Empower nurses to improve global health: lifting the profile of Nurses and Midwives

Nursing Now is a three-year global nursing campaign run in collaboration with the International Council of Nurses and the World Health Organization. It aims to improve health globally by raising the profile and status of nursing, worldwide – influencing policy makers and supporting nurses to lead and build a global movement. Nursing Now was launched on 28^th Feb 2018 by HRH the Duchess of Cambridge with nurses and health leaders across the world. The Pacific was represented by Ms Elizabeth Iro who recently joined WHO headquarters as Chief Nursing Officer.

Nursing Now is based on the findings of the “Triple Impact” report. The report concluded that as well as improving health globally, empowering nurses would contribute to improved gender equality – as the vast majority of nurses are still women – and build stronger economies. The campaign focuses on five strategic areas:

• Ensuring that nurses and midwives have a more prominent voice in health policy-making;

• Encouraging greater investment in the nursing workforce;

• Recruiting more nurses into leadership positions;

• Conducting research that helps determine where nurses can have the greatest impact; and

• Sharing best nursing practices.

Nurses are at the heart of most health teams, playing a crucial role in health promotion, disease prevention and treatment. As the health professionals who are closest to the community they have a particular role in developing new models of community based care, community engagement and support local efforts to promote health and prevent disease.

The Nursing Now global campaign wants to make sure that all nurses and midwives across the globe, in every role at every level, are skilled and supported to develop and strengthen nursing and midwifery practice, mobilise others and really make change happen. The campaign can be adapted to suit the Pacific environment – an opportunity to raise the profile of Pacific nurses.

For more information, please download background paper

On the early morning of 26^th February a massive earthquake of magnitude 7.5 struck PNG affecting the provinces of Southern Highlands, Hela and Western Highlands. The affected areas are largely mountainous and remote. The earthquake has claimed many lives with more than 50 deaths reported one week after the disaster. The exact numbers of deaths of those buried alive in landslides and rumbles are not known but estimated to have exceed hundreds.
An estimated 275,000 people live within 50km of the epicentre and experience frightening landslides and falling shelter and buildings. Approximately 325,000 people are estimated to have been displaced due to loss of basic needs for shelter, food and water. Immediate needs for survival include shelter, food and water, sanitation and life-saving health services. At least half of health facilities were damaged and became non-functional. Women, infants and children were the most affected as they struggled to get food, water and sanitation. More than 50% of rural health facilities and staffing homes have been flattened and buried under landslides. Some health workers are reported to be suffering from psychological trauma and post disaster depression.
The massive earthquake and destructive landslides caused severe destruction to homes, plantations, infrastructure, buildings, roads and bridges and cut off water and electricity. People were devastated while numerous strong aftershocks continued for at least a further week. Destroyed mining sites and gas plants posed the risks of potential toxic spills.

The government declared PNG in a state of emergency two days later. The last few weeks saw international aid flowing into the two most severely damaged provinces. Emergency responses to save lives were established but many deaths occurred unnoticed. Choppers are the main only means of transport to reach these remote communities. Villagers and communities are frustrated at the slowness of accessing food, water and essential health services. It will take a long time for people to sustain adequate food supplies and return to their usual routines. Outbreaks of food and water-borne diseases are likely to occur, while malnutrition from lack of food will surely affect small children.

Australia and New Zealand sent helicopters and planes to help deliver food, water and medicine to the remote region, where the government and aid agencies have been scrambling to reach villages stranded by landslides and collapsed roads.

A ferocious Tropical Cyclone Gita crashing with fierce winds of up to 260 km/h was the most intense tropical cyclone to impact Tonga since reliable records began.

After experiencing a fearful night, Tonga woke up to see massive destruction to their homes and belongings following Cyclone Gita’s merciless journey. Winds were forceful and roared angrily for many hours overnight. Many described the event as the most frightening experience they have come across. Some families cramped themselves up in small bathrooms as heavy rain and fearless winds bulldozed into their homes. In the middle of the night, brave doctors and nurses transferred patients to safe rooms as water sipped into the wards.

