Royal College of Midwives (RCM) conference paper presentation 2012 (sally Pezaro)


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Global Childbirth & Midwifery – Empowering births, enriching practice and celebrating projects to reduce childbirth mortalities within resource poor communities.

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  • The 20th century produced the Universal Declaration of Human Rights – Inspired by the terrible losses of the 1 st and 2 nd world wars as the world said “Never again” The 21st century, the world has produced the Millennium Development Goals for humanity to achieve faster progress towards a better life. POVERTY - permeates all sectors and holds back growth in every sense. HUNGER –15.5 per cent of the world population in 2008 were undernourished. PRIMARY EDUCATION – In 2010, 61 million children of primary school age were out of school. Cost - Poverty is a major barrier to education Social and cultural barriers Needs: Huge demand for teachers, classrooms & free education. GENDER EQUALITY – In Africa, 66 per cent of out-of-school children are girls – poor education relates to poorer outcomes in all MDG’s. Women offered poor jobs, paid less with no social benefits. unpaid family workers are less likely to seek and achieve their human rights CHILD MORTALITY – An estimated 40% of deaths in children under five occur in the first month of life, so improving newborn care is essential for further progress.  Four diseases—pneumonia, diarrhoea, malaria and AIDS— accounted for 43 per cent of all deaths in children under five worldwide in 2008. MATERNAL HEALTH – An estimated 287,000 maternal deaths occurred in 2010 worldwide The youngest, in the poorest households with the poorest education are three times more likely to become pregnant, have larger families and suffer poor maternal health. There is an unmet need for family planning – the poorest and uneducated are the least likely to engage with family planning. HIV - The spread of HIV appears to have stabilized in most regions, and more people are surviving longer (Continuing need for education and women's empowerment re: HIV) link between gender-based violence and HIV Increased need to safeguard newborn transmission in childbirth. ENVIRONMENTAL STABILITY Poor access to sanitation globally (bypassing the slums and poorest people) However – the world is on target to meet safe drinking water targets GLOBAL PARTNERSHIPS IN 2009, Official development assistance (ODA) amounted to 0.31 per cent of the combined national income of developed countries. Over the last decade, developing countries have gained greater access to the markets of developed countries and have tariff reductions. Forty countries are eligible for debt relief under the Heavily Indebted Poor Countries (HIPC) initiative. Millenium Development Goal progress shows the power of global goals and a shared purpose. Source –
  • Source - Liu, Li, H.L. Johnson, S. Cousens, J. Perin, S. Scott, J.E. Lawn, (2010) “Global, Regional, and National Causes of Child Mortality: An Updated Systematic Analysis for 2010 with Time Trends since 2000.” Lancet .
  • Delay in decision to seek care – Failure to recognise complications Acceptance of maternal death Low status of women Socio-cultural barriers to seeking care: women’s mobility, ability to command resources, decision-making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education Delay in reaching care - Poor roads, mountains, islands, rivers – poor organisation Delay in receiving care – Inadequate facilities, supplies, personnel Poor training and demotivation of staff Lack of finances
  • Preconceptually – Family planning – Prevention of infection – folic acid supplementation Antenatally – Screenings for infections and immunizations – Eclampsia preventions – Malaria treatment/prevention – Risk assessment During childbirth – Antibiotics for preterm rupture of membranes – Steroids for preterm birth – Clean and safe delivery practices – Risk assessment – labour surveillance Postnatally – resuscitation –breastfeeding – kangaroo care (especially in premature newborns) – Prevention and management of pneumonia & hypothermia Source - Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health: A Global Re view of the key Interventions related to Re productive, Maternal, Newborn and Child He alth (RMNCH) (WHO) - Committing to Child Survival: A Promise Renewed – Progress Report 2012 . Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L for the Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Published online March 3, 2005. WHO/UNICEF Joint Statement ,  Home Visits for the Newborn Child: A strategy to improve survival,  WHO, 2009.
  • When women have economic literacy and opportunities open to them, they are more empowered to make choices regarding their own bodies. If women are to benefit from economic progress, it require law reform and social change. The world must stop relying on women's unpaid work and involve and empower them as equal and able world decision makers.
  • Andrew Mitchell (Secretary of State for International Development (2010) “The UK’s Framework for Results for improving reproductive, maternal and newborn health in the developing world”. Accountability has been a missing ingredient. – Accountability can give women a channel to make demands through – empowering them further.
