The development of a global Midwifery Education Accreditation Programme.

BACKGROUND: Many countries are responding to the global shortage of midwives by increasing the student intake to their midwifery schools. At the same time, attention must be paid to the quality of education being provided, so that quality of midwifery care can be assured. Methods of assuring quality of education include accreditation schemes, but capacity to implement such schemes is weak in many countries. OBJECTIVE: This paper describes the process of developing and pilot testing the International Confederation of Midwives' Midwifery Education Accreditation Programme (ICM MEAP), based on global standards for midwifery education, and discusses the potential contribution it can make to building capacity and improving quality of care for mothers and their newborns. METHODS: A review of relevant global, regional and national standards and tools informed the development of a set of assessment criteria (which was validated during an international consultation exercise) and a process for applying these criteria to midwifery schools. The process was pilot tested in two countries: Comoros and Trinidad and Tobago. RESULTS: The assessment criteria and accreditation process were found to be appropriate in both country contexts, but both were refined after the pilot to make them more user-friendly. CONCLUSION: The ICM MEAP has the potential to contribute to improving health outcomes for women and newborns by building institutional capacity for the provision of high-quality midwifery education and thus improved quality of midwifery care, via improved accountability for the quality of midwifery education.

The Midwifery Services Framework: Lessons learned from the initial stages of implementation in six countries.

In 2015, the International Confederation of Midwives (ICM) launched the Midwifery Services Framework (MSF): an evidence-based tool to guide countries through the process of improving their sexual, reproductive, maternal and newborn health services through strengthening and developing the midwifery workforce. The MSF is aligned with key global architecture for sexual, reproductive, maternal and newborn health and human resources for health. This third in a series of three papers describes the experience of starting to implement the MSF in the first six countries that requested ICM support to adopt the tool, and the lessons learned during these early stages of implementation. The early adopting countries selected a variety of priority work areas, but nearly all highlighted the importance of improving the attractiveness of midwifery as a career so as to improve attraction and retention, and several saw the need for improvements to midwifery regulation, pre-service education, availability and/or accessibility of midwives. Key lessons from the early stages of implementation include the need to ensure a broad range of stakeholder involvement from the outset and the need for an in-country lead organisation to maintain the momentum of implementation even when there are changes in political leadership, security concerns or other barriers to progress.

Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda.

BACKGROUND: In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce. METHODS: The State of the World's Midwifery report 2014 used a broad definition of midwifery ("the health services and health workforce needed to support and care for women and newborns") and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework. RESULTS: Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation. CONCLUSIONS: The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued.

The Midwifery Services Framework: The process of implementation.

In 2015, the International Confederation of Midwives launched the Midwifery Services Framework: a new evidence-based tool to guide countries through the process of improving their sexual, reproductive, maternal and newborn health services through strengthening and developing the midwifery workforce. The Midwifery Services Framework is aligned with key global architecture for sexual, reproductive, maternal and newborn health and human resources for health, and with the recommendations of the 2014 Lancet Series on Midwifery. This second in a series of three papers describes the process of implementing the Midwifery Services Framework: the preparatory work, what happens at each stage of implementation and who should be involved at each stage. It gives an idea of the scale of the task, and the resources that will be required to implement the Midwifery Services Framework in a given country context. The paper will be of interest to health policy-makers, development partners and professional associations in countries considering different approaches to strengthening their sexual, reproductive, maternal and newborn health services, and it will help them to decide whether and when either full or partial/staged implementation of the Midwifery Services Framework will be an appropriate initiative to address identified deficits in their specific context, given the current and projected availability of resources.

The Midwifery services framework: What is it, and why is it needed?

Most low- and middle-income countries failed to meet the Millennium Development Goal targets for maternal, newborn and child health, and even more ambitious targets have been set under the Sustainable Development Goals and the Ending Preventable Maternal Mortality initiative. This means that many countries will need to accelerate progress on sexual, reproductive, maternal and newborn health over the next few years. Recent years have seen the publication of a large and convincing body of evidence about the potential of midwifery to make a significant contribution to this acceleration, but little practical guidance has emerged to help countries invest in midwifery services so that their health systems can meet the increasing need for sexual, reproductive, maternal and newborn health care. To help fill this gap, the International Confederation of Midwives designed and launched the Midwifery Services Framework, a new tool to guide countries through the process of strengthening and developing their midwifery services. This first of a series of three papers introduces the MSF, explains why it is needed, how it was developed, its guiding principles and its anticipated outcomes and impact. The other two papers explain the process of implementing the Midwifery Services Framework, and lessons learned in the first countries to start implementation.

