Educating skilled birth attendants in Mexico: do the curricula meet international confederation of midwives standards?

The experience of obstetric nursing students in an innovative maternal care programme in Chiapas, Mexico: a qualitative study

In Mexico, over the last decade, more non-physician medical professionals have been participating in birth care according to recent federal regulations. So far, very few sites have been able to implement birth care models where midwives and obstetric nurses participate. We describe the experience of a group of intern obstetric nurses participating in a model that provides respectful birth care to rural populations, managed by an international NGO in partnership with the Ministry of Health of Chiapas, Mexico. We conducted a case study including individual interviews and focus group discussions with obstetric nurse interns participating in the Compañeros En Salud programme over four years from 2016 to 2019. We applied targeted content analysis to the qualitative data. There were 28 participants from 4 groups of interns. Informants expressed their opinions in four areas: (a) training as a LEO, (b) training experience at CES, (c) LEO role in health care delivery; and (d) LEOs' perspectives about respectful maternity care. Interns identified gaps in their training including a higher load of theoretical content vs practical experience, as well as little supervision of clinical care in public hospitals. Their adaptation to the health services model has increased over time, and recent classes acknowledge the difficulties that earlier ones had to confront, including the challenging interactions with hospital staff. Interns have incorporated the value of respectful birth care and their role to protect this right in rural populations. Findings could be useful to call for the expansion of the model in public birth centres.

Obstetric care and method of delivery in Mexico: results from the 2012 National Health and Nutrition Survey

OBJECTIVE

To identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico.

MATERIALS AND METHODS

This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) of 6,736 women aged 12 to 49 years. Delivery types discussed in this paper include vaginal delivery, emergency cesarean section and planned cesarean section. Using bivariate analyses, sub-population group differences were identified. Logistic regression models were applied, including both binary and multinomial outcome variables from the survey. The logistic regression results identify those covariates associated with the type of delivery.

RESULTS

53.1% of institutional births in the period 2006 through 2012 were vaginal deliveries, 46.9% were either a planned or emergency cesarean sections. The highest rates of this procedure were among women who reported a complication during delivery (OR: 4.21; 95%CI: 3.66-4.84), between the ages of 35 and 49 at the time of their last child birth (OR: 2.54; 95%CI: 2.02-3.20) and women receiving care through private healthcare providers during delivery (OR: 2.36; 95%CI: 1.84-3.03).

CONCLUSIONS

The existence of different socio-demographic and obstetric profiles among women who receive care for vaginal or cesarean delivery, are supported by the findings of the present study. The frequency of vaginal delivery is higher in indigenous women, when the care provider is public and, in women with two or more children at time of the most recent child birth. Planned cesarean deliveries are positively associated with years of schooling, a higher socioeconomic level, and higher age. The occurrence of emergency cesarean sections is elevated in women with a diagnosis of a health issue during pregnancy or delivery, and it is reduced in highly marginalized settings.

Successful Game Development Partnerships between Academics and Physicians

This paper discusses the creation of two serious games developed by the Engender Games Group with the intention of meeting specific outcomes in the healthcare field. The processes and pitfalls of developing games of this kind are outlined with the intention of demonstrating how game developers and health care professionals can collaborate to produce compelling, fun games that meet specific goals. The Atendiendo el Parto en Casa (Home Birth), game is a collaboration with Drs. Dilys Walker and Carrie Rouse at the University of Washington Medical School to educate traditional midwives working in rural Mexico. The Flu Busters! game is a collaboration with a group of pediatric specialists at Winthrop-University Hospital on Long Island led by Dr. Leonard Krilov which explains how the flu vaccine works and encourages children to get vaccinated.

Capacity building of skilled birth attendants: a review of pre-service education curricula

OBJECTIVE

to assess the level, type and content of pre-service education curricula of health workers providing maternity services against the ICM global standards for Midwifery Education and Essential competencies for midwifery practice. We reviewed the quality and relevance of pre-service education curricula of four cadres of health-care providers of maternity care in Northern Nigeria.

DESIGN AND SETTING

we adapted and used the ICM global standards for Midwifery Education and Essential competencies for midwifery practice to design a framework of criteria against which we assessed curricula for pre-service training. We reviewed the pre-service curricula for Nurses, Midwives, Community Health Extension Workers (CHEW) and Junior Community Health Extension Workers (JCHEW) in three states. Criteria against which the curricula were evaluated include: minimum entry requirement, the length of the programme, theory: practice ratio, curriculum model, minimum number of births conducted during training, clinical experience, competencies, maximum number of students allowable and proportion of Maternal, Newborn and Child Health components (MNCH) as part of the total curriculum.

