Posts filed under ‘Maternal Health’
By Nasir Bashir, Samaila Yusuf and Ann LoLordo
With each pregnancy, Malam Abubakar Maikudi worried about the health of his wife, Hadiza. The father of three children, Maikudi feared that another baby, born too soon, would further weaken her and make it harder for her to care for the children. But what could he do? A visit by a community health counselor helped this Nigerian father attend to the needs of his family.
Ali Ibrahim, a male counselor who is part of a U.S. Agency for International Development (USAID)-supported program to enhance reproductive health services in northern Nigeria, explained to Maikudi the benefits of properly spacing future pregnancies. He discussed several family planning methods for the couple and referred them to the Kiru Comprehensive Health Centre.
“Your visit to my house has taken a big burden out of my life,” Maikudi told the counselor. “I am very much satisfied with the information you have given me on how to plan my family and where to get services.”
After meeting with a health provider at the center, Hadiza and Maikudi decided that an intrauterine contraceptive device (IUD) was their preferred method of family planning.
The couple is just one of thousands of families who have been helped through a comprehensive program supported by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), managed by Jhpiego and partners to strengthen reproductive, maternal and family planning services in three states in northern Nigeria. An estimated 30,000 women die annually from complications of childbirth in Nigeria. The program began under the ACCESS Program and is being continued by MCHIP.
Through its cooperation with the Nigerian Ministry of Health over the past four years, MCHIP in Kano, Katsina and Zamfara States has achieved steady and significant gains in women’s visits to antenatal care clinics, skilled birth attendance, active management of third stage of labor, essential newborn care and use of long-term family planning. Through this initiative, 164,040 women have received family planning and reproductive health counseling.
“We are partners in progress because from the time when they came and started the activities in this state, we have made a tremendous progress,” said Dr. Bello Buzu, the chairman of the Health Services Management Board in Zamfara State.
The goal of the program has been to strengthen health systems and improve the quality of care in the community and health facilities to reduce the deaths of women and newborns. In northern Nigeria, women have an average of five to seven children. Program partners launched a multi-tiered approach that targeted 57 health facilities in more than two dozen local government areas, and relied on community health counselors and mobilizers to reach women in their homes and villages. The program focused on strengthening emergency obstetric and newborn care and family planning services.
Key accomplishments of the program have included:
- Health facilities using active management of third stage of labor increased from about 30 percent to more than 60 percent in the three states in northwest Nigeria;
- The number of facilities performing newborn resuscitation nearly doubled;
- Use of family planning among postpartum women in the areas served by the program increased from one percent to 15 percent of households; and
- More than 8,000 women chose injectables as the preferred form of contraceptive during a one-year period, an increase over the estimated 6,000 women seen at the start of the program.
As part of the project, health care providers were educated in emergency obstetric and newborn care skills, and family planning methods and e-learning opportunities were strengthened to build capacity in these areas. Beyond community education and facility improvement, a key strategy was to integrate health screenings with immunizations, newborn care and well-baby visits so as not to miss an opportunity to address women’s health and family planning needs.
“We have a reason for being in northern Nigeria. If you look at the demographic characteristics, many indicators are very poor in northern Nigeria compared to southern Nigeria,’’ said Prof. Emmanuel Otolorin, Jhpiego’s Country Director. “Our household-to-hospital continuum of care approach aimed to eliminate the delays to accessing health care delivery such as ignorance of the danger signs in pregnancy and childbirth and/or inappropriate customs. It also aimed to address delays in reaching the point of care due to lack of appropriate transport or poor roads and geographic terrain, as well as delays in receiving care after arriving at the health facility because of weak health systems—including a shortage of skilled birth attendants or lack of equipment and supplies.”
A network of community health volunteers taught pregnant women and mothers basic health care skills to prepare for childbirth and encouraged them to access health care services before and after delivery. Men were recruited to participate in outreach efforts to discuss the importance of pregnancy spacing and family planning with husbands, fathers and other male relatives. Savings clubs were organized for women, giving them the financial means to contribute to their families and develop leadership skills.
A Jhpiego-pioneered quality assurance approach, Standards-Based Management and Recognition, was shared with health care providers and administrators in an effort to improve services at facilities; measurable progress was made. In addition, health facilities were renovated and equipment upgraded.
“In terms of capacity building, systems strengthening and physical infrastructure, ACCESS, followed by MCHIP, has really supported Kano State government,” added Dr. Ashiru Rajab, Deputy Director of Primary Health at the Ministry of Health in Kano State.
But there’s more work that can be done.
“While there is an increase trend in the uptake of family planning services in Kano, a large number of women still have an unmet need for family planning,” said Dr. Yusuf Munkaila, Medical Director of the Sir Muhammad Sanusi Specialist Hospital. “There is a need to step up engagement of the religious and traditional leaders to understand the health benefits of family planning so that they can actively participate in advocacy efforts and disseminating messages that promote family planning as a means to improve maternal and newborn health.”
By Ann LoLordo
Women’s accounts of giving birth in community health centers and local hospitals in three districts in Indonesia revealed a series of problems with the care and service they received. The women’s stories, told to a team of visiting health professionals, detailed improper assessments, lack of monitoring, questionable management of labor and birth, difficult emergency transport, poor attitudes among providers and numerous out-of-pocket expenses.
The interviews with 45 women offer a unique perspective on conditions that may discourage pregnant women from choosing to give birth in a health facility with skilled attendants, a key contributor to reducing the deaths of mothers and newborns. These first-person accounts provide an opportunity for Indonesian health care providers—with the support of the U.S. Agency for International Development’s Maternal and Child Health Integrated Program (MCHIP)—to strengthen hospital referral services through a Jhpiego-pioneered quality assurance program that has been successfully implemented in Indonesia and 30 other countries with demonstrable results.
