3. 6
Are you able to practice as the midwife
you want to be at work?
If you could design your our birth space to work in,
what would it look like?
Who would be the focus?
How would you make that happen?
How would you feel working there, with no barriers to
being a midwife?
6. 9
A health care facility serving women through their life course
Rooted in the midwifery philosophy and model of care
In a home-like shared space
Ensuring basic emergency maternal and neonatal care for all births
Integrated within the health care system
Responsive to needs of its community
With the woman's experience at its heart and center
The physical place for the practice of midwifery
fits into global QoC framework
A MIDWIFERY CENTER IS:
10. 16
Problems with facility based birth in low and middle income
countries (LMIC) (Bohren, M. et al, 2014) MDG and SDGs.
◦Distance to facility
◦Cost of delivery
◦Low QoC and fear of discrimination
◦Birth too medicalized and
dehumanized
Where are the MC globally?
FACILITY BASED BIRTH IN LMIC
11. 17
How does a MBC function in LMIC?
What do they do?
Is the care provided safe?
Is the experiences of care high quality?
Is it a viable options in a low resource health care
system?
RESEARCH PROJECT QUESTIONS
12. Data was collected on:
• 25 MLBC in 10 low and middle income
countries surveyed, 21 used (3 no births yet)
• Total of 3,549 births including transfers
IRB H-35803 Boston University
PILOT DESCRIPTIVE ANALYSIS OF MIDWIFERY
CENTER MODEL
13. Haiti (5)
Uganda
Sierra Leone
Cambodia (2)
South Africa
Peru (2)
Trinidad
Ecuador
Mexico (6)
Midwifery centers in LMIC
what's the environment like there?
PARTICIPATING MIDWIFERY CENTERS IN LMIC
Bangladesh
14. 20
PILOT DESCRIPTIVE ANALYSIS OF MIDWIFERY
CENTER MODEL
Birth centers surveyed Maternal
mortality ratio
per 100,000
Infant
Mortality per
1,000
#of births in 2016 at
MLBC (total
w/transfers)
1 in Sierra Leone 1,360 87 40
5 (+1) in Haiti 359 52 2,151
1 in Uganda 343 38 293
1 (+2) in Bangladesh 176 31 7 (just opening)
2 in Cambodia 161 25 573
1 in South Africa 138 34 99
2 in Peru 68 13 104
1 in Trinidad 63 13 59
1 Ecuador 64 18 23
6 in Mexico 38 11 200
total: 25 MLBC surveyed, 21
used (3 no births yet, 1 w/7)
3,549
Current MMR and IMR from:
https://data.unicef.org/topic/maternal-
health/maternal-mortality/
measuring quality and MW model in low resource areas
15. 21
Safety: Sustainable: Satisfying:
1. BeMONC 1. Provider to volume ratio 1. Respectful care
2. Health outcome data 2. Management model 2. Quality of care
3. Transfers 3. Staff Education
INDICATORS
Safety
16. 22
neonatal
mortality
3.5*
per 1,000
live births
maternal
mortality
105*
per 100,000
live births
Neonatal mortality
Surveys recorded 10 infant deaths in previous year.
80% had been transferred and died at the transfer facility.
Maternal mortality
There were 3 maternal deaths (2 in Haiti, 1 in Uganda) in the previous year.
All involved patients who were transferred and died at the transfer facility.
*n = 3,549 survey births
Safety measures:
1. BEmONC signal functions-
2. Outcome data
3. Transfer Relationship-
70% of BEmONC criteria met
25 min average- wide range
PROVISION OF CARE- SAFETY
BEmONC
17. 23
transfers
"sometimes is goes fine,
sometimes it doesn't. Hospital
has no phone." "not a very
good site, very subpart care, but
patients can afford it"
"sometimes the hospital is full"
"They insist advanced payment,
poor treatment, disrespect and
abuse." "Not a lot of confidence
in QoC, although outcomes
have been ok so far."- Haiti
"Sometime difficult to speak
to OBs or new hospital
directors, leadership changes
and we have to start over.
