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Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
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5

Country Perspectives

Key Messages

It is important to have continuity of care not only in practice but also in location.

—Amal Abu Awad

If you go to a primary health center that is staffed with community health workers and one that has a nurse or midwife, usually you can see the difference in the quality of care. So now the government is trying to get more nurses and more midwives into that system.

—Emilia Iwu

From the beginning, we have admitted women [of] lower-middle and lower economic status to training schools, and they have become nurses; they have become sustainers of families and sustainers of communities.

—Julie Fairman

The local context plays a strong role in the development of nursing and midwifery enterprise, despite global standards of education, training, and care provision. Speakers discussed the architecture, priority setting, and future development of nursing and midwifery education and programs in

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

Palestine, Nigeria, and the United States, highlighting both unique and communal challenges.

SYSTEMATIC INITIATIVES TO EMPOWER NURSES AND MIDWIVES AND IMPROVE HEALTH SERVICES IN PALESTINE1

There are many definitions of empowerment; Amal Abu Awad shared one from UN Women, which lists seven principles. These principles, she noted, align with the programs she runs. The principles are

  1. Leadership promotes gender equality;
  2. Equal opportunity, inclusion, and nondiscrimination;
  3. Health, safety, and freedom from violence;
  4. Education and training;
  5. Enterprise development, supply chain, and marketing practices;
  6. Community leadership and engagement; and
  7. Transparency, measuring, and reporting (UN Women, n.d.).

Awad explained that Palestine has two main regions: West Bank and Gaza. In the West Bank there are 6 midwifery programs and 15 nursing programs, while in Gaza there are 2 midwifery programs and 4 nursing programs. In the West Bank, two of the midwifery programs and seven of the nursing programs are 2-year programs, which they are working on phasing out because they do not meet the desired quality of care. Her college, Ibn Sina College in the West Bank, is the only governmental university college providing bachelor-level degrees in nursing and in midwifery. She praised the quality of the education, but also remarked that because of government subsidies, the tuition is low or, in the case of midwifery, free.

The national strategy to improve the quality of nurses and midwives is reflected in the curricula of the educational programs. Principles of the programs include

  • Commitment to using evidence-based practices, which includes using the most recent textbooks and designing courses around internationally recognized competencies;
  • Integration of new practice protocols within the curriculum, which includes bringing students and service providers closer together;
  • Curriculum update and regular review by the minister for health education every 5 years; and

________________

1 This section summarizes information presented by Amal Abu Awad, Palestinian Ministry of Health.

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
  • Quality assurance for training experience, including low student–teacher ratios, early patient contact, and clinical training.

She described that a special course was required for training about gender-based violence and domestic violence; lecturers were specially trained, and there were specific credits for the course and for family protection interventions. Awareness increased among students, and students reflected on their personal and family experiences. To create other specialty courses at the college, course designers from specialties such as medicine and radiology were trained so that they could design courses for their respective field. Ibn Sina College also hopes to connect with universities abroad in order to bring additional specialty courses to the college, such as courses on oncology or burns. By establishing these connections, the college is working to improve the health system and to ensure quality of care. She also said that due to improvements in internet access, the hospitals’ online resources have expanded; for example, hospitals now offer virtual training courses for both students and care providers.

Awad stated that the health ministry is also interested in increasing the capacity and quality of the midwifery programs, with campaigns to attract new students. The focus is to foster independence as well as to promote the use of natural birthing processes. The curriculum has been updated, and has the midwives’ job descriptions, which are now in accordance with the advanced competencies of the International Confederation of Midwives. This includes incorporating additional advanced competencies such as IUD (intrauterine device) insertion and removal and episiotomy cut and repair. It also includes a model for continuity of care supported by the Norwegian Aid Committee (NORWAC), which links and supports the midwifery practice in both hospitals and communities. Awad closed by noting areas of continued support and progress:

  • Faculty development,
  • Staff development,
  • Extracurricular activities,
  • Students involvement,
  • Professional regulation and organization, and
  • Upgrading of existing diploma holders to the bachelor of science level.
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

PERSPECTIVES FROM NIGERIA2

There are an estimated 124,629 nurses and 88,796 midwives in Nigeria as determined by the Nigerian National Strategic Health Development Plan, stated Emilia Iwu, but this data is in the process of being updated. The Nursing and Midwifery Council of Nigeria, she said, continuously seeks to improve nursing practice and professionalism, but further collaborative work is needed to better translate effective nursing programs and strategies from other countries to the Nigerian context. One challenge, she noted, is the public perception and media portrayal of nurses because “not everybody in a white uniform is a nurse” (especially in nonpublic facilities). Unfortunately, auxiliary nurses without any formal nursing education often present themselves to the public as “nurses,” she explained.

