Increasing Midwifery Care in Mexico: Interview with Cris Alonso

Luna Maya is a midwife-run birth center in Chiapas, Mexico. It was created in 2004 through a MacArthur Foundation (MAF) statewide initiative to reduce maternal mortality in Chiapas. Despite many years of interventions and investment, the maternal mortality ratio (MMR) in Chiapas had remained stagnant over the previous 10 years. We talked to Cris Alonso, the director of Luna Maya, to ask her some questions about the center and what it has done for the women of Southern Mexico.

Q. What need did you identify in Mexico that led you to envision and create a birth center?

When the MAF initiative launched, NGOs, government and experts were convened to form a commission to design an inter-institutional strategy to reduce maternal mortality. At the time, access to emergency obstetric and newborn care (EmONC) was the first line intervention in both evidence and practice. I was on the commission and as we designed the proposal and it was evident that there was a lack of creating access to normal birth. With increased access to facility-based delivery in a country where midwives are not part of the health system, without a goal to increase access for normal births, the risk was that medical interventions, cesareans and thus maternal mortality would continuously increase adding obstetric violence to the problem.

It seemed evident that the proposal also needed an expert entity in training community midwives, or TBAs, on safe delivery and to hold the space for normal birth. A logical step therefore was the opening of a midwife-run birth center where traditional and professional midwives could train and where low-risk women could access normal birth and be referred in a timely and safe way in the case of complications.

Here two issues were evident: first, there was need to improve the skills and training of professional midwives and, second, a need to document the safety of midwifery-led care in a state and country where this had barely been done.

The Luna Maya model, therefore, was conceived as a pilot project to demonstrate the efficacy and cultural pertinence of midwifery-led, primary level care units (birth centers) for attending normal birth. This would also provide improved secondary level care as the local hospital would decrease the amount of normal births attended, freeing up resources to attend to high-risk cases in a better way.

Q. Why did you choose Chiapas as the primary place for your intervention?

Chiapas had maintained a consistently high MMR over the last 10 years. Safe motherhood interventions were consistently lacking in cultural competence, and homebirth with traditional midwives remained the norm. It was a logical step to keep birth at home, where women felt safe and comfortable, but to improve the skills and competencies of midwives, while at the same time improving referral networks and access to EmONC.

Q. What experiences led you to the founding of Luna Maya?

In my apprenticeship as a midwife I worked in an urban birth center in Guatemala City, at CASA in San Miguel de Allende in Mexico and in a rural homebirth practice in Louisiana. I was familiar with cultural competence as a pillar of midwifery care and valued continuity of care as a positive health intervention that not only improved outcomes, but also increased maternal satisfaction enormously.

In my public health training I had interned and then consulted with Marie Stopes International, a reproductive health clinic network that provides family planning and post-abortion care. My vision with Luna Maya was to integrate the positive aspects of a birth center with the positive aspects of a family planning center, centering the care on femifocal care throughout the lifetime, knowing that women bond with their midwives and feel comfortable receiving care from them.

Q. What is innovative about Luna Maya’s model of care?

Once open, Luna Maya took an interesting turn. Other family care experts approached us and asked to join the team. Quickly, we also had a pediatric clinic, prenatal yoga, childbirth education, acupuncture, psychotherapy, massage and osteopathy. We, therefore, developed a model where the entire family could access a model that integrated complementary and medical care that also focused on continuity of care.

What is unique about the Luna Maya model is that it honors women´s choices throughout the lifetime. Women had sexual and reproductive needs as well as other wellbeing needs. We also know that women more and more integrate complementary and medical therapies in their care program and it made sense that all providers were working together with the woman to design a health and wellbeing program, which included prenatal care, treatment for an STI, infant illness, etc. By working together, the medical and complementary health providers could be informed of progress and ensure best outcomes. However, Luna Maya puts women at the center of the health care decisions. We provide a plethora of providers and services and the woman can thus chose what best suits her health care values and beliefs. If a woman is central to her health care program she is much more likely to adhere to treatment and attend consultations or therapy.

The Luna Maya model therefore is femifocal in that it expands much further than motherhood. It explores women’s health as something that happens to all women: women who are mothers, lovers, wives, single, lesbian, stressed, infertile, raped, tired, sick, happy, exposed to STIs, deciding whether or not to continue a pregnancy, choosing a family planning method, taking care of children, and who are part of a family system. I believe that this most reflects the reality of health, as part of a system where we take the woman as a central, intelligent agent of decisions and action.

Check back in next week for the second part of this two part interview.

Building Management Capacities in Maternal Health Clinical Leaders

By Priya Agrawal, Executive Director, Merck for Mothers 

Do management capacities in clinicians really matter for maternal health? This is a key question that MSD for Mothers, along with some of its partners, is trying to tackle. MSD for Mothers is a 10-year global initiative launched in 2011 by Merck Sharp & Dohme (MSD)—better known as “Merck” in the United States and Canada—to help create a world where no woman dies from complications of pregnancy and childbirth.

