Human resources and access to maternal health care

International Journal of Gynecology and Obstetrics (2006) 94, 226 — 233

www.elsevier.com/locate/ijgo

MATERNAL AND NEWBORN CARE

Human resources and access to maternal health care P. ten Hoope-Bender a,1, J. Liljestrand b,*, S. MacDonagh c,2 a

Partnership for Maternal, Newborn and Child Health, Secretariat: c/o World Health Organization, Geneva, Switzerland b Division of Social Medicine and Global Health, Department of Health Sciences, Lund University, ¨ University Hospital, Malmo ¨, Sweden Malmo c Options, CAP House, London, UK

KEYWORDS Maternal and child health; Human resources for health; Maternal and child mortality reduction; Access to health services; Health care professional

Abstract The lack of human resources is one of the main bottlenecks to achieving the Millennium Development Goals on maternal and child health. A coherent national policy, recognized across government, needs to be in place to overcome this especially in countries severely affected by HIV/AIDS. Such a policy should cover selection of pre-service students, the qualifications of trainers and training sites, supportive supervision, career path development, a package of carefully thoughtout incentives for the retention of staff, strategies for interaction with communities, and an agreed-upon health staff HIV/AIDS policy. Without such coherent human resource planning, a large number of countries will fail to reduce maternal and newborn mortality. D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Every year, more than half a million women and around 3.5 million newborns die from causes related to pregnancy and childbirth. In addition, 3.3 million stillbirths occur, and the mortality risks have hardly changed over the past few decades. Although a few countries have been able to make

* Corresponding author. Visiting address: Entrance 59, 8th Floor, UMAS, Sweden. Tel.: +46 40 336381; fax: +46 40 337096. E-mail addresses: [email protected] (P. ten Hoope-Bender), [email protected] (J. Liljestrand), [email protected] (S. MacDonagh). URL: http://www.pmnch.org (P. ten Hoope-Bender). 1 Tel.: +41 22 7913309; fax: +41 22 7914171. 2 Tel.: +44 20 7776 3900; fax: +44 20 7776 3978.

major advances in decreasing maternal and infant mortality, most have not even started to achieve the Millennium Development Goals (MDGs) globally agreed upon in 2000. Two of the eight MDGs aim at a reduction of maternal mortality by three quarters compared to the 1990 figures and, at the same time, a two-thirds reduction of child mortality. It is important to recollect that the MDGs are agreed goals for global societal development. Not meeting them means hindering human development on multiple fronts. Unfortunately, the devastating effects of HIV/ AIDS on both the general population and the health care providers in many African and Asian countries make it even harder to achieve the MDGs. Indeed,

0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.04.003

Human resources and access to maternal health care in some countries of sub-Saharan Africa, HIV/AIDS is already exerting a huge toll on health workers. At the same time, few governments have realistic plans on how to balance this loss against the need for more health workers due to the massive scaleup of antiretroviral treatment [1]. This paper provides an overview of the most important challenges of providing the human resources necessary to reach the Millennium Development Goal on maternal health. As newborn health constitutes a major part of the MDG on child health, human resources for maternal health will to a large extent also determine if that goal will be reached.

1. The need for human resources in the health system The clinical interventions necessary to reduce maternal, new-born and child deaths in low- and middle-income countries are not complex, nor are they expensive or yet to be discovered. Rather, they are known, cost-effective interventions that are widely available in high-income countries. However, their delivery can only be successfully achieved within a functioning health system and via a skilled birth attendant with emergency back-up services. A skilled attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbearing and the immediate postnatal period and in the identification, management and referral of complications in women and newborns. [2] A list of the core skills and abilities of skilled attendants is enumerated in the referenced Joint Statement developed by WHO, ICM and FIGO in 2004 [2]. This statement identifies skilled attendants as midwives (including nurse—midwives), nurses with midwifery skills, doctors with midwifery skills, and obstetricians. Importantly, the WHO World Health Report in 2005 [3] erases some of the previous separation between skilled birth attendants caring for bnormal birthsQ and those who provide emergency care for severe complications. It concludes that skilled staff is needed for both circumstances, as unskilled staff cannot cope effectively with either severe complications or pending, potentially life-threatening conditions. The road to improve maternal health is clearly through skilled human resources within the formal health system.

