not have even practical training rooms.” A stakeholder from a private educational institution noted the shortage of internship sites in their region: “we have health centers and only one hospital for eight private schools…When students arrive on the field, the plethora of numbers can be such obstacles that we are forced to use our practical work rooms.” A representative from a regional government training institution shared: “To get an internship site, now, it's not easy….often [the training supervisor] writes about the working conditions, the lack of materials, there are no gloves.” Several respondents noted that a small number of midwives would graduate their pre-service education program without having assisted women with delivery, a crucial practical skill they are responsible for in the workforce. A government-level stakeholder involved in training shared: “When we talk about a midwife who comes out with a diploma and who has never been in a maternity ward or in a delivery room, you see the problem where it arises.” Decreasing skill level of recent graduates from private institutions providing pre-service education Many respondents highlighted a lack of sufficient skills in recent graduates from pre-service training programs, with some respondents suggesting it may be linked to the rapid expansion of private training schools. A government official at the national level shared: “So, in fact, it's a notable regression. Because the skill level has nevertheless dropped significantly. So, it is perhaps linked to the multitude, to the proliferation of schools. There is not enough control over the quality of the finished product.” National exam success rates are another indicator of graduate skill levels. Respondents from the government suggested that current success rates on the national midwifery licensing exam are lower than 10%. Regulation & legislation School diplomas may be awarded without a state diploma There is limited regulation in Senegal around a unified state diploma system for nurses and midwives. Respondents shared that educational institutions could issue their own school diploma as a completion certificate for their program of study, without a graduate passing the national exam or receiving a state diploma. Despite the lack of skill validation, school diplomas are sufficient to work at a lower-level position in public health posts or in the private sector, such as an assistant nurse or assistant midwife (Supplementary Fig. 5). Limited accreditation or quality control on private nursing and midwifery schools Institutions providing pre-service education for nursing and midwifery in Senegal can open and operate without following all regulations and guidelines. Respondents raised concerns about basic midwifery training due to the variation in private training schools’ adherence to standards, citing a 2022 evaluation by the Human Resources Department of the Ministry of Health and Social Action or Ministère de la Santé et de l’Action Sociale (MSAS) and the World Health Organization (WHO) 22 . Though the national public school for midwives complies best with educational standards, it does not produce many midwives compared to the numerous private schools. One government official shared: \"The medical region has no control over private training schools, some of which are not accredited. There is also a plethora of training schools, particularly in Dakar: 48 at the last census in 2022!” We corroborated this by confirming that ANAQSUP, the organization responsible for accreditation, has approved several midwifery schools that do not meet all the criteria and are still issuing diplomas to students without certification. Fragmented and overlapping responsibilities for regulation between three ministries Respondents suggested that the split and overlap between different ministries’ responsibilities was a contributing factor to the challenges in regulation of educational institutions. Management of training is coordinated by three ministries: 1) Ministry of Health and Social Action ( in French, Ministère de la Santé et de l’Action Sociale - MSAS ), 2) Ministry of Vocational and Technical Training ( in French, Ministère Formation Professionnelle et Technique ), and Ministry of Higher Education, Research and Innovation ( in French, Ministère de l'Enseignement supérieur, de la Recherche et de l'Innovation - MESRI.). Different ministries are responsible for the quality assessment of a training institution and the closure of an institution if standards are not met. One government official shared: “ At the level of private structures as well, there is not enough control. So, in relation to the ministry. Since training is not managed directly by the Ministry of Health. It is managed by the Ministry of Vocational Training. There are schools where the Ministry of Health has decided to close, and they still are [open].” Another government official from the Ministry of Health shared: “We have the reports from all these training institutions submitted to the Ministry of Health which is also submitted to the Ministry of Vocational Training and Ministry of Higher Education…In our recommendations, almost half of the schools must be closed. And we do not have the ability to close training institutions. What we can do is ask the institution not to participate in the certification exam simply because the delivery of learning poses a problem.” Lack of authorization for practice and renewal for nurses and midwives, with delayed development of professional orders Respondents shared that there are no specific procedures for nurses and midwives for authorization to practice other than obtaining a diploma. The only condition for working as a midwife or nurse is to have passed a national examination leading to a state diploma, or to have obtained a school diploma awarded by the training schools. This differs from the Order of Physicians in Senegal, which authorizes doctors to practice in both the public and private sectors and is automatically renewable on an annual basis subject to payment of dues. Respondents also shared that there is no legal mechanism for the renewal of authorization to practice for nurses or midwives. A stakeholder from a national public school shared: “Apart from the diploma, there is no specific mandatory authorization document to practice midwifery in Senegal. Because perhaps if we had the order…perhaps they could do this role, see in relation to their competence and perhaps register them, accredit them so that they can practice.” It was planned that new professional orders for nurses and midwives would be established and would issue authorizations to practice. Though the process to establish these orders has commenced, stakeholders shared that their development has been significantly delayed (details in Supplementary Fig.5). A respondent from the midwife association shared: “It's been two or three years that we have been hearing this same language that it is in circularization that they are following it and that the legislation office.” In-service training and provision Variety of continuing education programs, but no requirements for these programs Respondents shared that several types of continuing education programs and in-service training programs exist in Senegal, including e-learning, formative supervision, coaching, and mentorship. However, continuing education as well as continued assessment of skills is not mandatory for authorization to practice for childbirth care providers, and there are no standards for continuing education. In-service training is not systematic, and there is no database that tracks the providers that have been trained. Development partners’ involvement in continuing education and training UNFPA, UNICEF, and JICA are involved in ongoing in-service training for providers. JICA’s investments through the PRESSMN projects (Projet de Renforcement des Soins de Santé Maternelle et Néonatale) have helped to train providers in respectful care and improve enabling environments in health facilities. Development partners tend to be more involved with in-service training, geared towards coaching and mentoring. A representative from the public training school shared: \"...they prefer to finance continuing training, which is less effective and more costly, rather than focus on basic teaching and the quality of supervision at training sites\". Challenges and opportunities with staff recruitment and retention Several respondents mentioned significant challenges with retention of health workers outside urban areas. Disparities exist in recruitment, salary, and job descriptions between the national or regional governments compared to the community through health center committees. Additionally, recruitment, assignment and redeployment processes are often not transparent or equitable. Several development partners suggested that more strategies are needed to retain qualified staff in remote areas and reduce turn-over, such as incentives or additional training opportunities. Another common theme discussed by respondents that current opportunities for career development were not clearly defined, sufficiently disseminated, and not always aligned with the country's needs. Coverage of competencies related to childbirth care in pre-service training curricula We assessed five pre-service training curricula: public midwifery program, private midwifery program, nursing program, assistant nursing program and medical doctor program. The curricula assessed were published in 2015, with a revision in 2022. The length of training varied from 3 to 5 years post-baccalaureate, in line with ICM’s recommendation for a minimum of 36 months for direct-entry midwifery education programs. Programs were found to cover the majority of assessed indicators, with the curricula averaging 84% coverage of the 54 indicators in the “care during labour and birth” category of the 2019 ICM Essential Competencies framework (Table 2, additional details in Supplementary Table 1). The assistant nursing program curriculum had the lowest coverage of indicators (70%), and the public and private midwifery program curricula had the highest coverage of indicators (91%). Unlike curricula for midwives and doctors, the curricula for nurses and nursing assistants do not specifically cover the management of a safe spontaneous vaginal delivery, the prevention, detection and stabilization of complications, or care of the newborn immediately after birth. Several indicators were also not found explicitly across all five curricula including considering cultural beliefs and traditions, assessing physical responses to labor, informing/supporting/encouraging the mother throughout labor, supporting the mother with pain, and managing the nuchal cord. Survey results A total of 30 students and 16 administrative staff consented and participated in the survey; background characteristics are shown in Table 3. Five public schools and nine private schools are represented in this survey. The average number of students in their schools, as reported by administrators, was 35 nursing students (IQR: 22) and 29 midwifery students (IQR: 25). Full surveys are available in Supplementary Fig. 4, and tabulated results are available in Supplementary Table 2. Staff evaluation Broadly, this survey found that all students rated both their teachers and their internship site supervisors as highly competent or moderately competent. Administrators report that 87% of teachers have formal preparation for teaching, and that 73% of internship sites have sufficient quality supervisors. Availability of learning materials, infrastructure, and practical training Overall, students and administrators reported that most schools have enough classroom space, access to electricity, teaching aids, and learning materials (Figure 1). However, prominent gaps are visible in the availability of updated libraries, skills labs, and quality skills lab equipment (Figure 1). Moderate gaps are also notable in the sufficiency of clinical learning sites, as well as availability of computers, non-stop internet, and materials at training facilities. All students reported that they had done at least some practical training (Figure 2). Nearly all reported that they had delivered a baby on their own during training, except for one student. However, some gaps are visible in the usage of mannequins for training and usage of a learner’s notebook, considered key components of skills-based training (Figure 2). Twelve questions were asked to both students and administrators about infrastructure and practical training. In 11 of 12 of these questions, administrator responses were more positive than student responses. The average difference between the two groups’ responses of the percent of respondents answering “no”/“not satisfactory” was 16%. The largest differences between the two groups responding “no”/“not satisfactory” were the availability of computers (33% difference) and sufficient clinical learning sites (33% difference) (Supplementary Table 2). Program administration and success Students and administrators see their programs as up to date, aligned with standards, and adapted to student needs. All administrators responded that course content is aligned with national/international standards. Of all students and administrators surveyed, 93% responded that the curriculum is adapted to the evolution of science and 89% believe the program is adapted to student needs. However, both groups believe that success rates of their class on annual exams are average to poor. Of all students and administrators surveyed, 20% believe success rates are excellent (70% or more of class passes), 51% believe that success rates are average (50% to 70% of class passes), and 29% believe success rates are poor (less than 50% of class passes). Discussion The findings of the study highlight many of the strengths and challenges in providing high quality childbirth care in Senegal. As the student survey, staff survey and coverage of competencies in pre-service education