OPTIMIZING THE CONTRIBUTIONS OF THE NURSING AND MIDWIFERY WORKFORCE TO ACHIEVE UNIVERSAL HEALTH COVERAGE AND THE SUSTAINABLE DEVELOPMENT GOALS THROUGH EDUCATION, RESEARCH AND PRACTICE

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ISBN 978-92-4-151197-1

OPTIMIZING THE CONTRIBUTIONS OF THE NURSING AND MIDWIFERY

WORKFORCE TO ACHIEVE

UNIVERSAL HEALTH COVERAGE AND THE SUSTAINABLE DEVELOPMENT

GOALS THROUGH EDUCATION, RESEARCH AND PRACTICE

Human Resources for Health Observer Series No. 22

OPTIMIZING THE CONTRIBUTIONS OF THE NURSING AND MIDWIFERY

WORKFORCE TO ACHIEVE

UNIVERSAL HEALTH COVERAGE AND THE SUSTAINABLE DEVELOPMENT

GOALS THROUGH EDUCATION, RESEARCH AND PRACTICE

Human Resources for Health Observer Series No. 22

© World Health Organization 2017

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Acknowledgements

3

Abbreviations

4

Executive summary

5

1. Introduction

6

The health priorities and targets of the Sustainable Development Goals

6

Strengthening nursing and midwifery research, education and practice

7

Effective universal health coverage and evidence-based practice

7

The need to facilitate the utilization of research evidence and evidence-based practice

7 Purpose of the Observer

8

Why do we need to develop this Observer?

8

Who are the target audiences?

8

What is included in the Observer?

8

2. Study approaches

9

Principles and activities underlying evidence-based practice

9

Presentation of relevant information

10

Presentation of study examples

10

Discussions on implications for action

10

3. Sexual, reproductive, maternal, newborn and child and adolescent health

11

What do we know?

11

What are the latest global strategies and targets?

13

Study examples on practice, education and research

17

Implications for action

17

TABLE OF CONTENTS

4. Noncommunicable diseases and mental health

20

What do we know?

20

What are the latest global strategies and targets?

21

Study examples on practice, education and research

25

Implications for action

25

5. HIV

28

What do we know?

28

What are the latest global strategies and targets?

29

Study examples on practice, education and research

30

Implications for action

32

6. Malaria

33

What do we know?

33

What are the latest global goals and targets?

34

Study examples on practice, education and research

35

Implications for action

35

7. Tuberculosis

38

What do we know?

38

What are the latest global strategies and targets?

39

Study examples on practice, education and research

41

Implications for action

41

Conclusion

43

References

44

The named authors alone are responsible for the views expressed in this publication.

This Observer was drafted by Dr Lily Dongxia Xiao, Associate Professor, School of Nursing & Midwifery, Flinders University, Australia. Dr Xiao developed this document while she was the nursing scholar with the 2015 Nursing and Midwifery Scholar Programme in the World Health Organization.

The development of this Observer was coordinated and finalized by Annette Mwansa Nkowane, World Health Organization, Department of Health Workforce. Technical input was provided by Onyema Ajuebor, Technical Officer, Health Workforce Department.

Ms Noriko Morioka helped with information-gathering in the early development of this document.

Several individuals reviewed and contributed to this document. The following WHO staff provided comments: Annabel Baddeley, James J Banda, Daniel Low-Beer, Venkatraman Chandra-Mouli, Ahmet Metin Gulmezoglu, Belinda Loring, Frances Emma McConville, Shivakumran Murugasampillay.

The following nursing and midwifery experts provided review comments: Mary Bi Suh Atanga, Faculty of Health Sciences, University of Bamenda, Cameroon; Jennifer Dohrn, Columbia University School of Nursing, USA; Lynda Wilson, University of Alabama, Birmingham, USA.

Acknowledgements

AAAQ Availability, accessibility, acceptability and quality of care services ACT artemisinin-based combination therapy

AIDS Acquired immune deficiency syndrome ART Antiretroviral therapy

ARV Antiretroviral

DALYs Disability-adjusted life years EBP Evidence-based practice FGM Female genital mutilation HIV Human immunodeficiency virus HPV Human papillomavirus HSV2 Herpes simplex virus 2

IPTp Intermittent preventive treatment during pregnancy ITN Insecticide-treated mosquito net

IUD Intrauterine Contraceptive Device MDGs Millennium Development Goals MDR-TB Multidrug-resistant tuberculosis MTCT Mother-to-child transmission NCDs Noncommunicable diseases

PEN Package of essential noncommunicable PEP Post-exposure prophylaxis

PET Practice questions−Evidence−Translation SDGs Sustainable Development Goals

SRMNCAH Sexual, reproductive, maternal, newborn, child and adolescent health STI Sexually transmitted infection

TB Tuberculosis

TBAs Traditional Birth Attendants UHC Universal Health Coverage

UNAIDS The Joint United Nations Programme on HIV/AIDS UNFPA The United Nations Population Fund

UNICEF The United Nations Children’s Fund WHO World Health Organization

XDR-TB Extensively drug-resistant tuberculosis

Abbreviations

The nursing and midwifery professions have been recognized for their crucial role in implementing the priorities envisaged in the Millennium Development Goals (MDGs), including their efforts to end preventable maternal and child mortality and to improve the health of populations they serve. Moving forward to ensure the full implementation and achievement of the targets of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) – through its Nursing and Midwifery Programme and in conjunction with partners – is fostering international collaboration and monitoring progress in developing the nursing and midwifery workforce towards these goals.

Despite the considerable achievements of the international community in driving progress towards the MDGs, many goals were not met.

