Midwifery and the 6Cs

As part of our Trusts ‘Celebrating Excellence in Nursing and Midwifery’ event recently our Director of Nursing emphasised to all participants the importance of delivering the values and behaviours of the 6 Cs as we go about our practicing our professions. The 6 Cs:

Care

Compassion

Competence

Communication

Courage, and

Commitment

are the key components of the ‘Compassion in Practice’ policy document of the NHS Commissioning Board, and outlines the 3 year vision and strategy compiled by the Chief Nursing Officer and Director of Nursing at the DoH.

On examination of the implementation plans within the document my focus is of course drawn to the midwifery specific sections. There is of course the usual midwifery rhetoric one would expect to find in such a policy document…holistic responsive care, developing supportive relationships, advocacy, safe practice, providing positive experiences and such like. There are two areas however which I pondered on for some time. Firstly, as direction on delivering the ‘vision’ the document states that the contributions midwives make to public health will be mapped, based on the Midwifery 2020 paper of 2008. This would include such public health issues as improved breastfeeding rates, screening programmes and working with vulnerable families. For example as a direct result of the obvious health benefits to mother and baby from exclusive breastfeeding UNICEF have stated that the NHS could save up to £40 million each year if we only moderately increased breastfeeding rates in the UK. And in poorer nations exclusive breastfeeding is not just a health issue it s matter of life or death – where clean water is scarce and malnutrition is rife Save the Children have stated that just from early and exclusive breastfeeding 830,000 babies lives could be saved every year (see previous blog entries).

Secondly, action five in the ‘Compassion in Practice’ document emphasises the need for adequate and safe staffing, stating how crucial it is that “we have the right staff, with the right skills, in the right place” in order to deliver the ‘vision’. Recently the Royal College of Midwives have estimated that in the UK we need another 5000 midwives to cope with rising birth rates, and we’ve all felt this shortfall affecting the care we give our women and families. Imagine working in a nation with a health worker deficit of over 2.5 million staff. This is the reality my colleagues and I saw as we visited India in January as Health Worker Ambassadors for Save the Children (see previous blog entries). In the absence of qualified midwives and doctors we observed accredited social health activists (ASHAs) undertaking midwifery and health education responsibilities for less than minimum wage in order to improve the health and birth outcomes for the women and babies in their communities, the very model of ‘compassion’ and who were delivering the 6 Cs on a daily basis.  The State of the Worlds Mothers report from Save the Children has highlighted the need to invest in health workers as one if its major recommendations in the struggle to reduce maternal and child mortality worldwide. Health staff need to be recruited and trained, be well equipped and be incorporated into fully functioning health care systems to deliver the life saving care that so many are desperately in need of. 99% of all maternal deaths worldwide occur in developing nations, that’s 800 every day. 8000 babies pass away within one month of birth. It’s a lot to take on, but so much is at stake.

We all have our role to play in the implementation of Compassion in Practice, and in improving maternal and child health both in the UK and abroad. The health staff I have worked with in Asia and Africa have shown some of the greatest of the 6Cs I have ever witnessed as they have carried out their duties in the toughest of settings. But we can’t do this is isolation. Let’s hope that our world leaders don’t forget this as they meet at the G8 summit this month. As the State of the World’s Mothers report states, improving newborn, child and maternal health should not only be on the public health agenda, is also vital for global development.

 Useful links:

Compassion in Practice:

http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf

Midwifery 2020: Delivering Expectations

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147752/dh_119470.pdf.pdf

UNICEF & breastfeeding

http://www.unicef.org.uk/Latest/News/breastfeeding-report-nhs-savings/

Save the Children, Superfood for babies:

http://www.savethechildren.org.uk/news-and-comment/news/2013-02/breastfeeding-could-save-830000-lives-year

Save the Children ‘State of the World’s Mothers’ report:

http://www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf

6c-logo

Aid and the budget

Great news from the 2013 Budget; last week the chancellor kept true to his word and allocated 0.7% of UK gross national income to overseas aid. For all the aid sceptics out there (and there are many!) here’s a great video from Save the Children that puts it all into context:

https://www.youtube.com/watch?v=-KhMj6p21dU

And you can’t argue with the need for aid with this kind of statistic:

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Here are two boys who benefitted from aid – Luv and Kush, twin boys who with the Support of Save the Children were born in hospital, mother and twins thriving!