We have been here for 21
years." - Peru
"In public hospital we can accompany the
women to the C/S room, not in private",
"When we transfer for FTP, the maternity
hospital is further, but relationship is
poor", "Depends on the docs present.
Some argue with MW, some request birth
info" "Continuity of care is interrupted,
personnel don’t listen to women or
clinical hx from MW. There is obstetrical
violence and disrespect for MW work.:"
- Mexico
"QoC at hospital no
the best- sometimes
they have no power,
sometimes the
surgeon is not
there."- Uganda
Much better (was
bad). They don’t
think the birth
center should do
primes. Not
supportive of
OOH" - Trinidad
18. Country (#of
MC)
# of
births
Admin
structure
IV
antibiotics
IV anti-
convulsants
IV
uterotonics
Removal of
retained
POC by
manual
vacuum
Assisted
Vaginal
delivery
(VAVD)
Manual
removal of
placenta
Resuscitation
of newborn
Haiti (5) n=2,151
NGO (4),
public (1) part yes yes part part yes yes
Mexico (6) n=200
NGO (3),
Priv (3) part part yes part part part yes
Cambodia (2) n=573 public (2) no no yes yes yes yes yes
Peru (2) n=104 priv (2) no part yes no no part yes
Ecuador n=23 priv yes yes yes yes no yes yes
Sierra L n=40 NGO yes yes yes yes no yes yes
South Africa n=99 priv no no yes no yes yes yes
Trinidad n=59 NGO no yes yes no no yes yes
Uganda n=293 NGO yes no yes no no yes yes
Key: No no
part part
yes yes
BeMONC criteria met in midwifery center by country
Summary Don’t forget about the country context
19. 25
BEmONC criteria: Haitian hospital/MC Ugandan MC S Africa SL
1. Parenteral antibiotics 80%/ 67% yes NO YES
2. Parenteral anticonvulsants 69.2%/ 71% NO NO yes
3. Parenteral uterotonics 87%/ 100% yes yes yes
4. Removal of retained POC by MVA 55.8%/ 54% NO NO yes
5. Assisted vaginal delivery (ie VAVD) 13.3%/ 54% NO yes NO
6. Manual removal of the placenta 52.5%/ 87% yes yes yes
7. Resuscitation of the newborn 50.8%/ 100% yes yes yes
Sustainable?
BEMONC: HOW DO THE MIDWIFERY CENTERS
COMPARE TO COUNTRY DATA?
20. 26
Sustainability measures:
1. Staff to volume ratio and transfer numbers
2. Management model
3. Staff education
Primary sources
of funding
37%- NGO
32% NGO/Patient fees
16% Patient Fees
10% Public
5%- Public/NGO
Education of staff n=71
26%= NMW
26%= nurse
19%= MW
17%= SBA
7%= MW aux
3%=EMT
2%=TBA
Average
50
births per
provider/year
PROVISION OF CARE- SUSTAINABLE
midwifery training
21. 27
Traditional birth attendant- informal, experience, no degree, no license
Skilled birth attendant- trained formally, no license or degree
Nurse- college degree, OB experience
Auxiliary Midwife- min 3 yrs basic training
Midwife- min 3 yrs basic training and licensed
Nurse Midwife- degree and licensed
additionally found: OBs, EMT
EDUCATION OF STAFF
experience of care
22. 28
100% of Newborn Care measures met by MC
84% of Quality of care measures met by MC
88% of Respectful maternity care measures met by MC
Experience of care/Quality measures:
1.Respectful maternity care (RMC) (based on Landscape)
2.Quality of care (QoC)
EXPERIENCE OF CARE- SATISFYING
RMC
24. Country
(# of MC)
Staff trained
at continual
risk
assessment
during
labor?
Staff have
regular
emergency
drills?
Partograph
used with
every
birth?
Process for
tracking
admission
time for
every
women?
Process
for
tracking
birth time
for each
woman?
