How a Nurse-Midwife in Haiti is Harnessing Contraceptive Knowledge to Better Serve New Mothers
(Cross-posted from K4Health's Medium publication The Exchange)
When “Esther” was 16 years old, she gave birth at the University Hospital in Mirebalais, Haiti — a facility supported by Partners In Health. Esther’s father was by her side, and one of his greatest concerns was that she finish her education. It was he who asked Esther’s care providers about postpartum family planning.
After being counseled on appropriate contraceptive options, Esther chose an implant. This long-acting reversible contraceptive (LARC) will allow Esther to focus on caring for her baby, finishing her education, and pursuing economic stability for her family.
As a nurse-midwife at the 300-bed University Hospital in Mirebalais, Meredith Jean-Baptiste sees the life-saving potential of contraceptive implants every day. “Jadelle (a five-year two-rod implant) is a very effective, reversible, and long-acting family planning method, which is already making an impact in our community and services,” she notes. However, while postpartum mothers like Esther do receive family planning counseling after giving birth, they are typically asked to schedule a follow-up appointment in order to actually receive contraceptives. Because of the distance between the typical mother’s home and her nearest health facility, and the expense of traveling that distance, not many women return for their follow-up appointments. As a result, Meredith was seeing the same women having babies year after year, not necessarily because they wanted to, but because they weren’t using family planning.
When women are unable to delay and space births at healthy intervals, they are less likely to be able to complete their education and are at greater risk of complications and death related to pregnancy or childbirth. In a country like Haiti, where the maternal mortality ratio (MMR) is 359 per 100,000 live births (compared to, for example, an MMR of 39/100,000 in Cuba, 14/100,000 in the U.S., or 5/100,000 in Japan), Meredith knows firsthand that every mother she can reach with family planning services is a potential life saved. “Our sincere hope is that birth spacing, especially among women with serious obstetrical complications, like severe preeclampsia or eclampsia or even peripartum cardiomyopathy, can benefit.”
Preeclampsia and eclampsia are the leading causes of maternal mortality in Haiti: About 20% of mothers delivering at University Hospital are affected by these conditions. These women with severe complications are often advised to avoid future pregnancies. Without access to LARCs — implants and IUDs — following this potentially life-saving recommendation can be difficult or impossible for some women. Expanding access to LARCs is critical in countries like Haiti, Meredith warns: “The reduction of risks for future unintended pregnancies or pregnancies that are closely spaced will ultimately impact maternal mortality.” For this reason, Meredith was determined to make implants an essential part of her hospital’s contraceptive method mix.
Because mothers are able to have a contraceptive implant inserted right after delivery, implants are a vital family planning option for postpartum mothers that allows them to return home after giving birth without worrying about follow-up appointments.
Meredith’s goal was to try and increase provision and uptake of LARCs at the hospital. Current LARC use was low, and Meredith wondered if one reason was lack of motivation or interest in LARC provision among hospital staff. She knew that proper training was essential to achieving her goal. A few years earlier, Meredith had used materials from the White Ribbon Alliance that she found in a K4Health Toolkit to develop and deliver a training on respectful maternity care. She returned to K4Health this year to seek training materials on contraceptive implant provision.
[Video caption: This short video by K4Health shares how Meredith developed a training curriculum for nurse-midwives on respectful maternity care.]
Meredith visited the Training Resource Package for Family Planning and was excited to find training materials for implant provision that had already been translated into French. The materials were open source, so she could edit and adapt them for her particular context before using them to train nurses, nurse-midwives, residents, and OB/GYNs. Meredith needed a few materials that the Training Resource Package did not include, but she was able to fill those gaps herself. She created her own instructional video on implant insertion and screened it during the training to reinforce implant insertion instructions.
She also wanted her training to address contraceptive counseling and provision for women living with HIV, but the original materials did not cover this topic. Meredith sought relevant information from additional sources, inserted it into her curriculum, and updated the presentations to include the most recent recommendations from the World Health Organization.
Meredith held three trainings in March 2016, leading her colleagues through pretests, lectures, presentations, case studies, a practicum where trainees inserted implants into dummies, and, finally, supervised insertion of implants into patients. After the trainings, provision of implants for immediate postpartum women at the hospital went from 0 per month to between 22 and 86 per month. The hospital also saw a great increase in outpatient uptake of implants. On average, each month between March 2016 and June 2017, 48 postpartum clients and an additional 30 outpatient family planning clients received implants. Nurses and nurse-midwives have provided the majority of implant insertions, with the staff who insert the most implants receiving recognition from their peers.
Meredith reflects on the success of the program: “We have more women coming in asking for the method than ever before as a result of this quality improvement project.” In fact, 20% of women who deliver at her hospital now go home with a long-acting or permanent contraceptive method, most with an implant.
“Here in Haiti,” Meredith observes, “women are considered ‘poto mitan nan famiy-a,’ or the ‘center supporting pole of the family.’ When a woman dies, the whole family collapses as her children no longer are able to go to school. Economically, the family, the community, and, consequently, the entire country are affected for generations.”
The socioeconomic cost of maternal mortality on countries like Haiti, where mothers’ survival is vital, is great. As Meredith and her team are proving, investment in postpartum implant provision is a simple but life-changing solution to preventable maternal death.