This post originally appeared in the American College of Nurse Midwives’ Quickening, Volume 46, Number 2 (Spring 2015) and by the Maternal Health Task Force. Written by Kathryn Millar. Slight changes were made from the original post.
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 maternal and 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:
- 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
- The World Health Assembly: provides a forum in May to discuss the new version of Every Woman, Every Child
- 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 Philippines 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
Health workers in Laos watch instructional videos from the Global Health Media Project to improve their birthing skills. Photo: Pascale Chantavong
“The R'shi women in Northern Laos traditionally cut the umbilical cord with a bamboo knife, put charcoal under it while cutting, and then put hot cobwebs on it,” said Pascale Chantavong, who works with the NGO World Renew. “They would tie the umbilical cord to the mother's foot, afraid that it could go back inside, and give the baby a bath soon after the birth.”
Chantavong used videos from Global Health Media Project’s newborn care film series to demonstrate a safer way to cut the cord, and to explain how drying the baby thoroughly and providing skin-to-skin contact on the first day, instead of a bath, promotes infant health more effectively.
When Chantavong trains birth attendants and village health volunteers in rural Laos, she needs to demonstrate how and why they should replace long-practiced customs with newer approaches that have proven to be more effective in lowering infant mortality rates. In an area with limited education and low rates of literacy, she recently met this challenge using Global Health Media’s simple, clear and relevant web-based training videos.
“When I discovered Global Health Media resources I was thrilled—really thrilled,” she said. “A birth or the range of warning signs in newborns cannot easily be demonstrated live. A picture or a role play can be helpful, but never as much as seeing a real birth unfold before your eyes, or seeing how a newborn really looks when he or she lacks energy or has jaundice. The videos bridge the gaps resulting from language barriers and the abstract explanation of real problems.”
Global Health Media’s Newborn Care Series includes 27 videos on topics ranging from conducting a newborn exam to taking a venous blood sample. The videos may be downloaded for free from the organization’s website, where all are available are in English, French, and Spanish. Most of the videos are also available in Swahili and Nepali, and a number have been translated into other languages for special uses and projects including Urdu, Hindi, Lao, and Luganda. A growing list of organizations are also narrating the videos in their local languages to be used in their own trainings. When Chantavong found the videos she needed, she dubbed them in Lao with the help of her husband and others.
Film team directing the shoot in Nepal. Photo: Global Health Media Project
The videos have been watched in more than 225 countries and territories and downloaded more than 25,000 times by organizations all over the world. These include leading global health organizations who have made the videos integral to their training and service delivery in low-resource settings. MSF/Doctors Without Border has downloaded the videos in 21 countries, Save the Children in 16 countries, and World Vision International in 15 countries.
The wide appeal of the videos is not only in their clear “how-to” presentation and step-by-step instruction of skills, but also in their use of live footage to teach the recognition of clinical signs. According to Subarna Mukherjee, community advisor for Last Mile Health in Liberia, “In previous trainings, frontline health workers were taught how to recognize breathing problems, for example, using sound tapes. This made it difficult for them to understand a range of symptoms associated with breathing problems, lessening their confidence when dealing with a suspected case. Watching the Global Health Media Project video ‘Breathing Problems’ brought clarity to their comprehension, and was the next best option to actually witnessing a case firsthand.”
Recent research has begun to document the effectiveness of video training of frontline health workers. The Makerere University School of Public Health in Uganda received support from Grand Challenges Canada to test whether videos could be used to effectively communicate maternal, neonatal and child health messages. The study—in Eastern Uganda—convincingly demonstrated the important contribution that videos can make in teaching mothers basic information about health care.
The video “Danger Signs in Newborns” was narrated in Lusoga for more than 600 mothers who participated in the research. According to principal investigator Juliet N. Mutanda, the study documented a dramatic increase in the number of women who could identify danger signs in a newborn after the video training, compared with a control group that did not use the video.
The success of the Newborn Care Series has led to a proposed new film series on the care of small babies in collaboration with the American Academy of Pediatrics and other members of the Survive and Thrive Global Development Alliance. Nearly one million newborns die each year because of complications of being born too soon or too small, yet many of these deaths could be prevented with simple interventions in caring for these babies. This video series would be used to help improve health workers skills in caring for preterm and small babies so that more of them survive and thrive.
Photo: Bina Valsangkar
Two months into my first pregnancy, I suffered a miscarriage and needed to seek medical care.
Although a miscarriage is difficult for any woman to experience, I had access to the best care. My physician was excellent, I trusted her judgment, and the imaging equipment, laboratory facilities and clinical care were all first-rate.
That's not surprising — except that I was then living in Lucknow, Uttar Pradesh, the capital city of one of India's poorest states.
In 2012, as a freshly minted pediatrician, I left my home in Washington, D.C., to manage a newborn-health project aimed at strengthening essential newborn care practices like breast-feeding and infection detection in rural Uttar Pradesh.
In Lucknow, a city of more than 2 million, the gap between rich and poor was a fact of life. For a foreigner like me, who grew up in the United States, it was my first real-life immersion into A Tale of Two Cities.