Nurses and midwives are now at a crucial point for reflecting on strengths and lessons learned in the MDG era in order to optimize their contributions to implementing the SDGs – the aim of which is to ensure universal health coverage (UHC). Areas that could be further improved include ensuring quality education and adequate generation and utilization of research evidence. Strengthening nursing and midwifery education is essential for improving the quality of health services. It is critical that competent educators develop and implement evidence-based curricula that are in line with local needs. In addition, nurses and midwives must be educated and trained to conduct relevant research and to translate research findings into practice to promote best practices and improve health outcomes. This document focuses on how research evidence can be used as a vital tool to strengthen nursing and midwifery education and evidence-based practice related to five specific areas, namely:

• sexual, reproductive, maternal, newborn, child and adolescent health

• noncommunicable diseases and mental health

• human immunodeficiency virus

• malaria

• tuberculosis.

The development of this Observer is inspired by nurses and midwives and those who support them in policy and resource development and in education and research activities. The aim is to further strengthen nursing and midwifery education and practice through research in order to contribute to the implementation of the SDGs and UHC. This responds to the United Nations Secretary-General’s call to action – “to transform the world agenda beyond 2015”.

The target audiences of this Observer are the following persons working in nursing and midwifery:

• researchers and academics involved in global health projects and activities;

• leaders engaged in health planning and policy development;

• health workers delivering direct care to clients/patients and populations;

• students engaged in global health topics, projects and activities; and

• partners and other relevant stakeholders.

Each section of this paper highlights current information/statistics about the selected thematic area from multiple sources, including WHO and other United Nations agencies. The discussions on implications of action concentrate on evidence generation and policy, research translation and practice, and development of the nursing and midwifery workforce.

Executive summary

The nursing and midwifery professions have been recognized for their crucial contribution to the Millennium Development Goals (MDGs) through several World Health Assembly resolutions, including resolution WHA64.7 on “Strengthening nursing and midwifery” (1). Resolution WHA 64.7 recognizes that nurses and midwives constitute a majority of the global health workforce and make significant contributions to improving health outcomes and saving lives through the delivery of wide-ranging nursing and midwifery services (2). Nurses and midwives provide a broad range of services (including screening, diagnosis, treatment, follow-up and nursing care) in improving maternal, newborn and child health and in caring for patients with human immunodeficiency virus (HIV), tuberculosis (TB) and malaria. They provide care in hard-to-reach communities where nurses and/or midwives may be the only health professionals available (3,4,5,6). The development of this Observer is inspired by practising nurses and midwives and those who support them in policy and resource development and in education and research activities.

The World Health Organization (WHO) through its Nursing and Midwifery Programme, and in conjunction with partners, is working strategically to foster international collaboration to support the nursing and midwifery workforce and monitor progress made towards the achievement of universal health coverage (UHC) and the Sustainable Development Goals (SDGs) (7,8,9,10,11). To ensure a sound and comprehensive response at both international and national levels, the Global strategy on human resources for health: Workforce 2030 (12) and the Global strategic directions for strengthening nursing and midwifery 2016−2020 (8) have been developed. These strategic documents aim to accelerate progress towards UHC and the SDGs by ensuring equitable access to competent and motivated nurses and midwives within strengthened health systems. Examples of recent publications aimed at strengthening nursing and midwifery from the WHO Nursing and Midwifery Programme include Nurse educator core competencies, Midwifery educator core competencies (13,14) and

1 Introduction

Strengthening the role of nursing and midwifery in addressing noncommunicable diseases (15). Many targets of the MDGs have not been met, although considerable achievements have been made through actions by national governments and the solidarity of the international community (16). It is reported that inadequate human resources at all levels of health-care systems, lack of high-quality local educational programmes, and limited access to information and communication technologies are major challenges to strengthening nursing and midwifery services (1,6,9).

Addressing these problems requires deliberate efforts to strengthen multisectoral approaches to addressing health labour market concerns in countries. The United Nations High-level Commission on Health Employment and Economic Growth highlighted the potential positive impact on economic growth of investments in health workers’ education and employment, including that of nurses and midwives. Recommendation 3 of the report aims to “scale up transformative, high-quality education and lifelong learning so that all health workers have skills that match the health needs of populations and can work to their full potential” (17).

The health priorities and targets of the Sustainable Development Goals

This is a crucial time for nurses and midwives to reflect on their strengths and on lessons learned in the MDG era in order to optimize their contributions to implementing the SDGs. Familiarity with the health priorities and goals of the SDGs is the first step for engagement. Goal 3 of 17 states: “Ensure healthy lives and promote wellbeing for all at all ages” (18,19). This goal includes the unfinished agenda from the MDGs and, inter alia, sets new priorities to reduce the burden of noncommunicable diseases (NCDs) and improve mental health. A summary of the health priorities, goals and targets of the SDGs are presented in Table 1.1.

Table 1.1 Health priorities and targets of the Sustainable Development Goals HEALTH PRIORITIES IN THE SDGS (18)

Accelerating progress on the present health MDGs.

Advancing sexual and reproductive health and rights.

Reducing the burden of NCDs and their risk factors.

Improving mental health.

TARGETS/SUB-GOALS UNDER THE SDG 3 (19)

Target 1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births.

Target 2: By 2030, end preventable deaths of newborns and children under 5 years of age.

Target 3: By 2030, end the epidemics of AIDS, TB, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.

Target 4: By 2030, reduce by one third premature mortality fr;om non-communicable diseases through prevention and treatment and promote mental health and well-being.

Target 5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.

