by Annie Clark, CNM, MPH, ACNM Senior Technical Advisor
Thanks to funding support from the United States Agency for International Development , ACNM has expanded its Life Savings Skills (LSS) series2 with the development and field-testing of Home Based Life Saving Skills (HBLSS). HBLSS aims to reduce maternal and neonatal mortality by increasing access to basic life saving measures within the home and community, as well as by decreasing delays in reaching referral facilities where life-threatening problems can be managed. However, for this program to reach its full potential, it is critical that staff at the first level referral facility be able and available to provide essential life saving interventions when a referred woman or newborn arrives. That is why ACNM proposes the Basic Five for Saving Livesâ„¢. The "Basic Five" are feasible interventions that, at even the most peripheral facility, could save the lives of women and newborns needing emergency care.
The following two illustrative cases are situations where the "Basic Five" could have been used to save lives. They are drawn from audit interviews with families of Ethiopian women3 with life threatening complications who sought care at their nearest health post.
CASE 1: A woman and her sick newborn were referred by a HBLSS and Ministry of Health (MOH) trained traditional birth attendant (TTBA). The newborn was septic, but no antibiotics were available.
CASE 2: A woman with a retained placenta bled all the way to the health post and all the way back home. No one was at the health post and no message was left where to find either of the two health post staff. The woman died.
Transportation is not available in some rural areas, and there are often long distances between villages and health posts. Many people lack the money needed to go for medical treatment, as it may take a family's entire savings and/or leave them in debt. In the minds of the woman with a complication, her community and her care givers, the trip to the health post must be worthwhile; thus lifesaving interventions not available in the community must become immediately available.
Comprehensive Emergency Obstetric Care (CEmOC) is typically only available at tertiary level facilities or district hospitals, which are often a greater distance from a woman's village than a health post. CEmOC includes:
Administration of antibiotics, oxytocics, or anticonvulsants
Manual removal of the placenta
Removal of retained products following miscarriage or abortion
Assisted vaginal delivery with forceps or vacuum extractor.
Caesarean section
Blood transfusion and intravenous infusion.
These procedures are not available at peripheral level facilities, where a woman is most likely to first seek help. A focus on peripheral level facilities is critical to establish a continuum of care for families that are unable to reach a CEmOC facility. This is where ACNM's proposed Basic Five for Saving Livesâ„¢ can help. The Basic Five is part of an effort to widen access to five critical elements of basic emergency obstetric care (BEmOC) at the most accessible point of entry into the health care system.
Basic Five for Saving Livesâ„¢:
1
24 HOUR AVAILABILITY OF AT LEAST ONE STAFF MEMBER
If a staff member is "on call" at home at night, a note could be posted to that effect with directions to her home.
2
HYDRATION
Infusion (solution, administration sets, and needles) for mother and baby
Oral hydration for mom
Sucking breast milk and/or expressed breast milk by cup for baby.
3
BROAD SPECTRUM ANTIBIOTICS
Oral and injectable antibiotics for mother and baby.
4
PREVENT POSTPARTUM HEMORRHAGE
ACTIVE MANAGEMENT OF THIRD STAGE
IMMEDIATE POSTPARTUM CARE
Appropriate oxytocics
Controlled cord traction
Empty bladder
Uterine monitoring and massage
Warmed baby to breast as soon as possible.
5
MANAGE POSTPARTUM HEMORRHAGE
BIMANUAL COMPRESSION
EVACUATION OF CLOTS
LACERATION REPAIR
Manage postpartum hemorrhage with:
Skills: catheterization, intravenous and intramuscular procedures, local anesthesia, vaginal manual and speculum examination, perineal and cervical laceration repair, infection prevention
Medicines: oxytocics, local anesthesia, intravenous solutions
Equipment: speculum, needle holder, syringes, suture/needles, catheter, gloves, light source, tape, time piece, soap and water.
It may be noted that the Basic Five does not include anti-convulsants for severe pre-eclampsia/eclampsia. In many countries, diazepam is the only anti-convulsant available, and regulations restrict its provision to providers in peripheral facilities. Magnesium sulfate, the drug of choice for treating severe pre-eclampsia/eclampsia, is often not available even in district hospitals. Since pre-eclampsia/eclampsia is a leading cause of maternal death world wide, a solution to the constraints of providing anti-convulsants to providers at peripheral facilities must be found. It is hoped that this additional element will be available in peripheral facilities at some point in the future.
