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Rachel Danmadgi: A Chadian midwife in a refugee camp


Women Deliver

 

 

 

State of World's Midwifery

 

Midwives help preventing fistula in Timor-Leste

Midwives

In all countries that have achieved dramatic improvements in maternal mortality, professionally trained midwives have been a key to success. They have an essential role in achieving the Millennium Development Goals to reduce maternal and newborn mortality. Yet today, the training of midwives is inconsistent and the profession of midwifery often garners little recognition, meager income, and limited career opportunities. These factors contribute to the acute shortage of these valuable health workers.

MOMS: Midwives and others with midwifery skills

UNFPA has begun using the expression ‘midwives and others with midwifery skills (MOMS)’, to mean ‘skilled birth attendant’. This change reflects a recognition of the unique skills, roles and responsibilities midwives bring to delivery care, and to the central role that midwives play in making motherhood safer. The term ‘skilled birth attendant’ encompasses the definition of a midwife, but is broader and more generic. It also includes nurses, physicians and others who have been trained in proficiency in midwifery skills. Traditional birth attendants who lack formal professional training are not considered skilled birth attendants in the calculation of the Millennium Development Goal 5 target.

The Midwife Shortage

Maternal mortality and morbidity cannot be reduced without midwives and others with midwifery skills. Yet the numbers of these skilled providers have not significantly increased, and have even started to decline in some countries, because of migration, deaths from AIDS-related illnesses, and dissatisfaction with pay and working conditions.

Midwives, who are overwhelmingly women, typically endure low status, poor pay and a lack of support despite the enormous responsibility they bear. Those who work within communities at the primary care level, where they are needed most, often receive the least respect and support from the health system. Gender biases frequently contribute to the problems facing midwives.

When they are properly trained, empowered and supported, midwives in the community offer the most cost-effective and high-quality path to universal access to maternal health care. Yet midwives are in short supply in many developing countries – WHO estimates some 350,000 are urgently needed worldwide. In particular, countries with high rates of maternal mortality need assistance to recruit, train and support professional midwives.

In 2011, UNFPA and 30 partners published the State of the World’s Midwifery 2011: Delivering Health, Saving Lives. The report, the first of its kind, surveyed 58 developing countries that together account for 91 per cent of the world’s maternal deaths. The State of the World’s Midwifery Report found that up to 3.6 million lives could be saved each year in 38 of the countries surveyed, if an additional 112,000 more health workers with midwifery skills were practicing in communities and backed up by a functioning health system. More than half of those skilled health workers are needed in the eight countries that contribute 56 per cent of all maternal deaths.

What midwives do

Pregnancy, whether planned or unintended, is often a key entry-point into the health system, and midwives can provide a welcoming gateway. They often introduce women to the health system and ensure that women and their babies receive a continuum of skilled care during pregnancy, childbirth, and in the important days and weeks after birth.

The basic services midwives routinely provide to protect the health of the mother and baby include:

  • Caring for women during pregnancy, childbirth and the postnatal period
  • Treating complications due to miscarriages and/or unsafe abortions
  • Providing newborn care
  • Providing pre-pregnancy advice and health education
  • Recognizing and addressing problems in the woman and newborn before, during and after childbirth
  • Offering general health information, including reproductive health care and family planning
  • Assisting women to successfully breastfeed
  • Referring women and newborns for higher level care when complications arise during and pregnancy and childbirth their scope of practice and capabilities
  • Providing additional health services in communities such as immunizations and treatment of common illnesses

Giving midwives more responsibility and protection

In some cases, basic emergency life-saving functions, such as vacuum extraction, manual removal of placenta, or manual vacuum aspiration of retained products could effectively be delegated to midwives or specially trained nurses if adequate facilities were available and relevant policies were in place, including support and protection of the providers.

In Mozambique, senior nurses trained to perform Caesarean sections have achieved outcomes as good as those performed by specialist obstetricians. The training was part of an effort to make emergency obstetric care available at the lowest levels of the health system possible, particularly in rural areas where distance may be a significant barrier.

However, this is occurring in very few places, even though experienced midwives argue that they have the requisite skills and would not hesitate to take on greater responsibility if they were so authorized.

UNFPA at work

In April 2008, UNFPA and the International Confederation of Midwives (ICM) launched a joint programme, “Investing in Midwives and others with Midwifery Skills,” to accelerate progress towards achieving MDG 4 and 5. The programme is today underway in some 30 countries, mainly in sub-Saharan Africa and a few in Asia and Latin America.

The goal of the Midwives Programme is to improve skilled attendance at birth in low-resource settings by developing a sustainable midwifery workforce. The programme is creating a “critical mass” of midwifery advisors (CMAs) who are indentifying gaps in midwifery education, regulation and professional associations. The CMAs are working with governments at the national and regional levels to develop policies and programmes to address these gaps in order to elevate the availability and quality of care provided by midwives.

Examples of progress:

Midwifery Education:
Until recently, Bangladesh had only community midwives. A cadre of certified midwives did not exist. UNFPA and ICM supported Bangladesh to establish its first three midwifery training institutions, and the first-ever midwifery class graduated in 2011. A new midwife association has been launched and a country midwifery adviser posted. Bangladesh also has begun implementing a three-year, direct-entry midwifery programme., a two-year community midwifery education programme and post-basic midwifery training for nurses. Bangladesh has committed to double the percentage of births attended by a skilled health professional by 2015 and seeks to train an additional 3,000 midwives in total.

Midwifery Association Strengthening:
UNFPA and ICM are working together to assess and address the capacities of midwifery assocations and to advocate for their creation where none exist. In Guyana, the first midwives association was launched in May 2009. In Ethiopia the Programme has supported the establishment of the Tigray and Amhara Regional Midwifery Associations. With these, Ethiopia now has one national and three regional midwifery associations. And in Djibouti, an extremely resource poor country, efforts are underway to form the country’s first midwifery association.

Regulation of Midwifery:
Support is being provided for capacity building, institutional development and strategic planning. The Ministry of Health in Djibouti has adopted a law that equates a midwifery certificate with equivalent of first level university degree. Cambodia now has a Midwifery Council and is drafting new guidelines for midwifery education, services and regulations. In Ghana, after a review of the falling standards of service provision by midwives and nurses, a code of ethics for midwives is being developed with support from Ghana’s Nursing and Midwifery Council.