NVESTING IN MIDWIVESAND OTHERS WITH MIDWIFERY SKILLSTO SAVE THE LIVES OF MOTHERS ANDNEWBORNS AND IMPROVE THEIR HEALTH

Policy and programme guidancefor countries seeking to scale upmidwifery services, especiallyat the community level

“The world needs midwives

now more than ever

to save the lives

of mothers and babies”

A UNFPA-ICM Joint Initiative to support the call for aDecade of Action for Human Resources for Health

made at World Health Assembly 2006

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TABLE OF CONTENTS

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ACKNOWLEDGEMENTS .............................................................................................................................................................. iiACRONYMS ............................................................................................................................................................................... iiiGLOSSARY OF TERMS ................................................................................................................................................................ ivINVESTING IN MIDWIVES AND OTHERS WITH MIDWIFERY SKILLS

TO SAVE THE LIVES OF MOTHERS AND NEWBORNS AND IMPROVE THEIR HEALTH ............................................................. 1Introduction and purposeDefining the problemThe factsThe solutionsSummary of the evidenceIssues for policymakers and programme managersFigure 1. Framework for addressing issues of scaling-up midwifery at the community level

1. POLICY, LEGAL AND REGULATORY FRAMEWORKS ............................................................................................................. 5Key IssuesKey Action PointsSummary

2. ENSURING EQUITY IN ACCESS ............................................................................................................................................ 7Key IssuesKey Action PointsSummaryContext-specific Recommendations

3. EDUCATION MATTERS: PRE-SERVICE, IN-SERVICE AND TRAINING TEACHERS ................................................................... 9Evidence on types of trainingKey IssuesKey Action PointsSummaryContext-specific Recommendations

4. SUPERVISION IS THE KEY TO MAINTAINING QUALITY AND MOTIVATION........................................................................ 12Key IssuesKey Action PointsSummary

5. ENABLING FACTORS, INCLUDING PROVISION OF SAFE PRACTICE ENVIRONMENTS ............................................................ 14Key IssuesKey Action PointsSummary

6. MONITORING AND EVALUATION: MEASURING WHAT, WHY AND HOW? ....................................................................... 17Key IssuesKey Action PointsSummary

7. FUNDING, STEWARDSHIP AND RESOURCE MOBILIZATION AND MANAGEMENT ................................................................ 19Key IssuesKey Action PointsSummary

CALL TO ACTION ..................................................................................................................................................................... 21REFERENCES .............................................................................................................................................................................. 22

In December 2006, ICM, UNFPA and WHO Making Pregnancy Safer, in collaboration with the globalInitiative for Maternal Mortality Programme Assessment (IMMPACT) based at Aberdeen University,

Scotland, UK and Family Care International (FCI), organized the 1st International Forum on Midwifery inthe Community, to look at lessons learnt and consider how best to scale up access to midwifery care at thecommunity level. The organizers of the Forum gratefully acknowledge the contribution of the TunisianGovernment for hosting the Forum and for their participation in the opening and closing sessions. Thisguidance note is a direct output from these proceedings. Neither the Forum nor the guidance note wouldhave been possible without the support provided by the Government of Luxembourg and the SwedishInternational Development Agency (SIDA), in particular Ms Gunilla Essner, Desk Officer, Health Section.Others who both supported and participated in the Forum include the African Development Bank; theAverting Maternal Death and Disability (AMDD) Programme, Columbia University, New York, USA, andthe Preventing Maternal Mortality Network, Africa (RPMM).

The present document was prepared by Ms Della R Sherratt, Senior International Midwifery Adviser& Trainer, and Ms Karen Odberg-Pettersson, Senior Lecturer, International Health & Development, LundUniversity, Sweden, based on the review of available evidence and the presentations, discussions andrecommendations made during the Forum. They are both gratefully acknowledged

Also gratefully acknowledged are the 23 country teams as well as the midwives from 4 industrialisedcountries, who shared lessons learnt during the two days of intense group work to draft the initial guidance.Gratitude is expressed to the Ministries of Health, programme managers, professional associations andstaff representatives from Bangladesh, Bolivia, Burkina Faso, Cambodia, Guatemala, Haiti, India, Indone-sia, Jordan, Kenya, Malawi, Mexico, Morocco, Mozambique, Nepal, Niger, Pakistan, Sudan, Tanzania,Tunisia, Yemen and Zimbabwe, as well as the midwives from Canada, The Netherlands, Sweden and theUnited Kingdom.

The preparation and printing of this document were co-financed by Luxemburg, Sweden, and UNFPA.The authors are most grateful to all the reviewers for their comments on the early text, specifically ArlettyPinel, Chief Reproductive Health Branch UNFPA, Vincent Fauveau, Senior Maternal Health Advisor,UNFPA, Luc de Bernis, Senior Maternal Health Advisor for Africa, UNFPA, Anneka Knutsson, Interna-tional Advisor Midwifery, UNFPA Bangladesh, Margareta Larsson, Midwifery Advisor Department ofMaking Pregnancy Safer WHO, Nester Moyo, Programme Manager, ICM, Barbara Kwast, Senior Ad-viser AMDD, Atf Gherissi, Midwife Consultant, Tunisia.

Final editing was done by Alex Marshall.

ACKNOWLEDGEMENTS

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AMDD Averting Maternal Death and Disability (AMDD) Program, Mailman Schoolof Public Health, Columbia University

EmONC Emergency obstetric and neonatal care

FCI Family Care International

JHPIEGO Affiliate of John Hopkins University

HRH Human resources for health

ICM International Confederation of Midwives

IMMPACT Initiative for Maternal Mortality Programme Assessment,Aberdeen University

MMR Maternal mortality ratio

PMTCT Prevention of mother-to-child transmission

TBA Traditional birth attendant

UNFPA United Nations Population Fund

WHO World Health Organization

ACRONYMS

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GLOSSARY OF TERMS ADOPTED AT THE FORUM

Midwifery (French lapratique de sage-femme;Spanish partería; Arabickebela)

Midwife (Sage-femme;Matrona)

In the community (Dans lacommunauté; En lacomunidad)

Midwifery workforce (Lesprofessionnels compétentsdans la pratique de sage-femme; Personal calificadode partería)

Maternity workforce (Lesprofessionnels compétentsdans la pratique de sage-femme; Personal calificadode partería)

Maternity support workers(Les agentscommunautaires de santématernelle; Asistantes dematernidad)

Emergency obstetric care(EmOC), basic and compre-hensive (Les soinsobstétricaux d’urgence(SOU) de base et complets;Cuidados Obstétricos deEmergencia (COEm)basicos y ampliados)

The scope of professional midwives’ practice. The art and science ofassisting a woman before during and after labour and birth

An accredited (qualified) healthcare practitioner who assists womenin pregnancy, throughout labour and childbirth and cares for womenand babies in postnatal period. She has an important promotive andpreventative function in broader reproductive health, health advocacy,empowerment of women and neonatal health. (See InternationalDefinition of a Midwife: http://www.internationalmidwives.org)

Level of health system close to where families live, e.g. government,private or NGO health post or clinic, or the family home (sometimesreferred to as primary health care level)

Healthcare workers whose primary functions include health care towomen in pregnancy and throughout labour and birth, and to mothersand babies in the postnatal period.

Total workforce needed for maternity care. The category includesmidwives and others with midwifery skills; obstetric and surgicalstaff; paediatric (neonatal physicians and nurses); laboratory techni-cians, radiologists and other specialists.

Healthcare workers, community workers and others, including tradi-tional healers and others, who work and have links with the midwiferyworkforce. They play an important role in supporting women’s andnewborns’ access to skilled care for safe pregnancy and childbirth,including postnatal and neonatal healthcare.

Consists of eight signal functions:

Basic: Parenteral administration of antibiotics,oxytocics andanticonvulsants; manual removal of the placenta; manual vacuumaspiration; vacuum extraction; (plus stabilization of woman forreferral), pre-referral care and referral.

Comprehensive: all the above plus surgery (caesarean) and safeblood transfusion.

