International Day of the Midwife: What are Global Leaders Saying?

- Written by Kate Millar, Technical Writer, Maternal Health Task Force

This post originally appeared in the American College of Nurse Midwives’ Quickening, Volume 46, Number 2 (Spring 2015). It was also posted on the Maternal Health Task Force blog on May 5th. 

Today, May 5, is the International Day of the Midwife. This is an opportunity for the global community to come together to recognize the incredible impact midwives have on maternal and newborn health and decreasing mortality. Want to know more about what global leaders are doing to strengthen midwifery?

On Monday, March 23rd, global leaders in midwifery and maternal, newborn and child health gathered in Washington, DC at the Wilson Center for Call the Midwife: A Conversation About the Rising Global Midwifery Movement. This symposium hosted four panels to discuss current data, country investments, important global initiatives and public private partnerships and innovation in midwifery. Each of the panels was presented in the context of exciting new strides in maternal health with the forthcoming Sustainable Development Goals, an updated strategy for the United Nations’ Every Woman, Every Child initiative and the World Bank’s Global Financing Facility that supports it.

While each speaker’s background and focus varied, the themes of the symposium were consistent:

• Improve management and leaderships skills of midwives
• Improve pre-service and in-service education
• Innovate to keep midwives in rural areas
• Fill the need for well-trained midwifery faculty
• Integrate maternal and newborn healthcare
• Provide respectful maternity care (RMC)
• Build capacity

To kick-off the symposium, His Excellency Björn Lyrvall, Swedish Ambassador to the United States told the story of midwifery in Sweden: in 1751, it was reported to parliament that 400 of 651 maternal deaths could be averted with midwifery. Parliament took this seriously and by training midwives with safe delivery techniques decreased Sweden’s maternal mortality ratio (MMR) from 900 deaths per 100,000 live births (among the highest in Europe at the time) to 230. Sweden’s passion and investment in midwifery can act as an example to countries that are now facing a similar burden of maternal mortality.

The data on midwifery

The first panel on data summarized the State of the World’s Midwifery 2014 (SoWMy 2014), the Lancet Series on Midwifery and the International Confederation of Midwives’ (ICM) vision and programs. In his presentation on SoWMy 2014, Luc de Bernis, Technical Adviser at UNFPA, focused on projections of workforce availability and met need, or the ratio of workforce time available to time needed. Projections identify countries with a low-met need, medium-met need and high-met need in 2030. Interestingly, two countries that are doing well now, Ethiopia and Burkina Faso, will not be able to meet their health workforce needs by 2030 if investment does not accelerate now to keep up with an increasing need for services.

In her review of the Lancet Series on Midwifery, Holly Kennedy, Varney Professor of Midwifery at Yale University, announced two papers that will be added to the series: one on disrespect and abuse and RMC and another that summarizes the top 10 research priorities from the series to improve maternal and newborn health using the QMNC framework.

Frances Day-Stirk, President of the International Confederation of Midwives (ICM), then spoke on her organization’s vision and programs, including “A Promising Future,” a campaign to promote midwifery as the norm and not a novelty. The focus of ICM is to have midwives who are appropriate (well-educated and regulated), accessible (especially in poor geographic areas) and cost-effective. Day-Stirk also outlined the critical pillars of midwifery—education, regulation and association—which stand on a foundation of ICM core competencies. The focus and pillars of ICM were echoed throughout the remainder of the symposium.

At the end of this panel, countries were encouraged to look at long-term plans for strengthening and scaling-up professional midwifery, instead of quick fixes with training auxiliary midwives.

Country investments and lessons learned

Representatives from Cameroon, Afghanistan, Liberia and Ethiopia presented data on current initiatives in their countries to support and scale up midwifery. Ethiopia and Cameroon have both seen improvements in midwifery and maternal health indicators through investing in midwifery education and establishing accreditation of schools and training sites. Although they have seen success in their efforts, challenges still remain with a shortage of midwifery faculty and clinical training sites.

In Afghanistan, the Community Midwifery Education (CME) program, supported by USAID, Jhpiego, WHO and UNFPA, provides quality, sustainable midwifery education. The 2-year program supports women with at least a 10th grade education, chosen by their communities to participate. After training is complete, women return to their communities where child care and transportation is provided to enable them to use their skills and also to incentivize them to stay in their community. Other initiatives include leadership training, accreditation and mobile programs.