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India Day 2. ASHAs, camels and mobile phones

On our second full day in India with Save the Children we travelled to Roopangarh village in Kishangarh district, Rajastan. Here we were to meet with ASHAs to see a tremendously successful yet simple health project in action. ASHAs are Accredited Social Health Activists who are a form of Community Health Volunteer. They are excellent grass roots change agents as each is from their community, chosen by their community and works for her community.  ASHAs are the first port of call for any health related demands of deprived sections of the population where there is one ASHA per 1000 persons. Damanjeet, the Save the Children India (SCI) staff explained to us how historically the ASHAs encountered constraints in their daily work which included poor counselling skills, a lack of visual aids or tools for their health promotion work, and poor resources for calculating and handing in their monthly reports and statistics. This is where Save the Children stepped in. In 2010 Save the Children designed a project which would help to tackle the constraints the ASHAs faced and help reduce the high infant and maternal mortality rates in the area. The solution was mobile phones. Incredible!

We began by meeting a selection of the local ASHAs of Roopangarh at the government offices. All were extremely enthusiastic about telling us how they use their new technology to spread vital health messages to the local families they serve. All the 70 ASHAs of Kishangarh block were given training to use the mobile application, and at the end had been given basic Nokia handsets to use. It seems the features of these applications included counselling guidance from pregnancy to safe newborn care, audio prompts, pictorials and registration through to data collection. Each ASHA was proudly clutching her precious mobile phone as they explained to us all how they go from household to household gathering data on each family, showing the women the pictorials and holding the phone out for all to hear the educational messages in the local language. It was fascinating to hear but I have to admit I was sceptical about how sustainable such a project was in such a resource poor setting. I was later reassured to hear that it costs the ASHAs less than USD$1 per month for mobile recharges. Also, the whole system had clearly given the ASHAs confidence in their work; the phones’ application meant that no vital health messages were left out, they no longer had to carry around their cumbersome health registers and it improved their credibility as health volunteers as advice is consistent and up to date. I was fascinated, and luckily we were all to see for ourselves how these worked.

Ralka and the ASHAs introducing us to the mobile phone technology in Roopangarh village, Rajastan.

Ralka and the ASHAs introducing us to the mobile phone technology in Roopangarh village, Rajastan.

We each went off with an ASHA to see the mobile phone project in action. Raj our video/photographer, Megan from the Save the Children UK and myself went with Ralka the ASHA to the community she serves. She took us to see a family where a young mother was expecting her second baby, she must have been around 32 weeks pregnant. We all sat around together as Ralka conducted her routine visit for us to see how she used her phone. I was gobsmacked. Ralka inputted the girl’s data and the phone knew where she lived, how many weeks pregnant she was and what her obstetric history was. The phone then displayed the relevant pictures and prompts for Ralka to give advice based entirely on this girl and her stage of pregnancy. For example there were pictorials and voice messages given about the importance of institutional birth, why she should start breastfeeding very soon after the birth and even how to position the baby during feeds. During the pre-birth section of the session there were even pictorials of antepartum haemorrhage, eclampsia, premature labour and other obstetric emergencies and prompts for discussions on what the women should do if any of these occurred before he got to hospital. I really was speechless – this simple device in the poorest of settings was delivering consistent but more importantly up to date advice based on UNICEF guidelines. I myself had recently attended a Baby Friendly Initiative breastfeeding update study session prior to heading to India with Save the Children, and the messages given by Ralka and her trusty phone were spot on in relevance and accuracy. We struggle to achieve this in the UK with many breastfeeding mums saying they switch to bottle feeding due to inconsistent & inaccurate advice. Shame on us. Also I couldn’t help but think about how women in the UK carry round one set of paper pregnancy records which we can’t even access at our hospitals and which could not be retrieved if lost or destroyed, yet here each woman’s pregnancy data and demographics were inputted electronically and sent to a central server for officials and ASHAs to access. For 1USD per month. Remarkable and inspirational. It’s no wonder Ralka and her fellow ASHAs were inseparable from their phones – not for Facebook or twitter but for interventions that are improving health and saving lives. What a learning curve for us all.