Since we are in the early stages of our intervention development and determining our investment path, we need you to share your thoughts and insight on this important topic and the evidence it requires.

Please take five minutes to help us better understand the types of evidence we need by completing this short survey: https://www.surveymonkey.com/s/85PQLNR

Maternal mortality needs our attention as Millennium Development Goal (MDG) 5—the target to reduce maternal mortality by three-quarters by 2015—is the most off-track MDG and is even further behind where health systems are poor. Recently, experts have concluded that progress has been stunted by a lack of commitment from development partners to strengthen the health systems that serve women and their maternal health needs. It has been argued that there is a link between safe motherhood and the performance of a health system, and—conversely—that strategies to improve safe motherhood may be a means of achieving wider health service improvements.

If this is true, could improving the management skills of clinicians in leadership positions help improve health facilities’ capacity to respond to obstetric emergencies, and ultimately reduce maternal and perinatal deaths?

Nick Bloom, Professor of Economics at Stanford University, and colleagues—whose research interests focus on measuring and explaining management practices across firms and countries—has found that:

  • There is a strong relationship between management practice and health outcomes (as well as better financial performance)
  • Hospitals with more clinicians as managers have better management
  • Larger hospitals perform better, and competition appears to be good for management
  • Government ownership is associated with poor incentives management (hiring, firing, pay and promotions)

If an intervention approach could be developed and tested to make clinicians better managers and if this were to result in better health outcomes, this could be an important innovative contribution to reducing maternal deaths.

The work of MSD for Mothers focuses on building the management capacity of clinicians who serve in leadership positions at facilities that offer comprehensive emergency obstetric care in Tanzania. These individuals typically split their time between delivering care to patients and overseeing the operations and management of a facility. They are often placed and/or promoted into managerial positions without adequate management training or tools to operate effectively and efficiently.

In April and May of 2014 we conducted a 360° assessment of clinicians in leadership positions across 17 operational and people management capabilities at six public and two private health facilities in Tanzania. A number of gaps were identified across a variety of management areas specifically for the publically managed facilities, but “data-driven decision-making” was identified as the key management capability since having a deeper understanding of and application of data will likely have an impact on maternal and perinatal health indicators and outcomes.

We believe the development of data-based decision-making capabilities must follow a cyclical path. Our recommendation to the Tanzania Ministry of Health and Social Welfare is to build an intervention package that helps clinicians progress through the full capability development cycle:

  1. Improve Data Collection Awareness
  2. Build Capacity for Data Interpretation
  3. Enable Data-Based Decision Making

Our focus on data-driven decision-making for an upcoming intervention package targeted to be launched 2015 is at a critical development point. We are looking to the Maternal Health Task Force community to help provide some insight into what levels of evidence this intervention needs to have to show relevance, scalability, and most importantly, sustainability. Understanding what type of evidence would be attractive to this community and beyond in the global health and international development space will help ensure that we build the right evaluation approach, and ultimately a smart investment decision.

Please follow the link here to complete the survey.

Ebola’s Victims: Not Just Those It Infects

By Katie Millar, Technical Writer, MHTF

Ebola’s victims are not just the people it infects, and eventually kills, but anyone who needs to access the health system in Sierra Leona, Liberia, and Guinea – especially women.

The current Ebola outbreak has proven deadly. Starting in March of this year in Guinea, it has now infected 2,615 people, killing 1,427 – 55-75% of them womenGender roles place women as caretakers administering to the sick, increasing their risk for infection. Attention to gender dynamics and how they affect transmission, care-seeking, and treatment is vital, and so far mostly ignored. Lack of attention to gender differences results in continued disparities and unnecessary deaths. Professor Wafaa El-Sadr told Foreign Policy last week that who dies in an outbreak “shows you who has power and who doesn’t. In a way, it holds a mirror to society. And it shows societies how they treat each other.”

Ebola’s impact goes beyond infections and deaths. The outbreak has demanded much of the affected countries’ health resources. Health facilities—poorly prepared and lacking gloves and personal protective equipment (PPE)—are now contaminated and seen as harbors of infection, resulting in abandoned health facilities and hospitals around West Africa.

When a woman is pregnant and needs care, lack of maternity services can mean disaster for both her and her baby. Stories in the last few weeks chronicle accounts of women with labor complications seeking services, offering small fortunes for care, only to be turned away, ignored. The result? Death.

And these are just deaths from direct causes. Indirect causes like infectious diseases—such as, malaria, typhoid, and others—are left untreated. In addition, fear and suspicion of the Ebola outbreak has led to patients refusing injections, avoiding health facilities, distrusting health care workers, even doubting the Ebola outbreak is real.

