Innovative Technology and Trainings Empower New Generation of Midwives

By Heather Randall, New Security Beat

The MHTF along with UNFPA worked with The Wilson Center to sponsor this policy dialogue.

afghan-midwivesImagine you are a physician working in a rural health center in a developing country. You’re helping a woman deliver her baby, and it’s just arrived but is not breathing. Meanwhile, the mother has started to hemorrhage. You’re the only one working in the clinic that day, and many life-saving treatments need to start within one minute. You have 60 seconds to make decisions that could cost the lives of two people. [Video Below]

That “golden minute” is critical for saving newborns in particular, said Dr. George Little, professor of pediatrics, obstetrics, and gynecology at Dartmouth Medical School and a fellow at the American Academy of Pediatrics, at the Wilson Center on September 30.

While maternal and child deaths have declined by almost 50 percent since 1990, according to the World Health Organization, approximately 40 percent of yearly under-five deaths are in the first 28 days of life, and 800 women die daily due to preventable causes, 99 percent of whom live in developing countries. That means that many of the countries striving to meet the Millennium Development Goals to reduce maternal mortality by three quarters and under-five mortality by two-thirds from 1990 to 2015 are likely to miss the mark.

“We have much to be happy about in terms of achievements we have done in the last 10 to 15 years, but our job is not done,” said Dr. Harshad Sanghvi, vice president of innovations and medical director at Jhpiego.

New techniques for training more midwives and technologies to help them make the right decisions in this golden minute could, however, make a big difference.

Low-Resource Settings

Many of the challenges to providing quality maternal and child health care in developing countries stem from a lack of training institutions and tutors, said Geeta Lal, senior advisor for strategic partnerships in the sexual and reproductive health branch at the United Nations Population Fund (UNFPA). “Even where [schools] exist, they are not properly equipped, the doctors are not there, the trainers are not there, and clinical skills training is particularly lacking.”

Jhpiego, a health NGO affiliated with Johns Hopkins University, is working to address this challenge through rapid training programs for midwives, said Sanghvi. Even in countries that meet the

World Health Organization’s recommendation of six midwives per 1,000 births, women aren’t necessarily getting the quality care they need, he said. “It’s not only about the numbers of midwives, it’s about the skills of our frontline workers.”

Training new midwives must include clinical governance, Sanghvi said, a term he used to describe techniques to ensure skills learned in the classroom are used and maintained in the workplace. For example, after training, there should be regular check-ins to ensure health workers are using their new skills – and doing so properly.

And if midwives work in a rural part of the country where women do not deliver in hospitals, it doesn’t make sense to train them in hospital settings, Sanghvi said. In Afghanistan, Jhpiego’s midwives complete a practicum in home births to ensure their training is as similar as possible to the conditions they’ll encounter in the field.

The Mobile Revolution

Technological innovations are also being developed to address these challenges. Lal outlined a new e-learning module designed by UNFPA that teaches birth attendants how to recognize potential red flags and respond accordingly with high quality care. The cost of laptops has declined so significantly that it’s now cheaper to buy them for students than to pay for the cost of midwifery books for three years, Lal said. And the modules can also be used offline, making them accessible in countries with limited internet access.

Not only are midwives learning about proper maternal and newborn care through the modules, but they’re also learning computer skills, said Lal, which they can use to improve record-keeping.

Jhpiego is also testing a virtual classroom training method in India to train new midwives, Sanghvi said. There are two instructors in the state of Bihar that conduct virtual lessons for 12 midwifery schools, and “every student in those 12 schools is receiving a standardized education at the highest possible level.”

Mobile technology is an area with great possibility for rural health care workers, said Lal. “Even where people don’t have food to eat or an adequate roof over their heads, they still have a mobile phone.”

A recent Broadband Commission report says that by the end of 2014, approximately 2.9 billion people will be online and 3.4 billion unique people will have mobile phones. There’s potential to use these new networks to promote maternal health, even in hard-to-reach parts of the world.

But the health sector isn’t taking advantage as much as it could, said Sanghvi. Farmers, for example, use mobile phones to monitor their crops and to find the right types of fertilizers. Mobile technology could help patients keep track of their appointment schedules and reduce the need to visit a clinic, and there may be even more innovative uses. “There is promise, but there isn’t the fullest of evidence yet,” he said.

Simplifying Training

Another way to improve training for midwives is to simplify. Sanghvi showed a modified World Health Organization Partograph, a midwife training chart. “My students at Hopkins asked me, ‘Which idiot developed this?’ and I had to tell them that I was the idiot,” Sanghvi said. “The midwife is supposed to collect all of this information and make sense of 13 to 15 pieces of information to predict problems in labor and to detect problems in labor. It’s very complicated.”