show, much of Senegal’s training and skills-building environment are operating commendably. However, in-depth interviews pointed to opportunities for improvement in the regulation of educational institutions, the practical training components, and licensing to continue Senegal’s progress in MNH. While increasing the number of nurses and midwives is crucial to improve access to childbirth care, maintaining education standards for these cadres is crucial to ensuring higher quality of care. This study’s findings mirror the 2022 report published by WHO and Ministère de la Santé et de l’Action Sociale (MSAS), an evaluation which found that many private training schools do not comply with training authorization criteria 22 . The government of Senegal is working towards improving these challenges by advocating for stronger regulations in private nursing and midwifery training schools. Potential paths forward include mandating the progressive closure of non-regulated schools by stopping new registrations, establishing criteria that schools need to meet before they re-open, and establishing a regulatory framework that ensures alignment and collaboration between the three accrediting ministries: 1) the MSAS, 2) the Ministry of Vocational and Technical Training, and the 3) MESRI. Corrective actions could be also based on the severity of non-compliance, with schools potentially receiving warning notices and being allowed to operate while implementing the recommended improvements. Our interviews and surveys also suggest that an increasing number of students graduate pre-service education in Senegal without adequate opportunities to gain clinical experience and practical skills before entering the workforce. These findings are consistent with another study in Senegal conducted by CEFOREP and UNFPA in 2020, which recommended the provision of additional simulation-based learning, hands-on training, and in-service supervision 16 . Beyond Senegal, the inclusion of sufficient practical experience is a challenge in MNH service provider training programs across SSA 23 . A lack of practical competency building in these programs has a direct impact on the quality of care provided by midwifery care providers including women’s experiences of care and health outcomes. 24 Regarding infrastructure, the data presented here suggests skills laboratory facilities, educator training, and practical training opportunities as potential future investments. Senegal is continuing to invest in these areas through several programs, including the series of PRESSMN programs led by MSAS and JICA to strengthen in-service training for SBAs and increase the provision of human-centered care. Additionally, future action may be needed on ensuring provider competency as well as developing licensing systems. One avenue is to consider combining the state diploma and school diploma to ensure that the competencies of graduates are tested via the national exam, and that passing the exam is required before obtaining the diploma and entering the workforce. Additionally, institutionalizing in-service training programs can support skill development throughout providers’ careers. Accelerating the development and legal authority of nursing and midwifery professional orders could also support the development of an effective licensing system. For example, ten countries in East and Southern Africa have compulsory licensing with periodic relicensing and requirements for continuous professional development for midwives 25 . Global evidence suggests that effective regulation and strong in-service training can contribute to improvements in the quality of health outcomes 23 , 26 . Despite these challenges, Senegal has expanded its health workforce and infrastructure, making successful strides in improving maternal and newborn health outcomes. With these and other key programs, Senegal has been identified as an Exemplar in NMR/MMR reduction for these and other topics 27 . For peer countries who are still progressing towards where Senegal is today, several strengths are essential to learn from and replicate. The competency coverage assessment shows that SBAs programs cover nearly the entire breadth of knowledge, skills and behaviors for care during childbirth recommended in category 3 of the ICM competencies 19 . Another core strength was identified through the survey of students and administrators, suggesting that many schools have the basic infrastructure to operate, including classroom space, access to electricity, teaching aids, and learning materials Senegal also has a variety of continuing education programs to support learning and training for in-service providers. The recent study by CEFOREP and UNFPA also noted many strengths including strong theoretical content, broad awareness of MSAS training programs, and overall student satisfaction with the majority of program infrastructure 16 . The findings also align with prior research and global reports on maternal and neonatal care in SSA 26,28 . Evidence from other studies in SSA indicate inadequate levels of competence among graduating midwifery care providers 29-31 . Midwifery programs vary substantially in minimum duration, level, public/private sector, academic standards, and credentials upon graduation – resulting in a variety of skillsets at the point of care. A cross-sectional study across four countries also found that gaps in quality of care may be attributed in part to a lack of sufficient training in pre-service education, as well as structural and operational facility characteristics which limit supervision, teamwork, appropriate commodities, or adequate time. Ensuring adequate opportunities for skills training as well as strengthening regulation around pre-service education programs were noted in the literature as paths forward, at a critical time when quality of care becomes increasingly important for saving lives. Especially at a time where midwifery models of care are positioned as a primary option for MNH service delivery, learning from Senegal’s experience will be important to help strengthen midwifery cadres in other low-income or middle-income countries. There are several limitations from this study, primarily linked to the sample size for the interviews and survey, as well as respondent biases. Though a range of stakeholders were included, only 25 key informant interviews were conducted. The purposive sampling design may also have risked bias towards informants known by the research team. Additionally, the qualitative methodology of interviews may have been influenced by a range of cognitive biases including skewing the data towards more recent events. For the survey, though the assessment included public and private schools across several regions, it was intended as an exploratory analysis and not designed as a representative sample of nursing and midwifery programs throughout Senegal. Finally, the curricula mapping only assessed theoretical frameworks of the intended learning outcomes, but did not systematically map other components of teaching such as infrastructure or educator background. Senegal has been identified an Exemplar in both its region and the globe across a variety of health areas, including maternal and newborn health, nutrition, and vaccination. Across these areas, Senegal has achieved rapid health gains beyond what could be expected due to economic improvements. As Senegal approaches global SDG targets for NMR and the national SDG target for MMR of 140 maternal deaths per 100,000 live births 1 , improving the quality of MNH services becomes increasingly important and especially because the end of the SGD era is rapidly approaching and if countries are to fulfill their commitments to achieve the SDG by 2030 urgent action is required. An essential component of quality is ensuring that health professionals are better trained, regulated, supervised, and equipped to deliver care. Throughout the process of educating healthcare workers, Senegal must prioritize policies and regulations for training schools, licensing, workforce entry, and continuing education that address the challenges revealed through this study. As the global health community moves into a new era of decreased development assistance for health and increased reliance on domestic resources, consistent health leaders such has Senegal will need to focus their efforts on what has worked so far, and what remains as barriers. For other peer nations looking to strengthen the quality of their health workforce, Senegal’s story offers notable suggestions, lessons, and paths forward. Abbreviations ANIIDES: Association Nationale des Infirmiers et Infirmières Diplômés d'Etat du Sénégal ANSD: Agence nationale de la statistique et de la démographie ANSFES: Association Nationale des Sages-Femmes d'Etat du Sénégal ASGO: Association Sénégalaise de Gynécologie-Obstétrique CEFOREP: Centre de Formation et de Recherche en Santé de la Reproduction (Center for Training and Research in Reproductive Health) CRFS: Centre Régional de Formation en Santé DRH: Direction des Ressources Humaines DSME: Direction de la Santé de la Mère et de l'Enfant JICA: Japan International Cooperation Agency ICM: International Confederation of Midwives KOICA: Korea International Cooperation Agency MCR: Médecins-chefs de région MMR: maternal mortality ratio MNH: maternal and newborn health NMR: neonatal mortality rate SDG: sustainable Development Goal SSA: sub-Saharan Africa SR: Santé Reproductive USAID: United States Agency for International Development UNFPA: United Nations Population Fund UNICEF: United Nations Children's Fund USAID: United States Agency for International Development WHO: World Health Organization Declarations Funding This work received funding from Gates Ventures, the Global Financing Facility, the United Nations Population Fund, and the United Nations Children’s Fund. Gates Ventures participated in the study conceptualization, design, analysis and synthesis of results. The other funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript. Contributions AM conceptualized of the study. MS led the overall design and implementation of the study. IM and SAD led field interviews. AD, AD, ETM, IM, MG, MS, SAD contributed to all stages of planning, implementing and finalizing results. AM, CN, DP, EYM, GI, IMAK, JPCS, JT, LHA, LPK, RB, YH contributed to the design and cross-country implementation of the study. DP, EYM, LHA, and MS wrote the first draft of the manuscript. All authors reviewed and approved the final manuscript. Acknowledgements The team would like to thank Senegal’s Directorate of Maternal and Child Health, Ministry of Health and Social Action for supporting this work, especially Dr. Amadou Doucouré and Dr. Elhadji Thierno Mbengue. Competing interests The authors declare no competing interests. Ethical statement The project received ethical approval from the following institution: Comité National d'Ethique pour la Recherche en Santé (CNERS), Sénégal – (ID :SEN22/126), date of approval 08.05.2023. Disclaimer The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. References United Nations Department of Economic and Social Affairs. Sustainable Development Goals. https://sustainabledevelopment.un.org/index.html. Published 2015. Accessed 07 July 2025. Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. (World Health Organization, Geneva, 2025). United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2024 – Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. (United Nations Children’s Fund, New York, 2025). Oona Maeve Renee, C., Agbessi, A., Cauane, B. & Ties, B. Learning from success: the main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes. BMJ Global Health 9, e012126 (2024). Ministère de la Santé et de l’Action Sociale, D.d.l.S.d.l.M.e.d.l.E. Politiques, Normes et Procédures des services de Santé de la Reproduction du Sénégal. ( Sénégal, 2018). Priebe, J., Amuasi, J., Dartanto, T., Mombo-Ngoma, G. & Guigas, M. Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data. The Lancet Global Health 12, e1104-e1110 (2024). Amouzou, A., Ziqi, M., Carvajal-Aguirre, L. & Quinley, J. Skilled attendant at birth and newborn survival in Sub-Saharan Africa. J Glob Health 7, 020504 (2017). Firew Tekle, B., Augustine, A., Mirkuzie, W., Angela, D. & Andrew, H. Spatial patterns and inequalities in skilled birth attendance and caesarean delivery in sub-Saharan Africa. BMJ Global Health 6, e007074 (2021). Olorunsaiye, C.Z., Yusuf, K.K., Harris, A.M. & Gaikwad, S. Association between birth attendant and early newborn care in Senegal. Midwifery 90, 102804 (2020). McIsaac, M., Buchan, J., Abu-Agla, A., Kawar, R. & Campbell, J. Global Strategy on Human Resources for Health: Workforce 2030—A Five-Year Check-In. Human Resources for Health 22, 68 (2024). Agence nationale de la statistique et de la démographie Sénégal & ICF. Enquête Démographique et de Santé Continue (Enquête Continue 2023) (Rockville, Maryland, USA 2024). Exemplars in Global Health. What did Senegal do? https://www.exemplars.health/topics/neonatal-and-maternal-mortality/senegal/what-did-senegal-do. Published 2025. Accessed 29 August 2025. World Health Organization. World health statistics 2025: monitoring health for the SDGs, Sustainable Development Goals, (World Health Organization, Geneva, 2025). Ministère de la Santé et de l’Action Sociale, Direction des Ressources Humaines & Division de la Formation. Établissements privés d’enseignement en santé du Sénégal. (Sénégal, 2023). Rasanathan, K., et al. Navigating health financing cliffs: a new era in global health. The Lancet 405, 1893-1895 (2025). UNFPA & Centre Régional de Formation, d.R.e.d.P.e.S.d.l.R. Evaluation de la formation des sages-femmes d’etat au Sénégal. (Ministère de la santé et de l’action sociale. Sénégal, 2020). World Health Organization. Defining competent maternal and newborn health professionals. (Geneva, 2018). Carter, A., et al. A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems. BMJ Glob Health 5(2020). The International Confederation of Midwives. The International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice Framework 2019. (The Hague, 2019). World Health Organization. Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA. (World Health Organization, Geneva, 2018). West African Health Organisation. Harmonized training curriculum for nurses and midwives in ECOWAS region. (West African Health Organisation, 2014). Ministère de la Santé et de l’Action sociale - Direction des Ressources Humaines. Rapport de synthèse de la mission de vérification des écoles de formation en santé (Février, Mars et Avril 2022). (Sénégal, 2022). Cavallaro, F.L., et al. What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal. BMJ Glob Health 5, e001915 (2020). Kawish, A.B., et al. Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review. Medicina (Kaunas) 59(2023). United Nations Population Fund East and Southern Africa Regional Office. The State of the World's Midwifery 2022: Analysis of the Sexual, Reproductive, Maternal, Newborn and Adolescent Health Workforce in East and Southern Africa. (South Africa, 2022). United Nations Population Fund. State of the World’s Midwifery 2021 (SoWMy 2021). (New York, United States of America, 2021). Exemplars in Global Health. How did Senegal implement? https://www.exemplars.health/topics/neonatal-and-maternal-mortality/senegal/how-did-senegal-implement. Published Undated. Accessed 28 May 2025. Agence nationale de la statistique et de la démographie (ANSD) [Sénégal], e.I. Enquête Démographique et de Santé Continue (Enquête Continue 2023) (Rockville, Maryland, USA : ANSD et ICF., 2023). Moller, A.B., et al. Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda. PLOS Glob Public Health 3, e0001399 (2023). Yigzaw, T., et al. How well does pre-service education prepare midwives for practice: competence assessment of midwifery students at the point of graduation in Ethiopia. BMC Med Educ 15, 130 (2015). Neal, S., et al. An analysis of the global diversity of midwifery pre-service education pathways. Women Birth 36, 439-445 (2023). Tables Table 1: Key informants’ groupings and area of responsibility Group Respondent organizations Number of respondents Group 1: Central and regional government organizations responsible for maternal and newborn health National MNCH a division, DSME b National human resources division, DRH c 4 Regional chief medical officers, MCR d 2 Regional government reproductive health coordinators 4 Group 2: Training institutions Managers of private schools, public schools, and public universities 4 Group 3: National government organizations responsible for maternal and newborn health data National MNCH a Division, DSME b National Agency for Statistics and Demography, ANSD e National Division of Planning, Research, and Statistics, DPRS f 3 Group 4: Professional associations Senegalese Association of Gynecology and Obstetrics, ASGO g National Association of State Midwives of Senegal, ANSFES h National Association of State Nurses of Senegal, ANIIDES i 3 Group 5: Technical and financial partners UNFPA j , UNICEF k , WHO l , USAID MOMENTUM m , JICA n , Regional Centre for Training, Research, and Advocacy in Reproductive Health, CEFOREP o 5 a. MNCH : Maternal, newborn, and child health b. DSME: Direction de la Santé de la Mère et de l'Enfant c. DRH: Direction des Ressources Humaines d. MCR: Médecins-chefs de région e. ANSD: Agence nationale de la statistique et de la démographie f. DPRS: Direction de la Planification, de la Recherche et des Statistiques g. ASGO: Association Sénégalaise de Gynécologie-Obstétrique h. ANSFES: Association Nationale des Sages-Femmes d'Etat du Sénégal i. ANIIDES: Association Nationale des Infirmiers et Infirmières Diplômés d'Etat du Sénégal j. UNFPA: United Nations Population Fund k. UNICEF: United Nations Children’s Fund l. WHO: World Health Organization m. JICA: Japanese International Cooperation Agency n. USAID MONENTUM: United States Agency for International Development o. CEFOREP: Centre Régional de Formation, de Recherche et de Plaidoyer en Santé de la Reproduction Table 2: Curricula assessment scores of five pre-service education programs mapped against the 2019 ICM Competencies in “care during labour and birth” category Program/curricula Curricula assessment scores Public midwifery program 91% Private midwifery program 91% Nursing program 78% Assistant nursing program 70% Medical doctor program 89% Table 3. Characteristics of survey respondents and their corresponding category of school Parameter Students Administrative staff Respondents (n) 30 16 Public schools (%) 23% 36% Private schools (%) 77% 64% Sex, female (%) 83% 29% Additional Declarations There is NO Competing Interest. Supplementary Files 20250917Senegalmanuscriptsupplementary.docx Supplemental material Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7643871\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":520705485,\"identity\":\"519e67df-8e2b-482e-b543-3d655356e1a9\",\"order_by\":0,\"name\":\"Ann-Beth Moller\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJACZiBOAGLGAw+AJD97A1FaDEBaGA6ASMmeA6RqMbiRgF85/+zeA8wFFX/yGMQOHziQUHGPgeHm82sSDH9scGqRuHMugXnGGYNiBum0hAMJZ4oZGGfnlEkwtqXhtuZGjvlv3jaDxAbpHIMDiW0JDMzSOWkSjA2HceqQv5FjwMz7D6blXwIDm+SZNKDD/uPUYgDW0gDT0pDAwCPBfkyCge0ATi2GIC0zjhkntoH9ciyBR4Inh9kisS0ZpxY5kJaCGrnEfunkgw8+1CTI2R8//vDGhz92uL0PA2xQmgeIDMCJgRTA/oBEDaNgFIyCUTDMAQDbLFJ/xVLiKAAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Ann-Beth\",\"middleName\":\"\",\"lastName\":\"Moller\",\"suffix\":\"\"},{\"id\":520705486,\"identity\":\"e71e1f02-0f16-4c76-9636-77720393acc2\",\"order_by\":1,\"name\":\"Moussa Sarr\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Moussa\",\"middleName\":\"\",\"lastName\":\"Sarr\",\"suffix\":\"\"},{\"id\":520705487,\"identity\":\"50043df6-4464-4464-be42-b200d93d7165\",\"order_by\":2,\"name\":\"Isabelle Moreira\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Independent Consultant\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Isabelle\",\"middleName\":\"\",\"lastName\":\"Moreira\",\"suffix\":\"\"},{\"id\":520705488,\"identity\":\"af6b4be2-5251-4c41-8364-8c0e7fe672b5\",\"order_by\":3,\"name\":\"Saly Amos Diatta\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Saly\",\"middleName\":\"Amos\",\"lastName\":\"Diatta\",\"suffix\":\"\"},{\"id\":520705489,\"identity\":\"9bd2259b-46d4-437c-bd68-793e85a7994e\",\"order_by\":4,\"name\":\"Raqeil Bdewy\",\"email\":\"\",\"orcid\":\"https://orcid.org/0009-0004-1868-9851\",\"institution\":\"School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Raqeil\",\"middleName\":\"\",\"lastName\":\"Bdewy\",\"suffix\":\"\"},{\"id\":520705490,\"identity\":\"3a7bad6b-f10b-443e-8f81-ad71a4581417\",\"order_by\":5,\"name\":\"Juan Castiblanco Salgado\",\"email\":\"\",\"orcid\":\"https://orcid.org/0009-0003-1082-0993\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Juan\",\"middleName\":\"Castiblanco\",\"lastName\":\"Salgado\",\"suffix\":\"\"},{\"id\":520705491,\"identity\":\"5670d5f2-56ba-46ce-8b38-7f858bd437c8\",\"order_by\":6,\"name\":\"Aissatou Diouf\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Institut de Recherche en Santé de Surveillance Epidémiologique et de Formation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Aissatou\",\"middleName\":\"\",\"lastName\":\"Diouf\",\"suffix\":\"\"},{\"id\":520705492,\"identity\":\"d9f5a63a-3a55-4c79-b5f3-cf84209a48ae\",\"order_by\":7,\"name\":\"Moctar Gningue\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Moctar\",\"middleName\":\"\",\"lastName\":\"Gningue\",\"suffix\":\"\"},{\"id\":520705493,\"identity\":\"f9b8d6a6-0d20-4904-9382-10d5aabddb04\",\"order_by\":8,\"name\":\"Yao He\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0003-0023-5515\",\"institution\":\"Department of Global Health, Schools of Public Health and Medicine, University of Washington\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yao\",\"middleName\":\"\",\"lastName\":\"He\",\"suffix\":\"\"},{\"id\":520705494,\"identity\":\"482fc0d8-3d7c-4493-ad60-17dd0f2267c4\",\"order_by\":9,\"name\":\"Laith Hussain-Alkhateeb\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Laith\",\"middleName\":\"\",\"lastName\":\"Hussain-Alkhateeb\",\"suffix\":\"\"},{\"id\":520705495,\"identity\":\"d8d6ff12-0ddc-41e3-953f-bf3d290719d3\",\"order_by\":10,\"name\":\"Gloria Ikilezi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Exemplars in Global Health, Gates Foundation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Gloria\",\"middleName\":\"\",\"lastName\":\"Ikilezi\",\"suffix\":\"\"},{\"id\":520705496,\"identity\":\"f03a0483-d4c6-425a-a71e-d875a2af1122\",\"order_by\":11,\"name\":\"Israa Mahmoud Abdelhameed Khaireldin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Israa\",\"middleName\":\"Mahmoud Abdelhameed\",\"lastName\":\"Khaireldin\",\"suffix\":\"\"},{\"id\":520705497,\"identity\":\"2e8f5b8b-2ee7-4608-ad20-2746507cc608\",\"order_by\":12,\"name\":\"Claire Nkamushaba\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Claire\",\"middleName\":\"\",\"lastName\":\"Nkamushaba\",\"suffix\":\"\"},{\"id\":520705498,\"identity\":\"664fbe10-7a3b-4da6-9d71-f74698498c64\",\"order_by\":13,\"name\":\"Loveday Penn-Kekana\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"London School of Hygiene and Tropical Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Loveday\",\"middleName\":\"\",\"lastName\":\"Penn-Kekana\",\"suffix\":\"\"},{\"id\":520705499,\"identity\":\"6fe30255-0dee-406e-b0ca-f0cc3fecc3f5\",\"order_by\":14,\"name\":\"David Phillips\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gates Foundation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"David\",\"middleName\":\"\",\"lastName\":\"Phillips\",\"suffix\":\"\"},{\"id\":520705500,\"identity\":\"442102f8-503f-43ae-9387-ffbd04f59a04\",\"order_by\":15,\"name\":\"Jordan-Tate Thomas\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Exemplars in Global Health, Gates Foundation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jordan-Tate\",\"middleName\":\"\",\"lastName\":\"Thomas\",\"suffix\":\"\"},{\"id\":520705501,\"identity\":\"00ffba9f-8ea7-44d8-ae62-1c19efed1e77\",\"order_by\":16,\"name\":\"Erica Yarmol-Matusiak\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Exemplars in Global Health, Gates Foundation\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Erica\",\"middleName\":\"\",\"lastName\":\"Yarmol-Matusiak\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-09-18 00:05:08\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7643871/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7643871/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":94632467,\"identity\":\"9551e445-26df-46ab-89cf-485e999e0172\",\"added_by\":\"auto\",\"created_at\":\"2025-10-29 06:29:40\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":43507,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eResponses from students and administrators about availability of learning materials, infrastructure, and practical training components (n=45)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7643871/v1/530b311d656399c987fc0211.png\"},{\"id\":94632466,\"identity\":\"ffbdf8d8-be36-4d77-b37d-9c1c6f8fb8e3\",\"added_by\":\"auto\",\"created_at\":\"2025-10-29 06:29:40\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":36361,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eResponses from students only about availability of learning materials, equipment, and practical training components (n=30)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7643871/v1/5631b71195e0d6522dacff70.png\"},{\"id\":94641058,\"identity\":\"8dfc02cb-8348-480e-9ffc-ecbf6369193e\",\"added_by\":\"auto\",\"created_at\":\"2025-10-29 07:50:34\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1684417,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7643871/v1/0e1f7798-fb8d-410b-a8e3-18d233ff9df4.pdf\"},{\"id\":94632468,\"identity\":\"904b0aa0-0151-4166-a003-e2d4e12af7da\",\"added_by\":\"auto\",\"created_at\":\"2025-10-29 06:29:40\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":311247,\"visible\":true,\"origin\":\"\",\"legend\":\"Supplemental material\",\"description\":\"\",\"filename\":\"20250917Senegalmanuscriptsupplementary.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7643871/v1/163d7099171c9123c8c58109.docx\"}],\"financialInterests\":\"There is \\u003cb\\u003eNO\\u003c/b\\u003e Competing Interest.\",\"formattedTitle\":\"Stakeholders' insights and perceptions on nursing and midwifery care providers' pre-service education, training, and regulations in Senegal: a mixed-methods study\",\"fulltext\":[{\"header\":\"Main\",\"content\":\"\\u003cp\\u003eSustainable Development Goal (SDG) 3 of the 2030 Agenda focuses on ensuring healthy lives and promoting well-being for all. Specifically, SDG 3.1 aims to reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births and SDG 3.2 aims to reduce neonatal mortality rate (NMR) to at least as low as 12 deaths per 1000 live births by 2030.