For more than 25 years, Jhpiego has worked collaboratively with the Indonesian government and other partners to help improve health care access and delivery in this nation of islands. This work has included building capacity among midwives, developing a model program for cervical cancer screening and prevention, and preparing health workers in prevention and treatment of avian influenza.
In two recent Jhpiego-supported programs, efforts to improve quality of care at health centers and clinics attended by midwives delivered substantive results. Health providers increased their competency in nine areas, ranging from antenatal care to infection prevention, and women received a higher quality of maternal and newborn services.
For example, when Jhpiego received support from British Petroleum and Rio Tinto in 2007 to improve maternal and newborn health care services in the district of Kutai Timur (pop. 250,000), many small, local health facilities were below standard, village midwives lacked basic emergency and newborn care skills, and poor infrastructure impeded women’s efforts to reach health centers to give birth.
Jhpiego’s pioneering Standards-Based Management and Recognition (SBM-R) approach helped administrators and staff at two community health centers identify problems and gaps in service, propose solutions and assess outcomes. The SBM-R approach gives health providers the means to develop and implement their own self-improvement program. It builds capacity by both motivating and rewarding employees who participate and encourages a sense of ownership in maintaining compliance with performance standards.
In Kutai Timur, to address gaps in knowledge and skills, an on-the-job mentoring program was devised for village and hospital midwives in basic and emergency obstetric care, infection prevention, and family planning counseling and services. Subsequent assessments showed steady improvement in antenatal care, labor and birth, newborn care, postpartum care, family planning, child immunization and infection prevention over the two years of the program, improving from an average of 69.4 percent to 87.9 percent in normal delivery care and from an average of 76 percent to 91 percent in infection prevention. Through the SBM-R approach, the midwives working in health clinics improved their level of care, meeting 90 percent of evidence-based standards, up from 50 percent.
MCHIP, which is led by Jhpiego, is presently working with six hospitals and 17 community health centers in the districts of Kutai Timur, Bireuen and Serang. SBM-R has been introduced in these facilities to identify problem areas and improve care and services. In just six months, the facilities have shown improvement, with some increasing their performance from 22 percent to 61 percent of the standards achieved.
A report from a midwife working in a small village health clinic in Teluk Pandan illustrates the impact of the program in helping to save lives. In May of 2010, the staff had their first complicated delivery since participating in the Jhpiego-supported training. A woman with prolonged labor had a breech birth and the umbilical cord was wrapped around the baby’s neck.
“We managed to deliver the baby, but it did not breathe,” wrote one midwife. “BEONC (basic emergency obstetric and newborn care) team consisted of me and two new midwives. After two minutes of using a resuscitation bag and mask, the baby finally breathes… . If there was no knowledge update from Jhpiego we might have failed to keep the baby alive.”
By Leslie Mancuso
Feroza Mushtari is a woman of substance. She is helping to bring quality health care to Afghanistan’s women and provide others with the skills to care for new mothers. She personifies the dedication and hands-on work required to rebuild her country.
Among the first graduates of the Jhpiego-supported national Afghan midwifery education program, this 26-year-old midwife is a selfless advocate for the needs of women and families and a stellar example of the young leaders Jhpiego is helping develop in the countries where we work—health care providers with the skills and commitment to provide competent care to their fellow citizens.
Feroza Mushtari embodies the strengths and successes of what the non-profit, international health community calls capacity building, a multi-faceted approach to improved health care service. She started out as a student in Afghanistan’s early midwifery training program, which was designed and supported by Jhpiego. She went on to become a trainer of midwives, a supervisor at a big maternity hospital in Kabul and an active member of the Afghan Midwives Association. Her journey was made possible through the initiative and support of the Afghan Ministry of Health, the U.S. Agency for International Development, and a host of international and local partners.
As conveyed in a recent report in the online magazine, The Daily Beast, Feroza overcame difficult circumstances to fulfill her dream of becoming a midwife. A teenaged Feroza once disguised herself as a young man to escort a pregnant neighbor to the hospital so the woman could receive lifesaving care. At the time, the Taliban prohibited women from traveling without a male escort.
“When you have a feeling in your heart, no one can stop you,” she said. “It’s every woman’s right to have a skilled provider during pregnancy and childbirth.”
I share Feroza’s story with you because she represents thousands of women and men—nurses, midwives, doctors, educators, officials, clinicians and community health workers—around the world who work hard every day to bring competent, skilled health care to their communities.
From Afghanistan to Zimbabwe and dozens of countries in between, Jhpiego is helping develop the capacity of countries to care for themselves and build a family of health care champions from the ground up—strengthening health care delivery for thousands.
By Jorge Anez
Maputo, Mozambique—When newborns at Mavalane General Hospital in Maputo developed skin rashes, the suspected culprit was a new policy of encouraging skin-to-skin contact between mother and child. But the maternity ward’s health review team saw it differently. They decided to implement some new infection prevention measures to help control the outbreak while identifying its cause. For instance, they banned the traditional practice of wrapping a newborn in a mother’s dress and offered pregnant women the chance to take a bath after admission to the maternity ward. Within days of taking those simple steps, the rashes subsided.
The health team’s approach to resolving the problem is a prime example of the operational changes evident in Mozambique’s main obstetric hospitals, which grew out of the government’s commitment to improve health care delivery at these facilities. Through the use of a Jhpiego-pioneered quality assurance program, hospital staff are actively engaged in setting standards for service, identifying gaps in care, recommending solutions and assessing outcomes. The Standards-Based Management and Recognition (SBM-R) approach puts a priority on employee input and compliance and recognizes achievement.
This approach was introduced as part of the nationwide Model Maternities Initiative begun in the country’s largest emergency obstetric and newborn care facilities. The project grew out of a Ministry of Health (MOH) call for a comprehensive review of maternal, newborn and child health policies, guidelines and programs in October 2009. This work was done with funding from the U.S. Agency for International Development’s flagship Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego.