Successful implementation of Helping Babies Survive and Helping Mothers Survive programs-An Utstein formula for newborn and maternal survival.

Globally, the burden of deaths and illness is still unacceptably high at the day of birth. Annually, approximately 300.000 women die related to childbirth, 2.7 million babies die within their first month of life, and 2.6 million babies are stillborn. Many of these fatalities could be avoided by basic, but prompt care, if birth attendants around the world had the necessary skills and competencies to manage life-threatening complications around the time of birth. Thus, the innovative Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) programs emerged to meet the need for more practical, low-cost, and low-tech simulation-based training. This paper provides users of HBS and HMS programs a 10-point list of key implementation steps to create sustained impact, leading to increased survival of mothers and babies. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts within the field, and can be used as a means to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment.

A descriptive analysis of midwifery education, regulation and association in 73 countries: the baseline for a post-2015 pathway.

BACKGROUND: Education, regulation and association (ERA) are the supporting pillars of an enabling environment for midwives to provide quality care. This study explores these three pillars in the 73 low- and middle-income countries who participated in the State of the World's Midwifery (SoWMy) 2014 report. It also examines the progress made since the previous report in 2011. METHODS: A self-completion questionnaire collected quantitative and qualitative data on ERA characteristics and organisation in the 73 countries. The countries were grouped according to World Health Organization (WHO) regions. A descriptive analysis was conducted. RESULTS: In 82% of the participating countries, the minimum education level requirement to start midwifery training was grade 12 or above. The average length of training was higher for direct-entry programmes at 3.1 years than for post-nursing/healthcare provider programmes at 1.9 years. The median number of supervised births that must be conducted before graduation was 33 (range 0 to 240). Fewer than half of the countries had legislation recognising midwifery as an independent profession. This legislation was particularly lacking in the Western Pacific and South-East Asia regions. In most (90%) of the participating countries, governments were reported to have a regulatory role, but some reported challenges to the role being performed effectively. Professional associations were widely available to midwives in all regions although not all were exclusive to midwives. CONCLUSIONS: Compared with the 2011 SoWMy report, there is evidence of increasing effort in low- and middle-income countries to improve midwifery education, to strengthen the profession and to follow international ERA standards and guidelines. However, not all elements are being implemented equally; some variability persists between and within regions. The education pillar showed more systematic improvement in the type of programme and length of training. The reinforcement of regulation through the development of legislation for midwifery, a recognised definition and the strengthening of midwives' associations would benefit the development of other ERA elements and the profession generally.

Midwifery 2030: a woman's pathway to health. What does this mean?

The 2014 State of the World's Midwifery report included a new framework for the provision of woman-centred sexual, reproductive, maternal, newborn and adolescent health care, known as the Midwifery2030 Pathway. The Pathway was designed to apply in all settings (high-, middle- and low-income countries, and in any type of health system). In this paper, we describe the process of developing the Midwifery2030 Pathway and explain the meaning of its different components, with a view to assisting countries with its implementation. The Pathway was developed by a process of consultation with an international group of midwifery experts. It considers four stages of a woman's reproductive life: (1) pre-pregnancy, (2) pregnancy, (3) labour and birth, and (4) postnatal, and describes the care that women and adolescents need at each stage. Underpinning these four stages are ten foundations, which describe the systems, services, workforce and information that need to be in place in order to turn the Pathway from a vision into a reality. These foundations include: the policy and working environment in which the midwifery workforce operates, the effective coverage of sexual, reproductive, maternal, newborn and adolescent services (i.e. going beyond availability and ensuring accessibility, acceptability and high quality), financing mechanisms, collaboration between different sectors and different levels of the health system, a focus on primary care nested within a functional referral system when needed, pre- and in-service education for the workforce, effective regulation of midwifery and strengthened leadership from professional associations. Strengthening of all of these foundations will enable countries to turn the Pathway from a vision into reality.

