Women and their newborns deserve quality and coordinated care at the time of birth, a vulnerable time when most preventable deaths occur.1 Midwives can provide up to 87% of maternal and newborn care, and when advanced care is needed, they can refer to a medical doctor.2
It is vital for the labor and birth health provider team to work collaboratively, communicate effectively, and maintain competence, especially in the rare cases in which basic emergency obstetric and newborn care is needed. In some countries, traditional basic emergency obstetric and newborn care training has been replaced with shorter and less resource-intensive Helping Babies Survive and Helping Mothers Survive training, developed by the American Academy of Pediatrics and Jhpiego, respectively. The International Confederation of Midwives (ICM), in partnership with national midwives’ associations, has been implementing projects using Helping Babies Survive and Helping Mothers Survive for many years, most recently in the 10 000 (2014–2016) and 50 000 (2018–2020) Happy Birthdays projects, supported by Laerdal Global Health, the American Academy of Pediatrics, Latter-day Saint Charities, and other stakeholders. More than 30 000 midwives from Malawi, Zambia, Ethiopia, Tanzania, and Rwanda were trained, with the ultimate goal of saving maternal and newborn lives at birth.
In this article, we will provide a midwifery perspective. We will explore how these modules, using Helping Babies Breathe (HBB) as an example, have provided a voice and empowered midwives, have enabled growth and expansion of midwives’ associations, and have improved communication between midwives and doctors through standardized language and training, resulting in improved maternal and newborn health outcomes.
Local midwifery leaders in the Happy Birthdays project countries were prepared as master trainers by a visiting international team of experienced trainers from ICM, Jhpiego, and Latter-day Saint Charities. The midwives’ associations were equipped with training resources (simulators and printed material) and used a cascade approach for train-the-trainer workshops. In addition to hands-on education and equipment distribution, the cascade embedded data collection and management systems. Low-dose, high-frequency practice corners were established in health facilities as well as skills laboratories in accompanying educational institutions. Availability of simulators, teaching resources, and preparation of master trainers at both health facilities and educational institutions helped to standardize the training in the pre-service and in-service areas, closing the gap between theory and practice. The low-dose, high-frequency practice corners in busy health facilities were more often used when a motivated master trainer coordinated the practice sessions, but over time, it became more common for health providers to practice together as a team before or after a shift.3
The midwives’ associations were accredited by their respective ministries of health (MoHs) to provide the training, and attendance by trainees was incentivized by acquisition of continuing professional development (CPD) points toward their compulsory requirement to relicense with the relevant regulatory authority. Unlike one-off training events, ICM continued to support the midwives’ associations over a 2-year period to maintain quality training and practice sessions, monitor data collection, build partnerships and networks, and strengthen the core functions of the association. The pre- and post-project comparison of association capacity revealed that knowledge and skill in project and finance management, communications and advocacy, and membership services were strengthened as a result of participating in the Happy Birthdays projects.4 The midwives’ associations made the training available to all health professionals and liaised with MoHs, nursing and medical professional societies (pediatrics and obstetrics and gynecology) to improve coverage of skilled maternal newborn health providers. This coordinated approach enabled midwives, nurses, and doctors to learn evidence-based skills together in a safe, simulated clinical environment; improved midwives’ confidence to communicate with other members of the team; improved provider’s capacity to recognize birth asphyxia; and improved competence in providing ventilation by bag and mask within the first minute of birth.
The interactive training pedagogy and practical content enabled trainees to advance knowledge and simulate immediate newborn care and resuscitation skills in a supported environment. The trainees’ and facilitators’ ability to provide and receive feedback was strengthened, and reflective practice was reinforced during the training by the facilitator. Specifically, trainees were asked, “What went well?” and “What could you have done better?” The midwives’ associations reported that during training, when midwives could simulate assessing breathing, drying and stimulating the infant, and providing effective ventilation using a bag and mask, they felt more confident in their role and demonstrated improved competence in the clinical area.
During the evaluation of the 10 0005 and 50 0003 Happy Birthdays projects, it was reported by health facility managers and senior medical staff that the midwives who attended HBB training more consistently identified the newborns who needed help to breathe and called for help more often, which resulted in fewer admissions to the newborn nursery. The medical teams stated that they had more respect for midwives’ knowledge and skill and more confidence in their ability to manage birth asphyxia.
A comparison of newborn health outcomes in HBB training sites in Rwanda revealed a 52% reduction in neonatal death and a 12% reduction in stillbirth. Similar positive results were seen in Tanzania, with a 31% reduction in neonatal death and an 18% reduction in stillbirth.3
Partnering with midwives’ associations increases the sustainability of the training approach6 because they are well connected locally and can influence policy related to CPD, curricula, and relicensing requirements for midwives. During the 10 000 and 50 000 Happy Birthdays projects, the associations were supported by ICM to lead the in-country training, work with other health professional societies, and create partnerships with nongovernmental organization and United Nations agencies. This increased the impact of the training, enabled resources to be shared, built long-lasting partnerships, and increased the status of the midwifery profession. Midwives’ associations were recognized as valued partners to pediatric and obstetrics and gynecology societies and to MoHs as CPD providers and recognized as a vehicle for quality improvement of the health workforce.
Recognition of the key role that midwives play in responding to compromised newborns and reducing the burden of newborn mortality has resulted in added appreciation for and recognition of these frontline providers. With the growing prioritization of reduction of the neonatal mortality rate and provision of resuscitative care, midwives have been given greater respect and a more prominent voice in health systems.
ICM would like to acknowledge the work of Andrea Nove and Martin Boyce and the Novametrics team for providing expert external monitoring and evaluation for the 50 000 Happy Birthdays project.
All authors conceptualized and designed the narrative article, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors are midwife advisors for the International Confederation of Midwives and are Helping Babies Survive and Helping Mothers Survive master trainers. The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.