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This low cost technology requires only a one off cost for the purchase and training of the staff. So far 95% of all ASHAs trained to use this mobile technology remain active and serve more around 938 mothers and 960 children.  We heard how the pilot project proved so successful in it’s ability to reach the vulnerable in their communities and initiating positive behaviour change that the Government of India are looking to roll this out in other areas.  Well done Save the Children, and I have no doubt that Ralka and her colleagues will continue to use this initiative to improve the lives of women and children in India, as they have already seen vaccination rates and numbers of women giving birth in hospitals increase.

From the village we were fortunate to see Roopangarh Fort affording us excellent views across the district, including the cutest camel and her baby.

Mum and baby camel near Roopangarh Fort, Rajastan, India

Mum and baby camel near Roopangarh Fort, Rajastan, India

View of Kishangarh district from Roopangarh Fort

View of Kishangarh district from Roopangarh Fort

For more info on Save the Children India see: http://www.savethechildren.in/

For more info on the Power of the First Hour – Breastfeeding see:http://www.savethechildren.org.uk/breastfeeding-more-info

India Day 1 part 2: Superfood for babies and religious leaders

Save the Children launch their breastfeeding campaign today as they publish their report “Superfood for Babies” http://www.savethechildren.org.uk/resources/online-library/superfood-babies and it is fortuitous that this blog concerns the very same topic.

Following on from my previous account we were in Tonk District of Rajasthan state, and our afternoon activities included viisiting our first Anganwadi (see future blogs) and meeting with religious leaders so they could explain to us more about their work as Health Advocates. Through their local partners Save the Children support the training and engagement of influential community members such as these religious leaders in promoting institutional delivery, immunisation and early breastfeeding. These men have been instrumental in bringing about a crucial behavioural change when it comes to pre-lateal feeds, or ghutti (see previous blog) which when given can lead to declining health for the newborn and restrict the mother from producing enough milk. It is concerns such as these which contribute to India’s astoundingly high neonatal mortality rate, roughly 1:30 babies, and the tragic statistic that more children in India die before their 5th birthday than any other country in the world.

That’s where interventions such as these play such a vital role. Here’s how it works: Save the Children work with their local partners to train health ambassadors such as these religious leaders, who then regularly share this information about child health with the local community attending prayers. These men then take these messages back to their homes and discuss with their wives, relatives and neighbours, and hence the valuable information is then passed throughout their areas. As with many cultures it is the men in society and respected religious leaders who have vast influence over their community and cultural practices, so here was a fantastic example of these community structures are being catalysed to promote positive behaviour change that literally saves lives. A near impossible task, or at least a tremendously long one from all the projects I have witnessed or been involved in in other cultures, yet here it is working, is sustainable and highly effective. To say our group was impressed is an understatement. What a simple cost effective way to promote health and reduce morbidity and mortality!

In the resource centre of the local partners the leaders were hugely proud and outspoken regarding their achievements, and it was fascinating to hear them talk of their work. Over chai (and rather fabulous samosas) they were all so keen to talk to us, share their successes and they told us how together with the Community Health Workers in their areas they have taught their community that there is an alternative to giving the pre-lacteal feeds or ghutti, and waiting for the prayers to be said at the Masjid. Now the community have learned that the prayer can be whispered by others to the infant as soon after birth as possible, rather than delaying the first vital breastfeeds for the baby. They all recognise the importance of the first breastfeed within the first hour following birth and are literally spreading the word. They also explained how due to the difficulty in reaching the women in their areas they address this by focussing on teaching the husbands, who then in turn return these messages back to their homes.

Issues such as family planning continues to remain controversial however the local partners informed us how they have seen an increase in institutional deliveries, immunisations and the use of anganwadi centres, which will feature in a future blog.