\\u003csup\\u003e1\\u003c/sup\\u003e Despite apparent global progress, maternal and neonatal mortality remains high in many countries, especially in sub-Saharan Africa (SSA). Recent estimates suggest that SSA accounted for nearly 70% of global maternal deaths and 46% of global neonatal deaths in 2023\\u003csup\\u003e2,3\\u003c/sup\\u003e. Current trends in MMR and NMR reduction globally will still fall short of meeting the SDG targets\\u003csup\\u003e2,3\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOver the past two decades, Senegal has been one of the best-performing countries in SSA at improving maternal and newborn health (MNH), beyond what could be expected when accounting for economic development. As a result of this progress, a program known as Exemplars in Global Health identified Senegal as an Exemplar (i.e. positive outlier) country in MMR and NMR reduction\\u003csup\\u003e4\\u003c/sup\\u003e, and documented the strategies to their success that others could learn from. These strategies include improving access to healthcare facilities, removing user fees for childbirth services, launching and tailoring a family planning action plan to improve contraceptive demand, and improving access and the availability of skills of healthcare workers\\u003csup\\u003e5\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSkilled birth attendants (SBAs) are essential to the health and survival of women and newborns. The extent to which SBAs are properly educated, competent and equipped is directly tied to MNH outcomes, as extensive global and sub-national studies have shown\\u003csup\\u003e6-9\\u003c/sup\\u003e, and the World Health Organization\\u0026rsquo;s global strategy on human resources for health (Workforce 2030) continues to reinforce\\u003csup\\u003e10\\u003c/sup\\u003e. Growing evidence, including new research provided in this series, point to the fact that merely having an SBA present during childbirth is insufficient to realize the complete health benefits required to meet positive health outcomes and SDGs 3.1 and 3.2 - health professionals must also have adequate competencies and an enabling environment to succeed. Recent data from the 2023 Demographic and Health Surveys (DHS) suggests that 93.5% of births in Senegal are assisted by SBAs. The 2023 DHS defines SBAs as doctors, midwives, nurses, nursing assistants, and heads of health posts, though the heads of health posts are not always considered SBAs in other contexts and data systems in Senegal\\u003csup\\u003e11\\u003c/sup\\u003e.\\u0026nbsp;Published decomposition analyses indicate that the majority of maternal and newborn lives saved come from healthcare interventions, health services, and medical products largely delivered by SBAs\\u003csup\\u003e12\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDespite positive health outcomes and progress in Senegal, challenges remain with the availability, distribution, access and quality of the health workforce in relation to MNH. Density of nurses and midwives in Senegal in 2023 was 4.2 per 10 000 population, below what is recommended to meet universal health coverage\\u003csup\\u003e13\\u003c/sup\\u003e. Substantial variation exists in these cadres\\u0026rsquo; training and education\\u003csup\\u003e11\\u003c/sup\\u003e. Senegal had 103 training institutions for midwives, nurses and assistant nurses registered in 2023\\u003csup\\u003e14\\u003c/sup\\u003e. Of these institutions, nine were public and 94 were private. Dakar and Thi\\u0026egrave;s regions now have the largest number of private pre-service education programs. This growth of nursing and midwifery schools in Senegal emerged post-2000s to address increasing healthcare demands, rapid population growth, and need for additional education programs across regions. Private schools came as a complement to the previously existing public education system, which was 100% state-managed and mostly centralized in the capital city of Dakar.\\u003c/p\\u003e\\n\\u003cp\\u003eFurthermore, an evolving global landscape may present new challenges for countries like Senegal to sustain exemplary progress. If international funding for health programs and data declines, countries will need to prioritize activities that address the most critical remaining barriers, as well as rely on domestic, low-cost data and indicators to monitor their progress\\u003csup\\u003e15\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eIn order for countries to improve MNH, scale up human resources for health, and meet the SDGs, it will be imperative to understand the barriers and contributors to quality of childbirth care provided by SBAs, in exemplary settings such as Senegal. To inform effective interventions, it is essential to examine both the drivers of improved care quality and the reasons it remains insufficient in some circumstances.\\u003c/p\\u003e\\n\\u003cp\\u003eTo date, there have been limited systematic efforts to evaluate the quality, theoretical and practical competencies of SBAs in Senegal, despite evidence of apparent gaps in managing childbirth care\\u003csup\\u003e16\\u003c/sup\\u003e. To address these health workforce challenges and support the improvement of MNH outcomes in Senegal and elsewhere, this study aimed at addressing and evaluating strengths and weaknesses in nursing and midwifery pre-service training programs related to care during childbirth focusing on the concept related to \\u0026ldquo;standard of practice\\u0026rdquo;, which includes training, education and regulation\\u003csup\\u003e17\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003ch2\\u003eSetting and study design\\u003c/h2\\u003e\\n\\u003cp\\u003eThis research was conducted as part of a multi-country, mixed-methods study to enhance the understanding of how the coverage of SBAs and SHP could be more reliably measured, including developing a valid metric and including all the concepts of the 2018 SHP definition\\u003csup\\u003e17\\u003c/sup\\u003e (Box 1). This project was conducted in Nepal, Senegal and Zambia, three countries involved in a program known as Exemplars in Global Health (EGH). EGH is a partnership dedicated to learning from countries that have demonstrated exceptional progress in a range of health areas, such as MNH\\u003csup\\u003e18\\u003c/sup\\u003e. This project included cross-country quantitative research as well as qualitative research components in all three study countries.\\u003c/p\\u003e\\n\\u003cp\\u003eThis article specifically focuses on three components of that study in Senegal: qualitative research from key informant interviews, a quantitative component of surveying students and administrative staff from the nursing and midwifery training institutions, and an assessment of SBAs pre-service curricula comparing to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice framework, 2019 update \\u003csup\\u003e19\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eA protocol was developed outlining the study approach and was adapted to the Senegalese context. A Technical Working Group composed of key government and international partners in Senegal was established to provide technical support for the project (Supplementary Fig. 1).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch4\\u003eBox 1. The 2018 definition of skilled health personnel (competent health care professionals)\\u003csup\\u003e20\\u003c/sup\\u003e\\u003c/h4\\u003e\\n\\u003ctable style=\\\"width: 100%;\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 100.0000%;\\\"\\u003e\\n \\u003cp\\u003eSkilled health personnel, as referenced by SDG indicator 3.1.2, are competent maternal and newborn health (MNH) professionals educated, trained and regulated to national and international standards.\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eThey are competent to:\\u003c/p\\u003e\\n \\u003cp\\u003e(i) provide and promote evidence-based, human-rights- based, quality, socio-cultural sensitive and dignified care to women and newborns;\\u003c/p\\u003e\\n \\u003cp\\u003e(ii) facilitate physiological processes during labour and delivery to ensure a clean and positive childbirth experience; and\\u003c/p\\u003e\\n \\u003cp\\u003e(iii) identify and manage or refer women and/or newborns with complications.\\u003c/p\\u003e\\n \\u003cp\\u003eIn addition, as part of an integrated team of MNH professionals (including midwives, nurses, obstetricians, paediatricians and anaesthetists), they perform all signal functions of emergency maternal and newborn care to optimize the health and well-being of women and newborns.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eWithin an enabling environment, midwives trained to International Confederation of Midwives (ICM) standards can provide nearly all of the essential care needed for women and newborns.* (In different countries, these competencies are held by professionals with varying occupational titles.)\\u003c/p\\u003e\\n \\u003cp\\u003e*The state of the world\\u0026rsquo;s midwifery 2014: a universal pathway: a woman\\u0026rsquo;s right to health. New York (NY): United Nations \\u003cem\\u003ePopulation Fund; 2014 (www.unfpa.org/sow\\u003c/em\\u003emy).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003ch2\\u003eSampling\\u003c/h2\\u003e\\n\\u003cp\\u003eKey informants were chosen through purposive sampling in collaboration with the Ministry of Health and Social Action and the Technical Working Group. The following pertinent stakeholders were considered throughout the country based on professional profile, experience and degree of involvement in aspects related to the training and provision of childbirth care providers. MNH government managers (national and regional levels), heads of training institutions for doctors, midwives and nurses, those responsible for collection and usage of data related coverage of SBAs and other childbirth related indicators, and members of professional organizations were selected.\\u003c/p\\u003e\\n\\u003cp\\u003eFor the online survey out of the 103 schools providing midwifery and nursing training at the time of the study, 38 schools were selected based on stratified random sampling to ensure acceptable representation by region, private versus public, and school size. Email addresses were obtained after telephone contact with the training schools using the directory of registered schools.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eData collection and tools\\u003c/h2\\u003e\\n\\u003ch3\\u003eIn-depth interviews\\u003c/h3\\u003e\\n\\u003cp\\u003eIn-depth interview guides were piloted with two people before being used with stakeholders. The key informant interviews were conducted from August to October 2023 applying an in-depth interview guide (Supplementary Fig. 2). Data were collected from 25 key informants by S.A.D and I.M and conducted in French and English according to the interviewee\\u0026apos;s preferred language. Twenty-one interviews were conducted online and four were conducted face-to-face based on the interviewee\\u0026rsquo;s preference. Interview participants were informed of the voluntary nature of the study through an explanatory document shared, and all signed the consent before the interviews were conducted (Supplementary Fig. 3).\\u003c/p\\u003e\\n\\u003ch3\\u003eSurvey\\u003c/h3\\u003e\\n\\u003cp\\u003eAn anonymized online survey was administered between August and October 2023 to address the quantitative perspective of the study (Supplementary Fig. 4). A context-adapted survey was developed by the team for educational settings to primarily assess the following key dimensions: i) staff competence and evaluation, ii) availability of learning materials, infrastructure and practical training, and iii) program administration, governance, and success.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTwo versions of the survey were developed \\u0026ndash; one survey for administrators (29 questions), and another survey for students (29 questions). Eighteen questions were the same in both the student survey and the administrator survey, with the remaining eleven questions unique to students and to administrators. The survey was hosted on Google Forms, with data collected in Google Sheets, and was sent via email to students and administrators. The full surveys are included in Supplementary Fig. 4. The online survey was pre-tested with members of the team.\\u003c/p\\u003e\\n\\u003ch3\\u003eCoverage of competencies related to childbirth care in pre-service training curricula\\u003c/h3\\u003e\\n\\u003cp\\u003eAn extraction form in Microsoft Excel was developed to map the pre-service training curricula to the ICM framework. The 2019 ICM Essential Competencies for Midwifery Practice consists of four main categories: i) general competencies, ii) pre-pregnancy and antenatal care, iii) care during labour and birth, and iv) ongoing care of women and newborns. For this study we only focused on the third category \\u0026ldquo;care during labour and birth\\u0026rdquo;, consisting of 54 competencies with 19 knowledge indicators and 35 skills and behaviours indicators\\u003csup\\u003e19\\u003c/sup\\u003e.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFor all components of the study, research files, recordings and transcriptions were stored, password protected and kept on a secure drive on Institut de Recherche en Sant\\u0026eacute;, de Surveillance \\u0026Eacute;pid\\u0026eacute;miologique et de Formation (IRESSEF) systems.\\u003c/p\\u003e\\n\\u003ch2\\u003eData analysis\\u003c/h2\\u003e\\n\\u003ch3\\u003eIn-depth interviews\\u003c/h3\\u003e\\n\\u003cp\\u003eAudio files of the interviews were transcribed verbatim. Quality checks were performed by transcribers and members of the research team to ensure the conformity of the audio files and transcripts. These transcripts were combined with detailed notes and uploaded into NVivo software version 12 for analysis by members of the team. The coding was guided by preset themes and sub-themes that were in the interview guides and protocol. For the analysis the following steps were used: i) data familiarization and generating notes of prevalent topics, ii) systematic data coding, iii) generating initial themes from coded and collated data, iv) developing and reviewing themes, v) refining, defining, and naming themes.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eSurvey\\u003c/h3\\u003e\\n\\u003cp\\u003eMicrosoft Excel was used to clean and tabulate data, calculate descriptive statistics for frequency and proportion. Responses were analyzed separately for all questions in each of the two surveys. Additionally, results were aggregated for questions that were the same in the students and administrators survey.