Process for
tracking
discharge/
transfer time
for every
woman?
Transport
to
CEmONC
arranged
Haiti (5) yes part part part yes yes yes
Mexico (6) yes part part yes yes yes yes
Cambodia (2) yes part part yes yes yes yes
Peru (2) yes yes part yes yes yes yes
Ecuador yes yes no yes yes yes yes
Sierra L yes no no no yes no no
South Africa yes no yes yes yes yes yes
Trinidad yes yes yes yes yes yes yes
Uganda yes yes yes yes yes yes yes
Key: No no
part part
yes yes
Quality of care criteria met in midwifery center by country
Quality criteria specifically for midwifery
centers in low resources areas.
Summary Looking forward- How can they strengthen a system?
25. 32
Health care workforce shortage:
◦ Utilizing appropriate provider for appropriate level of care needed.
Health care facility shortage, and cost effective:
◦ Utilizing appropriate level of facility for level of care needed
Bridging home and hospital:
◦ Providing optimal care experience
◦ Improving access and quality with an integrated health care system
Bridging professions:
◦ OB-Pediatrician-Midwife-Auxiliary-community workers- meeting women's and system's needs with
collaboration
MIDWIFERY LED BIRTH CENTERS STRENGTHEN:
future research
26. 34
Contributing Midwifery Birth Centers
Sierre Leone: Taiama Birth Center (n=40)
South Africa: Midwives Exclusive (n=99)
Ghana: Sampa Birth Center (to open)
Uganda: Shanti Uganda (n=293)
Trinidad: Mama Toto (n=59)
Peru: Pakarii Case de Nacimiento (n=104)
Ecuador: Dulce Espera (n=23)
Mexico: Casa Colobri, Luna Maya DF, Luna Maya Chiapas (n=200)
Haiti: Northwest Haiti Christian Mission, Carmelle Voltaire Women's HC, Sante Place Cazeau ("Smile Clinic"),
Maison de Naissance, Olive Tree projects, Carrie Wortham BC, (n=2,151)
Bangladesh: (Hope): Pockhali BC, Khunia Palong BC, Islampur BC, Bharuakhali BC (just opening) (n=7)
Cambodia: Thmar Krae Community BC, Sandan Community BC (Samaritan purse) (n=573)
28. RMC QoC
Country
(#of MC)
# of births at
MBC in 2016
(total
w/transfers)
BeMONC
criteria
met
RMC
criteria
met
QoC
criteria
met
Maternal
deaths
Newborn
deaths
Transfers
# IP, PP,
NB (%)
Haiti (5) 1,833 (2,151) 89% 86% 83% 2(tx site) 7 (tx site) 318 (15%)
Mexico (6) 157 (200) 69% 97% 86% 0 1 43 (22%)
Cambodia (2) 428 (573) 71% 84% 79% 0 2 (MC) 145 (25%)
Peru (2) 84 (104) 43% 93% 93% 0 0 20 (19%)
Ecuador 20 (23) 86% 95% 86% 0 0 3 (13%)
Sierra L 40 (40) 71% 67% 29% 0 0 0
South Africa 93 (99) 57% 86% 86% 0 0 6 (6%)
Trinidad 48 (59) 57% 95% 100% 0 0 11 (19%)
Uganda 275 (293) 57% 90% 100% 1 (tx site) 0 18 (6%)
2,978 (3,542) 70% 88%% 84% 3 10 564 (16%)
Summary of study data by country
BeMONC Haiti Mexico Cambodia Peru Ecuador Sierra L South Africa Trinidad Uganda
29. Country
(#of MC)
# of births at
MBC in 2016
(total
w/transfers)
Transfers #
IP, PP, NB
(%)
Transfer
time # FTE
#births/
provider
/year
Maternal
deaths
Newborn
deaths
Haiti (5) 1,833 (2,151) 318 (15%) 50 22 98 2(tx site) 7 (tx site)
Mexico (6) 157 (200) 43 (22%) 15 13 15 0 1
Cambodia (2) 428 (573) 145 (25%) 60 16 36 0 2 (MC)
Peru (2) 84 (104) 20 (19%) 15 3 35 0 0
Ecuador 20 (23) 3 (13%) 10 2 12 0 0
Sierra L 40 (40) 0 45 2 20 0 0
South Africa 93 (99) 6 (6%) 4 5 20 0 0
Trinidad 48 (59) 11 (19%) 5 2 30 0 0
Uganda 275 (293) 18 (6%) 10 5 56 1 (tx site) 0
2,978 (3,542) 564 (16%) 24 71 50 3 10
30
Median
Outcome data by country
30. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
5 Haiti 359/52 1,833 (2,151) 318 (15%) 89% 86% 83% 22 2 (tx site) 7(tx site)
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Haiti
