Utilizing Task Shifting to Increase Access to Maternal and Infant Health Interventions: A Case Study of Midwives for Haiti

Influence of the Quality of Antenatal Care on Early Breastfeeding Initiation and Exclusive Breastfeeding Among Haitian Women

OBJECTIVE

To assess the influence of the quality of antenatal care on early breastfeeding initiation and exclusive breastfeeding among Haitian women.

DESIGN

Secondary analysis of a cross-sectional household survey.

SETTING

Haiti Demographic and Health Survey, 2016 to 2017.

PARTICIPANTS

Women (N = 2,489) who were 15 to 49 years of age with children younger than 24 months of age.

METHODS

We used multivariable adjusted logistic regression analysis to examine the independent associations between quality of antenatal care and early breastfeeding initiation and exclusive breastfeeding.

RESULTS

The prevalence of early breastfeeding initiation and exclusive breastfeeding were 47.7% and 39.9%, respectively. Approximately 76.0% of the participants received intermediate antenatal care. The odds of early breastfeeding initiation were greater among participants who received antenatal care of intermediate quality than among those who did not receive antenatal care, adjusted OR (AOR) = 1.58, 95% confidence interval (CI) [1.13, 2.20]. Additionally, maternal age of 35 to 49 years (AOR = 1.53, 95% CI [1.10, 2.12]) was positively associated with early breastfeeding initiation. Factors negatively associated with early breastfeeding initiation were cesarean birth (AOR = 0.23, 95% CI [0.12, 0.42]), birth at home (AOR = 0.75, 95% CI [0.34, 0.96]), and birth in a private facility (AOR = 0.57, 95% CI [0.34, 0.96]). Factors negatively associated with exclusive breastfeeding were employment (AOR = 0.57, 95% CI [0.36, 0.90]) and birth in a private facility (AOR = 0.21, 95% CI [0.08, 0.52]).

CONCLUSION

Antenatal care of intermediate quality was positively associated with early breastfeeding initiation among women in Haiti, which highlights the influence that care during pregnancy can have on breastfeeding outcomes.

Which low- and middle-income countries have midwife-led birthing centres and what are the main characteristics of these centres? A scoping review and scoping survey

Evidence about the safety and benefits of midwife-led care during childbirth has led to midwife-led settings being recommended for women with uncomplicated pregnancies. However, most of the research on this topic comes from high-income countries. Relatively little is known about the availability and characteristics of midwife-led birthing centres in low- and middle-income countries (LMICs). This study aimed to identify which LMICs have midwife-led birthing centres, and their main characteristics. The study was conducted in two parts: a scoping review of peer-reviewed and grey literature, and a scoping survey of professional midwives' associations and United Nations Population Fund country offices. We used nine academic databases and the Google search engine, to locate literature describing birthing centres in LMICs in which midwives or nurse-midwives were the lead care providers. The review included 101 items published between January 2012 and February 2022. The survey consisted of a structured online questionnaire, and responses were received from 77 of the world's 137 low- and middle-income countries. We found at least one piece of evidence indicating that midwife-led birthing centres existed in 57 low- and middle-income countries. The evidence was relatively strong for 24 of these countries, i.e. there was evidence from at least two of the three types of source (peer-reviewed literature, grey literature, and survey). Only 14 of them featured in the peer-reviewed literature. Low- and lower-middle-income countries were more likely than upper-middle-income countries to have midwife-led birthing centres. The most common type of midwife-led birthing centre was freestanding. Public-sector midwife-led birthing centres were more common in middle-income than in low-income countries. Some were staffed entirely by midwives and some by a multidisciplinary team. We identified challenges to the midwifery philosophy of care and to effective referral systems. The peer-reviewed literature does not provide a comprehensive picture of the locations and characteristics of midwife-led birthing centres in low- and middle-income countries. Many of our findings echo those from high-income countries, but some appear to be specific to some or all low- and middle-income countries. The study highlights knowledge gaps, including a lack of evidence about the impact and costs of midwife-led birthing centres in low- and middle-income countries.