To read the rest of this blog visit the NPR Goats and Soda blog
Rizelle, 17 has a three-week-old baby. She fed the baby immediately after birth so that she got the colostrum. Rizelle has had a post-natal check up and vaccinations. Roselle wants to breastfeed for a year and is planning to go to the health centre for the next dose when sheís six weeks old. Rizelle lives in a squatted home under a bridge in San Dionisio, Manila, Philippines, where they live with 30 other families. Photo: Lucia Zoro/Save the Children
I will never forget the moment when I looked out the car window at a bustling, steamy intersection in the heart of Manila, and locked eyes with a young woman. She was holding a tiny baby while begging in the street.
I glanced down at my six-month-old son, sleeping contentedly in my arms inside our air-conditioned car. The enormous inequalities between my world and hers struck me as never before. The child in my arms was about the same age and no smarter, cuter, or better than hers. Yet due to mere circumstance of birth, I knew my son would have many more opportunities in life, while this mother and her child would struggle to survive each day to the next.
It’s been 20 years since that fleeting moment, but the vision of the mother and her child has stuck with me. It drove me to change careers and join Save the Children, where we work tirelessly to ensure that every mother and child has a fair chance in life.
These days, more and more mothers in urban areas are seeking better opportunities for their children. That’s why Save the Children’s new report, State of the World’s Mothers 2015: The Urban Disadvantage — released with support from Johnson & Johnson — focuses on the health and survival of moms and babies in cities. The findings reveal a harrowing reality: for babies in the big city, their survival comes down to their family’s wealth.
I have been back to Manila many times. I am happy to report that, along with other urban centers in the Philippines, it is an example of how cities can narrow survival gaps between the rich and the poor by increasing access to basic maternal, newborn and child services, and making care more affordable and accessible to the poorest urban families.
A child’s chance of dying before his fifth birthday has been steadily declining over the years among the poorest 20 percent of urban families in the Philippines. From when I first visited that country in the mid ‘90s until today, child mortality rates among the urban poor have been cut by more than half and the urban child survival gap has narrowed by 50 percent between wealthy and poor kids.
Sadly, the Philippines is one of just a few countries with such dramatic improvements for poor urban children. In too many countries, urban child survival inequality is worsening, even as those nations have been successful in reducing overall child mortality rates.
In my travels throughout the developing world, I’ve never had to look very far to see evidence of these differences. For example, in New Delhi, India – a city with one of the largest health care coverage gaps between rich and poor – it is not unusual to see a gleaming hospital steps away from a sprawling slum, and to have babies literally dying on the doorstep.
But it’s not just in the developing world where our report found stark disparities between the haves and have nots. In our nation’s capital, Washington, D.C., a baby born in the lowest-income district, where half of all children live in poverty, is at least 10 times as likely as a baby born in the richest part of the city to die before his first birthday. And while Washington, D.C. has cut its infant mortality rate by more than half over the past 15 years, the rate at which babies are dying in the District of Columbia is the highest among the 25 wealthiest capital cities surveyed around the world.
We all have a lot more work to do to ensure that every mother has the same opportunities for her baby, whether she lives in Manila, Washington, D.C. or anywhere else in the world.
Find out more about Save the Children’s new report at www.savethechildren.org/mothers.
We attended an inspiring workshop in Harare at the end of January. It was organised by Harmonisation for Health Africa, the World Health Organisation and others, and aimed to get different types of stakeholders from the same country in the same room so they could agree together on a health budget advocacy plan. These different groups included budget CSOs, health CSOs, the media, parliamentarians, and representatives from Ministries of Health and Finance. Teams from Ghana, Malawi, Nigeria, Zambia and Zimbabwe were invited.
The outcomes of the meeting were pretty exciting – each team drafted an advocacy plan and returned to their own countries to sharpen the objectives and activities. Subject to approval, the WHO will provide a US$20,000 seed grant for implementation of each country plan in the first year. The Africa Health Budget Network has also agreed to share updates among countries on the implementation of such plans. In line with this commitment, we have provided an update on each country below:
Ghana: The Ghana team is led by the Alliance for Reproductive Health Rights. The team has submitted a draft advocacy plan to WHO. Furthermore, one of the MPs at the workshop, Mr Alhaji Amadu Sorogho, called on his colleagues to use the National Health Insurance Funds at their disposal to fight maternal and newborn mortality, according to the Ghana News Agency.
Malawi: The Malawi team is led by Malawi Health Equity Network – so far they have met once since the workshop in order to finalise a strategic plan which has been submitted to WHO.
Nigeria: The team is led by Community Health Research and has held two meetings since the workshop in order to approve their advocacy plan, which has now been shared with WHO.
Zambia: Have commenced engagement – further updates in the next newsletter.
Zimbabwe: Have commenced engagement – further updates in the next newsletter.
Featured HNN Blogs
About the Blog
The Healthy Newborn Network Blog provides timely information and insights from the global newborn health field and seeks to promote dialogue on important newborn health issues. The blog is a platform for the HNN Editors and guest contributors to post commentaries on current happenings in the newborn health field. The content of each post and comments expressed on the HNN blog are those of the individual contributors and do not necessarily represent the views and opinion of the HNN or its Partner Organizations. >>Read a note on leaving comments
Recent Member Responses
This is kind of charitable work that every one should follow.
I just leaned something very important from your article. I like it because it gave me lots of knowledge and wisdom. Thanks for sharing this! Keep...