  • RCM’s Global midwifery twinning Project The overall goal of the project is to strengthen midwifery associations in three countries - Uganda, Cambodia and Nepal  72 individual UK midwife volunteers connect with midwives in project countries, to stimulate the potential and scope of midwifery associations in raising the standards of midwifery education and practice. Overwhelming response shows UK midwives willingness to make a difference (This project is funded through the Health Partnership Scheme , which is funded by the  UK Department for International Development (DFID) for the benefit of the UK and partner country health sectors, and is managed by the  Tropical Health Education Trust (THET) .
  • MATERNAL MORTALITY – Only a decline of only 0.1% in maternal mortality per year in sub-Saharan Africa (annual rate of decline of 2.3% globally) - (MGD Target is 5.5%) Deaths during childbirth/pregnancy as a result of complications have decreased by 34% overall, globally. The report found 66 countries are unlikely to meet  MDG 5a (reducing maternal mortality) 25 countries have made insufficient or no progress in reducing maternal deaths and 13 have shown no progress in cutting the number of children who die. The good news - The report “Trends in maternal mortality: 1990 to 2010”, shows that from 1990 to 2010, the annual number of maternal deaths dropped from more than 543,000 to 287,000 – a decline of 47 per cent.
  • Progress is made in richer groups, widening the disparity. Populations are growing, people are migrating to urban areas, seeking a better life, yet still have high childbirth mortality rates. International response – variations in corruption and contribution levels. Lack of comitment? Commitments made in 2010 to strengthen accountability, from the African Union and the UN Secretary General’s Global Strategy for Women’s and Children’s Health provide opportunities to ensure that countries and development partners deliver on their promises. Shortcuts? - immunisation reduces infant mortality (can be done relatively easily, cheaply with huge impact) Lack of a united front? -  UN agencies pulling in different directions – UNFPA think its about contraception, WHO skilled birth attendants, UNICEF different focus Focus has previously been on HIV/AIDS? Are these all excuses? > Is it because it is women?
  • The Gambia faces serious challenges in its efforts to reliably track the MDGs. There is no framework in which to measure real progress – consensus is that it is not on track and has made insufficient progress in MDG progress. Visited in 2007 To experience midwifery where you have little or no medical resources. To enhance and enrich my practice To experience world midwifery and see for myself the troubles faced by resource poor countries. To help in any small way I could Maternal mortality ratio remains high at 400 deaths per 100,000 live births, 60% of Gambians live in poverty – has an Human Development Index rank in 2010 of 151 out of 169 countries. Gambia suffers from poor access to healthcare, lack of skilled workers and infrastructure/management. I returned in 2008 to see if any changes had occurred – all the staff had moved on – desperate to thrive in areas of prosperity.
  • RVTH were kind enough to have me, share knowledge and gain experience with them, including; Gynae ward – many miscarriages witnessed due to Malarial season
  • Labour ward – Breech deliveries, twin deliveries, Ventouse/medical care done by midwives eg; sintocinon infusion in drip bags (making do) – few doctors. Many neonatal deaths/still births witnessed One maternal death through eclampsia/poor management of magnesium sulphate infusion. Drugs and equipment were often out of date – even new donations were out of date Staff were using out of date midwifery techniques – their access to medical literature was that of 20 years ago Staff were poor themselves – unable to afford glasses to see for suturing etc – suturing material also poor Flies everywhere, around cannulas (which women had for the duration of their stay) and around open wounds in theatres. Live chickens were found on the labour ward as staff stored their evening meals bought at the market during the day. Any blood transfusions must be done contemporaneously by a willing relative as there are no storage facilities and limited compliance with HIV testing. Special care baby units were filled with comparatively well babies – unlike our premature babies who have access to advance resources.
  • The Gambians are a very warm and welcoming community, I was invited to naming ceremonies and family gatherings. Most Gambian women birth at home with traditional birth attendants without electricity and limited water supply. I assisted at some of the local clinics in Brikrama where women come to birth, have their infants checked and weighed and receive low level medical care. I became a part of their programme to train traditional birth attendants in the community, the TBA’s were keen to learn from midwifery staff in the local clinics, however, much of the midwifery practice was again, dated such as birthing with fundal pressure. Everybody breastfeeds, everywhere. Mothers, daughters, sisters and aunties assist each other, there were never any problems…..(No clean water to mix up formula either)
  • Ventouse is an old suction cup (top left) – manually pumped and used by midwives. Women labour together on flat beds – poor hygiene facilities even when cleaned constantly. Deceased babies are lined up in the bathroom window sill where all women shower/use the toilet. – Women must take their dead home to bury (often issues with transport). Language barriers were hard as rural women spoke no English and could be conversing in one of several tribal dialects. – The cleaner was often my translator as labour ward was often left un manned with labouring women requiring care. Antenatal record keeping was minimal – women have one antenatal card containing all visits (usually 1-2) and any minimal knowledge known about her obstetric history. The registering of births and deaths was seemingly an easy/fast process.
