Ariadna Capasso is senior technical advisor for the FCI Program of Management Sciences for Health.
We know how to prevent maternal and newborn deaths, but globally, almost 300,000 women and 3 million newborns continue to lose their lives because they lack access to high-quality obstetric services–services which midwives provide. Skilled midwives can prevent up to two-thirds of maternal and newborn deaths by ensuring a safe birth for both mother and baby and responding quickly when complications arise.
Midwives not only provide essential care, they also provide a powerful voice for policies and programs that advance access to affordable and high-quality health services. They understand the health needs of women and newborns, as they work to meet those needs everyday. And they experience, firsthand, the gaps in health systems, from human resources and infrastructure to regulations that limit their practice.
Nongma Evariste Sawadogo is a trained midwife. He joined Family Care International (FCI) two years ago as a program officer and managed Burkina Faso’s reproductive, maternal, newborn and child health (RMNCH) projects. He will soon join Management Sciences for Health (MSH) as a member of the recently launched FCI Program.
Nongma is passionate about improving RMNCH in his country and community. He works with community-based organizations, leads workshops, provides technical support to community health facilities, and evaluates projects to advance RMNCH and to ensure the greatest impact for women and children.
Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the Maternal Health Task Force blog as part of a series for the Global Maternal and Newborn Health Conference, October 2015 in Mexico City.
The year 2015 has been one of dramatic movement for global maternal and newborn health—from the end of the Millennium Development Goals to the beginning of a universal and even more ambitious global agenda. The Global Maternal and Newborn Health Conference is a key moment to examine how the Sustainable Development Goals will help ensure and improve quality of care, integration and equity. I’m pleased to see on the conference program a focus on midwives, a key partner in turning the conference themes and focus into a reality for women and their families everywhere.
At this crossroads moment in global development, it’s a travesty that the countries burdened with 92% of the world’s maternal and newborn deaths have only 42% of the world’s midwives, nurses and doctors. Even though we have the medicines and the technology to make sure no woman or newborn dies from preventable causes, a person’s place of residence often still determines whether–and how–she will live or die. This is simply unacceptable. Fortunately, skilled midwives can prevent up to two-thirds of maternal and newborn deaths, and in doing so can turn around health care in their communities, according to UNFPA’s State of the World’s Midwifery Report 2014.
Alexia Escóbar is the National Coordinator for FCI-Bolivia.
In April, I journeyed by boat along Bolivia’s Ichilo River to a remote community of the Yuracaré people. I hoped to better understand how pregnant women from these poor indigenous villages travel to the nearest health facility–located an hour and a half away—for the skilled care they need. During our trip to Tres Islas, colleagues from UNICEF Bolivia and I discovered that these women face not only transportation difficulties but also many other barriers in accessing culturally respectful, high-quality health care. Continue reading “My journey to Tres Islas”
Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
For women around the world, compassionate and competent care from a midwife can mean the difference between life and death. We know that midwives provide life-saving care during pregnancy, childbirth, and in the postnatal period. Midwives, and other mid-level and community health providers, can administer essential medicines, such as oxytocin and misoprostol, which are safe and effective for preventing and treating life-threatening postpartum bleeding or hemorrhage (PPH), the leading cause of maternal death in most developing countries. Access to misoprostol is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used in poorly equipped health facilities and even home births.
In order for midwives to provide life-saving maternal health care, they need the support of policies that enable them to provide a full range of medical interventions. In some countries, however, midwives are not legally authorized to administer oxytocin and/or misoprostol —despite evidence that administration by low and mid-level health providers is feasible and effective. But physicians sometimes resist or oppose expansion of midwives’ scope of practice, based on notions of “professional territoriality” and concerns about their capacity to correctly and safely administer these medications.