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Emergency obstetric andneonatal care (EmONC)(Les soins obstétricaux etnéonatals d’urgence[SONU]; Cuidadosobstetricos yneonatologicos deemergencia [CONEm])

Skilled care for pregnancyand birth (Soinsobstétricaux qualifiés;Atención calificada du-rante el embarazo y elparto)

Competency

Skills

Core competencies

MDG-5

Consists of ten signal functions:

Basic: Parenteral administration of antibiotics, oxytocics andanticonvulsants; manual removal of the placenta; manual vacuumaspiration; vacuum extraction; basic newborn care; (plus stabilizationof woman and newborn for referral), pre-referral care and referral.

Comprehensive: all the above plus caesarean surgery and safe bloodtransfusion, neonatal resuscitation.

“Skilled care” denotes a skilled attendant assisting pregnancy andbirth in an enabling environment, supported by a functional referralsystem.

The knowledge, skills, attitudes and experience required for individu-als to perform their jobs correctly and properly.

Abilities learned through training or acquired by experience toperform specific actions or tasks. Usually associated with individualtasks or techniques, particularly requiring the use of the hands orbody.

An area of specialized expertise such as midwifery made up of acombination of complementary skills and knowledge bases (i.e. morethan one knowledge base) embedded in that group’s, team’s orprofessional cadre’s expertise. Descriptions of core competencies arefound in the joint ICM/WHO Manual.

The fifth of the Millennium Development Goals adopted by worldleaders at the Millennium Summit at the United Nations in the year2000, with the aim of halving extreme poverty by 2015. The goal is toreduce the maternal mortality ratio by three-quarters between 1990and 2015.

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INTRODUCTION AND PURPOSE

The Hammamet Forum “Midwifery in the com-munity: lessons learned”, 11-15 December 2006,

the first international meeting focusing on scaling upof the midwifery workforce at community leveldrafted a Call to Action for all countries with highMMR to embark on urgent and intensified action toscale up midwifery care at the community level (seeAnnex 1).

The Forum also decided to issue a document toprovide guidance to national programmes for scalingup midwifery services at the community level. Theresult is the present guidance note, which outlines inmore detail the action required by policy-makers andprogramme managers to effect change at countrylevel and scale up midwifery capacity, specificallyfor families in poor and hard-to-reach areas.

The guidance note tries to capture and respondto the issues, questions, debates and outcomes ofthe group work, as well as the many country presen-tations made during the Forum. It is not intended totake the place of guidelines, which are more of atechnical resource. Technical guidelines foroperationalizing the guidance note will follow.

Participants in the Forum were drawn from in-ternational agencies and organizations such as theInternational Confederation of Midwives (ICM); theUnited Nations Population Fund (UNFPA); the WorldHealth Organization (WHO); the Initiative for Ma-ternal Mortality Programme Assessment(IMMPACT) based at Aberdeen University; FamilyCare International (FCI), and the Averting Mater-nal Death and Disability (AMDD) Program, Co-

lumbia University, along with midwives, nurses,physicians, health policy makers, professional as-sociations, regulatory bodies and researchers from23 countries where maternal and neonatal mor-tality and morbidity remain high. The 23 coun-tries were Bangladesh, Bolivia, Burkina Faso,Cambodia, Guatemala, Haiti, India, Indonesia, Jor-dan, Kenya, Malawi, Mexico, Morocco, Mozambique,Nepal, Niger, Pakistan, Sudan, Tanzania, Tunisia,Yemen and Zimbabwe

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DEFINING THE PROBLEM

Forum participants made an urgent request for clearand practical guidance on best-practice options forthe rapid scaling-up of midwifery care at the com-munity level. WHO estimates that providing univer-sal access to skilled care and meeting the reproduc-tive needs of all women calls for around 700,000additional midwives, allowing for attrition. At leasthalf as many more will be needed to meet the MDG-5 target (WHO, 2005a). The question in many coun-tries is how best to go about this with the scarceresources at their disposal.

The Lancet’s recent series on maternal survivaldescribed the need to professionalize and scale upmaternity care as a contribution to lower maternaland perinatal mortality and morbidity (see TheLancet editorial on maternal survival, September2006). Scaling-up–increasing numbers and compe-tence of the midwifery workforce–requires in-vestments and capacity-building at all levels ofthe health system.

INVESTING IN MIDWIVES AND OTHERS

WITH MIDWIFERY SKILLS TO SAVE THE LIVES

OF MOTHERS AND NEWBORNS AND IMPROVE THEIR HEALTH

POLICY AND PROGRAMME GUIDANCE FOR COUNTRIES SEEKING TO SCALE UP

MIDWIFERY SERVICES, ESPECIALLY AT THE COMMUNITY LEVEL

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The term “capacity-building” is often used in-correctly as a synonym for “training” (Potter,Brough, 2004). In addition to training, capacity-building requires attention to structure, systems,roles, staff and facilities, skills and tools. Becauseof the complexity of providing quality midwiferycare at the community level, capacity-buildingmust also address policies, legal frameworks, in-frastructure and logistics within the communityand the right to practice life-saving interventions,as well as gender inequalities, women’s empower-ment, resource mobilization and collaboration be-tween different professional groups.

This guidance note is focused on action to scaleup midwifery care at the community level, re-sponding to participants’ feeling that the criticalshortages and bottlenecks that deny women andtheir families access to adequate care are to befound in this area. Specifically there is an urgentneed to address the needs of underserved people,who are often in rural and poor urban areas. Pro-vision of midwifery care in the community re-sponds to the human right of all women in theworld to competent midwifery care, regardless ofwhere they live

Thanks to the excellent work of WHO, UNFPA,AMMD, JHPIEGO and other organizations operat-ing at global, regional and national level, there is anabundance of practice guidelines and guidance onEmONC care and facilities, and on strengtheningreferral-level care and systems; but not on scaling-up midwifery care at the community level, whichleaves a critical gap in the continuum of care neededfor safe motherhood.

Quality midwifery care, provided close towhere women live, can increase families’ capac-ity to self-care during pregnancy, as well as be-fore, during and after childbirth; it can also in-crease access to EmONC care by educating andempowering women and their communities. De-spite repeated evidence that midwifery care at thecommunity level is inadequate and lacks competentproviders with the requisite back-up and support,country plans often fail to address the need.

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THE FACTS

An estimated 530,000 women die each year fromcomplications of pregnancy and childbirth; overninety per cent in South Asia and sub-Saharan

Africa, and less than one per cent in more de-veloped regions (WHO, 2005a).

An estimated 10 to 20 million women annuallysuffer severe health problems such as obstetricfistula as the result of pregnancy and childbirth(WHO, 2005a).

Five major complications, most of which occurduring labour, delivery and the postpartum pe-riod account for seventy per cent of maternaldeaths (WHO, 2005).

The technology for preventing these deaths al-ready exists: the same five complications alsooccur in more developed regions, but rarely re-sult in death.

Approximately 15 per cent of women will expe-rience a complication during pregnancy or child-birth–most of which cannot be predicted, but al-most all of which can be managed (WHO,2005a).

Most maternal deaths and disabilities could beaverted if all births were attended by a skilledhealth professional with access to a quality re-ferral facility (FCI, 2002).

Despite evidence of the need for skilled care atbirth, almost half of all women still give birth with-out it (WHO, 2006a).

Almost all births in high-income countries takeplace with a skilled attendant, but only 57 percent of births in low income countries and lessthan a third in very low-income, war-torn or col-lapsed-economy countries (WHO, 2006a).

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THE SOLUTIONS

Midwives and others with midwifery skills have apivotal role in addressing the first two of the “threedelays” that eventually lead to death from pregnancy-related complications, by working with and empow-ering women and communities and providing basicEmONC. They also contribute to reducing the thirddelay by providing prompt, high quality, essential mid-wifery care, and by giving first-line treatment whilewaiting for medical practitioners with obstetric andor neonatal skills.

Many reports show that women would use askilled midwife or other healthcare provider with

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midwifery skills, if they were readily available andaffordable, and offered culturally acceptable ser-vices (MoH Kingdom of Cambodia 2004, Koblinsky,2003).

The World Bank estimates that maternal deathswould decrease by 75 per cent, if coverage of keyinterventions rose to 99 per cent (Wagstaff andClaeson, 2004). Equally, WHO has recently con-cluded that almost half of all perinatal deaths couldbe prevented with skilled care at birth (WHO,2006b). Properly trained and supported, midwives atthe community level can deliver many of the inter-ventions needed to address maternal health(Campbell, Graham, 2006).

