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The Role of The Role of Midwives and TBAs Midwives and TBAs in MCH Care in the in MCH Care in the Developing WorldDeveloping World

Katherine Camacho Carr, Katherine Camacho Carr, PhD, ARNP, CNMPhD, ARNP, CNM

Women & Girls in the Women & Girls in the Developing WorldDeveloping World

Women & Girls are at risk of dying because there is: Female infanticideFemale infanticide Girl neglectGirl neglect Genital cuttingGenital cutting Early sex, marriage Early sex, marriage Early pregnancy and abortionEarly pregnancy and abortion Sex trafficking and rapeSex trafficking and rape Domestic violence, dowry killingDomestic violence, dowry killing Seclusion or displacement due to war or unrestSeclusion or displacement due to war or unrest Rejection of widowsRejection of widows

Midwifery and MCHMidwifery and MCH

Worldwide, Worldwide, midwivesmidwives assume the assume the primary care of women during their primary care of women during their reproductive years.reproductive years.

Midwives are in a unique position to Midwives are in a unique position to support healthy behaviors in women support healthy behaviors in women and have the skill to prevent and have the skill to prevent maternal and infant death and maternal and infant death and morbidity in many cases.morbidity in many cases.

What is a midwife?What is a midwife?

A midwife A midwife is a person with midwifery skills. is a person with midwifery skills.

She/he has successfully completed the She/he has successfully completed the prescribed course prescribed course in midwiferyin midwifery in an education program recognized in the in an education program recognized in the country where she is located, and is able to give the country where she is located, and is able to give the necessary supervision, care and advice to women during necessary supervision, care and advice to women during pregnancy, labor and the postpartum period, to conduct pregnancy, labor and the postpartum period, to conduct deliveries alone, to provide lifesaving obstetric care, and to deliveries alone, to provide lifesaving obstetric care, and to care for the newborn and the infantcare for the newborn and the infant

Countries may also have their own specific requirements Nursing may or may not be a prerequisite Scope of practice may vary

What kind of care does a What kind of care does a midwife provide?midwife provide?

Provides preventive measures Provides preventive measures Detects abnormal conditions in mother and childDetects abnormal conditions in mother and child Procures medical assistance if neededProcures medical assistance if needed Executes emergency measures in the absence of Executes emergency measures in the absence of

medical help. medical help. Provides health counseling and education, not Provides health counseling and education, not

only for the woman, but also within the family only for the woman, but also within the family and community. and community. Antenatal education and preparation for parenthood Antenatal education and preparation for parenthood Gynecology, family planning, as well as infant and Gynecology, family planning, as well as infant and

child care. child care.

What kind of care does a What kind of care does a midwife provide?midwife provide?

She may practice in hospitals, She may practice in hospitals, clinics, health units, domiciliary clinics, health units, domiciliary settings or in any other servicesettings or in any other service

Skilled Health Personnel Skilled Health Personnel

Skilled health personnelSkilled health personnel or skilled or skilled attendants include doctors (specialist or attendants include doctors (specialist or non-specialist) and/or persons with non-specialist) and/or persons with midwifery skills who can diagnose and midwifery skills who can diagnose and manage manage obstetrical complications,obstetrical complications, as as well as normal deliverieswell as normal deliveries

Skilled health personnel may also have Skilled health personnel may also have additional skills related to additional skills related to family family planningplanning and and gynecologygynecology..

Traditional Birth Traditional Birth Attendants (TBA)Attendants (TBA)

A A traditional birth attendant (TBA)traditional birth attendant (TBA) initially initially acquires her abilities by delivering babies herself or acquires her abilities by delivering babies herself or through apprenticeship to other TBAsthrough apprenticeship to other TBAs

TBAs may not be integrated into the health care TBAs may not be integrated into the health care system or adhere to defined standards of midwifery system or adhere to defined standards of midwifery carecare

A A trained traditional birth attendanttrained traditional birth attendant has has undergone subsequent extensive training and is undergone subsequent extensive training and is now integrated into the formal health care system; now integrated into the formal health care system; and has some adherence to midwifery standards, and has some adherence to midwifery standards, but this varies by country.but this varies by country.