\\u003c/p\\u003e\\n\\u003ch3\\u003eCoverage of competencies related to childbirth care in pre-service training curricula\\u0026nbsp;\\u003c/h3\\u003e\\n\\u003cp\\u003eOur team obtained five pre-service training curricula through literature review and conversations with stakeholders: public midwifery, private midwifery, nurses, assistant nurses, and medical doctors. Data extraction was performed by two members of the team (I.M. and S.A.D.) and each curriculum was read and reviewed several times to determine the content related to the third category \\u0026ldquo;labour and birth care\\u0026rdquo; inclusion the curricula. The 54 indicators (19 knowledge and 35 skills and behaviours) were considered equally important. The content of the curriculum was considered to have met the ICM frameworks third category competencies if the 54 indicators (maximum score) were included in the curriculum or in other words 100% alignment with the ICM framework. For each curriculum a summary score was calculated.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003ch2\\u003eIn-depth interviews\\u003c/h2\\u003e\\n\\u003cp\\u003eA total of 25 key informant interviews with details about their area of responsibility described in Table 1. This section is structured by findings about 1) quality of pre-service education, 2) regulation and legislation, and 3) in-service training and provision. Additional quotes supporting all themes are included in Supplementary Fig. 5.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch3\\u003eQuality of pre-service education\\u003c/h3\\u003e\\n\\u003cp\\u003ePositive aspects of pre-service education for childbirth care, according to the key informants, included alignment between the curriculum and international guidelines; educational programs for senior nursing and midwifery in development; and continuous quality improvement projects receiving support from external funders.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eBarriers to quality training included low availability and insufficient experience of educators and supervisors and insufficient practical training due to infrastructure and material constraints. Respondents suggested that these challenges contribute to lower skill levels in graduates and low national exam success rates.\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eCurriculum has been aligned with international guidelines\\u0026nbsp;\\u003c/h4\\u003e\\n\\u003cp\\u003eAcross both public and private nursing and midwifery schools, key informants suggested that their schools\\u0026rsquo; curricula for childbirth care providers had been recently adapted to be aligned with the training curriculum from the West African Health Organization\\u003csup\\u003e21\\u003c/sup\\u003e. \\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eDevelopment of programs for more senior nursing and midwifery positions\\u0026nbsp;\\u003c/h4\\u003e\\n\\u003cp\\u003eSeveral master\\u0026rsquo;s and doctoral-level programs have been set up at \\u0026Eacute;cole Nationale de D\\u0026eacute;veloppement Sanitaire et Social (ENDSS), Universit\\u0026eacute; Gaston Berger and other universities for midwives and nurses to develop their skills. Over time, these programs can help to increase the number of nursing and midwifery educators in Senegal. \\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eOngoing initiatives to monitor and improve quality of pre-service education\\u003c/h4\\u003e\\n\\u003cp\\u003eSenegal continues to work with development partners to strengthen pre-service education.\\u003c/p\\u003e\\n\\u003cp\\u003eFor example, United Nations Population Fund (UNFPA) has been involved in evaluations of curriculum, training approaches, and infrastructure at the national public school, ENDSS. UNFPA also partners with other universities to train students on new evidence-based guidelines in MNH care. The Japanese International Cooperation Agency (JICA) has supported the AQSIS (Am\\u0026eacute;lioration de la Qualit\\u0026eacute; des Stages des Infirmiers et des Sage-femmes) project to strengthen student supervision during practical training, and facilitate coordination between schools, health facilities and medical region/district managers. Takeda Pharmaceuticals has also been supporting the development of four public and private training schools.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eEducators and supervisors at some schools do not have sufficient experience to effectively teach students\\u0026nbsp;\\u003c/h4\\u003e\\n\\u003cp\\u003eSeveral respondents shared that it was challenging to find and employ qualified teachers to teach at training schools. Additional quotes and details about requirements are in Supplementary Fig. 5. Respondents suggested that the combination of a shortage of teachers and their limited qualifications contributes to poorer learning outcomes at some educational institutions.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA respondent from a government regional health training centre shared: \\u003cem\\u003e\\u0026ldquo;There is a glaring deficit in human resources. And when we don\\u0026apos;t have teachers, we can\\u0026apos;t provide quality training\\u0026hellip;there are many institutes where the quality and skill level [of teachers] pose a problem.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAnother national-level government stakeholder shared: \\u003cem\\u003e\\u0026ldquo;We cannot have [so many] private health schools in Senegal and on the other hand you do not have the human resources to train them. Who will provide that training?\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eInsufficient practical training due to infrastructure and material constraints\\u003c/h4\\u003e\\n\\u003cp\\u003eOne common challenge discussed by respondents was insufficient practical training, either through limited skills laboratory infrastructure, a shortage of internship sites, or inadequate materials and supervision in these environments. These gaps may contribute to graduates lacking practical training when they enter the workforce.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA reproductive health coordinator shared: \\u003cem\\u003e\\u0026ldquo;There are some schools that have training materials, but there are others that do not have even practical training rooms.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA stakeholder from a private educational institution noted the shortage of internship sites in their region: \\u003cem\\u003e\\u0026ldquo;we have health centers and only one hospital for eight private schools\\u0026hellip;When students arrive on the field, the plethora of numbers can be such obstacles that we are forced to use our practical work rooms.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA representative from a regional government training institution shared: \\u003cem\\u003e\\u0026ldquo;To get an internship site, now, it\\u0026apos;s not easy\\u0026hellip;.often [the training supervisor] writes about the working conditions, the lack of materials, there are no gloves.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eSeveral respondents noted that a small number of midwives would graduate their pre-service education program without having assisted women with delivery, a crucial practical skill they are responsible for in the workforce. A government-level stakeholder involved in training shared: \\u003cem\\u003e\\u0026ldquo;When we talk about a midwife who comes out with a diploma and who has never been in a maternity ward or in a delivery room, you see the problem where it arises.\\u0026rdquo;\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eDecreasing skill level of recent graduates from private institutions providing pre-service education\\u0026nbsp;\\u003c/h4\\u003e\\n\\u003cp\\u003eMany respondents highlighted a lack of sufficient skills in recent graduates from pre-service training programs, with some respondents suggesting it may be linked to the rapid expansion of private training schools.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA government official at the national level shared: \\u003cem\\u003e\\u0026ldquo;So, in fact, it\\u0026apos;s a notable regression. Because the skill level has nevertheless dropped significantly. So, it is perhaps linked to the multitude, to the proliferation of schools. There is not enough control over the quality of the finished product.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eNational exam success rates are another indicator of graduate skill levels. Respondents from the government suggested that current success rates on the national midwifery licensing exam are lower than 10%.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch3\\u003eRegulation \\u0026amp; legislation\\u003c/h3\\u003e\\n\\u003ch4\\u003eSchool diplomas may be awarded without a state diploma\\u003c/h4\\u003e\\n\\u003cp\\u003eThere is limited regulation in Senegal around a unified state diploma system for nurses and midwives. Respondents shared that educational institutions could issue their own school diploma as a completion certificate for their program of study, without a graduate passing the national exam or receiving a state diploma. Despite the lack of skill validation, school diplomas are sufficient to work at a lower-level position in public health posts or in the private sector, such as an assistant nurse or assistant midwife (Supplementary Fig. 5). \\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eLimited accreditation or quality control on private nursing and midwifery schools\\u003c/h4\\u003e\\n\\u003cp\\u003eInstitutions providing pre-service education for nursing and midwifery in Senegal can open and operate without following all regulations and guidelines. Respondents raised concerns about basic midwifery training due to the variation in private training schools\\u0026rsquo;\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003eadherence to standards, citing a 2022 evaluation by the Human Resources Department of the Ministry of Health and Social Action or Minist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action Sociale (MSAS) and the World Health Organization (WHO)\\u003csup\\u003e22\\u003c/sup\\u003e. Though the national public school for midwives complies best with educational standards, it does not produce many midwives compared to the numerous private schools.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eOne government official shared: \\u003cem\\u003e\\u0026quot;The medical region has no control over private training schools, some of which are not accredited. There is also a plethora of training schools, particularly in Dakar: 48 at the last census in 2022!\\u0026rdquo;\\u003c/em\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eWe corroborated this by confirming that ANAQSUP, the organization responsible for accreditation, has approved several midwifery schools that do not meet all the criteria and are still issuing diplomas to students without certification.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eFragmented and overlapping responsibilities for regulation between three ministries\\u003c/h4\\u003e\\n\\u003cp\\u003eRespondents suggested that the split and overlap between different ministries\\u0026rsquo; responsibilities was a contributing factor to the challenges in regulation of educational institutions. Management of training is coordinated by three ministries:\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e1) Ministry of Health and Social Action (\\u003cem\\u003ein French, Minist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action Sociale - MSAS\\u003c/em\\u003e), 2) Ministry of Vocational and Technical Training (\\u003cem\\u003ein French, Minist\\u0026egrave;re Formation Professionnelle et Technique\\u003c/em\\u003e), and Ministry of Higher Education, Research and Innovation (\\u003cem\\u003ein French, Minist\\u0026egrave;re de l\\u0026apos;Enseignement sup\\u0026eacute;rieur, de la Recherche et de l\\u0026apos;Innovation - MESRI.).\\u003c/em\\u003e Different ministries are responsible for the quality assessment of a training institution and the closure of an institution if standards are not met.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eOne government official shared: \\u0026ldquo;\\u003cem\\u003eAt the level of private structures as well, there is not enough control. So, in relation to the ministry.\\u0026nbsp;\\u003c/em\\u003e\\u003cem\\u003eSince training is not managed directly by the Ministry of Health. It is managed by the Ministry of Vocational Training. There are schools where the Ministry of Health has decided to close, and they still are [open].\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAnother government official from the Ministry of Health shared: \\u003cem\\u003e\\u0026ldquo;We have the reports from all these training institutions submitted to the Ministry of Health which is also submitted to the Ministry of Vocational Training and Ministry of Higher Education\\u0026hellip;In our recommendations, almost half of the schools must be closed. And we do not have the ability to close training institutions. What we can do is ask the institution not to participate in the certification exam simply because the delivery of learning poses a problem.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eLack of authorization for practice and renewal for nurses and midwives, with delayed development of professional orders\\u003c/h4\\u003e\\n\\u003cp\\u003eRespondents shared that there are no specific procedures for nurses and midwives for authorization to practice other than obtaining a diploma. The only condition for working as a midwife or nurse is to have passed a national examination leading to a state diploma, or to have obtained a school diploma awarded by the training schools.\\u0026nbsp;This differs from the Order of Physicians in Senegal, which authorizes doctors to practice in both the public and private sectors and is automatically renewable on an annual basis subject to payment of dues. Respondents also shared that there is no legal mechanism for the renewal of authorization to practice for nurses or midwives.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eA stakeholder from a national public school shared: \\u003cem\\u003e\\u0026ldquo;Apart from the diploma, there is no specific mandatory authorization document to practice midwifery in Senegal. Because perhaps if we had the order\\u0026hellip;perhaps they could do this role, see in relation to their competence and perhaps register them, accredit them so that they can practice.