Background
Assumed competencies of Auxiliary Nurse Midwives (ANM) within WHO recommendations | Current Auxiliary Midwives competency in Myanmar | Potential competency for Auxiliary Midwives |
---|---|---|
Promotion of maternal, newborn and reproductive health interventions |
√
|
√
|
Oxytocin administration to prevent and treat PPH – standard syringe/ CPAD | Χ | Not allowed due to strict restriction on injection |
Misoprostol administration to prevent PPH | Χ |
Possible
|
Misoprostol administration to treat PPH | Χ | After the preventions dose must refer the patient immediately to hospital |
Oral supplement distribution to pregnant women | Χ |
Possible
|
Low dose aspirin distribution to pregnant women at high risk of pre-eclampsia/eclampsia | Χ | After detection of high blood pressure must referred pregnant mothers to the MWs for further care |
Continuous support for women during labour, in the presence of a skilled birth attendant |
√
|
√
|
Puerperal sepsis management with oral antibiotics | Χ |
Possible
|
Puerperal sepsis management with intramuscular antibiotics – CPAD | Χ | Not allowed due to strict restriction on injection |
Maternal intrapartum care (including labour monitoring, e.g. using a partograph; foetal heart rate monitoring by auscultation; decision to transfer for poor progress; delivery of the baby) |
√
|
√
|
Methods
Study setting
Study methodology
Sampling and recruitment
Data management and analysis
Results
Background characteristics of respondents
AMWs current role and responsibility
• Expected to identify pregnant mothers as early as possible and give antenatal care within their agreed authority, ideally aiming for at least four antenatal consultations. (AMW need to refer all registered pregnant women routinely as well as when showing danger signs and necessary must refer a pregnant mother (between 20 weeks and 35 weeks gestation) to the rural health centre for necessary investigation and if needed must accompanied the pregnant mother for emergency referral to the hospital) |
• AMW should provide health education to pregnant and lactating women to promote healthy eating and prevention of locally endemic diseases to the community in the village. |
• To encourage all pregnant mother to prepare thoroughly for delivery with a comprehensive birth plan |
• AMW conducts home deliveries, postnatal care and new born care. Must be able to refer high risk cases of mothers and the newborns defined in the AMW manual to the hospital in timely manner |
• AMW should provide support to infants through education to mothers on breast feeding practices such as exclusive breast feeding (for 6 months) and start of supplementary feeding at the age of 6 months. |
• Monitor the growth and nutritional status of infants and under five children on a regular basis |
• Must provide first aid care in the capacity of her skill and must be able to refer needed cases to the hospital |
• Must report unusual diseases to the authority and must record the cases |
• Must help and provide assistance to Basic Health Staff in carrying out reproductive health activities. |
Perception of the role of AMWs
“If they (AMW) do not exist, patients do not have anyone to rely on especially in the hilly villages. You see when a mother gets in trouble during her pregnancy and if AMWs do not exist and we are out of town, there will be lots of problems” (MW FGD hard-to-reach)
“Well….when they find out new pregnant women, they tell us, I give the pregnant woman antenatal care. They can tell us immediately because they are always around in the village regularly, so, they can get information easily and quickly. They help us when we do health talk sessions and measure babies’ weight. Moreover, they call anyone who needs to receive service and they make sure no one misses.” (MW FGD non hard-to-reach)
“We are a common slave for the villagers and the health staff. We don’t have days and nights and whenever there is an emergency they (villagers and health care providers) remember to call us. Sometime we had to come with our own expanse and eat from out of pocket. No one pays us a penny” (AMW FGD hard-to-reach)
Potential for task shifting responsibilities
“For those AMWs in far mountain villages who listen to us, we teach them how to use and what amount should be given for what kind of drugs. We tell them how much should be given for adult and for children. We thoroughly tell them” (MW FGD hard-to-reach)
“MW usually asks the number of pregnant women. We provide the number and MW gives the medicine (Ferrous sulphate and folic acid) monthly”
“we usually buy the drugs from the drug store in town and sometime MWs share their drugs if they get a lot from the township” (AMW FGD hard-to-reach)
Task | AMWs (N = 33) | MWs (N = 15) | Mothers (N = 29) | Community (N = 36) |
---|---|---|---|---|
Oral supplementation to pregnant women | Confident; Majority of AMWs already in practice, and drugs are mainly supplied by the respective MW during the immunization sessions | Agreed; No difficulty being mentioned | Agreed; Have been taking drugs given by AMWs during pregnancy and childbirth | Agreed; AMWs have been providing oral medication to villagers for minor illnesses |
Misoprostol for prevention of PPH | Confident; Some of the AMWs are distributing 2 tablets misoprostol to mothers with drugs provided by MWs especially in hard to reach villages | Agreed; Refresher training suggested on PPH and drug administration | Agreed; Some mothers have received 2 tablets after the birth of the baby from the AMWs, but could not identify the name of the drug | Agreed; Limited knowledge of the drug and if it is for the benefit of the mother and the baby willing to accept |
Oral antibiotics for puerperal sepsis | Confident; Only a few AMWs have used antibiotics for puerperal sepsis as cases are rare | Agreed; Refresher training suggested on puerperal sepsis and use of antibiotics | Agreed; Have received some drugs for fever and cough but were not able to identify the name of the drug | Agreed; AMWs have treated fever and cough cases with paracetamol and amoxicillin. Only some were able to identify the name of antibiotics |
“As long as it is not an injection, I think any form of oral drugs like vitamins and antibiotics will be ok. However, we need to train them[AMWs] on how to use the drugs with clear guidelines. Is life saving and it can be given to them safely.”
Feasibility of integrating new interventions into the current health system
Guidelines on use and availability of drugs
“We (MWs) just give the drugs when we have it and when we don’t we cannot give it, they (AMWs) also get the drugs direct from the NGO working in the area, sometime” (MW FGD non hard-to-reach)
Inconsistent MW availability
“If you are not a native, the very first problem is language. We can’t live because their life styles are not the same….quite frankly, one who is not local will only stay for 15 days in an assigned area while local stays because the local one doesn’t need to return home” (MW FGD hard-to-reach)
Supervision and monitoring issues
“No one from the health department has ever been to my village because it is very far and it takes me about 9 hours to get here but for you it may take the whole day” (AMW FGD hard-to-reach)
Training gaps
“For the AMW, we must have a specific curriculum for the training and all the oral drugs usage needs to be in the guideline, it should be standardized from the Department of Health Human Resource and Planning. We need one trainer and trainee manual for the whole country. It should not be project or funding based. It is the responsibility of the health system to control the trainings” (District level key informant)
Health system priorities
“At the moment AMW trainings are continuing but I think is not a priority anymore after the change of government and there is no clear policy….MW upgrading and curriculum development…. new Public Health Supervisor 2 trainings…is all here and there”