Ann M. Starrs is Executive Vice President for Family Care International.
Five weeks ago, some 8-10,000 of the world's obstetrician-gynecologists met in Kuala Lumpur for their triennial Congress. While the meeting paid more attention to the problem of maternal mortality and morbidity in the developing world than it ever has in the past, the fact is that much of the conference proceedings were about new technologies, innovative techniques, and drugs under development – many of which will have no impact whatsoever on the health of 95% of the pregnant women of the world, because they are unaffordable and inaccessible to those women.
This week, in Tunisia, about 100 maternal health advocates, health care professionals, and program planners met to talk about an approach that could have a tremendous impact on women's ability to go through pregnancy and childbirth safely, if it can generate the policy commitment, strategic thinking, and funding it needs and deserves: how to train, deploy, and support midwives in or close to the communities where women are living – and dying.
The workshop on "Midwifery in the Community: Lessons to be Learnt," co-sponsored by UNFPA, WHO/Making Pregnancy Safer, and the International Confederation of Midwives (ICM), zeroed in on an enormous gap in the health sector workforce in the developing world. The World Health Organization's World Health Report 2006, cites a "crisis in the global health workforce," with a shortage of almost 4.3 million midwives, nurses and doctors worldwide. This publication, and the 2005 World Health Report focusing on maternal, newborn and child health, have highlighted some key facts:
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- Almost 45% of women in the developing world give birth without a midwife, nurse or doctor at their side;
- In order to meet the Millennium Development Goal 5 target for skilled attendance at childbirth, we need an additional 334,000 midwives (or others with midwifery skills) by the year 2015;
- Africa has perhaps the world's most severe shortage of health care professionals in general, and midwives in particular; while 13% of the world's population lives in sub-Saharan Africa, that region accounts for 25% of the world's maternal deaths, and less than 3% of the world's health workers.
The solution seems obvious; train the midwives and get them out there, so they can start taking care of pregnant women and their babies. But it's not that easy. Training costs money, of course, and takes time; many donors and governments do not want to hear that they need to invest in long-term solutions like upgrading and expanding midwifery schools, with the payoff 3-5 years down the road. And even if the midwives were trained in the quantities needed, there are the ongoing challenges of paying their salaries, making decent housing available, ensuring they have the equipment and supplies they need to provide life-saving care, setting up systems for monitoring and supervision, and – perhaps most crucially, at least in terms of saving lives – establishing referral mechanisms so that those women who do need a doctor or a hospital (for a C-section or blood transfusion, for example) can get there quickly and efficiently.
Hence the Tunisia workshop, which was looking at some so-called intermediary or alternative strategies that countries have been testing. Globally, midwives and ob/gyns, along with WHO, have set out a clear definition of what constitutes a "skilled birth attendant" – someone with the basic skills and competencies to care for a woman during pregnancy and childbirth, as well as her newborn infant. That includes care for both normal cases and for those – estimated at 15% – who develop some sort of illness or complication that requires a medical intervention. The length of training needed to ensure this minimum level of skill varies; but most midwifery training programs require at least three years of education, much of it hands-on, before someone can be certified as a midwife.
But are there cheaper, faster options? What if people were trained for six or nine or 12 months – would that be enough to equip them with the skills they need to save lives? A range of countries are trying these approaches: Indonesia, Bangladesh, India, Ethiopia, Cambodia, Nepal, among others. The jury is still out for many of these programs; but while hopes are high, most of the experts at the workshop this week are concerned that these shorter-term training efforts, without adequate support, are unlikely to make a significant dent in the high rates of maternal mortality prevalent in these countries. The few assessments to date indicate that many of these "junior midwives" lack the skills, the knowledge, and the confidence to manage serious complications like hemorrhage or severe infection. While calling them "skilled birth attendants" may enable a government to say it will meet the MDG 5 target for skilled attendance at delivery, the reality is that these workers cannot provide the care that women need to survive.
So do we give up on the "junior midwife" approach? Not necessarily. Ideally, we would have enough fully qualified midwives to take care of every pregnant woman, and wherever she wanted to deliver – at home, in a local clinic or health center, or in a hospital. But looking at the numbers, that isn't going to happen, not anytime soon.
The Lancet Maternal Survival Series steering group, in their recent series of articles analyzing program options for reducing maternal mortality, outlined an approach that may be the best of both worlds. The Lancet group proposes having fully-skilled midwives (or their equivalents), working in health centers or other facilities that are in the community close to where women live, with midwife assistants to help them out. In this way, the midwife assistants can attend the women who have normal deliveries; the midwives (or doctors) can be there to handle the tough cases, and to oversee referral to a hospital if that is necessary. These teams – experienced midwife and midwife assistant together – can also support and supervise community health workers in villages, who can provide education and follow-up during pregnancy and after delivery, especially critical for vulnerable newborns.
FCI's Skilled Care Initiative, funded by the Bill and Melinda Gates Foundation, followed a similar approach in four pilot districts in Africa, with a combination of training and recruitment of skilled attendants, upgrading infrastructure, ensuring essential supplies and equipment, improving referral and supervision, and working with communities to encourage women to deliver in a health facility. While results varied, the district with the lowest rate of skilled attendance at the beginning of the project more than doubled its rate (from 25% to 56%) in just over two years of implementation.
The global Safe Motherhood Initiative is turning 20 next year. We've made mistakes in the past, recommending strategies that hard-nosed research revealed not to be effective. We don't know for sure that this strategy – skilled midwifery care in community-level health facilities – is going to be the answer. But looking at what we've learned, it's the most promising option we have – if we care about giving women the chance they deserve, to survive and thrive.