Most women in low-resource settings give birth in lower-level health facilities or at home, attended by a midwife or other mid-level health provider. So restrictive policies requiring that administration of medications be carried out only by physicians limits women’s access to essential medicines they need for safe pregnancy and childbirth. Placing misoprostol in the hands of non‐physician providers, for example, can expand access to timely PPH treatment. In remote and rural areas, where transfer for emergency obstetric treatment at a higher-level facility may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
The global health community can play an important role in addressing and removing policy and regulatory barriers, and ultimately in improving women’s access to essential medicines. Making this happen will require that governments, in many countries, revise policies that allow administration of medications only by physicians. In 2012, WHO issued guidelines on task-shifting for maternal and newborn health. They called for a “more rational distribution of tasks and responsibilities among cadres of health workers …[to] significantly improve both access and cost-effectiveness – for example by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions otherwise provided only by cadres with longer (and sometimes more specialized) training.” This makes excellent sense.
The leading global health professional associations focused on pregnancy and childbirth, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO), can work together to ensure that these international recommendations translate into changes in national norms and in clinical practice. Earlier this year, ICM and FIGO issued a joint statement, Misoprostol for the treatment of postpartum hemorrhage in low resource settings, which called on partners to:
Promote task-sharing approach
Ensure that skilled health providers (and not just doctors) can administer uterotonic drugs like misoprostol and oxytocin
Challenge regulatory and policy barriers that limit access to high quality maternal health care
Advocate for increasing the midwifery workforce
Implement innovative strategies to strengthen the role of midwives and non-physician providers in providing high-quality maternal health services
Health professionals, policy makers, and other partners must work together to ensure that every woman has access to the uterotonic medicines that can protect her from the suffering and potential death that can be caused by postpartum hemorrhage.
 Beverly Winikoff, Why misoprostol in the hands of non-physician providers matters, Presentation at the ICM Trienniel Congress, Prague, June 3, 2014.
Today, at the London School of Hygiene and Tropical Medicine, The Lancet launched its newest series Midwifery. This series provides concrete actions for stopping preventable maternal and newborn death and ensuring perinatal health. The knowledge that midwives are key to preventing perinatal death is not new. However, scaling up the utilization of midwives on a systems level is lacking, which has prevented this solution from becoming a reality.
The Midwifery Series was created to provide concrete guidance and frameworks on how to utilize midwives and a new standard of care for Quality Maternal and Newborn Care (QMNC). At the center of this model of care are the needs of women and their newborn infants. Even though the needs of women across the world seem to differ greatly, this series clarifies that no matter where a woman lives, care led by a midwife is the answer to ensuring health. The series comprises four separate papers which were created by a multidisciplinary group, including academics, researchers, advocates for women and children, clinicians, and policy-makers. This multidisciplinary approach is necessary for addressing current gaps in perinatal care.
The current maternal and newborn health landscape often offers fragmented solutions and interventions to address the needs of women and their newborns. This fragmentation is a barrier to adequate perinatal care. These gaps in care lead to 98% of the annual 289,000 maternal deaths, 2.6 million stillbirths, and 2.9 million neonatal deaths. In order to mitigate these preventable deaths, improvements in the quality throughout the continuum of care and emergency services are imperative. The series supports a whole-system approach to improving perinatal care by ensuring skilled care for all.
The Lives Saved Tool (LiST) was used in the series to model different levels of scale-up of essential interventions for reproductive, maternal, and newborn health (RMNH) which are within the scope of practice of a midwife. In low-resource settings even a 10% increase in the interventions covered by midwifery would decrease maternal mortality by 27%. Therefore, more rigorous scale-up could have an incredible impact on reducing maternal mortality.
The standard for QMNC presented in the series is globally applicable as it not only focuses on the scale-up of essential interventions, but also the harmful effects and necessary mitigation of over-medicalization of birth and perinatal care. Professor Petra ten Hoope-Bender, of the Instituto do Cooperación Social Integrare, Barcelona, Spain, said, “Although the level and type of risks related to pregnancy, birth, postpartum and the early weeks of life differ between countries and settings, the need to implement effective, sustainable, and affordable improvements in the quality of care is common to all, and midwifery is pivotal to this approach. However, it is important to understand that to be most effective, a midwife must have access to a functioning health-care service, and for her work to be respected, and integrated with other health-care professionals; the provision of health care and midwifery services must be effectively connected across communities and health—care facilities.”
