A Scoping Review Continuing Professional Development Programs for Midwives: Optimising Management of Obstetric Emergencies and Complications.

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Maurine Rofhiwa Musie, Oslinah Buru Tagutanazvo, Nombulelo Veronica Sepeng, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4600318/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Feb, 2025 Read the published version in BMC Medical Education → Version 1 posted 13 You are reading this latest preprint version Abstract Background: Midwives play a pivotal role in ensuring safe childbirth, particularly in the management of obstetric emergencies and complications. Continuous Professional Development (CPD) programs are essential to keep midwives updated with the latest skills and knowledge, ensuring high-quality maternal care. Problem statement: Aim: We conducted a scoping review to map and synthesize evidence on continuing professional development for midwives optimising management of obstetric emergencies and complications to reveal evidence to address the knowledge gap and implementation of policy. Methods: This scoping review was guided by the adapted version of Arksey and O’Malley methodological framework (2005). We searched the following databases from 2013 to 2023: PubMed, SCOPUS, Web of Science, EBSCOhost (CINAHL, MEDLINE and Academic search): and ProQuest central. The quality of the included studies was appraised using mixed methods appraisal tool (MMAT) version 2018. Content analysis and synthesis of the findings were conducted using Nvivo 12. Results: Of the 752 articles identified through database searching, 32 articles met the inclusion criteria and reported according to the Preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) checklist. After data extraction, content analysis yielded the following 4 major themes: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation of CPD programs and Suggestion for implementation of CPD programs. Conclusion: Our findings revealed the significance of CPD programs in equipping midwives with the necessary skills and knowledge to handle obstetric emergencies effectively. The program can be offered in various approaches including simulation-based training, technology-based simulation, online modules, workshops, and interdisciplinary/interprofessional learning sessions, have shown to be effective. Each method offers unique advantages, such as hands-on practice in simulations and flexibility in online learning with smart applications such as SAFE delivery applications. Trial registration: Research Ethics reference #322/2023, date of registration: 14/02/2024. Continuing professional development (CPD) obstetric emergencies and complications maternal healthcare Figures Figure 1 Introduction Historically, there was a greater emphasis on the skills required to achieve Millennium Development Goals (MDGs) 4 and 5, which elevated midwives to the forefront as an essential cadre of healthcare providers, prompting governments to invest heavily in midwifery education and rapidly scale up programs to produce more midwives [ 1 ]. The need for midwifery education extended beyond the MDGs. In 2015, all United Nations member countries adopted the 2030 Agenda for Sustainable Development goals (SDG). It outlines 17 goals, including 169 targets [ 2 ]. The SDG 4 is all about to "ensure inclusive and equitable education and promote lifelong learning for all." Therefore, this SDG goal is linked with the need for Continuous Professional Development (CPD) to promote lifelong learning for all including midwives and midwifery educators. CPD refers to ongoing education and competency development by health professionals beyond their initial training; the purpose is to update and advance their knowledge, skills and professional proficiency [ 3 ]. CPD keeps midwives up to date, allowing them to better serve their patients (women and babies) and the health-care system [ 4 ]. It entails the continuous acquisition of new knowledge, skills, and attitudes to sustain and improve professional competent practice [ 5 ]. The CPD package is linked to the International Confederation of Midwives (ICM) essential competencies for midwifery practice that meet the requirements of Nursing and Midwifery councils in low- and middle-income countries (LMICs) according to the World Continuing education alliance (WCEA). Midwives and nurses are essential providers of emergency obstetric and neonatal care (EmONC) services, and need to remain competent and update their knowledge to enhance the quality of EmONC service delivery [ 6 , 7 ]. An obstetric emergency is a life-threatening medical condition that develops during pregnancy, labour, or the postpartum period [ 8 , 9 ]. Globally, the maternal mortality ratio (MMR) is still unacceptably high; on average every day, nearly 810 women die while giving birth especially in low-middle income countries [ 6 , 7 ]. Sub-Saharan Africa remains the region with the highest burden of maternal mortality and morbidities with an MMR of 542 per 100,000 live births, which is higher than the ratio of 216 per 100,000 live births globally. The Sustainable Development Goal (SDG) 3.1 sets out that by 2030, the global maternal mortality ratio (MMR) is reduced to less than 70 per 100,000 live births [ 7 ]. According to the World Health Organization (WHO,2022) [ 9 ], the following conditions are considered obstetrical emergencies: ectopic or tubal pregnancy, placenta abruptio and previa, preeclampsia or pregnancy-induced high blood pressure, eclampsia and premature membrane rupture (PROM), amniotic fluid embolism (AFE), inversion or rupture of the uterus, placenta accreta, prolapsed umbilical cord, and shoulder dystocia, postpartum haemorrhage (PPH), and postpartum infection. These potentially life-threatening emergencies frequently occur unexpectedly, necessitating immediate action by healthcare professionals as indicated by the American college of Obstetricians and Gynaecologists [ 9 , 10 , 11 ], can result in tragic outcomes such as death or serious morbidity in women and/or newborns. Most of these deaths could be prevented if quality EmONC is provided by skilled health care professionals. As a result, CPD training programs for midwives in global settings are required to improve the management of obstetric emergencies and complications (EmONC). Midwives attend a variety of CPD training programs to help them manage obstetric emergencies and complications. In one previous study conducted in Tanzania midwives participated in a CPD training program known as Midwifery Emergencies Skills (MSE) Training. This MSE training improved midwives' knowledge and skills in managing obstetric emergencies and following referral protocols [ 12 ]. Another previous study found that midwives who attended the Essential Steps in Managing Obstetric Emergencies (ESMOE) and emergency obstetric simulation training reported that the training benefited the patient by preparing them to manage obstetric emergencies competently [ 13 ]. As a result, the purpose of this review is to map and synthesise the evidence on CPD programs for midwives in optimising the management of obstetric emergencies and complications globally. Materials and Methods Herein, we conducted a scoping review to map, synthesise and summarise the available evidence on continuing professional development (CPD) for midwives and midwifery educators globally. A scoping review is useful to mapping available range of evidences that exists around a topic of interest and focus the research questions by charting existing research findings and identification of research gaps. This scoping review was guided by the methodological framework proposed by Arksey and O’Malley (2005) [ 14 ] and further advanced by Levac, et al., (2010) [ 5 ]. According to this framework, we conducted the review in the following five stages: (i) identifying the research question; (ii) identifying the relevant studies; (iii) selection of eligible studies; (iv) data extraction process and (v) collating, summarising and reporting of results. Arksey and O’Malley 2005 proposed a sixth optional stage compromising consultations with the key stakeholders [ 14 ]. This scoping review did not include consultations with stakeholders. The results of this scoping review were reported according to the Preferred reporting items for Systematic reviews and Meta-analyses extension for scoping review (PRISMA-ScR) checklist [ 16 ] see (Additional file 1). Research question The main question was: What evidence exists on CPD training programs for midwives for management of obstetrics emergencies and complications globally? We assessed the eligibility of the research question for a scoping review study by applying the Population, concept and Context (PCC) mnemonic framework. Database literature search strategy The search strategy was developed in consultation with the university librarian and with the input of the research team. We conducted the keyword search to identify all relevant studies from the various databases. The following electronic databases were used: PubMed, SCOPUS, Web of Science, EBSCOhost, CINAHL and ProQuest central for full text relevant studies. Studies were identified using the following keywords and Medical subject heading (MeSH) terms( “Midwives” OR “Nurses” OR “Midwifery” OR “Midwife” OR “Accoucheurs” OR “nurse-midwife” OR “Midwifery educators” OR “Midwife educator” OR “Midwife teachers” ) AND ( “Continuous Professional Development” OR “CPD” OR “Continuing Education Programs” OR “Education programs” OR “Training programs” ) AND ( “Obstetric emergencies” OR “Obstetric complications” OR “Intrapartum complications” OR “Childbirth complications” OR “Labour complications” OR “Intrapartum emergency” OR “Midwifery complications” ). Searches were limited to English, articles published between 2013–2023. Each search was documented in detail showing the keywords/MeSH terms, date of search, electronic database and number of retrieved studies. The complete search strategy is shown on (Additional file 2). Selection of eligible studies The scoping review selection of eligible studies was guided by using inclusion and exclusion criteria to ensure that relevant studies are selected. There were (n = 752) articles retrieved from the database searches. After the duplicates were removed there were (n = 629) articles, the titles and abstracts were screened based on the inclusion criteria (See Additional file 3) Population We included articles that reported evidence of midwives, accoucheurs, midwifery educators’ and midwifery preceptors across the globe. The South African Nursing Council (SANC) R2488 indicates the regulations that a registered midwife is supposed to practice under. A midwife is a licensed person who is registered with the South African Nursing Council based on completion of a recognized education and training programme to nurture, assist and treat the client, who can be a woman, a neonate or a family, in the process of promoting a health pregnancy, labour and post-partum period [ 17 ]. The regulation includes under Chap. 10: that the midwife is responsible to manage and refer the illnesses, abnormalities or complications occurring during pregnancy, labour or the puerperium or in the child, the registered midwife shall, subject to the provisions of sub regulation. The articles focused on the health professionals that are responsible for managing women during intrapartum and required skills to manage obstetrical emergencies and complications [ 7 – 9 ]. CPD Training programs CPD training programme is defined as purposeful statutory process where the healthcare practitioners registered with SANC are required to engage in learning activities or programmes to maintain and improve their knowledge and skill to remain abreast to the new sciences, innovation and health care developments within the evolving scope of practice [ 18 ]. The South African Nursing Council (SANC), is responsible to guide the implementation of the continuing professional development (CPD) program for nurses and midwives in terms of the Nursing Act (Act no 33 of 2005). We included articles that described other various types of Continuing professional development programs and education implemented in ensuring that the midwives and midwifery educators are competent to manage the obstetrical emergencies. Training programs for management of obstetric emergencies and complications We also included articles that described obstetric emergencies and complications as an evidence-based service required to manage potentially life-threatening complications that affect many women during pregnancy, childbirth, and the immediate postpartum period [ 19 ]. Selection of sources of evidence All records from the database searches were downloaded into Endnote 20 library, and the duplicates were removed. The articles were screened in three stages, namely: title, abstract and full-text screening. The reviewers used a screening tool developed PI (MRM) and the university librarian. The articles were then exported from endnote to Ryann software. The screening process was iterative and involved multiple steps: To reduce selection bias the two independent reviewers conducted comprehensive titles and abstracts screening guided by the eligibility criteria. After deduplication the first 629 titles and abstract were screened by two reviewers (MRM and TH) and discrepancies were discussed until consensus was reached. The two independent reviewers sorted the studies into “included” and “excluded category” based on the inclusion criteria. The articles flagged for inclusion were independently assessed by MRM and TH and the selection of these articles were prioritised for full text review. To be considered for full text the article would have some information on midwives, CPD training programs and obstetric emergencies. A third screener (NVS) confirmed the final selection of articles for data extraction. Both abstract and full-text article screening were guided by the screening tool that factored all aspects of inclusion/exclusion criteria and the PCC elements. Finally, 32 articles were included for content data analysis. Data extraction process A data charting form were used to capture all relevant data from the included articles using Excel. Two independent reviewers (MRM and TH) plot the data charting form and recommend modifications that will be implemented. The following data were extracted from the included articles: author and year of publication, the title of study, aim of the study, study design, study setting, study population, country, available CPD programs on management of obstetric emergencies and outcomes of the programs. Content analysis was conducted to identify similarities and differences among the retrieved themes and subthemes of the studies using Nvivo 12 software. Two reviewers (MRM and TH) read all the articles several times to understand the main concepts (see additional file 4) Collating, summarising and reporting the results The authors extracted the Qualitative data and summarised it according to emerging themes and subthemes. The following themes emerged from the data: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation and Suggestion for implementation of CPD programs. The quantitative data was extracted and presented in form of descriptive statistics in use of tables and chart (see Table 1 ). Quality appraisal We used the mixed method appraisal tool (MMAT) version 2018 to evaluate the quality of the included articles [ 20 ]. Using MMAT, we appraised the methodological quality of five categories of research: qualitative research, randomised controlled trials, nonrandomised studies, quantitative descriptive studies and mixed methods studies [ 20 ]. Two independent reviewers (MRM and TH) carried out the quality appraisal process. The following percentage scores were used to grade the quality of evidence: (i) ≤ 50% represented low-quality evidence, (ii) 51–75% represented average-quality evidence and (iii) 76–100% represented high-quality evidence. Ethical considerations This scoping review is guided by the ethical approval obtained from the Faculty of Health Sciences Research Ethics Committee, reference no 322/2023. Results Of the 752 articles identified through the database searching, 32 articles met the inclusion criteria. The PRISMA flowchart of article screening and selection process is shown in Fig. 1 . Of the 32 articles, eleven were from the low- and middle-income countries LMIC (three Rwanda [ 21 , 31 , 46 ], three Tanzania [ 24 , 26 , 52 ], two Ethiopia [28,], three Kenya [ 30 , 37 , 43 ], two Uganda [ 33 , 39 ], one Ghana [ 50 ], one Bangladesh [ 38 ], one China [ 27 ], three India [ 32 , 44 , 48 ], one Brazil [ 40 ] and one Mexico [ 41 ]). Six of the extracted articles were from High income countries including (three Europe [ 22 , 49 ], one Australia [ 23 ], one United states [ 29 ], one Spain [ 34 ], one Netherlands [ 35 ] and one Saudi Arabia [ 36 ]). The other included two were from South Africa [ 45 , 51 ] and one from Botswana [ 47 ]. These studies include the following research designs seven Qualitative descriptive design, two workshops, seventeen Quantitative studies (including quasi experimental, longitudinal studies and pre-and post-studies), two observational studies and fourth mixed methods study design. Eleven of the included articles described CPD programs for midwives, while four included midwifery educators and the remaining seventeen included other multidisciplinary members working in the maternity units including (obstetricians, doctors and gynaecologists). The types of obstetric emergencies and complications managed included shoulder dystocia (n = 8), postpartum haemorrhage (n = 8), preterm labour (n = 2), amniotic fluid embolism AFE (n = 3), pre-eclampsia/eclampsia (n = 4), neonatal resuscitation (n = 2) and breech delivery (n = 4). Themes and subthemes of extracted data Four themes were synthesised from the extracted data: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation of CPD programs and Suggestion for implementation of CPD programs. The articles supporting these categories are summarised in Additional file 4. Theme 1: Types of CPD training programs. The overall theme including the following 5 subthemes: Standardised simulation CPD program , T echnology-enhanced simulation-based training (TESBT), Inter-professional simulation-based training (IPSBT), Onsite clinical mentorship programme, and Train-the-Trainer program. The studies indicate the types of CPD programs utilised globally in the provision of training health professionals including midwives on the management of obstetric emergencies and complications. Standardised simulation CPD program Majority of the studies reported the implementation of standardised simulation CPD programme [ 23 , 24 , 27 30 , 38 , 41 , 42 , 45 , 48 , 49 , 50 , 51 , 52 ] involves developing a standard simulation programme based on the curriculum stipulated by the World Health Organisation standards in maternal and newborn care guidelines [ 42 ]. The programme includes simulating case scenarios or conducting ONE (obstetric and neonatal emergency) simulation workshops [ 32 ] on the following obstetrical emergencies such as shoulder dystocia, amniotic fluid embolism and postpartum haemorrhage during pre and post-test intervention yielded significant results < p value 0,005. The results revealed that 78% of nurses had inadequate knowledge on management of obstetric emergencies as pre-test, however after the simulation training was done the post-test questions proven improved knowledge [ 48 ]. A tool called simulation effectives tool modified (SET-M) can be used to assess the effectiveness of the trainings/ workshops [ 27 ]. T echnology-enhanced simulation-based training This type of CPD program refers to employing technologies such as high-fidelity mannequins/simulations drills (HFS) [ 22 , 33 , 34 ], Advanced life support in obstetrics (ALSO) [ 31 , 46 ] and mHealth technology such as the safe delivery app (SDA) to train health professionals to manage obstetric emergencies and complications [ 31 ]. The Safe Delivery mHealth Application (SDA) is one of the recent m-health applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC) [ 31 ]. Most of the articles noted that CPD training can be done in a form of TESBT using simulation mannequins such as Neolle interactive neonate [ 33 , 34 , 36 , 39 , 40 ]. These programs were found to significantly improve clinical skills, decision-making abilities, and teamwork among midwives. Inter-professional simulation-based training Interprofessional simulation-based training (IPST) is an educational approach identified in the articles where health professionals from different healthcare disciplines (such as midwives, obstetricians, gynaecologist, physicians, physiotherapist etc) learn and practice together in simulated environments [ 25 , 26 , 29 , 35 , 44 ]. This type of training is designed to enhance collaboration, communication, and overall team performance, which ultimately improves clinical competence and confidence on the management of obstetric emergencies and complications. A study conducted in Tanzania identified reduced obstetric mortalities and morbidities when the health professionals are trained in teams [ 26 ]. The recommended obstetrical training for interprofessional or multi-professionals is the practical obstetrical multi professional training course (PROMPT) [ 29 ]. The Kirkpatrick training evaluation tool [ 35 ] is used indicated that the trained teams need to practice the skills to manage obstetrical emergencies repeatedly in form of drills assisted with mastery of skills and competence. Train-the-Trainer program Two of the studies conducted in Ethiopia and Kenya reported on the importance of conducting CPD in a form of Training the trainer [ 28 , 43 ] which often last for 5 days course. This includes identifying individuals in the maternity wards which can be trained as trainers so that they may continue with training the staff members that enters the institution. The training of trainer’s program is designed to equip experienced professionals with the skills and knowledge needed to effectively train others. In the context of a standardized simulation program, a TTT program ensures that facilitators are well-prepared to deliver high-quality simulation training consistently. Onsite clinical mentorship programme One of the studies [ 37 ] conducted in Kenya reported on identification of onsite clinical mentors in emergency obstetrics and newborn care (EmONC). Clinical mentorship is an approach for in-service training, healthcare workers were mentored on key evidence-based intrapartum and immediate newborn care practices, using current national/global guidelines on job site. A clinical mentor (also a master trainer) was either a doctor, nurse/midwife or reproductive health clinical officer from high volume facilities which were defined as a facility with an average of five or more deliveries in a day. Theme 2: Effectiveness of CPD on management of obstetric emergencies The second identified theme is on the effectiveness of CPD programs including the four subthemes: Enhanced clinical skills and knowledge acquisition, Team-based care/ Interprofessional collaboration, improve maternal and neonatal outcomes and WHO Standardised curriculum for management of obstetrics emergencies. Enhanced clinical skills and knowledge acquisition Several studies indicate that when midwives undergo continuous professional development in the management of obstetric emergencies they become competent, knowledgeable and confident to manage the emergencies during childbirth [ 21 , 26 , 36 , 40 , 41 , 47 , 48 , 52 ]. Hands-on training and simulation scenarios or drills improve the practical skills of healthcare providers, enabling them to manage emergencies more effectively such as postpartum haemorrhage, preterm labour and shoulder dystocia [ 25 , 27 , 43 , 50 ]. A study done in Rwanda added that health professionals may improve their confidence and ability to manage childbirth complications by using the m-health SAFE app [ 31 ]. When health professionals practice the management of obstetric emergencies repeatedly they master the skills [ 35 ]. The standardised trainings on obstetrical emergencies (STrObE) indicated that the health professional knowledge and confidence improved after the trainings especially for those with less work experience they benefited from the online and hands on simulation training with the multidisciplinary team [ 49 ]. Improve maternal and neonatal outcomes The main purpose of the CPD programs is to ensure the achievement of the sustainable developmental goals (SDG) which focuses on improved maternal and neonatal outcomes [ 24 , 52 ]. When midwives and other health professional undergo continuing professional development, they remain abreast to latest evidence on the management of the obstetric emergencies. Teamwork and collaboration were associated with better perinatal outcomes [ 29 ]. In additional clinical mentorship and supervision on EmONC on the following breech deliveries halved from 1,5 to 0,7% (p value 0,00475) indicating significant association in mentorship facilities [ 37 ] thus improving perinatal outcomes. Team-based care/ Interprofessional collaboration Most studies report on the benefits of interprofessional simulation learning is helpful in enhancing competence and confidence in managing emergencies [ 22 , 25 , 26 , 29 , 35 , 44 ]. Team-based care and interprofessional collaboration are essential components in the effective management of obstetric emergencies. These approaches enhance the quality of care provided to patients by leveraging the diverse skills and expertise of different healthcare professionals. Training in teams enhancing capacity building in emergency obstetrics and newborn care assisted to reduced maternal mortality rates by 1.5%. Team training and team work resulted in better perinatal outcomes and reduced c-section rates (p < 0.05) [ 29 ]. WHO Standardised curriculum for management of obstetrics emergencies. The World Health Organization (WHO) has developed standardized curricula to guide healthcare professionals in the management of obstetric emergencies [ 38 , 41 ]. These curricula are part of the broader effort to reduce maternal and neonatal morbidity and mortality by improving the skills and competencies of healthcare providers. The training manuals includes the Basic Emergency Obstetric and Newborn Care (BEmONC) [ 37 , 42 , 43 ]: Covers essential skills for managing common obstetric and newborn emergencies. Comprehensive Emergency Obstetric and Newborn Care (CEmONC) [ 26 , 47 ]: Includes advanced procedures that are specific interventions associated with the health systems. Essential steps in the management of obstetric emergencies (ESMOE), which is a package used in South Africa for simulation training on the management of obstetric emergencies [ 51 ]. Theme 3: Barriers/Challenges with lack of implementation of CPD programs Implementing Continuing Professional Development (CPD) programs, especially in the context of obstetric emergencies, can face numerous barriers and challenges. The challenges include the following four subthemes Insufficient resources result in suboptimal care, Inadequate skills attributed to maternal mortality, lack of educational opportunity for continuing education and Insufficient sustainability of CPD programs Insufficient resources result in suboptimal care Understaffing and insufficient resources is known to attribute to poor perinatal outcomes [ 24 ], this was especially in remote areas contributed to mismanagement of obstetrical emergencies [ 32 ]. A study conducted in Botswana identified