  • Use of traditional medicines (herbs and tree barks etc) is wide in the Gambia, as I attended this rally, the President Jammeh was announcing his discoveries of herbal medicine to treat conditions such as HIV/AIDS, Diabetes and many others.  Superstition and traditional medicines are very much respected and Politics are rarely challenged. I left the Gambia with the desire to explore projects to reduce childbirth mortalities within resource poor countries.
  • Integrated maternal health programme - To combat the 3 delays model – Health posts – health centres - hospital The project plans - Carrying out community health promotion sessions on maternal and reproductive health, addressing women’s rights and status. Establishing women’s income generating groups enabling financial independence. Improving the quality of maternal health care by training local clinical staff and providing essential equipment, drugs and supplies. In addition a Safe Birth Fund was set up to pay the fees being charged by the hospitals for delivery. Successes - The number of women having their babies at the hospital and health centres increased by 51%. There were 110,000 attendances at health promotion sessions (ten times higher than the target) Sixteen staff were trained as Skilled Birth Assistants along with 11 assistants. 1200 women participated in the income generating scheme and set up their own businesses.  Within two years 90% of the women had made profits and were able to make loan repayments Extended the programme to 60 new villages in 2011 The provision of e-ranger motorcycle ambulances to provide quick and relatively cheap transport for pregnant women when it is needed.
  • CRADLE – looking at Eclampsia prevention, introducing automated, solar powered blood pressure monitors The safe Birthplace Study – Exploring women's choices in maternity care in Ethiopia – Suggesting *waiting houses* near health centres for high risk women.Demonstrates women's enthusiasm to partake in their care when they are educated in choice and their own maternal health. 
  • Muffins for midwives – Tea party/coffee morning - will pay for the training of midwives in Africa.  It costs £80 a month to provide the training. You can sign up for a pack at the stall and get a free muffin! To be drawn on 5th January, tickets are £2 each and the prizes are: 1st Prize -  Return flights for two people from Gatwick to any European destination  (Donated by British Airways) 2nd Prize  – Gourmet three course meal for two with a champagne cocktail at a 4* hotel in Mayfair 3rd Prize  – Socialites spa day with afternoon tea for two at Foxhills Hotel and Spa, Surrey  (Donated by Six Degrees Group) 4th Prize  – Two lucky winners will receive a crate (12 bottles) of luxury boutique wine  (Donated by Hausmann Vineyard)
  • Health Extension Workers (should be able to do a delivery but not trained sufficiently) The $1.5 billion that the Gates Foundation will invest through to 2014 and will support projects directly addressing maternal and child health. Ethiopian government has stepped up to deliver physical and human resource capacity, making maternity care free at the point of delivery THIS IS FRAGILE Ethiopia would have to spend almost half of its gross domestic product (GDP) to reach their health worker quota (International Monetary Fund) Provides debt relief linked into achieving the MDG’s… is this the reason governments are keen? Is it sustainable? Are there contracts? or just direct payments? Are faith based hospitals less likely to require contracts? (Source - Reuters (2010) Gates Foundation Gives $1.5 Billion for Women’s Health)
  • The United Nations Conference on Sustainable Development - or Rio+20 - took place in Rio de Janeiro, Brazil on 20-22 June 2012.  Resulted in Sustainable development goals (Built upon Millennium Development Goals) 700 voluntary commitments were made to women's empowerment, new partnerships, investment and economic stimulation. David Cameron will be one of the co-chairs of the UN’s forthcoming High Level Panel on what should follow the Millennium Development Goals after they expire in 2015 generate momentum! Should there be Nationally specific targets? Diluted goals which are voluntary? Combine Mgd’s with Sdg’s (MDG-PLUS) going on until 2020/2025? .
