1AMREF has been working for a long time on maternal health with programs about:
Reducing maternal mortality by improving access to and use of reproductive health services.
Fighting against the lack of health workers training community midwives.
Encouraging pregnant women to take preventive measures against malaria.
Preventing HIV and raising awareness about how to prevent mother-to-child transmission.
Educating about hygiene and improving access to clean water and sanitation.
Promoting reproductive rights, helping women to make informed choices about family planning.
Raising awareness about violence against women and helping women to access the relevant services and work with authorities to better protect them.
2The Stand Up for African Mothers campaign is designed to spread one simple and clear message: healthy Africa means healthy mothers and healthy mothers need African midwives. The African midwives will reduce maternal mortality providing medical care to pregnant women and during childbirth but will also enhance prevention against malaria and HIV, and promote hygiene and reproductive rights.
3The organization is particularly concerned about healthcare for women, for mothers and their children, and believes that it is unacceptable that almost 200,000 African women still die every year during pregnancy and labor, and that 1.5 million children are orphaned. Thus in order to reduce mother and child mortality, AMREF supports an ambitious project under the UN's Millennium Development Goals (MDG): to train 15,000 midwives by 2015 (Figure 1). In this paper, we consider the example of training midwives in South Sudan, the new African state which is undergoing face-to-face training. We also consider eLearning midwives training programs with the example of AMREF in Uganda.
Figure 1. An AMREF community midwife trained by AMREF in Ethiopia
4What women in high-income countries take for granted – trained midwives, obstetricians and delivery rooms, antibiotics and drugs in the event of complications – all these apparently basic things are true privileges for African women.
5In Africa, 1 woman in 39 risks dying during pregnancy or delivery, against 1 in 4,300 in developing countries. This is the greatest inequality in the world.
6On the continent, 200,000 mothers die every year. The women and children most affected are those in the more remote and poorer regions. Every year 1.5 million children are orphaned, losing their mothers during delivery of a little brother or sister. These newborns have a ten-fold risk of dying during the first two years of their lives.
7In many countries in Sub-Saharan Africa, the rate of maternal mortality is rising. The Millennium goal No. 5 of cutting back maternal mortality by 75% in the region by 2015 will never be achieved unless emergency action is taken.
8The direct causes of death of African mothers are hemorrhage, infections, obstructed labor, high blood pressure, or complications resulting from unsafe abortion. Moreover, at least 20% of the diseases suffered by children below 5 years of age can be traced back to mothers in poor health during pregnancy, dietary deficiencies, and insufficient care at birth.
9HIV/Aids is another threat. The transmission of the virus from mother to child in Sub-Saharan Africa, where the infection continues to spread or has stabilized at very high levels, remains a major problem. Indeed, 45% of infected mothers pass the infection to their children. The virus is also becoming one of the major causes of maternal mortality in some African regions.
10And yet a large number of these deaths could be avoided because they are caused by the absence of basic care during pregnancy and delivery. Only 15% of pregnancies and deliveries require emergency care for hard-to-diagnose complications. Access to basic care during pregnancy, delivery and the first month following delivery, would be crucial in saving mothers and newborns.
11AMREF is a key player in mother and child healthcare. It has set up mother and child programs that have become the baseline and been adopted by other organizations and governments throughout Africa. In the course of the next five years we wish to reinforce these programs. Our efforts will continue to be devoted to those in the greatest need: the mothers and their families in the poorer and more remote rural areas or in shantytowns.
12One of the organization's strategic axes is to focus its efforts on the healthcare of women, mothers and their children. AMREF undertakes to strengthen women's programs aimed at:
Reducing maternal mortality by improving access to healthcare and health services.
Preventing HIV and malaria during pregnancy and transmission of HIV between mother and child.
Raising awareness of hygiene and providing access to safe drinking water.
Protecting the rights of women, particularly as regards reproductive health.
Train midwives, nurses and community healthcare assistants.Midwives who will also work in prevention, education in reproductive health rights, and help fight mother-to-child transmission (PMTCT) of HIV.