Target 6: By 2020, halve the number of global deaths and injuries from road traffic accidents.

Target 7: By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.

Target 8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Target 9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.

Strengthening nursing and midwifery research, education and practice

Efforts to strengthen nursing and midwifery are documented in recent policy tools, including the World Health Assembly resolution WHA 64.7, nursing and midwifery progress reports and other relevant literature. These documents refer to strengthening nursing and midwifery education to support better research and evidence- based practice as part of major frameworks to develop nursing and midwifery (1,7,8,12,20,21). Quality nursing and midwifery education is a key driver for improved quality of health services. There is a critical need for competent educators to develop and implement evidence-based curricula that are in line with local needs. Education, research and evidence-based practice are interrelated and

interdependent; together they promote lifelong learning and advance the knowledge base of the nursing and midwifery workforce to ensure full competency in the administration of best practices in order to guarantee future health gains (18,19). Best practices that stem from these three areas have been demonstrated across the globe, including from low-income countries and resource-poor care settings. They are described in the study examples in later sections of this document (20,21,22). However, marked variations occur globally in the level of development of research to support education and evidence-based practice. A recent literature review revealed weaknesses and significant gaps in countries of the WHO African Region where research evidence is needed to address the hefty disease burden across all health priority areas, including infectious diseases, HIV and NCDs (23,24,25). This situation strongly suggests that research in basic and post-basic nursing and midwifery education needs to be strengthened and scaled up to produce nursing and midwifery researchers who are prepared to lead research projects.

Effective universal health coverage and evidence-based practice

UHC is essential to ensure that “all people obtain the good-quality essential health services that they need without enduring financial hardship”. UHC has two main aspects – health services coverage and financial protection coverage. Effective health services coverage should apply to the spectrum of health promotion, prevention, treatment, rehabilitation and palliation and should encompass the four domains of availability, accessibility, acceptability and quality of care services (known as the AAAQ domains) (6). These AAAQ domains have implications for research, education and evidence- based practice in nursing and midwifery. Nurses and midwives must be prepared to work in multidisciplinary public health teams and to address both individual and population-level health problems (26),

The need to facilitate the utilization of research evidence and evidence-based practice

It has been widely recognized that access to research evidence (including evidence-based guidelines) is a prerequisite for health professionals to adopt and adapt best practice in the local context (20,21). However, findings from the WHO Nursing and Midwifery

progress report 2008−2012 reveal that access to information and communication technologies are a major challenge to addressing nursing and midwifery, particularly in low-income countries (9). The Millennium Development Goals report 2015 has shown that disease burden and mortality rates are still much higher in low- and middle- income countries where resources, including information resources, are more limited (28). Improving health and ending preventable mortality in the poorest populations may not be achieved without building supportive mechanisms for those who care for them.

Activities to disseminate research evidence and to communicate with potential users on how to adopt/adapt best practice to the local context are highly demanded in the era of evidence-based practice.

These activities need to be undertaken proactively and regularly.

Purpose of the Observer

The purpose of this Observer is to further strengthen nursing and midwifery education and practice through research, and to contribute to the implementation of the SDGs and UHC. This is in response to the United Nations Secretary-General’s call to action

“to transform the world agenda beyond 2015” (29). This Observer presents epidemiological data, goals, targets and references to guidelines in a ready-to-use manner. It utilizes selected study examples from peer-reviewed journals and WHO reports to advocate for nurses and midwives and other beneficiaries to adopt or adapt best practices in local contexts.

Why do we need to develop this Observer?

Based on evidence obtained from WHO reports and literature on activities linked to the MDGs, the need to develop this Observer is outlined as follows:

• to summarize and disseminate information about health priorities in the SDGs, including targets and goals, agreed strategies and guidelines to support the nursing and midwifery community;

• to mobilize information resources for use by nurses and midwives across the areas of education, research and practice, in facilitating collaboration and partnership for implementing the SDGs.

Who are the target audiences?

The main target audiences are nurses and midwives who are:

• in research, academic institutions and related global health projects and activities;

• in leadership positions engaged in health planning, policy development, practice/service development, workforce

development/management, education programmes and research;

• working in direct health-care service delivery to individual clients and communities – particularly those who work in resource-poor settings in middle- and low-income countries;

• students engaged in global health studies, projects and activities.

Other partners supporting nurses and midwives to deliver on the mandates of UHC and the SDGs are also targeted by this paper.

What is included in the Observer?

This paper includes five areas of focus under sections 3−7. The areas covered are:

• Sexual, reproductive, maternal, newborn, child and adolescent health

• Noncommunicable diseases and mental health

• HIV

• Malaria

• Tuberculosis.

Each area is organized in the following order to reflect the objectives of the Observer:

• What do we know?

• What are the latest global strategies and targets?

• Study examples on research, education and practice.

• What are the implications for action?

Section 2 describes the structure of the next five chapters of this paper as well as the key principles underlying the organization and contents of the subsections. The contents are based on recent policy outcomes and evidence published by WHO, the United Nations and other relevant agencies and institutions.

Principles and activities underlying evidence-based practice

Research is the most advanced approach used to develop, accumulate and validate knowledge, and this is equally relevant to the nursing and midwifery disciplines. Effective research with good outcomes can have a positive impact on decision-making, course of action and patient care outcomes by nurses and midwives (20,21).

There are different ways to apply research evidence to practice;

application of research evidence can be derived from original professional journals, systematic reviews and summaries of such reviews.