In order to assist the development of health systems and their integration of midwives, the series provides three new tools:
The Framework for Quality Maternal and Newborn Care is applicable to all countries on not only what needs to be implemented, but how to implement strategies to reduce maternal, neonatal, and infant mortality and morbidity, improve quality of care, and increase efficiency of health systems.
Country diagrams can be used to identify the most important elements required to strengthen a country’s health systems to provide quality midwifery services.
Pragmatic steps provide a guide to initiate or further develop their midwifery services.
Midwives not only provide care at the time of birth, but work with women from before their pregnancy through their newborns infancy to prevent death and ensure health. This life course approach is essential for having a large impact on the needless numbers of deaths and morbidities. Check out The Lancet’s Midwifery Series for more details on how midwives will make a large difference in the lives of women and their children in the coming years as the post-2015 agenda is implemented.
Amy Boldosser-Boesch is FCI’s Director of Global Advocacy. This article originally appeared on the Global Motherhood section of Huffington Post.
In 1998, Fatimata Kané was still a practicing midwife, visiting a local village when she met Kadija.* Kadija was pregnant and nearing the end of her third trimester. Fatimata could immediately see that Kadija was not well: she looked exhausted, was severely anemic, and had edema in her lower extremities. If she didn’t seek care right away, both she and her baby could die during labor. Fatimata told the woman and her family that she needed to get to a hospital quickly, but the family did not understand. Kadija had many children and had never once received pre-natal care or been to a hospital. All of her babies had been delivered at home, and she used the traditional medicines available in her village. She lived over 10 miles from a hospital and the trip was expensive.
After a lot of persuading, Fatimata convinced the woman’s family to let her deliver in the hospital. Sadly, they could not get to the hospital fast enough to save the baby, but were able to save Kadija’s life. Fatimata often replays the moment over and over in her head. Had she not been there, and had she not been trained as a midwife, she would not have known that Kadija was in urgent need of care.
Fatimata, now the director of FCI-Mali, is using her firsthand knowledge of the need for quality reproductive, maternal and newborn health care at the community level to advocate full time for improved maternal and newborn health care in Mali. She makes the case for strengthening midwifery through increased investments in training and supportive policies so that midwives can continue to provide lifesaving care to pregnant women and newborns, including pre-natal and post-natal care and family planning, in their communities.
Midwives, like Fatimata, can be a profound and powerful voice for change in their countries. If their services were available and accessible to all women and babies who need them, midwives could help avert two-thirds of the nearly 300,000 maternal deaths and half of the 3 million newborn deaths that occur each year, provided they are well-trained, well-equipped, well-supported and authorized. Midwives understand the health care needs of women and newborns, because they work to meet those needs every day. They see the gaps in the health care system — in resources, staffing, facilities, and policies — because they struggle to fill those gaps, day in and day out. And they are uniquely positioned to speak the truth about midwives’ need for training, for support, and for enabling policies – because they have dedicated their lives to doing this crucial job for women and their families.
In partnership withJohnson and Johnson, the International Confederation of Midwives and UNFPA, Family Care International (FCI) is helping to prepare midwives to advocate for improved maternal and newborn health services using evidence from a new report on The State of the World’s Midwifery. Although providing quality midwifery care will always be their first priority, midwives can also be champions for their profession, helping to hold governments accountable for keeping the promises they’ve made to women and babies, and ensuring that young midwives just starting out in their careers will enter a workplace that recognizes, values and supports their role.
National midwives associations have already been successful in advocating for new policies ranging from a policy for development of a national education system for midwives in Afghanistan to a policy on improving quality family planning services to improve maternal health in Nigeria.
Enis Banda, a midwife from Malawi, said on this year’s International Day of the Midwife that “life starts in the hands of a midwife.” With tools to support their advocacy efforts, stronger policies and programs to improve midwifery care and maternal and newborn health can start in the hands of a midwife too.
