Midwifery Centers in LMIC: Evidence, quality and standards

presentation on midwifery centers- evidence, standards and impact in LMIC

1. Midwifery centers in LMIC: evidence, quality and standards Jennifer Stevens Associação Portuguesa dos Enfermeiros Obstetras (APEO) May 3,2024

2. Acknowledgements AABC Foundation Boston University Cris Alonso Cynthia Ingar Stan Shaffer And all the midwifery centers out there!

3. Introductions ER/ICCU nurse 10 years Midwife for 16 years, 10 director of a freestanding midwifery center DrPH in global public health Co-Founder of Goodbirth Network Supported work in: Haiti, Geneva, Bangladesh, India, Niger, Nigeria, Sri Lanka, Mexico, Peru.

4. Overview Evidence and Quality History and Evidence from HIC LMIC research: GBN studies, Burnet studies Standards Development of definition Development of standards Accreditation pilot Potential impact on health systems Global implementation Examples, Challenges, form and function- the facility

5. 1. Evidence and Quality HIC evidence LMIC- GBN studies, Burnet studies history

6. Brief history of modern B irth C enter in US 1946 : La Casita opened in Santa Fe, New Mexico by the midwives at Catholic Maternity Institute 1975: The Maternity Center Association opens the Childbearing Center in NYC 1979: Tour of the 14 known birth centers finds they need support 1981: Cooperative Birth Center Network formed (CBCN) - with Amer. Public Health Assoc. to develop definition, facility requirements, and regulation 1983: CBCN becomes the American Association of Birth Center (AABC) 1985: National Standards adopted, 12 centers accredited through pilot program research

7. Midwifery birth center research in HIC outcomes

8. Outcomes of Birth center research in US Of those planning a birth center birth: 84% gave birth at the birth center. 4% were transferred to a hospital prior to birth center admission , and 12% were transferred in labor after admission . (most were primigravid) Regardless of where they gave birth: 93% of women had a SVB, 1% an assisted vaginal birth, and 6% a Cesarean . 2.4% of women who birthed in the center required transfer PP, and 2.6% of newborns were transferred after birth. Of all transfers: J ust 1.9% were emergent transfers during labor or after birth. (fetal distress, PPH) No maternal deaths. IP fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. Neonatal mortality rate was 0.40/1000 excluding anomalies. Stapleton, S, Osborne, C, Illuzzi , J (2013) Outcomes of care in birth centers: Demonstration of a durable model. J of Mid and Wom Health

9. Safe Effective Efficient Satisfying research summary of Midwifery centers in HIC What about LMIC

10. No standard definition, model, or services No standards, regulation, or accreditation Diverse systems for quality Financial challenges Staffing Challenges Most people or organizations who open a midwifery center in LMIC, must reinvent the idea every time. What we know about Midwifery centers in LMIC GBN quest

11. GBN questions (2016): Where are they? Where we got our data (2016): Literature reviews Internet searches Midwifery associations Bulletin boards Personal communication /word of mouth map

12. Global distribution of midwifery centers High income countries Low and middle income countries Safe?

13. GBN question (2017): Are they safe? How are they functioning in LMIC? How does a MBC function in LMIC? Is the care provided safe ? Is the experience of care high quality and compassionate? Is it an option for a low resourced health care system? Participating MC

14. Haiti (5) Uganda Sierra Leone Cambodia (2) South Africa Peru (2) Trinidad Ecuador Mexico (6) Midwifery centers in LMIC characteristics 21 Participating Midwifery centers Bangladesh

15. Characteristics of Midwifery Centers in LMIC Goals: Midwifery model of care (MMOC), Respectful Maternity care (RMC) and to increase access to care. Staffing: usually 2 to 8 full time equivalents Clinical volume: Average of 50 deliveries per year Facility resources: 12 of 21 centers had a continuous supply of electricity Safe care: all 21 centers had IV uterotonics & staff trained on neonatal resus. Respectful care: 17 of 21 had a formal policy for respectful care Country outcome

16. GBN standards

17. 2. GBN Standards Development of definition of midwifery centers in LMIC Development of standards for midwifery centers in LMIC Pilot accreditation of midwifery centers in LMIC Definition process

18. Definition Consensus through: 4 FGD at internationally conferences 3 online meetings with 11 countries: Haiti, Mexico, Peru, UK, US, Canada, France, Trinidad & Tobago, Netherlands, Switzerland, and Australia definition

19. Definition a health care facility serving women through their life course rooted in midwifery philosophy and model of care in a home-like shared space ensuring basic emergency maternal and neonatal care for all births integrated within the health care system responsiv e to needs of its community with the woman's experience at its heart and center MC in system

