Global Health Nursing & Midwifery
UNFPA Chief of Sexual and Reproductive Health Addresses Midwifery Needs and HPV Vaccine
Last September, exactly one year after the launch of Every Woman Every Child (http://www.everywomaneverychild.org/images/content/files/Every_Woman_Every_Ch...), an initiative to save the lives of 16 million women and children by 2015, a new report shared progress made thus far and announced more than 100 new partners and major new commitments including $500 Million from Merck (http://www..merckformothers.com).
During an interview with us in which she discusses the initiative and what it means for midwives, Dr. Laura Laski, Chief of Sexual and Reproductive Health at the United Nations Population Fund (UNFPA), announced country-level assessments to be conducted in eight countries that accounts for nearly 60% of all maternal and newborn deaths starting December 2011 and in 2012 with the goal of providing countries with “the tools necessary to prioritize the training, recruitment, deployment and support of health workers with midwifery skills in marginalized communities, and ensure access to care close to where women, adolescents and children live.”
Asked about providing wider access to human papillomavirus (HPV) testing and vaccine as part of the initiative, Laski noted that although five countries have made commitments in that area, the question has not received much focus. On its end, the GAVI Alliance (http://www.gavialliance.org/) is paying attention, announcing yesterday that it was “taking first steps” to introduce the HPV vaccine in nine countries by 2015 with negotiations underway to secure a sustainable price from manufacturers and for countries to demonstrate their ability to deliver the vaccines. According to Ziad El-Khatib, PhD (http://www.ghdonline.org/ncd/discussion/hpv-vaccine-scale-up-in-limited-resou...), Fellow in the Department of Epidemiology, Biostat and Occupational Health at McGill University, the Alliance is committed to making the vaccine available for 5$ per dose, with ministries of health sharing 0.20$ per dose.
--- Interview ---
GHD: Please share highlights from the Progress Report that, in your opinion, have the potential to impact the work of midwives and the lives of women and children the most.
Laski: A critical development since the launch of the Global Strategy has been in the launch by the H4+ (WHO, UNICEF, UNFPA, UNAIDS and The World Bank) of a gap analysis examining the resources the countries will need to implement their commitments pertaining to human resources for health and of commodities in 8 of the countries that are responsible for nearly 60% of the maternal and newborn mortality. These countries are Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Mozambique, Nigeria and the United Republic of Tanzania.
The gap analysis revealed that health professionals needed both further training in real-life settings and functioning health systems for referrals and adequate supervision. Findings also showed that midwives were rarely trained to interact well with communities. The gap analysis provided a preliminary estimation of the number of community health workers and health workers with midwifery skills to be placed close to where women live and its cost.
As part of the next steps, H4+ will (1) conduct country-level assessments in each of the high-burden countries in order to be able to assist on strategic decision-making and planning; (2) facilitate more pro-active fundraising efforts, involving in particular the private sector, in order to assist countries raise the additional funds they require to implement activities that will assist in improving midwifery services at the community level; (3) collect evidence and develop guidelines on human resources management; (4) provide recommendations to develop national (and sub-regional) strategies to strengthen education and training capacities for reproductive health; and (5) monitor and evaluate the implementation of national education, training and management of human resources for maternal health in the context of reproductive health programmes.
These steps will provide countries with the tools necessary to prioritize the training, recruitment, deployment, and support of health workers with midwifery skills in marginalized communities and ensure access to care close to where women, adolescents and children live, while at the same time providing them with the resources they need to do so. By doing this, countries will improve their service delivery quality at the community level, whilst at the same time develop additional interventions to improve the demand for and use of these services in communities. They will also be on track to achieve the most rapid decrease in maternal and neonatal deaths by the 2015 MDG deadline and ensure universal access to reproductive health.
Regarding women's health, is there a commitment to providing wider-access to the HPV vaccine and/or HPV testing? If so, would pharmaceutical companies commit to providing the Gardasil vaccine and care HPV rapid-antigen testing to low and middle income countries?
