APPROACH
Every Mother Counts (EMC) will provide financial support to Partners in Health's (PIH) organization in Haiti Zanmi Lasante (ZL), in order to increase the number of highly skilled birth attendants in Haiti and the percentage of births taking place in a facility; with the ultimate goal of lowering maternal and neonatal deaths and disability in Haiti. Leveraging the combined service delivery and training capacity of PIH's new teaching hospital in the Central Plateau, Hôpital Universitaire de Mirebalais (HUM), EMC will fund a two-year midwifery and obstetric skills in-service training and continuing education program that will provide a cadre of PIH/ZL nurses, nurse-auxiliaries, and nurse midwives with the skills to capably identify high-risk births, manage labor and delivery, and handle complications and obstetric and neonatal emergencies. This cohort will include an estimated 80 nurses, nurse-auxiliaries, and nurse midwives from 12 PIH/ZL sites, mainly the Central Plateau, and approximately 20 ajan fanm, or frontline health workers. The program includes a community outreach component that will educate frontline health workers, as well as engage traditional birth attendants, or matrons, in the HUM catchment area to recognize and refer high-risk pregnancies. With focused high-quality training, continuing education and community outreach, the project will scale up the number of skilled providers who are able to deliver the level and quality of care necessary to reduce the rates of maternal and neonatal death and disability in Haiti, particularly in the Central Plateau and other rural areas.
A needs assessment will be conducted at the beginning of the project to evaluate existing knowledge of trainees and identify gaps, in order to inform the design of the trainings. The program will deliver semi-annual reports on a specific set of metrics, including skills and knowledge assessments, referrals, and labor and delivery outcomes.
Over the long-term, EMC hopes to work in concert with PIH/ZL and other partners to explore and broaden opportunities for formalized midwifery/skilled birth attendant training in Haiti and specifically in the rural areas. Such an endeavor would seek to leverage existing health facilities in the rural areas, like HUM, where clinical practice can take place. The project would hope to capitalize on a spectrum of innovative education elements drawn from a global community of experts, for example leveraging PIH's digital Global Health Delivery Partnership to facilitate a level of rich educational exchange on a global scale.
ACTION PLAN
Throughout the duration of the project, ongoing weekly and monthly topical lectures will take place along with monthly data reviews of women's health statistics and outcomes to inform the need for additional or modified educational training. Continuing education trainings and content-based staff evaluations will take place on a quarterly basis to measure progress and knowledge and skills gained, with a demonstrated increase at the end of year 1 both in knowledge and skill levels and in facility births. At the end of year 2, the project seeks to also show demonstrated management of normal labors and deliveries as well as obstetric and neonatal emergencies.
Q1/2 will include a skills and needs assessment of staff. The Outreach Facilitator will begin to identify and build relationships with matròns in the HUM catchment area; adapt the Maternal Mortality Reduction Project training curriculum for Haiti; and work in partnership with Midwives For Haiti to identify lessons learned from their matròn outreach program.
In Q3, monthly matròn training meetings will begin, along with monitoring of the matròn integration program and tracking of in-hospital and out-of-hospital birth outcomes for the HUM catchment area, showing an increase in identification of high-risk pregnancies, referrals and facility births in those areas resulting from the program.
One in 83 Haitian women dies from pregnancy and childbirth related causes, the highest in the western hemisphere (WHO et al., 2010). For every death, 20 women suffer from debilitating complications like obstetric fistulae. Newborn (neonatal) deaths number 31 out of 1,000 live births. Rural conditions are particularly dire. Three in four women in rural Haiti gives birth at home without a skilled birth attendant, and many women do not have access to emergency obstetric care (DHS 2012). An untrained traditional birth attendant (matròn) accompanies many of these births. This is largely because Haiti suffers from a critical shortage of skilled healthcare professionals, particularly skilled birth attendants and midwives; the UN has named Haiti as 1 of 9 countries facing a, 'severe midwifery workforce shortage,' particularly in the rural areas, with just 174 midwives in a country of 10.17 million people (UNFPA 2011). To ensure 95% of births are assisted by a skilled birth attendant by 2015, Haiti needs to increase its midwifery workforce by 6-15 times (UNFPA 2011). Yet Haiti has just one midwifery school, in Port-au-Prince, which only just reopened in fall 2013, following its destruction during the 2010 earthquake. Most graduates prefer to remain in Port-au-Prince rather than move to a remote rural area. Additionally, for existing nurses and other medical personnel, there are few opportunities to receive obstetric training, participate in clinical practice or be mentored by a maternal health expert. And there are few continuing education opportunities for nurses and midwives to reinforce their skills and learn about advances in medical care. Attrition is also a major issue due to personnel shortages, poor working conditions, and a lack of support.
Reducing Haiti's high rate of maternal and neonatal deaths and disability requires donor and government commitments to supporting high-quality training, education, mentorships and clinical practice, all linked to Haiti's broader health system, which will significantly increase the number of skilled birth attendants and facility births in Haiti, particularly in the rural and outlying areas.