the following factors inadequate resources and doctors refusing to change as obstacle hampering the implementation of emergency obstetric care (EmOC) in-service trainings [ 47 ]. Inadequate skills attributed to maternal mortality A study conducted in India, Andhra Pradesh found that 78% of the midwives had inadequate knowledge with regard to the management of obstetric emergencies [ 48 ]. Other studies confirm that poor knowledge contributed to maternal deaths thus affecting the countries ability to achieve that sustainable developmental goals [ 24 , 40 , 46 ]. Lack of educational opportunity for continuing education Another barrier towards the implementation of CPD programs for management of obstetric emergencies includes lack of educational opportunity for continuing education [ 25 ]. The trainers of the advanced life support in obstetrics (ALSO) program did not get enough opportunity to apply the knowledge and skills in their hospitals after training on CPD. The lack of a formalised CPD training programme for health professionals also impeded the implementation [ 46 ]. A study done in Botswana highlighted the issues related to the duration of the training being 2 weeks could contribute to the health professionals not being confident in managing obstetric emergencies and complications [ 47 ]. The study suggested the need for the Ministry of Health to prioritise EmOC training policy reviews. insufficient sustainability of CPD programs The last barrier to the implementation of CPD programs is the lack of effective sustainability processes in place for CPD programs. There is a need to formalise the CPD trainings for all health professionals [ 46 ]. It is also important to ensure certain monitoring and evaluation of CPD attendance. Maintenance of practitioner standards and resources required for successful implementation [ 23 ]. Theme 4: Suggestion for implementation of CPD programs Effective implementation of CPD programs for managing obstetric emergencies requires a strategic approach and can be achieved as supported by the following three subthemes: Interprofessional training, Policy directives to govern implementation and Evaluate impact of CPD training using Kirkpatrick scale. Interprofessional training Implementing Continuing Professional Development (CPD) programs through interprofessional training can significantly enhance collaboration, communication, and overall care quality in managing obstetric emergencies across the relevant team members. Most of the studies [ 22 , 25 , 26 , 29 , 35 , 44 ] suggested interprofessional simulation training as an important strategy to ensure effective skills acquisition on the management of obstetric emergencies and complications. Evaluate impact of CPD training using Kirkpatrick scale Studies [ 33 , 37 , 40 ], suggest that the Kirkpatrick theoretical model may be used to assess the impact of a CPD training program which includes four levels reaction, learning, behaviour and results. The Kirkpatrick Model is a widely used framework for evaluating the effectiveness of training programs developed by Donald Kirkpatrick in the 1950s. Level 1 reaction, this level measures participants' immediate reactions to the training program. Level 2 Level 2 evaluates the extent to which participants have acquired new knowledge, skills, or attitudes as a result of the training, this includes using the pre- and post-tests and skills assessments. Level 3 behaviour assesses whether participants apply the knowledge and skills acquired during training to their job roles. The last level 4 results tracking of key clinical outcomes related to obstetric emergencies, such as reduction in maternal mortality rates or improvement in neonatal resuscitation success rates. Discussion Our aim was to conduct a scoping review to and synthesize the evidence that is available evidence, globally on continuing professional development programs for midwives, midwifery educators within an interdisciplinary team in order to address the knowledge gap and implementation of policy in an effort to optimise management of obstetric emergencies and complications and ultimately reduce their resultant impact on maternal and infant mortality. The review does point to the various approaches that have been used in CPD programmes to improve the knowledge and skills that midwives, midwifery educators and other members of the interdisciplinary collaborative team have gained to manage obstetric emergencies. Management of obstetric emergencies and complications requires the collaborative effort of the interdisciplinary team. It is clear from the literature that most of the CPD programmes targeted midwives in practice, physicians and obstetricians while leaving out midwifery educators as there is only one article that refers to midwifery educators (Table:1). Hence knowledge of the programs employed in CPD to improve the knowledge and skills of the interdisciplinary teams which also include midwives, midwifery educators and leaders will inform the knowledge gap and implementation of policy for CPD for Midwifery educators. The findings revealed that CPD training programs were conducted in various countries globally mainly for nurses, midwives, midwifery educators and members of the inter-professional teams such as physicians and obstetricians and physiotherapists. Most of the training programs focused on equipping the skilled personnel with knowledge, skills and confidence in managing obstetric emergencies through simulation-based training, advanced life support in Obstetric Educational programs (ALSO) including team training to scale up and strengthen comprehensive emergency obstetric and neonatal care including innovative use of mobile(mHealth) technology [ 21 , 22 , 23 , 29 , 41 , 50 ]. Four themes emerged from the scoping review: types of CPD training programs, effectiveness of CPD on management of obstetric emergencies, barriers/challenges with lack of implementation and suggestions for implementation of CPD programs. The scoping review highlighted different types of CPD training programs across the globe. The training programs were conducted among various professionals and the subthemes are highlighted. A standardised CPD program is mandatory for all levels of healthcare staff who service a health care facility that offers emergency obstetric care as this allows for evaluation of the expected standard competencies for the level of practice. Successful implementation of such programs is reported to result in significant improvements of healthcare provider (including midwives) knowledge, skills and behaviour change in clinical practice related to emergency obstetric care [ 52 , 53 ] Worth noting is that CPD systems vary between high income countries and low and lower –middle income countries (LMICs) due to lack of resources to facilitate technology-based simulation, access barriers and lack of recent reviews on development, implementation and sustainability of CPD systems in LLMICs [ 53 ]. Since the advent of COVID-19 pandemic, the use of technology and innovation in most educational institutions, practice setting in healthcare settings and for continuous development programs seems mandatory. The literature reviewed identified high fidelity, mobile applications, telemedicine and virtual reality. High fidelity simulation is suitable and has a high benefit as a teaching tool in training healthcare workers in dealing with emergency obstetric care for continuing education [ 22 ]. Impact of the training will be evaluated using the four levels of the Kirkpatrick scale as the training and the participants continues to facilitate evaluation of impact [ 22 ]. Mobile applications are useful as they are accessible and easy to use as information is programmed. Currently most people own smart phones making it easy to down load applications. The Safe Delivery application (SDA), a safe delivery Health application used in Rwanda, was described as a useful tool and it was recommended as a useful tool for continuous learning hence can be useful as it does not interrupt health services [ 31 ]. Clinical simulation in obstetrics is one of the tools that can reduce the rate of perinatal morbidity and mortality through improving knowledge and skills of members of the multidisciplinary team in the management of emergency obstetrics and neonatal care [ 28 , 34 ]. In an effort to improve competencies in maternity care services, [ 23 ] recommend mandatory interdisciplinary CPD education, training of trainer, programme monitoring for quality and maintenance of practitioner standard. However, interprofessional CPD training requires a buy in from stakeholders, clear outlined policies and protocols, accreditation mechanisms, resources for implementation, monitoring and evaluation especially in low and lower-middle income countries [ 53 ]. Simulation training conducted for both midwives and other health care providers in clinical settings and others trained as simulation facilitators is reported to have increased knowledge, self-efficacy, teamwork and enhanced patient provider communication including providing respectful maternity care [ 50 ].. The training also focussed on including respectful maternity care. For successful implementation of such a program requires a lot of resources and time for preparation including a simulated mother, fetus and infant as well as items required for the procedures to be carried to implement the highly simulated procedures which will contribute to reduction of maternal and neonatal mortality and morbidity related to childbirth. Literature highlighted that on-site clinical mentorship contributed to reduction of intrapartum fetal deaths through a structured and supportive supervision on EmONC signal functions that were conducted during the intervention [ 37 ]. Ongoing support which includes provision of the relevant resources, scheduling practice sessions, monitoring and communication of motivation factors is required to sustain CPD programs [ 39 ]. Some of the training programs in the reviewed literature utilised the Essential Steps in the Management of Obstetric emergencies (ESMOE) WHO guidelines on obstetric management. The use of standardised curriculum or recommended protocols is essential to achieve the purpose of the training consistent with the organisational needs irrespective of who will be offering the training. The WHO standardised curriculum for management of obstetric emergencies and complications serves as a blueprint to address specific organisational needs. Team based care brings about effective collaboration of care among professionals and also enhances communication and mutual understanding of each other’s professional worthy and collaboration[ 44 ]. Effective communication among the obstetric team is imperative and this can be achieved through mHealth and Telemedicine including other communication strategies [ 44 , 39 ]. Generally, almost all the reviewed literature point to the increased knowledge, skills and confidence in management of obstetric emergencies for the healthcare workers who attended the trainings [21; 28;43]. Implementation of CPD challenges programs like any new programs have encountered both successes and challenges which include insufficient resources to operationalise the programs. Insufficient resources to both implement basic standard emergency obstetric care and the CPD programs bring challenges to the success of both provision of care and utilisation of knowledge and skills obtained as well as implementing the CPD programs. In one training in Addis Ababa, trainers did not achieve the required knowledge based mastery during the first attempt requiring further resources to repeat the training [ 42 ] Furthermore, the initial planning for the CPD program should have the relevant resources to conduct the required relevant steps when introducing a CPD program ( especially in low and lower-middle income countries) such as: conducting needs assessment, policy development(laws/norms),the CPD, accreditation mechanism, monitoring and evaluation, financing plan, identification and production of the relevant and appropriate CPD materials and activities and a communication strategy [ 54 ]. Furthermore, the sustainability plan should be considered to ensure availability of the relevant resources. required in the respective healthcare facilities to facilitate implementation of the knowledge and skills learnt through the CPD program. In all the literature reviewed, the purpose of the CPD program was to improve the inadequate knowledge and skills of healthcare providers on emergency obstetric care with the aim of reducing maternal mortality. In summary the health care workers (midwives included) gained the required knowledge and skills on reducing obstetric emergencies, prevention and management of obstetric emergencies including timely referral of emergencies. Reviewed literature indicated lack of opportunity for continuing education to apply the knowledge and skills learnt after training, lack of formalised CPD training programs and limited time for training as impediment to successful implementation of the CPD programs as participants did not get adequate time to practice what they learnt [25;46;47]. The need for a policy to prioritize EmOC training was recommended [ 47 ]. Most of the CPD programs for interprofessional teams or midwives which were once off and there is no reference on supervision and mentoring as follow up of the training or subsequent refresher courses to enhance the knowledge and skills gained. Sustainability of CPD programs hinges on leadership form healthcare professionals, a clear CPD framework, adequate funding, CPD materials and activities that are responsive to local needs, monitoring and evaluation, regulation and accreditation [ 53 ]. Implementation of CPD training programs has contributed to improvement of knowledge and skills for healthcare