Using auxiliary nurse midwives to improve access to key maternal and newborn health interventions
improve access to key maternal and newborn health interventions
© WHO
An auxiliary nurse midwife is defined as someone who assists in the provision of maternal and newborn health care, particularly during childbirth but also in the prenatal and postpartum periods. They possess some of the midwifery competencies but are not fully qualified as midwives. They have basic nursing skills and no training in nursing decision-making. Auxiliary nurse midwives have some training in secondary school, and may have a period of on-the-job training, sometimes formalised in apprenticeships.
Who is this summary for? People making decisions regarding the use of auxiliary nurse midwives for maternal and newborn health care This summary includes: Key recommendations from the World Health Organization’s OptimizeMNH task shifting guidance. Not included: The OptimizeMNH recommendations also cover other cadres of health workers. Recommendations relating to these cadres are not described in this summary. Please visit www.optimizemnh.org for further information on: Recommendations for other health cadres The evidence supporting these recommendations Interventions that were considered to be within or outside the competency of auxiliary nurse midwives.
Summary information Problem: Option: Comparison: Setting: Poor access to or low uptake of key interventions for improving maternal and neonatal health Auxiliary nurse midwives providing interventions Care delivered by other cadres or no care Community/primary health care settings
Key message: The WHO recommends the use of different non-physician health worker cadres to provide the following family planning services: Performance of neonatal resuscitation Treatment of postpartum haemorrhage with intravenous fluid and/ or bimanual uterine compression Suturing of minor perineal/genital lacerations Initiation and maintenance of injectable contraceptives Insertion and removal of intrauterine devices
Background The shortage of health workers is having a negative impact on the achievement of the health-related Millennium Development Goals (MDGs) in many low- and middle-income countries (LMICs). Closing the existing gaps in health service coverage and improving maternal and newborn health outcomes will require active human resource policy interventions by those countries affected. Some countries use auxiliary nurse midwives within their health care systems, who are trained to deliver specific health interventions in communities and health care facilities. In some contexts they have been offered additional training to deliver interventions that were not necessarily within the competencies that formed their initial training. In some cases, auxiliary nurse midwives have even been taught to perform minor surgical procedures, delivering interventions that were previously restricted to health cadres with higher levels of training. The WHO recommendations Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting were published in 2012. These recommendations were developed by identifying appropriate research questions on task shifting, and using a technical team to retrieve, assess and synthesize the relevant scientific evidence. Recommendations were then discussed and approved by a WHO-led panel (Figure 1). The guidance offers 17 recommendations related to the use of auxiliary nurse midwives. These recommendations are intended to provide guidance for optimizing the delivery of key interventions. Each recommendation has been evaluated in terms of whether it could be delivered both safely and effectively by an auxiliary nurse midwife. Implementing these recommendations in different settings requires a consideration of local political, financial, and health system factors.
Summary of findings The use of auxiliary nurse midwives in community and primary health care settings for certain interventions can be effective, acceptable, and feasible, and may reduce health inequalities by extending care to underserved populations. In the case of some interventions, auxiliary nurse midwives already have the necessary skills for delivery of the intervention. In other cases, further training or a well-functioning referral system may be required. It is suggested that these interventions be implemented where auxiliary nurse midwives are already an established cadre. A number of tasks were accepted as being within the competence of auxiliary nurse midwives, and were therefore not considered in the guidance. These tasks included: Promotion of maternal, newborn and reproductive health interventions Administration of oxytocin to prevent and/ or treat PPH using a standard syringe or a compact, prefilled auto-disable device (CPAD) Administration of misoprostol to prevent and/ or treat PPH Oral supplement distribution to pregnant women Low-dose aspirin distribution for women at high risk of preeclampsia or eclampsia Continuous support for women during labour, in the presence of a skilled birth attendant Management of puerperal sepsis with oral antibiotics, or intramuscular antibiotics using a standard syringe or a CPAD Maternal intrapartum care (including labour monitoring, foetal heart rate monitoring, decision to transfer for poor progress, and delivery of the baby)
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Figure 1: How were the OptimizeMNH recommendations developed?