Burnout, Self-Efficacy, and Resilience in Haitian Nurses: A Cross-Sectional Study

Purpose of Study: Though nursing burnout is a global problem, research on nurse burnout in Haiti is scarce. In a context of multiple personal, social, and environmental challenges, this study assessed burnout and associated factors among Haitian nurses. Design of Study: A multi-site cross-sectional study. Methods: A survey in French and Haitian Creole was conducted in five Haitian hospitals using forward and back translated scales measuring burnout (emotional exhaustion [EE], depersonalization [DP], personal accomplishment [PA]), self-efficacy, nursing work environment, resilience, and demographics. Findings: Haitian nurses (N = 179) self-reported moderate EE (M = 21, SD = 11.18), low DP (Mdn = 2.0, range = 29), and high personal accomplishment (Mdn = 41.0, range = 33). General self-efficacy (M = 32.31, SD = 4.27) and resilience (M = 26.68, SD = 5.86) were high. Dissatisfaction with salary, autonomy, and staffing were evident. Conclusions: It is noteworthy that burnout was lower than expected given the scarce resource, difficult socio-politico-economic environment. High levels of self-efficacy and resilience likely mitigated a higher level of burnout. Adaptation enables these nurses to manage their critical conditions and practice holistic nursing, which may inspire hope among nurses in similar contexts.

Dedication in a Difficult Context: Faith-Based Nursing in Haiti

ABSTRACT

Haitian nurses live in a precarious environment, with healthcare disparity and low wages. In the presence of significant politico-social-economic disparities, adverse effects of natural disasters, deleterious infrastructure, challenged self-boundaries, and the burden of caring for high-need patients, the authors sought a better understanding of nurses' perspective of the situation. During qualitative interviews, Haitian nurses in two faith-based hospitals (N = 17) reported feeling powerless yet exhibited resilience and dedication to nursing as a calling. These conditions cry out for support of nurses' self-care needs. Future interventions may help nurses identify better resources to care for themselves and guide their practice.

Maternal health training priorities for nursing and allied health workers in Colombia, Honduras, and Nicaragua

Objective

To assess maternal health training priorities for primary care human resources for health (HRH) in nursing and allied health workers in Colombia, Honduras, and Nicaragua, to inform maternal care HRH strategic planning efforts.

Methods

This Washington, D.C.-based study utilized cross-sectional survey methodology to collect country-level data. From October 2016 to March 2017, a needs assessment tool was developed by the Pan American Health Organization/World Health Organization (PAHO/WHO) and PAHO/WHO Collaborating Centers. Data collection was completed by PAHO/WHO country offices, in collaboration with national health authorities and other high-level government personnel. The collected data included information on the composition, capacities, and training priorities of traditional birth attendants (TBAs), community health workers (CHWs), registered nurses (RNs), and auxiliary nurses in the three study countries; the findings were summarized in a report.

Results

Data on the health workforce composition in the three countries indicated reliance on HRH with low levels of education and training, with limited integration of TBAs. In all three countries, management of obstetric emergencies was a training priority for RNs, and identification of danger signs was a priority for CHWs and TBAs. Training priorities for auxiliary nurses varied widely across the three countries and included health promotion, preconception and prenatal care, and obstetric emergencies. There was also a wide range in the total number of HRH across the three countries.

Conclusions

Reliance on health workers with low levels of training is concerning but can be mitigated through in-service training. Training priorities are consistent with the major causes of maternal mortality, and Latin America and Caribbean region training programs show promise for improving quality of care. In the long term, planning for maternal care HRH should seek to increase the concentration of health professionals that are more highly skilled.

Combining task shifting and community-based care to improve maternal health: Practical approaches and patient perceptions

Globally, community-based care and task shifting strategies are used to address maternal healthcare shortages in low-income countries. Limited research exists on models that combine these strategies. Using a qualitative approach, we explored Haitian women's perceptions of the Midwives for Haiti model, which unites task shifting and community-based care by training nurses as skilled birth attendants and offering healthcare via rotating, mobile clinics. Eight focus groups (N = 52) were conducted in rural Haiti in March 2017. Thematic analysis of data indicated that perceptions of care were universally positive. Participants cited accessible patient-centred care, affordable services, and health education as primary motivators to attend. Results illustrated the importance of women's perceptions on the future use of mobile clinic sites or other formal care. Future efforts to address maternal healthcare shortages should consider the Midwives for Haiti model, combining task shifting and community-based care to address common social, topographical, or financial barriers to maternal healthcare.