While some clinics are reopening, they still face challenges including nervous staff and scarce resources. PPE—the full-body suits that protect health care workers from the virus—have to be rationed carefully as they are expensive and limited, forcing health care workers into difficult decisions. When one woman from an Ebola hot spot needed a c-section in Monrovia’s John F. Kennedy Memorial Hospital, health care workers were forced to weigh the implications of using 12 PPE suits for the procedure. Saving the woman’s life could endanger hospital staff by placing them at risk of infection while caring for patients in the future.

The Ebola outbreak has caused significant problems, and not just for those infected. Poor health systems—weakened by the outbreak—mean women are especially at risk for infection, poor birth outcomes, and death.

Read more about Ebola implications for maternal health:

Providing for Mom and Baby: Countrywide Programs Promoting Antenatal and Postnatal Care

By Annie Kearns, Project Manager, MHTF

This post is part of our “Continuum of Care” blog series hosted by the Maternal Health Task Force

Our Adding Content to Contact (ACC) project is working to identify antenatal care (ANC) and postnatal care (PNC) delivery strategies across the world. In a recent blog post, we highlighted several ANC and PNC programs at both the regional and local levels. Now we present four country-level ANC and PNC delivery models. We’ve outlined their designs below and hope you’ll take a minute to explore lessons learned from these delivery models.

Health Extension Workers—Ethiopia

The Ethiopian government began its Health Extension Worker (HEW) Programme in 2003. By training young women with at least some schooling to provide basic health services to their communities, the Federal Ministry of Health hoped to improve access to quality primary health care in a country that is predominately rural.

By 2010, Ethiopia had trained 33,819 HEWs who were deployed in 89% of communities throughout the country. While HEWs do not focus exclusively on maternal and child health, they do provide WHO’s recommended Focused Antenatal Care (FANC), connect women to facilities for delivery, provide at least one PNC visit, and coordinate immunizations for newborns. Results have been largely promising, with the percentage of women receiving at least one ANC visit almost doubling from 2000 to 2011. However, linkages with higher-level health services need to be strengthened since the vast majority of women are still giving birth at home and without a skilled attendant.

Lady Health Workers—Pakistan

The Lady Health Worker (LHW) Programme began in 1994 to reduce poverty and improve health. With 110,000 LHWs across the country, Pakistan has one of the largest cadres of community health workers in the world. Each LHW has a catchment area of about 1,000 people and is responsible for providing education on reproductive health and nutrition, distributing family planning, immunizing children, and encouraging women to seek ANC–but LHWs do not provide ANC themselves. LHWs have built strong relationships with traditional birth attendants and midwives to ensure pregnant women and mothers receive adequate care. Women who are served by LHWs are more likely to use contraception and to receive early PNC. The program has also contributed to a reduction in maternal and infant mortality in recent years. In order to sustain LHWs and their impact, future attention should focus on ensuring manageable caseloads and adequately integrating LHWs with primary care facilities.

Postnatal care—Nepal

In recent years, Nepal has implemented a variety of programs to improve access to and quality of PNC in the country. While these programs have been implemented by a variety of agencies, most have been run in partnership with the Government of Nepal and have relied heavily on Female Community Health Volunteers (FCHVs) and other cadres of community health workers.

  1. The Community-Based Neonatal Care Package, for example, aimed to change health-related behaviors in the community and also provide three home visits in the week after delivery for mothers and newborns alike.
  2. The Nepal Family Health Programme II worked to increase access to family planning as well as basic health services, including postpartum care.
  3. The Birth Preparedness Package encouraged women and families to plan for their pregnancies as well as the postnatal period, including how to deal with emergency situations.

These programs have been quite successful in increasing uptake of PNC among women in their target areas. As many postnatal programs have been scaled up to a national level, crucial facilitators of success have been thorough, high-quality care guidelines; community buy-in; and an adequate number of appropriately-trained personnel.

Focused Antenatal Care—Tanzania

Tanzania adapted and implemented the WHO-recommended FANC model soon after the guidelines were released in 2002. FANC shifted the focus of ANC from a “risk approach,” which targeted women based on risk factors, to an individualized, targeted approach, which aims to detect complications as they arise.

Tanzania’s FANC model includes four ANC visits: one before 16 weeks, if possible; at 20-24 weeks; at 28-32 weeks; and at 36 weeks of gestation. When the model was implemented, the government hosted trainings on the new guidelines at the district, regional and national levels. Providers in Tanzania were trained on the importance of health promotion, individualized counseling, targeted assessments, and evidence-based interventions. While maternal mortality has declined in recent years and access to ANC has increased, more research is needed to establish the role the FANC model has played in these trends.

Follow the “Continuum of Care” series to learn more about these and other innovative models of ANC and PNC care.

What’s new? Maternal health jobs

There are a lot of exciting new positions in maternal health that opened up this month. Check out the listing below: