The American College of Nurse-Midwives (ACNM) is one of the oldest continuing women's health organizations in the United States, representing certified nurse-midwives (CNMs) and certified midwives (CMs). The ACNM's vision is to advance the health and well being of women and newborns by setting the standard for midwifery excellence (ACNM, 2012). We believe in the basic human rights of all persons, recognizing that women often incur an undue burden of risk when these rights are violated (ACNM, 2004).
Every year at least 350,000 women die from childbirth, and 2 million babies die in the first day of life (Hogan et al., 2010; WHO, UNICEF, UNFPA & the World Bank, 2010). These poor outcomes are in part because of a lack of qualified healthcare providers to care for women, particularly in low-resource countries where 52 million women will not be attended by a skilled birth attendant (UNICEF, 2009). The United Nations Population Fund (UNFPA, 2011) recently published The State of the World's Midwifery 2011: Delivering Health, Saving Lives, which presents a triple problem of competencies, coverage, and access. The World Health Organization estimates that 38 countries have severe shortages of midwives, and many will need a 10-fold increase to stem this tide (Global Call to Action, 2010; WHO, UNICEF, UNFPA, & the World Bank, 2010). For the last 30 years, the ACNM has been a leader in global outreach and capacity building of women, midwives, and communities. Our work is undergirded by the Millennium Development Goals #4 to reduce child mortality, especially for children under age 5, and #5 to improve maternal health through reduction of maternal mortality and increasing access to reproductive health (United Nations, 2000). This article presents our history and experience in global outreach as we work to fulfill those goals.
History of ACNM Global Outreach
The mission of ACNM's Department of Global Outreach is to lead efforts that improve health and well-being of women and infants worldwide through strengthening the profession of midwifery and building the capacity of midwives and other healthcare professionals to serve their communities. ACNM's areas of expertise have evolved in response to the travesty of human rights that maternal mortality represents. In reviewing and observing firsthand the complex sociocultural, physiological, and gender-based phenomenon of maternal mortality, ACNM examined a range of modalities to address the issues on multiple fronts. To enhance healthcare providers' capacity to respond to obstetric and neonatal complications, we have worked with facilities, educational institutions, and healthcare providers themselves. To address sociocultural issues, we have supported community-based initiatives that examine long-held beliefs, practice, and attitudes, encouraging and supporting individuals and communities to explore their responses to women's and infants' morbidity and mortality. Unless a multifocal approach is used to address these deaths, single targeted interventions will have minimal impact.
Since 1982, ACNM has implemented projects and provided technical assistance in more than 30 countries in Africa, Asia, Latin America, and Eurasia (Figure 1). We have received numerous grants and cooperative agreements from United States Agency for International Development (USAID), development agencies from outside of the United States, Department of Health & Human Services, private foundations, and volunteer organizations. We also have worked as a subcontractor on USAID's global maternal health programs including but not limited to MotherCare (http://pdf.usaid.gov/pdf_docs/PDABS900.pdf), PRIME II (http://www.prime2.org/prime2/section/60.html), ACCESS-FP (http://www.accesstohealth.org/), and the Prevention of Postpartum Hemorrhage Initiative (http://www.pphprevention.org/). Through programmatic and technical expertise of its staff and membership, the ACNM supports a full range of clinical maternal and newborn health topics across the globe.
The ACNM membership has sustained a long-term interest in global activities and believes it is essential to work with midwives interested in serving internationally. In addition to the Department of Global Outreach, staffed in our national office and off campus, we have a Division of Global Health supported by volunteer effort. A recent survey of ACNM members revealed that 96% believe the organization should be involved in international work, 88% want educational opportunities by ACNM to prepare them in those efforts, and 74% are interested in working internationally themselves. Half of our members speak a second language, and one-third has experience working/living as a midwife in an international setting.
ACNM's Department of Global Outreach emphasizes partnership and capacity building with both individuals and organizations, and incorporates flexibility and creativity with evidence-based best practices. A systems approach, which improves accountability, is employed to support quality of care. Leadership from ACNM staff is initially provided while simultaneously strengthening the locus of control and ownership of projects within host countries.
Current Projects and Areas of Expertise
Over the past three decades through working in more than 30 countries, our Department of Global Outreach has developed invaluable institutional knowledge of the components required to build a profession that creates competent and qualified healthcare providers. This knowledge has led to the development of areas of expertise, which are used by the Department of Global Outreach when providing technical assistance and support throughout the world. Our major focal areas include (1) development and implementation of in-service training systems, (2) integrated preservice education, (3) strengthening of midwifery and other healthcare professions, and (4) community education and mobilization.
In-Service Training Systems
Human resources are at the heart of any healthcare system, and continuing education is critical to maintaining a competent workforce. In-service training has been the centerpiece of ACNM's international work since the Department of Global Outreach's inception. The ACNM Department of Global Outreach has experience creating both learning resource packages and full-scale training systems for healthcare cadres. These range from community health workers to midwives to physicians and encompass a full range of maternal and infant health topics. Through experience, ACNM has carefully studied and learned the elements necessary to sustain a successful training system. These include a concise curriculum tailored to priority needs; a course design built around critical thinking and competency-based objectives, which employs adult learning principles, well-trained facilitators, and clinical practice sites that have been prepared to model best practices; and a robust posttraining mentoring system (ACNM, 2011a).