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SUMMARY OF THE EVIDENCE

There is compelling evidence for care by pro-fessional trained midwives or others with mid-wifery skills to reduce maternal death and dis-ability (WHO 2005a, Loudon 2000, FCI, 2002).

In all countries poverty is strongly associatedwith less access and use of healthcare, includ-ing skilled midwifery care at birth. The WorldBank study, Listening to the Voices of the Poor:Crying out for Change, gave a vivid illustrationof the importance of health care to poor and vul-nerable people, and their hardship in its absence(Deepa et al., 2000). Studies among pregnantwomen support these findings (Jewkes et al.,1998, Knutsson, 2004, Pettersson et al., 2004,Pettersson et al., 2007).

Lack of gender sensitivity in healthcare provi-sion, together with lack of women’s empower-ment, has a direct impact on uptake and accessto healthcare (Fonn et al., 2001).

Midwives and others working at the communitylevel contribute to delivery of essential primaryand reproductive healthcare and can deliver manyof the needed interventions to save the lives ofmothers and babies (Campbell, Graham, 2006,de Bernis et al., 2003).

One of the main findings of the recentIMMPACT evaluation of their safe motherhoodplan in Indonesia shows that midwives who liveand work in the community attend births and re-

act appropriately in case of complications, andare more able to make a contribution to safemotherhood.

Investment in midwifery care in the communityhas additional benefits: a referral system set upfor maternal and newborn care was also usedfor transferring other seriously ill or injured mem-bers of the community (Predhan et al., 2002.Razzak, Kellermann, 2002).

As respected members of the community, mid-wives promote health: women and men seek theiradvice on a wide range of health issues, includ-ing pre-conception health; family planning andcare of newborns and young children; nutrition;general healthcare, and, increasingly, sexualhealth (Prathmanathan et al., 2003).

Training for the midwifery workforce has beendebated for many decades, long before the early1990s, when the WHO task force on human re-source development for maternal health and safemotherhood met in Geneva (WHO 1993). The taskforce meeting reached agreement on the minimumlevel of midwifery skills, including essential skills tosave the lives of women and newborns. Recent in-ternational consensus confirms that midwives musthave the basic EmONC skills (WHO, 2004).

Because their work brings them close to womenand families, midwives and others with midwiferyskills working in the community also make ideal ad-vocates and actors in HIV/AIDS programmes, es-pecially for PMTC; reducing congenital syphilis; pre-vention and treatment of malaria, and adolescent andyouth health.

Deep and pervasive poverty, coupled with theimpact of the HIV/AIDS pandemic, civil unrest andexposure to extreme natural disasters such as se-vere droughts, floods, earthquakes and typhoons,make midwifery in many African and some SouthAsian countries the most complex in the world.

However, the production of skilled midwiferyproviders is an important component of the AfricaRoad Map for reducing maternal and neonatal mor-tality, to which the UN agencies and their partnersare committed. Many middle and low-incomecountries with high MMR are now making skilledcare at birth a priority in their national health anddevelopment plans.

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ISSUES FOR POLICYMAKERS AND PROGRAMME

MANAGERS

Based on a preliminary review of available evidence,the issues to be considered when planning scaling-up human resources for health, including building thecapacity of the midwifery workforce are:

Policy, legal and regulatory frameworks–basedon human rights for clients and providers;

Equity approach–to reach all in need of accessto a competent midwifery provider, especially theurban poor and rural communities;

Competency-based education and training–bothpre- and in-service, employing evidence-basedstandards;

Supervision and support for setting up and main-taining standards and quality improvements–in-cluding links, support and backup from the localEmONC facility;

An enabling environment–including safe prac-tice sites; safe living conditions; fair recompense(a living wage); access to basic amenities in-cluding schooling and childcare; an adequatesupply of essential drugs and equipment, and re-liable transportation to an EmONC facility;

Monitoring and evaluation–to identify gaps aswell as progress;

Stewardship, resource mobilization and manage-ment–to enable all of the above.

PoliticalCommitment toAccess for All

MIDWIFERYIN THE

COMMUNITY

EquityApproach to

Reach All Educationand

Training

EnablingEnvironment

Stewardship,Resource

Mobilization &Management

Supervision

Monitoringand

Evaluation

FIGURE 1. FRAMEWORK FOR ADDRESSING ISSUES OF SCALING-UP MIDWIFERY AT THECOMMUNITY LEVEL

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Political priority for safe motherhood has beenshown to be crucial for reducing maternal mor-

tality (Pathmanathan et al., 2003, Shiffman et al.,2004).

The World Heath Report 2005–Make EveryMother and Child Count called for access to pro-fessional midwifery care to begin ideally beforepregnancy; if not, it should start as soon as preg-nancy is known and continue until successfulbreastfeeding has been established. WHO focuseson the period during and immediately after child-birth, when most maternal and neonatal deaths oc-cur. The Report further recommends that care shouldbe provided as close as possible to where womenlive and that providers should be backed by readyaccess to a functioning facility, able at all timesto provide proper emergency management andcare for women and newborns with complications(WHO, 2005a).

Policies to achieve the above are crucial but in-sufficient. Implementation plans and regulatoryframeworks are needed to make policies workable.Above all, there is a need for legal and regulatoryframeworks which protect the right to practise ofmidwives and others with midwifery skills, includingbasic EmONC.

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KEY ISSUES

Policies should make explicit that all women,wherever they live, have the basic right to ac-cess to professional midwifery care.

The international consensus is that all healthcareproviders who care for women and newbornsduring childbirth should be empowered to pro-vide, at a minimum, basic EmONC.

Legal and regulatory frameworks that protectmidwives and ensure that their scope of prac-tice covers provision of essential life-saving in-

terventions, such as basic EmONC are essen-tial, but are too often inadequate.

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KEY ACTION POINTS

Because of the complexity of scaling-up midwifery,consensus across all stakeholder groups is essential,including especially the other key professional group,obstetricians. While governments hold the ultimateresponsibility for ensuring access to skilled care,partners including civil society organizations are es-sential to consensus-building and political action(WHO, 2005b).

Communities are major stakeholders in such part-nerships. Studies on partnership in community healthalso point to the need for collaborative leadership.To be effective leadership must be built on sharedvision, power sharing, systems thinking and processbuilding (Alexander et al., 2001).

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SUMMARY

Policy makers and programme managers should:

Create a coalition of interested stakeholders,ideally through conducting a rapid stakeholderanalysis.

Create partnerships and ensure community par-ticipation from the start.

Develop a few but distinct messages to addressthe priority for access to midwifery care at thecommunity level.

Develop and implement an advocacy plan forconsensus-building and political commitment, in-cluding strategies for execution.

Develop a consensus on the need for scaling upmidwifery services at the community level.

1. POLICY, LEGAL AND REGULATORY FRAMEWORKS

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Identify and gain the support of champions toensure affirmative action to promote midwiferyacross society and in the health sector through avariety of media

Review and revise where necessary current le-gal and regulatory frameworks, to ensure theyprotect the right of midwives and others with mid-wifery skills to practise to the full extent of theirrole, including providing basic EmONC. For thisit is essential to include consultation with otherkey stakeholders such as obstetricians, who of-ten have the most difficulty with midwives per-forming some interventions.

SUCCESS STORY FROM CAMBODIA

A group of stakeholders including the CambodiaMidwifery Association and the NationalReproductive Health Programme, withsupport from UNFPA and other agencies,successfully advocated for a High-levelMidwifery Forum.

THE HIGH-LEVEL MIDWIFERY FORUM

The first national Forum with high-level supportincluded support by UNFPA, and was led bythe Office of the Council of Ministers –specifically by the Deputy Prime Ministerand MoH, with involvement of:

• the Ministry of Education, Youth and Sport;• the Council for Administrative Reform;• the Secretariat of Public Function;• the Ministry of Economics and Finance;• multilateral and bilateral agencies.

The Forum considered the many challenges facingthe provision of midwifery care, whichincluded:

• low enrolment of students in the midwiferycourse;

• low motivation to work in rural and remoteareas;

• uneven distribution of midwives;• low salaries;• limited resources for retention of midwives in

the public sector;• poor social services infrastructure in rural

areas;• lack of places for clinical practice.