TBA and her apprentice in Ethiopia

Teaching TBAs in Njeru, Uganda

Gambian TBAs

Working with Community Midwives

Indian TBA - Dai

TBA in Uganda – Prenatal Care

Trained TBA from Ghor, Afghanistan

TBA with Preterm, SGA Baby

Midwifery and Maternal Midwifery and Maternal MortalityMortality

The midwife can assist in the The midwife can assist in the prevention of maternal and child prevention of maternal and child mortality and morbidity by providing:mortality and morbidity by providing: Nutritional education Nutritional education Family planning services (birth spacing, Family planning services (birth spacing,

safe abortion and post abortion care, safe abortion and post abortion care, contraception) contraception)

Safe sex information to prevent STDs, Safe sex information to prevent STDs, HIV/AIDs and cervical cancerHIV/AIDs and cervical cancer


The midwife can assist in the The midwife can assist in the prevention of maternal and child prevention of maternal and child mortality and morbidity by mortality and morbidity by providing:providing: High quality maternity care including High quality maternity care including

antepartum, intrapartum and antepartum, intrapartum and postpartum care; timely identification postpartum care; timely identification and referral of abnormal conditions & and referral of abnormal conditions & emergency obstetrical careemergency obstetrical care


Antepartum CareAntepartum Care Maternal nutrition - Maternal nutrition -

Vitamin A, Folic Acid, Vitamin A, Folic Acid, Protein, Iron – prevention Protein, Iron – prevention of anemia, congenital of anemia, congenital anomaliesanomalies

HIV screening/prevention HIV screening/prevention of MTCTof MTCT

Malaria prophylaxis/bed Malaria prophylaxis/bed netsnets

Recognition of PIH, other Recognition of PIH, other maternal conditionsmaternal conditions

Promotion of Promotion of breastfeedingbreastfeeding


Intrapartum CareIntrapartum Care - -Identify problems Identify problems early and transfer to early and transfer to the next level of carethe next level of care

Prolonged or Prolonged or obstructed labor – use obstructed labor – use of partogramof partogram

Life Saving SkillsLife Saving Skills for for mother – delivery of mother – delivery of placenta, management placenta, management of maternal of maternal hemorrhage, oral hemorrhage, oral rehydration, transfer of rehydration, transfer of carecare

Prevention of Post Partum Prevention of Post Partum Hemorrhage Initiative Hemorrhage Initiative

(POPPI)(POPPI) http://www.pphprevention.org/http://www.pphprevention.org/

USAID funded three-year project USAID funded three-year project awarded to a partnership of PATH, awarded to a partnership of PATH, RTI International, EngenderHealth, RTI International, EngenderHealth, the International Confederation of the International Confederation of Midwives (ICM) and the Midwives (ICM) and the International Federation of International Federation of Gynecology and Obstetrics (FIGO) Gynecology and Obstetrics (FIGO)

POPPI PurposesPOPPI Purposes

Expand the use of active Expand the use of active management of the third stage management of the third stage (placental delivery).(placental delivery).

Make uterotonic drugs and devices Make uterotonic drugs and devices available at low cost.available at low cost.

Oral fluids given


Postpartum CarePostpartum Care Early identification of problems with Early identification of problems with

mother mother HemorrhageHemorrhage Infection Infection EclampsiaEclampsia

Early identification of problems with infantEarly identification of problems with infant PrematurityPrematurity Trouble breathing – needs resuscitationTrouble breathing – needs resuscitation InfectionInfection

Surviving twin - preterm


Postpartum CarePostpartum Care Family Family

planning/child planning/child spacingspacing

Promotion of Promotion of breastfeedingbreastfeeding

Midwifery and Infant Midwifery and Infant MortalityMortality

Infant careInfant care Cutting of umbilical cordCutting of umbilical cord Kangaroo care for premature infantsKangaroo care for premature infants Neonatal resuscitation appropriate to a low Neonatal resuscitation appropriate to a low

resource settingresource setting BreastfeedingBreastfeeding

Kangaroo Care for preterm infants


Post abortion carePost abortion care Many legal and other barriersMany legal and other barriers Training needs are great in this areaTraining needs are great in this area Need to provide preventive services, as Need to provide preventive services, as

well as safe abortion integrated into well as safe abortion integrated into reproductive health services, making reproductive health services, making midwives and other skilled health midwives and other skilled health workers the ideal providers.workers the ideal providers.