13AMREF has set itself the target of training 15,000 African midwives by 2015. To this end, in 2011 it launched a wide mobilization campaign on the subject, Stand up for African Mothers. Recognizing that women and mothers are at the very heart of African communities, the Stand Up for African Mothers campaign will support the highly symbolic candidacy of African midwife Esther Madudu for the 2015 Nobel Peace Prize (Figure 2).
Figure 2. Esther Madudu, a Uganda midwife trained by AMREF and candidate for the 2015 Nobel Peace Prize
14Several African countries are covered by AMREF's training programs using varying and appropriate methodologies (18-month course in South Sudan, 3 year program in Ethiopia, e-learning training in Uganda, and in West Africa). This campaign was officially launched in October 2011 on the occasion of the Women’s Forum and will have a press section, a petition, advertising, events, and high points until 2015.
1 doctor for 100,000 people, one of the lowest ratios in the world.
1 child in 4 dies before age 5.
The world's highest maternal mortality rate.
Healthcare coverage is 25%, mostly funded by NGOs.
15AMREF started to train healthcare assistants in South Sudan during the violent civil war that devastated the country from 1983 to 2005. In 1998, at the Government's request, AMREF set up training for program healthcare assistants in the town of Maridi, where the National Medical Training Institute had just been created. Today, this Institute is still the only source of training for healthcare assistants in South Sudan. After 12 years in activity, it has trained 75% of healthcare operators present in the region (Figure 3A et Figure 3B). The Maridi school graduates are thus the main human resource and the only hope for providing medical care to all populations. AMREF works in close partnership with the South Sudan Ministry of Health to set up a national healthcare development plan, train healthcare professionals, and implement a basic healthcare access program to cover the needs of 150,000 people. With the European Union's support, a program to improve mother and child healthcare is being implemented. These programs target 300,000 direct beneficiaries. AMREF is also carrying out other programs in the region aimed at improving access to drinking water and hygiene to prevent disease and support research into healthcare needs in order to find solutions suited to the country's needs.
Figure 3. Community midwives trained by AMREF in South Sudan in Maridi.
16In South Sudan, there is an overwhelming lack of qualified midwives in first-level healthcare centers. In the communities, the situation is extremely serious because women have no access to qualified personnel. About 95% of births take place in villages with midwives who have no training.
17Before AMREF's intervention, there were only 20 qualified midwives for a total population of approximately 10 million. With the support of UNFPA, the Fondation Elle, the Fondation Raja, Gas Bijoux and the donors of the AfriCAN 2010 gala, 34 student midwives were registered for classes at the Maridi National Medical Training Institute in March 2011, where they attended lectures and had hands-on training in the healthcare centers of Maridi and surrounding villages. Once they graduate, these midwives will help 1000 mothers every year.
18The aim is to improve health in South Sudan in the long term, and in particular reduce morbidity and mortality of mothers and young children, as well as disabilities linked to pregnancy and delivery.
Train competent community midwives, capable of handling deliveries and providing quality reproductive healthcare in the communities.
Train 2,000 midwives in the next 5 years.
19For every midwife trained, 1,000 mothers benefit from pre- and post-natal care.
20AMREF is currently training 34 midwives in Maridi National Medical Training Institute, and 46 students already graduated in 2010. Candidates from the most remote regions, where there are as yet no midwives, are given priority for the course.
21By government request, AMREF supervises this program. The teachers come from South Sudan, Uganda and Kenya. The students are chosen by the community leaders with AMREF and based on different criteria. AMREF undertakes its own selection process twice a year. When they graduate, the government provides them with work in the health centers of the country or in organizations working there.
22The cost of training for one midwife is 6250 euros, which includes the 18 month global training and registration, accommodations, food, practical exercises in the health centers, uniform, and trip from the community to the Institute of Maridi.
23There are still 1,920 students to finance in order to attain the program targets.