professionals including midwives in the management of obstetric emergencies and complications. Interprofessional training, developing and implementing policy directives on CPD programs including monitoring and evaluation of CPD programs can enhance successful implementation of CPD programs [22,25,26,29,30,35,43’,44,54]. Interprofessional training is ideal as it encompasses team work and presents the roles and responsibilities of each healthcare provider within the team and prevents overlap of activities which may overlap during an emergency or may interfere with the referral process. Clear steps that were followed to develop the CPD program, clear protocols, roles and responsibilities, procedures, definition of the different levels of care as well as the scope of practice of each healthcare worker in an interprofessional team should be defined [ 54 ]. In the reviewed studies most of the studies focussed on the type of CPD programs, actual evaluation and training on knowledge and skills and implementation of CPD programs including perceptions of the healthcare workers. However, for any program to be successful, there should be policy directives to guide implementation, monitoring and evaluation including the implications which are contextualised nationally [ 54 , 55 ]. The Kirkpatrick scale/model is best suited to evaluate the impact of the CPD training as it is usable across disciplines and is used to evaluate the effectiveness of a training-learning or an educational program. The four levels of the model allow for evaluating: the reaction of participants to the training learning-the learning which will have taken place; the behaviour-evaluates the expected behaviour following the training and the results. The model was successfully used in Addis Ababa [ 43 ] for levels 1 and 2; and in Kenya, (four levels 3 and 4 using Benner’s stages of clinical competence [ 30 ]. Applied to the CPD for midwifery educators it will evaluate the knowledge and skills the midwifery educators will gain as trainers of the midwifery students, and use to pass on to the students which reflects a behaviour change in developing pedagogic content and evaluate the pact based on the knowledge and skills that will be transferred to the students. Strengths and limitations The scoping review provide a broad overview of the available global literature related to CPD for midwives in managing obstetric emergencies. The findings suggested in the scoping review may assist in the development of evidence-based practice and policy-making, guiding the development and implementation of effective CPD programs for midwives. The limitations include due to rapid nature of the scoping review and the prioritization process used to select the articles, not all the literature may have been included. scoping reviews provide a broad overview, however may lack depth in assessing the quality and strength of evidence. Conclusion This scoping review aimed to map the existing literature on continuing professional development (CPD) programs for midwives, specifically focusing on optimizing the management of obstetric emergencies and complications. The findings provide a comprehensive overview of the diverse approaches and interventions used in CPD programs worldwide, highlighting both the strengths and gaps in current practices. The CPD program can be offered in various approaches including simulation-based training, technology-based simulation, online modules, workshops, and interdisciplinary/interprofessional learning sessions, have shown to be effective [ 21 – 52 ]. Each method offers unique advantages, such as hands-on practice in simulations and flexibility in online learning with smart applications such as SAFE delivery applications and improved confidence and skills in the management of obstetric emergencies thus contributing to achievement of the SDG goals through improved maternal and neonatal outcomes. Declarations Acknowledgements: The continuing education program (CPD) project is led by the Principal investigator Dr M Musie in collaboration with interprofessional stakeholders from the Gauteng National Department of Health, South African Nursing Council, Representation from Department of Obstetrics and Gynaecology and the representative from World Continuing Education Alliance (WCEA). We would like to thank Winkie Siebane, the librarian for the Faculty of Health Sciences, Nursing Department, University of Pretoria for her assistance in developing the database search strategies. Author contributions MRM: Conceptualization, Methodology, Investigation, Formal Analysis, Writing Original draft, Review and Editing and Funding Acquisition. TH: Conceptualization Methodology, Formal Analysis and Writing Original draft. NVS: Conceptualization, Methodology, Formal Analysis and Writing Original draft, Writing-Review & Editing. FMM: Conceptualization, Supervision, Review & Editing. OBT: Conceptualization, Methodology, Formal Analysis and Writing Original draft. All authors have read and approved the manuscript. Funding: This research received funding from the Research development programme (RDP grant no #5662, University of Pretoria. Availability of data and materials All data generated or analysed during the study are included in this published articles and its supplementary information files. Ethics approval and consent to participate Not applicable. Consent for publication: Not applicable Competing interests None References Lori JR, Stalls S, Rominski S. Strengthening midwifery to end preventable maternal, child, and newborn health. J Midwifery Women's Health. 2015;60(4):343. World Health Organization. World Health Statistics 2016 [OP]: Monitoring Health for the Sustainable Development Goals (SDGs). World Health Organization; 2016. Baloyi OB, Jarvis MA. Continuing professional development status in the World Health Organisation, Afro-region member states. 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Obstetric neonatal emergency simulation workshops in remote and regional South India: a qualitative evaluation. Adv Simul. 2021;6:1–0. van Tetering AA, Segers MH, Ntuyo P, Namagambe I, van der Hout-van MB, Byamugisha JK, Oei SG. Evaluating the instructional design and effect on knowledge, teamwork, and skills of technology-enhanced simulation-based training in obstetrics in Uganda: Stepped-wedge cluster randomized trial. JMIR Med Educ. 2021;7(1):e17277. Hernández E, Camacho M, Leal-Costa C, Ruzafa-Martínez M, Ramos-Morcillo AJ, Cazorla E, Díaz-Agea JL. Does multidisciplinary team simulation-based training improve obstetric emergencies skills?. InHealthcare 2021 Feb 5 (Vol. 9, No. 2, p. 170). MDPI. van Tetering AA, Fransen AF, van der Hout-van MB, Oei SG. The use of a stronger instructional design by implementing repetitive practice in simulation-based obstetric team training: trainees’ satisfaction. BMJ Simul Technol Enhanced Learn. 2020;6(5):284. Sami AY, Nabeel AY, Amatullah AF. Simulation-based training to improve obstetric/perinatal nurses competency in managing obstetric emergencies in Saudi Arabia (KSA). Int J Caring Sci. 2019;12(3):1788. Shikuku DN, Mukosa R, Peru T, Yaite A, Ambuchi J, Sisimwo K. Reducing intrapartum fetal deaths through low-dose high frequency clinical mentorship in a rural hospital in Western Kenya: a quasi-experimental study. BMC Pregnancy Childbirth. 2019;19:1–2. Khan AN, Karim F, Chowdhury MA, Zaka N, Manu A, El Arifeen S, Billah SM. Competence of healthcare professionals in diagnosing and managing obstetric complications and conducting neonatal care: a clinical vignette-based assessment in district and subdistrict hospitals in northern Bangladesh. BMJ open. 2019;9(8):e028670. Williams E, Bazant ES, Holcombe S, Atukunda I, Namugerwa RI, Britt K, Evans C. Practice so that the skill does not disappear: mixed methods evaluation of simulator-based learning for midwives in Uganda. Hum Resour health. 2019;17:1–1. Siaulys MM, da Cunha LB, Torloni MR, Kondo MM. Obstetric emergency simulation training course: experience of a private-public partnership in Brazil. Reproductive health. 2019;16:1–8. Walker D, Cohen S, Fritz J, Olvera M, Lamadrid-Figueroa H, Cowan JG, Hernandez DG, Dettinger JC, Fahey JO. Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators. BMC Pregnancy Childbirth. 2014;14:1–1. Mirkuzie AH, Sisay MM, Bedane MM. Standard basic emergency obstetric and neonatal care training in Addis Ababa; trainees reaction and knowledge acquisition. BMC Med Educ. 2014;14:1–7. Shikuku DN, Tallam E, Wako I, Mualuko A, Waweru L, Nyaga L, Bashir I, Ameh C. Evaluation of capacity to deliver Emergency Obstetrics and Newborn Care updated midwifery and reproductive health training curricula in Kenya: Before and after study. Int J Afr Nurs Sci. 2022;17:100439. Noblot E, Raia-Barjat T, Lajeunesse C, Trombert B, Weiss S, Colombié M, Chauleur C. Training program for the management of two obstetric emergencies within a French perinatal care network. Eur J Obstet Gynecol Reproductive Biology. 2015;189:101–5. Makhado LC, Mangena-Netshikweta ML, Mulondo SA, Olaniyi FC. The roles of obstetrics training skills and utilisation of maternity unit protocols in reducing perinatal mortality in Limpopo Province, South Africa. InHealthcare 2022 Apr 1 (Vol. 10, No. 4, p. 662). MDPI. Tuyisenge G, Hategeka C, Luginaah I, Babenko-Mould Y, Cechetto D, Rulisa S. Continuing professional development in maternal health care: barriers to applying new knowledge and skills in the hospitals of Rwanda. Matern Child Health J. 2018;22:1200–7. Nkhwalume L, Mashalla Y. Health care workers experiences in emergency obstetric care following implementation of an in-service training program: case of 2 Referral Hospitals in Botswana. Afr Health Sci. 2021;21(1):51–8. Dhanasiri G, Vasundhara R. Knowledge of nurses working in maternity units before and after the implementation of structured teaching program on obstetrical emergencies in selected hospitals, Guntur District, Andhra Pradesh. Manipal J Nurs Health Sci (MJNHS). 2019;5(1):32–6. Urbutė A, Paulionytė M, Jonauskaitė D, Machtejevienė E, Nadišauskienė RJ, Dambrauskas Ž, Dobožinskas P, Kliučinskas M. Perceived changes in knowledge and confidence of doctors and midwives after the completion of the Standardized Trainings in Obstetrical Emergencies. Medicina. 2017;53(6):403–9. Afulani PA, Dyer J, Calkin K, Aborigo RA, Mcnally B, Cohen SR. Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana. Midwifery Elservier. June ( 2020;85:102667. https://doi.org/10.1016/j.midw.2020.102667 . Moran NF, Naidoo M, Moodley J. Reducing maternal mortality on a countrywide scale: The role of emergency obstetric training. Best Pract Res Clin Obstet Gynecol. 2015;29(8):1102–18. Mwakawanga DL, Rimoy M, Mwanga F, Massae AF, Mushy SE, Kisaka L, Komba N, Mabada L, Mlay E, Mwakalinga E, Mwasha L. Strengthening midwives' competencies for addressing maternal and newborn mortality in Tanzania: Lessons from Midwifery Emergency Skills Training (MEST) project. Midwifery. 2023;122:103695. Ameh CA, Mdegela M, White S, van den Broek N. The effectiveness of training in emergency obstetric care: a systematic literature review. Health Policy Plann. 2019;34(4):257–70. Merry L, Castiglione SA. al, (2023) Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low –lower –middle –income countries: a rapid scoping review.BMC Medical Education. https://doi.org/10.1186/s12909-23-04427-6 . Encarna Hernández,Marcos Camacho et.al. (2021) Does Multidisciplinary Team Simulation-Based Training Improve Obstetric Emergencies Skills? Healthcare 2021, 9 (2), 170; https://doi.org/10.3390/healthcare9020170 . Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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class=\"CitationRef\"\u003e1\u003c/span\u003e]. The need for midwifery education extended beyond the MDGs. In 2015, all United Nations member countries adopted the 2030 Agenda for Sustainable Development goals (SDG). It outlines 17 goals, including 169 targets [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The SDG 4 is all about to \"ensure inclusive and equitable education and promote lifelong learning for all.\" Therefore, this SDG goal is linked with the need for Continuous Professional Development (CPD) to promote lifelong learning for all including midwives and midwifery educators. CPD refers to ongoing education and competency development by health professionals beyond their initial training; the purpose is to update and advance their knowledge, skills and professional proficiency [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCPD keeps midwives up to date, allowing them to better serve their patients (women and babies) and the health-care system [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It entails the continuous acquisition of new knowledge, skills, and attitudes to sustain and improve professional competent practice [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The CPD package is linked to the International Confederation of Midwives (ICM) essential competencies for midwifery practice that meet the requirements of Nursing and Midwifery councils in low- and middle-income countries (LMICs) according to the World Continuing education alliance (WCEA). Midwives and nurses are essential providers of emergency obstetric and neonatal care (EmONC) services, and need to remain competent and update their knowledge to enhance the quality of EmONC service delivery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. An obstetric emergency is a life-threatening medical condition that develops during pregnancy, labour, or the postpartum period [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Globally, the maternal mortality ratio (MMR) is still unacceptably high; on average every day, nearly 810 women die while giving birth especially in low-middle income countries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sub-Saharan Africa remains the region with the highest burden of maternal mortality and morbidities with an MMR of 542 per 100,000 live births, which is higher than the ratio of 216 per 100,000 live births globally. The Sustainable Development Goal (SDG) 3.1 sets out that by 2030, the global maternal mortality ratio (MMR) is reduced to less than 70 per 100,000 live births [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization (WHO,2022) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the following conditions are considered obstetrical emergencies: ectopic or tubal pregnancy, placenta abruptio and previa, preeclampsia or pregnancy-induced high blood pressure, eclampsia and premature membrane rupture (PROM), amniotic fluid embolism (AFE), inversion or rupture of the uterus, placenta accreta, prolapsed umbilical cord, and shoulder dystocia, postpartum haemorrhage (PPH), and postpartum infection. These potentially life-threatening emergencies frequently occur unexpectedly, necessitating immediate action by healthcare professionals as indicated by the American college of Obstetricians and Gynaecologists [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], can result in tragic outcomes such as death or serious morbidity in women and/or newborns. Most of these deaths could be prevented if quality EmONC is provided by skilled health care professionals.