UNIVERSITY
EDUARDO
MONDLANE
Faculty of
Medicine
Dr Tavares Madede, University of Eduardo Mondlane,
Mozambique
& HSSE team
Supported by:
Irish Aid & Ministry of Foreign Affairs, Denmark
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Centre for Global Health, University of Dublin, Trinity College, Dublin
(Eilish McAuliffe, Susan Bradley)
Averting Maternal Death and Disability Program (AMDD), Heilbrunn
Department of Population and Family Health, Mailman School of Public
Health, Columbia University, USA (Lynn Freedman
(Helen de Pinho, Samantha Lobis, Rachel Waxman and Sang Hee Won)
Realizing Rights: the Ethical Globalization Initiative, USA ( Mary Robinson,
Peggy Clark, Ibadat Dhillon, Naoko Otani)
Regional Prevention of Maternal Mortality network, Accra, Ghana (Angela
Sawyer, Dora Shehu)
Ifakara Health Institute, Mikocheni, Dar Es Salaam, Tanzania (Godfrey
Mbaruku, Honorati Masanja, Tumaini Mikindo, Neema Wilson, Debby Wason,
Abdallah Mkopi, Aloisia Shemdoe)
University of Malawi, College of Medicine, Centre for Reproductive Health,
Malawi (Francis Kamwendo, Mwizapanyuma Simkonda, Wanangwa
Chimwaza, Andrew Ngwira, Effie Chipeta, Linda Kalilani)
Department of Community Health, Faculty of Medicine, Eduardo Mondlane
University, Mozambique (Mohsin Sidat, Maria de Fatima Cuembelo, Sozinho
Daniel Ndima)
Expand the evidence base in support of effective use
of mid-level health workers within an enabling
environment through the generation of new evidence
and a critical analysis of existing evidence;
Increase recognition and effective use of mid-level
health workers among national, regional, and global
policymakers to address the human resources crisis in
district health systems based on project evidence;
High levels of maternal and infant mortality in sub-Saharan
Africa
 proportion of global maternal deaths in sub-Saharan Africa
increased from 23% (18–27) in 1980 to 52% (45–59) in 2008
Lack of human resources for healthcare plays a key role
 Malawi vacancy rates - 77% for specialist doctors, 45% for medical
officers, 80% for nursing officers, 44% for nursing sisters.
Evidence for clinical efficacy, economic value of mid-level
cadres
 Fenton et al. (2003), N = 7622 caesarean sections
 Clinical officers vs Qualified doctors in Malawi - emergency
caesarean section maternal death rate of 1·3% (.6% for qualified
doctor), perinatal deaths 8% vs 13% - non sig (statistically)
Hongoro & McPake (2004): Main conclusions:
The “… expansion of the numbers and roles of auxiliaries whose
qualifications are not internationally recognised seems to be a
quiet success story, providing large numbers of health workers
who keep the system running in a number of countries. Much
more needs to be documented about the parts played by these
workers and their safety in different areas.”
“…the human resource management function needs to be
substantially upgraded in the public sector as a whole, and
specifically the health sector.”
In resource poor countries what factors contribute to job
dissatisfaction and demotivation, which negatively impacts
outcomes such as worker productivity and retention of staff ?
Health professionals clinically trained to
perform the tasks of doctors (NPCs).
Existent evidence show that:
Provide quality of care comparable to a doctor
Cost to train by far less than a doctor
Takes only 3 years to train
More likely to retain in rural settings
Include nurses and nurse mid-wifes
Mixed Methods approach
2065 healthcare providers from 286 facilities
were surveyed.
Nurses, nurse mid-wives and non-physician
clinicians comprised 75% of respondents
(N=1,552)
They are comprised by 9 functions divided into
two subgroups:
Basic EmOC services
Comprehensive EmOC services
Basic EmOC services:
1.
2.
3.
Administer parenteral antibiotics
4.
5.
6.
7.
Perform manual removal of placenta
Administer uterotonic drugs
Administer parenteral anticonvulsivants for preeclampsia and eclampsia
Perform removal of retained products
Perform assisted vaginal delivery
Perform neonatal resuscitation
Comprehensive EmOC services (1 – 7 plus the
following):
8)
9)
Perform surgery
Perform blood transfusion
The functions are provided by a wide range of
health care providers, with:
Over 75% of nurses and nurse-midwifes
providing at least four of the basic services –
administering parenteral antibiotics,
uterotonics and anticunvulsivants, as well as
neonatal resuscitation
Around 60% of NPCs providing all
comprehensive services
High reported performance of c-section across
countries
Over 85% of clinical officers in Malawi and assistant
medical officers in Tanzania performed c-sections
100% of tecnicos and high level nurses performed csections in Mozambique.
Those not performing c-sections were mainly
working in health centres where surgery is not
performed.
Cadres
Assisted vaginal Removal of
delivery
retained
products
Manual removal
of placenta
Nurse-midwife
technicians
(n=262)
14%
13%
39%
Enrolled nursemidwives
(n=133)
14%
17%
41%
Registered
nurse-midwives
(n=54)
67%
22%
56%
Clinical officers 88%
(n=136)
93%
85%
Cadres
Assisted vaginal Removal of
delivery
retained
products
Manual removal
of placenta
Enrolled
midwives
(n=247)
27%
39%
51%
Registered
nurses (n=150)
24%
33%
48%
Registered
30%
midwives (n=20)
50%
45%
Assistant
60%
medical officers
(n=68)
87%
82%
Cadres
Assisted vaginal Removal of
delivery
retained
products
Manual removal
of placenta
Nurse
elementary
(n=130)
34%
56%
67%
Nurse basic level 51%
(n=223)
79%
68%
Nurse middle
level (n=107)
73%
85%
72%
Nurse high level
officers (n=6)
83%
100%
83%
Tecnicos de
cirurgias (n=17)
76%
94%
88%
Assisted vaginal delivery (AVD) was the signal
function that was least likely to be performed in
all three countries.
AVD is performed mainly by NPCs and higher level
nurses.
These staff work mainly in hospitals rather than
health centres, thus limiting the availability of this
function.
In Tanzania, performance of AVD is low among all
cadres
Countries should focus on ensuring the equitable
distribution, availability, and accessibility of
facilities and skilled health providers who can
provide effective EmOC.
Policy makers and professional associations should
advocate for increased global recognition on the
effective use of MLPs to increase access to EmOC
and reduce maternal mortality.
Further research to assess why key signal functions
like AVD are not being performed.
HSSE Team:
* AMDD, Mailman School of Public Health, Columbia University, USA
* Centre for Global Health, Trinity College, University of Dublin
* Centre for Reproductive Health, College of Medicine, Malawi
* Dept. of Community Health, Eduardo Mondlane University,
Mozambique
* Ifakara Health Institute, Tanzania
* Realizing Rights: Ethical Globalization Initiative, USA
* Regional Prevention of Maternal Mortality Network, Ghana
Funders:
* IrishAid
& Ministry of Foreign Affairs, Denmark