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2. What about traditional birth attendants? WHO, FIGO and ICM all identify traditional birth attendants as b. . .independent of the health system, non-formally trained and community-based providers of care during pregnancy, childbirth and the post-natal periodQ [2]. The regions in the developing world with the highest mortality figures are countries in subSaharan Africa and Southeast Asia. Many have health systems that function at a small percentage of what is required to provide care to the inhabitants or access to emergency services for those who need it. Over the years, many quick-fix solutions have been tested to increase health systems’ capacities. One was the training of traditional birth attendants (TBAs)—the women who lived in the community and traditionally dealt with pregnancy and childbirth. Many such individuals received a short course to upgrade their skills, a box of instruments and materials, and were sent back into the community to save the lives of women and children. They were not successful [4]. The documented failure of this attempted solution has a number of causes, only a few of which will be mentioned here. Foremost is that the onus of saving lives cannot be put on the shoulders of a single provider. TBAs were not given access to the rest of the health system, so that when the time came to refer to a higher level of care, they had no means of accessing the system, were not accepted as certified care providers, were not taken seriously, were ridiculed and/or turned away. They had no access to communication systems nor could they count on transportation for their patients should referral to a hospital be needed. Another reason for the failure of the training of TBAs is, paradoxically, that the health system may not be able to receive the additional numbers of women being referred to it. Many communities have learned that women need to be near a health facility when giving birth, so delivery suites in hospitals are overloaded with physiological births and the staff in those facilities cannot cope with the large numbers of patients. Thus, an already weak health system is put under even greater pressure [5]. These problems became abundantly clear when the failure of TBA training programs emerged. Despite much investment, mortality remained static. When choosing cost-effective, evidencebased solutions, i.e., the skilled birth attendant with emergency backup, it is important to remember the lessons from the TBA failure. Skilled birth attendants must be linked to and valued by community; must be part of a functioning health

228 system; and must be skilled, not just trained, having competency-based training.

3. The skilled attendant—and the conducive environment leading to bskilled attendanceQ Good evidence on the clinical interventions required to prevent maternal death and disability is available. However, there is much less understanding of how to deliver these interventions, particularly in settings characterized by high maternal mortality ratios (MMR) and failing or inherently weak health systems. Much of the devidenceT that informs maternal and new-born health (MNH) policy and programming comes from reviews of the steps taken in countries that have successfully reduced maternal deaths. What is needed to ensure that a skilled attendant is successful and that maternal mortality is reduced has been summarized as follows [6]:

! High-level

political commitment towards improving maternal health and saving women’s lives. ! Investment in social and economic development with emphasis on achieving gender equity and on ensuring access to basic services for the poor. ! Strengthening health systems with emphasis on ensuring access, by all, to an extensive network of facilities, and on providing an essential package of evidence based care (including family planning, comprehensive [post]abortion care, and emergency obstetric care). ! Investment in developing, deploying and supporting a cadre of health providers with midwifery skills (skilled attendants), and ensuring they attend women before, during and after childbirth. All of these individual elements are important. It is unlikely that any one of them can be singularly held responsible for the decline in maternal mortality, and they all need to be addressed in synergy. However, of specific interest is a striking characteristic that is common to all reviews, and which is currently driving MNH policy due to its choice as an indicator for the maternal health MDG—that is, ensuring the presence of a skilled attendant at delivery. In-depth country reviews conclude that the decision to commit to the development, widespread deployment and support of a cadre of health professionals with

P. ten Hoope-Bender et al. midwifery skills (a skilled attendant) to attend women during pregnancy and childbirth was critical to reduce maternal deaths:

!A

comprehensive and detailed analysis of the factors behind the fall in maternal mortality in Malaysia and Sri Lanka suggests that dan outstanding feature of both countries is the long standing professional status of midwifery. . . the special identity and competence of these workers are well recognized by communities and professionals in both communitiesT [7]. ! Recent reviews of maternity services in Bolivia, China, Egypt, Honduras, Indonesia, and Jamaica and Zimbabwe found that din all the historical and present case studies there is high availability of both skilled birth attendants and birthing facilities... . .T [8]. ! Detailed reviews of the different ways in which maternal mortality was addressed in industrialized countries such as the USA, England, Wales and Sweden during the 1870—1937 period (when MMRs were as high as many of the low-income countries in Asia and Africa today) found that the speed of MMR reduction was drelated to the way professionalization of delivery care was determined first by the willingness of decision makers to take up responsibility; second, by the strategy adopted for making modern obstetrical care available to the population (and particularly by the encouragement or dissuasion of midwifery care). . .T [9]. The graph illustrating the fall in maternal deaths after midwifery skills became available on a wide basis is persuasive (see Fig. 1). However, it is critical to bear in mind the nature of the evidence on which decisions are based. Graham et al. [10] urge MNH policy makers and practitioners to practice caution when interpreting historical data, which, reviewed retrospectively, fail to control for confounding factors, such as changes in other health care practices or the status of women in society, and therefore inherently represent a weak form of evidence. Country case studies are complemented by epidemiological studies, evaluations of intervention programs and data modeling. Similarly to the reviews, all of these studies provide relatively weak forms of evidence3 (e.g., quasi-experimental or descriptive studies). Nonetheless, positive and

3

dGold standardT evidence can only be provided by randomized controlled trials and it would be unethical today to consider randomizing women to skilled or unskilled care at delivery.