MAIN OUTCOMES OF THE FORUM

• Increased salaries and scales.• Statute for establishing a Midwifery Council.• Consensus on the need for a full assessment

of midwifery capacity and agreeing terms ofreference for a comprehensive review ofmidwifery, June – September 2006.

• Strong commitment from the Royal Governmentof Cambodia to midwifery issues.

• Midwifery review report to be submitted as partof the mid-term review of the current healthsector strategic plan so that actions can beincorporated into the next strategy plan.

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In all countries poverty is strongly associated withless access and use of healthcare, including skilled

midwifery care at birth (Gwatkin et al., 2004). TheWorld Bank study, Listening to the Voices of the Poor:Crying out for Change, gave a vivid illustration of thehardship faced by poor and vulnerable individuals inmeeting their health care needs (Deepa et al., 2000).These findings are supported by various studies con-ducted among pregnant women (Jewkes et al., 1998,Knutsson, 2004, Pettersson et al 2004, Pettersson et al2007) and in the World Bank Development Report 2004(WDR, 2004). At the heart of women’s access to ma-ternal care lies women’s autonomy. Evidence showsthat even in relatively low-income groups, women withhigher levels of autonomy find it easier to access ma-ternal health services (Mathews et al., 2005).

In most countries poor people are not only sub-jected to inadequate infrastructure and insufficientmedical supplies, but also to negative attitudes fromhealth care professionals. It has been recognized for along time that women in particular are subject to inad-equate access and poor quality of care, a great deal ofwhich can be associated with lack of gender sensitivityand women’s lack of status and power (Doyal, 1995).

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KEY ISSUES

Evidence shows the poorest quintile in a countryoften have the least access to skilled care at birth;even when care is available close by, they fre-quently use services less than wealthier families(WHO, 2005a, Kunst and Houweling, 2001).

Research shows that introduction of formal userfees and demands for payment “under the table”have a negative influence on utilization of ma-ternal health care services, particularly duringchildbirth (Borghi, 2006, Pettersson et al., 2004,Pettersson et al., 2007).

Introduction of free care for childbirth can havea negative impact on quality of care and on staff

2. ENSURING EQUITY IN ACCESS

retention if staffing levels are not kept under con-stant review and increased to meet increasingworkload (IMMPACT Symposium 2007).

Sometimes lack of female service providers, orsomeone who speaks the local language andshares–or at least appreciates–local culturalnorms stop women accessing care, even when itis available (Knutsson, 2004).

In some situations, the community’s perceptionsof quality care and provider performance, espe-cially staff attitudes, can have a greater influ-ence on uptake of services than access and costs(Andaleeb, 2001, Pettersson et al., 2004).

Ensuring equity in relation to access to midwiferyrequires gender-sensitive policies and practicesfor human resources deployment.

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KEY ACTION POINTS

To achieve equitable access to quality midwiferycare, the health sector must work in close col-laboration with many other sectors, including edu-cation; roads and transport; communications; en-ergy and power; finance–specifically the healthbudget–and in some instances the judiciary systemworking for women’s rights and to improve the sta-tus of women.

Recruiting from the local area and ensuring thatservice provision is culturally cognizant will be easierif education also takes place locally: this will encour-age the community’s involvement and participationin the programme. This may require radical steps todecentralize schools of midwifery, or at least provid-ing satellite sites close to the community, (see Sec-tion 3 on education and training).

Finally, it is crucial to know where the gaps are;a baseline needs assessment that includes assess-ment of equity in access is essential to identify pri-ority areas. (Reference pitchworth et al.)

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SUMMARY

Policy makers and programme managers should:

Review current human resources policies andplans to ensure they make explicit the need formidwifery services, to be provided by compe-tent midwives or others with midwifery skills.

Conduct a needs assessment to identify priorityareas for increasing recruitment, or implement-ing special measures to support recruitment forhard-to-recruit areas and ethnic minority groupswhere relevant.

As an interim measure, while the number of mid-wives and others with midwifery skills is beingincreased, non-midwifery community healthcareproviders must be given some additional trainingand allocated to a team with (or be supervisedby) a competent healthcare practitioner with coremidwifery competencies.

Make efforts to decentralise services to the near-est possible community point.

Actively involve local communities in decision-making on the location of midwifery services,and in monitoring.

Wherever possible, recruit midwives or others withmidwifery skills from the local area. Ideally, thelocal community should be involved in both selec-tion and support of students through their trainingprogramme and in their posting after graduation.

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CONTEXT-SPECIFIC RECOMMENDATIONS:

In conflict and post-conflict countries

Ensuring security of staff, their families, train-ees, and training institutions will be paramount –this is especially important for female workers.Simple measures such as providing mobile phonesand using solar systems to supply electricity arepossible even in low-income countries. Aboveall, work with the community leaders and get theirinvolvement in supporting and protecting the mid-wives in the community.

Maintain cultural congruence and ensure servicesare provided by local people who families know

and accept. Include the community in recruit-ment and posting decisions.

Pre-service and in-service training programmesshould require as little time as possible away fromfamilies. This may call for modular programmesso that clinical practice can be undertaken in thetrainees’ own community.Ensure that all healthstaff have minimum midwifery competencies,while at the same time building long-term plansfor developing professional midwives.

In medium to large countries

Regularly undertake a human resources (labour)survey to identify where midwives are working,and how many live and work in a specific area.Some countries require professionals such as mid-wives to submit an annual or biannual notificationof where they are working; whether they are part-time or full-time; what type of practice they pro-vide–private, public or both–and other details.

MEXICO FINDS A LOCAL SOLUTION FORREACHING INDIGENOUS WOMEN

CASA (Centro Para los Adolescentes San Miguelde Allende), an NGO based in San Miguel deAllende aiming at providing sexual and repro-ductive healthcare to the indigenous population,has demonstrated an impressive reduction ofmaternal mortality by training indigenous women tobecome professional midwives. The school wasinitiated by TBAs who wanted their daughters andwomen from rural communities to have access toa career in professional midwifery.

In 1997 the Ministry of Health and the Ministry ofEducation accredited the school and its graduates.After a four-year education programme, thegraduates are given a professional licence as anautonomous midwife. Although bound to work withCASA for a specified period of time aftergraduation, graduates are now obtaining posts ingovernment services.

CASA believes that key to success has been acommitment to ensuring that every new idea andinitiative is carefully monitored, evaluated anddocumented to build a stronger evidence base forwhat works and what does not work. Building theevidence base also helps to develop confidence inthe programme among the local community, and inhigh levels of authority and the Ministry of Health.

For more information visit their website – http://www.casa.org.mx/midwife.html

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Midwifery education needs to be of good qualityand include critical thinking and decision-mak-

ing, as well as community mobilization skills. As theauthors of an article on the weakness of referralsystems for dealing with obstetric emergencies pointout, “The arrival of a woman at a referral facility isthe end of a long and often complex decision-mak-ing process by both client and provider, of which theproviders’ skills, including interpersonal skills, areparamount.” (Bossyns, Van Lerberghe, 2004).

Both pre-service and in-service education andtraining programmes should be based on a compe-tency model. The competencies for a midwife orother healthcare worker providing midwifery care inpregnancy, before, during and after birth and for thenewborn have been defined by ICM (ICM, 2000).They include family planning and other reproductivehealth services. These competencies were developedon the basis of a rigorous Delphi study involving clini-cal midwives, educators, managers and senior mid-wifery policy makers (Fullerton, Thompson, 2005).

Competence requires skills, knowledge, attitudeand experience. Development of competence re-quires regular, repeated, supervised, hands-on prac-tice in the clinical area and assessment of the com-petencies acquired. Too often current curricula donot allow for the development or testing of compe-tency, and assume that a level of competency hasbeen reached based on simulations in the classroomor on models, and attendance of a limited number ofcases for hands-on-care. One of the major challengesamong low-income countries is the gap between themidwifery school, its theoretical teachers and super-visors, and the clinical reality. It is crucial to reduceor eliminate this gap (Lugina, 2003).

Advocacy messages should not leave the issueof competence open to interpretation. Where this hashappened there has been a tendency for short, “quick-fix” solutions, which often prove to be neither effec-tive nor sustainable, as many countries are now find-ing. They can often prove more costly in the longerterm (Report of the 1st International Forum on Mid-

3. EDUCATION MATTERS:PRE-SERVICE, IN-SERVICE AND TRAINING TEACHERS

wifery in the Community: Lessons Learned,Hammamet, Dec 2006).