A year later, MCHIP-assisted programs, in partnership with the MOH, have shown measurable improvements in health care policy and service delivery that include:
• Development of 15 separate national maternal, newborn and child health strategies, standards and guidelines;
• Establishment of the Model Maternities Initiative in 34 of the busiest hospitals with emergency obstetric services, which account for 21 percent of all births in health care facilities nationwide; and
• Integration of reproductive health and family planning services with the country’s first ever national cervical cancer prevention program.
The goal of the Model Maternities Initiative is to provide a humane, caring environment in which women give birth and improve maternal and newborn health care services. The program encourages women to have a companion join them in the birth process and choose their birth position, and practice skin-to-skin contact between mother and child and immediate breastfeeding. During labor and delivery, birth attendants are urged to use the partograph to monitor labor and assist in decision-making and actively manage the third stage of labor.
“Mozambique, as in other African countries, is a place where many women have their babies outside of a health facility. Sometimes access to health services is not easy for them. Other times, they are afraid of not being well treated at the health facility and they feel more comfortable at home,” said Dr. Veronica Reis, MCHIP’s technical advisor on the program. “The biggest problem is that when complications occur at home with the mother or baby, the possibility of solving the problem or reaching a health facility in time to ensure the appropriate care is very limited.
“In this context, the MMI is a very important effort by the Mozambique government and partners because this initiative is focused on improving the quality of care and creating a good environment where the woman can feel respected, well treated and safe.
“The preliminary results from the implementation of MMI show an increase in mothers’ and families’ satisfaction,” said Dr. Reis. “It’s expected that, as the program continues, use of maternal and neonatal health services will consequently impact the health of Mozambican mothers and babies.”
Since the October 2009 launch of MMI, improved quality of care for women is becoming more routine in the maternity ward at Mavalane General Hospital. For example, in March 2010, hospital staff used active management of third stage of labor during the majority of the 820 births (520 or 63.4 percent). The same number of new moms also immediately put their babies on their chests as part of the skin-to-skin contact initiative. And lessons have been learned. As the skin rash outbreak showed, “it is extremely important to put in place simple measures for hygiene to prevent skin infections among newborns,” said Dr. Bernadina Gonzalves, the pediatrician in charge of the maternity ward at Mavalane General Hospital.
A key achievement resulting from the improved maternal health services under the Model Maternities Initiative has been an increase in the number of Mozambican women who choose to give birth in a health facility with a skilled birth attendant present, a critical factor in safeguarding the lives of mother and child. Through the Model Maternities Initiative, 318 skilled birth attendants have been taught emergency obstetric and newborn care skills and family planning.
As a result of this capacity building, health care services have been strengthened dramatically according to key indicators charted by participating hospitals:
• 44 percent of births have a completed partograph;
• 65 percent of births included active management of third stage of labor;
• 89 percent of women with pre-eclampsia/eclampsia were treated with magnesium sulfate;
• 59 percent of newborns have skin-to-skin contact with mother; and
• 57 percent of infants are breastfed within one hour of birth.
Targets were achieved in every area but complete use of the partograph, which helps health care providers monitor the progress of labor and make decisions about when further interventions are needed.
As a result of the integration of services, cervical cancer screening units have been established in nine rural and six referral health facilities. The women are screened in a single visit approach, a method championed by Jhpiego that uses the application of acetic acid (the main component in household vinegar) to detect pre-cancerous lesions of the cervix.
If such lesions are found, a health provider will immediately treat the cervix with a freezing agent that eradicates the cells. Women with a more serious condition will be referred for further treatment. Through this new national protocol, at least 4,791 women have been screened for cervical cancer. Of those, 341 were positive for pre-cancerous cells and 60 percent of these women received treatment for the pre-cancerous lesions on the same day.
Integrating cervical cancer screening with maternal health services is important because cervical cancer—the leading cancer killer of women in the developing world—is preventable. If symptoms are detected early, women can be treated successfully. Women who are HIV-positive are more at risk for cervical cancer and, in Mozambique where over 11% of adults are HIV-positive and a third of the population doesn’t know their HIV status, early screening is critical to saving lives.
By Somesh Kumar and Kailash Saran
In the northwestern Indian state of Rajasthan, the past 60 years have seen a three-fold surge in population, increasing to an estimated 65 million people. Women on average have at least three children, and less than 60 percent of women of childbearing age or their partners use contraception. The need for focused family planning services was never more strongly felt here.
To help meet that need, Jhpiego joined with the Government of Rajasthan, the Norway India Partnership Initiative (NIPI) and other partners to provide family planning services immediately after childbirth, with a focus on the intrauterine contraceptive device (IUCD). This collaboration is already showing encouraging results in helping Rajasthani women plan smaller families. At three small hospitals, in less than three months, nearly 300 women decided to have an IUCD implanted immediately after delivering their babies.
The joint venture is building capacity among health providers in Rajasthan and strengthening the health system, a model partnership for family planning services that other states in Indian can adopt as their own.
Dr. M.L. Jain, Director of the Reproductive and Child Health Program, said that the focus of family planning in Rajasthan has shifted from sterilization to birth spacing methods because “Jhpiego helped us to show the importance and correct timing of family planning counseling [in antenatal care] and services [in immediate postpartum].”
“Before training of trainers we were not convinced about IUCD, specially the IPPIUCD (Immediate Postpartum Intrauterine Contraceptive Device) program, which had failed miserably in the past. But after attending the training, I have noticed palpable changes among all trained staff as their approach and vision is quite different now,” added Dr. Vimla Jain, Head of the Department of Gynecology-Obstetrics at Sawai Man Singh (SMS) Medical College, Jaipur. “The way the program has started again shows that training provided by Jhpiego is worthwhile and we are confident that the current approach will be successful.”
