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Clean Birth KitsTraining, Laos: Part 1

IMG_0016What a day! Twelve nurses showed up in the rainy morning for a full day of training.  They were smiling and ready to learn from the first moment.

We began with an exploration of the kit, the WHO’s “6 Cleans”, how Clean Birth Kits prevent infection, how to explain their use to families, and how to record data.

These bright nurses, led by Dr. Nong, had questions about the use of each item and how to best explain to mothers and families how to use them.  They answered my questions about number of births, population per village, birth traditions, family planning, etc…

Then we asked them about their ideas for communicating best with families.  As Dr. Nong was writing furiously to keep up with the nurses ideas, I thought “This is exactly what I wanted. I’m in the background, providing the funding, while they come up with their own answers.”

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Laos Needs More Midwives

This article sums it up. Laos needs more midwives. Like 15,000 more. In addition to lack of total trained midwives “the distribution of medical staff is not properly balanced and most medical staff and recent graduates are unwilling to work in rural areas.” This is a critical issue — and once which I hope to do something about.

Laos needs more midwives to stem maternal mortalityOunkham Pimmata Vientiane Times Publication Date : 18-09-2012

Laos will fail to reach its Millennium Development Goal of reducing the maternal mortality rate by 2015 without more trained midwives and easier access to health services.

The country has one of the highest maternal mortality rates in Southeast Asia, Sally Sakukhu, from the Maternal Neonatal and Child Health Unit of the United Nations Population Fund (UNFPA), told the media recently.

In 2005, 450 women out of every 100,000 live deliveries died in the process of giving birth. The government wants to reduce the ratio to 260 deaths per 100,000 live births by 2015.

The latest figures show the ratio is still 300 deaths per 100,000 live births – which presents a challenge to authorities concerned about reaching the target within three years.

“There aren’t enough midwives to help pregnant women in rural areas. In these parts of the country, 5 per cent of pregnant women will lose their life giving birth,” Sakukhu said.

Another problem is that many midwives are undertrained and don’t have the skills to help pregnant women give birth.

The government plans to improve medical services at rural health dispensaries. Each dispensary should have at least five medical staff. The government has also increased funding to create 15,000 midwife positions to reduce infant and maternal mortality rates by 2015.

At present, there are only around 300 midwife positions, a number recognised as a serious hindrance to the government in achieving its target.

However, the distribution of medical staff is not properly balanced and most medical staff and recent graduates are unwilling to work in rural areas.

Sakukhu said ethnic groups’ traditions, inability to pay for medical services, and lack of essential food were contributing factors to higher rates of mortality in rural and poor areas.

According to the UNFPA, every day in Laos more than two women die of complications related to pregnancy and childbirth.

More than 50 per cent of pregnancies are unplanned and a number of these will be unwanted. Each unwanted pregnancy multiplies a woman’s chance of dying from complications from pregnancy or childbirth.

One in four women aged 15-49 years gives birth before the age of 20.

Meeting the demand for family planning services would be expected to reduce maternal deaths and injuries by more than 25 per cent.

Midwives: Rural Areas in Developing Countries Not Appealing

I have often said that while my immediate focus is to combat birth-related infections in remote villages in Southern Laos, my longer term goal is to fund midwifery training.  But how do you ensure that midwives trained in the relative prosperity and comfort of the capital Vientaine return to their villages?  This study examines this exact issue in Ghana and reveals that it’s not easy.

The staffing of public sector health facilities in remote rural areas is a serious challenge for many ministries of health in low- and middle-income countries.

Results
Three themes were identified through a broad inductive process: 1) social amenities; 2) professional life; and 3) further education/career advancement. Together they create the
overarching theme, quality of life, we use to describe the influences on midwifery students’ decision to accept a rural posting following graduation.

Conclusions
In countries where there are too few health workers, deployment of midwives to rural postings is a continuing challenge. Until more midwives are attracted to work in rural, remote areas health inequities will exist and the targeted reduction for maternal mortality will remain elusive.

As an aside, I am shocked to see that Ghana actually has much better maternal and infant stats than Laos (400 per 100k, 80% give birth alone, 27% antenatal care):

Maternal death in Ghana is currently estimated at 350 per 100 000, in part a reflection of the low rates of skilled support during birth [13]. According to the Demographic Health Survey,
43% of Ghanaian women give birth alone or with a non-skilled attendant [14] although 62.8% of women surveyed had attended the minimum standard of four antenatal visits [15].

Lao PDR celebrates the month of midwives

Great article about the Month of Midwives in Laos (Lao PDR).  I am so pleased to see the commitment to increased midwifery training!
Date: 15/06/2012

Every day in Lao PDR, more than two women die because of complications during pregnancy and childbirth. For every woman who dies many more suffer from illness or disability from complications during pregnancy or childbirth. Most of these deaths and illnesses can be prevented when mothers have access to skilled care at birth.

As part of the strategy to reduce maternal mortality in Lao PDR, the Ministry of Health (MoH) with support from the United Nations Population Fund, (UNFPA) and other development partners, specifically UNICEF WHO and the World Bank, is implementing the National Skilled Birth Attendance (SBA) plan that supports the delivery of the national Integrated Package of Maternal, Neonatal and Child Health Services. Specifically the SBA plan includes production and deployment at community level (Health Centre and Hospital Type-B) of trained professional Midwives that are currently being produced in 7 Provincial health schools all over the country.