How will you help make the case for midwifery in your community?
Imtiaz Kamal is the president of the Midwifery Association of Pakistan. She has led a “one-woman crusade” to promote the midwifery profession for more than 50 years.
In June 2013, all four provinces of Pakistan—Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan—included misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) on their respective Essential Medicines Lists (EMLs). EMLs indicate medicines that “satisfy the priority health care needs of the population” and should be affordable and available at all times within the context of a functioning health system. As advocates working towards improving reproductive and maternal health in Pakistan, we’ve come a long way in our mission to expand access to misoprostol. In this post, I share our advocacy strategy and the challenges we faced.
The sixth most populous country in the world, Pakistan has an alarmingly high maternal mortality ratio: 260 maternal deaths per 100,000 live births. Every year, almost 12,000 women in Pakistan die from pregnancy and childbirth related complications, accounting for almost 5% of the world’s maternal deaths, and PPH—excessive bleeding after childbirth—causes 27% of these deaths. About 57% of deliveries still take place without a skilled birth attendant present, and in these situations, women often do not have the means to address life-threatening complications when they arise. Fortunately, there is a safe and effective solution to treat and prevent PPH—misoprostol, a low-cost medicine that is practical for use in both facility and home births.
One step for improving access to this essential medicine was to get provincial governments to include misoprostol on their respective EMLs. Then, the provincial governments can supply it to the public sector health facilities, which would provide this essential medicine at minimal or no cost to women wherever they live.
Usually, the Pakistani government follows the World Health Organization’s (WHO) EML, but due to misoprostol’s association as an “abortion drug,” we had to sell it to policymakers, highlighting misoprostol’s huge lifesaving potential and the urgency to expand access to women who need it. Misoprostol is an essential part of a package of strategies to improve maternal health, and we must ensure that its use for other indications does not lead to limitations on its availability for PPH.
We devised an advocacy strategy to share the evidence and stimulate supportive policy change through:
Public education and awareness:fact sheets and case studies in English and Urdu, press conferences, trainings with journalists, and air time on television;
Advocacy with decision-makers, including high-level Ministry of Health authorities, district health officers, OB/GYNs, and other health providers: face-to-face meetings and dissemination seminars in Punjab, Sindh, and the federal capital, Islamabad, to share guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO).
Our advocacy strategy led to very specific, positive outcomes:
Endorsements from key champions: The Director General of Health in Sindh province became a close ally and guided us on how to move forward in garnering support from OB/GYNs and district health officers;
A widely distributed position paper on misoprostol for PPH and post-abortion care (PAC) was signed by six professional organisations working for maternal and neonatal health;
The National Assembly decided that the federal government should provide training to midwives and other health care providers on the administration of misoprostol to manage incomplete abortion and miscarriage and prevent PPH. In Sindh, the Directorate of Nursing came to us for guidance, and the first misoprostol workshop for midwifery teachers is scheduled for late February 2014.
Our advocacy efforts weren’t without challenges, however. For example, many physicians were cautious or opposed to making misoprostol more widely available. The most senior OB/GYN (from a province with very high maternal mortality) raised a number of concerns after a presentation we held on misoprostol, commenting: “It is not candy. We cannot let it be available freely.” We explained that, given the high prevalence of home births, we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births. Distributing misoprostol doesn’t replace efforts to promote skilled care, but we need to recognize the reality that many women are not able to give birth in well-equipped health facilities with skilled staff. All women, wherever they decide to give birth, need access to effective medicines.
We faced similar comments and questions at every advocacy meeting. But this didn’t stop us; we continued to make our case. Eventually, that very same OB/GYN signed our position paper on misoprostol.
The movement to achieve national recognition of misoprostol for PPH has been challenging, but we are making progress, turning heads, and changing minds. Step by step, we push forward. Now that we have achieved Federal approval of misoprostol, we are working to advance community level distribution of misoprostol to women in their eighth month of pregnancy. As a global community, with partners such as FCI rallying behind the cause, we will succeed in making sure women no longer have to fear for their lives when giving birth.