24The training course lasts 18 months and combines lectures with practical exercises. The students learn to handle the most common complications that could arise during delivery, such as a drop in blood pressure, excessive bleeding, and difficult delivery. They also learn to provide pre- and post-natal care to mothers and to recognize the symptoms of more severe complications in order to refer the women to better-equipped medical establishments. Finally, and under close supervision, the students learn to carry out deliveries in order to be ready once they return to their communities.
25The new student class which began in March 2011 has already studied:
26Courses covered since March 2011
27The first term examination took place in the last week of May 2011.
28Courses studied from June to August 2011
29In September the Students finished the remaining topics on:
30In October and part of November, the students had the 2nd clinical rotation which covers: Antenatal care, Health Education, Immunization, and supervised deliveries. In November, the Students had final examinations. The students who passed continued in the second Year of Training. Students who failed fewer than 3 subjects were given the chance to retake the tests. If, on the other hand, a student failed more than 3 subjects, then they were discontinued.
31Peace and stability in the region.
32Mobility must not be limited by safety issues.
33The food insecurity situation must not worsen.
34The project's success requires close cooperation between public bodies (the Ministry of Health in particular), decentralized healthcare structures throughout the country, and renewed financial support from the South Sudan government for health in the region.
35This program is part of a close partnership with the South Sudan Ministry of Health to implement a national healthcare development plan, train healthcare professionals, and implement a basic healthcare access program to cover the needs of 150,000 people (Figure 4). Since July 2011, the country is officially independent. The health care system is changing. The AMREF training midwives program is also changing. The midwives will be trained at a professional level with a longest training of 30 months, with acquisition of theoretical concepts in the National Training Institute of Maridi, and with the acquisition and application of skills through clinical placements. AMREF France has promised South Sudan teams to set up a new class of 30 midwives for the first trimester of 2012. One professional training of 30 months now costs 12 000 euros. (The new cost is due to the duration of the course, the increasing professionalism, inflation, and new evaluation systems.)
Figure 4. Mothers and babies in Uganda, Kitgum
36In 2008, Uganda’s parliament passed the Business, Technical, Vocational Education and Training Act No. 12 of 2008 (BTVET Act, 2008), which restricted the Uganda Nurses and Midwives Council to maintaining professional standards by monitoring, supervising and registering qualified nurses. The Uganda Nurses and Midwives Examinations Board (UNMEB), which falls within the Ministry of Education, was given the full mandate to carry out final national examinations for nurses and midwives and offer certificates and diplomas.
37AMREF was chosen as a project leader to train more midwives to a diploma (registered) level more rapidly in order to help improve the health care of the rural based and disadvantaged populations in Uganda. Significantly, UNMEB requested that AMREF convert this upgrading program into eLearning on the model of the project that the organization is running in Kenya for 22,000 nurses.
Design, test and implement a feasible eLearning solution to upgrade Ugandan midwives’ skills (11,000 midwives identified).
Build the capacity of the AMREF in the Uganda Country Office, Human Resources Directorates of the Ministries of Education and Health, and Uganda Nursing Council, thereby enabling them to develop, implement and monitor effective eLearning.
Use results to influence policy and replicate the program in Uganda and beyond – i.e. create an alternative, reusable model for upgrading health professionals in a resource-constrained environment.
Standardized midwife upgrading curriculum
Increased number of highly skilled midwives
Modular eLearning diploma program
15 Regional Training Centres (RTCs) – with registration, testing and training services
Knowledge transfer to course coordinators from the schools in IT skills and eLearning
eLearning platform available for use in heath training in Uganda
38Using existing modes of training it is not possible to rapidly increase the number of qualified nurses required for the provision of quality health care to the people of Uganda. ELearning will have the dual advantage of rapidly increasing the numbers substantially and also keeping the health workforce at work and home while studying. The products of the program will impact on health delivery and hence facilitate the achievement of the health-related Millennium Development Goals (MDGs) and improve health care for the people of Uganda.
39The organization is actually implementing the eLearning structure around the country, expecting to begin the training of the midwives in 2012.