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003cp\\u003eIt was planned that new professional orders for nurses and midwives would be established and would issue authorizations to practice. Though the process to establish these orders has commenced, stakeholders shared that their development has been significantly delayed (details in Supplementary Fig.5). A respondent from the midwife association shared: \\u003cem\\u003e\\u0026ldquo;It\\u0026apos;s been two or three years that we have been hearing this same language that it is in circularization that they are following it and that the legislation office.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003ch3\\u003eIn-service training and provision\\u003c/h3\\u003e\\n\\u003ch4\\u003eVariety of continuing education programs, but no requirements for these programs\\u003c/h4\\u003e\\n\\u003cp\\u003eRespondents shared that several types of continuing education programs and in-service training programs exist in Senegal, including e-learning, formative supervision, coaching, and mentorship. However, continuing education as well as continued assessment of skills is not mandatory for authorization to practice for childbirth care providers, and there are no standards for continuing education. In-service training is not systematic, and there is no database that tracks the providers that have been trained.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eDevelopment partners\\u0026rsquo; involvement in continuing education and training\\u003c/h4\\u003e\\n\\u003cp\\u003eUNFPA, UNICEF, and JICA are involved in ongoing in-service training for providers. JICA\\u0026rsquo;s investments through the PRESSMN projects (Projet de Renforcement des Soins de Sant\\u0026eacute; Maternelle et N\\u0026eacute;onatale) have helped to train providers in respectful care and improve enabling environments in health facilities. Development partners tend to be more involved with in-service training, geared towards coaching and mentoring. A representative from the public training school shared: \\u003cem\\u003e\\u0026quot;...they prefer to finance continuing training, which is less effective and more costly, rather than focus on basic teaching and the quality of supervision at training sites\\u0026quot;.\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\n\\u003ch4\\u003eChallenges and opportunities with staff recruitment and retention\\u003c/h4\\u003e\\n\\u003cp\\u003eSeveral respondents mentioned significant challenges with retention of health workers outside urban areas. Disparities exist in recruitment, salary, and job descriptions between the national or regional governments compared to the community through health center committees. Additionally, recruitment, assignment and redeployment processes are often not transparent or equitable. Several development partners suggested that more strategies are needed to retain qualified staff in remote areas and reduce turn-over, such as incentives or additional training opportunities. Another common theme discussed by respondents that current opportunities for career development were not clearly defined, sufficiently disseminated, and not always aligned with the country\\u0026apos;s needs.\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eCoverage of competencies related to childbirth care in pre-service training curricula\\u003c/h2\\u003e\\n\\u003cp\\u003eWe assessed five pre-service training curricula: public midwifery program, private midwifery program, nursing program, assistant nursing program and medical doctor program. The curricula assessed were published in 2015, with a revision in 2022. The length of training varied from 3 to 5 years post-baccalaureate, in line with ICM\\u0026rsquo;s recommendation for a minimum of 36 months for direct-entry midwifery education programs. Programs were found to cover the majority of assessed indicators, with the curricula averaging 84% coverage of the 54 indicators in the \\u0026ldquo;care during labour and birth\\u0026rdquo; category of the 2019 ICM Essential Competencies framework (Table 2, additional details in Supplementary Table 1). The assistant nursing program curriculum had the lowest coverage of indicators (70%), and the public and private midwifery program curricula had the highest coverage of indicators (91%). Unlike curricula for midwives and doctors, the curricula for nurses and nursing assistants do not specifically cover the management of a safe spontaneous vaginal delivery, the prevention, detection and stabilization of complications, or care of the newborn immediately after birth. Several indicators were also not found explicitly across all five curricula including considering cultural beliefs and traditions, assessing physical responses to labor, informing/supporting/encouraging the mother throughout labor, supporting the mother with pain, and managing the nuchal cord.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\n\\u003ch2\\u003eSurvey results\\u003c/h2\\u003e\\n\\u003cp\\u003eA total of 30 students and 16 administrative staff consented and participated in the survey; background characteristics are shown in Table 3. Five public schools and nine private schools are represented in this survey. The average number of students in their schools, as reported by administrators, was 35 nursing students (IQR: 22) and 29 midwifery students (IQR: 25). Full surveys are available in Supplementary Fig. 4, and tabulated results are available in Supplementary Table 2.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eStaff evaluation\\u003c/h3\\u003e\\n\\u003cp\\u003eBroadly, this survey found that all students rated both their teachers and their internship site supervisors as highly competent or moderately competent. Administrators report that 87% of teachers have formal preparation for teaching, and that 73% of internship sites have sufficient quality supervisors.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch3\\u003eAvailability of learning materials, infrastructure, and practical training\\u003c/h3\\u003e\\n\\u003cp\\u003eOverall, students and administrators reported that most schools have enough classroom space, access to electricity, teaching aids, and learning materials (Figure 1). However, prominent gaps are visible in the availability of updated libraries, skills labs, and quality skills lab equipment (Figure 1). Moderate gaps are also notable in the sufficiency of clinical learning sites, as well as availability of computers, non-stop internet, and materials at training facilities.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll students reported that they had done at least some practical training (Figure 2). Nearly all reported that they had delivered a baby on their own during training, except for one student. However, some gaps are visible in the usage of mannequins for training and usage of a learner\\u0026rsquo;s notebook, considered key components of skills-based training (Figure 2).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTwelve questions were asked to both students and administrators about infrastructure and practical training. In 11 of 12 of these questions, administrator responses were more positive than student responses. The average difference between the two groups\\u0026rsquo; responses of the percent of respondents answering \\u0026ldquo;no\\u0026rdquo;/\\u0026ldquo;not satisfactory\\u0026rdquo; was 16%. The largest differences between the two groups responding \\u0026ldquo;no\\u0026rdquo;/\\u0026ldquo;not satisfactory\\u0026rdquo; were the availability of computers (33% difference) and sufficient clinical learning sites (33% difference) (Supplementary Table 2).\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch3\\u003eProgram administration and success\\u003c/h3\\u003e\\n\\u003cp\\u003eStudents and administrators see their programs as up to date, aligned with standards, and adapted to student needs. All administrators responded that course content is aligned with national/international standards. Of all students and administrators surveyed, 93% responded that the curriculum is adapted to the evolution of science and 89% believe the program is adapted to student needs.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eHowever, both groups believe that success rates of their class on annual exams are average to poor. Of all students and administrators surveyed, 20% believe success rates are excellent (70% or more of class passes), 51% believe that success rates are average (50% to 70% of class passes), and 29% believe success rates are poor (less than 50% of class passes).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe findings of the study highlight many of the strengths and challenges in providing high quality childbirth care in Senegal. As the student survey, staff survey and coverage of competencies in pre-service education show, much of Senegal\\u0026rsquo;s training and skills-building environment are operating commendably. However, in-depth interviews pointed to opportunities for improvement in the regulation of educational institutions, the practical training components, and licensing to continue Senegal\\u0026rsquo;s progress in MNH.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eWhile increasing the number of nurses and midwives is crucial to improve access to childbirth care, maintaining education standards for these cadres is crucial to ensuring higher quality of care. This study\\u0026rsquo;s findings mirror the 2022 report published by WHO and Minist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action Sociale (MSAS), an evaluation which found that many private training schools do not comply with training authorization criteria\\u003csup\\u003e22\\u003c/sup\\u003e. The government of Senegal is working towards improving these challenges by advocating for stronger regulations in private nursing and midwifery training schools. Potential paths forward include mandating the progressive closure of non-regulated schools by stopping new registrations, establishing criteria that schools need to meet before they re-open, and establishing a regulatory framework that ensures alignment and collaboration between the three accrediting ministries: 1) the MSAS, 2) the Ministry of Vocational and Technical Training, and the 3) MESRI. Corrective actions could be also based on the severity of non-compliance, with schools potentially receiving warning notices and being allowed to operate while implementing the recommended improvements.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eOur interviews and surveys also suggest that an increasing number of students graduate pre-service education in Senegal without adequate opportunities to gain clinical experience and practical skills before entering the workforce.\\u0026nbsp;These findings are consistent with another study in Senegal conducted by CEFOREP and UNFPA in 2020, which recommended the provision of additional simulation-based learning, hands-on training, and in-service supervision\\u003csup\\u003e16\\u003c/sup\\u003e. Beyond Senegal, the inclusion of sufficient practical experience is a challenge in MNH service provider training programs across SSA\\u003csup\\u003e23\\u003c/sup\\u003e. A lack of practical competency building in these programs has a direct impact on the quality of care provided by midwifery care providers including women\\u0026rsquo;s experiences of care and health outcomes.\\u003csup\\u003e24\\u003c/sup\\u003e Regarding infrastructure, the data presented here suggests skills laboratory facilities, educator training, and practical training opportunities as potential future investments. Senegal is continuing to invest in these areas through several programs, including the series of PRESSMN programs led by MSAS and JICA to strengthen in-service training for SBAs and increase the provision of human-centered care.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAdditionally, future action may be needed on ensuring provider competency as well as developing licensing systems. One avenue is to consider combining the state diploma and school diploma to ensure that the competencies of graduates are tested via the national exam, and that passing the exam is required before obtaining the diploma and entering the workforce. Additionally, institutionalizing in-service training programs can support skill development throughout providers\\u0026rsquo; careers. Accelerating the development and legal authority of nursing and midwifery professional orders could also support the development of an effective licensing system. For example, ten countries in East and Southern Africa have compulsory licensing with periodic relicensing and requirements for continuous professional development for midwives\\u003csup\\u003e25\\u003c/sup\\u003e. Global evidence suggests that effective regulation and strong in-service training can contribute to improvements in the quality of health outcomes\\u003csup\\u003e23\\u003c/sup\\u003e\\u003csup\\u003e,\\u003c/sup\\u003e\\u003csup\\u003e26\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eDespite these challenges, Senegal has expanded its health workforce and infrastructure, making successful strides in improving maternal and newborn health outcomes. With these and other key programs, Senegal has been identified as an Exemplar in NMR/MMR reduction for these and other topics\\u003csup\\u003e27\\u003c/sup\\u003e. For peer countries who are still progressing towards where Senegal is today, several strengths are essential to learn from and replicate. The competency coverage assessment shows that SBAs programs cover nearly the entire breadth of knowledge, skills and behaviors for care during childbirth recommended in category 3 of the ICM competencies\\u003csup\\u003e19\\u003c/sup\\u003e. Another core strength was identified through the survey of students and administrators, suggesting that many schools have the basic infrastructure to operate, including classroom space, access to electricity, teaching aids, and learning materials Senegal also has a variety of continuing education programs to support learning and training for in-service providers. The recent study by CEFOREP and UNFPA also noted many strengths including strong theoretical content, broad awareness of MSAS training programs, and overall student satisfaction with the majority of program infrastructure\\u003csup\\u003e16\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eThe findings also align with prior research and global reports on maternal and neonatal care in SSA\\u003csup\\u003e26,28\\u003c/sup\\u003e. Evidence from other studies in SSA indicate inadequate levels of competence among graduating midwifery care providers\\u003csup\\u003e29-31\\u003c/sup\\u003e. Midwifery programs vary substantially in minimum duration, level, public/private sector, academic standards, and credentials upon graduation \\u0026ndash; resulting in a variety of skillsets at the point of care. A cross-sectional study across four countries also found that gaps in quality of care may be attributed in part to a lack of sufficient training in pre-service education, as well as structural and operational facility characteristics which limit supervision, teamwork, appropriate commodities, or adequate time. Ensuring adequate opportunities for skills training as well as strengthening regulation around pre-service education programs were noted in the literature as paths forward, at a critical time when quality of care becomes increasingly important for saving lives. Especially at a time where midwifery models of care are positioned as a primary option for MNH service delivery, learning from Senegal\\u0026rsquo;s experience will be important to help strengthen midwifery cadres in other low-income or middle-income countries.