The focus on services for postpartum family planning and immediate postpartum IUCD (PPFP/IPPIUCD) began in earnest in 2009. The goal was challenging: The Government of India wanted to reach a contraceptive prevalence rate of 68 percent by the year 2016. In this vast state known for its forts, camels and legendary rulers, women marry at an early age and literacy rates are low. According to the National Family Health Survey-3 (2005–06), only about 1.6 percent of married women ages 15–49 in Rajasthan use IUCDs, and there was a huge unmet need for family planning (14.6 percent).
With the help of Jhpiego and partners, a strategy to increase the use of PPFP/IPPIUCD services was developed: establish nodal education sites for health providers, strengthen family planning services, create awareness, generate demand for services and evaluate the work done.
LAYING THE GROUNDWORK
The Government of Rajasthan identified three NIPI focus districts in the northeastern part of the state (Dausa, Alwar and Bharatpur) for the introduction of these services to be phased in, under the national Reproductive and Child Health Program II. After an evaluation of the performance there, the services are to be expanded over the entire state of Rajasthan.
The education of health providers took place at SMS Medical College (through its affiliates, Mahila Chikitsalaya and Zenana Hospital) and the District Hospital in the capital city of Jaipur. Those providers will in turn share their skills with colleagues at the district hospitals and support implementation of the government-approved IPPIUCD performance standards.
Recognizing that public health services are best utilized when clients and prospective patients are not only aware of, but actually demand the services being offered, the PPFP/IPPIUCD project developed counseling materials for community- and facility-based health workers who strive to link residents with the services they need. The demand-generation activities were undertaken in collaboration with the state’s Information, Education and Counseling Unit and the Indian Institute of Health Management Research (IIHMR), Jaipur.
Another important component of the PPFP/IPPIUCD project is the establishment of a robust documentation and monitoring and evaluation system to measure and disseminate results. The goal is to generate useful information based on family planning service statistics and trends for policymakers, program managers and relevant stakeholders.
JHPIEGO’S PROJECT ACTIVITIES
For its part, Jhpiego was actively involved in a number of activities between June and November 2010. At the start, the India team co-hosted a stakeholders’ meeting on May 31 at the Health Directorate in Jaipur. During the meeting, stakeholders shared their opinions and ideas for designing a strategy to revitalize PPFP/IPPIUCD services. With a strategy and plan approved, it was time to build a platform to support PPFP/IPPIUCD services among the providers who would be directly involved in implementation—gynecologists. An orientation for these providers from all district hospitals and medical colleges was held on July 12, 2010.
Five days later, coinciding with Population Week, Ashok Gehlot, the Chief Minister of Rajasthan, along with Ghulam Nabi Azad, the Union Minister for Health and Family Welfare, and other dignitaries formally inaugurated the PPFP/IPPIUCD services in the state.
To identify areas for improvement and direct specific actions, a baseline assessment of training sites was done at Mahila Chikitsalaya, Zenana Hospital, Kawantiya Hospital and District Hospital in Dausa. Clinical skills and standards for PPFP/PPIUCD service delivery were examined. Following the baseline assessment, 24 service providers from Zenana Hospital, Mahila Chikitsalaya and Kawantiya Hospital attended seminars on PPFP/IPPIUCD services at Safdarjang Hospital in Delhi.
Jhpiego then supported Mahila Chikitsalaya and Zenana Hospital with equipment, teaching materials, anatomic models and other logistics so they could begin to offer the services and hold subsequent education courses.
Recognizing that India has one of the largest private health sectors in the world, Jhpiego’s India team knew that involving private practitioners in PPFP/IPPIUCD services would help generate broader awareness and create an environment for such services to be incorporated within the private health sector. In November, 27 private practitioners attended an orientation program.
To further the success of the project, Jhpiego is now developing packages for PPFP/IPPIUCD counseling, which will be used by community health workers—Yashodas, ASHAs (Accredited Social Health Activists) and AWWs (Anganwadi Workers). These packages will be integrated with existing education packets for Yashodas and home-based postnatal care services provided by ASHAs.
The packages will be a joint collaboration with the Government of Rajasthan and IIHMR, and discussions about the work plan and scope of the materials have already been initiated with IIHMR.
For accountability, Jhpiego helped develop a monitoring and evaluation framework and identified a set of indicators to be integrated with the regular family planning reporting system. The state has also assigned a nodal officer and a training and state program officer to collect, compile and analyze project data on a routine basis.
After launching this project, the state has shown a good start-up with nearly 300 IPPIUCD insertions in just two months. “There was a serious apprehension among service providers about success of this initiative, which has a bitter experience in previous attempt three decades back. But after technical assistance from Jhpiego and support from NIPI, new guidelines for insertion have been prepared and early stage expulsion is comparatively very low, which shows that strategy which has been adopted this time will result in successful implementation of the program,” said Dr. S. P. Yadav, State Program Officer, Rajasthan for NIPI.
Jhpiego India continues on-site support through regular visits to the SMS Medical College and District Hospital, Jaipur. Through supervision, the India team strives to integrate PPFP/IPPIUCD with maternal and child health services, and motivate health care providers to maintain their enthusiasm.
By Abrar Muhibbul and Charlene Reynolds
Since her marriage nine years ago, Munni Manjari has given birth to six children. All but one has survived. She is just 25 years old and lives in the Sylhet area of northeast Bangladesh. When receiving maternal and newborn health care services from her local community health worker, Munni begged for some family planning options. But the health worker was neither trained nor equipped to provide such options to her. Munni’s repeated pregnancies have left her anemic, suffering from chest pains and generally weak. Her recurrent fatigue keeps her from working several days a week. With limited means, she and her husband, Kripa, can barely provide for their children, who range in age from four months to nine years old.