Critical thinking underpins the process of translating knowledge into practice to address “know-do” gaps in nursing and midwifery practice (30,31). However, promoting best practice via knowledge translation also requires the education/training of nurses and midwives so that they can adapt new practices into their local context. In addition, strategies such as in-service supervision, mentoring support and support from health-care organizations are needed to sustain the best practice (32,33,34). The levels of engagement in evidence-based practice across individuals and organizations are summarized in Table 2.1.

2 Study approaches

Table 2.1 Levels of engagement in evidence-based practice (EBP)

LEVEL OF

EBP ACTIVITIES CONTRIBUTING TO EBP Individual

nurse • Pay attention to clinical problems from everyday practice.

• Read professional journals regularly and critique research evidence.

• Identify patients’ preferences for change of practice.

• Identify resources to support change.

• Integrate rigorous research evidence to inform decision-making and the course of action for better outcomes of patient care.

Ward/unit/

clinics • Identify clinical problems through quality improvement activities.

• Co-develop EBP guidelines, protocols and procedures with researchers.

• Participate in implementing and evaluating EBP.

Organizational • Build a culture of EBP: mission and vision statement.

• Establish clinical governance to facilitate EBP: a nursing expert group, a patient advisory group and clinical audit.

• Develop and evaluate evidence-based standards, guidelines, protocols and procedures.

Regional • Promote and share EBP among multiple organizations in a region.

National • Promote and share EBP through professional bodies or research networks.

International • Promote and share EBP through international collaboration and research networks, e.g. through evidence-based guidelines/recommendations from WHO (http://www.who.int/en/), the Cochrane Collaboration Library (www.cochrane.org/), the Joanna Briggs Institute (http://joannabriggs.org/) and other organizations.

Source: References (20,21).

Presentation of relevant information

The information in each section highlights the latest information/

statistics on disease morbidity and mortality from published reports and web-based fact sheets from WHO, United Nations agencies and other research institutions. Information and data are kept as brief as possible and are organized in a ready-to-use manner. Readers are advised to refer to the primary documents (particularly WHO’s recommended guidelines) which they find relevant to their local practices and needs.

Presentation of study examples

The studies selected reflect the three areas of education, research, and evidence-based practice. Databases used to search for the literature included Web of Science, PubMed, Science Direct, and WHO library databases for articles and reports published from January 2004 to June 2016. The principles underlying selection included the quality of the case study, representation of countries that experience a higher disease burden and mortality rate, and the implications for action. Selected examples demonstrate how nursing and midwifery practice contributes to research outcomes and how research in turn produces knowledge that helps improve practice and patient care.

The “Practice questions−Evidence−Translation” (PET) model process described by Newhouse et al. was also used to select some case study examples (30). The PET process is as follows:

• Practice questions (or challenges). The nurse/midwife identifies challenges from a clinical setting.

• Evidence. The nurse/midwife searches databases to find research evidence in order to address the challenges. In this phase, the nurse/midwife needs to identify evidence-based guidelines or the best available research evidence, and synthesize research evidence and non-research evidence (such as ethical, personal and aesthetic evidence) in order to identify the best solution. Partnerships with researchers and other academics are encouraged to identify evidence.

• Translation: The nurse/midwife takes action to implement the research evidence in accordance with the local context and evaluates the outcome.

Discussions on implications for action

Discussions on implications for action are based on the following steps: 1) evidence-generation and policy to inform practice;

2) translation of research evidence and policy into practice;

and 3) development of the nursing and midwifery workforce.

Epidemiological data, case study examples, WHO reports and other relevant studies are used to support the discussion. It is anticipated that the discussion will promote reflective thinking and develop ideas and thoughts for improved nursing and midwifery practice.

Sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) is a broad field that covers a wide range of health issues for women and men, directly and indirectly affecting almost all age groups. Information and evidence on ending

preventable child, newborn and maternal mortality are broad and are clearly stated in the MDGs target framework (28).

In line with the Global strategy for women’s and children’s health and Every Woman Every Child, this section mainly focuses on the most vulnerable and hardest-to-reach women and children from the 75

“Countdown” countries where more than 95% of maternal and child deaths occur (35,36). The updated strategy (37) is a follow-up to the version that was created to track, stimulate and support country progress towards MDGs 4 and 5 by 2015. This pivotal strategic document, together with the Global strategy on human resources for health: Workforce 2030, can guide nurses and midwives to work strategically through the SDG era to reinforce the achievements they made in the MDG era in order to improve universal access to sexual and reproductive health services, end preventable maternal mortality, and improve the quality of life of the populations they serve.

What do we know?

The following facts and figures are extracted mainly from recent global health reports. They present an outline of the situational analysis in the field of SRMNCAH. The latest data reveal unmet targets, although substantial progress towards the goals has been made by the international community (28).

3 Sexual, reproductive,

maternal, newborn and

child and adolescent health

Preventable maternal mortality

• Globally, women from the richest 20% of households are still more than twice as likely as those from the poorest 20% to have a skilled attendant at birth. (38).

• Haemorrhage, pre-eclampsia or eclampsia, and infection are leading causes of maternal mortality during the intrapartum and immediate postpartum periods (40).

• The median coverage for maternal health care is at least 75%

(with a lowest range of below 50%) for antenatal care (at least one visit), vitamin A supplementation (two doses), immunization and improved drinking-water sources

Malaria contributing to preventable maternal and child mortality

The information given below is mainly extracted from the 2014 WHO report on The contribution of malaria control to maternal and newborn health (39).

• It is estimated that 10 000 women and up to 200 000 infants die annually in Africa as a result of malaria infection during pregnancy.

• Pregnant women living in malaria-endemic areas show a 1.5 times higher risk of being infected by malaria compared with the opposite group.