  • An educator and grassroots women's rights activist founded the Joyce Banda Foundation, which supports young people and children, Safe Motherhood, Women’s Leadership and Economic Development for Women. African Union Goodwill Ambassador for Safe Motherhood. founder of the National Association of Business Women Forbes  named President Banda as the 71st most powerful woman in the world and the most powerful woman in Africa
  • Per woman – per year PAYING FOR PREVENTION SAVES MONEY! Save money by paying for preventative measures - In Zambia, by reducing fertility and pressure on services, one dollar invested in family planning saved $4 in health, education and other sectors. In one district in Maputo in Mozambique, post-abortion care admissions represented more than 55% of obstetric complications (DFID 2010) Source ( Maternal and child undernutrition: global and regional exposures and health consequences Prof Robert E Black MD,Prof Lindsay H Allen PhD,Prof Zulfiqar A Bhutta MD,Prof Laura E Caulfield PhD,Mercedes de Onis MD,Majid Ezzati PhD,Colin Mathers PhD,Prof Juan Rivera PhD,for the Maternal and Child Undernutrition Study Group  The Lancet  - 19 January 2008 ( Vol. 371, Issue 9608, Pages 243-260 ) 
  • Royal College of Midwives (RCM) conference paper presentation 2012 (sally Pezaro)

    1. 1. •Every two minutes, a woman dies of pregnancy-related complications •Ninety-nine per cent of maternal deaths occur in developing countries •most could have been prevented with proven interventions.
    2. 2. Causes of Mortality
    3. 3. Delay in seeking care Delay in reaching care Delay in receiving care
    4. 4. •Pre-conceptually •Ante-natally •During childbirth •Postnatally ““When we deliver for every woman and every child, we will advance a better life for all people around the world”. (U.N. Secretary General Ban Ki-moon , 2011)
    5. 5. “Representation by women in parliament is at an all-time high, but falls shamefully short of parity” (UN, 2011) Globally only 19% of political decision making positions are held by women
    6. 6. Department for international Development Framework: By 2015: •Save 50,000 mothers & 250,000 newborns •Prevent 5 million unintended pregnancies •support 2 million safe deliveries •10 million women using modern family planning •(4 pillars of action) Empower women, remove barriers, Expand quality services, Increase accountability
    7. 7. Millennium development goal 5 How are we doing?: Only 10 countries are considered to be “on track” to meet MDG 5. "Women are not dying of diseases we can't treat. ... They are dying because societies have yet to make the decision that their lives are worth saving." (Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists)
    8. 8. • The poorer, suffer more? • Population changes? • International fragmented response? • Lack of commitment? • Short cuts? • Lack of a united front? • Is it because ‘it is women’? Why are we failing? “Achieving the MDGs depends so much on women’s empowerment and equal access by women to education, work, health care and decision-making - let us not relent until all the MDGs have been attained.” Ban Ki-moon Secretary-General, United Nations (2012)
    9. 9. • Educates • Empowers • Improves healthcare access • Trains local midwives • Provides resources
    10. 10. • The maternal mortality ratio in Ethiopia is 676 for every 100,000 births. (UN, WHO) • Only 51% of hospitals are qualified as offering fully equipped, comprehensive care. (UNFPA, 2012 ) • Ethiopia uses only 5.7 percent of its GDP on health • 90% of women birth at home • Ethiopia is ranked 174 of 187 in the UN Human Development health Index (UNDP 2012)
    11. 11. Ongoing improvements Expanding projects Uganda Malawi Research: CRADLE The Safe Place of Birth Project
    12. 12. Join in with Muffins for Midwives & the Grand Draw! Maternity Worldwide (downstairs stand 82)
    13. 13. • The Government of Ethiopia, with the support of several donors, has invested heavily in Health Extension Workers. (currently 31,000) • $1.5 billion Gates Foundation investment • Ethiopia's government have built physical and human resource capacity. • Maternity care is now free at the point of delivery • THIS IS FRAGILE
    14. 14. •Full Sustainable Development Goals (SDG’s) - Rio+20 •Will major powers sign up? •Why are targets not achieved? •Promises made must be promises kept •Demand accountability
    15. 15. Malawi's first female president (7th April, 2012 –present) Africa's second female president. Joyce Banda
    16. 16. •£5 to provide modern •contraception •£45 to treat severe eclampsia & emergency newborn care •£17.50 To manage an obstructed labour •£22 to treat maternal sepsis •(Source: WHO-CHOICE published in the BMJ, 2005)