Midwives in Action:

1. Midwives in Action: Improving Childbirth, Newborn and Young Children’s Health with Continuing Education Updates and Neonatal Resuscitation Courses for Global Peers

2. Terri Clark, PhD, ARNP, CNM, FACNM Associate ProfessorSeattle University College of Nursing Circle of Health International Volunteer and Member, Board of Directors

3. Healthy Mothers, Healthy Babies

4. More than 7 million infants die 0-12 months. Almost two-thirds of infant deaths occur in the first month of life. Among those who die in the first month of life, almost two-thirds die within the first week. Among those who die in first week almost two-thirds die in the first 24 hours of life.

5. Nurses and midwives are the most needed health care providers around the globe today. They provide three-quarters of the world’s skilled health care.

6. Skilled nurses by day, midwives at night

7. Highly experienced midwifery and nursing educators and clinicians from “capacity building countries” can contribute improving nursing and midwifery care in global settings which have low educational resources.

8. Some countries have excess educational capacity Many countries around the world have a chronic unmet health care need.

9. Midwives want to be able to make a contribution besides writing a check.

10. US Midwives are already contributing • A substantial proportion of nurses and midwives work in or volunteer in global sites • Many CNMs/CMs would utilize their midwifery skills if they had access to appropriate opportunities and support– and important niche for COHI. • A significant number have been employed or live overseas and can speak more than one language

11. So how can midwife and nurse volunteers prepare for educational opportunities? • Don’t reinvent the wheel! Anticipate what you will want to have or teach: “Don’t skate to where the puck is, skate to where it going to be.” • Get as much information as you can about the situation your global partner before you travel. • Load up your laptop and take CDs with culturally appropriate educational material for updates on clinical practice.

12. Resources for your laptop • http://www.midwife.org/global.cfm • Source of information on Life Saving Skills, Home Based Life Saving Skills: Publications and course opportunities that adapt to many settings • Opportunities for Africa’s Newborns. Practical data, policy and programmatic support for newborn care in Africa. The Partnership for Maternal and Child Health. (2006 CD) • http://www.hesperian.org/ •  Hesperian works in close collaboration with health workers, grassroots groups, and community organizations around the world

13. More resources • World Health Organization has a modular Midwifery Curriculum adaptable to a variety of settings and available in 6 languages. • It can be printed off the web or ordered as modular texts. • http://www.who.int/making_pregnancy_safer/documents/9241546662/en/index.html • www.globalhealthlearning.org (USAID)

14. Sample Topics for “Midwifery Clinical Updates” in Global Partner Settings • Routine infection prevention practices • Hygienic clamping and cutting of the cord • Tetanus immunizations • Early and exclusive breastfeeding • Limited number of vaginal exams • No routine episiotomies • Providing eye care to prevent GC infection where this is local policy • Partographs to monitor labor progress

15. For example: Promoting family centered care

16. For example: Promoting hand washing

17. For example: Promoting Sanitation

18. Use Millennium Development Goals in Curriculum Design • Goal 3. Promote gender equality and empower women • Goal 4. Reduce child mortality • Goal 5. Improve maternal health

19. Elements of Curriculum Design • Identify Educational Goal or Skill • Specify Objectives: (At the end of the session the participants will be able to…) • Steps for Educational Session • Identify the rational for training professional staff • List the steps in the normal process • Illustrate the pertinent physiology and anatomy • Discuss known risk factors and complications • Identify indications for intervention and nonintervention • Demonstrate the steps in assessment and in using the skill • Identify benefits of professional staff being trained in the skill • Link skill to overall local health and education strategic plan

20. Sample Curriculum • Newborn Resuscitation • At the end of the session the participants will be able to: • Identify the rational for training professional staff in every birth facility in Neonatal Resuscitation • List the steps in the normal process of transition to extrauterine life • Discuss the physiology and anatomy pertinent to immediate assessment of newborn well-being. • Identify indications for support of the newborn and for resuscitation • Demonstrate the steps in assessment and resuscitation • Why should all birth attendants know Neonatal Resuscitation? • It is never known for sure that any newborn will be in good condition at birth- even when there are no known risk factors • Extending neonatal resuscitation skills to professional staff in every birth facility would contribute to significant improvement in newborn survival and prevention of asphyxia at birth • Substantial improvements in child health outcomes cannot be made without improving newborn survival rates on the day of birth…

21. Train-the-Trainers Be prepared with educational equipment and supplies to donate

22. When you are at your site • Observe quietly and take in everything • Note equivalent ways of meeting the same goals • Acknowledge what they are teaching you, and offer to reciprocate • Everyone likes a Clinical Update! • Assume everyone wants to do the best thing • Be very sensitive of consuming resources, even paper • Consider that everyone’s behavior makes sense to them-- • What do you have to know to understand the context?

23. Remember: • You have an accent and probably talk too fast or too slow! • If you are from the US your vernacular probably sounds ungrammatical to other English speakers • When people correct you it is a sign they care • International visitors are a lot of work for the hosts • Dress appropriately. To much of the world casual dress is a sign of disrespect– it is assumed that you do have nice clothing and are choosing not to wear it because you don’t care and don’t take the hosts seriously.

24. Sample topics that travel well— all supported by good evidence • Routine infection prevention practices • Hygienic clamping and cutting of the cord • Tetanus immunizations • Early and exclusive breastfeeding • Limited number of vaginal exams • Providing eye care to prevent GC infection where this is local policy • Partographs to monitor labor progress

25. Potential limitations of working with translators and cultural interpreters: • Interpreters are in a difficult position– they feel no one trusts them • Everyone wants to put the best face on, including interpreters • If the interpreter thinks you are not making a good impression or missing the mark they will “improve” what you are saying • They may asked to translate technical terms which they don’t understand • Make a glossary of terms with them before translation begins • Slides and glossaries can be translated and back translated

26. Elements that contribute to success • Invitations from local professional leaders • Work with leaders and opinion leaders in planning. • Use local documents that have already been approved. • Seek local input on clinical issues, educational topics, cultural and language sensitivities • Be flexible, sensitive, and practical • Advanced preparation helps • Be prepared for things to move deliberatively • Remember, Americans are known for working too hard!

27. Use local documents, where possible

28. Be alert to information that is important to your hosts

30. Methods of overcoming language and cultural barriers • Enjoy social situations with your hosts • Bonds of trust are developed • People get to know each other • Be cognizant of social norms • Eat what everyone else eats • For example, your eagerness contribute to your share of doing the housework may be seen as putting someone out of work Returning to the same site is critical: It demonstrates commitment Bringing donated equipment may present problems: Ask first!

31. IF you are planning to teach a particular skill set • Example: Neonatal Resuscitation Program • Sustainability: • Be sure the equipment is already in place or bring it to donate • Donors are easy to find! Mothers and newborns are very inspiring to them, and depending on the type of NRP equipment cost varies from $200- $1400. • Resuscitation equipment is available from health education supply companies and can be ordered on line

32. Example: Neonatal Resuscitation Program • Use the existing country NRP courses– they are almost always based on WHO standards and curricula • The curricula are more elaborate with the degree of development of the country, but principles are the same • Plan a basic skills test and follow-on with a Train the Trainer session • Include principles of teaching • Have a skills test-out (if not a paper and pencil assessment) • Plan opportunities to practice their teaching skills with supervision

34. Local Leaders and Active Learning

35. Training the Trainers

37. “What did you learn that you liked best?” “Before I always put a baby with a low APGAR to the side. I didn’t know there was anything to do. Now I know if I follow the steps we learned, many babies can be saved!”