Thanks to Save the Children and their implementing partners more than 26 religious leaders in Tonk have been trained in health, sanitation and nutrition issues in their communities, and are well aware of the vital role they play in sharing their knowledge. Due to their status as highly respected influential public leaders they are listened to avidly and hence behaviours change. For Tonk, whose population is around 70% Muslim, these kind of initiatives have surely reached more people than conventional health workers could. And with a 2.2 million deficit in trained health staff the children of India can only benefit from such programmes. How this would continue now that funding has been cut to India from 2015 is anyone’s guess, yet for now the great work of these individuals continues, breastfeeding education and support is promoted and concerns regarding malnutrition are tackled effectively. Diarrhoea alone is responsible for 20% of the worlds under fives deaths. Breast milk is free, sterile, available and nutritionally tailored to each child. Thanks to these religious leaders and community health workers more and more babies are thriving on it. Literally.

Hemant leads our discussion with the religious leaders in Tonk District, Rajasthan

Hemant leads our discussion with the religious leaders in Tonk District, Rajasthan

India Day 1. Truckers, ghutti and special babies.

So far a lot of thought has gone into this blog, and not a lot of typing. So here goes: a day by day account of our trip to India with Save the Children.

Part 1. Day 1, morning. Rajasthan State.

Our group departed Jaipur for Kaliptan in Tonk district of Rajasthan. The first visit planned for today was to meet Save the Children India (SCI) partner NGO & visita primary health care centre. Later we were to visit the District level hospital, meet Anganwadi workers at carrying out their daily duties then liaise with religious leaders making a difference in their areas.

As we weaved our way between the most elaborately decorated trucks, errant cows on the road and rickshaws Hemant the Indian SCI staff member who was leading our visits gave us an overview of the situation for the children of Tonk and Rajasthan in general. In the whole state 48% of children are malnourished, and in Tonk district this rises to a staggering 70%.  As such, a large proportion of SCI work is focussed on nutrition, hygiene and breastfeeding. For India’s infants already facing a 1:20 chance of dying before they reach their first birthday exclusive breastfeeding can be a real lifesaver, yet only 46% of India’s babies are exclusively breastfed. Hemant explained that this is due in part to the cultural practice of giving pre-lacteal feeds. These are feeds, known locally as ghutti, are traditionally given to the baby instead of breastmilk which they believe cannot be given until the first prayer – the Azan, is announced from the Masjids in the Mosque. Ghutti can be honey water, cows milk or water with herbs added. For the newborn this means they are deprived of the many benefits of its mothers colostrum – sterile, nutritious and protective, and for the mother this means she often does not go on to produce enough milk as the crucial early feeds fail to stimulate her to provide the baby sufficient milk. The Unicef Baby friendly Initiative recommends the baby feed from its mother within one hour of birth. For most babies in Rajasthan this may not happen for days with dire consequences for mother and baby.

As we passed (precariously overtook) many of the lavishly decorated truck en route Hemant went on to explain how HIV and STIs are a major problem there as the truckers use sex workers and ‘bar girls’, something I had also witnessed in Cambodia. In some families a child is even kept for this ‘profession’ as the financial remunerations can be great. The health consequences however are devastating. Men pay more when a condom is not used and hence HIV and other sexually transmitted diseases are rife in these groups. Alcohol abuse can result as the men use liquor to gain ‘strength’ and the girls use it in order to cope and give them ‘energy for their work’. With so many clients they rely on alcohol to see them through their duties and nutritious food, condom use and healthcare becomes less of a priority with the obvious consequences.

As we approached our destination we crossed a vast river on the fly-over, the main river and water source for the area. It was parched and completely bone dry.

On our arrival in Kalipaltan we met with SCI local implementing partners CECODECON. They are a health and sanitation NGO, and we could not have received a warmer welcome – coffee, flower garlands, red powder bindis were etched on our foreheads and we were all introduced to each other. They took us to visit a primary healthcare facility in their town. One Doctor is based here, responsible for a catchment population of 40,000 people. The place was heaving; he sees around 200 people every day and is only supported by 2 other ancillary staff. Whilst it was fantastic to see that the local community trust and utilise the services there it was humbling to see such a dedicated doctor work so hard to serve his community. They also provide DOTS (directly observed treatment, short course) for tuberculosis, and have seen an incredible 85% coverage. He explained to us about his hardships working there. In 2011 India initiated a free drug policy for about 175 medications, yet one of the biggest problems he faces is replenishment of his supplies from the state health department. Malnutrition is one of the biggest health concerns for his community, reflected in the figures mentioned above for Rajasthan and Tonk district. This again highlighted the importance of promoting exclusive breastfeeding and growth monitoring in improving the health of children here. CECODECON with support from Save the Children India largely focus on these issues, and have implemented the use of community score cards to track progress in these areas and use results to steer their programs, achievements they were proud to show us in their offices displayed on their wall charts.