• Maternal malaria infection is frequently asymptomatic but is associated with anaemia, low birth weight and stillbirth in areas of high and stable P. falciparum malaria transmission.

• Surviving infants may experience long-term detrimental effects on their lives (e.g. in their development and learning).

• Globally, approximately 11% (100 000) of neonatal deaths are due to low birth weight resulting from P. falciparum infections in pregnancy.

• Malaria prevalence is higher in pregnant women who live in rural areas, are less than 20 years of age, are in their first or second trimester of pregnancy, are HIV-infected, and do not have/use malaria prevention tools, compared with other groups or other situations.

Maternal mortality and HIV

• Sub-Saharan Africa accounted for 6800 (91%) of the estimated 7500 maternal deaths attributed to AIDS worldwide (41).

• The maternal mortality rate attributed to AIDS in sub-Saharan Africa was 546 deaths per 100 000 live births in 2015 (41).

Antenatal care and skilled birth attendance (28)

• In developing regions overall, only 52% of all pregnant women receive the minimum recommended number of four antenatal visits.

• Nearly 40 million babies worldwide (about 31% of live births) are delivered without skilled care.

• The lowest antenatal coverage rate (at least four care visits) in 2011 was in southern Asia (36%) and sub-Saharan Africa (49%).

• Significant disparities in skilled attendance at delivery exist between rural areas (53%) and urban areas (84%). In sub- Saharan Africa and southern Asia, the disparities were larger.

Reproductive and sexual health

The information listed below is taken from WHO’s fact sheet on Sexually transmitted infections (42).

• More than 1 million people acquire a sexually transmitted infection (STI) every day.

• Each year, an estimated 357 million people become ill with one of four STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

• More than 500 million people have the herpes simplex virus 2 (HSV2) that causes genital herpes.

• More than 290 million women have a human papillomavirus (HPV) infection.

• Some STIs can increase the risk of HIV acquisition three-fold or more.

• Drug resistance, especially against gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

• HPV infection causes 528 000 cases of cervical cancer and 266 000 cervical cancer deaths each year.

• STIs can have serious consequences beyond the immediate impact of the infection itself, through mother-to-child transmission of infections and chronic diseases (45).

• Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis and congenital deformities].

• It is estimated that 47 000 deaths and 5 million disabilities each year are attributed to unsafe abortion among the world’s poorest populations (45).

Preventable child mortality among the under-fives

• There were 5.9 million under-five deaths in 2015, almost half of them caused by infectious diseases and conditions such as pneumonia, diarrhoea, malaria, meningitis, tetanus, measles, sepsis and AIDS. (38)

• The neonatal mortality rate was 20 per 1000 live births in 2013 (38).

• A median of only about 50% of mothers in Countdown countries reported early initiation of breastfeeding for their most recent child, and only 41% reported exclusive breastfeeding (35).

• It is estimated that the number of cases of mother-to-child HIV transmission was 17.4 million in 2014(38).

• About half of under-five deaths occur in only five countries:

China, Democratic Republic of Congo, India, Nigeria and Pakistan. India (21%) and Nigeria (13%) together account for more than a third of all under-five deaths (45).

• The poorest 20% of the world’s children are twice as likely as the richest 20% to be stunted by poor nutrition and to die before their fifth birthday (38).

Intimate partner violence and sexual violence against women

The following information is extracted from the WHO fact sheet on Violence against women (43).

• Approximately 35% of women worldwide have experienced either intimate partner violence or non-partner sexual violence in their lifetime.

• Globally, up to 38% of murders of women are committed by an intimate partner.

• Violence can result in physical, mental, sexual and reproductive health problems, and other health problems, and may increase vulnerability to HIV acquisition.

• In high-income settings, there is evidence that school-based programmes to prevent relationship violence among young people (or dating violence) may be effective.

• In low-income settings, primary prevention strategies, such as microfinance combined with gender equality training and community-based initiatives that address gender inequality and communication and relationship skills, hold promise.

• Risk factors for being a perpetrator include low education, exposure to child maltreatment or witnessing violence in the family, harmful use of alcohol, and attitudes that accept violence and gender inequality.

• Risk factors for being a victim of intimate partner and sexual violence include low education, witnessing violence between parents, exposure to abuse during childhood, and attitudes that accept violence and gender inequality.

• Situations of conflict, post-conflict and displacement may exacerbate existing violence and present additional forms of violence against women.

Female genital mutilation (FGM)

The following information is extracted from the WHO fact sheet on Female genital mutilation (44).

• FGM can cause severe bleeding, problems of urination and, later, cysts, infections, complications during childbirth and increased risk of newborn deaths.

• FGM is a violation of the human rights of girls and women.

• More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia where FGM is concentrated.

• An estimated 1–2 extra perinatal deaths per 100 deliveries occur among children born to women who have undergone FGM.

• Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women.

• In Africa, more than 3 million girls have been estimated to be at risk of FGM annually.

Family planning and adolescent childbearing (28)

• In 2015, the prevalence of using some form of contraception was 64% among women who were married or in a union.

• In 2015, 12% of married or in-union women of reproductive age still had unmet needs for contraception to avoid unintended pregnancies.

• Sub-Saharan Africa showed the lowest contraceptive prevalence (only 28%) and the highest unmet needs for family planning.

• In developing countries, modern contraceptive methods including female sterilization and the intrauterine contraceptive device (IUD) were usually used.

• The number of births to women aged 15–19 years was about 56 per 1000 women in developing countries.

• The highest adolescent birth rate (116 births per 1000 girls) is in sub-Saharan Africa and is associated with child marriage and unmet contraceptive needs.