The use of auxiliary nurse midwives is recommended for: Performance of neonatal resuscitation Administration of intravenous fluid as part of treatment for postpartum haemorrhage (PPH) Internal bimanual uterine compression for PPH Suturing of minor perineal/genital lacerations Initiation and maintenance of injectable contraceptives using a standard syringe Insertion and removal of intrauterine devices (IUDs) The use of auxiliary nurse midwives should be considered for the following interventions, but with targeted monitoring and evaluation: Initiation and maintenance of kangaroo mother care for low birth weight infants Administration of antihypertensives for severe high blood pressure in pregnancy Insertion and removal of contraceptive implants The use of auxiliary nurse midwives for the following interventions should be considered only in the context of rigorous research: Diagnosis of preterm pre-labour rupture of membranes (pPROM) and delivery of initial treatment of injectable antibiotics using a standard syringe, before referral Delivery of antibiotics for neonatal sepsis, using a standard syringe or a CPAD Administration of corticosteroids to pregnant women in the context of preterm labour to improve neonatal outcomes Administration of magnesium sulfate to women in preterm labour as a neuroprotective for the fetus Performance of vasectomy The use of auxiliary nurse midwives is not recommended for: Performance of tubal ligation Additionally, a number of tasks were accepted as being outside the competency of auxiliary nurse midwives, and were therefore not considered in the
guidance. These tasks included: External cephalic version for breech presentation at term Administration of maintenance doses of magnesium sulfate to treat preeclampsia Caesarean section.
Implementation considerations for auxiliary nurse midwife recommendations General considerations Implementation will be shaped by specific sociocultural and political factors in specific contexts National dialogue is required to determine whether: –– Health worker availability contributes to accessibility/utilization of key interventions –– There is a willingness to consider task shifting Health care workers need to be supported by other interrelated health systems components The individual recommendations should be considered as ‘packages’, in terms of health worker categories and the condition being addressed. New tasks should be considered in the context of overall health care delivery, rather than being implemented as standalone measures. Task shifting to auxiliary nurse midwives Planners should ensure that programme recipients, auxiliary nurse midwives, and the relevant professional bodies are involved in the planning and implementation of auxiliary nurse midwife programmes. Additionally, the use of multidisciplinary training may promote respect and trust between providers Planners need to ensure that: The roles and responsibilities of auxiliary nurse midwives and other health workers are made clear Auxiliary nurse midwives and their supervisors receive initial and ongoing training Supervisory responsibilities are clear and supervision is regular and supportive
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Necessary referral systems are in place, and function well with consideration to financial, logistical and relational barriers Supplies of drugs and other commodities are secured Necessary changes to regulations are made to support any changes in the scope of practice of auxiliary nurse midwives Salaries and incentives reflect changes in the scope of auxiliary nurse midwife practice, including non-monetary incentives Visible support for auxiliary nurse midwives is provided from the health system, and reasonable insurance cover is provided for malpractice Support systems are in place for auxiliary nurse midwives who are delivering interventions that may be perceived to be potentially harmful
Using auxiliary nurse midwives for contraceptive delivery It may be helpful to ensure that auxiliary nurse midwives who promote or deliver contraceptives are the same gender as their target audience It may be advantageous to ensure that the relevant training of female health workers is conducted by women, due to confidentiality issues or cultural sensitivities Initial and ongoing training should include communicating with recipients and the sideeffects of different contraceptive methods, and should reinforce that fact that auxiliary nurse midwives should not introduce their own criteria when determining who should receive contraception Training should include confidentiality issues, and recipients should be made aware that their interactions with health workers are confidential’ Using auxiliary nurse midwives for care of the neonate Clinical treatment algorithms need to be validated for auxiliary nurse midwives who are managing neonatal sepsis or delivering neonatal resuscitation Using auxiliary nurse midwives to prevent and/or manage postpartum haemorrhage These interventions should be operationalized in the context of the WHO’s guidelines on prevention and management of postpartum haemorrhage.
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Local views and beliefs as well as local conditions related to the health issues in question are addressed within the programme design Using auxiliary nurse midwives for health promotion activities Auxiliary nurses, their trainers and their supervisors need initial and ongoing training in both information content and communication skills It may be useful to involve husbands, partners, and other family members in delivering some interventions
For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth WHO/RHR/14.22 © World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.