Iwu described how nursing education in Nigeria occurs at different levels. Diploma nursing and diploma midwifery are each 3-year programs. There are also post-basic specialty certificate programs, such as pediatric; ear, nose, and throat; occupational; orthopedic; peri-operative; and intensive care nursing. The baccalaureate nursing degree is a 5-year program that usually contains a midwifery component and at times offers elements of public health education. Twenty universities offer baccalaureate degree, three offer masters, and two offer doctorates in nursing. Registered nurses and midwives work at all levels of health facilities, she said, but those with graduate degrees work mostly in academic settings.

However, she raised a few challenges in nursing and midwifery education, including faculty shortage and faculty academic progression and retention difficulties. These, coupled with lack of educational infrastructure availability or upgrade challenges, lead to accreditation difficulties for many of the schools. Lack of faculty retention also affects student–teacher ratios, which is supposed to be 1-to-10 in the diploma programs. Iwu stated that there is a dire need for faculty career and education progression strategies, as well as a need to develop a faculty pipeline for future educators especially with anticipated retirement of the baby boomer generation from the system. The Nursing and Midwifery Council acknowledges the gap in the salaries of nurse educators when compared to their counterparts in practice settings. Therefore, they are exploring ways to equalize and create incentives to make the salary equitable. These strategies include provision of opportunities to further education, search for collaborations for scholarship, tuition support, and endowment funds. Additionally, she said, there is limited capacity for existing baccalaureate programs to move diploma nurses through the universities. Iwu described a desire in Nigeria for increased south–south

________________

2 This section summarizes information presented by Emilia Iwu, PEPFAR (The U.S. President’s Emergency Plan for AIDS Relief) in Abuja, Nigeria.

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

and north–south collaborations to enhance the capacity of university-based programs through twinning relationships and online learning opportunities to resolve these nursing education workforce challenges.

Both the nursing and midwifery programs are postsecondary education, which Iwu believes is disadvantageous for socially vulnerable girls and young women who drop out of school or who are married off before they finish secondary education. There are some remedial programs especially in northern Nigeria that assist such girls and young women to attain the requisite educational preparation and qualification for admission to nursing, midwifery, and community health practitioner schools. If they are able to go through the remedial programs and pass, they are admitted to these programs.

Although nurses and midwives can be found in every community in Nigeria, said Iwu, historically the majority of them work in urban and semi-urban hospitals as opposed to community health centers. To address this maldistribution and to increase the number of skilled obstetric care providers, the government implemented the Midwives Service Scheme in 2009 in an effort to reduce maternal/child mortality and morbidity in rural areas. This program deploys newly graduated and retired midwives to rural primary health centers often served by community health workers alone. The objective is to augment and improve quality of care provided especially in hard-to-reach communities with limited access to urban or semi-urban health facilities. Iwu remarked that this is very important as inclusion of nurses and midwives in these settings improves quality and provides opportunities for expanded holistic care.

NURSING AND MIDWIFERY IN THE UNITED STATES3

Nursing in the United States has traditionally been a way of upward social and economic mobility, Julie Fairman explained. Working class women have attended nursing schools over the last century and acquired skills needed to care for the health of families and communities. The Institute of Medicine (IOM) in 2010 noted that 80 percent of nurses should have a bachelor of science degree in nursing by 2020 because baccalaureate programs support their students to develop skills and knowledge to provide care in communities and lead community-based models of care (IOM, 2010). However, community colleges and associate degree nursing programs are an important pipeline for lower-income women to gain access to the profession. This has presented a challenge to address both the needs of students and of patients. She also noted that historically, nurses have been

________________

3 This section summarizes information presented by Julie Fairman, University of Pennsylvania.

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

involved in the provision of affordable community-based care, which raises the question of why some of these approaches have not been successfully scaled up.

