Innovative Training of Birth Attendants

Imagine you are a physician working in a rural health center in a developing country. You’re helping a woman deliver her baby, and it’s just arrived but is not breathing. Meanwhile, the mother has started to hemorrhage. You’re the only one working in the clinic that day, and many life-saving treatments need to start within one minute. You have 60 seconds to make decisions that could cost the lives of two people.

That “golden minute” is critical for saving newborns in particular, said Dr. George Little, professor of pediatrics, obstetrics, and gynecology at Dartmouth Medical School and a fellow at the American Academy of Pediatrics, at the Wilson Center on September 30.

While maternal and child deaths have declined by almost 50 percent since 1990, according to the World Health Organization, approximately 40 percent of yearly under-five deaths are in the first 28 days of life, and 800 women die daily due to preventable causes, 99 percent of whom live in developing countries. That means that many of the countries striving to meet the Millennium Development Goals to reduce maternal mortality by three quarters and under-five mortality by two-thirds from 1990 to 2015 are likely to miss the mark.

“We have much to be happy about in terms of achievements we have done in the last 10 to 15 years, but our job is not done,” said Dr. Harshad Sanghvi, vice president of innovations and medical director at Jhpiego.

New techniques for training more midwives and technologies to help them make the right decisions in this golden minute could, however, make a big difference.

Low-Resource Settings

Many of the challenges to providing quality maternal and child health care in developing countries stem from a lack of training institutions and tutors, said Geeta Lal, senior advisor for strategic partnerships in the sexual and reproductive health branch at the United Nations Population Fund (UNFPA). “Even where [schools] exist, they are not properly equipped, the doctors are not there, the trainers are not there, and clinical skills training is particularly lacking.”

Jhpiego, a health NGO affiliated with Johns Hopkins University, is working to address this challenge through rapid training programs for midwives, said Sanghvi. Even in countries that meet the World Health Organization’s recommendation of six midwives per 1,000 births, women aren’t necessarily getting the quality care they need, he said. “It’s not only about the numbers of midwives, it’s about the skills of our frontline workers.”

Training new midwives must include clinical governance, Sanghvi said, a term he used to describe techniques to ensure skills learned in the classroom are used and maintained in the workplace. For example, after training, there should be regular check-ins to ensure health workers are using their new skills – and doing so properly.

And if midwives work in a rural part of the country where women do not deliver in hospitals, it doesn’t make sense to train them in hospital settings, Sanghvi said. InAfghanistan, Jhpiego’s midwives complete a practicum in home births to ensure their training is as similar as possible to the conditions they’ll encounter in the field.

The Mobile Revolution

Technological innovations are also being developed to address these challenges. Lal outlined a new e-learning module designed by UNFPA that teaches birth attendants how to recognize potential red flags and respond accordingly with high quality care. The cost of laptops has declined so significantly that it’s now cheaper to buy them for students than to pay for the cost of midwifery books for three years, Lal said. And the modules can also be used offline, making them accessible in countries with limited internet access.

Not only are midwives learning about proper maternal and newborn care through the modules, but they’re also learning computer skills, said Lal, which they can use to improve record-keeping.

Jhpiego is also testing a virtual classroom training method in India to train new midwives, Sanghvi said. There are two instructors in the state of Bihar that conduct virtual lessons for 12 midwifery schools, and “every student in those 12 schools is receiving a standardized education at the highest possible level.”

Mobile technology is an area with great possibility for rural health care workers, said Lal. “Even where people don’t have food to eat or an adequate roof over their heads, they still have a mobile phone.”

A recent Broadband Commission report says that by the end of 2014, approximately 2.9 billion people will be online and 3.4 billion unique people will have mobile phones. There’s potential to use these new networks to promote maternal health, even in hard-to-reach parts of the world.

But the health sector isn’t taking advantage as much as it could, said Sanghvi. Farmers, for example, use mobile phones to monitor their crops and to find the right types of fertilizers. Mobile technology could help patients keep track of their appointment schedules and reduce the need to visit a clinic, and there may be even more innovative uses. “There is promise, but there isn’t the fullest of evidence yet,” he said.

Simplifying Training

Another way to improve training for midwives is to simplify. Sanghvi showed a modified World Health Organization Partograph, a midwife training chart. “My students at Hopkins asked me, ‘Which idiot developed this?’ and I had to tell them that I was the idiot,” Sanghvi said. “The midwife is supposed to collect all of this information and make sense of 13 to 15 pieces of information to predict problems in labor and to detect problems in labor. It’s very complicated.”

New infographic and mobile training materials make it easier for midwives to identify problems and track the labor process. Sanghvi said that Jhpiego is now testing a tablet application to enter information and plot data. If something goes wrong, the app will automatically send alerts to the midwife and her supervisor.

The Helping Babies Breathe curriculum, an initiative of the American Academy of Pediatrics with support from a number of global health organizations, trains midwives in neonatal resuscitation and simplifies the post-delivery action plan for midwives using a color-coded infographic.

When only one care provider is available, “the first golden minute belongs to the baby and not to the mother…and that’s very new,” Little said.

Using stoplight colors to indicate increasing urgency, the infographic highlights actions to be taken within the golden minute to ensure that the baby starts breathing after delivery. If the baby is still not breathing after 60 seconds, midwives are instructed to call for help.

The infographic is designed for universal use, said Little, accommodating varying degrees of health infrastructure. This is a break from past approaches that relied heavily on textbooks originally written for North American audiences.

The infographic is supplemented with additional training tools, including a flipchart, workbook, and simulator doll called NeoNatalie, all of which are available at relatively low cost, said Little.

The curriculum’s universality means that “it’s not trying to do all things for all babies at all times,” said Little. “It’s linked to trying to get to babies and save as many as you can with the resources that you have.”

Respect for Mother and Midwife

Empowerment – both of the patients and the midwives treating them – is vital to better maternal and child health outcomes, said Sanghvi.

He cited an example from Afghanistan, where a midwife stood up to a woman’s husband who repeatedly barred her from entering their home to help his wife. Eventually he relented and the midwife saved the woman’s life by manually removing a placenta that had not evacuated after birth.

“All of these things were not just about training a midwife,” Sanghvi said. “It was about empowering her with knowledge and abilities.” The midwife almost certainly would have been killed had she failed and the woman had died, he said – that supreme confidence to perform a very difficult procedure anyway is what training should strive to give every midwife.

Likewise, “each woman is entitled to respectful care in maternity,” said Lal. In some countries, “women no longer trust health facilities…simply because it’s better to die at home than travel and spend all the little money that you have and come to reach a facility and then die there.”

Sixty seconds may not be long to make key life-saving decisions, but through training and empowering midwives and embracing innovation, there are tremendous opportunities to save mothers and babies from death during childbirth.

Event Resources:

• Friday Podcast With Dr. Harshad Sanghvi
• Photo Gallery

Sources: Broadband Commission for Digital Development, United Nations, USAID, World Health Organization.

Drafted by Heather Randle, edited by Schuyler Null.