Case report: massive postpartum transfusion of Jr(a+) red cells in the presence of anti-Jra.

Jr(a) is a high-prevalence antigen. The rare Jr(a-) individuals can form anti-Jr(a) after exposure to the Jr(a) antigen through transfusion or pregnancy. The clinical significance of anti-Jr(a) is not well established. This study reports a case of a 31-year-old woman with a previously identified anti-Jr(a) who required massive transfusion of RBCs after developing life-threatening postpartum disseminated intravascular coagulopathy. Despite the emergent transfusion of 15 units of Jr(a) untested RBCs, she did not develop laboratory or clinical evidence of acute hemolysis. The patient's anti-Jr(a) had a pretransfusion titer of 4 and a monocyte monolayer assay (MMA) reactivity of 68.5% (reactivity > 5% is considered capable of shortening the survival of incompatible RBCs). The titer increased fourfold to 64 and the MMA reactivity was 72.5% on Day 10 posttransfusion. Review of laboratory data showed evidence of a mild delayed hemolytic transfusion reaction by Day 10 posttransfusion. Despite rare reports of hemolytic transfusion reactions due to anti-Jr(a) in the literature, most cases, including this one, report that this antibody is clinically insignificant or causes only mild delayed hemolysis. Clinicians should be advised to balance the risks of withholding transfusion with the small chance of significant hemolysis after transfusion of Jr(a+) RBCs in the presence of anti-Jr(a).

Prevention of immunization to D+ red blood cells with red blood cell exchange and intravenous Rh immune globulin.

BACKGROUND: Although young women who are D- occasionally receive unintentional transfusions with D+ red blood cells (RBCs), there are little data to assist with management of such an event. Two cases of D- girls transfused with D+ RBCs are reported. In an effort to prevent formation of anti-D, RBC exchange followed by administration of intravenous (IV) Rh immune globulin (RhIg) was used. CASE REPORTS: Patient 1, a 56-kg, 16-year-old D- girl, was involved in a motor vehicle crash. She received 4 units of Group O uncrossmatched D+ RBCs. Thirty-six hours after admission, she underwent RBC exchange with 10 units of D- RBCs, followed by a total of 2718 microg of IV RhIg over 32 hours. Six months later, her antibody screen was negative. Patient 2, a 39-kg, 10-year-old D- girl with aplastic anemia, received 1 unit of D+ RBCs. She underwent RBC exchange on the same day with 5 units of D- RBCs, followed by a total of 900 microg of IV RhIg over 8 hours. Six months later her antibody screen was negative. CONCLUSION: RBC exchange followed by a calculated dose of IV RhIg was successful in preventing allo-immunization to D. Several small studies suggest that both trauma and hematology patients may be less capable of becoming immunized with the transfusion of D+ blood components. Until these findings are more clearly defined, there will be times when prevention of immunization of any D- girl is desired. RBC exchange followed by RhIg appears to be one way to achieve this goal.

[The antimutagenic activity of biomass extracts from the cultured cells of medicinal plants in the Ames test]. / Doslizhzhennia antymutahennoï aktyvnosti ekstraktiv iz biomasy kul'tyvovanykh klityn deiakykh likars'kykh roslyn u testi Eimsa.

Antimutagenic activity of 20 and 40% ethanol extracts from the biomass of Rhodiola rosea, Polyscias filicifolia, Panax ginseng and Ungernia victoris cultured cells have been studied. DDDTDP, ethidium bromide, benz(a)pyrene, benzidine served as model mutagens for Salmonella typhimurium TA 98 strain (the latter two were tested in presence of metabolic activation system); for S. typhimurium TA 100 strain these were tio-tefa, bichromate potassium and sodium azide and heavy metal compounds (chlorides of manganese, zinc, cadmium, lead acetate) for both strains. Higher capacity of the extracts from the biomass of R. rosea and P. filicifolia to counteract gene mutations induced by various mutagens was demonstrated (ca. 90% inhibition in isolated cases). In the experiment with the metabolic activation most effective proved to be the extracts from the P. ginseng biomass (up to 34% and 47% mutagenicity inhibition).

Calciphylaxis mimicking dermatomyositis: ischemic myopathy complicating renal failure.

