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:

Mexfam Conference: Priorities for Adolescent Maternal Health in Mexico

By Katie Millar, Technical Writer, MHTF

Dr. Ana Langer

Dr. Ana Langer, Director of the Women and Health Initiative, presents at the meeting

Adolescent maternal health, a subject of renewed international and national concern, took the spotlight in Mexico City earlier this month. In a two-day meeting, “Towards Better Adolescent Maternal Health in Mexico: Challenges and Opportunities,” 43 academics, civil society representatives, and state and federal policymakers focused on three aims:

  1. Analyze the state of adolescent maternal health in Mexico
  2. Identify needs and opportunities for policy and public programs
  3. Identify gaps in knowledge and priorities for future research on this subject

Financed by the John D. and Catherine T. MacArthur Foundation, the meeting was organized jointly by the Women and Health Initiative and Mexfam, an International Planned Parenthood Federation (IPPF) affiliate.

Analyze the state of adolescent maternal health in Mexico

Contrary to previous thinking, the maternal mortality ratio (MMR) among 15-19 year olds is not higher than that of women aged 20-29 years in Mexico. However, the MMR is significantlyhigher among 10-14 year olds when compared to 15-24 year olds.

One of the most notable themes that emerges when assessing adolescent maternal health in Mexico is socioeconomic disparity. Adolescents living in poorer, more disadvantaged municipalities—where a higher proportion of indigenous and illiterate residents live and where the Human Development Index is lower—MMR is higher. Not only do rates differ, but so do the causes. In disadvantaged municipalities, post-partum hemorrhage remains the leading cause of death, whereas in the country as a whole, indirect causes, such as diabetes and obesity-related conditions, play a larger role.

Other disparities among adolescents exist in terms of abortions, post-abortion care, and antenatal care (ANC). Adolescent girls in Mexico experience a very high rate of hospitalization for abortion complications. In addition, only 64% of pregnant adolescents aged 15-19 years old receive ANC, compared to 80% of 20-24 year olds.

The adolescent birth rate (ABR) in Mexico is relatively high; equal with Guatemala at 57 births per 1000 adolescent women, it is higher than the average ABR in Central America (56), and much higher than the average ABR in South America (38). Inequity and limited life opportunities were identified as contributing factors that need to be addressed through multisectoral and sustained public policy and programs to address the high ABR.

Identify needs and opportunities for policy and public programs

So what can we do? We know that keeping girls in school can help prevent pregnancy in the first place. Adolescent girls may face disruptive life events during the school years—moving, losing a parent, etc.—and those of better socioeconomic status often have the resources to cope with these events more effectively and stay in school, but disadvantaged girls do not. Scholarships and action to make education systems more flexible could have an impact on not only keeping girls in school, but in preventing adolescent pregnancy.

In Mexico, many of the existing policies are progressive and high quality. Therefore, the issue is not developing new policies but enhancing managerial and leadership capacity to improve implementation of existing policies and programs. Efforts to build managerial and leadership capacity should focus at the state-level, especially those with a high MMR.

One area that does need attention is the current policy around service delivery. The publication of new legislation governing adolescent sexual and reproductive health is an important opportunity to ensure that adolescents can access information and services without the necessity of parental presence or consent. Parental consent has been shown to be a significant barrier to promoting adolescent sexual and reproductive health. The meeting participants called on the Ministry of Health to ensure that the new legislation allows adolescents to access the care they need without the consent of their parents.

In addition, strategies moving forward should be multidisciplinary—housing, education, livelihood— to ensure comprehensive adolescent health is protected and promoted.

Identify gaps in knowledge and priorities for future research on this subject

As we move forward on improving adolescent maternal health in Mexico, meeting participants shared two key take away messages. First, when it comes to measuring many relevant indicators of adolescent maternal health, Mexico does well with good national health surveys and vital statistics. So the first priority is to analyze the available data and use the evidence better and more. Second, there are knowledge gaps, such as reproductive health among 10-14 year olds, the perspectives and reproductive health needs of male partners and male adolescents, the evaluation of scalable and sustainable approaches for service delivery, and human rights issues such as child marriage.