Severe Tropical Cyclone Gita left a trail of destruction – ripped roofs off houses, uprooted large trees, destroyed buildings and homes. Thousands of residents faced prolonged cut off of electricity and water supplies.
In responding to the aftermath of Gita, Tongans have been resilient to pick themselves up and immediately start clean-up operation and restoration within 24hours post cyclone.
There have been no confirmed deaths from the storm, although there were reports of injuries, a few major but mostly minor injuries.

A/Prof Pushpa Nusair of FNU reports on those who recently graduated with Masters and research topics:
1)Ailsa T.Benati (Kiribati)- Research project –A Retrospective audit of trial of Labour after Caesarean Section (TOLAC) cases at Lautoka Hospital (1st January 2015-31^st December 2016)
2) Mairini Rokovunisei (Fiji)-Retrospective Audit of Antenatal Care of Syphilis in Pregnancy at Colonial War Memorial Hospital (January 2015 to January 2017)
3) Nitik Ram-Post Caesarean Section wound Infection at Colonial War Memorial  Hospital ,Suva ,Fiji (1^st January 2016 to 31^st December 2016). RANZCOG Best Student.
4) Byron Fatiaki-Retrospective Audit of Pregnancy complicated by Intrauterine Growth Restriction diagnosed at Lautoka Hospital from January 1^st 2016 to December 31^st 2016
5) Viliame Mataitolu –Outcomes of Women with Hypertension in Pregnancy at Labasa Hospital (1st March 2016 to 28^th February 2017)

PSRH offers ten Research Awards per annum to assist research capacity building in reproductive health in the Pacific region. Each award is to the value of NZ$500 and can be used to develop a larger research proposal or for paying expenses in performing a clinical audit. Where the awards are over-subscribed, priority will be given to projects that have part-funding from another source.
The criteria are:

1. The Principal Investigator (PI) is a financial member of PSRH
2. The PI has ready access to the internet and a computer
3. The project addresses a priority area/service
4. Have the support of the Head of Unit/Ward/Service/Hospital
5. Sound research/audit application and methods
6. A research team (2-7 members) will perform the project with one member having performed research before
7. Take no more than two years to complete
8. Findings to be published in the Pacific Journal of Reproductive Health
9. The application must be typed with referencing where appropriate

Applications on the linked form close 30th March 2018.
 

Every year, there is global advocacy on ending violence against women; 25^th November is recognized as the International Day for the Elimination of Violence against Women and Girls. This day also kicks start the “16 Days of Activism” against Gender-Based Violence up to 10 December, which is globally recognized as “Human Rights Day”.
The 16 Days of Activism provide an excellent opportunity to raise awareness of GBV as a gender and health priority issue. WHO launched a new manual for health managers and policy-makers to strengthen health systems to deliver better quality of care to women who are subjected to violence, “Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers”.
Additional information, including existing resources and materials can also be found at:

• HQ: http://www.who.int/life-course/news/events/2017-intl-day-for-elimination-of-violence-against-women/en/
• WPRO: http://www.wpro.who.int/equity_social_determinants/en/

Pacific Associate Members are invited to apply for the following scholarships offered to Associate Members participating in the RANZCOG Pacific CPD.

• CPD Program ASM Scholarship 2018 to be held in Adelaide, 15-19 September 2018
• Brian Spurrett Fellowship to attend the Anatomy of Complication Workshop, Perth, 19-20 October 2018

Applications close 31 January 2018.
For more information contact Ms Carmel Walker on email:  cwalker@ranzcog.edu.au