If funds and time dictate continuing education programs, ACNM urges an assessment of the skills of health care facility staff to see if they can provide the Basic Five. If updating is needed, a continuing education program using the ACNM's Life Saving Skills curriculum is recommended to build competency with the possibility of yearly recertification. Continuing education is not all providers need to save lives. The ongoing provision of pharmaceuticals and supplies requires political will, the commitment of the Ministry of Health (MOH), and development of a management and distribution system. It is when we can address maternal and newborn emergencies at all levels, with linkages between the home and needed health care facilities, that we have the greatest chance of reducing maternal and newborn morbidity and mortality.
Notes for main text above:
ACNM worked through the PRIME I (CCP-3072-C-00-5005-00, Core, and CCP-3072-Q-00-5006-00, Requirements) and PRIME II (HRN-A-00-99-00022-00) projects in India, in collaboration with the Program for International Training in Health (Intrah) Regional Office/New Delhi and local non-governmental organization, Shramik Bharti 1998-2000. The ACNM worked through the Child Survival XIII project (Cooperative Agreement No.FAO-A-97-00054-00) in Ethiopia, in collaboration with Save the Children/USA and the Ethiopia Ministry of Health 2000-2002.
The Life Saving Skills series includes Life-Saving Skills Manual for Midwives 3rd Ed. (8) an advanced in-service training program for physicians, nurses, and midwives; Healthy Mother and Healthy Newborn Care (9) a basic in-service training program for nurses, midwives and other health post staff; and the Home Based Life Saving Skills (10).
3 ACNM Follow-Up Trip Report HBLSS from Liben Woreda, Guji Zone (formerly Borana Zone) of southern Ethiopia as part of the Save the Children /USA Gates-funded Saving Newborn Lives and in collaboration with the Ethiopia MOH 2003-2004.
*Additional editing by Deborah Gordis, MPH, director of Global Outreach; Sandy Buffington, CNM, Senior Technical Advisor; and Diana Beck, CNM.
Notes for sidebar:
Source: Sibley, L., Sipe, T., Armelagos, J., Barret, K., Finley, E.P., Kamat, V., Loomis, A., Long, P.J., Morreale, S., Quimby, C. 2002. Traditional birth attendant training effectiveness: a meta-analysis. Unpublished technical report. Washington, D.C.: Academy for Educational Development SARA Project.
Traditional birth attendant training effectivenss: a meta-analysis. World Bank Safe Motherhood Special Grants Program, United States Agency for International Development (USAID) Bureau for Global Programs, Office of Population (PRIME I Project), and USAID Bureau for Africa Office of Sustainable Development, (Academy for Educational Development/SARA Project), p.107, Technical Report
Traditional Birth attendants (TBAs
remain a major workforce in maternity care in developing countries. Yet, after more than three decades of experience, the evidence in support of TBA training is limited and often conflicting. Moreover, there is controversy over the cost-effectiveness of TBA training in relation to the global Safe Motherhood Initiative.
The American College of Nurse-Midwives undertook this meta-analysis of TBA training effectiveness with support from USAID Bureau for Africa (SARA Project), USAID Bureau for Global Health (PRIME I Project), and the World Bank Safe Motherhood Special Grants Program.
The meta-analysis of published and unpublished studies describes the effect of TBA training on TBAs and on women cared for or living in areas served by trained TBAs, including maternal and perinatal deaths. The findings are relevant in light of the current controversy on efficacy of TBA training where home birth is common and maternal and neonatal mortality remain high and in light of the recent shift to skilled attendance at delivery--a distant reality for some.1
Retained Placenta: After the birth, the placenta usually is pushed out by the womb pains and the woman pushing a little. The placenta usually comes out a few minutes after the birth but sometimes may take up to one hour. Then the womb gets smaller, hard, and the bleeding slows.
It is not normal if the placenta is still in the womb one hour after the baby is born. Signs: When the placenta is still in the womb, the womb cannot get smaller, and the womb cannot get hard. When this happens the bleeding does not stop. (a) The bleeding may be coming to the outside so it can be seen. (b) Sometimes the bleeding is inside the womb. Only a little blood can be seen outside but the woman is very weak and very sick.
When this happens, the womb becomes bigger and hard as it fills up with blood. Too much bleeding outside or inside the womb is very dangerous. The woman can bleed to death in two to three hours. Causes: After the baby is born, the placenta does not come out in one hour and there is too much bleeding. The placenta is stuck because: (a) the woman has too much urine, (b) the womb is too tired from a long labor or too many pregnancies, (c) the womb pains stop. A stuck placenta is called a retained placenta.
Sometimes the placenta can be stuck with no bleeding. This is serious but no emergency as long as the woman is not bleeding.2
