October 30, 2014 —Summary of "Improvement of Material and Newborn Health Through Midwifery," Petra ten Hoope-Bender et al., The Lancet, Sept. 27, 2014.
In the last of a series of papers examining "the contribution of midwifery to the survival, health, and wellbeing of childbearing women and newborn infants," Petra ten Hoope-Bender of the Instituto de Cooperación Social Integrare and colleagues focus on policy implications, "the potential effect of life-saving interventions that fall within the scope of practice of midwives" and how health systems changes in countries that have embraced midwifery have contributed to reductions in maternal mortality.
In the paper, the authors briefly summarize three previous papers published in the series; highlight research priorities "to generate better evidence and suggest practical steps for all countries to move towards people-centred and woman-centred care"; and discuss "how achievement of universal, effective coverage of high-quality maternal and newborn care is of central importance to primary health care and the broader agenda for global health."
The three prior papers in the series examined the "evidence base that distinguishes between what care is needed, how it is provided, and who should provide it," ten Hoope-Bender and colleagues write. They write in summary of the papers:
~ One found that "when systems are consistently strengthened over a long period of time, investment in midwives is a realistic and effective strategy to reduce maternal mortality";
~ One identified "key aspects of quality maternal and newborn care" and proposed an "evidence-based framework for quality maternal and newborn care, which expands the notion of quality of care from the conventional technical dimensions of what is done, to include how, where, and by whom this care is provided"; and
~ One found that "scaling up midwifery could help reduce adverse health outcomes ... and could be implemented with successful outcomes at any stage of a country's transition to lower maternal and newborn mortality rates."
Developing Effective Maternal and Newborn Health Care
The authors write that the "varied competencies and expertise" of different health care providers "should be brought together into an interprofessional practice-ready team" to "ensure continuity and quality of care." Well-educated midwives, when provided with adequate support, "possess the competencies across the reproductive, maternal and newborn health continuum and are both a connector across and a driving force behind that continuum," they add.
However, they note several potential obstacles for "implement[ing] the framework for quality maternal and newborn care" in middle- and low-income countries. They argue, "Investment in education alone will not suffice and will have to be combined with investment in regulation, effective human resource management, and the service delivery environment in which future midwives will work, so that they will not only be able to cope with the increased workload, but will also ensure quality clinical and psychological care."
Further, the authors note that "[m]ore evidence is needed to inform effective ways of scaling up the midwifery workforce," such as education, regulation and in-service training, among others. To this end, they propose "three priority research areas." Those areas include:
~ Better evidence on labor mobility, including "the recruitment, posting, and transfer of staff to remote and underserved areas; how to measure and improve staff deployment and retention; and how to ensure that the net increase in the number of midwives matches increases in demand in rural and urban areas";
~ A better understanding "of the productivity of the midwifery workforce, maternity units, and the models of practice, such as midwifery led care," as well as a "set of effective implementation strategies"; and
~ "The development of adequate strategies to manage the increasing commercialisation [of childbirth] ... that will mitigate the adverse effects of commercialisation and tackle the resulting inequalities."
Improving the Quality of Maternal and Newborn Care
The authors note that while primary care services have "fully recognised the importance of people-centred care," maternal and newborn health care has remained focused "on life-saving interventions and increases in coverage."
They continue, "To deliver high-quality care, health professionals and policy makers need to create an environment in which the 72 effective midwifery interventions identified in this Series can be implemented consistently with the woman-centred values and philosophy outlined in the framework for maternal and newborn care." According to the authors, this environment would include education for health care professionals, "efficient regulation of practice" and "partnership and dialogue between care providers and with care users and communities."
How Midwifery Can Contribute to 'Effective Coverage and Women-Centred Agendas'
"Midwives, when working to the framework for quality maternal and newborn care and within an enabled environment, have the potential to bring care close to women and communities and tailor it to their social and cultural needs," the authors write.
Specifically, they note that effective midwifery can optimize "the normal processes of reproduction and the early years of life"; safely manage health complications "before they become life-threatening"; and help reduce maternal mortality, stillbirths and complications while boosting rates of breastfeeding, patient satisfaction and vaginal births.
Recognizing High-Quality Maternal and Newborn Care as a Global Priority
"People-centred care that recognises people's legitimate right to and expectations for equitable, high-quality, safe, and respectful care should be a global health priority and be put at the heart of the movement to improve maternal and newborn care," the authors write, adding that midwifery is a "vital solution" for providing such care for women and newborns "in all countries."
However, they note that "progress made in the midwifery workforce" has been insufficient "to enable the attainment of [Millennium Development Goal] 4 and MDG 5 in all countries by 2015." Citing studies about the efficacy of midwifery, the authors write that "investment in midwifery is an effective solution to attain MDG 4 and MDG 5 and the new global targets, provide a basis for primary health care and universal health coverage, achieve the grand convergence in global health by 2035, and deliver on women's rights to sexual and reproductive health."
"As shown by the estimates of lives saved through increases in coverage of the midwifery package of care and the experiences of a few exemplary low-income and middle-income countries that have invested in midwives, use of the framework for quality maternal and newborn care is a means to good health and improved social outcomes for women, men, and children," the authors write.
They add, "The high-quality maternal and newborn care described in this Series should be at the heart of all subnational, national, regional, and global efforts to improve women's and children's health and wellbeing, and it needs a core position within the post 2015 agenda."