The lack of adequate curricula to prepare mid-wives to address the needs for safe motherhood, in-cluding competence in the essential life saving skillsand competence to practice in the community, hasbeen and remains a major concern (Kwast andBentley, 1991, Kwast and Bergström, 2001).

It is also essential that curricula and practice arecontext-based. Midwives working in low-resourcesettings might avoid acting in a crisis because of theirinadequate knowledge of appropriate techniques andprocedures, such as aortic compression for post-partum haemorrhage as in the WHO manual Man-agement of Complications in Pregnancy and Child-birth, (WHO, 2000), or resuscitating the newbornwith room air in the absence of oxygen (Saugstad,2005). It is also important that care be culturally sen-sitive, to encourage women to seek health care dur-ing childbirth (Knutsson, 2004, Pettersson et al., 2004,Leininger 2002).

Finally, there is need for research at an institu-tional level, to provide information on what is work-ing and what is not. There must be more and bettercollaboration between the training institution and theclinical areas, as well as collaboration between in-stitutions at the national and district level. Lack ofthis collaboration can delay implementation ofchanges and introduction of new procedures. Im-proving quality of care depends on new graduateshaving these new skills rather than outdated and dis-carded procedures.

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EVIDENCE ON TYPES OF TRAINING

There are basically four types of pre-service train-ing to prepare professional midwives: a) the appren-tice model, where the trainee works with and learnsunder direct supervision from a professional midwife;b) vocational training, where training takes place ina specific training institution, with clinical experience

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under supervision of a qualified tutor, midwiferyprac t i t ioner, nurse or doc tor ; c ) academicprogrammes, based in universities or other insti-tutions of higher education and d) pre-service orin-service preparation for those already trained asnurses. (Benoit, et al., 2001)

All types of programmes have been shown toproduce competent midwives, with varying degreesof success. There is very little evidence to show thatone type of programme has advantages over another.Programmes for those without nursing training (di-rect entry) usually last between 18 months and fiveyears, with a mean of three years. Those for en-trants already qualified as nurses last from one totwo years, with a mean of 18 months. Mostprogrammes of all types usually require a minimumof 10 years schooling as an entry requirement. Oneor two countries have tried to produce professionalmidwives with less than 10 years schooling, but withlittle success (Sherratt, 2006).

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KEY ISSUES

Many evaluations and reports for low-incomecountries show a lack of competency-based cur-ricula for teaching midwifery, whether pre-ser-vice or in-service.

Community exposure and experience should bean important part of midwifery curricula, but of-ten is not.

Teachers of midwifery should be competent andexperienced midwives; such teachers are in shortsupply in many middle- and low-income coun-tries.

Midwife teachers should have received compe-tency-based education and training in moderneducation and training technologies, but in manycountries have not.

It is important to have national updated standardsfor education programmes and institutions; it isalso important to have accreditation systemswhich permit external verification that practitio-ners completing training programmes have therequisite competencies.

National standards are needed for clinical mid-wifery practice, based on best available evidenceand tailored to the specific context; they often

do not exist or are outdated and ignored by clini-cal practitioners.

People are willing to make use of publichealthcare services if they perceive pre-serviceeducation programmes to be of adequate qual-ity. More work is needed in many countries tobuild confidence in public services.

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KEY ACTION POINTS

Rectifying shortfalls in pre-service training can becostly in organization, human resources and funding,and may take many years, to say nothing of the hard-ship to health providers and their patients, as well asthe community at large (MoH Indonesia, WHO,UNFPA, UNICEF, 2004).

Early exposure to community-based learningexperiences throughout the curriculum, accompaniedby vertical sequencing of community-based learningexperiences – starting from primary health care set-tings and going on to secondary and tertiary levels –are of great value in developing the competenciesrequired for nursing, according to evaluations in SouthAfrica (Ntshali, 2005); there is every reason to be-lieve that midwifery training programmes would de-rive similar benefits from such approaches. Mobi-lizing senior midwives to be tutors on equal par withobstetricians could help empowering the professionwhere needed.

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SUMMARY

Policy makers and programme managers should:

Establish or review national standards for mid-wifery education and practice, including stan-dards for pre-service and in-service programmes;qualifications entering training, and preparationof midwife teachers and institutions, dialoguewith obstetricians and professors to empowermidwives in partnership.

Review all relevant training programmes to en-sure they comply with new standards, in par-ticular that they are adapted to the local contextand include sufficient exposure to midwiferypractice in the community.

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Establish quotas for ethnic minority candidates,to ensure that there will be sufficient recruits tomeet demand.

Ensure that quality assurance systems for edu-cation and training are in place, including strength-ening or establishing robust accreditation systems,to ensure that all midwives and others with mid-wifery skills working at the community level havethe essential competencies, including basicEmONC skills.

Review and revise, or if necessary establish, mid-wife teacher programmes that ensure midwifeteachers are both competent in clinical skills andhave the requisite modern education and train-ing competencies.

Ensure that midwifery teachers are collaborat-ing with clinical midwives, to promote coherencebetween theory and practice.

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CONTEXT-SPECIFIC RECOMMENDATIONS

In countries where there is difficulty in recruiting intomidwifery, or in very weak or complex situations:

Ensure that midwives participate in setting stan-dards of care before being accountable for theiradherence

Consider decentralising training, so that it cantake place close to where recruits live; but main-tain national accreditation.

Consider modular programmes as a new option,with variable exit points that allow a phased de-velopment of skills. Modular training would al-low trainees to leave the course when they reachtheir personal level of attainment, with a certifi-cate that would qualify them as support work-ers, but without the competencies of professionalmidwives. The model is Canada’s programmefor training aboriginal midwives (NAHO, 2004).

Ensure that training materials are available inlocal languages including in ethnic minority lan-guages where feasible.

Establish incentive schemes to support recruit-ment into midwifery, in particular support fordaughters of current TBAs, so they can continuewith the family tradition on a professional basis.

THE ZIMBABWE EXPERIENCE

Between 1980 and 1990 Zimbabwe needed to accelerate the production of providers to offer maternal andneonatal health care in the community because of the rapid movement of the population soon after theliberation struggle.

The country embarked on a six-month programme to upgrade cadres who were medics. After two years itwas clear that this programme was too short to give providers the competencies which would make adifference in the community. The upgrading course was therefore extended to 12 months, adding morecompetencies.

After brief experience, decision-makers in the community demanded that the cadres have still morecompetencies, so midwifery training was extended again from 12 months to 18 months. The 18-monthprogramme produced midwives able to make decisions, offer life-saving procedures, manage somecomplications and refer others appropriately and timely.

This programme was then used to upgrade all care providers working in the community as nurse-midwifetechnicians and to rationalise the different types of care providers, so that the country ended up with only onelevel of midwife. Once all the people trained at the lower grade were upgraded, all subsequent cadrestrained as general nurses first and underwent a one-year midwifery programme. This is currently in use andserving the nation well.

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The problem of getting staff to act on evidence iswidely recognized (Grimshaw et al 2001). As ac-

knowledged by Penny and Murray in their review oftraining initiatives for essential obstetric care, com-munity staff, particularly midwives, are required toapply knowledge to solve problems (Penny & Sheen,2006). Problems are varied and may arise only oc-casionally. Indeed, many midwives working at thecommunity level may never have experienced in theirinitial training some of the problems and complica-tion that they may meet during their professionalcareer. With this in mind and because quality controland improvements need to be continuous, providingmidwives with capacity-building supervision is es-sential, especially for those working in the commu-nity. However, supportive supervision has been ne-glected until recently, and there is limited evidencefrom which to draw models of best practice.

For supervision to build capacity it must go fur-ther than assessing records and reviewing case reg-isters. It needs to be supportive; undertaken by clini-cally competent midwives; allow free and open dis-cussion of clinical practices, and give an opportunityfor providers to acknowledge their weaknesses andneed for further support or training. Supervisionshould empower midwives to work to the full extentof their role. It should offer a framework for scru-tiny of professional standard practice, through a non-confrontational, confidential, midwife-led review ofknowledge, understanding and competence (ENB,1999, Stapleton et al., 1998).

Providing peer support by competent midwivesand networking of staff, especially those working inisolated areas where there is little professional sup-port can be advantageous and improve quality of care.