\u003c/p\u003e \u003cp\u003eAs a result, CPD training programs for midwives in global settings are required to improve the management of obstetric emergencies and complications (EmONC). Midwives attend a variety of CPD training programs to help them manage obstetric emergencies and complications. In one previous study conducted in Tanzania midwives participated in a CPD training program known as Midwifery Emergencies Skills (MSE) Training. This MSE training improved midwives' knowledge and skills in managing obstetric emergencies and following referral protocols [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another previous study found that midwives who attended the Essential Steps in Managing Obstetric Emergencies (ESMOE) and emergency obstetric simulation training reported that the training benefited the patient by preparing them to manage obstetric emergencies competently [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As a result, the purpose of this review is to map and synthesise the evidence on CPD programs for midwives in optimising the management of obstetric emergencies and complications globally.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eHerein, we conducted a scoping review to map, synthesise and summarise the available evidence on continuing professional development (CPD) for midwives and midwifery educators globally. A scoping review is useful to mapping available range of evidences that exists around a topic of interest and focus the research questions by charting existing research findings and identification of research gaps. This scoping review was guided by the methodological framework proposed by Arksey and O\u0026rsquo;Malley (2005) [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] and further advanced by Levac, et al., (2010) [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to this framework, we conducted the review in the following five stages: (i) identifying the research question; (ii) identifying the relevant studies; (iii) selection of eligible studies; (iv) data extraction process and (v) collating, summarising and reporting of results. Arksey and O\u0026rsquo;Malley 2005 proposed a sixth optional stage compromising consultations with the key stakeholders [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. This scoping review did not include consultations with stakeholders. The results of this scoping review were reported according to the Preferred reporting items for Systematic reviews and Meta-analyses extension for scoping review (PRISMA-ScR) checklist [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] see (Additional file 1).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eResearch question\u003c/h2\u003e\n \u003cp\u003eThe main question was: What evidence exists on CPD training programs for midwives for management of obstetrics emergencies and complications globally?\u003c/p\u003e\n \u003cp\u003eWe assessed the eligibility of the research question for a scoping review study by applying the Population, concept and Context (PCC) mnemonic framework.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eDatabase literature search strategy\u003c/h2\u003e\n \u003cp\u003eThe search strategy was developed in consultation with the university librarian and with the input of the research team. We conducted the keyword search to identify all relevant studies from the various databases. The following electronic databases were used: PubMed, SCOPUS, Web of Science, EBSCOhost, CINAHL and ProQuest central for full text relevant studies. Studies were identified using the following keywords and Medical subject heading (MeSH) terms( \u0026ldquo;Midwives\u0026rdquo; OR \u0026ldquo;Nurses\u0026rdquo; OR \u0026ldquo;Midwifery\u0026rdquo; OR \u0026ldquo;Midwife\u0026rdquo; OR \u0026ldquo;Accoucheurs\u0026rdquo; OR \u0026ldquo;nurse-midwife\u0026rdquo; OR \u0026ldquo;Midwifery educators\u0026rdquo; OR \u0026ldquo;Midwife educator\u0026rdquo; OR \u0026ldquo;Midwife teachers\u0026rdquo; ) AND ( \u0026ldquo;Continuous Professional Development\u0026rdquo; OR \u0026ldquo;CPD\u0026rdquo; OR \u0026ldquo;Continuing Education Programs\u0026rdquo; OR \u0026ldquo;Education programs\u0026rdquo; OR \u0026ldquo;Training programs\u0026rdquo; ) AND ( \u0026ldquo;Obstetric emergencies\u0026rdquo; OR \u0026ldquo;Obstetric complications\u0026rdquo; OR \u0026ldquo;Intrapartum complications\u0026rdquo; OR \u0026ldquo;Childbirth complications\u0026rdquo; OR \u0026ldquo;Labour complications\u0026rdquo; OR \u0026ldquo;Intrapartum emergency\u0026rdquo; OR \u0026ldquo;Midwifery complications\u0026rdquo; ). Searches were limited to English, articles published between 2013\u0026ndash;2023. Each search was documented in detail showing the keywords/MeSH terms, date of search, electronic database and number of retrieved studies. The complete search strategy is shown on (Additional file 2).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eSelection of eligible studies\u003c/h2\u003e\n \u003cp\u003eThe scoping review selection of eligible studies was guided by using inclusion and exclusion criteria to ensure that relevant studies are selected. There were (n\u0026thinsp;=\u0026thinsp;752) articles retrieved from the database searches. After the duplicates were removed there were (n\u0026thinsp;=\u0026thinsp;629) articles, the titles and abstracts were screened based on the inclusion criteria (See Additional file 3)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003ePopulation\u003c/h2\u003e\n \u003cp\u003eWe included articles that reported evidence of midwives, accoucheurs, midwifery educators\u0026rsquo; and midwifery preceptors across the globe. The South African Nursing Council (SANC) R2488 indicates the regulations that a registered midwife is supposed to practice under. A midwife is a licensed person who is registered with the South African Nursing Council based on completion of a recognized education and training programme to nurture, assist and treat the client, who can be a woman, a neonate or a family, in the process of promoting a health pregnancy, labour and post-partum period [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. The regulation includes under Chap.\u0026nbsp;10: that the midwife is responsible to manage and refer the illnesses, abnormalities or complications occurring during pregnancy, labour or the puerperium or in the child, the registered midwife shall, subject to the provisions of sub regulation. The articles focused on the health professionals that are responsible for managing women during intrapartum and required skills to manage obstetrical emergencies and complications [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eCPD Training programs\u003c/h2\u003e\n \u003cp\u003eCPD training programme is defined as purposeful statutory process where the healthcare practitioners registered with SANC are required to engage in learning activities or programmes to maintain and improve their knowledge and skill to remain abreast to the new sciences, innovation and health care developments within the evolving scope of practice [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. The South African Nursing Council (SANC), is responsible to guide the implementation of the continuing professional development (CPD) program for nurses and midwives in terms of the Nursing Act (Act no 33 of 2005). We included articles that described other various types of Continuing professional development programs and education implemented in ensuring that the midwives and midwifery educators are competent to manage the obstetrical emergencies.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTraining programs for management of obstetric emergencies and complications\u003c/h2\u003e\n \u003cp\u003eWe also included articles that described obstetric emergencies and complications as an evidence-based service required to manage potentially life-threatening complications that affect many women during pregnancy, childbirth, and the immediate postpartum period [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eSelection of sources of evidence\u003c/h2\u003e\n \u003cp\u003eAll records from the database searches were downloaded into Endnote 20 library, and the duplicates were removed. The articles were screened in three stages, namely: title, abstract and full-text screening. The reviewers used a screening tool developed PI (MRM) and the university librarian. The articles were then exported from endnote to Ryann software. The screening process was iterative and involved multiple steps: To reduce selection bias the two independent reviewers conducted comprehensive titles and abstracts screening guided by the eligibility criteria. After deduplication the first 629 titles and abstract were screened by two reviewers (MRM and TH) and discrepancies were discussed until consensus was reached. The two independent reviewers sorted the studies into \u0026ldquo;included\u0026rdquo; and \u0026ldquo;excluded category\u0026rdquo; based on the inclusion criteria. The articles flagged for inclusion were independently assessed by MRM and TH and the selection of these articles were prioritised for full text review. To be considered for full text the article would have some information on midwives, CPD training programs and obstetric emergencies. A third screener (NVS) confirmed the final selection of articles for data extraction. Both abstract and full-text article screening were guided by the screening tool that factored all aspects of inclusion/exclusion criteria and the PCC elements. Finally, 32 articles were included for content data analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eData extraction process\u003c/h2\u003e\n \u003cp\u003eA data charting form were used to capture all relevant data from the included articles using Excel. Two independent reviewers (MRM and TH) plot the data charting form and recommend modifications that will be implemented. The following data were extracted from the included articles: author and year of publication, the title of study, aim of the study, study design, study setting, study population, country, available CPD programs on management of obstetric emergencies and outcomes of the programs. Content analysis was conducted to identify similarities and differences among the retrieved themes and subthemes of the studies using Nvivo 12 software. Two reviewers (MRM and TH) read all the articles several times to understand the main concepts (see additional file 4)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCollating, summarising and reporting the results\u003c/h2\u003e\n \u003cp\u003eThe authors extracted the Qualitative data and summarised it according to emerging themes and subthemes. The following themes emerged from the data: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation and Suggestion for implementation of CPD programs. The quantitative data was extracted and presented in form of descriptive statistics in use of tables and chart (see Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eQuality appraisal\u003c/h2\u003e\n \u003cp\u003eWe used the mixed method appraisal tool (MMAT) version 2018 to evaluate the quality of the included articles [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Using MMAT, we appraised the methodological quality of five categories of research: qualitative research, randomised controlled trials, nonrandomised studies, quantitative descriptive studies and mixed methods studies [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Two independent reviewers (MRM and TH) carried out the quality appraisal process. The following percentage scores were used to grade the quality of evidence: (i)\u0026thinsp;\u0026le;\u0026thinsp;50% represented low-quality evidence, (ii) 51\u0026ndash;75% represented average-quality evidence and (iii) 76\u0026ndash;100% represented high-quality evidence.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003eThis scoping review is guided by the ethical approval obtained from the Faculty of Health Sciences Research Ethics Committee, reference no 322/2023.