SummaryCharges: $6, $20, $60, $60,$100 SBA, MWaux, nMW, 10-60min
31. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
6 Mexico 38/11 157 (200) 43 (22%) 69% 97% 86% 13 0 1(tx site)
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Mexico
SummaryCharges: $200, 350, 650, 650, 950 MW, aux MW, nMW, SBA, 15min
32. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early
Infant
deaths
2 Cambodia 161/25 428 (573) 145 (25%) 71% 84% 79% 16 0 2
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Cambodia
Summary$12 USD, SBA, nsg, MW, nurseMW, 1hr
33. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
2 Peru 68/13 84 (104) 20 (19%) 43% 93% 93% 3 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Peru
SummaryCharges: $900USD- $1,070 MW, Obs, 5min,
34. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in
2016 at MBC
(total w/
transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early
Infant
deaths
1 Ecuador 64/18 23 3 (13%) 86% 95% 86% 2 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Ecuador
Summary$1,400 USD MW, MW aux, 10-15 min to hosp
35. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/
transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early
Infant
deaths
1
Sierra
Leone 1360/87 40 0 71% 67% 29% 2 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Sierra Leone
Summary$10USD TBA, nsg, nMW, 45min,
36. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016 at
MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
1 South Africa 138/34 99 6 (6%) 57% 86% 86% 5 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
South Africa
Summary$1080 USD 4min,
37. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
1 Trinidad 63/13 59 11 (19%) 57% 95% 100% 2 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Trinidad
Summary$2,300USD auxMW, MW, nMW, 5min
38. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in 2016
at MBC
(total w/ transfers)
Transfers- IP,
PP, NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early NB
deaths
1 Uganda 343/38 293 18 (6%) 57% 90% 100% 5 1 (tx site) 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Uganda
Summary$2USD, MW, auxMW, TBA, 10min
39. # of MBC
surveyed Country
2015
MMR*/
IMR*
# of births in
2016 at MBC
(total w/
transfers)
Transfers- IP, PP,
NB (%
transferred) BeMONC RMC QoC #FTE
Maternal
deaths
Early Infant
deaths
1 Bangladesh 176/31 7 0 100% 90% 100% 1 0 0
21 TOTALs 2,985 (3,549) 564 (16%) 70% 88% 84% 71 3 10
Bangladesh (not included in summary data)
Summary$12 USD MW, 1 hr
40. 48
References
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School of Public Health. University research Co., LLC. Available from: https://www.ghdonline.org/uploads/Respectful_Care_at_Birth_9-20-101_Final1.pdf
Feldstein, A., Glasgow, R. (2008) A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. The joint commission
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RMHP
Le Nouvelliste. 50% des sages-femmes formees en Haiti exercent leur profession a l’etranger. [Internet]. Haiti. 2017-08-09. [cited Feb 7, 2018]. Available from:
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Martineau.(2016) Quel avenir pour la profession d’infirmiere en Haiti? [Internet]. [cited Feb 7, 2018]. Availble from: http://www.lescacosnoirs.com/quel-avenir-pour-la-
profession-dinfirmiere-en-haiti/
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UK: percent of women who began prenatal care at a birth center developed a complication that precluded out of hospital birth.