Marion Subah, a senior nurse midwife and Jhpiego’s country representative in Liberia, reported that since Ebola, antenatal care (ANC) coverage, skilled birth attendance and institutional delivery have all had an absolute decrease of about 10%, reversing recent advances in maternal health in Liberia. She recounted the difficulties of delivering maternal health care in the context of Ebola: six midwives have died from Ebola and women who need post abortion care are especially at risk because of the fears associated with contracting Ebola through bodily fluids. Moving forward, the ministry of health (MOH) has created a 10-year plan that focuses on increasing the number and quality of midwives, faculty development and establishing well-working computer and science labs and clinical sites.

Global midwifery initiatives

All over the world, organizations of all types are banning together to improve maternal and newborn health by investing in midwifery. With initiatives by the World Bank, USAID, GE Foundation and global policy experts, there was a lot to be excited about.

These initiatives are focused on creating a sustainable midwifery workforce, strengthening professional associations, improving workplace conditions for midwives, promoting RMC,building leadership and management skills, implementing global policies for ending maternaland newborn deaths and a new ICM Midwifery Services Framework. Many of the initiatives presented have overlapping goals, all to the end of creating a healthy, well-educated, accessible midwifery workforce.

At the close of this panel, Laura Laski, Chief of the Sexual and Reproductive Health Branch at UNFPA, noted three upcoming critical turning points for midwifery:

1. The Global Maternal Newborn Health Conference in Mexico City: timed right after the agreement of countries on the SDGs, this conference in October 2015, provides an opportunity to emphasize the need to invest in midwives to accomplish the SDGs
2. The World Health Assembly: provides a forum in May to discuss the new version of Every Woman, Every Child
3. The Women Deliver Conference in 2016

Innovation and Public-Private Partnerships for Midwifery

To end the day, we looked forward to the future with a focus on innovation and pioneering public-private partnerships (PPPs). Greeta Lal of UNFPA shared recently developed e-learning modules that were created in partnership with Jhpiego, UNFPA, Intel and WHO. With topics ranging from family planning to essential newborn care, these e-learning modules can be conducted almost anywhere with a battery-operated projector, solar powered charger and a cheap tablet, these modules can be used in almost any part of the world.

In addition, Survive & Thrive and Nurses Investing in Maternal Child Health both seek to strengthen young professionals to become leaders in the field to create sustainable change. Both programs work internationally, but with different strategies. Survive & Thrive, supported by ACNM and other partners, works to strengthen professional associations and host master training of trainer courses for the management of maternal and newborn complications, from Malawi to Afghanistan. Nurses Investing in Maternal Child Health is an 18-month program supported by Johnson & Johnson and Sigma Theta Tau for nurse fellows to work with a mentor in order to gain leadership and technical skills in order to improve maternal and child health through evidence-based practice, health systems improvements and program evaluation.

Lastly, the NGO Direct Relief, with technical support from ICM, creates midwife kits for facility-based deliveries. With essential commodities, these kits have the potential to decrease MMR and the neonatal mortality rate by 63%. Thus far, these kits have been distributed in the Phillipines after Typhoon Haiyan and in Sierra Leone in the wake of Ebola.

The symposium was a full day of reviewing the incredible impact midwifery can have and what we need to do as a global community to realize that impact.

Resources discussed at this symposium:

• Call the Midwife: A Conversation About the Rising Global Midwifery Movement
• Ending Preventable Maternal Mortality
• EPMM: USAID maternal health vision for action, evidence for strategic approaches
• Every Newborn Action Plan
• ICM Midwifery Services Framework (Pilot)
• Updated Global Strategy for Every Woman, Every Child
• State of the World’s Midwifery 2014
• Lancet Series on Midwifery

Capacity Building to Address Global Health Challenges

~Written by Karen Hicks – Senior Health Promotion Strategist, Auckland New Zealand. (Contact: Karen_ahicks@hotmail.com)

Increasingly the world is challenged with complex health problems. Developing a competent health promotion workforce is essential to addressing the related inequities and global health challenges.

Global health issues provide both a challenge and an opportunity for a competent health promotion workforce to work across cultures and settings with an international perspective.  An approach requiring an understanding of the determinants of health and the vital role health promotion has in achieving sustainable health gains.

At times health promotion has been challenged by the belief that anyone can undertake health promotion. This is partly the result of its strategy to promote its principles across the community making it everyone’s business. However health promotion is increasingly acknowledged as a discipline with specific knowledge, skills and distinct approaches that challenges such beliefs. 

Health promotion competencies have been developed as a capacity building tool that has successfully defined the knowledge and practice for effective health promotion, ensuring that health promotion principles, values and philosophy are reflected.