Learning to pay the price: The need for remuneration of frontline health workers

Cindil RedickCindil Redick, Communications & Advocacy Advisor, One Million Community Health Workers (1mCHW) Campaign

In many parts of rural sub-Saharan Africa, clinics and hospitals are few and far between. A recent report by Save the Children estimates that every day approximately 22,000 children die before they reach their fifth birthday. This fact is augmented by the World Health Organization’s (WHO) estimation that at least 1 billion people have little to no access to health workers. The worst part is that this results in death. Quality care provided by a health worker can prevent most of the causes of maternal and child mortality.

CHW checking children for malnutrition, Kenya

CHW checking children for malnutrition in Kenya (credit: MDG Center, Kenya)

This health worker shortage is a critical issue in over 80 countries. The WHO and Global Health Workforce Alliance estimate that there is a global shortage of at least 7.2 million doctors, nurses and midwives. In an attempt to address these serious healthcare gaps, many organizations, communities, and countries train and deploy community health workers (CHWs). CHWs are community members, often female, who volunteer to provide essential health services to their communities. From prenatal and postnatal care, to malaria diagnosis and nutrition assistance, CHWs provide lifesaving treatment often at little or no cost to the community. They are vital in the fight to improve maternal and child health.

On average, CHWs are responsible for visiting about 100 households and are usually expected to provide follow-up treatment as well as health promotion services to the greater community. However, far too often, CHWs do all of this—enough work for a full-time job—for little or no pay. That’s right, this cadre of health workers is largely unpaid. This lack of remuneration only exacerbates the already stressful job of CHWs, which can have a devastating impact on maternal and child health.

So, what’s the rationale for not paying CHWs? The most widely cited reasons include:

  • Compensating CHWs will detract from their sense of community
  • Compensating CHWs will reduce their value or legitimacy within the community
  • Compensating CHWs is difficult due to lack of domestic resources
CHW performing routine check-up on an infant in Senegal

CHW performing routine check-up on an infant in Senegal (credit: 1mCHW Campaign)

Although this list is not extensive, it is telling. There appears to be a general absence of “willingness to pay” for CHWs within the international community. However, research has shown that CHWs who are compensated, either financially or non-financially, perform better than those who volunteer. This is indicative of a growing trend in both programmatic and academic literature that demonstrates not only the need for, but also the value of remunerating CHWs. Some of the most recent evidence can be found in USAID’s 2011 CHW Assessment and Improvement Matrix Toolkit, which suggests financial and non-financial incentives as one of 15 recommendations for CHW improvement.

Across the world CHWs are making healthcare accessible. They are an integral part of a country’s health system because they are members of the same communities as the people they serve. As such, they too face the same barriers to health and livelihood as their community. By not compensating CHWs, the international community is not only failing to recognize them professionally, but is also perpetuating poverty and reducing the capabilities of an effective cadre of health workers. All of which adds up to this: we are stalling progress in maternal and child health.

CHWs improve health and communities by bringing care to those who need it. It’s time to reciprocate and show CHWs the care and dignity they deserve through health workforce formalization and proper remuneration.

Beyond Didactic Trainings: Structured Mentorship to Improve Antenatal Care Delivery in Rwanda

By Manzi Anatole, Director of Mentorship and Quality Improvement, Partners In Health

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

Rwandan Health Workers

MESH-QI mentor conducting training on neonatal resuscitation at health center level

Partners In Health, in collaboration with the Rwandan Ministry of Health, implemented a program entitled Mentorship and Enhanced Supervision at Health Centers and Quality Improvement (MESH-QI) to address inefficiencies in current health center training and clinical practice of nurses.  MESH-QI improves care delivery through:

  1. Decentralized pre-service training at the district level
  2. Building capacity of the existing district supervisory structure
  3. Initiation of a systems focus on clinical mentoring and coaching of health center teams
  4. Use of data for continuous quality improvement

Figure 1: Pillars of Mentorship, Enhanced Supervision and Quality Improvement Program

Current health center training for nurses consists of centralized pre-service training and limited in-service supervision. The pre-service training includes emergency obstetrics and newborn care (EmONC) and focused antenatal care (FANC), but periodic supervision visits by district hospital supervisors are largely consumed with data collection and reporting, with limited opportunities for on-site clinical mentoring and re-training.