Like Munni, the women of Sylhet face an uncertain future because health services are scarce and poorly equipped. A group of Bangladeshi and U.S. health care professionals, Baltimore researchers and local community health workers are coming together to change that. They have joined together to educate women, men and families on the benefits of healthy birth spacing and to provide information on family planning options.
More than 2,200 mothers are participating in the Healthy Fertility Study, a collaboration of the Bangladesh Ministry of Health and Family Welfare, Jhpiego, two local nongovernmental organizations (NGOs)—Shimantik and the Center for Data Processing and Analysis—and the Johns Hopkins Bloomberg School of Public Health.
Previously supported by the ACCESS-FP Program, with funding through the U.S. Agency for International Development (USAID) from 2007 to 2010, the study is now supported by USAID’s Maternal and Child Health Integrated Program (MCHIP), which is led by Jhpiego, and Johns Hopkins public health researchers.
The study is already making a difference in the lives of the women participants.
The area of Sylhet has the highest fertility rate in the country—women there have about four children, compared to an average of about three in the five other divisions in the country. The maternal mortality ratio (MMR) is highest in Sylhet (471 per 100,000 live births, compared to the national average of 322), and the infant mortality rate is twice what it is elsewhere in the country, according to country health data.
But results from the Healthy Fertility Study so far show that women and their families are getting the message that pregnancies spaced too closely after a live birth or miscarriage carry very high risks for the mother and her newborn. Three years into the project, the use of family planning in the area is up—36 percent of women reported using contraception as compared to 18 percent in the comparison area at six months postpartum.
A key aspect of the project is providing community-based postpartum family planning along with maternal and newborn health services to women. This integration of services maximizes the benefits of the contact between the community health worker and the woman.
Community health workers—who are typically young, unmarried women with a tenth grade education—are trained to visit homes in their communities to identify pregnant women and educate women enrolled in the study about maternal and newborn health. They also provide information about postpartum family planning, supply oral contraceptive pills and condoms based upon the women’s fertility intentions, and make referrals to government and NGO health facilities for other contraceptive methods.
One effective method that new mothers can use is the Lactational Amenorrhea Method, in which breastfeeding women follow specific criteria in order to avoid pregnancy during the initial six months after a birth. After that period, women need to use other modern contraceptive methods to avoid unplanned pregnancies.
The recent results from the Healthy Fertility Study found exclusive breastfeeding rates were higher, at 38 percent as compared to 28 percent at three months postpartum. In addition, 94 to 95 percent of women in Sylhet said they had seen communications materials developed for the project and 87 percent said they attended a community meeting related to it.
“The Healthy Fertility Study is important because it is using innovative strategies that are helping Bangladeshi women avoid unplanned pregnancies,” said Catharine McKaig, a family planning specialist with MCHIP. “The study is helping women, men, families and communities understand that modern contraceptive methods can be used to ensure that pregnancies occur at healthy times, and avoided at unhealthy times.
“Findings from this study will influence how family planning is integrated in community-based maternal and newborn health care programming elsewhere in the world,” McKaig said.
By Charlene Reynolds
Sixty seconds can mean the difference between life and death for a newborn who isn’t breathing. That’s the window of time a health provider has for resuscitation before a baby suffers injury from lack of oxygen. Jubaida Shirin knows how quickly that golden minute can tick by.
A community-based skilled birth attendant in Habiganj District of Bangladesh, Shirin got a call this past July from one of the women she routinely visited during pregnancy. Minara Khan was in labor. When Shirin arrived, she found Minara’s baby in the breech position. She quickly applied her training to deliver the child, but as she dried and wrapped the infant, she heard no cries.
The baby girl wasn’t breathing.
Shirin put the newborn on her left side on the mother’s abdomen, and tried with all of her might to stimulate the baby’s breathing by rubbing the skin over her backbone. But the tiny girl did not respond. Shirin next began resuscitating the child using a bag and mask as she had been trained to do through an initiative sponsored by the U.S. Agency for International Development (USAID) and promoted by its Maternal and Child Health Integrated Program (MCHIP), which Jhpiego leads, and its partner, Save the Children.
“We thought the child already died, but watched as Jubaida revived her, because of her training,” said a member of the new mother’s family.
Baby Shifa survived and is now a healthy three-month-old.
“MCHIP is proud to be an implementing partner in this commitment to provide lifesaving newborn care,” said Koki Agarwal, director of MCHIP. “Every child should have the opportunity to take their first breath and they deserve us being prepared to help them do so.”
An estimated four million newborns die annually during their first month of life. Half of these deaths occur during delivery and within the next 24 hours, often as a result of inadequate breathing or a failure to breathe. Every year, 10 million babies require help to breathe immediately after birth. Simple means to stimulate breathing, including drying and rubbing, and ventilation with a bag and mask, could save the majority of these babies who die. However, such care is available for fewer than one out of four newborns.
“When staff are recording still births, it may not actually always be a still birth,” said A. Udaya Thomas, a public health specialist with Jhpiego, who has observed high counts of still births and a lack of attention to the newborn post delivery. “It may be that the child was born needing assistance to breathe and was not revived. Timing is everything. You have that golden minute. If you take the right steps in that 60 seconds, you can prevent death and preserve life. A core group of Jhpiego international and regional trainers were trained recently at the Helping Babies Breathe (HBB) training in Washington, D.C., and we are already working on rolling out the training to other trainers, faculty and providers in the countries where we work.”
In Bangladesh, Jubaida Shirin got her resuscitation training through a successful pilot study conducted by Bangabandhu Sheikh Mujib Medical University Hospital, through MCHIP. The study included Habiganj District, where 212 community skilled birth attendants, including Jubaida, were first trained as part of the pilot. The results of this work so impressed the Bangladesh Minister of Health and Family Welfare, Dr. Ruhal Haque, that he pledged the government’s support in implementing a national scale-up of the HBB training program, beginning in October.