 
Dr Susan Tutty
GP Liaison for Women’s Health, Counties Manukau, Auckland, New Zealand
Counties Manukau is responsible for providing women’s health services in the Counties Manuka District Health Board boundary. It covers a population of over half a million and has one of the largest populations of Maaori, Pacific Islanders and Asian communities with relatively rapid population growth and high socio-economic deprived status. Therefore family planning is an essential service for these communities.
Improving access to contraception was highlighted as an important intervention in women’s health, and recommended in perinatal mortality meetings. Despite this, there is little data on women accessing contraception of their choice in Counties Manukau.
In an attempt to estimate planned pregnancy rates, an audit of folic acid use prior to pregnancy was undertaken. It found that only 5% of mothers start folic acid prior to pregnancy. Contraceptive data taken from pharmacies in 2015 suggested that approximately 20% of women in Counties Manukau use some form of contraception, but of that 20% only 8% use long acting reversible contraception (LARC). LARC is now considered first line contraception for all women but its uptake is still low. The Beach Study found that if women seeking contraception were given free access to the contraception of their choice, with no barriers, 67% of women would prefer a LARC.
Unplanned pregnancy: In a survey conducted at Middlemore Hospital, 54% of women reported that their pregnancies were unplanned: 62% of Pacifika women and 88% of Maaori women. Of the 16 women in the survey who were under 21, all of them had not planned their pregnancy. This demonstrates the “unmet need for family planning” and suggests inequities in access to contraception with particular disadvantages for Maaori and Pacifika women and young people.
The effect of poverty: Over half of all births in New Zealand in 2015 were to women living in quintile 4 or 5 neighbourhoods. Maori and Pacifika women are clustered in quintile 4 and 5 as shown in the table below.
 
Thirty seven percent of New Zealand’s Pacific Island people live in Counties Manukau and 76% of the Pacific Islanders of them live in the most socio-economically deprived areas in New Zealand. Pacifika women make up the largest proportion of births (30.6%) at Counties Manukau Health.
The women’s story: The stories of our women, collected from focus groups and freely shared in situations where LARCs are being made available, are incredibly moving and suggest there is a huge unmet need for contraception and for LARCs. Anecdotally, one of our midwives who agreed to help with the insertions of Jadelle on the post-natal ward has become a very strong advocate for LARCs after experiencing the appreciation and relief expressed by women who have received this service.
About LARCs
LARCs are described as “fit-and-forget contraception”, as their failure rate is not user-dependent, which makes them very suitable for the young and for women with busy and complex lives. Once Jadelle is removed the woman returns rapidly to fertility; ideal for spacing children and also for family completion. Jadelle have only been available in New Zealand since August 2010. Not all GPs are confident or skilled in the insertion of LARCs which may influence the options they present to women.
 
Postnatal Contraception
The provision of contraception to women whilst on the post-natal ward is the most cost-effective and convenient service delivery model. However, it is difficult to provide a service to reach all women. Currently, here is only a very limited number of staff doing Jadelle insertions on the postnatal ward with no service on weekends or outside normal working hours. Postnatal tubal ligations are occasionally performed on high needs women but frequently cannot be done due to pressures on theatre time. Immediate postpartum IUDs are currently not being inserted in Counties Manukau.
To accommodate the growing number of women requesting postnatal LARC insertions funding has been made available to primary care facilities for these insertions.  Whilst this is providing a more timely service than the previous referral to a secondary care clinic, there is concern over the high DNA rate of these new mums who already have to manage a new baby in a high needs area.
 
Vasectomy
Counties Manukau Health funds a vasectomy service for partners of post-natal women within 6 months of birth; services for women requesting termination and those requesting tubal ligation. Funding based on other criteria including family size has recently been withdrawn. This funding has provided vasectomies to men from high deprivation areas twice as often as men from low deprivation areas, but the numbers of Maaori or Pacifika men receiving this service are still relatively low.
 
Health Equity Project
Ko Awatea and CM Health have initiated a Health Equity campaign with the vision of reducing health disparities experienced by Maaori and Pacific communities by December 2020.  Women in high deprivation areas, Maaori and Pacific women need to be offered appropriate contraception. This project has removed barriers related to the cost of LARC insertions for women in Otara and is working on understanding other barriers within the GP practices, and build on women’s awareness or experience of LARCs.
A model for change has been introduced as illustrated by the following figure which highlights some of the change ideas being explored.
 