Human resources and access to maternal health care 450

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7,200 new midwife registrations

400 Thailand: midwives since late 1930s

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150 MCH programm 50% of deaths: home

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Figure 1 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand. Source: Van Lerberghe and De Brouwere [9].

negative lessons emerging from these sources often echo factors noted in country reviews: ! In Indonesia, the presence of a skilled attendant at birth increased dramatically between 1996 and 1999; however, the use of life-saving EmOC fell during the same period. Potential reasons for this are lack of responsive referral systems (e.g., transport), low cultural acceptability and the high out-of-pocket cost of EmOC services [11]. In contrast, in the Maternity Care Program in Matlab, Bangladesh, a significant decline in maternal mortality took place in the intervention area where the number of skilled attendants increased, together with development of a referral chain and basic essential obstetric care (BEOC) facilities. This decline was not found in the control area; however, similar gains in maternal mortality reduction occurred in a comparison area that had not benefited from the intervention, but did have access to a facility providing comprehensive essential obstetric care (CEOC) [12]. ! In Malaysia and Sri Lanka in the 1950s, the simultaneous improvement in underserved areas of roads, water and sanitation, and schooling, especially for girls and women, were the three key ingredients that accompanied the increased access to skilled birth attendance [7]. Today, this would be called a poverty reduction strategy. It was very successful, building on two pre-existing

cornerstones: the formal recognition of midwifery, and the existence of civil registration of births and deaths.

4. Ensuring human resources for birthing care in resource-poor settings Many health systems, particularly in countries with high MMRs, are characterized by an overall lack of qualified staff, inequitable distribution of providers, high levels of absenteeism, and decreasing numbers of skilled workers due to the impact of HIV/AIDS and regional/international migration. Key steps that need to be taken include: ! Obtaining consensus on the cadre(s) of health care providers that will be developed as skilled attendants; ! Developing an effective midwifery and obstetric skill mix with authorization for nursing/midwifery staff to provide basic emergency obstetric care; ! Providing increased human resources production and increased recruitment of students; ! Obtaining consensus on strategies for the equitable distribution of skilled attendants, including retention policies; and ! Ensuring revised supervision of skilled attendants addressing issues that affect morale and motivation.

230 A first important step is to gain consensus on which cadre(s) of health service staff will be designated as dskilled attendantsT. This needs to take account of the short-, medium- and long-term needs to increase availability of skilled birth attendants. It also requires a national strategy that is downedT across the government—by the educational sector, civil service reform processes, and health authorities—and that it is included in the national master plan for human resources. Planning needs to take account of the country’s existing workforce situation and build on this in a sustained manner. One critical difference in the human resource needs for MNH services compared to, for example, TB or child health services, is the level and type of skills required by frontline workers. Most primary health care (PHC) frontline workers are not sufficiently skilled to deliver a minimum MNH service package. Adding on a few weeks or even months of in-service midwifery training for these workers may seem to be a useful shortcut to producing skilled attendants. However, this is unlikely to be a successful strategy. Innovative approaches are also required to recruiting appropriate trainee skilled attendants. In many countries, particularly in the rural areas, there are insufficient girls graduating from secondary school with the necessary qualifications to enter midwifery training. This situation has worsened where the effects of HIV/AIDS have undermined education systems and school attendance. In addition, the midwifery profession has a low status in many parts of Asia and Africa. In high HIV prevalence countries, it may be perceived as a driskyT job. The context-specific barriers to recruitment of skilled attendants need to be assessed and addressed. Increasing investment in girls’ education, including secondary education, is essential in the long term. In the shorter term, it may be necessary to provide basic education upgrading opportunities to young women who would like to pursue a career in nursing or midwifery but who have not had the opportunity to achieve entrance level qualifications. In addition, there may be ways to attract skilled attendants who have left the profession, e.g., retired nurses and midwives back to work [13].