New infographic and mobile training materials make it easier for midwives to identify problems and track the labor process. Sanghvi said that Jhpiego is now testing a tablet application to enter information and plot data. If something goes wrong, the app will automatically send alerts to the midwife and her supervisor.

The Helping Babies Breathe curriculum, an initiative of the American Academy of Pediatrics with support from a number of global health organizations, trains midwives in neonatal resuscitation and simplifies the post-delivery action plan for midwives using a color-coded infographic.

When only one care provider is available, “the first golden minute belongs to the baby and not to the mother…and that’s very new,” Little said.

Using stoplight colors to indicate increasing urgency, the infographic highlights actions to be taken within the golden minute to ensure that the baby starts breathing after delivery. If the baby is still not breathing after 60 seconds, midwives are instructed to call for help.

The infographic is designed for universal use, said Little, accommodating varying degrees of health infrastructure. This is a break from past approaches that relied heavily on textbooks originally written for North American audiences.

The infographic is supplemented with additional training tools, including a flipchart, workbook, and simulator doll called NeoNatalie, all of which are available at relatively low cost, said Little.

The curriculum’s universality means that “it’s not trying to do all things for all babies at all times,” said Little. “It’s linked to trying to get to babies and save as many as you can with the resources that you have.”

Respect for Mother and Midwife

Empowerment – both of the patients and the midwives treating them – is vital to better maternal and child health outcomes, said Sanghvi.

He cited an example from Afghanistan, where a midwife stood up to a woman’s husband who repeatedly barred her from entering their home to help his wife. Eventually he relented and the midwife saved the woman’s life by manually removing a placenta that had not evacuated after birth.

“All of these things were not just about training a midwife,” Sanghvi said. “It was about empowering her with knowledge and abilities.” The midwife almost certainly would have been killed had she failed and the woman had died, he said – that supreme confidence to perform a very difficult procedure anyway is what training should strive to give every midwife.

Likewise, “each woman is entitled to respectful care in maternity,” said Lal. In some countries, “women no longer trust health facilities…simply because it’s better to die at home than travel and spend all the little money that you have and come to reach a facility and then die there.”

Sixty seconds may not be long to make key life-saving decisions, but through training and empowering midwives and embracing innovation, there are tremendous opportunities to save mothers and babies from death during childbirth.

Event Resources:

Photo Credit: Improve the quality and access of emergency obstetric care in Afghanistan,” courtesy of Sandra Calligaro/Foreign Affairs, Trade and Development Canada.

Sources: Broadband Commission for Digital Development, United Nations, USAID, World Health Organization.

This post originally appeared at The New Security Beat.

The True Cost Of A Mother’s Death: Calculating The Toll On Children

By Emily Maistrellis, Policy Coordinator, FXB Center for Health and Human Rights

A health worker interviews a client at a health care facility in Tharaka, Kenya. (Photo: Family Care International)

A health worker interviews a client at a health care facility in Tharaka, Kenya. (Photo: Family Care International)

Walif was only 16 and his younger sister, Nassim, just 11 when their mother died in childbirth in Butajira, Ethiopia.

Both Walif and Nassim had been promising students, especially Walif, who had hoped to score high on the national civil service exam after completing secondary school. But following the death of their mother, their father left them to go live with a second wife in the countryside. Walif dropped out of school to care for his younger siblings, as did Nassim and two other sisters, who had taken jobs as house girls in Addis Ababa and Saudi Arabia.

Nassim was married at 15, to a man for whom she bore no affection, so that she would no longer be an economic burden to the family. By the age of 17, she already had her first child. Seven years after his mother died, Walif was still caring for his younger siblings, piecing together odd jobs to pay for their food, although he could not afford the school fees.

In all, with one maternal death, four children’s lives were derailed, not just emotionally but economically.

More than 1,000 miles away, in the rural Nyanza province of Kenya, a woman in the prime of her life died while giving birth to her seventh child, leaving a void that her surviving husband struggled to fill. He juggled tending the family farm, maintaining his household, raising his children and keeping his languishing newborn son alive.

But he didn’t know how to feed his son, so he gave him cow’s milk mixed with water. At three months old, the baby was severely malnourished. A local health worker visited the father and showed him how to feed and care for the baby. That visit saved the baby’s life.

As these stories illustrate, the impact of a woman’s death in pregnancy or childbirth goes far beyond the loss of a woman in her prime, and can cause lasting damage to her children — consequences now documented in new research findings from two groups: Harvard’s FXB Center for Health and Human Rights, and a collaboration among Family Care International, the International Center for Research on Women and the KEMRI-CDC Research Collaboration.

