Introduction to Maternal and Newborn Health
last authored: Dec 2011, David LaPierre
last reviewed:
Introduction
Maternal and newborn health, more than any other field of health care, combines primary care, public health, communication, clinical skills, diagnosis, medical mangement, emergency management, procedures, and operations. This domain seeks to offer primary care learners comprehensive resources on antenatal, intrapartum, and postpartum care of the mother, along with care of the neonate.
Threats to Maternal Health
Canada and Uganda have very similar populations
(34M for Canada, 33M for Uganda, 2011 statistics).
Based on 2010 maternal mortality rates (Hogan et al, 2010):
- Canada: 7/100,000 x 386,000 births = 27 maternal deaths/year
- Uganda: 352/100,000 x 1,502,000 births = 5287 maternal deaths/year
birth statistics from Statistics Canada and UNICEF
Pregnancy, birth, and the first few days outside the womb are both exciting and dangerous.
The millenium development goal 5 is to reduce the maternal mortality ratio (MMR) by three quarters between 1990 and 2015, and achieve universal access to reproductive health by 2015.
In 2008, an estimated 358 000 women (a 34% decrease from 1990 levels) died due to largely preventable complications during pregnancy, childbirth and the postnatal period (WHO, 2010). Of these, 99% were in developing countries, while 87% occurred in sub-Saharan Africa.
In some places in the developing world, maternal mortality rate is close to 1%, in large part due to post-partum hemorrhage. However, this need not be the case. The mortality rate in Canada is ~ 5 in 100,000, or 0.005%, due to widespread availablity of prevention, screening, and appropriate care.
Threats to Fetal/Neonatal Health
Each year, approximately 3.6 million infants die in their first month of life, the majority within 7 days (Black et al, 2010). Almost half of newborn deaths are due to infections, including tetanus, sepsis, meningitis, pneumonia, and diarrhea. Hygiene and immunization are extremely important to address these preventable causes. Low birth weight is an important cause of morbidity and mortality. It can be caused by many factors, many of which are modifiable.
Canada: 2.6/1000 livebirths (in the first 28 days)
Uganda: 27.1/1000 livebirths
The Maternal and Newborn Health Workforce
A skilled birth attendant is an accredited health care professional - usually a doctor, nurse, or midwife - who has been trained to become competent in the management of uncomplicated pregnancy, labour and delivery, and postnatal care, and to recognize and refer complications. The world is lacking 350,000 skilled birth attendants, primarily midwives (The State of World's Midwifery 2011: Delivering Health, Saving Lives).
Country Snapshot (2011)
In Haiti, only 26% of births are attended by skilled health personnel.
As of June 2011, Haiti has only 65 midwives, but requires over
1300 to ensure 95% skilled attendance at all births.
They have only one midwife training program.
About 60 million births in developing countries occur outside healthcare facilities, and perhaps 52 million births occur without the assistance of a skilled birth attendant (Darmstadt et al, 2009). Of these, many deliveries are performed by traditional birth attendants (TBAs), who are trained through apprenticeship and/or experience. TBAs are thought to assist in delivering more than 50% of births in developing countries, with attendance being as high as 90% in some countries (WHO, 2004). Education of TBAs is usually informal, and roles and practices vary across cultures.
There is much debate over the role of traditional birth attendants (TBAs) and the extent of training that should be provided to them. A 2011 meta-analysis showed that training and equipping of TBAs appears to benefit neonatal outcomes, (relative risk 0.79, 95% confidence interval 0.69 to 0.88, P<0.001; number needed to treat in high risk population 98, 66 to 170), though with non-significant impact on maternal mortality (Wilson A et al, 2011).
Training Programs
The World Health Organization has developed a course termed Essential and Newborn Care (ENC). It includes:
- cleanliness: clean delivery and clean cord care
- thermal protection
- early and exclusive breastfeeding
- initiation of breathing and recuscitation
- eye care
- immunization
- management of newborn illness
- care of the preterm/low birth-weight infant
Guidelines for each of these need to be adapted to local settings, including home, health centre, and hospital.
Simulations
Simulations are an increasingly integral part of training for health care. Maternal and newborh health is perhaps the best field suited for this, given the various skills that are important to develop and the high stakes that accompany potential disasters. Simulations are also valuable when clinical volume is a limitation. Lastly, as patients are usually awake during procedures, there can be added stress during the initial acquisition of skills. Simulations can allay much of this. Medical students report greater self-comfort when using simulations (Deering et al, 2006), improved performance, and increased particpation in actual deliveries (Dayal et al, 2009). They may be used during initial learning, to maintain skills, and to demonstrate competency when required.
There are very expensive, high-fidelity simulators with sophisticated electronics. However, these may not be much more effective that low-fidelity materials (Hammoud et al, 2008). One group suggests that simulations be 'As reasonably realistic as objectively needed', or ARRON (Macedonia, Gherman, and Satin, 2003). Resources that are low-cost and easily obtained can be extremely effective, if used within simple scenarios and with educators who care.
Simulations are best performed in an actual clinical environment. Scenarios should be prepared in advance for practice as time permits, as the labour and delivery environment can be quite unpredictable.
Simulations require facilitated debriefing afterwards, with tutor and peer feedback, as well as self-reflection. Simulations may also be recorded for further benefit.
It is critical to have a team of people to develop, run, maintain, and refine scenarios. Ideally this includes members with adequate clinical knowledge and experience. Important characteristics include creativity, perseverance, and energy (Ennen and Satin, 2010).