Meeting the doctor, Primary health care facility, Kaliptan, Tonk, Rajasthan

Meeting the doctor, Primary health care facility, Kalipaltan, Tonk, Rajasthan

 From there we went on to Sahadat District hospital, Tonk District. A free government facility led by the Chief Medical Officer who explained to us the services that are provided there. It is a 200 bedded tertiary level hospital serving a staggering 1.4 million. They are awaiting the build of a 100 bedded maternity hospital in the near future. Here they see 1000 outpatients per day, conduct 20 births per day and have 2 operating/surgical rooms. Also here is a malnutrition ward, special care baby unit and family planning, STI services. The staff include 10 midwives, 29 female nurses and 3 obstetricians. We asked the CEO what were the main constraints he faces at this hospital. He stated there are not enough staff for the number of patients, and the salary is poor, which in turn detracts staff from seeking employment here and impacts greatly on staff retention. Understandable. Where I work in the UK we conduct about 12 births per day and have on duty at least 12-15 midwives per shift with 3 doctors. How they manage at this hospital with only 10 midwives on their books and 3 doctors for maternity for 24 hours a day service provision I can’t imagine. A worrying example of how this could affect safe intrapartum care became evident to me whilst visiting the special care baby unit. Here there were about 4-5 newborn babies in quite a well looked after ward with power and medicines, yet there were no incubators. Instead each baby was on a resuscitaire trolley of the kind we us in the UK which is only for very short term use immediately after the baby is born if it needs oxygen, an overhead heater and suction for example. But here these were being used as makeshift incubators, with the overhead heaters used continuously and oxygen being delivered via head-boxes instead. I enquired as to why these babies had been admitted and it seems that at least 2 that I saw were there due to prolonged labour and birth asphyxia. I assumed then that these babies had been transferred in from the surrounding villages yet sadly these labours had been managed from the outset within the hospital. I immediately began to question the level of care that was being provided at this tertiary facility where labour had been allowed to become prolonged and birth asphyxia had ensued undetected. Was there any difference then in labouring at home or in the hospital if the outcome was going to be the same? For a nation striving to promote 100% ‘institutional deliveries’ I wondered if they were really ready for this with a lack of staff and equipment. As we did not get to see the labour ward at this hospital I kept my judgment reserved as we were to visit a maternity hospital in Delhi where I would see for myself the services offered. For one baby there attached to an IV and oxygen, the nasal flaring, sternal recession, palid colour, and very poor tone on day 3 following birth I wondered how long it could realistically remain on that makeshift incubator with no prospect of any further advanced treatment. Even here he had not been offered any of its mothers milk.

Special care baby, Sahadat Hospital, Tonk District

Special care baby, Sahadat Hospital, Tonk District

Sahadat District Hospital, Tonk, Rajasthan

Sahadat District Hospital, Tonk, Rajasthan

Next time: Day 1 afternoon, visit to an Anganwadi and meeting the religious leaders making a difference in their communities.

Return to normality – normality.

After a week spent witnessing the work of health staff in Jaipur and Delhi with Save the Children India http://www.savethechildren.org.uk/where-we-work/asia/india I faced a barrage of questions on my return to work today. Where to begin! How fortunate we are that for a maternity department focussing on normality, our ‘normal’ is the assumption that safety is a given, and quality one-to-one care fulfilling women’s dreams of the perfect birth is the aim. For millions of others normal means going hungry and risking your life to give birth. Every 7 minutes a woman dies in childbirth in India. ‘Incredible India’ as the tourist advertisement states. Incredible that a quarter of the worlds child deaths occur there.

Hopefully this blog will enable me to put into words the numerous visions, experiences, delights and challenges we saw. Just need to put them into some sort of order first….