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KEY ISSUES

Supervision is more than filling in a checklistfrom provincial or national health offices and

4. SUPERVISION IS THE KEY TO MAINTAINING QUALITY AND

MOTIVATION

should be undertaken by someone who pos-sesses the requisite knowledge and experienceof midwifery.

Lack of supervision is strongly associated in manycountries with lack of funds, for example BurkinaFaso (country presentation made during the 1stInternational Forum on Midwifery in the Commu-nity: Lessons Learned. Hammamet, Tunisia, 2006).

STRENGTHENING SUPERVISION IS THE KEY

Since 2001, Bangladesh has been developing atailor-made training programme for a special typeof community midwife called a community-basedskilled birth attendant (CSBA), based on existingcommunity health workers, the family welfareassistant and the female health assistant. Thetraining programme for CSBAs has been designedin the light of the special circumstances inBangladesh, where 90 per cent of all births stilltake place in the home and only 13 per cent with askilled birth attendant. Training is in threemodules: an initial six-month training is followed bya nine-month (or longer) supervised period withpractical work in the field. After completing settargets for work practice, a further three-monthcourse completes the programme.

Supervisors of the CSBAs – a cadre known asfamily welfare visitors – receive special training inmidwifery, focused on life-saving skills, as well asa separate training on supportive supervision. TheCSBA is required to keep a logbook and reflect onpractice during supervised practical work. Thelogbook forms an important part of supportivesupervision: the supervisor goes through thelogbook to discuss issues of clinical practice, andprovides on-the job training for areas of perceivedweakness.

The supportive supervision of CSBAs is not astand-alone activity, but only one component of acomprehensive supervision mechanism currentlyunder development, which will eventuallyencompass all levels of maternal healthcareprovision.

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Supervision is a separate function from the man-agement of the midwifery service, althoughlinked to it. In some areas supervisors may haveresponsibility for both. Supervision, and there-fore those who supervise midwives, play an im-portant role in protecting the public.

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KEY ACTION POINTS

Supervision is a critical component of “clinical gov-ernance”, which has been defined as “A frameworkthrough which organisations are accountable for con-tinuously improving the quality of their services andsafeguarding high standards of care by creating anenvironment in which excellence in clinical care willflourish.” (DoH, 1998)

Professional self-regulation and life-long learn-ing (continuous professional updating and develop-ment) are the other key elements of clinical gover-nance. Supportive supervision, aimed at helping staffreflect purposefully on their practice, lies at the heartof clinical governance and therefore the safeguard-ing of standards. (DoH, 1998)

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SUMMARY

Policy makers and programme managers should:

Establish systems built on models of clinical gov-ernance, aimed at maintaining and improving thequality of midwifery care in the community;

Require each district to appoint an experiencedsenior midwifery supervisor, to oversee and sup-port supervision of midwifery within the district;offer technical advice to the district planning andmanagement teams on quality of midwifery andrelated issues, and commission in-service train-ing as required;

Develop criteria for supervisors of midwivesworking at the community level, which shouldinclude the requirement that all who supervisemidwifery care are themselves competent inmidwifery and receive training in supervisingmidwifery practice.

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An effective health system is the cornerstone ofsuccessful efforts to reduce maternal and new-

born mortality. According to Koblinsky, (2003, p.6)“Assistance at birth by a skilled birth attendant inthe home or any health facility, supported by a func-tioning referral system, can reduce the MMR toaround 50 or below.”

An effective health system is also the corner-stone of many other priority health issues such asrolling back malaria; STI and HIV/AIDSprogrammes; efforts to address neglected diseases;health education and promotion, and even immedi-ate first aid referral for accidents and emergencies.Strengthening health systems is therefore an abso-lute necessity for all countries.

Reducing maternal mortality does not call forsophisticated equipment or technologies. It requiresa regular and adequate supply of safe, inexpensivedrugs; basic equipment such as supplies for main-taining universal precautions against infections (HIV/AIDS and other blood-borne diseases); effective,supportive supervision; transportation, and links to afunctioning EmONC facility.

Active involvement by the community is crucial,including support for midwives working at the com-munity level to function as integral and key mem-bers of the total maternity workforce. Further, thecommunity needs to encourage and support womento seek available services and avoid women fromgiving birth at home without skilled care. The com-munity plays an important part in creating an en-abling environment and must be supported in the role.

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KEY ISSUES

Some countries find women’s empowerment amajor challenge in their efforts to increase pro-vision and access to midwifery care. Womenmust be empowered to demand access to mid-wifery care, as well as to participate in estab-

5. ENABLING FACTORS, INCLUDING PROVISION OF SAFE PRACTICE

ENVIRONMENTS

lishing services and monitoring quality improve-ments to ensure that maternity care is accept-able, accessible and culturally appropriate(Portela, Santarelli, 2003).

Support from the local community and commu-nity leaders, and the active participation of men,are vital, despite the barriers to male participa-tion (Mullay, 2006).

Gender inequality also affects the status of mid-wives and makes it more complex to give mid-wives the support they need to function effec-tively (Sherratt, 2006). Gender perceptions alsoaffect issues of recruitment, mobility, career de-velopment, and remuneration.

Evidence from many maternal mortality studiesreveal that continuing high rates of MMR arelinked to failure of the health system to respondwith the right care, at the right time, in the rightways (Geelhoed et al., 2003 [Ghana], Castro etal., 2000 [Latin America], Massawe et al., 1997[Tanzania]).

Clinical protocols must be adequate, regularly up-dated, and deal with both facility-and commu-nity based care.

The essential drugs for EmONC should be in-cluded in the national drugs list. Safe and con-tinuous supply of essential drugs down to thecommunity level must be assured.

Lack of basic equipment and supplies, and main-tenance of equipment, are major issues in mosthigh-burden countries.

National efforts are needed to prioritise the needfor emergency referral and primary health care,strengthening referral networks and emergencytransportation systems (Razzak, Kellerman,2002, De Brower, Van Leberghe, 2004)

Midwives or others with midwifery skills whowork at the community level are an integral part

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of the maternity care team, and must be givendue respect and appreciation, including in termsof status and commensurate remuneration.

Staff morale and motivation, feelings of secu-rity etc., will all contribute to the sense of work-ing in an enabling environment (Vlassoff, Fonn2001) and should be given high priority. Addi-tional research is needed in that area

Career opportunities for personal advancementaffect staff motivation and are part of an en-abling environment.

All workers, including midwifery practitionerswho work in the community, have rights to pro-tection under various international conventions,not least ILO - C155 Occupational Safety andHealth Convention, 1981.

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KEY ACTION POINTS

In order to strengthen health systems, priority ac-tions need to be identified and focused. Quality im-provement systems, such as continuing total qualitycare improvements, quality circles, even having ba-sic monitoring systems in place, as well as use ofneeds assessments, clinical audits, community sur-veys, confidential enquiry into maternal death, in-vestigations of near-miss cases can all be used asmeans of identification of priority areas. They canpinpoint priority action so that midwives working atthe community level can function in a positive prac-tice environment. By addressing priority actions overtime, improvements will take place.

In a positive practice environment, health carepractitioners can carry out all their tasks and func-tion effectively according to national standards, with-out concern for their health or damage to the healthof patients or clients. Patients’ and clients’ rights donot supersede the rights of health practitioners interms of safety, protection from harassment andphysical or mental harm. (ICN, 2006)

While both employers and staff have a responsi-bility for ensuring a positive practice environment, gov-ernments must hold ultimate responsibility for prioritisinglegislation and frameworks on safety at work. They dothis by establishing national standards for practice, andsafety frameworks for all employed personnel, as wellas rights for patients and clients, all of which mustapply to both the public and private sectors.

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SUMMARY

Policy makers and programme managers should:

Establish or revise national standards for clinicalpractice, education and human resource manage-ment, including review and revise the regulatoryframeworks to ensure midwifery providers’ rightto practise, including their right to practise basic

TANZANIA IMPROVES MIDWIFERY CARECLOSE TO WHERE WOMEN LIVE

In early 2001, Family Care International (FCI)and the Tanzania Ministry of Health conductedan assessment of the availability and quality ofmaternity care in Igunga District, in TaboraRegion in central-western Tanzania. Theassessment revealed serious problems inIgunga’s health facilities, including chronicshortages of supplies and medicines, as wellas gaps in providers’ knowledge and skills, anon-functioning referral system, and lack ofclean water. The assessment also showed thatlower-level health facilities, where the majority ofbirths take place, were the worst off and leastable to provide good quality care to prevent andmanage obstetric and neonatal emergencies.