When developing a program, start small and manageable. Learners may initially be unwilling to become engaged, ususally due to embarassment or fear. Help allay these fears by creating a comfortable, low-pressure environment and with adequate preparation. Paper cases and models are often best to begin with, followed by more realistic simulations.
MamaNatalie is a birthing simulator that makes it easy to simulate very compelling simulations of normal to more complex birthing scenarios.
Clinical scenarios
A variety of scenarios can be represented during simulation. These include normal vaginal delivery, shoulder dystocia, postpartum hemorrhage, vaginal repair, and others.
- normal vaginal delivery
- shoulder dystocia
- vaginal repair
- breech delivery
- other
Normal vaginal delivery
To simulate a birth, a facilitator can sit/lie behind a simulated pelvis, control descent of the baby, and release simulated blood as appropriate.
Shoulder dystocia
An actor, doll, and pelvis can be used to demonstrate techniques for treating shoulder dystocia. As well, documentation following the simulation can reinforce the importance of this aspect of care.
Vaginal repair
Pig vaginas, purchased at the butcher shop, can be used to practice episiotomy and repair, as described by Dr Lynn Busey, Dalhousie University.
A sponge perineum may also be used with a two-layer sponge cut to represent perineal anatomy Sparks, Beesley, and Jones (www.fmdrl.org)
Breech Delivery
There are standard procedures to safely delivery a breech fetus. In many countries, however, experience with breech deliveries is uncommon due to ultrasound identification and cesarean delivery.
A standard obstetric doll and pelvis may be used. The Johns Hopkins program uses a thin plastic bag filled with water, within which the doll is placed to simulate the amniotic sac. This is tied and placed within a larger, heavier bag to simulate the uterus. The open end of the bag is placed facing downwards within the pelvis. The learner must identify the feet and then delivery the fetus (Ennen and Satin, 2010).
Other
Oranges may be placed inside a surgical glove with water to practice ARM and placement of scalp clips.
Eclampsia has been simulated using patient actors (Ellis et al, 2008).
Cost-Effectiveness of Training
Cost-effectiveness is an important concern. It has been estimated that over 1 million newborn lives could be saved yearly with low-cost interventions (Darmstadt et al, 2008). A 2011 study in Zambia has estimated that training in essential newborn care for health care providers results in intervention costs of $208 per life saved (Manasyan et al, 2011). Improving clinical care is more costly than outreach or community services, but appears much more cost-effective, given its greater impact (Darmstadt et al, 2005).
Packaging maternal and newborn interventions together, within a common service delivery model, appear to be more cost-effective due to synergy (Adam et al, 2005). It appears as though effective antepartum and postpartum care results in a 2-3x greater impact than antepartum care interventions (Darmstadt et al, 2005).
Organizations and Individuals
Reducing Maternal and Child Mortality Through Strenghtneing Primary Health Care (South Africa)
Maternova.net - Tools and Ideas that save mothers and newborns
Maternal and Childhealth Advocacy International
WHO - Safe childbirth checklist
WHO - Midwife Training Modules
WHO - The Partnership for Maternal, Newborn & Child Health
Global Library of Women's Medicine
K4Health - Reproductive Health Gateway
Dr. Rachel Spritzer U of T, work in Africa
Reproductive Health Response in Crisis Consortium (RHRC) - great website with a multitude of resources
Reproductive Health Access, Information and Services in Emergencies (RAISE)
Resources and References
Adam T et al. 2005. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ. 331(7525):1007.
Black RE et al. 2010. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 375(9730): 1969-1987.
Darmstadt GL et al. 2005. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 365(9463):977-988.
Darmstadt et al. 2008. Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of internations within the continuum of care. Health Policy Plan. 23(2):101-117.
Darmstadt GL et al. 2009. 60 million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths? Int J Gynaecol Obstet. 107(suppl 1):S89-112.
Dayal AK et al. 2009. Simulation training improves medical students' learning experiences when performing real vaginal deliveries. Simulations Healthcare. 4(3): 155-159.
Deering SH et al. 2006. Additional training with an obstetric simulator improves medical student comfort with basic procedures. Simulations Healthcare. 1(1): 32-34.
Ellis D et al. 2008. Hospital, simulation centre, and teamwork training for eclampsia managementL a randomized controlled trial. Obstetrics and Gynecology. 111(3):723-731.
Ennen CS, Satin AJ. 2010. Training and assessment in obstetrics: the role of simulation. Best Practice and Research, CLinical Obstetrics and Gynecology. 24:747-758.
Gill CJ et al. 2011. Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ. 342:d346.
Gupta N et al. 2011. Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes. Human Resources for Health 9:16.
Hammoud MM et al. 2008. To the point: medical education review of the role of simulators in surgical training. Am J Obstet Gynecol. 199(4):338-343.
Hogan MC et al. 2010. Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 375(9726):1609 - 1623.
Macedonia CR, Gherman RB, and Satin AJ. 2003. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 102(2):388-392.
Manasyan A et al. 2011. Cost-effectiveness of essential newborn care training in urban first-level facilities. Pediatrics. 127:e1176-1181.
Wilson A. 2011. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis. BMJ. 343.
World Health Organization. 2004. Health in the millennium development goals. Millennium development goals, targets and indicators related to health.
World Health Organization. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank. 2010. World Health Organization, 2010.
WHO - Pregnancy, childbirth, postpartum and newborn care - A guide for essential practice
http://www.who.int/hac/network/global_health_cluster/chapter1.pdf
http://www.raiseinitiative.org/library/pdf/fs_misp.pdf
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