The causes and high number of maternal deaths in Ethiopia, Malawi, Tanzania, South Africa, and Kenya — the five countries explored in the research — are well documented, but this is the first time research has catalogued the consequences of those deaths to children, families, and communities.

The studies found stark differences between the wellbeing of children whose mothers did and did not survive childbirth:

  • Out of 59 maternal deaths, only 15 infants survived to two months, according to a study in Kenya.
  • In Tanzania, researchers found that most newborn orphans weren’t breastfed. Fathers rarely provided emotional or financial support to their children following a maternal death, affecting their nutrition, health care, and education.
  • Across the settings studied, children were called upon to help fill a mother’s role within the household following her death, which often led to their dropping out of school to take on difficult farm and household tasks beyond their age and abilities.

How to use these new research findings to advocate for greater international investment in women’s health?

At a webcast presentation earlier this month, a panel of researchers, reproductive and maternal health program implementers, advocates and development specialists discussed that question.

Central to the discussion was the belief that the death of a woman during pregnancy and childbirth is a terrible injustice in and of itself. The vast majority of these deaths are preventable, and physicians and public health practitioners have long known the tools needed to prevent them. And yet, every 90 seconds a woman dies from maternal causes, most often in a developing country.

The panelists expressed hope that these new data, which show that the true toll of these deaths is far greater than previously understood, can help translate advocacy into action.

“It’s important to recognize that, beyond the personal tragedy and the enormous human suffering that these numbers reflect — some hundreds of thousands of women die needlessly every year — there are enormous costs involved as well,” said panelist Jeni Klugman, a senior adviser to the World Bank Group and a fellow at the Harvard Kennedy School of Government.

“So quantifying those effects in terms of [children’s] lower likelihood of surviving, the enormous financial and health costs involved and the repercussions down the line in terms of poverty, dropping out of school, bad nutrition and future life prospects are all tremendously powerful as additional information to take to the ministries of finance, to take to the donors, to take to stakeholders, to help mobilize action,” she said.

Just what does “action” mean? Currently, the countries of the world are debating the new global development agenda to succeed the eight Millennium Development Goals, an ambitious global movement to end poverty. Advocates can use this research to make the case that reproductive, maternal, newborn, and child health should play a central role in this agenda, given that it reveals the linkages between the health of mothers, stable families, and ultimately, more able communities, according to Amy Boldosser-Boesch, Interim President and CEO of FCI.

Panelists also called for more aggressive implementation of the strategies known to prevent maternal mortality in the first place; as well as for the provision of social, educational, and financial support to children who have lost their mothers; and for continued research that outlines the direct and indirect financial costs of a woman’s contributions to her household, and what her absence does to her family’s social and economic well-being.

But action is also required outside of the realm of health care, said Alicia Ely Yamin, lecturer in Global Health and Population at the Harvard School of Public Health and policy director of the FXB Center.

In fact, the cascade of ill effects for children and families documented by this research doesn’t begin with a maternal death. The plight of the women captured in these studies begins when they experience discrimination and marginalization in their societies: “It [maternal death] is not a technical problem. It’s because women lack voice and agency at household, community, and societal levels; and because their lives are not valued,” she said.

Klugman added that this research adds to work on gender discrimination, including issues like gender-based violence, which affects one in three women worldwide.

It’s a tall order: advancing gender equality, preventing maternal, newborn, and child death, and improving the overall well-being of families. But panelists were hopeful that this research can show policy makers, and the public, that these issues are intertwined, and must be addressed as parts of a whole.

As Aslihan Kes, an economist and gender specialist at ICRW and one of the researchers on the Kenya study concluded, this research is “making visible the central role women have in sustaining their households.”

“This is an opportunity to really put women front and center,” she said, “making all of the arguments for addressing the discrimination and constraints they face across their lives.”

This article originally appeared on WBUR’s CommonHealth.

Adolescent Motherhood: Challenges and Lessons Learned for SRHR Advocacy

CeciliaGarciaRuizBy Cecilia Garcia Ruiz, Gender Projects Coordinator, Espolea

Working on the phenomenon of adolescent and young motherhood requires a deep understanding of the various structural factors leading to early pregnancies and parenting. As my team and I have carried out our project, the first challenge we faced was the invisibility of teenage and young mothers as key populations within the country’s sexual and reproductive health policies.

