Posted Thursday 5th May 2022 for the International Day of the Midwife 2022.
Rachel Campbell, PhD Researcher, Ulster University
Emergency obstetric care education and training in a remote area of Myanmar
Just over a decade ago, I remember experiencing an overwhelming sense of feeling lost with no direction in life. I knew something had to change and unsure what direction to take, I packed my bags and travelled solo across the world to a small village in East Africa. I spent a year in an orphanage which was dedicated to ethical volunteering. Every morning I was greeted by a plethora of children sporting the biggest smiles, however as the weeks went by I came to realise that these smiles often masked a colossal amount of suffering and loss. With approx. 153 million orphans globally,  I often found myself asking, why?
It was during this trip that I was inspired to pursue my dreams of becoming a midwife. I undertook a four-week shadowing program within both a rural and urban maternity hospital in Tanzania. I remember coming home most days crying, devastated by the daily challenges healthcare providers faced in providing safe care to women and their babies. Despite the lack of adequate infrastructure and resources, I was awestruck by the dedication of these healthcare providers, even in the face of adversity. This brought me back to my previous question, why were there so many orphans in the world? Whilst the answer to this question is multifaceted, the unacceptable high rates of maternal mortality in many developing countries is undoubtedly a large contributing factor.
Worldwide over 800 women a day die from preventable causes related to pregnancy and childbirth, and 94% of these deaths occur in low and lower middle-income countries . Myanmar, also known as Burma, is a lower-middle income country located in the western portion of mainland Southeast Asia. Myanmar has a most recent maternal mortality rate (MMR) of 289 deaths per 100,000 live births and in remote areas this is estimated to be 721 deaths per 100,000 births . Utilisation of maternity care in Myanmar has been associated with geographical location, education, household income and access to transport. In hard-to-reach areas, one midwife could be providing care for 8-10 villages, with approximately 40-50,000 people . Many women located within remote and conflict areas rely on traditional birth attendants (TBAs). Whilst often possessing a wealth of experience, TBAs generally have no formal training.
Major complications, which account for 75% of all maternal deaths include severe bleeding, infections, high blood pressure (pre-eclampsia and eclampsia), complications from delivery and unsafe abortions. . The minimum care package required during pregnancy and childbirth in order to manage these potentially life-threatening complications is referred to as emergency obstetric care (EmOC) . Although evidence highlights that the provision of timely and quality EmOC can have a positive impact on maternal and neonatal mortality, many healthcare providers in developing countries do not possess the necessary knowledge and skills to effectively deliver this care.
In an aim to reduce maternal and neonatal mortality and morbidity, a growing body of literature has examined the various educational strategies employed to enhance the management of obstetric emergencies in Myanmar. This includes the universally accepted concept of learning by hands-on experience through the use of anatomic models and is currently being adopted in Myanmar with the establishment of 23 skills labs in 2014 . Additionally, in response to Myanmar being described as a digitally connected country, an innovative smartphone application was developed to provide skilled birth attendants with access to evidence based up-to date guidelines on basic obstetric and neonatal care .
My PhD study is part of a wider project called “Birth Across the Borders”, which addresses maternal mortality and morbidity in remote, rural communities in Myanmar. This study aims to evaluate the current level of EmOC education and training within a novel physician assistant (PA) program located in Karen state. Karen state in a remote mountainous area in the Southeast Region of Myanmar, in which basic resources and infrastructure are limited. The covid pandemic along with the on-going political instability in Myanmar has placed further challenges in the delivery of EmOC education and training within this region.
This study will adopt a multi-methods approach, utilising interviews and focus groups to gain an in-depth understanding of the PA program from the perspective of educators and students. Graduate PAs will be asked to keep a diary reflecting on their experiences of managing obstetric emergencies to determine if their education met the practice needs of their graduate role. The final component of this study will be to work in partnership with key stakeholders to identify areas of potential enhancement and propose strategies to incorporate into their current EmOC training and education programme. The involvement of key stakeholders aims to ensure these strategies are culturally tailored and increase sustainability on completion on this study.
This study is a fundamental component within the wider project which aims to support Myanmar in achieving Sustainable Developmental Goal 3 (reducing maternal mortality to 70 per 100,000 live births in low-income countries).
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