There are a number of international health promotion competencies frameworks that can be used to:

• Guide planning, implementation and evaluation of initiatives
• Provide the base for accountable practice and quality improvement
• Inform education, training and qualification frameworks
• Clarify health promotion roles and develop relevant job descriptions
• Improve recognition and validation of health promotion
•   Further reading and examples of some health promotion competency frameworks:

References:

http://www.iuhpe.org/images/PROJECTS/ACCREDITATION/CompHP_Project_Handbooks.pdf

http://www.hauora.co.nz/assets/files/Health%20Promotion%20Competencies%20%20Final.pdf

http://www.healthpromotion.org.au/images/stories/pdf/core%20competencies%20for%20hp%20practitioners.pdf

http://www.healthpromotercanada.com/competencies-development/

Health Issues on the African Horizon for 2015

~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich 

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.

Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.

Empowerment is Key to Improving Health Infrastructure in Developing Countries

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Providing greater health access and more efficient health care delivery, especially for vulnerable populations, are priorities for anyone involved in public health. Poor health systems in developing countries mean a shortage of trained health care workers, inconsistent inventory of medical supplies, and inadequate surveillance systems. This list is not exhaustive, but we can start here. Building a better health infrastructure, like many public health priorities, requires multi-level coordination. Empowerment has to spread out from the government to the community and to the individual.

We can address the problem first by tackling the shortage of health care workers. Doctors in developing countries are in critically short supply. In 2006, the World Health Organization compiled data on the impact of HIV/AIDS on the health workforce in developing countries. Results showed that while European and North American countries have doctors at a ratio of 160 to 560 per 100,000 people, African countries only have two to sixty doctors for every 100,000. In Malawi, for example, there is one doctor for every 50,000 people. The global shortage of trained hospital and health care staff currently exceeds four million. Training more staff and volunteers is one solution for improving health systems in developing countries. Training other previously unqualified individuals could ameliorate these shortages. Providing incentives for already trained workers to stay in a vulnerable state or country could help build a struggling health system. Having a foundation of trained workers and preventing them from migrating to wealthier countries is an important first step. Empowerment and opportunities to grow and help are at the heart of this strategy.

The second hurdle is maintaining a constant inventory of equipment, medicines, and other health supplies. War, along with political and social unrest, in certain regions further dampens the efforts to provide a steady supply chain. There has to be cooperation between donors and the government to work with the private sector to ensure receipt of necessary health supplies. Partnering with emerging pharmacy chains increases the availability of medicines and drives down the cost for the patients. In the Philippines, Generics Pharmacy has thousands of small storefronts that are widely used by both the rich and poor. Convenience and ease of access are often of paramount interest to every person, regardless of income. The issue of payment is another facet of the supply and demand problem. Corruption that trickles to the local governments, and even the health care workers themselves, leads to some patients having to pay for medicine or services that should have been free. Reforming payment systems to ensure that patients have the medicines delivered before payment is processed directly to the provider will empower the patients and promote compliance. 

Compounding the shortage problems, both of trained workers and supplies, are the inadequate surveillance systems in place. This is the third issue that needs to be addressed, and it is arguably the most crucial. Surveillance is necessary to monitor not only the needs within health facilities, but also within the community and surrounding areas. Without real-time tracking of disease and medical supplies, logisticians, doctors and community health workers are unable to properly estimate need and completely evaluate the effectiveness of their clinic’s efforts. This is where data comes into play. The Novartis Malaria Initiative, under the Roll Back Malaria Partnership, has led SMS for Life, which harnesses mobile phones, internet, and electronic mapping technology to track stock levels for health facilities. Sending SMS messages between health facilities and the district medical officers ensures treatment availability. Stock-outs have been reduced in Tanzania during a six-month pilot program from 79% to 26% in three districts. Not only are these stock-outs reduced, but when they occur, they are also resolved much quicker due to the ease of communication. In areas where internet is unavailable or running inconsistently, Relief Watch has offered a similar solution. It also uses mobile technology, but the application allows workers to not only track supplies but also disease (http://www.reliefwatch.com/). The easy and free setup is invaluable to developing countries that have previously relied on paper spreadsheets and forms. Giving workers data at their fingertips gives them more control over their health facility and their patients. These technological innovations are not only crucial for immediate supply tracking and disease surveillance, but they provide research institutions and governing bodies more accurate data. After all, it is data that public health professionals and policy-makers rely on to make decisions and plan strategies. 

