ACNM Global Work Adapting to COVID-19 Pandemic

The Accessible Continuum of Care and Essential Services (ACCESS) program targets improvements in health care for mothers, babies, and children in Madagascar as part of the work of the Global Health Team of ACNM. ACNM partners with the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) to provide technical assistance to the medical supervisors and clinicians in Madagascar.

ACCESS is an innovative, multifaceted, collaborative project. The program uses specific health indicators for each district and region and the needs of clinicians to guide training and improvements in the healthcare systems of basic clinics and district and regional hospitals.

The emphasis is on adult learning and involves intensive follow-up by supervisors and directors, who are doctors and midwives themselves, often with years of administrative and leadership experience. They encourage clinicians to self-identify skill and knowledge deficits, and then help them tailor those skills and didactic knowledge training, using interactive methodologies and technology. 

In November 2019, in conjunction with the local team, representatives from ACNM, ACOG, and AAP participated in introductory trainings in Tulear and Antananarivo, Madagascar with four groups of doctors and midwives, to discuss how to improve the health of Malagasy mothers, neonates, and children under five. Visits to Madagascar to work closely with the national team were planned for three to four times yearly.

However, the global COVID-19 pandemic has changed the course of the ACCESS program. Travel is restricted. Supervisors work from home, counting on unreliable internet connections to do their jobs. The need for ACNM and its partners to adapt came swiftly.

For ACNM, there are two main foci: Tele-mentoring and ACCESS University. 

Like most global health programs, ACCESS relies on face-to-face interactions and visits to the field to fulfill its objectives. The COVID-19 pandemic has changed the communication, trainings, and support that have been integral to international health programs.

Global health trainings are context specific. As trainers who must have “cultural competency,” we rely on personal observations, cultural subtleties expressed in body language, and facial expressions to tailor our presentations, personal interactions, and learning approaches. 

On site, communication is central to how and whether one connects personally with the national staff.  Tele-communication has changed our communication techniques. We have learned to be more sensitive to tone of voice, word phrasing, and group dynamics – which exist even via Zoom.

Tele-mentoring

To reinforce clinical capacity and capitalize on the enthusiasm and motivation from the November trainings, in December the ACCESS program began a monthly tele-mentoring series. Given the new shelter-in-place orders, this tele-mentoring has become an integral part of the work of the technical advisors. Attendance in the online sessions by ACCESS staff has increased seven-fold from December to April, which saw 61 participants. This has served as a good example of adaptation to distance learning.

Each month, a district in Madagascar selects a case relevant to the topics identified by medical indicators as most crucial to the health of mothers and children. The case is real, not theoretical; thus, it generates interest and a serious approach to analyzing solutions to gaps or barriers to care. In April, the case was of a pregnant 14-year-old who comes alone to the clinic for her first prenatal visit with a history of unknown menstrual period and fever. Her pregnancy determined by fundal height is in the third trimester and she has acute malaria. 

The key discussion points were treatment of malaria in pregnancy, risks of pregnancy for very young adolescents, social supports, barriers to contraceptive use in adolescents, and sexual violence. The discussion was animated, with facilitation shared by ACNM and the district supervisor that selected the case.

Active participation has increased with each session as participants become accustomed to the organization of the sessions and the expectation that they are interactive. As is often the case in group meetings, there are those who speak a lot and others who prefer to share answers and ask questions through the Chat Box.

ACCESS U

In conjunction with Medical Services for Health, ACNM is developing an online learning platform to support activities promoting the concept of short “low dose-high frequency” clinical training modules. These self-directed learning sessions can be in clinics or at home, on a schedule compatible with working hours. The emphasis is on adult learning, innovative learning techniques, and evidence-based best practices.

Subjects include postpartum hemorrhage, preeclampsia, neonatal resuscitation, neonatal infections, triage of sick children, immunization, and safe surgical techniques.  The objectives are to:

• Develop a skilled cadre of professionals to supervise and develop the clinical capacity of health professionals and facilities in the field
• Provide supported virtual access to professional development curriculum and content

This is the beginning of new approaches to clinical training and collaboration among specialties in Madagascar. It builds on the strengths of the Ministry of Health in Madagascar and the dedicated, motivated clinicians and leaders in the ACCESS program. This is a strong beginning, now made more challenging with the global pandemic. Monitoring and evaluation will determine whether it will make a sustainable difference for the lives of mothers, babies, and children in Madagascar.