5. Doctors or midwives? How? Policy decisions need to consider the midwifery and obstetrics skill mix required among skilled attendants. In many countries, the skill mix depends too much on doctors. Not only are they more expensive but it is usually more difficult to attract doctors to

P. ten Hoope-Bender et al. work in remote areas. One solution that has helped in many countries is to advocate for practice and legal changes that enable nurses/midwives or others to provide the advanced skills that are normally only provided by doctors. Careful involvement of professional associations is necessary to engender support for and to limit dturf warsT that prevent the necessary legal, policy and practice changes. Another current dilemma is how to teach appropriate procedures at the higher institutions where teaching is typically carried out. As an example, many teaching hospitals in low-income countries rely increasingly on cesarean section for birthing problems, leading to the decline or disappearance of operative vaginal delivery, for instance, by vacuum extraction, and without access to practical knowledge and equipment to perform vacuum deliveries in rural areas, many women and newborns will suffer. Clearly, policy, teaching curricula, and clinical practice at the teaching and referral level should also take into account the rural reality. Academics and professional societies have an important role in this area. The need to ensure skilled and experienced trainers is highlighted by this challenge, as well as the educational system as a whole.

6. Placement and retention of staff Equitable deployment of skilled attendants is mandatory. Even where workers are available, their distribution is often inequitable. To reduce maternal and new-born mortality, skilled attendants must be available where women are giving birth—in rural areas and urban slums as well as the more attractive middle class suburbs. This requires commitment, transparency and innovation on the part of governments to make shifts in the manner health workers are deployed. In Thailand, successes have been based on distribution of rural doctors through ! Development of a rural infrastructure through a shift of resources from urban to rural areas. This made placements more attractive through the provision of good logistic support and housing. ! Educational strategies such as rural recruitment, training in rural health facilities and hometown placement. Career development incentives such as special quota for specialty training for rural doctors were also initiated. ! Administrative mechanisms such as bonding contracts for 2 to 4 years of public sector employment in the province of recruitment and training.

Human resources and access to maternal health care Training and living expenses during training were highly subsidized, as was recruitment through transparent and participatory mechanisms. Flexible working arrangements were also developed to enable part-time return to work by retired doctors. ! Financial strategies such as increasing tuition fees and allowing payback by rural public work, non-private practice allowances, non-official work-hour services with special workload-related payments and remote area allowances [14]. Retention of existing workers is a key issue and very pertinent to skilled attendants. There is a global shortage of staff with midwifery skills and many skilled attendants are tempted to migrate to countries such as the UK or USA where their skills are in demand. In other settings, skilled attendants are available but are so poorly paid and motivated that their engagement in dual practice means they are largely unavailable to the public sector and, thus, to poorer clients [15]. HIV attrition has further exacerbated the human resource crisis in high-prevalence countries. Many push and pull factors affect retention; wage concerns are important but not the only concern. Other important factors include professional fulfillment and career advancement opportunities and working and living conditions such as safety, transport and housing [16]. Clearly, not all these issues are under the control of the Ministry of Health and there are key links between health worker retention and broader development issues (e.g., development of rural infrastructure such as communications, schools) and civil service reforms (e.g., salaries, hardship allowances, compulsory public work, etc.). If access to maternal health services for all is to be a reality development partners and governments from resource-rich countries need to work in partnership with resource-poor countries to ensure positive effects and diminish bpoachingQ. This is important both across resource-poor country government departments (e.g., to link the MoH with civil service reform) and between country governments to ensure that the flow of staff to the health systems in wealthier nations does not undermine efforts to improve health system functioning and reach the MDGs in poor countries. An innovative package of approaches was developed in Malawi: ! Introducing an attractive package of benefits and incentives, ! Providing care and treatment for health workers infected with HIV/AIDS,

231 ! Mobilizing staff who have left the system to reenter (e.g., retired midwives), ! Devolving responsibilities to other cadres of staff, ! Expanding pre-service training capacity, and ! Bringing in expatriate volunteers to provide stopgap support as specialist physicians and nurse tutors [17].

7. Supportive supervision Supervisory systems and working conditions also require attention if skilled attendants are to achieve their potential. A study in Vietnam showed that health workers perceived supervision as control, selection processes for in-service training as unequal, and performance appraisal as unhelpful [18]. Gilson et al. and Freedman et al. suggest that dhealth workers performance is a very tangible manifestation of the values and norms not only of the health system but also of the government itself. . .. health workers act as dstreet bureaucratsT with the power to interpret, implement or sabotage health policies and programs [19,20]. Findings in Zimbabwe, Mali, Benin, Vietnam and Armenia all confirm the importance of da sense of achievementT, dprofessional and public/community recognitionT and dhaving the tools for the jobT (e.g., being empowered with necessary skills, having the necessary equipment and supplies, etc.) as key motivating factors [18,21].