Considerations for Implementing Group-Level Prenatal Health Interventions in Low-Resource Communities: Lessons Learned From Haiti

Haiti's high maternal and infant mortality rates evidence an urgent need for implementation of evidence-based strategies. A potential cost-effective strategy to mitigate high maternal and infant mortality rates is group prenatal care, an innovative model that combines antenatal clinical assessment with pregnancy education. Despite research demonstrating the effectiveness of this model in high-resource settings, less is known about the challenges of implementing it in low-resource settings. The purpose of this article is to provide recommendations for overcoming challenges of implementing group prenatal care in low-resources communities globally. Challenges addressed include language, literacy, space, cultural appropriateness of intervention content, and sociopolitical climate. Using examples from work conducted in Haiti, this information can be used to assist practitioners and researchers with overcoming challenges of implementing models of group care in international low-resource communities.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders

BACKGROUND

This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation.

METHODS

NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care.

RESULTS

Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting.

CONCLUSIONS

Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

Experiences of pregnancy complications: Voices from central Haiti

The purpose of this study was to explore the lived experience of pregnancy/birth complications in central Haiti from the perspectives of skilled birth attendants (saj fanm), traditional birth attendants (matwons), and postpartum mothers. Hermeneutic phenomenology guided the study. With the assistance of a Creole-English translator, four saj fanm, ten matwons, and seven postpartum mothers were interviewed. Their stories explain barriers and challenges to safe motherhood-serious limitations in transportation, staffing, and lack of the most basic of material resources, but also illustrate tremendous resiliency, spirituality, power of partnerships, and commonsense solutions to problems impacting maternal/newborn health in central Haiti. Haiti has one the world's highest maternal and neonatal mortality, and findings of this study provide perspective of this reality from those most affected by it-Haitian mothers and front-line maternity workers.

Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: a case study

BACKGROUND

A better understanding of the processes of collaboration between midwives who work in the birthing centers, and hospital-based obstetricians, family physicians and nurses may promote cooperation among professionals providing maternity care in both institutions. The aim of this research was to explore the barriers and facilitators of the interprofessional and interorganizational collaboration between midwives in birthing centers and other health care professionals in hospitals in Quebec.

METHODS

A case study design was adopted. Data were collected through semi-structured interviews with midwives, multidisciplinary professionals and administrators, through direct observation of activities in maternity units and field notes, and a variety of organizational and policy documents and archives. A qualitative thematic analysis method was used for analyzing transcribed verbatim.

RESULTS

The study suggests the close intertwinement between interactional, organizational and systemic factors in regard to barriers and opportunities for collaboration between midwives in birthing centers, and physicians and nurses in hospitals in Quebec. At interactional level, our findings show a conflict in scope of midwifery practice, myth about midwives, pre-judgment, and lack of communication skills between health care providers in the studied birthing center and hospital. At the organizational level, this investigation shows that although midwives have complete access to the hospital with which a formal agreement was signed, they were not integrated in hospital because of lack of interest of midwives and differences in philosophy and scope of practice among healthcare professionals as well as the culture of organizations. At a systemic level, in spite of excessive demand for midwifery care, there are not enough midwives to cover these demands.

CONCLUSION

Maternity care professionals require taking a collaborative approach in working and the boundaries of responsibility need to be redrawn. The inter-professional collaborative work between midwives and other maternity care professionals is crucial to improve access and women's choices for maternity care in Canada. Although having collaborative and multidisciplinary teamwork is a goal of maternity care systems, it is hard to achieve.

Simulation Learning Among Low Literacy Guatemalan Traditional Birth Attendants

Guatemalan maternal and infant mortality rates remain high, particularly among indigenous populations. In remote areas, traditional birth attendants (TBAs), without formal midwifery education, are frequently the only maternal care providers. We conducted a mixed methods study to evaluate knowledge, skills, and attitudes of 26 TBAs in western Guatemala. The purposes of this study were to evaluate the efficacy of a community-based midwifery training program and to determine how the knowledge, skills, and attitudes of TBAs influence the care provided to indigenous mothers and infants. Themes from 5 key informant interviews included survival of mother and baby, facilitating referrals, and community pressure not to refer. We offered a 2-week simulation-based training designed for low resource settings. Participants completed pre- and posttests and demonstrated midwifery skills. Knowledge scores and objectively measured skills improved significantly. Attitude outcomes included increased endorsement regarding importance of pre- and postnatal visits, recognizing risk/complications, and partnering with medical providers. Potential effects discussed include safe TBA practice, training value, and intent to disseminate learnings in their communities.