Preservice Strengthening
Strong, basic clinical education systems are akin to preventive medicine, saving precious time and resources by producing competent graduates. The ACNM Department of Global Outreach works to strengthen preservice midwifery education programs through an integrated approach that focuses on creating continuity among three central learning environments: (1) theoretical learning in the classroom, (2) practice of skills in a skills laboratory prior to direct patient care, and (3) clinical practice in the actual clinical setting. For each environment, standards, curricula, and teaching materials are reviewed, created, and implemented; clinical, teaching, and management skills are improved for teachers and clinical preceptors; and adequate infrastructure, equipment, and supplies are procured. We are currently evaluating specific components and activities within this integrated approach in Ghana to identify those components with the highest transformative potential. We also work with schools, national nursing and midwifery councils, Ministries of Health, health development partners, and donors to address specific components of this integrated approach. For instance, under the USAID-funded ACCESS program, the ACNM provided technical assistance to develop a Basic Emergency Obstetric and Newborn Care curriculum and implement faculty training in Ghana, Ethiopia, Malawi, and Tanzania. In our current USAID-funded project in Zambia preservice strengthening focuses specifically on enhancing environment, standards, curricula, and teaching materials for the existing midwifery school skills laboratories. These long-standing efforts have helped us to become adept at tailoring integrated preservice strengthening to the needs of the specific country (ACNM, 2011b).
Strengthening Midwifery and Other Healthcare Professions
A strong regulatory system that supports professional healthcare cadres is essential to sustain a fully functioning healthcare system. Regulatory systems ultimately ensure a population of well-educated clinicians with standardized and updated skills who can competently serve their communities. ACNM possesses decades of domestic experience strengthening the profession of midwifery in the United States. This includes addressing regulatory issues ranging from certification and licensing to continuing education, scope of practice, and codes of ethics.
Healthcare professionals are often the first to recognize the need for practice regulation. Clinicians are well-positioned to understand the limitations to improving health systems and patient care, as well as the potential solutions to overcoming these limitations. As such, professional associations can be powerful change agents. In addition to working on regulatory structures with midwifery and nursing councils and ministries of health, ACNM has assisted with capacity building and institution strengthening of midwifery associations around the world including Ghana, Pakistan, Uganda, Zimbabwe, Zambia, Senegal, Eritrea, Tanzania, Morocco, Indonesia, and Afghanistan. ACNM's work with healthcare professional associations focuses on building membership capacity to become in-country resources for the profession and systems strengthening to effectively impact policy and establish standards for the profession (ACNM, 2011c).
Community Education and Mobilization
In many parts of the world, women lack access to a skilled healthcare provider who can respond to health emergencies; women are often unable to leave their communities for any number of sociocultural, economic, and gender equity reasons. In response to this reality, ACNM has developed an extensive community education and mobilization program (ACNM, 2011d). These include the Home Based Life Saving Skills (HBLSS) (ACNM HBLSS, 2011) as the community level counterpart to its flagship program, Life Saving Skills (LSS) (ACNM LSS, 2011). HBLSS is a community education and mobilization program specifically designed for nonliterate or low-literacy populations. HBLSS was born out of collective decades of work in both villages and health centers across the globe. The curriculum, implemented through a series of community meetings, focuses on community member's experience with recognizing obstetric and neonatal problems. Building on this recognition, community members learn to relate cause and effect through community facilitators, using pictures and role playing, showing how trained healthcare workers respond to such problems. The community then negotiates and agrees on actions that can be taken by the family and community, including obstetric first aid skills and rapid referral. HBLSS has been implemented in more than 20 countries, leading to large increases in facility-based births and referrals from rural communities to higher levels of care. The methodology developed for HBLSS can be adapted to many topics and in different contexts.
The Future
The United Nations Millennium Development Goal 5 is to improve maternal health and Goal 4 is to reduce child mortality (United Nations, 2000). There is significant work ahead for all of us in order to achieve these in the future. ACNM is currently working with Jhpiego, an affiliate of Johns Hopkins University (http://www.jhpiego.org/), to develop a clinical trainer pathway for midwives and other maternal-child healthcare providers who want to become global health consultants.
ACNM has mentored several generations of midwives who have contributed talent and commitment to making the world a safer place for women and children. The clinical implications are directly related to the United Nations Millennium Development Goals (United Nations, 2000) and are outlined in Box 1. Our staff and members work with many healthcare professionals and organizations in this effort. Table 1 provides suggested considerations for those interested in pursuing international work in this field. The future relies on upcoming generations to creatively work with multiple disciplines and across nations to solve the complex issues endangering women and families worldwide, especially mothers and infants. It requires promise, commitment, and innovation.
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