“I want to start work within the shortest possible time,” he said at a ceremony in Dhaka where Shirin came to receive her diploma and to share her experiences. “The government will take necessary steps to implement HBB in Bangladesh as soon as possible.”
A preliminary goal of the national scale-up plan will be to train close to 30,000 providers in newborn resuscitation. Eighty-five percent of births take place in homes in Bangladesh, but only 18 percent have a skilled birth attendant present. The remaining births are handled by untrained providers or family members.
Currently, there are 5,500 community-based skilled birth attendants in Bangladesh; the Health and Family Welfare Ministry plans to increase their ranks to 13,500, and provide them with six months of training to make them more effective in saving the lives of mothers and newborns.
Bangladesh was among a handful of countries (India, Kenya, Pakistan and Tanzania) in which HBB debuted with a curriculum specially designed for limited-resource settings. Sponsors of the program include the American Academy of Pediatrics, Save the Children, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Laerdal Medical. With MCHIP’s support, the plan is to introduce HBB in 15 countries in conjunction with governments, ministries of health and other partners.
Master trainers identified in each country will train birth attendants, who in turn will train others in the community. Just as Jubaida Shirin saved the life of baby girl Shifa, these newly trained birth attendants will possess the skills to help other babies breathe.
For more information, visit http://www.helpingbabiesbreathe.org
From staff reports
Integrated health services and innovations promoted by the Maternal and Child Health Integrated Program (MCHIP), the U.S. Government’s flagship global maternal and child health program led by Jhpiego, are helping women to better plan for their families after giving birth, prevent transmission of HIV from mother to child and save women’s lives.
Experts from Jhpiego and MCHIP, which is funded by the U.S. Agency for International Development (USAID), gave more than a dozen presentations at the 2010 Global Maternal Health Conference in New Delhi last month. Results of their work show that integration of a range of services for women leads to improved health care for mothers, newborns, children and families.
Jhpiego and MCHIP colleagues showcased interventions and program innovations aimed at increasing birth spacing and family planning, reducing postpartum hemorrhage, detecting pre-eclampsia and eclampsia and preventing the transmission of HIV from mothers to children. The results reported from Paraguay, Kenya, Bangladesh and Malawi underscored successful efforts under way to reduce maternal and newborn deaths, an imperative of the Millennium Development Goals.
“MCHIP is at the forefront in delivering care and services to women, newborns and children,” said Koki Agarwal, Director of MCHIP. “We were proud to have so many members of our team sharing their great work and showcasing how MCHIP is truly a leader within the global community.”
Here is a sample of the successful programs presented:
• In the Embu District of Kenya, Jhpiego developed an integrated package of post-birth care and family planning services and field-tested it at four health facilities under USAID’s ACCESS-Family Planning Program. According to health surveys, 68 percent of women in Kenya have an unmet need for family planning, resulting in almost one-fourth of all births occurring at intervals of less than 24 months. Research has shown that waiting two to three years to have another child helps safeguard the health and welfare of the mother and child. The Embu health providers used the integrated service package and accompanying brochures to counsel new mothers before they were discharged after giving birth and also when they returned for infant care visits. A study of the effectiveness of the postpartum intervention found that women undergoing counseling avoided getting pregnant within six months of their previous delivery. What’s more, they started family planning much earlier (2.8 months) than the mothers who did not undergo the counseling (3.7 months). The proportion of women receiving high-quality counseling also nearly doubled to 81 percent.
• Women in Paraguay are not routinely using family planning methods, as reflected in 2005 data from the Hospital Nacional in Asunción where more than 76 percent of women giving birth there had unplanned pregnancies. An MCHIP-led study reviewed the 10-year history of approximately 5,100 women receiving intrauterine devices (IUDs) after giving birth at the hospital. Globally, the reported expulsion rate of IUDs inserted in the period after birth ranges from 10 to 14 percent. However, the MCHIP study found the overall expulsion rate was less than 1 percent among the sample of women treated at Hospital Nacional. The study team attributed the low rate to careful training and simple insertion techniques. Based on these findings, MCHIP is now planning to incorporate a postpartum IUD counseling and insertion program in maternal health services with their current project in Paraguay.
• In areas with a high prevalence of HIV, programs to prevent mother-to-child transmission of HIV (PMTCT) should be linked to maternal, newborn and child health services that provide good care. Though conventional postnatal care starts between four to six weeks after delivery, most maternal and newborn deaths occur within the first 72 hours of birth, often from causes other than HIV/AIDS, which are generally more common and often preventable. These causes are generally more common and often preventable. In Swaziland, HIV prevalence in women of reproductive age is 26 percent, and 39 percent among pregnant women. Follow-up for HIV care and treatment after delivery, however, has been poor. The Ministry of Health decided that PMTCT services should be integrated so both mother and child care are assessed and managed together. This shift in emphasis showed that mothers and newborns should receive special attention in the first week, especially the first three days after birth, at both the facility and community levels. PMTCT programs should ensure that mothers and babies receive quality routine and HIV care, treatment, prevention and counseling services.
• In Malawi, community outreach efforts to increase awareness and use of maternal and newborn health services can lead to more mothers receiving care and to the prevention of newborn deaths. In many instances, when a child is ill, mothers delay seeking treatment, have difficulty reaching a heath facility or must wait to receive care once they arrive. The MCHIP team in Malawi found that such barriers can be reduced when communities are engaged in ensuring family members receive care and their leaders and heads of families know what to do to get it. A program was developed to train public health workers in community outreach and basic health care services. In a series of home visits, “health surveillance assistants” encouraged pregnant women to seek prenatal care, give birth in a health facility and seek health services for their newborns. Those assistants in turn identified members of the community to champion good health habits. As a result of these efforts, more mothers and children received basic health care services and healthy behaviors increased.