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 752 articles identified through the database searching, 32 articles met the inclusion criteria. The PRISMA flowchart of article screening and selection process is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 32 articles, eleven were from the low- and middle-income countries LMIC (three Rwanda [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], three Tanzania [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], two Ethiopia [28,], three Kenya [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], two Uganda [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], one Ghana [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], one Bangladesh [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], one China [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], three India [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], one Brazil [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and one Mexico [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]). Six of the extracted articles were from High income countries including (three Europe [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], one Australia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], one United states [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], one Spain [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], one Netherlands [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and one Saudi Arabia [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]). The other included two were from South Africa [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and one from Botswana [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These studies include the following research designs seven Qualitative descriptive design, two workshops, seventeen Quantitative studies (including quasi experimental, longitudinal studies and pre-and post-studies), two observational studies and fourth mixed methods study design. Eleven of the included articles described CPD programs for midwives, while four included midwifery educators and the remaining seventeen included other multidisciplinary members working in the maternity units including (obstetricians, doctors and gynaecologists). The types of obstetric emergencies and complications managed included shoulder dystocia (n\u0026thinsp;=\u0026thinsp;8), postpartum haemorrhage (n\u0026thinsp;=\u0026thinsp;8), preterm labour (n\u0026thinsp;=\u0026thinsp;2), amniotic fluid embolism AFE (n\u0026thinsp;=\u0026thinsp;3), pre-eclampsia/eclampsia (n\u0026thinsp;=\u0026thinsp;4), neonatal resuscitation (n\u0026thinsp;=\u0026thinsp;2) and breech delivery (n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThemes and subthemes of extracted data\u003c/h2\u003e \u003cp\u003eFour themes were synthesised from the extracted data: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation of CPD programs and Suggestion for implementation of CPD programs. The articles supporting these categories are summarised in Additional file 4.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Types of CPD training programs.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe overall theme including the following 5 subthemes: \u003cem\u003eStandardised simulation CPD program\u003c/em\u003e, T\u003cem\u003eechnology-enhanced simulation-based training (TESBT), Inter-professional simulation-based training (IPSBT), Onsite clinical mentorship programme, and Train-the-Trainer program.\u003c/em\u003e The studies indicate the types of CPD programs utilised globally in the provision of training health professionals including midwives on the management of obstetric emergencies and complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStandardised simulation CPD program\u003c/h2\u003e \u003cp\u003eMajority of the studies reported the implementation of standardised simulation CPD programme [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] involves developing a standard simulation programme based on the curriculum stipulated by the World Health Organisation standards in maternal and newborn care guidelines [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The programme includes simulating case scenarios or conducting ONE (obstetric and neonatal emergency) simulation workshops [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] on the following obstetrical emergencies such as shoulder dystocia, amniotic fluid embolism and postpartum haemorrhage during pre and post-test intervention yielded significant results\u0026thinsp;\u0026lt;\u0026thinsp;p value 0,005. The results revealed that 78% of nurses had inadequate knowledge on management of obstetric emergencies as pre-test, however after the simulation training was done the post-test questions proven improved knowledge [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. A tool called simulation effectives tool modified (SET-M) can be used to assess the effectiveness of the trainings/ workshops [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eT\u003c/b\u003e \u003cb\u003eechnology-enhanced simulation-based training\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis type of CPD program refers to employing technologies such as high-fidelity mannequins/simulations drills (HFS) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Advanced life support in obstetrics (ALSO) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] and mHealth technology such as the safe delivery app (SDA) to train health professionals to manage obstetric emergencies and complications [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The Safe Delivery mHealth Application (SDA) is one of the recent m-health applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Most of the articles noted that CPD training can be done in a form of TESBT using simulation mannequins such as Neolle interactive neonate [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. These programs were found to significantly improve clinical skills, decision-making abilities, and teamwork among midwives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInter-professional simulation-based training\u003c/h2\u003e \u003cp\u003eInterprofessional simulation-based training (IPST) is an educational approach identified in the articles where health professionals from different healthcare disciplines (such as midwives, obstetricians, gynaecologist, physicians, physiotherapist etc) learn and practice together in simulated environments [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This type of training is designed to enhance collaboration, communication, and overall team performance, which ultimately improves clinical competence and confidence on the management of obstetric emergencies and complications. A study conducted in Tanzania identified reduced obstetric mortalities and morbidities when the health professionals are trained in teams [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The recommended obstetrical training for interprofessional or multi-professionals is the practical obstetrical multi professional training course (PROMPT) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The Kirkpatrick training evaluation tool [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] is used indicated that the trained teams need to practice the skills to manage obstetrical emergencies repeatedly in form of drills assisted with mastery of skills and competence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTrain-the-Trainer program\u003c/h2\u003e \u003cp\u003eTwo of the studies conducted in Ethiopia and Kenya reported on the importance of conducting CPD in a form of Training the trainer [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] which often last for 5 days course. This includes identifying individuals in the maternity wards which can be trained as trainers so that they may continue with training the staff members that enters the institution. The training of trainer\u0026rsquo;s program is designed to equip experienced professionals with the skills and knowledge needed to effectively train others. In the context of a standardized simulation program, a TTT program ensures that facilitators are well-prepared to deliver high-quality simulation training consistently.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eOnsite clinical mentorship programme\u003c/h2\u003e \u003cp\u003eOne of the studies [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] conducted in Kenya reported on identification of onsite clinical mentors in emergency obstetrics and newborn care (EmONC). Clinical mentorship is an approach for in-service training, healthcare workers were mentored on key evidence-based intrapartum and immediate newborn care practices, using current national/global guidelines on job site. A clinical mentor (also a master trainer) was either a doctor, nurse/midwife or reproductive health clinical officer from high volume facilities which were defined as a facility with an average of five or more deliveries in a day.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Effectiveness of CPD on management of obstetric emergencies\u003c/h2\u003e \u003cp\u003eThe second identified theme is on the effectiveness of CPD programs including the four subthemes: \u003cem\u003eEnhanced clinical skills and knowledge acquisition, Team-based care/ Interprofessional collaboration, improve maternal and neonatal outcomes and WHO Standardised curriculum for management of obstetrics emergencies.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eEnhanced clinical skills and knowledge acquisition\u003c/h2\u003e \u003cp\u003eSeveral studies indicate that when midwives undergo continuous professional development in the management of obstetric emergencies they become competent, knowledgeable and confident to manage the emergencies during childbirth [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Hands-on training and simulation scenarios or drills improve the practical skills of healthcare providers, enabling them to manage emergencies more effectively such as postpartum haemorrhage, preterm labour and shoulder dystocia [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. A study done in Rwanda added that health professionals may improve their confidence and ability to manage childbirth complications by using the m-health SAFE app [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. When health professionals practice the management of obstetric emergencies repeatedly they master the skills [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The standardised trainings on obstetrical emergencies (STrObE) indicated that the health professional knowledge and confidence improved after the trainings especially for those with less work experience they benefited from the online and hands on simulation training with the multidisciplinary team [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImprove maternal and neonatal outcomes\u003c/h2\u003e \u003cp\u003eThe main purpose of the CPD programs is to ensure the achievement of the sustainable developmental goals (SDG) which focuses on improved maternal and neonatal outcomes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. When midwives and other health professional undergo continuing professional development, they remain abreast to latest evidence on the management of the obstetric emergencies. Teamwork and collaboration were associated with better perinatal outcomes [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In additional clinical mentorship and supervision on EmONC on the following breech deliveries halved from 1,5 to 0,7% (p value 0,00475) indicating significant association in mentorship facilities [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] thus improving perinatal outcomes.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eTeam-based care/ Interprofessional collaboration\u003c/h2\u003e \u003cp\u003eMost studies report on the benefits of interprofessional simulation learning is helpful in enhancing competence and confidence in managing emergencies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Team-based care and interprofessional collaboration are essential components in the effective management of obstetric emergencies. These approaches enhance the quality of care provided to patients by leveraging the diverse skills and expertise of different healthcare professionals. Training in teams enhancing capacity building in emergency obstetrics and newborn care assisted to reduced maternal mortality rates by 1.5%. Team training and team work resulted in better perinatal outcomes and reduced c-section rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eWHO Standardised curriculum for management of obstetrics emergencies.