Status of MidwiferyStatus of Midwifery The role of the midwife has been The role of the midwife has been

undervalued in many countries and undervalued in many countries and midwives have not been adequately midwives have not been adequately supported or have been eliminated from supported or have been eliminated from the health care system in favor of other the health care system in favor of other groups.groups.

The education & training of midwives The education & training of midwives may not have kept pace with current may not have kept pace with current practicepractice

Few educational updates or CE programs Few educational updates or CE programs are available for midwives and TBAsare available for midwives and TBAs

Key Areas for ActionKey Areas for Action Safe motherhood can be advanced through Safe motherhood can be advanced through

respecting existing human rights, through respecting existing human rights, through empowering women to make choices in their empowering women to make choices in their reproductive lives with the support of their families reproductive lives with the support of their families and communities. and communities.

The access to and quality of maternal health The access to and quality of maternal health services needs to be improved. All deliveries should services needs to be improved. All deliveries should be overseen by be overseen by skilled attendantsskilled attendants and essential care and essential care should be available when obstetric complications should be available when obstetric complications arise. arise.

Women need to be able to choose if and when to Women need to be able to choose if and when to become pregnant, through ensured access to become pregnant, through ensured access to voluntary family planning information and services. voluntary family planning information and services.

MidwiferyMidwifery

Midwifery care is keyMidwifery care is key – skilled – skilled birth attendants who can conduct birth attendants who can conduct safe, clean deliveries, recognize safe, clean deliveries, recognize complications and manage obstetric complications and manage obstetric complications (either themselves or complications (either themselves or through referral)through referral)

Trained TBAs from the communityTrained TBAs from the community Partnerships with women and Partnerships with women and

communitiescommunities

TBAs with Certificates after a training session in Njeru, Uganda

Pathway to SurvivalPathway to Survival Traditional birth attendants (TBAs) may Traditional birth attendants (TBAs) may

be women's only source of care in many be women's only source of care in many placesplaces

They can be a source of culturally They can be a source of culturally appropriate care and provide a first-line appropriate care and provide a first-line link with the health care system. link with the health care system.

Pathway to SurvivalPathway to Survival

However, we know that the training However, we know that the training of TBAs or skilled birth attendants of TBAs or skilled birth attendants alone is ineffective. alone is ineffective.

Back-up from a functioning referral Back-up from a functioning referral system and support from system and support from professionally trained health professionally trained health workers is also needed to effectively workers is also needed to effectively reduce maternal and neonatal reduce maternal and neonatal mortality.mortality.

From: Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement. 1999


Where TBA training is undertaken, it Where TBA training is undertaken, it should be part of a should be part of a broader broader strategystrategy that includes a built-in that includes a built-in mechanism for referral, supervision, mechanism for referral, supervision, and evaluation.and evaluation.


PROBLEM

Recognize Problem

Give First Aid

Care

Decide to Seek Care

Seek Care

Get Quality Emergency

Care

SURVIVAL

Home & Community Context

(HBLSS)

Referral Site

(LSS)

From: Sibley L, Buffington S, Beck D, Armbruster D. (2001). Home based life saving skills: promoting safe motherhood through innovative community interventions. JMWH 46(4): 258-66.

Community Mobilization• Health promotion• Referral linkages

• Support to TBAs &others

A community partnership model

LSS(Basic)

• Trainers• Referral facility staff

HBLSS•Women, families

• Home birth attendants•TBAs

LSS(Advanced)• Trainers

• Referral facility staff

for saving lives

HBLSS Developed and HBLSS Developed and Field Tested by ACNMField Tested by ACNM

In collaboration with :In collaboration with :

Ethiopian Ministry Ethiopian Ministry

of Healthof Health

Save the Children

Home Based Life Saving Home Based Life Saving SkillsSkills

A family, woman, community focused, A family, woman, community focused, competency based program competency based program

Goals of HBLSSGoals of HBLSS Reduction of maternal & newborn mortalityReduction of maternal & newborn mortality Increased access to basic life saving Increased access to basic life saving

measures within the home and communitymeasures within the home and community Decreased delays in reaching referral Decreased delays in reaching referral

facilities, where obstetrical emergency care facilities, where obstetrical emergency care is availableis available