“Whether it be implementing an integrated package of post-birth care and family planning services, increasing awareness and use of maternal and newborn health services through community outreach efforts or working to ensure that programs are in place so that mothers and babies receive quality routine and HIV care, treatment, prevention and counseling services, MCHIP is leading the way,” notes Agarwal. “
“Through our work with government partners, these maternal health interventions and innovations show results for women and their families, help strengthen health systems and make the case to continue progress.”
Kinshasa, Democratic Republic of Congo — We arrive at N’Djili International Airport late on an August night. It is a beautiful evening, the vast African sky is welcoming. We learned before our arrival of the recent rape of 200 women by rebels in Eastern Congo. Walking through a dark parking lot, I’m guarded—and thankful that our Congolese colleagues from MCHIP, the U.S. Government’s flagship program for maternal and child health led by Jhpiego, are here to welcome us.
In Congo, more than half a million children under the age of five die each year. Their killers? Diarrhea, measles, respiratory infections, malaria, pneumonia, HIV/AIDS and malnutrition. MCHIP has been working to improve health outcomes for children in Congo through supporting immunization, helping prepare new mothers to care for their newborns and advising health authorities on providing quality care. We are here to visit staff, assess the state of maternal and child health, and support our MCHIP colleagues in their life-sustaining work.
In one of my very first meetings, the impact of Congo’s turbulent times on health services is acknowledged. We climb four flights up in a concrete-block building to meet Pierre Lokadi Otete Opetha, Secretary General of Public Health. He explains that the DRC has just finished a very dark period, 25 years when almost all of the country’s health care was responding to emergencies. Now, a national plan for health care has been developed and the very first need is to develop the country’s human resources potential. Congo needs more doctors, nurses and midwives—and funding for infrastructure and information systems— to build a service delivery system for newborn and maternal health care, to prevent infections and treat diseases, he says. This new strategic plan envisions a multi-sector health system that will serve clients from the facility to the community.
Our next stop, at the U.S. Agency for International Development, is to talk about the health challenges in Congo and efforts to improve care. But first we have to get into the building. Passport checks, security gates, metal detectors, pat downs—the security is extensive. Once inside, we meet with staff who lay out the geographic realities of traveling across the country—the land mass of Congo is a quarter the size of Europe and the system of paved roads covers only about 2,000 miles. Reaching people outside of Kinshasa is a logistical challenge and often risky. Two days before our arrival, a plane carrying a team of five health workers to a remote area for an immunization project crashed.
Poor or nonexistent roads and infrastructure often impede efforts in developing countries to improve or increase health care services. Building a network of locally based community health workers, as is being done in Congo, is a practical, efficient way of meeting the basic health needs of women and families. I have seen the life-changing work of such health workers in Rwanda, Afghanistan and Nepal. Trained in basic methods of assessing clients, they are helping women and families in villages and towns confront diarrheal disease, malaria, infection and malnutrition. With a kit of basic supplies, they provide a basic level of care in the most remote locations. Their work can build support for reducing maternal deaths and, at the same time, raise awareness about the impact a lower maternal mortality rate will have on newborn lives.
At Roi Baudouin Hospital, a small but busy facility with more than 300 births a month, there is plenty to be proud of, even with the hospital’s limited resources. I notice many positive infection prevention strategies—buckets with bleach for cleaning instruments, sharps boxes and other infection prevention tools. Staff in the maternity ward show off its recent installation of air conditioning in the labor and delivery room, an achievement most appreciated on this 100-plus-degree day.
During the visit, I am introduced to Dr. Ebondo Ngoie. Now, my favorite question to ask as I travel the world and meet with physicians, nurses and midwives fighting to keep women and their families alive in these difficult places is: “Have you been trained by Jhpiego?” Dr. Ngoie proudly answers, yes—he was trained in Burkina Faso by Dr. Blami Dao, one of Jhpiego’s veteran master trainers. I ask what improvements he has made since that training. He points to a metal pole in the labor room from which he will hang a curtain to provide privacy and stop cross-contamination as women give birth on the five delivery tables that are side by side, with only a foot or two between them.
No curtains yet, but recognizing the need for them is a small step forward. He tells us that he is now talking to women during labor—trying to interact with them—to offer them information and feedback while they are giving birth. This is a new skill. He also permits women to give birth in a position they find comfortable and does not force them to deliver on their backs because they often prefer to give birth in a seated or squatting position. Many African women often refuse to deliver in a health care facility—even though that’s where they can get help if complications arise—because they are restricted in their birthing position.
A facility with competent providers intent on doing things to make women safer and more comfortable while giving birth—there is reason to be hopeful here. As we head for the hospital exit, we pass a cleaning crew in an examination room. The workers are sweeping needles and gauze, syringe vials and used cotton into an open gutter in the middle of the compound—a vivid reminder of the work Jhpiego and partners have yet to do here.
At St. Joseph Hospital, the maternity ward is one of the far-off buildings. I always notice that the maternity space is usually in the most distant, least tended part of any hospital. As we pass through a final gate, a sign warns, “No firearms allowed.” A woman physician, young, energetic, immaculate in her white clogs and coat, enthusiastically greets us. We enter the delivery area to the heartening sounds of a crying infant. A small but apparently healthy baby is on the scale getting its first weigh-in. The baby is flailing and howling—a wonderful sign—and the nurses and midwives are all smiles.
After the baby girl is weighed, she is dried and dressed, a little pink hat placed on her head and her umbilical cord is perfectly managed—all standards of good practice. I am warmed to see this beautiful child tended to by competent caregivers.
Jhpiego’s reputation precedes us as the doctor introduces me to several staff who have been trained by Jhpiego. She has heard such wonderful things from her colleagues; she wishes she too had been trained by us. As we chat, a pregnant woman in a wheelchair is rushed into the ward. Her ankles are swollen and her blood pressure is very elevated. For almost five days, the woman has been trying to reach a health facility. She is in grave condition, apparently suffering from severe pre-eclampsia, very likely to deteriorate into life-threatening eclampsia—the No. 2 killer of women in the developing world. We quickly exit the ward to allow everyone to attend to this dire situation.
