Medicine and Radiology - Theses
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ItemOptimising the role of auxiliary midwives to improve maternal and newborn health care in Myanmar: the potential for task shifting( 2018)Background: Over 800 women die from preventable causes related to pregnancy and childbirth every day, almost all of them in low and middle-income countries. Human resource constraints, both in terms of numbers and quality, are at the core of the problem. Task shifting is an approach designed to address the crisis in human resources for health. In 2015, Myanmar reported a maternal mortality ratio of 282 per 100,000 live births with only 14 health care providers per 10,000 people, well below WHO recommendations of 23 health care providers. Currently in Myanmar, most babies are born without the assistance of a skilled birth attendant (e.g. a midwife), a situation believed to be a major contributor to high maternal and newborn mortality. The Ministry of Health and Sports trains and deploys a cadre of volunteers, called auxiliary midwives (AMWs) to provide maternal and newborn care in areas without skilled birth attendants. This thesis examines the role of AMWs and the feasibility and acceptability of task shifting selected interventions to AMWs to improve maternal and newborn health care in Myanmar. Methods: This research involved two studies. The first was a mixed methods study conducted in Magwe Region, Myanmar between July, 2015 and June, 2016 involving a survey of 262 AMWs, complemented by 15 focus group discussions (FGDs) with midwives, AMWs, mothers and community members and 10 key informant interviews with health care providers at different levels within the health care system. This study aimed to understand the skills, knowledge and role of AMWs and the feasibility and acceptability of task shifting essential maternal interventions to AMWs. A second qualitative study, conducted in Magwe and Yangon Regions between June, 2015 and February, 2016, involved 11 FGDs with midwives, AMWs and mothers and 16 key informant interviews to explore the feasibility and acceptability of a new inhaled formulation of oxytocin currently under development for the prevention of postpartum haemorrhage (PPH), and potentially ideal for task shifting to AMWs in future. Results: AMWs are trusted members of the community and provide preventive, promotive and childbirth care in hard-to-reach rural areas. However, in emergency situations involving curative care, AMWs are often required to exceed their assigned role. This pressure to provide curative care in hard-to-reach rural villages where there is no skilled provider or support infrastructure, concerned and frustrated AMWs. Simultaneously, their knowledge of danger signs and skills in conducting safe delivery and newborn practices were found to be poor. AMWs often work alone in many hard-to-reach villages, and both the community and health care providers believe they should be better equipped with the skills needed to undertake basic emergency care. The research also found that AMWs were capable of being utilised – with proper training and supervision – to deliver a package of maternal interventions through task shifting. The main interventions identified as feasible and acceptable for task shifting were oral vitamin supplementation during the antenatal care period, provision of misoprostol to prevent postpartum haemorrhage after childbirth, and the use of oral antibiotics for puerperal sepsis during the postpartum period. The study also endorsed the feasibility of introduction of an inhalable formulation of oxytocin (currently under development) for use by community-based birth care providers in areas lacking electricity and cold storage facilities. Conclusion: AMWs are a large body of health volunteers who have been embedded within the community and health system in Myanmar for nearly four decades, and enjoy widespread community acceptance and trust. The role of this valuable health workforce can be optimised through task shifting of essential maternal interventions to provide effective care to mothers in rural and remote areas. This will require extensive skills-based training, ongoing supportive supervision and strong policy commitment, but if done well, AMWs could play an important role towards reducing maternal and neonatal mortality.