What are the latest global strategies and targets?

WHO strategies focused on ending preventable maternal and child mortality

SRMNCAH sub-goals and targets that need to be achieved by 2030 and set in the SDGs are outlined in Table 3.1. These are based on a recent discussion paper and other relevant documents by WHO (19,40,46).

Table 3.1 Sub-goals and targets in the health-related post-2015 SDGs

SUB-GOALS TARGETS

Reduce the global maternal mortality ratio to less than 70

per 100 000 live births • Reduce the global maternal mortality ratio to less than 70 and no country to have a maternal mortality ratio above 140 per 100 000 live births

• Skilled birth attendance ≥ 80%

End preventable newborn and under-five child deaths • All countries to reduce under-five mortality to less than 25/1000 live births

• All countries reduce neonatal mortality to less than 12 per 1000

• Full immunization coverage/DTP3-containing vaccine ≥ 90, 80% in all districts End the epidemics of HIV/AIDS, TB, malaria and neglected

tropical diseases • Zero new infections among children

Ensure universal access to sexual and reproductive health- care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

• Ensure universal access to sexual and reproductive health-care services

• At least 75% of demand for modern contraceptive satisfied

End all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.

• 40% reduction in the number of children under 5 years who are stunted

• 50% reduction of anaemia in women of reproductive age

• 30% reduction in low birth weight

• no increase in childhood overweight

Source: References (19,40,46).

Table 3.2 WHO guiding principles, cross-cutting actions and strategic objectives for policy and programme planning

GUIDING PRINCIPLES FOR EPMM

• Empower women, girls and communities.

• Protect and support the mother–baby relationship.

• Ensure country ownership, leadership and supportive legal, regulatory and financial frameworks.

• Apply a human rights framework to ensure that high-quality reproductive, maternal and newborn health care is available, accessible and acceptable to all who need it.

CROSS-CUTTING ACTIONS FOR EPMM

• Improve the quality of data measurement systems to ensure that all maternal and newborn deaths are counted.

• Allocate adequate resources and effective health-care financing.

FIVE STRATEGIC OBJECTIVES FOR EPMM

• Address inequities in access to and quality of sexual, reproductive, maternal and newborn health care.

• Ensure universal health coverage for comprehensive sexual, reproductive, maternal and newborn health care.

• Address all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities.

• Strengthen health systems to respond to the needs and priorities of women and girls.

• Ensure accountability to improve quality of care and equity.

Source: Reference (40), p. 9.

WHO guiding principles, cross-cutting actions and strategic objectives for policy and programme planning

Table 3.2 outlines the ultimate goal of ending preventable maternal mortality (EPMM) in three areas for stakeholders’ policy and programme planning (40).

WHO Every Newborn Action Plan

Table 3.3 outlines WHO’s 2015 Every Newborn Action Plan (47).

WHO recommendations on health promotion

interventions for maternal, child and newborn health Table 3.4 outlines the 12 recommendations for the health promotion interventions for maternal, child and newborn health at the community level. These are based on the WHO framework of individuals, families and communities to improve maternal and newborn health and are grounded on a rigorous study (48). The reader should refer to the original document for more details of the recommendation.

Table 3.3 WHO Every Newborn Action Plan GOALS

• Goal 1: Ending preventable newborn deaths: By 2035, all countries will have reached the target of 10 or fewer newborn deaths per 1000 live births and will continue to reduce death and disability, ensuring that no newborn is left behind.

• Goal 2: Ending preventable stillbirths: By 2035, all countries will have reached the target of 10 or fewer stillbirths per 1000 total births and will continue to close equity gaps.

GUIDING PRINCIPLES

• Country leadership

• Human rights

• Integration

• Equity

• Accountability

• Innovation

STRATEGIC OBJECTIVES

• Strengthen and invest in maternal and newborn care during labour, birth and the first day and first week of life.

• Improve the quality of maternal and newborn care.

• Reach every woman and newborn to reduce inequities.

• Harness the power of parents, families and communities.

• Count every newborn through measurement, programme tracking and accountability.

Source: Reference (47), p. 5.

Table 3.4 WHO recommendations on health promotion interventions for maternal and newborn health STRONG RECOMMENDATIONS

• Birth preparedness and complication readiness

• Male involvement interventions for maternal and newborn health

• Partnership with Traditional Birth Attendants (TBAs)

• Provision of culturally appropriate skilled maternity care

• Companion of choice at birth

• Community mobilization through facilitated participatory learning and action cycles with women’s groups

• Community participation in quality-improvement processes

• Community participation in programme planning and implementation CONDITIONAL RECOMMENDATIONS

• Maternity waiting homes

• Community-organized transport schemes RESEARCH RECOMMENDATIONS

• Interventions to promote awareness of human, sexual and reproductive rights and the right to access quality skilled care

• Community participation in maternal death surveillance and response Source: Reference (48).

WHO guidelines/recommendations on maternal, newborn and child health

In addition to the above recommendations, there are other evidence- based guidelines and recommendations on SRMNCAH that Member States may adopt or adapt to their own contexts in order to promote best practice (see Table 3.7). Table 3.5 lists some recent WHO guidelines/recommendations in this regard. The WHO guidelines for the identification and management of substance use and substance use disorders in pregnancy (49) contain 18 recommendations on the management of substance use and its disorders in women and

children. Closely related are the WHO recommendations on prevention and management of tobacco use and second-hand smoke exposure in pregnancy (50). These guidelines, along with several others, help to draw the links between the risk factors for NCDs and how they affect SRMNCAH. Other related background documents and updated guidelines are obtainable on the WHO website.