HBLSS - ObjectivesHBLSS - Objectives

Increase access to life-Increase access to life-saving measures within saving measures within home & communityhome & community

Decrease delays in referralDecrease delays in referral

Increase use of Increase use of postpartum postpartum

& post abortion family & post abortion family planningplanning

HBLSS – Intended HBLSS – Intended AudienceAudience

Pregnant women Pregnant women & family & family caregiverscaregivers

Home birth Home birth attendants, TBAsattendants, TBAs

Community PartnershipCommunity Partnership

Community Self AssessmentCommunity Self Assessment is used is used to initiate the process of community to initiate the process of community mobilizationmobilization Obtain information about local norms Obtain information about local norms

surrounding childbirthsurrounding childbirth Discuss perceptions of causes of Discuss perceptions of causes of

maternal and newborn deathmaternal and newborn death Identify birth attendants, healers, wise Identify birth attendants, healers, wise

men & women to guide the processmen & women to guide the process

Community PartnershipCommunity Partnership

In depth analysis of maternal and In depth analysis of maternal and neonatal mortality, routines of neonatal mortality, routines of pregnancy care, available resources, pregnancy care, available resources, health seeking behaviors, birth health seeking behaviors, birth preparedness, problem recognition, preparedness, problem recognition, first aid applied, referral decisions first aid applied, referral decisions and utilization.and utilization.

Community meetings play an important role in Community meetings play an important role in HBLSS HBLSS Involves all community leaders interested in health Involves all community leaders interested in health

promotion in decision-makingpromotion in decision-making Identifies the participants for HBLSSIdentifies the participants for HBLSS Encourages participation of women and families Encourages participation of women and families Community resources may be available to assistCommunity resources may be available to assist

Home Based Life Saving Home Based Life Saving SkillsSkills

HBLSS is unique in its audience, focus HBLSS is unique in its audience, focus and approachand approach The audience includes those likely to be in The audience includes those likely to be in

attendance at a birth - the woman herself, attendance at a birth - the woman herself, family care givers, and birth attendants. family care givers, and birth attendants.

The curriculum is modular and focuses on The curriculum is modular and focuses on prevention, recognition and initial home prevention, recognition and initial home management of life threatening complications management of life threatening complications for mother and newborn and referral where for mother and newborn and referral where possible.possible.

HBLSS - FocusHBLSS - 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

Example-- Example-- Take Action Take Action CardCard

‘Too Much Bleeding After ‘Too Much Bleeding After Birth’Birth’Problem side Action Side

Learning how to do bimanual compression

HBLSSHBLSS Field trials completed in Ethiopia, India Field trials completed in Ethiopia, India

and Vietnam suggest that it increases and Vietnam suggest that it increases access to basic life saving care in the access to basic life saving care in the home and community, decreases delays home and community, decreases delays in women reaching referral facilities and in women reaching referral facilities and supports the supports the communities effortscommunities efforts to to decrease maternal and infant death.decrease maternal and infant death.

Further evaluations are planned.Further evaluations are planned. Complete training materials are available Complete training materials are available

at:at:http://www.acnm.orghttp://www.acnm.org

HBLSS Does Not Stand HBLSS Does Not Stand AloneAlone

HBLSS is an integral part of a larger HBLSS is an integral part of a larger community partnership model, community partnership model, which has the potential for added which has the potential for added community supported interventionscommunity supported interventions Emergency transportationEmergency transportation Orientation of the general community Orientation of the general community

and referral facilities to HBLSSand referral facilities to HBLSS Development of a simple monitoring Development of a simple monitoring

system for pregnancy outcomessystem for pregnancy outcomes

Safe motherhood may Safe motherhood may begin, but does not end at begin, but does not end at

homehome If needed, the community If needed, the community

partnership model can include partnership model can include LSS LSS trainingtraining to enhance emergency to enhance emergency obstetric care at referral facilities.obstetric care at referral facilities.

LSS - ObjectivesLSS - Objectives

Increase trained health workers Increase trained health workers skills in managing complications skills in managing complications

Increase referral facilities ability to Increase referral facilities ability to provide emergency obstetrical care.provide emergency obstetrical care.

LSS - AudienceLSS - Audience

Trained health workers in referral Trained health workers in referral facilitiesfacilities HospitalsHospitals Health centersHealth centers

LSS - FocusLSS - Focus A comprehensive training program and A comprehensive training program and

series of manuals designed to help reduce series of manuals designed to help reduce maternal mortality through skill maternal mortality through skill acquisition appropriate for low resource acquisition appropriate for low resource settings. settings.

Modules include: Antenatal Care, Labor Modules include: Antenatal Care, Labor Progress, Episiotomies, Hemorrhage, Progress, Episiotomies, Hemorrhage, Resuscitation, Sepsis, Rehydration, Resuscitation, Sepsis, Rehydration, Vacuum Extraction and Other Vacuum Extraction and Other EmergenciesEmergencies. .

LSSLSS

Competency based training programs Competency based training programs that equip midwives and physicians with that equip midwives and physicians with the skills to intervene in the top five life the skills to intervene in the top five life threatening maternal conditions threatening maternal conditions including obstetrical hemorrhage, including obstetrical hemorrhage, obstructed labor, obstetric sepsis, obstructed labor, obstetric sepsis, hypertensive disorders and hypertensive disorders and complications of unsafe abortion.complications of unsafe abortion.

Involves classroom and clinical training.Involves classroom and clinical training.

LSSLSS

LSS manual is translated into LSS manual is translated into French, Spanish, Vietnamese, French, Spanish, Vietnamese, Bahasa Indonesian.Bahasa Indonesian.

Experience in Ghana, Uganda, Experience in Ghana, Uganda, Indonesia, Nigeria and Vietnam Indonesia, Nigeria and Vietnam suggest that it is sustainable and suggest that it is sustainable and effective.effective.

Community Partnership Community Partnership ModelModel

HBLSS and LSS training within the Community HBLSS and LSS training within the Community Partnership Model strengthen the entire Partnership Model strengthen the entire continuum of mother-baby care in the community continuum of mother-baby care in the community and have great potential for the reduction of and have great potential for the reduction of

maternal and neonatal mortality.maternal and neonatal mortality.

ReferencesReferences

Buffington ST, Sibley L, Beck D, Armbruster D. Home-based life saving skills Buffington ST, Sibley L, Beck D, Armbruster D. Home-based life saving skills manual. Silver Springs, MD: American College of Nurse-Midwives, 2004.manual. Silver Springs, MD: American College of Nurse-Midwives, 2004.

Marshall M, Buffington ST. Life saving skills manual for midwives, 3Marshall M, Buffington ST. Life saving skills manual for midwives, 3rdrd edition. MotherCare/John Snow Inc. & the American College of Nurse-edition. MotherCare/John Snow Inc. & the American College of Nurse-Midwives, 1997.Midwives, 1997.

Sibley L, Buffington ST. Building community partnerships for safer Sibley L, Buffington ST. Building community partnerships for safer motherhood: Home-based life saving skills. At-a-glance. Washington (DC): motherhood: Home-based life saving skills. At-a-glance. Washington (DC): NGO Networks for Health, 2003, January.NGO Networks for Health, 2003, January.

Sibley L, Buffington ST, Beck D, Armbruster D. Home-based life saving skills: Sibley L, Buffington ST, Beck D, Armbruster D. Home-based life saving skills: Promoting safe motherhood through innovative community based Promoting safe motherhood through innovative community based interventions. J Midwifery & Women’s Health 2001; 46:258-66.interventions. J Midwifery & Women’s Health 2001; 46:258-66.

Sibley L, Buffington ST, Haileyesus D. The American College of Nurse-Sibley L, Buffington ST, Haileyesus D. The American College of Nurse-Midwives’ home-based lifesaving skills program: A review of the Ethiopian Midwives’ home-based lifesaving skills program: A review of the Ethiopian Field Test. J Midwifery & Women’s Health, 2004;49:320-328.Field Test. J Midwifery & Women’s Health, 2004;49:320-328.

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Documents

child care

mch care

formal health care system

primary care of women

post abortion care

varywhat kind of care

lifesaving obstetric

health units