This is a very good question that has not received much focus. At least 5 countries have commitments in this area: Niger, Uganda and Rwanda committed to introducing HPV, Vietnam committed to ensuring that 20% of women aged 30-54 are screened for cervical cancer, and Mali committed to ensuring the introduction of the screening and treatment of cancers. Many countries have within their national health plan the target of addressing HPV and cancers in general. Technically, H4+ country offices will be given support to use cervical cancer guidelines in their programmes as part of the SRH package. In delivery, HPV is an area where private-public partnerships could make immense progress.
It seems that the objectives of Every Woman Every Child mostly relate to the childbearing aspect of women's health. What about increasing access to primary and secondary education, or objectives that focus on intimate partner violence, or reproductive cancers?
The Global Strategy was created to ensure progress for the health MDGs, particularly 4 and 5. It would be recalled that MDG 5 draws attention to the child-bearing aspect of women’s health. However, the global strategy is explicit about the network of responses necessary to address MDGs 4 and 5. It links reproductive health to education (MDG 2), to nutrition (MDG 1), and to the rights of women including reducing child marriages and addressing gender based violence (MDG -3 - see p9 of the Global Strategy – PDF http://www.everywomaneverychild.org/images/content/files/global_strategy/full...). So there is no oversight of the importance of these issues: there is acknowledgement that reproductive health outcomes are affected by the other MDGs. What the Strategy points out is that, in addition to all the other ways in which these other MDGs will improve the lives of women, they will make very specific contributions towards the reproductive health targets of MDG 5. For instance, access to primary education is good for a girl for its literacy effect, but evidence shows that it also affects her ability to choose when to have a family.
For the H4+ agencies, the health of the woman has to be addressed in an integrated, holistic manner. Any training for human resources for health will ensure that they can address not just reproductive health, but also cancers and violence. Through an integrated operational approach at the community level, the agencies will ensure that comprehensive needs of women are met.
What are the next steps following the 2011 State of the World's Midwifery 2011: Delivering Health, Saving Lives report (http://www.who.int/pmnch/media/membernews/2011/20110620_sowmr/en/index.html)?
The State of the World’s Midwifery report was significant, and includes findings from 58 highest maternal mortality countries representing 91% of the global burden of maternal mortality and 82% of newborn mortality. It highlights the critical role midwives play in saving lives when they are supported by strong national health systems, shows that many countries do not have a comprehensive overview of the state of their health workforce in general and skilled birth attendants in particular; and provides recommendations on how to scale-up health personnel with midwifery competencies who can deliver quality care and save lives. It shows that a robust regulatory environment is the key to quality services. The report found a gap in midwifery skills, coverage, and uneven access. It found that there was a lack of standardization in education and training, a lack of regulation of this workforce, and weak policy frameworks.
As a next step, the H4+ will work systematically, using the lessons of the report, to specify in greater details what the needs are in each of the 8 countries responsible for almost 60% of mortality, and in particular how to strengthen human resources for health with midwifery skills at the community level, and the related policies, laws, budgets, recruitment, placement, education and training, and costs.
A comprehensive survey tool will be developed by the end of December 2011, with field testing to take place possibly in Ethiopia, in January 2012. By the end of March 2012, 3 to 4 assessments are set to be completed in Ethiopia, Tanzania, Mozambique, and Bangladesh. By end April 2012, a meeting will be held to disseminate results.
Building on the National Assessments and using other complementary tools, the H4+ and partners will hold a meeting in Maputo during the first trimester of 2012 to assess the capacities of Universities and specific training institutions in each of the target countries. Meeting participants will develop and publicize the specific national and regional strategies that will be needed to meet the MDG target for skilled birth attendance in each country and sub-region.
Dr. Laski was previously the UNFPA coordinator of the Adolescent and Youth Cluster, and before that worked on maternal health at UNICEF. Past experiences include many years in programme evaluation research at the University of California, San Francisco and as an OB/GYN in her native country, Argentina, where she provided services to low-income women in the metropolitan area of Buenos Aires.
---
Interview by Sophie G. Beauvais and Maggie Sullivan, nurse praticitioner and moderator of the Global Nursing and Midwifery Community on GHDonline.org.
