Improving Maternal Care: Midwives Leading, Managing, and Governing in Ten Sub-Saharan African Countries

{Photo credit: Mark Tuschman}Photo credit: Mark Tuschman

Leadership, management, and governance skills are critical for medical, nursing, and public health professionals. The MSH-led, US Agency for International Development (USAID)-funded Leadership, Management & Governance (LMG) Project with project partner Amref Health Africa developed an action-based learning, in-service certificate course to equip midwife managers with the leadership, management, and governance skills they need to deliver quality health services. To translate knowledge into practice, participants develop and implement custom quality improvement projects in their work places.

Forty-eight midwives from Malawi, Kenya, Uganda, Tanzania, and Ethiopia completed the training pilot in the first half of 2014. Another iteration was launched this month with a new cohort from South Sudan, Rwanda, Lesotho, Zambia, and Zimbabwe.

Before beginning their quality improvement projects, midwives participate in a five-day intensive course focusing on leadership, management, and governance practices; strategic problem solving; leading people; mentoring; human resources for health; and monitoring and evaluation.  These modules introduce participants to these technical areas, which are meant to be practiced during their quality improvement projects.

Over the next six months, participants create an action plan to identify an area of workplace improvement, develop creative solutions, and measure results.

The action plans from the pilot cohort of midwives can be categorized into four groups: maternal health, neonatal care, postnatal care, and male involvement in reproductive health. Many health service delivery improvements were documented during the pilot and presented at the end of the six-month implementation period. The initial results are promising: A Ugandan hospital systematized a new record filling system and 90 percent of staff were trained in its use. A Malawian hospital increased the number of premature babies initiated on Kangaroo Mother Care by 47 percent. A Kenyan hospital increased the percentage of deliveries by skilled birth attendants by 115 percent. A Tanzanian health center recorded a steady monthly increase in male spouses attending antenatal care services with their partners.  

Spotlight: Male involvement in maternal care in Tanzania

Jerry, a midwife at Mikindani Health Centre in Tanzania, aimed to increase involvement of men in his community in the antenatal care of their partners.  After identifying this need during the five-day training, he explained, “There was a time when one expectant mother delayed coming to the clinic because the husband was not at home to give her permission; the male spouses are the ones who keep the money and permission.”

After participating in the LMG Project’s Course for Midwifery Managers, he set out to increase the number of men accompanying their pregnant partners to antenatal care for the first visit. Jerry developed a leaflet campaign encouraging male accompaniment and offered a workshop to men in the community on maternal health. At the start of Jerry’s action plan, only two men accompanied their partners during first antenatal care visits. His target was eight per month, and within five months, he had ten accompanied visits, surpassing his goal.

Spotlight: Increasing deliveries by skilled birth attendants in Kenya

Fewer than 44 percent of births in Kenya are attended by a skilled birth attendant. A participant from Kilungu Sub-County Hospital in Kenya noted how mothers were often delivering in their own homes or with non-skilled birth attendants, putting themselves and their babies at risk. During the LMG Project training, she developed a plan to increase the number of deliveries by skilled birth attendants from 30 to 47 in six months.

She found that community members were often intimidated and distrusting of the midwives in her hospital, influencing them not to seek medical care during pregnancy and childbirth.  In response to this, she launched a weekly “Know Your Kilungu Midwife” outreach campaign at the open air market and a hospital tour where midwives demonstrated to community members how machines were used, the emergency capacity of staff, and the overall quality of delivery services. By implementing these priority actions while receiving coaching from a course facilitator, she reached 65 deliveries with an attendant, easily surpassing her goal. 

Supported midwives, Better maternal care 

Midwives play a key role in preventing maternal and neonatal death.  Well-trained midwives could help prevent up to two thirds of all maternal and newborn deaths, according to the most recent State of the World’s Midwifery report. By supporting these midwives and helping them gain leadership, management, and governance skills, they are better able to provide maternal services to those who need it most. We eagerly await results from the second cohort of midwives as they work to strengthen MNCH outcomes throughout sub-Saharan Africa.