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eThere are several limitations from this study, primarily linked to the sample size for the interviews and survey, as well as respondent biases. Though a range of stakeholders were included, only 25 key informant interviews were conducted. The purposive sampling design may also have risked bias towards informants known by the research team. Additionally, the qualitative methodology of interviews may have been influenced by a range of cognitive biases including skewing the data towards more recent events. For the survey, though the assessment included public and private schools across several regions, it was intended as an exploratory analysis and not designed as a representative sample of nursing and midwifery programs throughout Senegal. Finally, the curricula mapping only assessed theoretical frameworks of the intended learning outcomes, but did not systematically map other components of teaching such as infrastructure or educator background.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eSenegal has been identified an Exemplar in both its region and the globe across a variety of health areas, including maternal and newborn health, nutrition, and vaccination. Across these areas, Senegal has achieved rapid health gains beyond what could be expected due to economic improvements. As Senegal approaches global SDG targets for NMR and the national SDG target for MMR of 140 maternal deaths per 100,000 live births\\u003csup\\u003e1\\u003c/sup\\u003e, improving the quality of MNH services becomes increasingly important and especially because the end of the SGD era is rapidly approaching and if countries are to fulfill their commitments to achieve the SDG by 2030 urgent action is required. An essential component of quality is ensuring that health professionals are better trained, regulated, supervised, and equipped to deliver care. Throughout the process of educating healthcare workers, Senegal must prioritize policies and regulations for training schools, licensing, workforce entry, and continuing education that address the challenges revealed through this study.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAs the global health community moves into a new era of decreased development assistance for health and increased reliance on domestic resources, consistent health leaders such has Senegal will need to focus their efforts on what has worked so far, and what remains as barriers. For other peer nations looking to strengthen the quality of their health workforce, Senegal\\u0026rsquo;s story offers notable suggestions, lessons, and paths forward.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eANIIDES: Association Nationale des Infirmiers et Infirmi\\u0026egrave;res Dipl\\u0026ocirc;m\\u0026eacute;s d\\u0026apos;Etat du S\\u0026eacute;n\\u0026eacute;gal\\u003c/p\\u003e\\n\\u003cp\\u003eANSD: Agence nationale de la statistique et de la d\\u0026eacute;mographie\\u003c/p\\u003e\\n\\u003cp\\u003eANSFES: Association Nationale des Sages-Femmes d\\u0026apos;Etat du S\\u0026eacute;n\\u0026eacute;gal\\u003c/p\\u003e\\n\\u003cp\\u003eASGO: Association S\\u0026eacute;n\\u0026eacute;galaise de Gyn\\u0026eacute;cologie-Obst\\u0026eacute;trique\\u003c/p\\u003e\\n\\u003cp\\u003eCEFOREP: Centre de Formation et de Recherche en Sant\\u0026eacute; de la Reproduction (Center for Training and Research in Reproductive Health)\\u003c/p\\u003e\\n\\u003cp\\u003eCRFS: Centre R\\u0026eacute;gional de Formation en Sant\\u0026eacute;\\u003c/p\\u003e\\n\\u003cp\\u003eDRH: Direction des Ressources Humaines\\u003c/p\\u003e\\n\\u003cp\\u003eDSME: Direction de la Sant\\u0026eacute; de la M\\u0026egrave;re et de l\\u0026apos;Enfant\\u003c/p\\u003e\\n\\u003cp\\u003eJICA: Japan International Cooperation Agency\\u003c/p\\u003e\\n\\u003cp\\u003eICM: International Confederation of Midwives\\u003c/p\\u003e\\n\\u003cp\\u003eKOICA: Korea International Cooperation Agency\\u003c/p\\u003e\\n\\u003cp\\u003eMCR: M\\u0026eacute;decins-chefs de r\\u0026eacute;gion\\u003c/p\\u003e\\n\\u003cp\\u003eMMR: maternal mortality ratio\\u003c/p\\u003e\\n\\u003cp\\u003eMNH: maternal and newborn health\\u003c/p\\u003e\\n\\u003cp\\u003eNMR: neonatal mortality rate\\u003c/p\\u003e\\n\\u003cp\\u003eSDG: sustainable Development Goal\\u003c/p\\u003e\\n\\u003cp\\u003eSSA: sub-Saharan Africa\\u003c/p\\u003e\\n\\u003cp\\u003eSR: Sant\\u0026eacute; Reproductive\\u003c/p\\u003e\\n\\u003cp\\u003eUSAID: United States Agency for International Development\\u003c/p\\u003e\\n\\u003cp\\u003eUNFPA: United Nations Population Fund\\u003c/p\\u003e\\n\\u003cp\\u003eUNICEF: United Nations Children\\u0026apos;s Fund\\u003c/p\\u003e\\n\\u003cp\\u003eUSAID: United States Agency for International Development\\u003c/p\\u003e\\n\\u003cp\\u003eWHO: World Health Organization\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eFunding\\u003c/h2\\u003e\\n\\u003cp\\u003eThis work received funding from Gates Ventures, the Global Financing Facility, the United Nations Population Fund, and the United Nations Children\\u0026rsquo;s Fund. Gates Ventures participated in the study conceptualization, design, analysis and synthesis of results. The other funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.\\u003c/p\\u003e\\n\\u003ch2\\u003eContributions\\u003c/h2\\u003e\\n\\u003cp\\u003eAM conceptualized of the study. MS led the overall design and implementation of the study. IM and SAD led field interviews. AD, AD, ETM, IM, MG, MS, SAD contributed to all stages of planning, implementing and finalizing results. AM, CN, DP, EYM, GI, IMAK, JPCS, JT, LHA, LPK, RB, YH contributed to the design and cross-country implementation of the study. DP, EYM, LHA, and MS wrote the first draft of the manuscript. All authors reviewed and approved the final manuscript.\\u003c/p\\u003e\\n\\u003ch2\\u003eAcknowledgements\\u003c/h2\\u003e\\n\\u003cp\\u003eThe team would like to thank Senegal\\u0026rsquo;s Directorate of Maternal and Child Health, Ministry of Health and Social Action for supporting this work, especially Dr. Amadou Doucour\\u0026eacute; and Dr. Elhadji Thierno Mbengue.\\u003c/p\\u003e\\n\\u003ch2\\u003eCompeting interests\\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e\\n\\u003ch2\\u003eEthical statement\\u003c/h2\\u003e\\n\\u003cp\\u003eThe project received ethical approval from the following institution:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eComit\\u0026eacute; National d\\u0026apos;Ethique pour la Recherche en Sant\\u0026eacute; (CNERS), S\\u0026eacute;n\\u0026eacute;gal \\u0026ndash; (ID :SEN22/126), date of approval 08.05.2023.\\u003c/p\\u003e\\n\\u003ch2\\u003eDisclaimer\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eUnited Nations Department of Economic and Social Affairs. Sustainable Development Goals. https://sustainabledevelopment.un.org/index.html. Published 2015. Accessed 07 July 2025.\\u003c/li\\u003e\\n \\u003cli\\u003eTrends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. (World Health Organization, Geneva, 2025).\\u003c/li\\u003e\\n \\u003cli\\u003eUnited Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels \\u0026amp; Trends in Child Mortality: Report 2024 \\u0026ndash; Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. (United Nations Children\\u0026rsquo;s Fund, New York, 2025).\\u003c/li\\u003e\\n \\u003cli\\u003eOona Maeve Renee, C., Agbessi, A., Cauane, B. \\u0026amp; Ties, B. Learning from success: the main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes. BMJ Global Health 9, e012126 (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eMinist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action Sociale, D.d.l.S.d.l.M.e.d.l.E. Politiques, Normes et Proc\\u0026eacute;dures des services de Sant\\u0026eacute; de la Reproduction du S\\u0026eacute;n\\u0026eacute;gal. ( S\\u0026eacute;n\\u0026eacute;gal, 2018).\\u003c/li\\u003e\\n \\u003cli\\u003ePriebe, J., Amuasi, J., Dartanto, T., Mombo-Ngoma, G. \\u0026amp; Guigas, M. Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data. The Lancet Global Health 12, e1104-e1110 (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eAmouzou, A., Ziqi, M., Carvajal-Aguirre, L. \\u0026amp; Quinley, J. Skilled attendant at birth and newborn survival in Sub-Saharan Africa. J Glob Health 7, 020504 (2017).\\u003c/li\\u003e\\n \\u003cli\\u003eFirew Tekle, B., Augustine, A., Mirkuzie, W., Angela, D. \\u0026amp; Andrew, H. Spatial patterns and inequalities in skilled birth attendance and caesarean delivery in sub-Saharan Africa. BMJ Global Health 6, e007074 (2021).\\u003c/li\\u003e\\n \\u003cli\\u003eOlorunsaiye, C.Z., Yusuf, K.K., Harris, A.M. \\u0026amp; Gaikwad, S. Association between birth attendant and early newborn care in Senegal. Midwifery 90, 102804 (2020).\\u003c/li\\u003e\\n \\u003cli\\u003eMcIsaac, M., Buchan, J., Abu-Agla, A., Kawar, R. \\u0026amp; Campbell, J. Global Strategy on Human Resources for Health: Workforce 2030\\u0026mdash;A Five-Year Check-In. Human Resources for Health 22, 68 (2024).\\u003c/li\\u003e\\n \\u003cli\\u003eAgence nationale de la statistique et de la d\\u0026eacute;mographie S\\u0026eacute;n\\u0026eacute;gal \\u0026amp; ICF. Enqu\\u0026ecirc;te D\\u0026eacute;mographique et de Sant\\u0026eacute; Continue (Enqu\\u0026ecirc;te Continue 2023) (Rockville, Maryland, USA 2024).\\u003c/li\\u003e\\n \\u003cli\\u003eExemplars in Global Health. What did Senegal do? https://www.exemplars.health/topics/neonatal-and-maternal-mortality/senegal/what-did-senegal-do. Published 2025. Accessed 29 August 2025.\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization. World health statistics 2025: monitoring health for the SDGs, Sustainable Development Goals, (World Health Organization, Geneva, 2025).\\u003c/li\\u003e\\n \\u003cli\\u003eMinist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action Sociale, Direction des Ressources Humaines \\u0026amp; Division de la Formation. \\u0026Eacute;tablissements priv\\u0026eacute;s d\\u0026rsquo;enseignement en sant\\u0026eacute; du S\\u0026eacute;n\\u0026eacute;gal. (S\\u0026eacute;n\\u0026eacute;gal, 2023).\\u003c/li\\u003e\\n \\u003cli\\u003eRasanathan, K., et al. Navigating health financing cliffs: a new era in global health. The Lancet 405, 1893-1895 (2025).\\u003c/li\\u003e\\n \\u003cli\\u003eUNFPA \\u0026amp; Centre R\\u0026eacute;gional de Formation, d.R.e.d.P.e.S.d.l.R. Evaluation de la formation des sages-femmes d\\u0026rsquo;etat au S\\u0026eacute;n\\u0026eacute;gal. (Minist\\u0026egrave;re de la sant\\u0026eacute; et de l\\u0026rsquo;action sociale. S\\u0026eacute;n\\u0026eacute;gal, 2020).\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization. Defining competent maternal and newborn health professionals. (Geneva, 2018).\\u003c/li\\u003e\\n \\u003cli\\u003eCarter, A., et al. A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems. BMJ Glob Health 5(2020).\\u003c/li\\u003e\\n \\u003cli\\u003eThe International Confederation of Midwives. The International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice Framework 2019. (The Hague, 2019).\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization. Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA. (World Health Organization, Geneva, 2018).\\u003c/li\\u003e\\n \\u003cli\\u003eWest African Health Organisation. Harmonized training curriculum for nurses and midwives in ECOWAS region. (West African Health Organisation, 2014).\\u003c/li\\u003e\\n \\u003cli\\u003eMinist\\u0026egrave;re de la Sant\\u0026eacute; et de l\\u0026rsquo;Action sociale - Direction des Ressources Humaines. Rapport de synth\\u0026egrave;se de la mission de v\\u0026eacute;rification des \\u0026eacute;coles de formation en sant\\u0026eacute; (F\\u0026eacute;vrier, Mars et Avril 2022). (S\\u0026eacute;n\\u0026eacute;gal, 2022).\\u003c/li\\u003e\\n \\u003cli\\u003eCavallaro, F.L., et al. What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal. BMJ Glob Health 5, e001915 (2020).\\u003c/li\\u003e\\n \\u003cli\\u003eKawish, A.B., et al. Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review. Medicina (Kaunas) 59(2023).\\u003c/li\\u003e\\n \\u003cli\\u003eUnited Nations Population Fund East and Southern Africa Regional Office. The State of the World\\u0026apos;s Midwifery 2022: Analysis of the Sexual, Reproductive, Maternal, Newborn and Adolescent Health Workforce in East and Southern Africa. (South Africa, 2022).