WHO malaria prevention and control strategies for pregnant women, newborns and children

The main recommendations on improving malaria prevention and

control for pregnant women, newborns and children are outlined in Table 3.6 (63). These approaches are based on research evidence.

Please refer to the original document for more details.

WHO targets for the elimination of mother-to-child transmission of HIV and syphilis (64)

• For HIV, ≤ 50 new paediatric infections per 100 000 live births and a transmission rate of either < 5% in breastfeeding populations or < 2% in non-breastfeeding populations.

• For syphilis, ≤ 50 cases of congenital syphilis per 100 000 live births.

• Coverage of HIV and/or syphilis testing of pregnant women ≥ 95%.

• Antiretroviral treatment coverage of HIV-positive pregnant women

≥ 90%.

• Treatment of syphilis-seropositive pregnant women ≥ 95%.

WHO response to sexually transmitted infections (STIs) (41)

• Scale up effective STI services including: a) STI case

management and counselling, b) syphilis testing and treatment, particularly for pregnant women, and c) hepatitis B and HPV vaccination.

• Promote strategies to enhance the impact of STI prevention, including: a) integrate STI services into existing health systems, b) promote sexual health, c) measure the burden of STIs, and d) monitor and respond to STI antimicrobial resistance.

Table 3.5 Examples of evidence-based guidelines/

recommendations on SRMNCAH

WHO statement on caesarean section rates 2015 (51) WHO recommendations for augmentation of labour 2014 (52) WHO recommendation on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health 2014 (27)

WHO: Guideline: updates on the management of severe acute malnutrition in infants and children 2013 (53)

WHO: Recommendations on child health 2013 (54)

WHO: Recommendations on maternal and perinatal health 2013 (55) WHO Recommendations on newborn health 2013 (56)

WHO: Short-term effects of breastfeeding: a systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality 2013 (57)

WHO recommendations on postnatal care of the mother and newborn 2013 (58)

WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting 2012 (5)

WHO recommendations for the prevention and treatment of postpartum haemorrhage 2012 (59)

WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia 2011 (60)

WHO: Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health 2011 (61) WHO: Standards for improving quality of maternal and newborn care in health facilities (62)

WHO recommendations on prevention and management of tobacco use and second-hand smoke exposure in pregnancy (50)

WHO: Guidelines for the identification and management of substance use and substance use disorders in pregnancy (49)

Table 3.6 Improving malaria prevention and control in pregnant women, newborns and children MAIN RECOMMENDATIONS

• WHO 2012 recommendations: (63) In areas of moderate-to-high malaria transmission, IPTp with SP is recommended for all pregnant women at each scheduled antenatal care visit. WHO recommends a schedule of four antenatal care visits. (1) The first IPTp-SP dose should be administered as early as possible during the second trimester of gestation. (2) Each SP dose should be given at least 1 month apart. (3) The last dose of IPTp with SP can be administered up to the time of delivery, without safety concerns. IPTp diminishes severe maternal anaemia.

• Improved policy and programme coordination between reproductive, maternal, newborn and child health programmes, and other health programmes: For example, integrated laboratory services, integrated procurement/supply chain management, and task-shifting for improving human resources bottlenecks.

• ITN use in pregnancy: This prevention tool reduces miscarriages/stillbirths by one third. ITNs should be delivered to all pregnant women, using both routine antenatal care systems and campaigns to ensure continuous delivery.

• Case management: This care approach reduces the adverse consequences of malaria in pregnancy and can save lives, especially among low-immunity pregnant women with severe, life-threatening malaria.

IPTp = intermittent preventive treatment during pregnancy; SP= sulfadoxine-pyrimethamine; ITN = insecticide-treated mosquito net.

Source: References (39,63).

• Support the development of new technologies for STI prevention such as: a) point-of-care diagnostic tests for STIs, b) additional drugs for gonorrhoea, and c) STI vaccines and other biomedical interventions.

Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines

The evidence-based guidelines include six domains and 38 items (65). Member States are encouraged to strengthen the implementation of the recommendations in accordance with local contexts and needs. Table 3.7 briefly outlines the six domains of the guidelines.

Elimination of female genital mutilation (FGM)

• Prevent health-care providers from performing FGM (66).

• Strengthen the health sector response, with guidelines, training and policy to ensure that health professionals can provide medical care and counselling to girls and women living with FGM (44).

• Increase advocacy by developing publications and advocacy tools for international, regional and local efforts to end FGM within a generation (44).

Study examples on practice, education and research

The selected studies in Table 3.8 help to show how nursing and midwifery contributions in the areas of research, education and practice helped to support country implementation of health programmes towards achieving the MDGs. These studies demonstrate interprofessional collaboration in facilitating the utilization of health services that are socially and culturally congruent for the populations (Example 1). The second example describes the educational impact on health promotion and disease prevention. In this study, interventions to teach the prevention of sexually-related illnesses and diseases to ninth and tenth grade students was more lasting in terms of knowledge gathering and behavioural change when conducted by nurses than it was when conducted by teachers alone. This study highlights the significance of nurses and midwives to disease prevention and health promotion in an important group (adolescents).