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) has developed standardized curricula to guide healthcare professionals in the management of obstetric emergencies [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. These curricula are part of the broader effort to reduce maternal and neonatal morbidity and mortality by improving the skills and competencies of healthcare providers. The training manuals includes the Basic Emergency Obstetric and Newborn Care (BEmONC) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]: Covers essential skills for managing common obstetric and newborn emergencies. Comprehensive Emergency Obstetric and Newborn Care (CEmONC) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]: Includes advanced procedures that are specific interventions associated with the health systems. Essential steps in the management of obstetric emergencies (ESMOE), which is a package used in South Africa for simulation training on the management of obstetric emergencies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Barriers/Challenges with lack of implementation of CPD programs\u003c/h2\u003e \u003cp\u003eImplementing Continuing Professional Development (CPD) programs, especially in the context of obstetric emergencies, can face numerous barriers and challenges. The challenges include the following four subthemes Insufficient resources result in suboptimal care, Inadequate skills attributed to maternal mortality, lack of educational opportunity for continuing education and Insufficient sustainability of CPD programs\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eInsufficient resources result in suboptimal care\u003c/h2\u003e \u003cp\u003eUnderstaffing and insufficient resources is known to attribute to poor perinatal outcomes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], this was especially in remote areas contributed to mismanagement of obstetrical emergencies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A study conducted in Botswana identified the following factors inadequate resources and doctors refusing to change as obstacle hampering the implementation of emergency obstetric care (EmOC) in-service trainings [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eInadequate skills attributed to maternal mortality\u003c/h2\u003e \u003cp\u003eA study conducted in India, Andhra Pradesh found that 78% of the midwives had inadequate knowledge with regard to the management of obstetric emergencies [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Other studies confirm that poor knowledge contributed to maternal deaths thus affecting the countries ability to achieve that sustainable developmental goals [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eLack of educational opportunity for continuing education\u003c/h2\u003e \u003cp\u003eAnother barrier towards the implementation of CPD programs for management of obstetric emergencies includes lack of educational opportunity for continuing education [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The trainers of the advanced life support in obstetrics (ALSO) program did not get enough opportunity to apply the knowledge and skills in their hospitals after training on CPD. The lack of a formalised CPD training programme for health professionals also impeded the implementation [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. A study done in Botswana highlighted the issues related to the duration of the training being 2 weeks could contribute to the health professionals not being confident in managing obstetric emergencies and complications [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The study suggested the need for the Ministry of Health to prioritise EmOC training policy reviews.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003einsufficient sustainability of CPD programs\u003c/h2\u003e \u003cp\u003eThe last barrier to the implementation of CPD programs is the lack of effective sustainability processes in place for CPD programs. There is a need to formalise the CPD trainings for all health professionals [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. It is also important to ensure certain monitoring and evaluation of CPD attendance. Maintenance of practitioner standards and resources required for successful implementation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Suggestion for implementation of CPD programs\u003c/h2\u003e \u003cp\u003eEffective implementation of CPD programs for managing obstetric emergencies requires a strategic approach and can be achieved as supported by the following three subthemes: Interprofessional training, Policy directives to govern implementation and Evaluate impact of CPD training using Kirkpatrick scale.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterprofessional training\u003c/h3\u003e\n\u003cp\u003eImplementing Continuing Professional Development (CPD) programs through interprofessional training can significantly enhance collaboration, communication, and overall care quality in managing obstetric emergencies across the relevant team members. Most of the studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] suggested interprofessional simulation training as an important strategy to ensure effective skills acquisition on the management of obstetric emergencies and complications.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eEvaluate impact of CPD training using Kirkpatrick scale\u003c/h2\u003e \u003cp\u003eStudies [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], suggest that the Kirkpatrick theoretical model may be used to assess the impact of a CPD training program which includes four levels reaction, learning, behaviour and results. The Kirkpatrick Model is a widely used framework for evaluating the effectiveness of training programs developed by Donald Kirkpatrick in the 1950s. Level 1 reaction, this level measures participants' immediate reactions to the training program. Level 2 Level 2 evaluates the extent to which participants have acquired new knowledge, skills, or attitudes as a result of the training, this includes using the pre- and post-tests and skills assessments. Level 3 behaviour assesses whether participants apply the knowledge and skills acquired during training to their job roles. The last level 4 results tracking of key clinical outcomes related to obstetric emergencies, such as reduction in maternal mortality rates or improvement in neonatal resuscitation success rates.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our aim was to conduct a scoping review to and synthesize the evidence that is available evidence, globally on continuing professional development programs for midwives, midwifery educators within an interdisciplinary team in order to address the knowledge gap and implementation of policy in an effort to optimise management of obstetric emergencies and complications and ultimately reduce their resultant impact on maternal and infant mortality. The review does point to the various approaches that have been used in CPD programmes to improve the knowledge and skills that midwives, midwifery educators and other members of the interdisciplinary collaborative team have gained to manage obstetric emergencies. Management of obstetric emergencies and complications requires the collaborative effort of the interdisciplinary team. It is clear from the literature that most of the CPD programmes targeted midwives in practice, physicians and obstetricians while leaving out midwifery educators as there is only one article that refers to midwifery educators (Table:1). Hence knowledge of the programs employed in CPD to improve the knowledge and skills of the interdisciplinary teams which also include midwives, midwifery educators and leaders will inform the knowledge gap and implementation of policy for CPD for Midwifery educators.\u003c/p\u003e \u003cp\u003eThe findings revealed that CPD training programs were conducted in various countries globally mainly for nurses, midwives, midwifery educators and members of the inter-professional teams such as physicians and obstetricians and physiotherapists. Most of the training programs focused on equipping the skilled personnel with knowledge, skills and confidence in managing obstetric emergencies through simulation-based training, advanced life support in Obstetric Educational programs (ALSO) including team training to scale up and strengthen comprehensive emergency obstetric and neonatal care including innovative use of mobile(mHealth) technology [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Four themes emerged from the scoping review: types of CPD training programs, effectiveness of CPD on management of obstetric emergencies, barriers/challenges with lack of implementation and suggestions for implementation of CPD programs.\u003c/p\u003e \u003cp\u003eThe scoping review highlighted different types of CPD training programs across the globe. The training programs were conducted among various professionals and the subthemes are highlighted. A standardised CPD program is mandatory for all levels of healthcare staff who service a health care facility that offers emergency obstetric care as this allows for evaluation of the expected standard competencies for the level of practice. Successful implementation of such programs is reported to result in significant improvements of healthcare provider (including midwives) knowledge, skills and behaviour change in clinical practice related to emergency obstetric care [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] Worth noting is that CPD systems vary between high income countries and low and lower \u0026ndash;middle income countries (LMICs) due to lack of resources to facilitate technology-based simulation, access barriers and lack of recent reviews on development, implementation and sustainability of CPD systems in LLMICs [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Since the advent of COVID-19 pandemic, the use of technology and innovation in most educational institutions, practice setting in healthcare settings and for continuous development programs seems mandatory. The literature reviewed identified high fidelity, mobile applications, telemedicine and virtual reality. High fidelity simulation is suitable and has a high benefit as a teaching tool in training healthcare workers in dealing with emergency obstetric care for continuing education [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Impact of the training will be evaluated using the four levels of the Kirkpatrick scale as the training and the participants continues to facilitate evaluation of impact [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Mobile applications are useful as they are accessible and easy to use as information is programmed. Currently most people own smart phones making it easy to down load applications. The Safe Delivery application (SDA), a safe delivery Health application used in Rwanda, was described as a useful tool and it was recommended as a useful tool for continuous learning hence can be useful as it does not interrupt health services [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical simulation in obstetrics is one of the tools that can reduce the rate of perinatal morbidity and mortality through improving knowledge and skills of members of the multidisciplinary team in the management of emergency obstetrics and neonatal care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In an effort to improve competencies in maternity care services, [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] recommend mandatory interdisciplinary CPD education, training of trainer, programme monitoring for quality and maintenance of practitioner standard. However, interprofessional CPD training requires a buy in from stakeholders, clear outlined policies and protocols, accreditation mechanisms, resources for implementation, monitoring and evaluation especially in low and lower-middle income countries [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Simulation training conducted for both midwives and other health care providers in clinical settings and others trained as simulation facilitators is reported to have increased knowledge, self-efficacy, teamwork and enhanced patient provider communication including providing respectful maternity care [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].. The training also focussed on including respectful maternity care. For successful implementation of such a program requires a lot of resources and time for preparation including a simulated mother, fetus and infant as well as items required for the procedures to be carried to implement the highly simulated procedures which will contribute to reduction of maternal and neonatal mortality and morbidity related to childbirth. Literature highlighted that on-site clinical mentorship contributed to reduction of intrapartum fetal deaths through a structured and supportive supervision on EmONC signal functions that were conducted during the intervention [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Ongoing support which includes provision of the relevant resources, scheduling practice sessions, monitoring and communication of motivation factors is required to sustain CPD programs [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Some of the training programs in the reviewed literature utilised the Essential Steps in the Management of Obstetric emergencies (ESMOE) WHO guidelines on obstetric management. The use of standardised curriculum or recommended protocols is essential to achieve the purpose of the training consistent with the organisational needs irrespective of who will be offering the training. The WHO standardised curriculum for management of obstetric emergencies and complications serves as a blueprint to address specific organisational needs. Team based care brings about effective collaboration of care among professionals and also enhances communication and mutual understanding of each other\u0026rsquo;s professional worthy and collaboration[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEffective communication among the obstetric team is imperative and this can be achieved through mHealth and Telemedicine including other communication strategies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Generally, almost all the reviewed literature point to the increased knowledge, skills and confidence in management of obstetric emergencies for the healthcare workers who attended the trainings [21; 28;43]. Implementation of CPD challenges programs like any new programs have encountered both successes and challenges which include insufficient resources to operationalise the programs. Insufficient resources to both implement basic standard emergency obstetric care and the CPD programs bring challenges to the success of both provision of care and utilisation of knowledge and skills obtained as well as implementing the CPD programs. In one training in Addis Ababa, trainers did not achieve the required knowledge based mastery during the first attempt requiring further resources to repeat the training [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Furthermore, the initial planning for the CPD program should have the relevant resources to conduct the required relevant steps when introducing a CPD program ( especially in low and lower-middle income countries) such