This course will review challenges for maternal and newborn health in the developing world, where a great many women and babies are suffering from complications during pregnancy, childbirth, and the days following birth. Themes covered include the epidemiology of maternal and newborn mortality and morbidity, relevant issues for the global health workforce, community-based interventions to improve maternal and newborn health and survival, and sociocultural dynamics surrounding birth. This course provides a broad overview of maternal and newborn health issues facing low-income and transitional countries, where more than 2.6 million babies are stillborn and nearly 500,000 women die during childbirth or from pregnancy-related complications each year. In the developing world, many women deliver at home without a skilled care provider, drugs, or technological supports. Maternal and newborn survival can be improved by mobilizing communities and improving access to skilled care. Through lectures, case studies and readings, course participants will learn about delivery challenges for maternal and newborn health services and how to utilize community-based strategies to improve the health and survival of mothers and babies.
Policy Issues
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Childbirth: A Global Perspective
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从本节课中
The Impact of the Health Care Workforce Shortage
In this module we’ll be discussing the critical importance of having an adequate and well-trained health workforce for reducing maternal and newborn morbidity and mortality. We’ll be discussing the problems of shortage and maldistribution, as well as some important strategies for addressing these problems such as task shifting and task sharing.
与讲师见面
Lynn SibleyProfessor
Neil Hodgson Woodruff School of Nursing
The last section of this presentation pertains to
policy issues regarding task shifting, and their impact on maternal and
newborn services, especially in sub Saharan Africa.
As previously noted, beginning with the new millennium, healthcare, cadres,
roles and responsibilities in low income countries have changed and
expanded due to the variety and number of global health initiatives,
accompanied by recent advances in disease prevention and control.
Mid-level practitioners such as nurses,
midwives, non physicians, clinicians, are now trained to assume new program
responsibilities as a result of trainings organized and supported by outside donors.
Additionally, a number of ministries of health,
having benefited from outside funding to launch new initiatives in malaria,
tuberculosis, maternal and child health, HIV/AIDS, currently endorse expanded
task-shifted roles previously considered the exclusive purview of medical doctors.
However, because these roles have evolved informally,
usually at the facility or program level,
there's frequently an absence of corresponding laws, regulations, or
official policies to support the newly acquired duties and responsibilities.
Although global normative bodies have endorsed expanded scopes of practice for
non-physicians, including community health workers, and
have developed specific guidance supporting their implementation,
policy challenges arise when official regulations regarding task
shifting lag behind program efforts to scale up a health initiative.
This asymmetric state of affairs is especially notable within HIV care and
treatment services delivered in maternal and child health settings.
For example, until recently PMPCT Programs consisted of anti-retroviral
regimens that focused on preventing HIV transmission to the newborn.
Recently this protocol has been replaced with a more comprehensive regimen that
incorporates maternal HIV care and HIV prevention for the infant.
Current WHO guidelines regarding PMTCT services recommend the provision
of lifelong ART to all pregnant and breastfeeding women infected with HIV,
regardless of their immune status or clinical stage of the disease.
This newer focus on the mother, also referred to as option B+ is based on
the latest scientific understanding of HIV transmission, and was introduced as
a means to simplify the diagnosis and treatment of the disease among pregnant
women, while simultaneously reducing mother-to-child viral transmission.
While this latest protocol has the potential to simplify the work of
healthcare providers, by reducing diagnostic complexity and
promoting service integration between PMTCT and ART, it has also
increased task shifted responsibilities among lid, mid-level providers.
A number of ministries of health have adopted option B+ services in
their maternal and child health clinics, and have informally accepted task
shifted practices, even though their national laws and
regulatory policies restrict diagnosing and prescribing ART to medical doctors.
In some instances, these restrictions are supported by the medical
profession councils, who view task shifting as an erosion of their authority.
In other instances, pharmacy boards responsible for
determining which drugs can be prescribed by which health provider,
are the barrier to developing and advancing national task shifted policies.
Additionally, there are situations of unintentional oversight,
where lack of awareness and
communication between national HIV programs and the respective policy and
legal governmental units have resulted in an absence of updated policies,
making health workers vulnerable to legal, professional, and ethical violations.
In a recent East, Central, and Southern Africa survey of nurse-Initiated and
managed ART or NIMART, Zuber, et al noted in the Journal of the Association
of Nurses in AIDS Care, that among the countries they surveyed, the lowest
ART coverage was found within those countries where NIMART was not practiced.
The survey, which was conducted in 2012, queried senior nursing
leadership teams about the extent to which NIMART was widely practiced and
authorized in policy, regulation, and pre-service education, that is,
education provided prior to professional entry into practice.
Their findings further noted that while NIMART may have been practiced and
authorized at local facilities, the practice lacked
regulatory reinforcement and incorporation into pre-service training.
In addition to national laws and
government policy supporting task shifting,
expanded non-physician roles also require professional regulatory board endorsement.
Professional regulatory counsels that govern the practices of nurses,
midwives and non-physician clinicians need to formally acknowledge expanded
practices and revise their respective professional boundaries or
scopes of practice, and communicate these changes to their constituency and
academic training institutions and monitor the task shifted duties, so as to
assure patient quality of care, while supporting their constituents' standing.
As you can see, introducing task shifted roles into health services,
requires a health systems approach, that incorporates evidence based and
formalized program guidance, supportive legal policies and official
recognition by professional regulatory councils regarding approved practices.
Failure to include these components when introducing task shifting to
health service delivery can delay official endorsement of the practice,
jeopardize program implementation and place health care providers at risk of
violating legal or accepted professional practices.
In summary this lecture introduced the concepts of task shifting and
task sharing and explained the difference between the two.
We also reviewed the scientific literature in order to
appreciate the evidence base for this approach and
recognize trends within maternal, newborn health, and HIV programs.
Lastly policy considerations regarding cash shifting were presented so
as to acquaint you, a current or future global health practitioner,
with non clinical issues needing attention, in order to affect change and
ensure support and successful implementation of task shifted practices.
The preceding program is copyrighted by Emory University.