FINDINGS

four pre-service education programmes were reviewed; the 3 year basic midwifery, 3 year basic nursing, 3 year Community Health Extension Worker (CHEW) and 2 year Junior Community Health Extension Worker (JCHEW) programme. Findings showed that, none of these four training curricula met all the standards. The basic midwifery curriculum most closely met the standards and competencies set out. The nursing curriculum showed a strong focus on foundations of nursing practice, theories of nursing, public health and maternal newborn and child health. This includes well-defined modules on family health which are undertaken from the first year to the third year of the programme. The CHEW and JCHEW curricula are currently inadequate with regard to training health-care workers to be skilled birth attendants.

KEY CONCLUSIONS

although the midwifery curriculum most closely reflects the ICM global standards for Midwifery Education and Essential competencies for midwifery practice, a revision of the competencies and content is required especially as it relates to the first year of training. There is an urgent need to modify the JCHEW and CHEW curricula by increasing the content and clinical hands-on experience of MNCH components of the curricula. Without effecting these changes, it is doubtful that graduates of the CHEW and JCHEW programmes have the requisite competencies needed to function adequately as skilled birth attendants in Health Centres, PHCs and MCHs, without direct supervision of a midwife or medical doctor with midwifery skills.

Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives

BACKGROUND

In Mexico 87% of births are attended by physicians. However, the decline in the national maternal mortality rate has been slower than expected. The Mexican Ministry of Health's 2009 strategy to reduce maternal mortality gives a role to two non-physician models that meet criteria for skilled attendants: obstetric nurses and professional midwives. This study compares and contrasts these two provider types with the medical model, analyzing perspectives on their respective training, scope of practice, and also their perception and/or experiences with integration into the public system as skilled birth attendants.

METHODOLOGY

This paper synthesizes qualitative research that was obtained as a component of the quantitative and qualitative study that evaluated three models of obstetric care: professional midwives (PM), obstetric nurses (ON) and general physicians (GP). A total of 27 individual interviews using a semi-structured guide were carried out with PMs, ONs, GPs and specialists. Interviews were transcribed following the principles of grounded theory, codes and categories were created as they emerged from the data. We analyzed data in ATLAS.ti.

RESULTS

All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth. The three types of providers recognize limits to their practice, namely in the area of managing complications.We found differences in how each type of practitioner perceived the concept and process of birth and their role in this process. The barriers to incorporation as a model to attend birth faced by PMs and ONs are at the individual, hospital and system level. GPs question their ability and training to handle deliveries, in particular those that become complicated, and the professional midwifery model particularly as it relates to a clinical setting, is also questioned.

CONCLUSIONS

Hospitals in the Mexican public health sector have a heavy obstetric workload; physicians carry the additional burden of non-obstetric cases. The incorporation of a non- physician model at the primary health center level to attend low-risk, normal deliveries would contribute to the reduction of non-necessary referrals. There is also a role for these providers at the hospital level.

Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines?

INTRODUCTION

We evaluated the quality of basic obstetric care provided by Mexican general physicians, obstetric nurses, and professional midwives compared with World Health Organization (WHO) guidelines for evidence-based practices and national guidelines.

METHODS

Vaginal births were observed in 5 hospitals in 5 states from June 2006 until July 2007. We created 5 indices based on WHO guidelines and national standards for care during normal birth. These indices included 1) favorable practices at admission, 2) favorable practices during labor, birth, and immediately postpartum, 3) harmful or excessively used practices, 4) newborn practices, and 5) obstetric outcomes. We assessed each provider type's performance as high or low compared with the WHO standard and performed bivariate and multivariate logistic regression analyses to assess the association between indices, patient characteristics, and provider type, adjusting for standard errors for intragroup correlation.

RESULTS

We observed 876 independently managed vaginal births. Adjusted regression analyses compared with the general physicians standard revealed significant results for favorable care by obstetric nurses on admission (odds ratio [OR] 6.25; 95% confidence interval [CI], 2.08-18.84); for care by professional midwives (OR 21.08; 95% CI, 4.24-104.94) and obstetric nurses (OR 7.88; 95% CI, 2.76-22.52) during labor, birth, and postpartum; and for newborn practices by obstetric nurses (OR 4.14; 95% CI, 1.08-15.90). Professional midwives were least likely to perform harmful/excessively used practices during labor, birth, and the postpartum period (OR 0.06; 95% CI, 0.00-0.35).

DISCUSSION

Professional midwives and obstetric nurses perform equally or better than general physicians when assessed by use or misuse of evidence-based practices. Professional midwives are an underutilized resource in Mexico. If integrated into the mainstream Mexican health system, they may improve the quality of obstetric care.