as: conducting needs assessment, policy development(laws/norms),the CPD, accreditation mechanism, monitoring and evaluation, financing plan, identification and production of the relevant and appropriate CPD materials and activities and a communication strategy [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Furthermore, the sustainability plan should be considered to ensure availability of the relevant resources. required in the respective healthcare facilities to facilitate implementation of the knowledge and skills learnt through the CPD program. In all the literature reviewed, the purpose of the CPD program was to improve the inadequate knowledge and skills of healthcare providers on emergency obstetric care with the aim of reducing maternal mortality. In summary the health care workers (midwives included) gained the required knowledge and skills on reducing obstetric emergencies, prevention and management of obstetric emergencies including timely referral of emergencies. Reviewed literature indicated lack of opportunity for continuing education to apply the knowledge and skills learnt after training, lack of formalised CPD training programs and limited time for training as impediment to successful implementation of the CPD programs as participants did not get adequate time to practice what they learnt [25;46;47]. The need for a policy to prioritize EmOC training was recommended [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Most of the CPD programs for interprofessional teams or midwives which were once off and there is no reference on supervision and mentoring as follow up of the training or subsequent refresher courses to enhance the knowledge and skills gained. Sustainability of CPD programs hinges on leadership form healthcare professionals, a clear CPD framework, adequate funding, CPD materials and activities that are responsive to local needs, monitoring and evaluation, regulation and accreditation [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImplementation of CPD training programs has contributed to improvement of knowledge and skills for healthcare professionals including midwives in the management of obstetric emergencies and complications. Interprofessional training, developing and implementing policy directives on CPD programs including monitoring and evaluation of CPD programs can enhance successful implementation of CPD programs [22,25,26,29,30,35,43\u0026rsquo;,44,54]. Interprofessional training is ideal as it encompasses team work and presents the roles and responsibilities of each healthcare provider within the team and prevents overlap of activities which may overlap during an emergency or may interfere with the referral process. Clear steps that were followed to develop the CPD program, clear protocols, roles and responsibilities, procedures, definition of the different levels of care as well as the scope of practice of each healthcare worker in an interprofessional team should be defined [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In the reviewed studies most of the studies focussed on the type of CPD programs, actual evaluation and training on knowledge and skills and implementation of CPD programs including perceptions of the healthcare workers. However, for any program to be successful, there should be policy directives to guide implementation, monitoring and evaluation including the implications which are contextualised nationally [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. The Kirkpatrick scale/model is best suited to evaluate the impact of the CPD training as it is usable across disciplines and is used to evaluate the effectiveness of a training-learning or an educational program. The four levels of the model allow for evaluating: the reaction of participants to the training learning-the learning which will have taken place; the behaviour-evaluates the expected behaviour following the training and the results. The model was successfully used in Addis Ababa [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] for levels 1 and 2; and in Kenya, (four levels 3 and 4 using Benner\u0026rsquo;s stages of clinical competence [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Applied to the CPD for midwifery educators it will evaluate the knowledge and skills the midwifery educators will gain as trainers of the midwifery students, and use to pass on to the students which reflects a behaviour change in developing pedagogic content and evaluate the pact based on the knowledge and skills that will be transferred to the students.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e The scoping review provide a broad overview of the available global literature related to CPD for midwives in managing obstetric emergencies. The findings suggested in the scoping review may assist in the development of evidence-based practice and policy-making, guiding the development and implementation of effective CPD programs for midwives. The limitations include due to rapid nature of the scoping review and the prioritization process used to select the articles, not all the literature may have been included. scoping reviews provide a broad overview, however may lack depth in assessing the quality and strength of evidence.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This scoping review aimed to map the existing literature on continuing professional development (CPD) programs for midwives, specifically focusing on optimizing the management of obstetric emergencies and complications. The findings provide a comprehensive overview of the diverse approaches and interventions used in CPD programs worldwide, highlighting both the strengths and gaps in current practices. The CPD program can be offered in various approaches including simulation-based training, technology-based simulation, online modules, workshops, and interdisciplinary/interprofessional learning sessions, have shown to be effective [\u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46 CR47 CR48 CR49 CR50 CR51\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Each method offers unique advantages, such as hands-on practice in simulations and flexibility in online learning with smart applications such as SAFE delivery applications and improved confidence and skills in the management of obstetric emergencies thus contributing to achievement of the SDG goals through improved maternal and neonatal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe continuing education program (CPD) project is led by the Principal investigator Dr M Musie in collaboration with interprofessional stakeholders from the Gauteng National Department of Health, South African Nursing Council, Representation from Department of Obstetrics and Gynaecology and the representative from World Continuing Education Alliance (WCEA). \u0026nbsp;We would like to thank Winkie Siebane, the librarian for the Faculty of Health Sciences, Nursing Department, University of Pretoria for her assistance in developing the database search strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMRM: Conceptualization, Methodology, Investigation, Formal Analysis, Writing Original draft, Review and Editing and Funding Acquisition. TH: Conceptualization Methodology, Formal Analysis and Writing Original draft. NVS: Conceptualization, Methodology, Formal Analysis and Writing Original draft, Writing-Review \u0026amp; Editing. FMM: Conceptualization, Supervision, Review \u0026amp; Editing. OBT: Conceptualization, Methodology, Formal Analysis and Writing Original draft. All authors have read and approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received funding from the Research development programme (RDP grant no #5662, University of Pretoria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during the study are included in this published articles and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLori JR, Stalls S, Rominski S. 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Midwifery. 2023;122:103695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeh CA, Mdegela M, White S, van den Broek N. The effectiveness of training in emergency obstetric care: a systematic literature review. Health Policy Plann. 2019;34(4):257\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerry L, Castiglione SA. al, (2023) Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low \u0026ndash;lower \u0026ndash;middle \u0026ndash;income countries: a rapid scoping review.BMC Medical Education.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-23-04427-6\u003c/span\u003e\u003cspan address=\"10.1186/s12909-23-04427-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEncarna Hern\u0026aacute;ndez,Marcos Camacho et.al. (2021) Does Multidisciplinary Team Simulation-Based Training Improve Obstetric Emergencies Skills? \u003cem\u003eHealthcare\u003c/em\u003e 2021, \u003cem\u003e9\u003c/em\u003e(2), 170; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare9020170\u003c/span\u003e\u003cspan address=\"10.3390/healthcare9020170\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Continuing professional development (CPD), obstetric emergencies and complications, maternal healthcare","lastPublishedDoi":"10.21203/rs.3.rs-4600318/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4600318/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMidwives play a pivotal role in ensuring safe childbirth, particularly in the management of obstetric emergencies and complications. Continuous Professional Development (CPD) programs are essential to keep midwives updated with the latest skills and knowledge, ensuring high-quality maternal care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProblem statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eWe conducted a scoping review to map and synthesize evidence on continuing professional development for midwives optimising management of obstetric emergencies and complications to reveal evidence to address the knowledge gap and implementation of policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis scoping review was guided by the adapted version of Arksey and O’Malley methodological framework (2005). We searched the following databases from 2013 to 2023: PubMed, SCOPUS, Web of Science, EBSCOhost (CINAHL, MEDLINE and Academic search): and ProQuest central. The quality of the included studies was appraised using mixed methods appraisal tool (MMAT) version 2018. Content analysis and synthesis of the findings were conducted using Nvivo 12.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf the 752 articles identified through database searching, 32 articles met the inclusion criteria and reported according to the Preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) checklist. After data extraction, content analysis yielded the following 4 major themes: Types of CPD training programs, Effectiveness of CPD on management of obstetric emergencies, Barriers/Challenges with lack of implementation of CPD programs and Suggestion for implementation of CPD programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur findings revealed the significance of CPD programs in equipping midwives with the necessary skills and knowledge to handle obstetric emergencies effectively. The program can be offered in various approaches including simulation-based training, technology-based simulation, online modules, workshops, and interdisciplinary/interprofessional learning sessions, have shown to be effective. Each method offers unique advantages, such as hands-on practice in simulations and flexibility in online learning with smart applications such as SAFE delivery applications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eResearch Ethics reference #322/2023, date of registration: 14/02/2024.\u003c/p\u003e","manuscriptTitle":"A Scoping Review Continuing Professional Development Programs for Midwives: Optimising Management of Obstetric Emergencies and Complications.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-17 18:09:51","doi":"10.21203/rs.3.rs-4600318/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-25T06:33:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-24T22:06:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96692855443913513639692173918900433681","date":"2024-11-05T18:08:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304809144230092736180551979222533347618","date":"2024-11-01T14:34:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-04T16:54:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97920606727331854169435418184013920573","date":"2024-10-02T08:31:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149171463834493028201276003585137491081","date":"2024-09-16T10:16:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281552096883884955484723410899227977251","date":"2024-07-20T10:00:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T13:45:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-26T10:02:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-26T07:08:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-26T07:07:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-06-18T13:27:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"850fc5d0-eb35-4b8c-b856-3a3759168ba9","owner":[],"postedDate":"July 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:05:27+00:00","versionOfRecord":{"articleIdentity":"rs-4600318","link":"https://doi.org/10.1186/s12909-025-06830-7","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-02-24 15:57:14","publishedOnDateReadable":"February 24th, 2025"},"versionCreatedAt":"2024-07-17 18:09:51","video":"","vorDoi":"10.1186/s12909-025-06830-7","vorDoiUrl":"https://doi.org/10.1186/s12909-025-06830-7","workflowStages":[]},"version":"v1","identity":"rs-4600318","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4600318","identity":"rs-4600318","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}