Normally, all over the world, the International day of the Midwives is celebrated on 5th May each year, but in Laos, in order to ensure that all provinces can take part in the celebrations, MoH have designated the whole month of June as the “Month of Midwives”, because in June the country will see the graduation of the second batch of community midwives. Over the whole month, MoH in collaboration with UNFPA and other development partners is organizing a number of events, the first of which was in Luang Namtha on June 7th, where a health promotion day for mothers and babies in Viengphouka District was held. Two other events are in Savannaketh on 15th and Oudomxay 22nd June, where MOH will present the graduating midwives from the south and north respectively, their certificate of licence to practice as a midwife.

All activities are focused on keeping mothers and babies safe and healthy through access to birth spacing, use of professional midwives before, during and after pregnancy and childbirth and ready access to emergency obstetric care. To make this possible, it is acknowledged that midwives working at the community level must have an unbroken supply of essential supplies and medicines, and must work closely with the community, especially village leaders, in order to promote the key messages and to encourage more men to take proactive action to save the lives of their wives, mothers and daughters.

The main event of the month was the celebration in Savannaketh. The High-level event in Savannaketh on 15th June, saw MoH award the national midwifery certificates of accreditation of competences to the 80 midwives in second batch trained in Khammouane, Champasack and Vientiane Province. The event brought together senior level officials from MOH at central and Provincial level, including the Vice Minister, Associate Prof. Dr. Som Ock Kingsada, as well as representatives from key line ministries such as the Ministry of Planning and Investment (MPI) and the Ministry of Education and Sports, as well as the Lao Women’s Union and government officials from UN supported districts.

“Midwives can provide much more than family planning and skilled care at birth. They can be the link between the community and the health services. They can work together with local leaders to plan and implement actions to improve the quality of life in the community. They can save mothers and babies lives. If people make use of their services, if communities provide them with support and information and local leaders involve them in the planning and decision-making, Midwives can help to make healthier and more productive communities. The work of midwives is the foundation for healthy families, healthy communities and a prosperous nation” said Dr. Esther Muia, UNFPA Representative.

The Vice Minister of Health, Associate Prof. Dr. Kingsada said “In many parts of the world, and now in Lao PDR, midwifery is seen as a very important and gratifying profession. This is why we would like to encourage educated girls and women from the community to consider becoming midwives. We would also like to ask the community and its leaders to identify and encourage girls in particular to become midwives. Every community needs to have its own professional midwife to work with community leaders, families and individual women and adolescent girls to improve knowledge of safe pregnancy, childbirth and care of mothers and babies after birth, but also to provide quality services”

During the event a 15 minutes documentary about the Community Midwives Programme in remote areas of Lao PDR was presented. The video, recorded in Xiengkouang Province and produced by UNFPA’s Asia Pacific Regional Office in collaboration with the Country Office Lao PDR, shows how having skilled birth attendants is helping to improve the health of mothers and babies in these communities.

The training of community midwives is part of the Joint Maternal, Neonatal, Child Health and Nutrition (MNCHN) programme developed and implemented by the MoH and the United Nations. This programme combines the skills and expertise of UNFPA, UNICEF, WFP and WHO and is made possible through a co-financing agreement of more than 8-million euros over five years between 2011-2015, signed between the Grand Duchy of Luxembourg, MoH and the UN.

Contact information:
Diego De La Rosa, Tel.: (+856 21) 315547, Mobile: (+856) 20 59936509, drosa@unfpa.org

Let’s not export our flawed social views on Maternal Health

Today I had a conversation with a friend who is in her 50s about breastfeeding her four children, who were born over approximately a 15 year period.  She said with her first, she didn’t breastfeed at all.  With her second, she breastfed for a month.  And with her third and fourth, born 22 months apart, she breastfed each for a year — and was sad to stop.

What made the difference with her last two?  She said that noone breastfed when she had her first, there was no support.  By the time the last two came, breastfeeding was acceptable if not embraced.  Breastfeeding in the US is increasingly embraced but breast milk substitutes are still being given to almost half of US babies by day 7, according to the CDC.

Thinking about this conversation about social context,  it is clear that society drives what is acceptable/good when it comes to breastfeeding and birth.

In the US C-sections (often scheduled) are de rigeur among celebrities, thus they are regarded by US Weekly fans everywhere as a preferred choice.  The role of midwives is misunderstood, thus they are not sought out.  Birth is seen as dangerous and excruciating and voices opposing this media-driven view are drowned out.  Breast milk and formula are both regarded by many as equally nutritious, with formula having advantages like “baby is more full and sleeps better.”

One of my fears is that our views of maternal health will be exported to the developing world.  It has already begun in the areas of c-section and breastfeeding.

C-section rates in the developing world are on the rise.  One study by Belizan et al comments:

Although the epidemic of caesarean section in Latin America is not new,6 little action is taking place to reduce its use. This is partly because caesarean section is now culturally accepted as a normal way of giving birth.23

Breast milk substitutes are being pushed on populations with neither the money nor the clean water nor the need for them.  Laos is one example where the population has historically had high levels of breastfeeding, but influxes of breast milk substitutes are changing the situation.  This 2010 study by Barennes et al finds:

In Laos, mothers with the highest socio-economic status are showing a tendency to give up breastfeeding. Successful educational strategies and advocacy measures should be urgently developed to promote and sustain breastfeeding in developing countries.

Women in the third world need many things: among them community health workers, midwives, medicine, emergency care and supplies.    However, importing our flawed views of breastfeeding and birthing will not save lives.  Instead, practical solutions need to be found on the ground, where C-sections and milk substitutes are reserved for medically necessary conditions.

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