8. Increasing access to surgical interventions Increasing access to major surgery for maternal survival requires innovative solutions in countries where specialized or skilled doctors are scarce. In recent years, surgical training programs for higher nurses and/or clinical officers have been implemented in several countries of sub-Saharan Africa, and evaluations are very positive [22]. A positive spin-off of such programs is the increased access to surgery in rural areas for other potentially lifethreatening conditions such as hernia or trauma. Here again, however, designing and implementing such programs require the constructive support of professional societies including national societies of obstetricians—gynecologists. Countries with serious deficits in provision of major obstetric surgery for maternal survival must consider drawing on these positive African experiences.

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9. The role of the health care professional organizations The involvement of a professional organization and the commitment and leadership of individual health care providers are hugely important in all of the above matters. In order to achieve a working environment that is acceptable to all, national health professional organizations must work with other stakeholders, such as government departments and health care managers in advocating, educating and informing health policy development at the country level, as well as providing evidence-based, culturally appropriate skilled care. By setting standards of education, practice and professional competency, they develop the capacity to save the lives of millions of families. In Bangladesh, for example, the National Society of Obstetrics and Gynecology, in partnership with the government and WHO, has recently helped develop the competencies and training of a new midwifery cadre in order to meet the maternal health care needs of that country. The Rural Doctor’s Society in Thailand supported rural doctors and enabled their dvoiceT to be heard in the policy arena by developing management courses and handbooks, rewards and public recognition for excellence, visits to rural hospitals by senior doctors for coaching and moral support, distributing newsletters, etc. The society became widely influential, facilitated the election of rural doctors onto the Medical Council Committee and influenced changes in medical education and residency training that improved the distribution of doctors. The society dboosted the morale of rural doctors and allowed them to work more happily in the rural district hospitalsT [14]. In partnership, the international health care professional organizations FIGO, ICM, ICN, IPA and COINN have developed a joint statement committing themselves to collective contribution to the achievement of Millennium Development Goals 4 and 5 [23]. This statement calls for action at community, national and global levels. It identifies advocacy, country support, the promotion of effective interventions and capacity building as the main means for action and pledges that doctors, nurses and midwives will work together through their country-level members and societies towards the common vision and goal of improving maternal, new-born and child health. The weight of this statement lies in the important steps that are being made to slight the barriers between the various professional groups to reach a common ground of standing and, thus,

P. ten Hoope-Bender et al. together provide a safety net of health care that is vital to the development and creative capacity of a nation. This joint statement is an important point of departure and a strong message to national counterparts to follow suit in the collaborative efforts to be initiated in countries. It is an essential step towards inter-disciplinary dialogue and multidisciplinary service provision and will help abolish turf wars. It also will help create a system where collaboration, seamless referral and professional interaction are common and based on the desire and need to bring the health care system to where the nation needs it, close to the people.

10. What is needed? Improved health and poverty reduction go hand in hand. Key factors that affect basic health status are gender equity, access to clean water and sanitation, education and communications. However, more focused attention needs to be given to maternal, newborn and child health and how existing fragile health systems can be strengthened to provide people with basic care. This will determine if women and children can reach their full potential. One current major health system bottleneck is human resources. Key points in addressing this bottleneck have been summarized above: specific, planned measures to recruit, retain, support, protect, supervise and empower staff in the field of maternal health care in order to be able to provide skilled birth attendance and emergency obstetric care. Health care professionals have an important role to play in the strengthening of human resources. Historically, the professions have been involved in dturf warsT to protect their professional grounds, competencies and legal status. These activities often negatively impact on the total capacity of the health system The challenge must be taken up by all and addressed with an open mind and spirit. The power of decisions cannot remain with those who have the highest education or earn the most money. It has to be spread to those who need and use our services, in order for all to fulfil their human rights and to rid the world of the shame of unnecessarily losing 11 million children and half a million women each year. List of Acronyms WHO World Health Organization MDGs Millennium Development Goals

Human resources and access to maternal health care International Federation for Gynecology and Obstetrics IPA International Paediatrics Association ICM International Confederation of Midwives ICN International Council of Nurses COINN Council of International Neonatal Nurses

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FIGO

[11]

[12]

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