Project 2

Title: Assessing the Impact of Mentorship on Rwandan Nurses’ and Midwives’ Knowledge and Self-Efficacy in Managing Postpartum Hemorrhage



  • Marie Grace Sandra Musabwasoni, BSN, RM
  • Mickey Kerr. PhD, MSc, BSc
  • Yolanda Babenko-Mould, PhD, MScN, RN
  • Manasseh Nzayirambaho, MSc, PhD
  • Anaclet Ngabonzima, MPH, MD


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Introduction: Despite determined efforts that Rwanda employed to address critical development challenges, including those aimed at improving the health and quality of life of its population, Rwandan women are still prone to death while giving life. Up to 70% of these maternal deaths, are attributed to postpartum hemorrhage (PPH) (Ghalandari et al 2017). This is noticeable as the first leading cause of maternal mortality not only in Rwanda but worldwide. It accounts for 34% of maternal deaths in Africa (Mutunga, 2015). Rwanda, a landlocked, hilly country with an area of 26,338 square kilometers located in East Africa, has a workforce that is still not well skilled or educated, and has spent the last twenty-four years rebuilding all sectors after the devastating 1994 Genocide against the Tutsi. Nonetheless, it achieved its Millennium Development Goals (MDGs) for health when many countries in Sub-Saharan Africa were unable to achieve their targets. Despite these gains, PPH is still prevalent in Rwanda.

Prata, Bell, and Weidert (2013) define PPH as blood loss of more than 500 ml after a vaginal delivery or more than 1000 ml after a caesarean section. PPH may be classified into two categories, primary (or early) PPH, which occurs in the first 24 hours after delivery of a baby, and secondary (or late) post-partum hemorrhage, which occurs beyond 24 hours after delivery.

Sayinzoga et al (2016) report that 61% of all maternal deaths are attributed to the improper management of PPH. To address this challenge, the global commitment to sustainable development goal is to have reduced maternal deaths to less than 70 deaths per 100,000 live births by 2030 (Abbott, Sapsford, & Binagwaho, 2017). As an interim goal, Rwanda has committed to reduce PPH deaths from 210/100,000 live births to 126/100,000 live births by 2024 (Ministry of Health, 2018). However, the management of PPH is fostered by how knowledgeable nurses and midwives are about it and how self-motivated they are to employ this knowledge together with the efficacy beliefs to influence their capability (Bandura, 1977).

A study conducted by Ritchie, Bates, & Deary, (2015) in Scotland about educational mentorship and cognitive ability shows that if educational mentorship about PPH management is associated with improvements in general cognitive development, it reduces PPH-related maternal deaths, suggesting the positive impact of educational mentorship. Similarly, a current study conducted by Powell (2018) in United States emphasizes improving labour and delivery nurse’s knowledge through educational mentorship that helps them with rapid identification and treatment of PPH. Using a pre and post-test study design, the results reveal a statically significant increase in knowledge after the educational mentorship, where 63% of the participants passed the pre-test with an average of 80% compared to 90% of participants who passed the post-test with an average of 80%. Rwandan health facilities have very limited resources available for mentorship related to managing PPH at the level of health centers. It is from this context that, the Training Support Access Model (TSAM) developed a mentorship model to address this gap in selected Rwandan health facilities.

TSAM, is a 5-year international development partnership project sponsored through the Government of Canada with a mission of improving maternal, newborn and child health (MNCH) in Rwanda. It achieves its mission through working with local partners to improve maternal and child health. As part of its mentorship program, TSAM targets maternity nurses and midwives working in health centers within the Gakenke, Rulindo and Gicumbi districts in Northern Province of Rwanda. Evaluation of the TSAM’s mentorship is the focus of this study which was designed to assess the impact it has on nurses and midwives’ knowledge and self-efficacy in managing PPH.


The purpose of this study was to investigate whether educational mentorship improves nurses and midwives’ knowledge and self-efficacy in managing postpartum hemorrhage in selected health centers of Rwanda.


The TSAM Project has organized and delivered the educational mentorship to nurses and midwives. The researchers, who were not developing or delivering the mentorship, assessed the impact of that mentorship by comparing pre and post mentorship knowledge and self-efficacy. The sample for this study was 141 nurses and midwives who participated in pre-mentorship assessments that were conducted from July to August of 2018. A pre-mentorship assessment was conducted at the participant’s work place, using a self- administered survey about PPH knowledge adapted from Mutunga (2015) and PPH-related self-efficacy adapted from (Bandura, 2006). In addition, TSAM mentorship occurred monthly for a total of six months. Post-mentorship assessment was conducted in March 2019 to compare pre and post-mentorship nurses’ and midwives ‘knowledge and self-efficacy in managing PPH.


The preliminary assessment from pre-mentorship showed that most nurses and midwives had the advanced diploma level of education 65.2% (n=92), 5% had bachelor’s degree, while the rest had secondary level training. These results also showed an increase in knowledge scores from 68% prior to mentorship up to 87% (95% CI [15.65, 21.21] and self-efficacy from 6.9 to 9.5 (95% CI [2.3, 3.08] average score out of the maximum score of ten. The correlation between knowledge and self-efficacy was moderately positive at pre-mentorship (r= .214; p=.002) and strongly positive at post-mentorship (r= .585; p< .001). The frequency of mentorship visits was associated with post-mentorship knowledge scores (r=. 539; p< .001) and post-mentorship self-efficacy (r= .623; p< .001) as well. The results from this research will inform further studies and practitioners to develop a model to support knowledge and self-efficacy in managing PPH.


Maternal morbidity due to PPH is a serious health problem worldwide, and it is responsible for many preventable deaths. It is very important for nurses and midwives to gain more knowledge and practical skills on the management of PPH especially in developing world where maternal mortality rates are high. The study findings show a statistically significant improvement for nurses’ and midwives’ knowledge and self-efficacy in managing PPH as demonstrated by the pre and post-mentorship scores. Thus, the study results support the use of mentorship for increasing knowledge and self-efficacy of health professionals, which could then hold the potential for health care delivery improvement.

Keywords: Postpartum, Hemorrhage, mentorship, nurses, midwives, knowledge, self-efficacy