What we learned from this was the importance of exploring the diverse realities of the adolescent and young mothers in Mexico, while contextualizing the strategies aimed at promoting and ensuring their sexual and reproductive health and rights (SRHR). An example is identifying potential protective (e.g. family and community networks) or risk factors (e.g. violence and exclusion) in an adolescent or young mother’s life that could enable or hinder her to overcome the economic, social, and cultural barriers they face to fully exercise their rights.

The time constraints experienced by the adolescent and young women to participate in our project was another major challenge we encountered. Traditional gender roles, the lack of male partners who were meaningfully involved in child-rearing activities, as well as weak family ties, appear to be among the main factors for low participation. Above all, adolescent mothers continue to be the most difficult to reach. Whether it is because they are still considered underage or because they are no longer seen as part of the youth population, the truth is that their SRHR continue to be systematically restricted.

Overall, what we have realized is that to be a fundamental part of the interventions focused on preventing early pregnancies and motherhood, we must also tackle their underlying factors by linking our initiatives to the individual, community, and structural and institutional levels. As our theory of change emphasizes, bottom-up interventions require catalyzing change dynamics among individuals, strengthening community networks and scaling up the activities carried out at this level, and fostering sustained transformations in the government bodies, especially those involved in the sexual and reproductive health policies.

These seed grants were funded by Johnson & Johnson and WomanCare Global via the Women Deliver C Exchange Youth Initiative

This post was cross-posted from the Women Deliver blog.

Also, read about the work the MHTF is doing in adolescent health in Mexico.

New Maternal Health Jobs

Are you interested in working in maternal and newborn health? At the MHTF, we like to encourage knowledgeable and capable people, like yourself, to join the field and pursue new opportunities. Please find a list of some of the current job openings in maternal health below:

  1. Management Sciences for Health: Director of Grants and Contracts in Uganda. See more jobs at MSH.
  2. Pathfinder International: Chief of Party in Kenya
  3. Jhpiego: Program Officer in the US; Senior Monitoring & Evaluation Advisor in the US
  4. World Health Organization: National Consultant, Maternal and Neonatal Health in Ethiopia
  5. Save the Children: Advisor, Newborn MCSP; Coordinator, MCSP
  6. March of Dimes: State Director of Program Services in Alabama, US

Have you or your organization recently posted a job opening? Email us at kmillar@hsph.harvard.edu.

Building Community capacity for maternal health promotion: An important complement to investments in health systems strengthening

By Moustapha Diallo, Country Director, EngenderHealth|Guinea; and Ellen Brazier, Senior Technical Advisor for Community Engagement, EngenderHealth

EngenderHealth’s Fistula Care Plus project recently published the results of two studies in Guinea, one examining factors associated with institutional delivery and another investigating the effect of an intervention to build the capacity of community-level volunteers to promote maternal health care-seeking.

Community empowerment and participation has long been recognized as a fundamental component of good health programming and as a critical strategy for improving access to and use of health services. However, as Susan B. Rifkin notes in a 2014 review of the literature, evidence directly linking community participation to improved health outcomes remains weak.

For maternal health, the evidence gap is particularly acute. A 2014 World Health Organization (WHO) report reviewed a community mobilization approach that involves training and supporting women’s groups to carry out an ongoing process of problem exploration, priority-setting and action planning. The report concluded that, while such participatory approaches appeared to have a strong effect on neonatal mortality, there was no evidence of effects on maternal mortality or on other critical maternal health indicators, such as institutional delivery, delivery with a skilled attendant, or receiving the recommended number of antenatal care visits.

While important questions remain about what types of interventions are effective in improving maternal health, our recent research in Guinea found that women’s use of maternal health services was associated with the existence of strong support systems for maternal health within communities. Our study focused on villages where community volunteers had been trained to raise awareness about obstetric risks, including fistula, to monitor pregnancies, and to promote women’s routine use of maternal heath services. We assessed the extent to which community members were aware of and relied on community-level cadres as a main source of maternal health information and advice.

We also found that women living in communities with a high score on our community capacity index were much more likely to use maternal health services than those living in communities with weak support systems. In fact, women living in villages with a high score on our community capacity index were more than twice as likely to attend at least four antenatal care visits during their pregnancies, to deliver in a health facility, and to seek care for perceived obstetric complications.

Building the capacity of community cadres and volunteers to promote maternal heath and monitor maternal health care-seeking is challenging, and it does not occur overnight. However, our findings suggest that such capacity-building investments are worth it since community-level cadres can be important catalysts for changes in maternal health care-seeking when they have the training, support, and recongiztion they need to serve as a resource in their communities. Such investments are an important complement to ongoing efforts to improve the availability, accessibility, and quality of the continuum of maternal health services.