Before the day is over, we meet another Jhpiego alumnus at St. Joseph’s who has proudly displayed his Jhpiego training certificate at every job site in the past 20 years; we hear again about the difficulty in reaching Congolese families in the far corners of this vast nation; and we meet with more than 300 Congolese health care providers whom we’ve trained and toast their efforts in fighting against great odds to care for their countrymen and women. And, I learn that I can’t leave Congo without a CD from Papa Wemba, the country’s greatest musician.
Congo, novelist Joseph Conrad’s “heart of darkness”: The contrasts in this richly resourced, violence-weary country can disarm the toughest cynic, perpetuate feelings of despair and yet engender an unlikely spirit of hope. Consider our visit to Mama Yemo Hospital. Limited resources mean infants are doubled up in incubators, women labor in beds without mattresses and illness permeates the facility. Even in these circumstances, nurses are teaching new mothers about family planning and how to care for premature infants: Tuck them in a sling nestled on mother’s chest, skin to skin, incubating in a mother’s warmth, a knitted cap placed on the baby’s head. A primal, life-affirming solution to save newborns.
By Linda Fogarty and Altina Peshkatari
Tirana, Albania—Over the years at Koco Gliozheni Maternity Hospital, nurse-midwife Laureta Ramaj would see familiar faces. Women who had given birth just a year before were back again. A veteran of the maternity ward, Ramaj quietly wondered about the frequency of their return visits and how these young mothers were coping at home. After talking to them, Ramaj realized that the mothers had little or no information on how best to plan for their families—they “just got pregnant.”
In Albania, despite its relatively favorable health indicators, Western sensibilities and proximity to modern European capitals, the use of family planning methods and contraceptives has been surprisingly low. Although 70 percent of married women do not want any more children, according to a recent national demographic and health survey, only about 11 percent of Albanian women use modern, effective contraception methods. Although exact numbers are difficult to establish, providers report that many women use abortion as a back-up to failed traditional contraception.
With funding from the U.S. Agency for International Development (USAID), Jhpiego began working in Albania in 2007 with partners to change that scenario and help Albania move toward modern contraception as part of a healthy lifestyle. The goal was to improve family planning services for women after they gave birth or had an abortion, increase the use of intrauterine devices and other modern contraceptive options, and encourage local responses to the unmet need for family planning.
The USAID-funded, ACCESS-Family Planning Initiative helped the Albania government establish national protocols and standards for family planning, developed learning materials for providers and educational brochures for clients, trained health care providers to implement new family planning services and ensured availability of family planning supplies.
In Jhpiego-led trainings, more than 340 nurses and midwives like Ramaj learned to incorporate postpartum family planning in their routine services for pregnant women. The providers learn how to promote healthy birth spacing and effective family planning methods suitable for postpartum women, including the lactational amenorrhea method, an exclusive breastfeeding method that naturally helps avoid pregnancy, and to use client materials to make modern contraception understandable and acceptable for couples. The World Health Organization recommends that women wait two to three years before having another child, a period of time that allows a mother to nurture and provide for a child without compromising the needs of siblings.
At Koco Gliozheni Maternity Hospital in Tirana, where she has been head midwife for five years, Ramaj built on her USAID-supported training and established a counseling room, where she could provide well-baby and family planning information for new mothers in a convenient, accessible and inviting setting. She set her sights on a large, cluttered storage area that was just down the hall from where women gave birth. With help from Jhpiego and hospital staff, Ramaj transformed the storage area into a warm, cheerful resource center for new mothers to meet with doctors and nurses in training.
New mothers stop in at the center to learn about and discuss family planning methods and their babies’ needs. A selection of up-to-date brochures, DVDs and other materials are available for the new mothers, and Ramaj uses them to engage women in conversation and discussions. In any given month, about 40 women on the 18-bed maternity ward will visit the resource center, Ramaj says.
Ramaj’s decision to set up a family planning resource center on the maternity ward may be unique to her hospital, but she is an example of health care providers incorporating their new knowledge into the work place and expanding on it to improve and strengthen health care services to patients. According to a review of Jhpiego-initiated family planning services for postpartum women, 92 percent have discussed family planning while in the hospital and 76 percent left the hospital using (or planning to use) the lactational amenorrhea method at the time of discharge.
“One wishes to have a first baby and a second one, but after that planning is necessary,” Marjola Kupa, a new mother, told ACCESS-FP staff. “We do not want more than two children but they may happen. We now have books and materials that will help us not to have regrets later.”
Added Irida Daci, another new mom: “It was very interesting to know that breastfeeding can be a contraceptive method.”
Another important component of the family planning project in Albania was the integration of family planning services with pediatric care. In Albania, new mothers visit their pediatrician as many as 15 times a year. “Integration of family planning services in pediatrics is essential,” said Dr. Arta Mezezi, a pediatrician in Tirana. “We should use this opportunity to advise mothers how to avoid close spaced pregnancies. I provide information and leaflets to mothers in almost every visit and meeting.”
Ramaj says the needs of her patients motivated her to act.
“You see a woman for the second time with a second child and you say, ‘What are you doing here, I mean you just had a delivery?’ and she says, ‘Well, I got pregnant.’ I ask, ‘Do you protect yourself?’ But they lack information,” says Ramaj, who has two daughters.
“Before this training happened, postpartum women would come to this department and leave without any information on health education or family planning,’’ says Ramaj, referring to the USAID-funded and Jhpiego-implemented project. “But now I provide them with information that is meaningful to them.”
In counseling mothers on postpartum family planning methods, Ramaj also discusses breastfeeding techniques and well-baby messages and reinforces them.
“Patients are very happy and they really thank me a lot.”