1. The Role of Midwives in MCH 17 th of February, 2009 Alison Lindner BSN, CNM, MPH

5. What Do We Know? Skilled attendants for pregnancy care and birth are lacking Skilled attendants for pregnancy care and birth are lacking This lack of skilled attendants is disturbing since many maternal and infant deaths and morbidities are preventable during the prenatal period, as well as during labor and birth. This lack of skilled attendants is disturbing since many maternal and infant deaths and morbidities are preventable during the prenatal period, as well as during labor and birth.

6. Outcome In much of the developing world home birth with unskilled attendants or no attendant is the norm. In much of the developing world home birth with unskilled attendants or no attendant is the norm. Maternal and neonatal mortality is high in the developing world Maternal and neonatal mortality is high in the developing world

8. WHO Definition A midwife is a person, who, having been regularly admitted to a midwifery education program, duly recognized in the country in which she is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. A midwife is a person, who, having been regularly admitted to a midwifery education program, duly recognized in the country in which she is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant.

9. Midwifery and Maternal Mortality The midwife can assist in the prevention of maternal and child mortality and morbidity by providing: The midwife can assist in the prevention of maternal and child mortality and morbidity by providing: Nutritional education Nutritional education Family planning services (birth spacing, safe abortion and post abortion care) Family planning services (birth spacing, safe abortion and post abortion care) Safe sex information to prevent STDs, HIV/AIDs and cervical cancer Safe sex information to prevent STDs, HIV/AIDs and cervical cancer

10. Midwifery and Maternal Mortality Antepartum Care Antepartum Care Maternal nutrition - Vitamin A, Folic Acid, Protein, Iron – prevention of anemia, congenital anomalies Maternal nutrition - Vitamin A, Folic Acid, Protein, Iron – prevention of anemia, congenital anomalies HIV screening/prevention of MTCT HIV screening/prevention of MTCT Malaria prophylaxis/bed nets Malaria prophylaxis/bed nets Recognition of PIH, other maternal conditions Recognition of PIH, other maternal conditions

11. Midwifery and Maternal Mortality Intrapartum Care - Identify problems early and transfer to the next level of care Prolonged or obstructed labor – use of partogram Life Saving Skills for mother – delivery of placenta, management of maternal hemorrhage, oral rehydration, transfer of care

12. Midwifery and Maternal Mortality Postpartum Care Postpartum Care Early identification of problems with mother Early identification of problems with mother Hemorrhage Hemorrhage Infection Infection Eclampsia Eclampsia Early identification of problems with infant Early identification of problems with infant Prematurity Prematurity Trouble breathing – needs resuscitation Trouble breathing – needs resuscitation Infection Infection

13. Kangaroo Care for preterm infants

14. Midwifery and Maternal Mortality Post abortion care Many legal and other barriers Training needs are great in this area Need to provide preventive services, as well as safe abortion integrated into reproductive health services, making midwives and other skilled health workers the ideal providers.

15. Midwifery and Maternal Mortality Postpartum Care Postpartum Care Family planning/child spacing Family planning/child spacing Promotion of breastfeeding Promotion of breastfeeding

20. So what is this telling us? Postpartum care has been a relatively neglected aspect of maternity care. Postpartum care has been a relatively neglected aspect of maternity care. This low level of care is disturbing, since timely interventions during the postpartum period can prevent deaths of both mothers and newborn infants, and can reduce the incidence of long- term pregnancy-related morbidities This low level of care is disturbing, since timely interventions during the postpartum period can prevent deaths of both mothers and newborn infants, and can reduce the incidence of long- term pregnancy-related morbidities

24. Safe Motherhood Safe Motherhood Initiative Safe Motherhood Initiative Launched in 1987 in Nairobi, Kenya Launched in 1987 in Nairobi, Kenya Placed maternal health at the forefront of the international public health agenda Placed maternal health at the forefront of the international public health agenda Addressed the high rates of maternal mortality and morbidity related to the complications of pregnancy and childbirth Addressed the high rates of maternal mortality and morbidity related to the complications of pregnancy and childbirth

25. Midwifery Midwifery care is key – skilled birth attendants who can conduct safe, clean deliveries, recognize complications and manage obstetric complications (either themselves or through referral) Midwifery care is key – skilled birth attendants who can conduct safe, clean deliveries, recognize complications and manage obstetric complications (either themselves or through referral) Trained TBAs from the community Trained TBAs from the community Partnerships with women and communities Partnerships with women and communities

26. Community Mobilization Health promotion Referral linkages Support to Guides A community partnership model LSS (Basic) Trainers Referral facility staff HBLSS Guides Women, families Home birth attendants LSS (Advanced) Trainers Referral facility staff for saving lives

27. Home-Based Life Saving Skills - Objectives Increase access to life-saving measures within home & community Increase access to life-saving measures within home & community Decrease delays in referral Decrease delays in referral Increase use of postpartum Increase use of postpartum & post abortion family planning & post abortion family planning

28. HBLSS – Intended Audience Pregnant women & family caregivers Pregnant women & family caregivers Home birth attendants, TBAs Home birth attendants, TBAs

29. HBLSS - Focus Core Topics  Introduction *  Woman & baby problems *  Preventing problems  Referral * Mother Topics  Too much bleeding *  Sickness with pain & fever *  Birth delay  Pregnancy swelling & fits  Too many children ………………………………… Baby Topics  Trouble breathing at birth  Born too small  Baby falls sick * * Topic covered

30. Example-- Take Action Card ‘Too Much Bleeding After Birth’ Problem sideAction Side

31. HBLSS - Community Mobilization Meetings with community leaders to discuss ways to improve the situation including transportation and support for HBLSS guides

32. HBLSS Field trials completed in Ethiopia, India and Vietnam suggest that it increases access to basic life saving care in the home and community, decreases delays in women reaching referral facilities and supports the communities efforts to decrease maternal and infant death. Field trials completed in Ethiopia, India and Vietnam suggest that it increases access to basic life saving care in the home and community, decreases delays in women reaching referral facilities and supports the communities efforts to decrease maternal and infant death. Further evaluations are planned. Further evaluations are planned. A manual will be available soon. A manual will be available soon.

33. LSS - Objectives Increase trained health workers skills in managing complications Increase trained health workers skills in managing complications Increase referral facilities ability to provide emergency obstetrical care. Increase referral facilities ability to provide emergency obstetrical care.

34. LSS - Audience Trained health workers in referral facilities Trained health workers in referral facilities Hospitals Hospitals Health centers Health centers

35. LSS Competency based training program that equips midwives with the skills to intervene in the top five life threatening maternal conditions including obstetrical hemorrhage, obstructed labor, obstetric sepsis, hypertensive disorders and complications of unsafe abortion. Competency based training program that equips midwives with the skills to intervene in the top five life threatening maternal conditions including obstetrical hemorrhage, obstructed labor, obstetric sepsis, hypertensive disorders and complications of unsafe abortion. Classroom and clinical training. Classroom and clinical training.

36. Summary This is just a brief example of some of the efforts to improve MCH care through midwifery – there are many others working. This is just a brief example of some of the efforts to improve MCH care through midwifery – there are many others working. If we are to prevent unnecessary maternal and infant death anywhere in the world we must be committed to social justice and the rights of women to safe and effective reproductive care. If we are to prevent unnecessary maternal and infant death anywhere in the world we must be committed to social justice and the rights of women to safe and effective reproductive care.

37. Thank You to Katherine Carr