by Donna Walls, RN, BSN, IBCLC, CLC, ANLC
This collaboration grew out of discussions over many years between Dr. Abla Al Alfy’s team, an Egyptian pediatrician with the Ministry of Health and Royal College of Pediatrics and Child Health, and the Healthy Children Project’s team. The discussions centered around the Egyptian health priorities in intrapartum care and the gaps between goals and outcomes. Some concerns for childbearing women in Egypt are high cesarean rate (as high as 62% in some areas), commonplace episiotomies, high maternal and infant mortality rate, and little or no labor support. The Healthy Children Project’s team was composed of Karin Cadwell, Cindy Turner-Maffei, and Kajsa Bryndir and was initially a videography project in Cairo, Egypt focusing on the importance and process of skin-to-skin care immediately after birth. Cindy Turner-Maffei summarized the collaboration like this:
The hope of our collaboration is to provide a cadre of community and hospital companions who will provide support and carry important health, hygiene, and nutrition education to the families of Egypt, especially in communities where disparity of care is highest. Specific areas of focus will be to increase healthy pregnancy and supportive childbirth practices, such as companionship during labor, skin-to-skin in the first hours and establishment of exclusive breastfeeding. We also want to encourage responsive feeding practices including cue-based feeding, support for continued breastfeeding through 6 months, addition of adequate, timely, safe, and appropriate complementary foods at 6 months, and continued breastfeeding through at least 2 years.
Dr. Abla Al Alfy also envisioned a program she coined “The Family Counselor” program. The goal was to create a single source of needed education and resources encompassing the entire childbearing experience, and to train maternal and child health care providers in the basics of childbirth education, intrapartum labor support (doula care) and breastfeeding support. Planning and designing of the training curriculum and competencies was written collaboratively by the Healthy Children Project faculty with close consultation of the Egyptian team to ensure respect for the cultural aspects of pregnancy and early childcare. The education, including didactic information and clinical experience, was also designed to embrace the World Health Organization’s First 1000 Days. This concept focuses on developing programs and resources for nutrition and health of the mother and infant from conception to the child’s second birthday. “The first 1,000 days are a time of tremendous potential and enormous vulnerability. How well or how poorly mothers and children are nourished and cared for during this time has a profound impact on a child’s ability to grow, learn and thrive,” (https://thousanddays.org/why-1000-days). UNICEF describes the First Thousand Days concept as “a unique period of opportunity when the foundations of optimum health, growth, and neurodevelopment across the lifespan are established.” (https://www.unicef-irc.org/article/958-the-first-1000-days-of-life-the-brains-window-of-opportunity.html). The World Health Organization published “Recommendations for Intrapartum Care and a Positive Birth Experience” (https://www.ncbi.nlm.nih.gov/books/NBK513809) in 2018 and served as guidelines for developing the education on care of laboring women and their newborns. This document made 56 recommendations on establishing safe and evidence-based procedures and care practices during labor and birth. These recommendations are:
The first “train the trainer” curriculum was presented in April 2019 by the Healthy Children faculty and focused on:
- Prenatal nutrition
- Prenatal exercise and activities
- Coping with common pregnancy complaints
- Childbirth education including anatomy and physiology and labor coping techniques
- Unexpected outcomes
- Respectful communication
- Doula care including hands-on labor support, relaxation, massage and breathing patterns
- Early postpartum care in the hospital and at home for mother and newborn
- Breastfeeding basics including skin to skin care, latch, and responsive feeding
The training was very well received by both the participants and supporters within the Ministry of Health. The certification exam was developed collaboratively with the Healthy Children Project faculty and members of the ICEA board. Careful consideration was given to maintaining the ICEA philosophy and mission to blend with the unique needs of Egyptian families. The questions were reviewed and revised several times before being translated into Arabic with the first exam administration on January 30, 2022. The exam consisted of 82 questions and 18 beta questions. Fourteen examinees participated in the proctored exam with a passing rate of 71%. Care providers including colleagues from the Obstetrics and Gynecology Hospital, which provided clinical training sites for the original education course, will continue to train hospital and community Family Counselors to positively impact the care of laboring women and breastfeeding infants and meet the goals of the WHO Intrapartum Care model and the First Thousand Days program. As the program continues, monitoring of outcomes such as cesarean rates, maternal and infant mortality rates and percent of laboring women attended by companions or doulas will be reviewed and assessed. A long- term goal is to expand the program to other Arabic speaking countries and beyond.