Almost 90 percent of those complications occurred during the third trimester; (postterm pregnancy most common)
• 12 percent of the women admitted to birth centers in labor were transferred to hospitals before giving birth;
4 percent of the mothers and 4 percent of the newborns were transferred to hospitals because of postpartum or newborn complications.
• Only 2.4 percent of all transfers were emergencies. The most common reasons for intrapartum transfers were failure to progress (43 percent), meconium stained amniotic fluid (11 percent), and nonreassuring fetal heart rate (8 percent).
decades of research demonstrating the strength of the model in HIC
focus meetings- Haiti, Mexico, researchers at ICM, globally with network
how are MC in low resource areas (without healthy health care system to transfer to?)
SDGs- QoC, Human rights approach, RMC
Lancet
MDG approaches to MM- SBA, facility based birth
4 not included:
1 Ghana (no births yet)
1 Haiti (no births yet)
2 Bangladesh (no birth yet)
Picking what data to measure- how to we check to see if they are safe….AND offer midwifery model of care??
self reported, retrospective, unvalidated
tx time from 5 min to 60
read/discuss circles, 70%
WIDE range of births/year (12-98 births/year/provider)
****outline rmc- think about how to present and mw model****
measures chosen b/c MC are different than hosp….
make fewer words
100%.... than pick a few big words
MC offer a potential for improved quality with improved outcomes, safety and high level of satisfaction for women.
What else do MC provide?
consider bar graph
Transfer rates in labor in Netherlands- 22% (KNOV)
(http://www.europeanmidwives.com/upload/filemanager/content-galleries/members-map/knov.pdf)
Netherlands- max transfer time- 27 min
Births per provider per year:
mean- 50
median- 30
UK Birthrate Plus national benchmark- 29.5 birth/midwife- currently doing 33 births/midwife
midwifery services in England National Audit office
(https://www.nao.org.uk/wp-content/uploads/2013/11/10259-001-Maternity-Services-Book-1.pdf)
$6, $20, $60, $60,$100 Most with bottled water, solar/generator, SBA, MWaux, nMW, 10-60min
Burdened by poverty, communities isolated by geography, scarce health professionals, scare hospitals
$200, $350,$650, $650, $950 USD, MW, aux MW, nMW, SBA, 15min
Not integrated into system yet- but in the process, humanizing birth, high levels of obstetrical violence and C/S
$12 USD, river, solar panel, SBA, nsg, MW, nurseMW, 1hr
National strategy to train MW and adapt local health centers to birthing homes with 2-3 mw each "MW provide the backbone to the health workforce for mothers and children
Samaritan Purse
-Sandan Birth Center
-Thmar Krae Birth Center
, hosptial- 1 hour drive, charge
$900USD- $1,070, MW, Obs, 5min,
Pakarii and Ruruchay Case De Nacimiento-
$1,400 USD, MW, MW aux, placenta encapsulation, 10-15 min to hosp,
intercultural model of care, humanized birth
Dulce Espera
$10USD, TBA, nsg, nMW, 45min,
no kitchen (fire pit outside), intermittent power, well, Registration process,
work collaboratively with indigenous herbalist, incorporation of traditional women's society- 'solay'.
Intense poverty, armed conflict, recent ebola epidemic, 90% FGM, #1 for high MM and NM
Taiama birth center
Midwives Exclusive BC- $1080 USD, public water and elec, generator, 4min,
MamaToto- $2,300USD, public water and elec, 5 min, auxMW, MW, nMW
Shanti Uganda-
$2USD, rain water catchment and solar panels, MW, auxMW, TBA, 10min, (often no doc there), 1 MM at tx
Began as an empowerment project- skills for women, expanded to women's health
Have employment workshops, teen program, doula training, nutrition, yoga and wellness classes
$12 USD, well, public power, MW, 1 hr to transfer
Hope Foundation
-Bharuakhali BC
-Islampur BC
-Khunia Palong BC
-Pockhali BC