To address this gap in training, MESH-QI mentors make routine intensive visits to health centers, lasting at least two days, in which they provide on-site case management observation; support for higher level problem-solving, diagnostic, and decision-making skills; lead case discussions; and address quality improvement issues (see Figure 1). By routinely capturing valuable data on nurses’ clinical skills, facility conditions, and clinical indicators, clinical supervisors also enhance the feedback loop for quality improvement.

Key lessons learned

Mentorship catalyzes translation of theory to practice

Clinicians expressed this as one of the positive aspects of MESH-QI interventions. Mentors use various adult learning techniques to support nurses to address the “knowledge-practice gap.” This facilitates the implementation of FANC at MESH-QI supported sites.

Mentorship improves clinicians’ confidence, motivation and adherence to MCH protocols

Prior to the implementation of MESH-QI, there were challenges in learning how to effectively integrate and utilize national protocols, guidelines, and tools. One nurse mentee mentioned: “They built my confidence not only in screening and case management, but also in general nursing care I provide every day. I feel proud of the work when I can handle even the complicated cases that I could not manage before… their support.”

Mentoring checklists enable evidence-based feedback and continuous QI

Using mentoring and coaching tools, such as checklists for case management, facility, and systems observations, enables mentors to provide objective and constructive feedback and regular monitoring of ANC delivery.

MESH-QI is an effective strategy to improve the quality of antenatal care

Figure 2: Change in Antenatal Care Assessments from Baseline to Mentoring Stratified by Nurse FANC-Training Status

Figure 2: Quality of ANC Assessments at Baseline and Post-mentoring

With mentoring, uniform improvement was observed regardless of baseline EmONC/FANC-training status (Figure 2). This demonstrated that mentorship is a promising intervention to help improve the quality of FANC regardless of baseline training status. Mentoring, therefore, is particularly applicable to resource-limited healthcare settings facing human resources challenges. While EmONC and other didactic trainings are still costly—particularly in developing countries—on-site mentorship is an option to mitigate these challenges.

MESH-QI integrates in-service training and systems improvement into routine care delivery

In-service training bypasses the challenge of extracting nurses from their health centers to attend workshops in main cities, which could be hours away. Mentorship and coaching sessions take place at the health facility level, which avoids worsening staff shortages, an already significant challenge in resource-limited settings.

In Summary

The MESH-QI approach is also proving successful in several other health domains, including neonatal care and integrated management of childhood illness (IMCI), by strengthening the entire spectrum of care for families. The Ministry of Health of Rwanda has a number of efforts underway to replicate and scale this mentorship approach.

To learn more about mentorship, enhanced supervision and quality improvement in Rwanda, please see the following:

-          Description of the mentorship program in rural Rwanda
-          Perceptions and acceptability of health care workers
-          Mentorship and quality improvement strengthened the quality of pediatric care
-          Integrated mentorship and quality improvement to improves antenatal care

Why Men Matter to Improve Maternal and Newborn Health: A Global Conversation

Father and BabyHow often do we talk about men when we talk about maternal and newborn health? Not very often. But we know they play an integral role to the health of the mother, newborn, and family.

Join a Google+ Hangout with Girls’ Globe, Promundo, MenCare and MenEngage this Monday, August 18th, at 9:00 AM ET / 3:00 PM CET to discuss this very topic. The maternal health community will join together with the panelists below to speak about the integral role men play as we team up to accelerate progress for maternal and newborn health as we mark 500 days remaining to achieve the Millennium Development Goals.

Moderator:

  • Julia Wiklander, Founder of Girls’ Globe

Panelists:

  • Oswaldo Montoya, MenEngage Global Coordinator
  • Ruti Levtov, MenCare Global Co-Coordinator; Program Officer, Promundo-US
  • Shamsi Kazimbaya, National MenCare+ Project Coordinator, Rwanda Men’s Resource Center (RWAMREC)
  • Siska Dewi Noya (Chika), Program Manager for Gender-Based Violence, Rutgers WPF Indonesia; MenCare+ Indonesia Partner