It is well accepted that midwives are well-positioned to save women and newborn’s lives. In fact, a well-trained midwife can deliver 87% of essential care that woman and newborns need. But how can midwives provide this care when pre-service training is lacking, rural placement makes knowledge retention and career development difficult and women prefer traditional birth attendants (TBAs).
At the Global Maternal Newborn Health Conference yesterday in Mexico City, these barriers to quality midwifery care were addressed.
Foundational to current midwifery standards and recommendations are the recent Lancet Midwifery Series and the International Confederation of Midwives’ Midwifery Services Framework (MSF). The originators of these resources, Petra ten Hoope-Bender and Frances Ganges, respectively, summarized the evidence base and implications of these resources. Unique to the MSF is how it incorporates quality assurance. “Quality of care, when we look at the past, [has historically been incorporated] at the end [of projects]… but in MSF, quality is put first: quality should be addressed at the beginning and not just at the end to advance progress,” said Luc de Bernis, Senior Maternal Health Advisor for UNFPA.
This concept of putting quality first may change our current use of outcome indicators, like maternal mortality, as an accurate representation for maternal health and wellbeing. Hearing about local problems and solutions in Indonesia, Ethiopia and Afghanistan was both inspiring and made me think, do we value and measure the right indicators in maternal health?
In many areas around the world, women in tight knit, often rural communities prefer to give birth assisted by a traditional birth attendant (TBA). A pregnant woman has often known the TBA for the majority of her life and the TBA provides culturally appropriate care. This prevents women from seeking care from midwives and also keeps them out of many formal monitoring systems.
One project in Indonesia, Kinerja, does not introduce any new interventions, but increased midwifery deliveries by 11%. How? By improving collaboration between key stakeholders in maternal health, TBAs now work collaboratively with midwives to provide both culturally and medically appropriate care. TBAs receive a monthly salary only if they do not attend births alone and additional compensation for each birth referred to a midwife.
As a result of this collaboration, trust increased between TBAs and midwives, midwives were informed earlier about pregnancies, proportion of midwife deliveries increased and maternal mortality increased. That’s right, mortality increased. In this case, an increase in maternal mortality was a positive outcome. This meant that women previously invisible, left out of the system are now counted. This means that rural, marginalized women are now accessing the formal health care system and their outcomes are better understood. More accurate data allows better-informed decisions and initiatives to decrease mortality in this population.
According to the classic outcome indicator, maternal mortality ratio, this project would have been a failure. But when you dig deeper, it shows system improvement. As maternal health practitioners we must start thinking outside of just maternal mortality and look at system level improvements and failures because MMR does not always give us a clear picture of access to quality care.
A similar situation is seen in Afghanistan and Ethiopia. Both countries have worked tirelessly to increase the number of midwives in their countries. In Ethiopia, the number of midwifery schools and graduates doubled between 2008 and 2014, a huge success when evaluating the ratio of midwives to population. However, as we know, quantity does not always mean quality.
Tegbar Yigzaw, Chief of Party for USAID’s Human Resources for Health at Jhpiego, set out to assess just how competent these newly graduated midwives are. Shockingly, the average (median) number of births midwives attended during their training was 11, hugely insufficient when compared to the national standard of needing to attend more than 20 births and the international standard of more than 40 births during training. Moving forward accreditation and quality assurance of midwifery programs is crucial, Yigzaw shared.
In Afghanistan, midwives working in rural areas have little access to both technical and coaching resources. Yet, they are the ones who are serving the most marginalized women with the worst health outcomes. In-service training is not possible because it is costly and removes midwives from the communities they serve, leaving no one to take their place.
To fix this problem, the Afghan Midwifery Association created a field-based mentorship program. Pairing experienced midwives with rural midwives greatly improved knowledge along the continuum, from prenatal to postpartum care. Skills and knowledge were not the only aspects of care to improve: this mentorship helped identify and fill gaps in infrastructure, management and supplies.
These quality improvement programs show that true quality care must come before we look at outcomes. Improving and measuring processes, not just outcomes, can help us reach the goal of reaching every mother and every newborn with the quality care they need and deserve for health and wellbeing.
Photo: © 2014 by Jonathan Torgovnik/Reportage by Getty Images, under a Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) http://creativecommons.org/licenses/by-nc/4.0/