BACKGROUND: Among the complications of chronic renal failure is a syndrome of medial calcification of small- to medium-sized arteries associated with ischemic necrosis of the skin and other organ systems, leading to gangrene and a poor prognosis. The syndrome has been reviewed in the renal, dermatologic, and surgical literature under the term calciphylaxis, which describes a postulated pathogenetic mechanism whereby sensitization to an endogenous or exogenous substance (such as parathyroid hormone) predisposes to calcium deposition after exposure to a challenging agent. Myopathy has rarely been reported as the presenting feature, and the syndrome has not been discussed in the neurologic literature. METHODS: We report two patients with renal failure and systemic calciphylaxis who presented to our hospital with myopathic complaints and signs suggesting dermatomyositis. We also discuss possible disease mechanisms and treatment. CONCLUSIONS: Because early treatment (including aggressively lowering the calcium and phosphate levels and parathyroidectomy) may improve the outcome, early recognition of the syndrome of calciphylaxis is essential.

P-glycoprotein expression in cartilaginous tumors.

BACKGROUND AND OBJECTIVES: Malignant cartilage tumors demonstrate chemotherapeutic resistance through undetermined mechanisms. P-glycoprotein is the protein product of the multiple drug resistance gene 1 (MDR-1) and confers multidrug chemotherapeutic resistance in a variety of malignancies. METHODS: MDR-1 expression was examined in 55 benign and malignant cartilage tumor specimens by immunohistochemistry using C219, C494, and JSB-1 antibodies, and by in situ hybridization with an MDR-1 specific oligonucleotide cDNA probe. RESULTS: Constitutive expression of P-glycoprotein was observed in all benign and malignant cartilage tumor specimens with a similar pattern of immunohistochemical staining present with all three antibodies. In benign tumors and low grade chondrosarcomas, the staining pattern was weak to intermediate and localized to clusters of cells. However, higher grade-tumors (Grade II and III) expressed P-glycoprotein in a higher percentage of cells and with more intense staining. P-glycoprotein expression was absent in normal human articular cartilage, but was focally present in costal and growth plate cartilage. The immunohistochemistry results were confirmed by in situ hybridization in 10 cases. CONCLUSIONS: P-glycoprotein is expressed constitutively in cartilaginous tumors, with greatest expression in high grade malignancies. The findings may account for the resistance of cartilage tumors to chemotherapeutic agents.

Prediction of steady-state trough serum procainamide concentrations after administration of a sustained-release procainamide preparation.

Four methods of predicting steady-state trough serum procainamide concentrations (SPC) were compared in 15 patients receiving sustained-release procainamide (Procan-SR) therapy. All methods were based on a one-compartment pharmacokinetic model. Method 1 utilized nine initial measured SPC and individualized pharmacokinetic parameters for prediction of the steady-state SPC. Method 2 utilized three SPC and individualized pharmacokinetic parameters. Method 3 utilized two SPC and an individualized apparent elimination rate constant plus other average pharmacokinetic parameters. Method 4 utilized all averaged pharmacokinetic parameters (required no initial SPC). The predicted and measured SPCs for each method were analyzed by linear regression. Regression equations and correlation coefficients (r) for Methods 1, 2, 3, and 4 were as follows: predicted SPC = 0.72 measured SPC + 1.60 (r = 0.86), predicted SPC = 0.67 measured SPC + 1.74 (r = 0.82), predicted SPC = 0.13 measured SPC + 2.57 (r = 0.58), and predicted SPC = 0.15 measured SPC + 2.47 (r = 0.52), respectively. The precision, as measured by the mean squared prediction error (95% confidence interval) for Methods 1, 2, 3, and 4 was 1.44 (0.61, 2.27), 1.75 (0.93, 2.57), 2.81 (1.3, 4.49), and 3.68 (1.12, 6.26), respectively. (Eighty-five percent of the predictions were within +/- 1.5 micrograms/ml of the measured SPC by Methods 1 and 2, as compared with 69% by Methods 3 and 4.) Bias, as measured by the mean prediction error (95% confidence interval) for Methods 1, 2, 3, and 4 were -0.44 (-0.90, 0.03), -0.34 (-0.87, 0.18), -0.43 (-1.09, 0.24), and -0.98 (-1.66, -0.31).(ABSTRACT TRUNCATED AT 250 WORDS)