Originally published on the Frontline Health Workers Coalition blog.
Imagine being a novice midwife in rural Zambia. You’re working in a
peripheral health center in a remote area where you are the only health worker.
You are totally alone except for a cleaner and a guard. You regularly confront
emergency obstetric and newborn care cases where there is no time for referral.
You must act in the moment alone and do the best you can under sometimes dire
“Some emergencies cannot be referred without causing maternal and newborn
mortality and morbidity,” says Patrice White, CNM, DrPH, interim director of the
Department for Global Outreach for American College of Nurse-Midwives (ACNM).
“For example, if a midwife doesn’t know how to recognize and competently manage
postpartum hemorrhage—the leading cause of maternal mortality worldwide—a
newborn with asphyxia, or a woman with eclampsia, the woman or baby may
Ten years ago, committed to
addressing its maternal and newborn mortality and morbidity rates, Zambia’s
Ministry of Health conducted an emergency obstetric and newborn care
assessment. Then, as now, Zambian midwives and nurses provide approximately 87% percent of prenatal care and assist with 41% of deliveries (as compared with 4.5% of deliveries assisted by doctors or
clinical officers). Among the assessment’s conclusions was a recommendation to
emphasize building the skills of health providers in emergency obstetric and
newborn care, with a priority placed on strengthening pre-service midwifery
training to prepare them for their real-world role.
ACNM stepped up to help achieve this
goal. A Frontline Health Workers Coalition partner, ACNM is the professional
association of midwives that sets the standard for excellence in midwifery
education and practice in the United States and has worked globally to
strengthen the capacity of midwives in developing countries for more than 30
Beginning in 2010, ACNM and its
partner and subcontractor, the USAID-funded Zambia Integrated Systems
Strengthening Program (ZISSP) and its follow-on project, Systems for Better
Health (SBH) have worked with the Zambian Ministry of Health and the country’s General
Nursing Council to strengthen clinical simulation, a teaching method that
depicts real-life situations for students to address, in the skills lab. ZISSP
and SBH partnered with ACNM staff who trained midwifery tutors and clinical
instructors at 13 of country’s 18 midwifery schools. Guided by ACNM, the tutors
and clinical instructors created a variety of simulation scenarios and learned
to run the skills labs. Additionally, the projects, with the help of ACNM,
equipped each school with four to ten simulation stations.
In the skills lab, students can
practice various scenarios repeatedly before they go into clinical situations.
They focus first on the management of normal birth, and then on infant
resuscitation, postpartum hemorrhage, and other conditions such as breech
delivery and shoulder dystocia, which seriously impact maternal and newborn
mortality and morbidity. “We’re teaching students how to handle complications
and how to handle them, if needed, alone,” White stresses.
A clinical instructor (in white) and
a tutor simulate a normal delivery using the Mama Natalie model in Zambia.
Courtesy of American College of Nurse-Midwives.
This process optimizes students’
time in the hospital. First, they learn the clinical skills more quickly
because they’ve practiced them in the simulation lab. This leads staff members
at clinical sites to permit the students to perform procedures on clients
sooner, which builds the students’ confidence and skills. Additionally, as
their confidence grows, their patient interaction improves, which increases
their diagnostic ability.
Strong in their Skills
“We’ve had feedback from the doctors
and staff in the clinical areas, asking, ‘where did you find these students;
they are so good.’” White adds. “Additionally, educators tell us the students
themselves, all alone in their first posting, say they feel strong in their
skills and more prepared.”
Anecdotally, the improved training
is having a genuine impact. Though it’s difficult to accurately measure infant
and maternal mortality and morbidity and almost impossible to assign causality,
what’s clear is, in Zambia, infant and maternal mortality and morbidity is decreasing–one confidently
handled birth at a time.