The future
At a recent focus group discussion with Maaori and Pacifika women who had recently given birth, the women surprised us by saying, “why are you working with doctors and the nurses, let us know what is there for us.” This is a challenge to go out into the community; to discuss, to challenge and inform women.  The social, economic and health benefits of LARCs have been clearly documented; these should be recognised politically, and funded nationally. Our women, and particularly our Pacifika women, are missing out on appropriate contraception and resulting in many unplanned pregnancies. It is inequitable and unjust.  All women should be informed about contraception, and have timely access to the contraception of their choice. Planned pregnancy provides the opportunity to optimise healthcare and address issues prior to pregnancy; and to give babies the best possible start in life.
 

(Dr Rufina Latu, WHO Country Office, Port Moresby and a/Prof Pushpa Nusair, Fiji National University)
 The benefits of effective contraception have been well documented and family planning is widely promoted in the last 40 years as an essential intervention for improved maternal health. Studies show that investment in family planning incurs far-reaching health and economic gains at individual, community and national levels. However, despite global movements to step up the family planning agenda and increase access to service, contraceptive use is still low among Pacific island countries.
The concept of unmet need for family planning is not well understood by many service providers. It is defined as the proportions of women of reproductive age, either married or fecund (productive), who desire to delay childbearing or wish to stop having further children, but are not using an effective method of contraception. An unmet need points to the gap between a woman’s child-bearing intentions and contraceptive use.
Quite often, a health worker sees cases of unmet need. For instance, a mother becomes pregnant again when her baby is only six months old – this demonstrates an unmet need; similarly, when a 17-year-old student becomes pregnant; a 36 year-old mother enters her 7^th pregnancy; or a 44 year-old mother becomes pregnant again ten years after her last delivery. We are too familiar with these kinds of cases of unmet need and yet we don’t put enough emphasis and actions to prevent them.
The level of unmet need for contraception remains high. Today, 214 million women in developing countries globally want to avoid pregnancy but are not using a modern method of contraception. This number has dropped by 10m during the last three years due to global movements in family planning. Among Pacific island countries, the unmet need ranges from 20% to as high as 50%.  Various studies show that nearly half of women attending antenatal clinics had not intended to get pregnant.
The unmet need is especially high among particular groups such as adolescents, single mothers, urban settlement dwellers, refugees, older women with many children, women in the postpartum period, and those living in remote communities with poor access to health services.
The reasons for not using contraception can be a combination of various factors, including: not knowing about contraception, a perceived low risk of getting pregnant, lack of motivation, limited access to contraception inconvenience in seeking and receiving services, concerns about side-effects, cultural or religious opposition, providers’ bias and attitudes, gender-based barriers, cost to users, and concerns about social acceptability especially among young and/or unmarried people. For decades we continue to live with this list of familiar reasons, and unfortunately, there is a general tendency to accept them as the norm without finding practical solutions to address them. Consequently, the unmet need for family planning propagates among communities, resulting in more unplanned pregnancies, and subjecting more women and families to various levels of disadvantaged socio-economic circumstances and hardships.
It is a social responsibility for couples to plan the desired number of children they wish to have, and to determine the spacing between them. It is also a human right for a woman to choose if and when to become pregnant. Family planning has a direct impact on securing the well-being and autonomy of women, and has far-reaching benefits on the health and development of families and communities.
Family planning allows delaying pregnancies, spacing of pregnancies, and completing the size of families at the desired time. Evidence suggests that women who have more than 4 children are at more risk of life threatening maternal complications than those with fewer children. This also holds true for pregnancies among younger women under age 18 and those with short birthing intervals of less than two years.
The vicious cycle of events contributing to unmet need for family planning has to be interrupted if we are to gain the full health and socio-economic benefits of contraception. This involves taking pragmatic steps to get non-users to become dedicated contraceptive users. Effective contraception must be an essential part of basic healthy living.
The message is clear – we need to reduce the unmet needs for family planning. The unmet need declines as more non-users become users.  Women and their partners should be empowered to use effective contraception. We need to return to basics – make family planning simple, practical and essential, provide client-friendly services, remove unnecessary barriers, and make every contact with health care a golden opportunity to talk about contraceptive needs.