With assistance from FCI, the district healthofficials began to address these gaps.Specifically, interventions were introduced tostrengthen logistics systems and improve theavailability of essential medicines and supplies.In addition, FCI supported the purchase a newambulance and the installation of a radio callsystem linking the hospital to rural healthcentres so that patients requiring advanced carecould be quickly transferred. Maternity careproviders at all levels of the health system weretrained in life-saving obstetric care skills and inroutine maternal health care, including high-quality antenatal, delivery, and postpartum care.Many of these healthcare providers had not hadany refresher training in midwifery or obstetricssince their basic training – and pre-trainingassessments of their skills revealed seriousgaps in their knowledge and ability to recognizeand respond to complications. A recentevaluation of the work has shown increases inrates of skilled attendance at birth, andmaternity staff all various levels of the healthsystem are better able to recognize and respondto complications.

For more information on FCI support see http://www.familycareintl.org

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EmONC. This may need an autonomous mid-wifery regulatory body to be set up.

Review and revise as necessary the essentialdrug list, to ensure all essential drugs for mater-nal and newborn care are included.

Establish minimum criteria for EmONC facili-ties.

Develop and implement quality improvementssystems to ensure all EmONC facilities meetminimum standards for supply of essential equip-ment; drugs; staff; technical quality of care; ac-cess, and acceptability.

Actively encourage local communities’ partici-pation in management of local services, so thatthey feel a sense of responsibility for staff safetyand protection and can help arrange appropriateand realistic referral systems.

Establish systems so that staff and their familiescan have regular medical check-ups and essen-tial immunizations, and access subsidised or freemedical care.

Develop and apply quality improvements systemsfor community practitioners, including use of com-munity-based satisfaction surveys, follow-up ofall maternal deaths and near-miss cases and au-diting midwives’ practice.

Establish protocols for health and safety at work,including reporting and investigation of adverseincidents affecting clients or staff.

Work with professional associations to identifyappropriate career pathways for midwives work-ing in the community, including progress into edu-cation and management positions. This will helpimprove motivation, which in turn assists recruit-ment and retention of staff.

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Monitoring and evaluation is a very importantarea of programming, but yet another which

has been neglected. Until recently little attention hasbeen paid to the need for permanent monitoring andperiodic evaluation of large midwifery in the com-munity programmes. Very few current programmeshave built-in evaluation, and there is consequent un-certainty about their health outcomes, and thus theireffectiveness.

As mentioned in a presentation at the Forum byDr Hussein, (IMMPACT), it is not always feasibleto use the MMR, nor is it always the right parameterto monitor and evaluate the desired outcome of aprogramme. She suggests that a stepped wedge studymight be more appropriate for programmes aimed atscaling up midwifery in the community, through roll-ing out a cluster of interventions in a phased way indifferent districts. The design is also useful where,for logistical, practical or financial reasons, it is im-possible to deliver the intervention simultaneously toall participants. Stepped wedge designs offer a num-ber of opportunities for data analysis, particularly formodelling the effect of time on the effectiveness ofan intervention. (Brown, Lilford, 2006). The firstrecognized study to use this design was in the Gambiain 1987 Hepatitis study (Gambia Hepatitis StudyGroup, 1987).

Most safe motherhood programmes rely on fairlystandard process indicators (UNICEF, WHO,UNFPA, 1997; Pathak et al., 2000; Paxton, Bailey,Lobis, 2006). However, they are most often usedfor measuring the availability, use and quality of ob-stetric care.

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KEY ISSUES

Safe motherhood programmes should have moni-toring and evaluation plans built in from the verybeginning, in order to assess their effectiveness.

6. MONITORING AND EVALUATION: MEASURING WHAT,WHY AND HOW?

Lack of a universal benchmark to define a skilledbirth attendant has not only caused confusion andlack of validity around this indicator, but has ledto great variations and thus an inability to makecomparative judgements on programmes(Stanton, 2006).

There are currently few reliable and tested toolsto measure the midwifery competencies ofhealthcare providers.

Standards for calculating the number of midwivesor others with midwifery skills needed must takeaccount of the skill mix needed to care for ob-stetric emergencies. The commonly used basicnational standard of 1 midwife to 5,000 popula-tion may have to be adapted to reflect differentgeographical situations; other personal or workdemands on the midwife, and differences in fer-tility. For example, more midwives will be neededin very high fertility countries.

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KEY ACTION POINTS

“A goal cannot be met or missed unless it is mea-sured.” Unless regular monitoring and periodic evalu-ation plans are built in from the beginning, it will beimpossible to say how effective a programme is, orhow well a new intervention is reaching its objective.

Regular monitoring should be based on routinedata collection. Both monitoring and evaluationshould involve midwives at the community level, aswell as the community members themselves, for bothdata collection and analysis, so that midwives canuse the findings. This is particularly important forevaluating training initiatives, where for pragmaticreasons descriptive, non-experimental designs call-ing for before, during and after studies are the onlyoption for assessing effectiveness (Campbell, 1999).

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Finally, there is a need to ensure data is relevantand useful to those who are asked to collect it. With-out this, the reliability of the data will always be inquestion.

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SUMMARY

Policy makers and programme managers should:

Prepare a monitoring and evaluation plan as acomponent of the initial implementation plan.

Define precisely the expected outcome of theprogramme and ensure routine data is matchedto measure these outcomes.

Use ICM’s essential competencies for midwiferypractice as a benchmark for measuring the mid-wifery staff’s skills and abilities (available fromICM web-site http://www.internationalmidwives.org).

Establish baseline indicators through needs as-sessments. These need not be long or overlyambitious.

Ensure that the midwives at the communitylevel are involved in designing the monitoringand evaluation plan, as well as collection anduse of data

Involve the community in monitoring andevaluation: their perceptions of quality have adirect bearing on utilization of services.

Use data from regular monitoring and peri-odic evaluations to make changes in theprogramme.

Monitor midwifery coverage using the mid-wife-to-birth ratio (UNFPA, 2007) and ensuredata is disaggregated to identify underservedareas, and pockets within districts where ac-cess is limited.

SENEGAL – MAKING STRATEGIC INFORMED DECISIONS

For countries with limited resources, good data from regular monitoring and periodic evaluations arecritical in making informed decisions, as Senegal has discovered. Senegal has been able to show asignificant reduction in MMR from 691 in 2000 to 401 in 2005. Good data to track over time not only howmany but where maternal deaths were taking place in the country and from what causes, and wherehealthcare services and personnel were located and utilized, have enabled Senegal to develop andimplement strategies to address major priority areas.

Because they have relatively good time bound data, they know that healthcare access is not yet equitable.Recent reports suggest that only 40 per cent of the 11 million population have access to healthcareservices. Data on health facilities and personnel show that almost three-quarters of all qualified healthprofessionals are located in two cities, Dakar and Thiès. In 2000, Senegal was able to embark on anambitious programme based on this data to re-equip a large number of healthcare facilities and ensurethey were able to provide EmONC.

A recent evaluation of Senegal’s MMR reduction strategies, undertaken with the assistance of UNFPA,IMMPACT and CEFOREP (Centre de Formation et de Recherche en Santé de la Reproduction), has shownthe importance of political commitment for development and implementation of MMR reduction strategies. Ithas also shown the importance for effective decision-making of good data on all aspects of health careservices and delivery, as well as comprehensive data on maternal deaths.

Draft Report. Evaluation Des Strategies De Reduction Des Barrières Économiques, Socioculturelles,Sanitaires Et Institutionnelles À L’accès Aux Soins Obstétricaux Au Sénégal, March 2007

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It is a core responsibility of all governments to ensure that basic healthcare–which includes access

to skilled care during pregnancy, as well as duringand after childbirth–reaches all women and new-borns, especially those living in poverty in urbanand rural areas. The crucial message from theLancet’s series on maternal survival reminds theglobal community of the need for professionalisationof maternity care as an absolute priority (Horton,2006). This is needed more than ever for the ma-ternity workforce at the community level. AsCampbell et al., point out in their paper in theLancet series, “No single intervention can reducematernal mortality and morbidity, but rather it is apackage of interventions that is required. Above all,the package of interventions must be targeted forhigh coverage” (Campbell et al., 2006).