Two programs she spoke about include the nationwide Nurse–Family Partnership (NFP) in Denver, Colorado, and the Developing Families Center in Washington, DC. The NFP was developed by David Olds, a physician, and Harriet Kitzman, a nurse, in the 1970s. It pairs a nurse, and more recently a community health worker, with a low-income, first-time pregnant woman in her second trimester. The nurse follows the mother for 2 to 3 years and provides skills and knowledge as part of a “toolkit.” The program has been known for its outcomes, such as a 48 percent reduction in neglect and abuse, 59 percent decrease in criminal activity by children before the age of 15, and 67 percent reduction in behavioral and intellectual problems (NFP, 2011). There is also a decrease in partner violence, and increased possibility for mothers to go back to work (NNCC, 2014). While the model is still true to its original intent of nurse visitors, there has been a comparative study examining paraprofessionals and nurses in a randomized controlled trial. On most benchmarks, women and children visited by professional nurses performed at a higher level, although improvements were seen in all groups (Olds et al., 2002). Even so, in some very rural parts of the United States where the health care infrastructure is weak, the NFP is both sustainable and practiced.

The second model Fairman described is the Developing Families Center, created by nurse-midwife Ruth Lubic. The program was initiated based on women’s responses to the medicalization of birth and birthing in hospitals. The Center provides prenatal and postnatal care to women who can choose to give birth at the Center or at local hospitals while supported by the nurse midwives. Lubic began in New York, and in 2000 she opened the Family Health and Birth Center in Washington, DC. After 6 years, the outcomes were favorable among low-income African-American women in the Center, compared to African-American women in Washington, DC:

  • Preterm birth: 5 percent, compared to 15.6 percent;
  • Low birth weight: 3 percent vs. 14.5 percent;
  • C-section rates: 10 percent vs. 31.5 percent (RWJF, 2010).

The center is responsive to the community; Lubic asked the community what they preferred, and an advisory group of women in the community helped develop the programs. She also employed women from the community to serve as lactation consultants, Fairman remarked, illustrating the potential of a bidirectional dialogue around empowerment.

Fairman closed with a brief description of the community health workers movement in the United States, in which women in particular

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

from the community are trained to work with people with chronic illness. The University of Pennsylvania has such a program (the Penn Center for Community Health Workers), as do some tribal areas. There is also a similar program in Houston called Grand-Aides (mentioned by Krishna Udayakumar in Chapter 3). Fairman cautioned that while these programs have potential for providing greater access to health care and the health care field, the models should not be primarily profit driven to the point of depressed wage rates.

DISCUSSION

Following the presentations, speakers and participants commented further on the speakers’ presentations, particularly regarding the use of community health workers to share tasks. One participant raised the challenge of sustainability that she noticed through her work in Boston; in general, community health workers are intended to create links between health care services and communities. However, some of the workers do eventually seek additional training to “move up the ladder,” she said, and this can sometimes have the unintended side effect of removing their close tie to the community.

REFERENCES

IOM (Institute of Medicine). 2010. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

NFP (Nurse–Family Partnership). 2011. Evidentiary Foundations of Nurse–Family Partnership. http://www.nursefamilypartnership.org/assets/PDF/Policy/NFP_Evidentiary_Foundations.aspx (accessed Febuary 23, 2015).

NNCC (National Nursing Centers Consortium). 2014. Nurse–Family Partnership. http://www.nncc.us/site/index.php/program-center/improving-health-through-early-action/16nurse-family-partnership (accessed November 4, 2014).

Olds, D. L., J. Robinson, R. O’Brien, D. W. Luckey, L. M. Pettitt, C. R. Henderson, Jr., R. K. Ng, K. L. Sheff, J. Korfmacher, S. Hiatt, and A. Talmi. 2002. Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics 110(3):486-496.

RWJF (Robert Wood Johnson Foundation). 2010. Helping mothers and children with a families center in Washington, D.C. Princeton, NJ: RWJF.

UN Women (United Nations Entity for Gender Equality and the Empowerment of Women). n.d. Women’s empowerment principles. http://www.unwomenuk.org/corporate/womensempowerment-principles (accessed November 4, 2014).

Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×

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Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
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Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 46
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 47
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 48
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 49
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 50
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
Page 51
Suggested Citation:"5 Country Perspectives." Institute of Medicine. 2015. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/19005.
×
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In September 2014, the Global Forum on Innovation in Health Professional Education and the Forum on Public-Private Partnerships for Global Health and Safety of the Institute of Medicine convened a workshop on empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise. Experts in women's empowerment, development, health systems' capacity building, social enterprise and finance, and nursing and midwifery explored the intersections between and among these domains. Innovative and promising models for more sustainable health care delivery that embed women's empowerment in their missions were examined. Participants also discussed uptake and scale; adaptation, translation, and replication; financing; and collaboration and partnership. Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise summarizes the presentations and discussion of the workshop. This report highlights examples and explores broad frameworks for existing and potential intersections of different sectors that could lead to better health and well-being of women around the world, and how lessons learned from these examples might be applied in the United States.

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