The aforementioned plan to improve health systems is by no means novel. Public health practitioners have stressed the importance of training more workers, creating a steady supply chain of treatments, and addressing surveillance shortcomings for decades. Adhering to these solutions requires cooperation and active coordination that extend from the public to the private sector. This is something that cannot be over-emphasized. Empowerment—of individuals, community health workers, and governing bodies of fragile states—is an important foundation from which a better health infrastructure can grow.


Resources:

The impact of HIV/AIDS on the health workforce in developing countries http://www.who.int/hrh/documents/Impact_of_HIV.pdf
Healthcare logistics: delivering medicines to where they're needed most
http://www.theguardian.com/global-development-professionals-network/2013/jul/29/healthcare-logistics-best-practice
SMS for Life http://www.malaria.novartis.com/innovation/sms-for-life/
Relief Watch http://www.reliefwatch.com/
Avert: Universal access to HIV treatment http://www.avert.org/universal-access-hiv-treatment.htm

Challenges on the Frontlines of Ebola

~Written by Marilyn Perez Alemu (Contact: marilyn.perez@gmail.com) 

Healthcare workers on the frontlines of the Ebola crisis in West Africa are daily putting their lives at risk to save the lives of others. The current epidemic is the largest of its kind in history, exacerbated by a reported 70% case fatality rate. Yet Ebola is a disease that knows no mercy. Since the initial outbreak reported in March, more than 450 healthcare workers have been infected in Liberia, Sierra Leone, Guinea and Nigeria. More than 200 have died.

Despite being faced daily with this reality, as well as the looming stigmatization from their communities and families, healthcare workers continue to provide medical support to Ebola victims for the sake of those who will survive the disease. The initial international response was markedly slow and, as the outbreak intensifies, emerging challenges have severely impacted the ability of healthcare workers to respond to the growing need.

When executed properly, contact tracing is a key method for containing the outbreak spread. Ideally each contact, or person linked to a confirmed or probable case, would be identified by a healthcare worker and monitored for 21 days following exposure, allowing public health officials to track the movement of the outbreak. In theory, contact tracing is an effective method to ensure early detection of infections and immediate treatment, and stem the spread of the virus. Essentially, contact tracing has been called the key to “stop Ebola in its tracks”. And while the process seems simple enough, critical information gaps, limited databases, and an exponential increase in the number of Ebola cases have led to a breakdown in contact tracing in West Africa. With limited infrastructure and many living in remote villages, even finding patients is a challenge. Add that to the fact that people are often uncooperative with tracers, as the fear of going to a health center is something akin to a death sentence. Without the ability to do complete and proper contact tracing, rapid diagnosis and patient isolation is hindered and the outbreak will continue to spiral out of control.

While past outbreaks of Ebola were sporadic and contained within small rural areas, the current outbreak poses a serious challenge in that it has spread quickly to more crowded urban areas in West Africa. In rural areas, population density is lower, community ties are stronger, and transmission prevention measures are presumably easier to implement. Now, in vastly overpopulated urban areas, Ebola transmission has accelerated exponentially and the outbreak has gone beyond the ability to contain it. Control and prevention measures have thus intensified in both innovation and urgency, evidenced by accelerated efforts in vaccine development and experimental therapeutics.

While an Ebola outbreak is caused biologically, an Ebola epidemic is a crisis of poverty and fragile health systems. West Africa is faced with the repercussions of a weak health infrastructure, including scarcity of healthcare workers, limited resources, and poor management systems. It should be noted that these shortcomings preceded the Ebola outbreak, with just 51 doctors to serve Liberia’s 4.2 million people and 136 for Sierra Leone’s population of 6 million. To put this in context, this is fewer than many clinical units in a single hospital in the United States. Having worked its way through the cracks of a fragile health infrastructure, Ebola has effectively brought healthcare to a halt in Liberia, Sierra Leone and Guinea. An added complication is the shortage of resources, including personal protective equipment (PPE) and other control materials, and the lack of straightforward protocols and guidelines. Efforts must increase not only to ensure an ample supply of optimal PPE but also to effectively disseminate information on proper use of the equipment.

At the frontlines of the Ebola outbreak, healthcare workers face a daunting challenge. In Liberia, Emmanuel Boyah, a primary health manager with the International Rescue Committee, recounts the stress and fear of this work. Yet he and many others continue to dedicate themselves to the cause and risk their lives to care for those affected: “I feel that providing services to people during this time, when they’re in need of you, is my call.”