20. Midwifery center in the health system standards foundation

21. Standards Initial draft of standards developed from AABC, MuNET , WHO, ICI, and White Ribbon Alliance. development

22. Standards Development of global operational standards for midwifery centers Consensus through: FGD in 3 countries 2 international meetings Online forums Piloted in 8 countries: Sierra Leone, Cambodia, Bangladesh, Haiti, Mexico, Peru, Uganda, Trinidad & Tobago Final standards

23. Standards Final list had 43 standards in 3 domains Dignity: Woman focused Quality: Provider Focused Community: Administration focused accredit

24. Accreditation Pilot 5 Centers participated 1 completed (in Feb 2024) 2 in last stages 2 withdrew (1 in Haiti, 1 stopped participating) BMG research

25. BMG funded research in LMIC BMGF funded ICM  Burnett Institute 1. What are they? 2. Where are they? 3. Are they economically viable 4. Can we scale up- key features and challenges results

26. Burnett Institute results Challenges: Inadequate facilities, limited space, overcrowding, lack of basic infrastructure (beds, electricity, running water, toilets), lack of equipment and supplies, poor transportation infrastructure & geography What makes them work/key features: Leadership and governance, sustainable financial model, quality midwifery care, interdisciplinary/ interfacility collaboration Conclusion: No one size fits all Can be cost effective Potential to contribute to UHC Can provide quality midwifery care Community engagement, trust and recognition are important MC impact

27. 3. Impact Potential impact System strengthening Cost savings: Appropriate provider and facility for woman’s needs Strengthening midwifery education Clearer SOP of cadres System impact

28. Midwifery led birth centers strengthen health care systems: System Strengthening Bridging home and hospital: optimal care experience (model of care) Improving access and quality: integrated health care system (referral pathways) Bridging professions: OB-Pediatrician-Midwife-Auxiliary-community workers Improved midwifery education and identity: midwives’ place of practice, SOP System Strengthening/cost savings- Health care workforce shortage appropriate provider for level of care needed. Health care facility shortage, and cost-effective appropriate level of facility for level of care needed Improved quality with improved outcomes, safety and high level of satisfaction for women. Global implem

29. 4. Global implementation Country cases Challenges of implementation globally Form and Function cases

30. Cases Bangladesh: 2 MCs privately owned by private midwifery school to provide experience of MMOC 1 MC privately owned by midwife entrepreneur to increase access to compassionate MCH in her rural community 5 MC in humanitarian response South Africa: MC opened by independent midwife to provide MMOC and RMC challenges

31. Challenges of implementing Lack of identity: HCF but not medical (not hospital, not clinic) Lack of regulation: Variations in quality, no clear identity, restriction Lack of representation: Need national midwifery center organizations Lack of standards: Challenge of sustainably quality Lack of understanding and valuing MMOC concepts: Privacy, shared decision making, relationship-based care, and MC opening by orgs without midwifery. Challenge of collaboration between different models of care Challenge of weak health systems in LMIC (supply chain, education, midwifery SOP), financial sustainability, staffing issues facility

32. Importance of the Facility The relationship between form and function “home like” shared space, non-hierarchal Waiting area= living room Birth room= bedroom Lending library Classroom Kitchen Clean and dirty utility pics

33. Birth Rooms Baby Buddies Birth Center Marysville, California Baby Love Birth Center – Cape Coral, Florida Dar a Luz Birth & Health Center Albuquerque, New Mexico

