Making a Career of International Field Work as a Nurse-Midwife

Debbie Cunningham, CNM, MN, MPH, and DrPH (candidate), Doctors Without Borders Reproductive Health Field Advisor

Chad 2009 © MSF

Debbie Cunningham with refugees from Darfur at a camp in Chad

After completing my nursing studies, I spent three years working in a rural clinic in Burundi, sponsored by the United Methodist Church. I was called in several times for delivery complications, but lacked the skills to intervene appropriately. Finally, I learned to drive the ambulance, in order to accomplish quick referral to a mission hospital 25 miles away. Because of this experience, I decided to train as a midwife before taking another international assignment.

After completing my midwifery studies, I worked for three years as a nurse-midwife in the U.S. I returned to Africa in 1994, and spent 16 months working with Rwandan refugees in Tanzania for CARE.

With this experience I joined Doctors Without Borders, also known as Médecins Sans Frontières (MSF). My first mission was in 1998 in Sierra Leone. Eleven years and 13 assignments later, I am still with MSF, but now working in its operational center in Amsterdam as Reproductive Health Adviser.

Since I started with MSF, women’s reproductive health programs have grown in priority. This makes sense in light of high maternal mortality rates in the contexts where MSF works. With much more information and evidence available, I think we are doing a better job of providing “best practices” within our projects.

An example of where we increased resources and attention to women’s health is Haiti, which has one of the highest maternal mortality rates in the Americas. In 2007, when I was at the Jude Ann Hospital in the capital city, Port au Prince, in 2007, the MSF team handled 35% of all of the city’s births. Of those deliveries, 45% were obstetric complications. With such high numbers, we decided to develop a triage system so that we could delineate women with complications from women who were coming in with normal pregnancies. We referred those with normal labor progress to another facility where routine childbirth care was available, which left our project free to provide specialized care for women with actual pregnancy/labor complications.

Also, we created easier access to prenatal care. For instance, to lower maternal and child mortality and morbidity rates, our team set up a mobile clinic in four slum areas, which decreased barriers to women seeking this care.

Today, MSF has 234 projects with reproductive health activities. Last year, medical teams provided antenatal care for more than 576,000 women, assisted in over 100,000 deliveries, provided prevention of mother-to-child transmission care to some 11,000 HIV-positive mothers, carried out post-rape care for nearly 10,000 survivors of sexual violence, and performed surgical repair procedures for 300 women with vaginal fistula. There are 83 international field positions for midwives.

In my role as Reproductive Health Advisor, I support midwives on program implementation and training of national staff colleagues. My main responsibilities are to improve access to and maintain high quality of reproductive and sexual health services for MSF patients. I also develop field policies, tools, and guidelines, staff development manuals, and deliver training on reproductive health topics. I spend about 70% of my time in the field providing direct support. This past year, I visited field projects in Nigeria, Democratic Republic of Congo, Somalia, Sudan (Darfur and South Sudan), and Ethiopia.

One of my first and biggest challenges in this position was to improve quality of care for our beneficiaries by ensuring field staff have adequate training materials and are briefed before arriving in the field. As an international organization with 19 recruitment departments worldwide, we recognize that the preparation of midwives varies greatly from country to country. I created administrative and training materials for both our recruiters and field staff so that we can make better matches and also determine gaps in skills before staff are placed on assignment.

MSF performs a good deal of self-reflection, and, in its evaluation, it pushes itself to evolve and learn. Today, there are Reproductive Health Advisers in each of its operational centers, maintaining a focus on emergency obstetrical care and on quality pre- and post-natal care services that are evidence based.

One area I think we should be doing more on is post-partum care. In the field projects under my purview, only 25% of the women who come to us for prenatal care return for post-partum care. This is much too low. We should be following up with at least 90% of mothers and their babies during this critical period. Some of the biggest obstacles facing women accessing post-partum care are cultural, logistical (eg. inability to return to the clinic due to long distances), or women assuming that if the baby and they are doing well, then there’s no need to return for a consultation. We created an incentive program that included supplementary feeding for their child or new bed nets, which resulted in mothers and babies receiving follow-up care.

Another area of concern is the relative underutilization of sexual violence services. In places where there appears to be high cases of rape in conflict areas and where we have services available for survivors of sexual violence, we see a small number of women coming for help. We are really looking at avenues for us to help women access the care we have to offer.

MSF has given me the opportunity to use my nursing, midwifery, and public health skills in a variety of international settings, and to make a career out of it. I want to strongly encourage my midwife colleagues to expand their skills, knowledge, and experience by working abroad in resource poor areas. While MSF accepts clinicians who have never worked overseas, international travel is always an asset.