Part 2: The Continuum of Care: Call the Midwife

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By: Petra ten Hoope-Bender, Director of Reproductive, Maternal, Newborn and Child Health, ICS Integrare; Sheetal Sharma, Research and Knowledge Management Associate, ICS Integrare

blog-image1-9.8.2014This post is part of our “Continuum of Care” blog series hosted by the Maternal Health Task Force

In our first blog, Esther is faced with two issues: a) accessing information (long queues at the clinic) and b) accessing commodities (pregnancy test). Now, she is 31 weeks pregnant and though she’s been to the clinic twice, she still doesn’t know exactly what to do when the big day comes. And what if something strange happens before then? Should she call the midwife? Someone else? And how will she get to the clinic? What if there’s an emergency?

She could really use some of the innovative services that are available in other countries, such as

  • Women’s groups in Bangladesh, India, Nepal and Malawi that discuss and find solutions to help improve maternal and child health
  • Father’s groups in Spain helping ensure that immigrants have access to services
  • Maternity voucher schemes in India
  • Mobile phones in Ghana that remind women of their appointments or their medication schedule
  • Health promotion groups to encourage antenatal care uptake or address societal issues where the mother-in-law is the main decision-maker
  • Low-cost, locally supported means of transportation such as ambulances, boats, cars, bikes or donkey carts in Zambia
  • Education on nutrition and breastfeeding
  • Free services such as China’s free postnatal care home service

But Esther also needs the health system to support her by providing quality services along the continuum of care throughout her pregnancy – from home to the clinic. To do this well, health care providers need to know Esther and understand her circumstances. They need to be able to provide the continuum of care as a team, integrating antenatal care with labour services and postnatal care, and providing that care as close as possible to Esther.

The Manoshi project, for example, brought that level of care into the slum areas of Bangladesh. The project reduced the famous ”three delays” by providing solid health information on when referral might be necessary, keeping transportation means on stand-by, and dedicating staff to speed women through administrative requirements to facilitate access to emergency maternal and newborn care (EmONC) at the hospital.

Midwife-led Care

An existing model of care that is gaining traction in countries like Esther’s is the midwife-led unit. Midwives are able to provide effective comprehensive care from pre-pregnancy through pregnancy, birth and the postnatal period. Setting up a midwife-led unit with a waiting home and close to a hospital means that women can easily access midwifery services throughout pregnancy and childbirth and, if needed, can be seamlessly transferred to next level care or EmONC services. To provide true continuum of care the midwife must be able to call on an obstetrician and the hospital at any time and be part of an integrated team of health care providers, associates and lay health workers that reach from the community to the hospital and keeps the woman and newborn at the center of care.

Setting up such collaborative teams of providers requires quality education of all groups and effective regulation that supports and promotes their collaboration and integration. Providers also need continuing professional development, clear career pathways, and a regulatory environment that allows the provision of appropriate skill mix at all levels of the system.

In the midwife-led unit, Esther, as a new mum, would also obtain information on postnatal care along with her newborn’s care: exclusive breastfeeding, basic hygiene, infection control, cord care, etc. Because the midwife has taken care of Esther from beginning to end, she will be familiar with her circumstances at home and can ensure that effective follow-up care is provided in her community.

When asked, women made clear what they need for a healthy pregnancy. First, women feel that information and education are essential to allow them to learn for themselves. Also, they need to know and understand the organisation of services and receive care that is respectful and given by staff who engender trust, personalized to meet their individual needs, and offered by care providers who are kind. Making midwife-led units available is an effective way to increase the capacity of the health system, cover the needs of the population, contain costs, and increase user satisfaction. Midwife-led care is more than a simple win-win.