34. Mamatoto Birth Centre Trinidad Bangladesh Guatemala

35. Bangladesh -rural BD urban Bangladesh -urban

36. Peru Bali India Sierra Leone more

37. Luna maya Mexico

38. Guatemala Ecuador Haiti Cambodia Community work

39. Maison de naissance - H aiti Engaging communities

40. Engaging communities Space for safe MMOC

41. Creating a safe space for normal birth and MMOC Thank you

42. Obrigado !.......Thank you! Contact: Jennifer Stevens DrPHc CNM MS [email protected] Questions?

43. References Bohren et al. Facilitators and barriers to facility-based birth in low-and middle- income countries: a qualitative evidence synthesis. Reproductive Health 2014, 11:71. Bowser, D., Hill, K., (2010) Exploring evidence for disrespect and abuse in facility-based childbirth. Report of a landscape analysis. USAID- TRAction Project. Harvard School of Public Health. University research Co., LLC. Available from: https://www.ghdonline.org/uploads/Respectful_Care_at_Birth_9-20-101_Final1.pdf Feldstein, A., Glasgow, R. (2008) A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. The joint commission journal on quality and patient safety. April 2008; 34,4. Garfield, R., Berrymen , E. (2012). Nursing and nursing education in Haiti.[Internet] Nursing Outlook 60(2012) 16-20. Available from: http://www.nursingoutlook.org/article/S0029-6554(11)00093-5/pdf Jerome, J., Ivers , LC.(2011) Community health workers in health systems strengthening: a qualitative evaluation from rural Haiti. [Internet] AIDS. 2010 Jan; 24 ( suppl 1); S67-S72. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169202/pdf/nihms180962.pdf Koski-Karell , V., et al. (2016). Haiti's progress in achieving its 10-year plan to eliminate cholera: hidden sickness cannot be cured. Risk management and healthcare polity. 2016:9; 87-100. Available from: https:// www.dovepress.com /haiti39s-progress-in-achieving-its-10-year-plan-to-eliminate-cholera-h-peer-reviewed-fulltext-article-RMHP Le Nouvelliste . 50% des sages-femmes formees en Haiti exercent leur profession a l’etranger . [Internet]. Haiti. 2017-08-09. [cited Feb 7, 2018]. Available from: http://www.lenouvelliste.com/article/174626/50-des-sages-femmes-formees-en-haiti-exercent-leur-profession-a-letranger Martineau.(2016) Quel avenir pour la profession d’infirmiere en Haiti? [Internet]. [cited Feb 7, 2018]. Availble from: http://www.lescacosnoirs.com/quel-avenir-pour-la-profession-dinfirmiere-en-haiti/ Moloney, A. (2013). Haiti’s new generation of doctors hope to revive ailing health sector, rebuild country. [Internet]. England, Wales. [cited Feb 7, 2018]. Availble from: https://www.pih.org/media-coverage/reuters-haitis-new-generation-of-doctors-hope-to-revive-ailing-health-secto

44. References UHC: https://www.who.int/health-topics/universal-health-coverage#tab=tab_1 WHO standards for MCH facilities: https://www.who.int/docs/default-source/mca-documents/advisory-groups/quality-of-care/standards-for-improving-quality-of-maternal-and-newborn-care-in-health-facilities.pdf https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.13451 https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.13451 Lancet MCH quality framework: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext ICI mother-baby-family respectful care: https://www.whiteribbonalliance.org/wp-content/uploads/2019/11/ICI-full-document_EN_2018-colour_FINAL.pdf AABC standards: https://www.birthcenters.org/page/Standards MuNET Standards: http://www.midwiferyunitnetwork.org/wp-content/uploads/PDFs/LY1309BRO-MUNEt-Standards-PRINT-opt.pdf Development of MuNET standards: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263731/ White Ribbon Alliance- Universal Rights of Childbearing Women: https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/Final_RMC_Charter.pdf Global Definition of a Midwifery Center: https://www.sciencedirect.com/science/article/abs/pii/S0266613820300577?via%3Dihub Global midwifery center operational standards: https://www.sciencedirect.com/science/article/abs/pii/S0266613820302540?via%3Dihub

45. References ( cont ) Monroe College. Health care in Haiti. [cited Feb 7, 2018]. Available from: https://www.monroecollege.edu/uploadedFiles/_Site_Assets/PDF/Health_Care_in_Haiti.pdf Mullan, F. (2005). The metrics of physician brain drain. New England Journal of Medicine 2005;353,1810-8. Partners in Health (2013). Accompagnateur training guide. [Internet] Partners in health. ACME Books Inc. 2011. Available at: https:// www.pih.org /sites/default/files/2017-07/ Accompagnatuer_FM_Haiti_English.pdf Restavek Freedom. (2017). Haiti’s colleges and universities. [Internet] Restavek Freedom. Available from: https://restavekfreedom.org/2017/07/28/haitis-colleges-universities/ TB/ HaitiLibre . Häiti -Formation: Moins de 4% de étudiants es soins infirmiers , ont réussi examen d’État . [Internet] 13/03/2017. Haiti Libre .[cited Feb 7, 2018] Available from: http://www.haitilibre.com/article-20348-haiti-formation-moins-de-4-des-etudiants-en-soins-infirmiers-ont-reussi-l-examen-d-etat.html UNFPA. (2017). Midwives offer care, dignity and a lifeline for Haiti’s mothers. [Internet]. UNFPA. 2017 4 May. [cited Feb 7, 2018]. Availble from: https://www.unfpa.org/news/midwives-offer-care-dignity-and-lifeline-haitis-mothers?page=4 USAID, Global Health Workforce Alliance, WHO (2018). Human resources for health action framework. [Internet]. Geneva. [Cited: Feb 18, 2018] Available from: https:// www.capacityproject.org /framework/ WHO. (2006). Working together for health. The world health report 2006.[Internet] WHO. Geneva. Available from: http://www.who.int/whr/2006/whr06_en.pdf?ua=1 WHO. Global experience of community health workers for delivery of health related millennium development goals. [Internet] Available from: http:// www.who.int / workforcealliance /knowledge/publications/alliance/ Global_CHW_web.pdf