\\u003c/li\\u003e\\n \\u003cli\\u003eUnited Nations Population Fund. State of the World\\u0026rsquo;s Midwifery 2021 (SoWMy 2021). (New York, United States of America, 2021).\\u003c/li\\u003e\\n \\u003cli\\u003eExemplars in Global Health. How did Senegal implement? https://www.exemplars.health/topics/neonatal-and-maternal-mortality/senegal/how-did-senegal-implement. Published Undated. Accessed 28 May 2025.\\u003c/li\\u003e\\n \\u003cli\\u003eAgence nationale de la statistique et de la d\\u0026eacute;mographie (ANSD) [S\\u0026eacute;n\\u0026eacute;gal], e.I. Enqu\\u0026ecirc;te D\\u0026eacute;mographique et de Sant\\u0026eacute; Continue (Enqu\\u0026ecirc;te Continue 2023) (Rockville, Maryland, USA : ANSD et ICF., 2023).\\u003c/li\\u003e\\n \\u003cli\\u003eMoller, A.B., et al. Midwifery care providers\\u0026apos; childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda. PLOS Glob Public Health 3, e0001399 (2023).\\u003c/li\\u003e\\n \\u003cli\\u003eYigzaw, T., et al. How well does pre-service education prepare midwives for practice: competence assessment of midwifery students at the point of graduation in Ethiopia. BMC Med Educ 15, 130 (2015).\\u003c/li\\u003e\\n \\u003cli\\u003eNeal, S., et al. An analysis of the global diversity of midwifery pre-service education pathways. Women Birth 36, 439-445 (2023).\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003ch4\\u003eTable 1: Key informants\\u0026rsquo; groupings and area of responsibility\\u0026nbsp;\\u003c/h4\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"100%\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGroup\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRespondent organizations\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of respondents\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003eGroup 1:\\u003c/p\\u003e\\n \\u003cp\\u003eCentral and regional government organizations responsible for maternal and newborn health\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eNational MNCH\\u003csup\\u003ea\\u003c/sup\\u003e division, DSME\\u003csup\\u003eb\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eNational human resources division, DRH\\u003csup\\u003ec\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eRegional chief medical officers, MCR\\u003csup\\u003ed\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eRegional government reproductive health coordinators\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003eGroup 2: Training institutions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eManagers of private schools, public schools, and public universities\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003eGroup 3:\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNational government organizations responsible for maternal and newborn health data\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eNational MNCH\\u003csup\\u003ea\\u003c/sup\\u003e Division, DSME\\u003csup\\u003eb\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNational Agency for Statistics and Demography, ANSD\\u003csup\\u003ee\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eNational Division of Planning, Research, and Statistics, DPRS\\u003csup\\u003ef\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003eGroup 4: Professional associations\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eSenegalese Association of Gynecology and Obstetrics, ASGO\\u003csup\\u003eg\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eNational Association of State Midwives of Senegal, ANSFES\\u003csup\\u003eh\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eNational Association of State Nurses of Senegal, ANIIDES\\u003csup\\u003ei\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 22px;\\\"\\u003e\\n \\u003cp\\u003eGroup 5: Technical and financial partners\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003eUNFPA\\u003csup\\u003ej\\u003c/sup\\u003e, UNICEF\\u003csup\\u003ek\\u003c/sup\\u003e, WHO\\u003csup\\u003el\\u003c/sup\\u003e, USAID MOMENTUM\\u003csup\\u003em\\u003c/sup\\u003e, JICA\\u003csup\\u003en\\u003c/sup\\u003e,\\u003c/p\\u003e\\n \\u003cp\\u003eRegional Centre for Training, Research, and Advocacy in Reproductive Health, CEFOREP\\u003csup\\u003eo\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 15px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 99.866%;\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ea.\\u003c/sup\\u003eMNCH : Maternal, newborn, and child health\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003eb.\\u003c/sup\\u003eDSME: Direction de la Sant\\u0026eacute; de la M\\u0026egrave;re et de l\\u0026apos;Enfant\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ec.\\u003c/sup\\u003eDRH: Direction des Ressources Humaines\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ed.\\u003c/sup\\u003eMCR: M\\u0026eacute;decins-chefs de r\\u0026eacute;gion\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ee.\\u003c/sup\\u003eANSD: Agence nationale de la statistique et de la d\\u0026eacute;mographie\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ef.\\u003c/sup\\u003eDPRS: Direction de la Planification, de la Recherche et des Statistiques\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003eg.\\u003c/sup\\u003eASGO: Association S\\u0026eacute;n\\u0026eacute;galaise de Gyn\\u0026eacute;cologie-Obst\\u0026eacute;trique\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003eh.\\u003c/sup\\u003eANSFES: Association Nationale des Sages-Femmes d\\u0026apos;Etat du S\\u0026eacute;n\\u0026eacute;gal\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ei.\\u003c/sup\\u003eANIIDES: Association Nationale des Infirmiers et Infirmi\\u0026egrave;res Dipl\\u0026ocirc;m\\u0026eacute;s d\\u0026apos;Etat du S\\u0026eacute;n\\u0026eacute;gal\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ej.\\u003c/sup\\u003eUNFPA: United Nations Population Fund\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ek.\\u003c/sup\\u003eUNICEF: United Nations Children\\u0026rsquo;s Fund\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003el.\\u003c/sup\\u003eWHO: World Health Organization\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003em.\\u003c/sup\\u003eJICA: Japanese International Cooperation Agency\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003en.\\u003c/sup\\u003eUSAID MONENTUM: United States Agency for International Development\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003eo.\\u003c/sup\\u003eCEFOREP: Centre R\\u0026eacute;gional de Formation, de Recherche et de Plaidoyer en Sant\\u0026eacute; de la Reproduction\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch4\\u003eTable 2: Curricula assessment scores of five pre-service education programs mapped against the 2019 ICM Competencies in \\u0026ldquo;care during labour and birth\\u0026rdquo; category\\u003c/h4\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eProgram/curricula\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCurricula assessment scores\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003ePublic midwifery program\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e91%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003ePrivate midwifery program\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e91%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eNursing program\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e78%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eAssistant nursing program\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e70%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eMedical doctor program\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e89%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch4\\u003eTable 3. Characteristics of survey respondents and their corresponding category of school\\u003c/h4\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"100%\\\" class=\\\"fr-table-selection-hover\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 41px;\\\"\\u003e\\n \\u003cp\\u003eParameter\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 30px;\\\"\\u003e\\n \\u003cp\\u003eStudents\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 27px;\\\"\\u003e\\n \\u003cp\\u003eAdministrative staff\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 41px;\\\"\\u003e\\n \\u003cp\\u003eRespondents (n)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 30px;\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 27px;\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 41px;\\\"\\u003e\\n \\u003cp\\u003ePublic schools (%)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 30px;\\\"\\u003e\\n \\u003cp\\u003e23%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 27px;\\\"\\u003e\\n \\u003cp\\u003e36%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 41px;\\\"\\u003e\\n \\u003cp\\u003ePrivate schools (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 30px;\\\"\\u003e\\n \\u003cp\\u003e77%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 27px;\\\"\\u003e\\n \\u003cp\\u003e64%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 41px;\\\"\\u003e\\n \\u003cp\\u003eSex, female (%)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 30px;\\\"\\u003e\\n \\u003cp\\u003e83%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 27px;\\\"\\u003e\\n \\u003cp\\u003e29%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"nature-portfolio\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Nature Portfolio\",\"twitterHandle\":\"\",\"acdcEnabled\":false,\"dfaEnabled\":false,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7643871/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7643871/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eFew countries in sub-Saharan Africa (SSA) are on track to meet the Sustainable Development Goals (SDG) related to maternal and neonatal mortality, despite widespread progress towards the SDG target for births assisted by skilled health personnel. The inconsistent quality of care provided by skilled health professionals (SHPs) also known as skilled birth attendants (SBAs) has been identified as one contributor of this disconnect. Senegal has made exemplary progress reducing maternal and neonatal mortality, making it a strong setting to explore the myriads of factors that contribute to quality of childbirth care.\\u003c/p\\u003e\\n\\u003cp\\u003eThis research was conducted as part of a multi-country study to assess the quality of pre-service education of health professionals providing childbirth care and to enhance the measurement related to the coverage of SBAs and SHP. Twenty-five key informant interviews (KIIs) were conducted in Senegal with government bodies responsible for maternal and newborn health (MNH) at central and regional levels and MNH data collectors, training institutions, professional associations, as well as technical and financial partners. An online survey was carried out to assess the quality of pre-service education programs among 30 students and 15 program administrators, and SBAs pre-service training curricula were evaluated against international standards.\\u003c/p\\u003e\\n\\u003cp\\u003eInterviews suggested that the growing number of private training schools has led to insufficient oversight from government bodies and some schools not meeting national regulations or quality standards. Respondents shared that responsibilities for the regulation of pre-service education and training are split by three different government bodies, and the development of professional associations for nurses and midwives has been delayed. KIIs revealed that graduates can fail to pass the national licensing exam but may still be awarded a school diploma and recruited by health facilities. Additionally, respondents reported poor success rates on both annual school and licensing exams. The surveys also revealed quality gaps in pre-service education are due to lack of access to libraries, computers, equipment for skills labs, as well as the number of educators and their competencies at practical training sites.\\u003c/p\\u003e\\n\\u003cp\\u003eAmid commendable progress, this research reveals key gaps that continue to undermine the quality of care during childbirth in one of highest-performing countries in SSA. Recommendations include improving the regulation of SBAs pre-service education programs, introducing renewal process for licensing, developing professional orders, and ensuring continued training programs. Continuing to enhance pre-service education and in-service training programs in Senegal is crucial for sustainable improvements in the quality of MNH care.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Stakeholders' insights and perceptions on nursing and midwifery care providers' pre-service education, training, and regulations in Senegal: a mixed-methods study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-29 06:29:35\",\"doi\":\"10.21203/rs.3.rs-7643871/v1\",\"editorialEvents\":[],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"nature-health\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"nathealth\",\"sideBox\":\"Learn more about [Nature Health](https://www.nature.com/naturehealth/)\",\"snPcode\":\"44360\",\"submissionUrl\":\"https://mts-nathealth.nature.com\",\"title\":\"Nature Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"9a5c4691-0853-4f3f-9a2e-a5f9e8cd78b1\",\"owner\":[],\"postedDate\":\"October 29th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":56982586,\"name\":\"Health sciences/Health care/Public health/Epidemiology\"},{\"id\":56982587,\"name\":\"Health sciences/Health care/Health policy\"}],\"tags\":[],\"updatedAt\":\"2025-10-29T06:29:35+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-10-29 06:29:35\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7643871\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7643871\",\"identity\":\"rs-7643871\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}