Table 3.7 WHO response to intimate partner violence and sexual violence against women RECOMMENDATIONS

1. Women-centred care

2. Identification and care for survivors of intimate partner violence 3. Clinical care for survivors of sexual assault

4. Training of health-care providers on intimate partner violence and sexual assault

5. Health-care policy and provision

6. Mandatory reporting of intimate partner violence Source: Reference (65).

Implications for action

The latest research evidence generated from cross-national and national studies reveals that social determinants affect the utilization of SRMNCAH services for which global disparities in access remain (69,70). Also, women living with HIV, unmarried pregnant women, adolescents and sex workers have been excluded from receiving health services because of stigma, cultural norms and health professionals’ negative attitudes towards these populations (64,71,72). Nurses and midwives in leadership positions should act on the evidence of low rates of skilled birth attendance (70) (including the use of evidence from their local contexts) to advocate for policy changes and resource development in order to meet the SDG target of ≥ 80% skilled birth attendance in all population groups. In a female-dominated workforce and as health professionals, nurses and midwives have great potential through international solidarity to advocate for policy changes to address gaps in their countries.

Nurses and midwives need proactively to take leadership roles in the Countdown countries and champion policy changes to enable the effective coverage (73,74). For instance, advocating for policy changes to establish and regulate midwifery education is necessary to prepare a competent midwifery workforce to deliver effective coverage (14).

Service providers need to adopt/adapt WHO health-care standards to reflect the AAAQ domains. In addition, accreditation and regulation should be established or strengthened for health-care organizations to ensure effective coverage for SRMNCAH.

In rural hospitals in Uganda, a new and advanced practice cadre of nurses, the emergency care practitioners, has been established in order to improve access to emergency care for children and

Table 3.8 Nursing and midwifery studies in SRMNCAH COUNTRIES PROGRAMMES WITH MAJOR COMPONENTS Ethiopia

(practice) (67)

Example 1: The effect of community maternal and newborn health family meetings on the utilization of maternal health care Outcomes:

• Practice questions/challenges: A low level of care-seeking behaviours among pregnant women and family caregivers.

• Evidence/guidelines applied: Adapted from the American College of Nurse-Midwives Home-Based Life Saving Skills programme.

• Implementation:

a) Community maternal and newborn health (CMNH) family meetings are a series of participatory educational meetings that link community-level health workers with pregnant women and family caregivers.

b) The purpose of the CMNH programme was to build skills and care-seeking behaviours among pregnant women and family caregivers.

c) This intervention was implemented in 51 Kebeles (Ethiopia’s smallest administrative units with an approximate population of 2500−5000 each).

d) The CMNH programme used the “train the trainer” model to train health extension workers and their supervisors who subsequently trained their teams.

e) The care team made efforts to identify pregnant women within their community, helped the women register with health extension workers at their local health post and helped them schedule their first antenatal care visit.

f) Women were enrolled in a series of four family meetings during their second or third trimester of pregnancy.

g) The family meeting curriculum covers evidence-based practices to improve maternal and newborn health and survival during the critical birth-to-48-hours period.

• Outcomes:

a) There was a 151% increase in the proportion of care elements that women reported receiving during birth and the early postnatal period over a two-year period.

b) Women who participated in two or more meetings with a family member reported receiving even more complete care than those who participated alone, controlling for sociodemographic characteristics and maternal and newborn health service use.

USA (education) (68)

Example 2: Effectiveness of health education teachers and school nurses teaching STI/HIV prevention knowledge and skills in high school

Purpose of the programme: To test whether facilitator type education (health education classroom teacher versus school nurse) affects the effectiveness of a well-established HIV/STI prevention curriculum called “Be Proud! Be Responsible!”

Components of the programme:

a) HIV prevention curriculum

b) Six interactive sessions, each lasting 50 minutes: group discussions, role model stories depicted in videos, interactive exercises and role-playing

c) Experiential activities included to build skills in negotiation, refusal and condom use d) Educator training recommended.

Participants: Participants included 1357 ninth and tenth grade students in 10 schools in the USA.

Implementation:

a) A group-randomized intervention study design was applied.

b) Twenty-seven facilitators (6 nurses, 21 teachers) provided programming.

c) Nurse-led classrooms were randomly assigned.

d) Pre-tests and post-tests of knowledge, attitude, self-efficiency and intention to change behaviours were used to evaluate the outcomes of the programme.

Outcomes:

a) Students taught by teachers were more likely to report that their instructor was prepared, was comfortable with the material, and challenged them to think about their health than students taught by a school nurse.

b) Both groups reported significant improvements in HIV/STI/condom knowledge immediately following the intervention, compared to controls.

c) Students taught by school nurses reported significant and sustained changes in attitudes, beliefs and efficacy, whereas those taught by health education teachers reported far fewer changes, with sustained improvement in condom knowledge only.

Implications: School nurses are in an ideal position to lead educational programmes to prevent STI/HIV in students.

South Africa (research) (69)

Study 3: Study on factors that have an impact on utilization of maternal health services

• Aim of the study: To determine factors influencing utilization of maternal health services and barriers to utilization of maternal health services.

• Methodology:

a) A mixed methods design using semi-structured household interviews, case studies of women with no antenatal care and/or home birth, and verbal/social autopsies of maternal and infant deaths.

b) By contacting those who did not use maternal health services, the study was able to identify factors that had an impact on the utilization of maternal health services from a user’s perspective.

• Findings:

a) The study reported gaps in skilled birth attendance among three selected communities. For all pregnancies, the skilled birth attendance rate was 89% (range 80−95%) in this sample (n = 178).

b) For women living in rural areas, transport and distance to care were the major barriers in access to maternal health services.

c) The study also revealed that service providers’ poor communication with families was a factor affecting the utilization of maternal health services.

d) First maternal follow-up visit before 6-weeks post-delivery was very low (only 49%, range 18−92%).

e) HIV prevalence was high in these selected communities (prevalence rate 9−47%).