1. Dr Tavares Madede, University of Eduardo Mondlane, Mozambique & HSSE team Supported by: Irish Aid & Ministry of Foreign Affairs, Denmark UNIVERSITY EDUARDO MONDLANE Faculty of Medicine

2. Centre for Global Health, University of Dublin, Trinity College, Dublin (Eilish McAuliffe, Susan Bradley) Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, USA (Lynn Freedman (Helen de Pinho, Samantha Lobis, Rachel Waxman and Sang Hee Won) Realizing Rights: the Ethical Globalization Initiative, USA ( Mary Robinson, Peggy Clark, Ibadat Dhillon, Naoko Otani) Regional Prevention of Maternal Mortality network, Accra, Ghana (Angela Sawyer, Dora Shehu) Ifakara Health Institute, Mikocheni, Dar Es Salaam, Tanzania (Godfrey Mbaruku, Honorati Masanja, Tumaini Mikindo, Neema Wilson, Debby Wason, Abdallah Mkopi, Aloisia Shemdoe) University of Malawi, College of Medicine, Centre for Reproductive Health, Malawi (Francis Kamwendo, Mwizapanyuma Simkonda, Wanangwa Chimwaza, Andrew Ngwira, Effie Chipeta, Linda Kalilani) Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Mozambique (Mohsin Sidat, Maria de Fatima Cuembelo, Sozinho Daniel Ndima)

3. Expand the evidence base in support of effective use of mid-level health workers within an enabling environment through the generation of new evidence and a critical analysis of existing evidence; Increase recognition and effective use of mid-level health workers among national, regional, and global policymakers to address the human resources crisis in district health systems based on project evidence;

4. High levels of maternal and infant mortality in sub-Saharan Africa  proportion of global maternal deaths in sub-Saharan Africa increased from 23% (18–27) in 1980 to 52% (45–59) in 2008 Lack of human resources for healthcare plays a key role  Malawi vacancy rates - 77% for specialist doctors, 45% for medical officers, 80% for nursing officers, 44% for nursing sisters. Evidence for clinical efficacy, economic value of mid-level cadres  Fenton et al. (2003), N = 7622 caesarean sections  Clinical officers vs Qualified doctors in Malawi - emergency caesarean section maternal death rate of 1·3% (.6% for qualified doctor), perinatal deaths 8% vs 13% - non sig (statistically)

5. Hongoro & McPake (2004): Main conclusions: The “… expansion of the numbers and roles of auxiliaries whose qualifications are not internationally recognised seems to be a quiet success story, providing large numbers of health workers who keep the system running in a number of countries. Much more needs to be documented about the parts played by these workers and their safety in different areas.” “…the human resource management function needs to be substantially upgraded in the public sector as a whole, and specifically the health sector.” In resource poor countries what factors contribute to job dissatisfaction and demotivation, which negatively impacts outcomes such as worker productivity and retention of staff ?

6. Health professionals clinically trained to perform the tasks of doctors (NPCs). Existent evidence show that: Provide quality of care comparable to a doctor Cost to train by far less than a doctor Takes only 3 years to train More likely to retain in rural settings Include nurses and nurse mid-wifes

7. Mixed Methods approach 2065 healthcare providers from 286 facilities were surveyed. Nurses, nurse mid-wives and non-physician clinicians comprised 75% of respondents (N=1,552)

8. They are comprised by 9 functions divided into two subgroups: Basic EmOC services Comprehensive EmOC services

9. Basic EmOC services: 1. Administer parenteral antibiotics 2. Administer uterotonic drugs 3. Administer parenteral anticonvulsivants for pre- eclampsia and eclampsia 4. Perform manual removal of placenta 5. Perform removal of retained products 6. Perform assisted vaginal delivery 7. Perform neonatal resuscitation

10. Comprehensive EmOC services (1 – 7 plus the following): 8) Perform surgery 9) Perform blood transfusion

11. The functions are provided by a wide range of health care providers, with: Over 75% of nurses and nurse-midwifes providing at least four of the basic services – administering parenteral antibiotics, uterotonics and anticunvulsivants, as well as neonatal resuscitation Around 60% of NPCs providing all comprehensive services

12. High reported performance of c-section across countries Over 85% of clinical officers in Malawi and assistant medical officers in Tanzania performed c-sections 100% of tecnicos and high level nurses performed c- sections in Mozambique. Those not performing c-sections were mainly working in health centres where surgery is not performed.

13. CadresAssisted vaginal delivery Removal of retained products Manual removal of placenta Nurse-midwife technicians (n=262) 14%13%39% Enrolled nurse- midwives (n=133) 14%17%41% Registered nurse-midwives (n=54) 67%22%56% Clinical officers (n=136) 88%93%85%

14. CadresAssisted vaginal delivery Removal of retained products Manual removal of placenta Enrolled midwives (n=247) 27%39%51% Registered nurses (n=150) 24%33%48% Registered midwives (n=20) 30%50%45% Assistant medical officers (n=68) 60%87%82%

15. CadresAssisted vaginal delivery Removal of retained products Manual removal of placenta Nurse elementary (n=130) 34%56%67% Nurse basic level (n=223) 51%79%68% Nurse middle level (n=107) 73%85%72% Nurse high level officers (n=6) 83%100%83% Tecnicos de cirurgias (n=17) 76%94%88%

17. Assisted vaginal delivery (AVD) was the signal function that was least likely to be performed in all three countries. AVD is performed mainly by NPCs and higher level nurses. These staff work mainly in hospitals rather than health centres, thus limiting the availability of this function. In Tanzania, performance of AVD is low among all cadres

18. Countries should focus on ensuring the equitable distribution, availability, and accessibility of facilities and skilled health providers who can provide effective EmOC. Policy makers and professional associations should advocate for increased global recognition on the effective use of MLPs to increase access to EmOC and reduce maternal mortality. Further research to assess why key signal functions like AVD are not being performed.

19. HSSE Team: * AMDD, Mailman School of Public Health, Columbia University, USA * Centre for Global Health, Trinity College, University of Dublin * Centre for Reproductive Health, College of Medicine, Malawi * Dept. of Community Health, Eduardo Mondlane University, Mozambique * Ifakara Health Institute, Tanzania * Realizing Rights: Ethical Globalization Initiative, USA * Regional Prevention of Maternal Mortality Network, Ghana Funders: * IrishAid & Ministry of Foreign Affairs, Denmark