The graphic in the Campbell et al. paper clearlydemonstrates the contribution that midwives work-ing at the community level can make to maternaloutcomes. If they are properly trained and sup-ported, midwives can deliver almost all of the re-quired elements of the package of interventions.They cannot do life-saving surgery, but they canincrease access to surgical interventions whennecessary by helping families make realistic birthand emergency plans, by applying the partographcorrectly, and by following a management proto-col. Midwives can also deliver most of the essentialinterventions to save the lives of newborns. Mid-wives working at the community level are a cost-effective investment.

Only good governance – which includes accessto reliable data sets and a focus on reaching the poor– can make it possible for governments to demon-strate that they are meeting the internationally-ac-cepted obligation of reducing poverty, as stated inMDG-5. Ensuring equitable midwifery care requiresintensified actions and substantial investments, all ofwhich call for increased funds (Borghi et al., 2006).This calls for greater attention to resource mobiliza-tion and to strengthening managements systems, as

7. FUNDING, STEWARDSHIP AND RESOURCE MOBILIZATION AND

MANAGEMENT

well as establishing realistic health budgets thatrecognise the need for additional funds.

Financing healthcare and worker incentives areof particular concern, given the global shortage ofhuman resources. Further, it is acknowledged thathuman resources are likely to be the key to successof any wide-ranging efforts to scale up health-re-lated priority areas, including maternal and newbornhealth (JLI, 2004, Wyass, 2003). However, evidencesuggests that financing for health services in gen-eral, and for maternal and newborn health in par-ticular, has not reached required levels, and inmany areas has not been sufficient to meet evenbasic care for the majority (Ensor, Ronoh, 2005).Studies show poor women are especially vulner-able during pregnancy, more particularly at thetime of birth, and especially if the birth becomescomplicated (Ranson, 2002).

○ ○ ○ ○ ○ ○ ○

KEY ISSUES

Financing for midwifery services in the commu-nity has until recently received little attention andin most cases remains inadequate.

In many countries parliamentarians and seniorpolicy makers are not fully aware of the issuesaround access to midwifery care at the commu-nity level and often fail to understand the com-plexities involved.

User-fees for maternity care have been intro-duced without sufficient evidence that they ben-efit the poorest, while evidence suggests that userfees harm the poorest of the poor (Borghi, 2006).

In many countries midwifery care at communitylevel is too often left to volunteer workers orsemi-skilled, poorly supervised multi-purposeworkers.

Even where safe motherhood programmes are

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built on increasing access to childbirth in institu-tions such as health centres, clinics or hospitals,women and newborns need access to commu-nity-based midwifery care.

Women who access skilled care in the commu-nity during pregnancy are more likely to seekskilled care for the actual birth (FCI, 2002).

Provider performance can increase productivityand therefore reduce demands for human re-sources for health (Wyss, 2003); yet most ef-forts to improve provider performance have fo-cused on training rather than capacity-buildingand worker motivation.

Decentralization efforts have focused mainly onfinancial and structural reforms and have nottaken sufficient account of the human resourcedimension (Kolechmainen-Aitken, 2004).

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

KEY ACTION POINTS

The recent Lancet series on maternal survival sug-gests, “The next 12-18 months will be critical forsafe motherhood advocacy, offering an unprec-edented chance to redress errors of the past andtake advantage of new opportunities.” (Starrs, 2006)

The paper in the Lancet series by Koblinsky etal., “Going to scale with professional skilled care”suggests that the main obstacles to the expansion ofcare are the dire scarcity of skilled providers andhealth systems infrastructures; substandard qualityof care, and women’s reluctance to use maternityservices where costs are high and poorly attuned toservices. The paper goes on to call for strategic de-cision-making in three principal areas – training, de-ployment and retention of healthcare workers

(Koblinsky et al., 2006). All three areas are equallyimportant and all three areas ultimately require ac-tion at senior policy and programme level, and ad-equate funding.

○ ○ ○ ○ ○ ○

SUMMARY

Policy makers and programme managers should:

Identify economic factors that most crucially in-fluence motivation of the midwifery workforceat the community level, especially in rural andurban poor areas, and develop policies, proce-dures and systems to address them.

Ensure that realistic budgets at national, sub-na-tional and district level are set for maternal andnewborn health services, for training ofhealthcare personnel at all levels, for formaliz-ing accreditation, and advocate for full fundingof the budget.

Establish national levels of production for mid-wifery providers, based on realistic demands forequitable services and where necessary negoti-ate with other sectors, including education andfinance, to meet national production targets.

Leverage the influence of stakeholder groups,including NGOs, civil society including profes-sional associations and influential men’s groups,to advocate for increased investments in provid-ing midwifery care at the community as a hu-man-rights issue.

Ensure financing schemes for maternal healthwithout relying on payment for services, givingthe poorest access to maternal and newbornhealth services.

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The Forum gathered international agencies andorganizations, along with midwives, nurses, physi-cians, health policy makers, professional associations,regulatory bodies and researchers from 23 countriesaround the world where maternal and neonatal mor-tality and morbidity remain unacceptably high. Theobjective was to consider how to make midwifery caremore accessible, especially to women living in hard toreach and underserved areas. Having reviewed progressand constraints over these last twenty years, since thelaunch of the Global Safe Motherhood Initiative, par-ticipants concluded that intensified action is needed atglobal, regional and national levels to achieve the addi-tional midwives needed to work in contact with com-munities. Midwives working in close proximity towhere women live will help prevent 530,000 avoidablematernal deaths a year. In addition it will prevent manypost-delivery problems such as obstetric fistula, and helpto reduce the alarming rate of neonatal morbidity andmortality. In 2005 the World Health Organization esti-mated that 334,000 more midwives and others withmidwifery skills are needed around the world. If wellsupported by effective health systems, midwives willhelp governments to achieve their fourth and fifthMillennium Development Goals by 2015.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

THE CALL TO ACTION SAYS:

We, the participants of the 1st International Forumon Midwifery in the Community, call on governments,regulatory bodies, professional health care organiza-

CALL TO ACTION

HAMMAMET CALL TO ACTION ON SCALING-UP “MIDWIFERY IN THE COMMUNITY”RESULTING FROM THE 1ST INTERNATIONAL FORUM ON MIDWIFERY IN THE COMMUNITY

11 – 15 DECEMBER, 2006, HAMMAMET, TUNISIA

tions, educators, and communities worldwide to ensurethe provision of midwifery services in the communityby establishing or improving the following key areas:

Policies to ensure equitable access to midwiferyservices;

Policies and regulatory systems to improve the num-ber, deployment, status and conditions of work ofmidwives and others with midwifery skills;

Competency-based education and training in mid-wifery skills;

Peer and supportive supervision of providers inthe field;

An enabling environment to support effectivehealthcare delivery, including infrastructure, com-munication, emergency transportation, adequatefunding, equipment and supplies;

Permanent monitoring and periodic evaluation.

We believe that these actions will strengthenmidwifery as an integrated part of the healthcare inthe community. In addition they will improve the con-tinuum of care needed to protect the health of womenand babies, and save their lives by increasing accessto emergency obstetric and neonatal care (EmONC).

We also believe that it is the collective obliga-tion of all stakeholders to guarantee mothers andtheir newborns their human rights to safe preg-nancy, childbirth, and a safe postpartum recoverywherever they may live.

Every minute a woman dies somewhere in the world from pregnancy-related complications, and many more are leftdisabled, because they lack access to skilled midwifery care. Evidence shows that a midwife or other healthcare

provider with midwifery skills offers the most cost-effective, low-technology but high-quality solution to achieving safemotherhood, a central component of reproductive health. In addition, midwives are crucial to help ensure newborn sur-vival, improve maternal and newborn health and reduce the estimated 7 million perinatal deaths each year.

The 1st International Forum in Hammamet, Tunisia, on “Midwifery in the Community” concluded its week-longdeliberations with a Call to Action for the strengthening and scaling up of midwifery in the community–to contributeto the prevention of the avoidable death and disability of mothers and their newborns, as well as promoting the healthof mothers and babies.

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