In 1989, the American College of Nurse-Midwives (ACNM), in collaboration with the Government of Ghana, conducted two maternal mortality studies in the Greater Accra Region. Based on the results of these studies, the ACNM began providing assistance to Ghana on the development of a program for updating and expanding the skills of public and private-sector midwives with the goal of reducing the high infant and maternal mortality in the country. This program focused on training a core of midwife-trainers in life saving skills (LSS) and the development of a ten-module training package that came to be known as the Life Saving Skills Manual for Midwives (LSS Manual). ACNM's approach was to provide didactic training in critical knowledge, along with intensive on-the-job, competency-based clinical experience in specific interventions aimed at preventing or minimizing the mortality and morbidity associated with the major causes of maternal death and neonatal death.
In developing countries, 81% of maternal mortality is from direct causes: hemorrhage, sepsis, unsafe abortion, pregnancy induced hypertension and obstructed labor. Globally, 77% of neonatal death is from direct causes. Most of these deaths are preventable through quality maternity care, improved nutrition, family planning, access to postabortion care, available transportation and communication, rapid and safe blood services, improved education for women and girls, and improved status of women within the culture.
The LSS manual and training program encourages an expanded role for the midwife in recognizing and responding to life-threatening emergencies. The ten modules include Introduction to Maternal Mortality; Quality Antenatal Care; Monitoring Labor Progress; Episiotomies and Repair of Lacerations; Prevention and Treatment of Hemorrhage; Resuscitation (adult and infant); Prevention and Management of Sepsis (adult and infant); Hydration and Rehydration; Vacuum Extraction; Other Emergencies (labor and delivery problems, postabortion care, LSS Formulary). The manual addresses problem solving using a history and physical examination, problem identification and appropriate action, and referral with stabilization and transportation. Principals of infection prevention and the prevention of maternal-child transmission of HIV are incorporated throughout. The emphasis is on clinical practice with as much experience as it takes for each individual trainee to become competent. Class demonstrations and discussions are held near the clinical area so that participants are on hand when a laboring woman presents with a condition that requires the clinical management skills being learned. The process for implementing and sustaining an LSS program is presented in the LSS Manual for Policy Makers and Trainers.
Since 1989, trainers in more than 30 countries-including Ghana, Nigeria, Uganda, Indonesia, Vietnam, Eritrea, Tajikistan, Malawi, Zambia, Ethiopia, Tanzania, and Honduras-have helped midwives and doctors gain proficiency in life saving skills. The curriculum has been translated into French, Spanish, Vietnamese, Bahasa Indonesia, and Russian. The Life-Saving Skills Manual for Midwives is also used in continuing education programs for experienced midwives and other skilled providers, to strengthen pre-service training for midwifery students and incorporated into basic training programs which can be run by ministries of health, schools of education, or midwifery associations. Midwives and other skilled providers of maternity care assume the major \responsibility for the training of their peers. As adult learners, the trainers and trainees have much to share with one another. Midwives and other skilled providers tend to be realistic about their resources and knowledgeable about their own culture and community. Competency based training focuses on the individual trainee. The LSS trainer provides guidance, support and the opportunities for practice an individual trainee needs to perform each critical life saving skill correctly and confidently. A variety of teaching methodologies are utilized in the classroom and an equal amount of time is spent in the clinical area. Class size is determined by the number of clinical opportunities available in a particular facility and the number of trainees a trainer can realistically observe, evaluate and coach in the clinical area.
ACNM staff and consultants have trained nurse-midwives, midwives, physicians and other maternal/neonatal health care providers in safe delivery practices and the management of complications; assisted in policy development; developed pre-service and in-service training programs; developed standards and protocols; conducted research on maternal mortality; strengthened sister midwifery associations in developing countries; and helped institutionalize improved maternal and child health practices, including family planning, HIV/STI prevention and other aspects of reproductive health care. The direct result of this work has been expanded capacity for midwives and nurse-midwives in developing countries to provide safe and satisfying care, to reduce maternal and neonatal deaths, and to increase the public health impact of nurse-midwives and midwives in Africa, Asia, Latin America, Eurasia.
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