Evaluation of health workers' training in use of the partogram.

OBJECTIVE: To assess the impact of training on use of the partogram for labor monitoring among various categories of primary health care workers. METHODS: Fifty-six health workers offering delivery services in primary health care facilities were trained to use the partogram and were evaluated after 7 months. RESULTS: A total of 242 partograms of women in labor were plotted over a 1-year period; 76.9% of them were correctly plotted. Community health extension workers (CHEWs) plotted 193 (79.8%) partograms and nurse/midwives plotted 49 (20.2%). Inappropriate action based on the partogram occurred in 6.6%. No statistically significant difference was recorded in the rate of correct plotting and consequent decision-making between nurse/midwives and the CHEWs. CONCLUSION: Lower cadres of primary health care workers can be effectively trained to use the partogram with satisfactory results, and thus contribute towards improved maternal outcomes in developing countries with scarcity of skilled attendants.     

Midline versus transverse incision for cesarean delivery in low-income countries

While transverse incision is the recommended entry technique for cesarean delivery in high-income countries, it is our experience that midline incision is still used routinely in many low-income settings. Accordingly, international guidelines lack uniformity on this matter. Although evidence is limited, the literature suggests important advantages of the transverse incision, with lower risk of long-term disabilities such as wound disruption and hernia. Also, potential extra time spent on this incision appears not to impact neonatal outcome. Therefore, we suggest that it is time for a change in guidelines for low-income settings in which resources are limited for treating complications that may be life threatening.     

WOMEN'S HEALTH AND LOW-INCOME HOUSING

The inequities in health care and housing access experienced by low-income women in the United States are a continuing concern. This article addresses the interrelationships between housing and health as experienced by low-income clients so that health care practitioners can begin to build active and effective health-promoting partnerships with clients, their families, and their communities. A case study is presented that describes the actual experience of a woman living in a low-income housing development and its effect on her health and access to health care. The importance of the role of midwives in addressing the health care and advocacy needs of women in substandard housing is highlighted.     

The provision of midwife-led care in low-and middle-income countries: An integrative review

BackgroundThe provision of midwife-led care, the model of care in which midwives are the lead professionals for women and newborn infants across the continuum, has been shown to be effective in improving outcomes for women and newborn infants, but predominantly based on research in high-income countries.ObjectiveTo explore how midwife-led care is provided in low- and middle-income countries. The specific question was to examine how, where and by whom has midwife-led care been provided in low-and-middle-income countries? Design: An integrative literature review was undertaken and included studies using a range of methods.Data sourcesA systematic search was conducted in Pubmed, EMBASE (Ovid), Web of Science, Scopus, Google Scholar, The Cochrane Library and hand-searching of relevant journals and website of International Organizations and relevant grey-literature.Review methodsAfter applying inclusion criteria, systematic sifting and quality assessment processes, data were extracted from relevant studies. The software program NVivo was used to initially extract the findings and results of the studies. Coded data from primary data sources were iteratively compared, using patterns and themes as per the conceptual framework of the WHO on skilled health personnel providing care for childbearing women and newborn infants, including an analysis of the competent provider, standards of practice and the enabling environment.FindingsOf a total of 3324 articles retrieved, 31 studies were included. There were 18 qualitative, nine quantitative and four mixed method studies with different levels of quality from five of six global regions published between 1997 and 2017. In these studies, midwife-led care was not found to be a standardised model in low- and middle-income countries (LMIC) and there was limited evidence on the effectiveness of midwife-led care in these countries. Care provided across the continuum was however described in most studies. Standards of practice in education, regulation and training varied widely as did the enabling environment in which midwife-led care took place.Conclusion and implication for practice and researchMidwife-led care is provided across low- and middle-income countries but lack of enabling factors limits the quality of care that midwives can provide. Further research about this model of care is needed to understand the ingredients of successful implementation, their effectiveness and sustainability.     

Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries

Objectives

To evaluate pre-eclampsia/eclampsia-associated maternal mortality in high-income countries to understand better the potential improvements in pre-eclampsia/eclampsia-related mortality in low-income countries.

Methods

We searched Medline, PubMed, and the Cochrane Database (1900-2010) using relevant search terms. Studies of the incidence of pre-eclampsia/eclampsia and case fatality rates in various geographic regions were included. The incidence of pre-eclampsia/eclampsia and the pre-eclampsia/eclampsia-associated case fatality rates are presented by location and year.

Results

Most declines in maternal mortality associated with pre-eclampsia/eclampsia in high-income countries occurred between 1940 and 1970 and were associated with a 90% reduction in the incidence of eclampsia and a 90% reduction in the case fatality rate in women with eclampsia. The most important interventions were widespread use of prenatal care with blood pressure and urine protein measurement, and increased access to hospital care for timely induction of labor or cesarean delivery for women with severe pre-eclampsia or seizures.

Conclusions

A substantial reduction in pre-eclampsia/eclampsia-related mortality could be made in low-income countries by widespread hypertension and proteinuria screening and early delivery of women with severe disease. Magnesium sulfate may reduce mortality, but should not be the cornerstone of maternal mortality reduction programs.     

The disappearing art of instrumental delivery: time to reverse the trend.

PURPOSE: This paper focuses attention on declining rates of instrumental (vacuum or forceps) delivery. The decline often means that women must travel further to deliver in hospitals with capacity for cesarean delivery. BACKGROUND: The paper illustrates recent trends in the use of vacuum extraction and forceps in low- and high-income countries. It describes some of the obstacles to the use of instrumental delivery and why the techniques, especially vacuum extraction, should be reintroduced. Over the past two decades, many countries have observed a decline in instrumental delivery rates while cesarean rates have increased. Objections to instrumental delivery are largely due to the potential harm it causes newborns. Some medical schools no longer train their professionals to perform instrumental delivery. Elsewhere, only specialists are permitted to perform the procedures. METHODS AND RESULTS: As this is a policy paper rather than a research report, the methods and results sections are not applicable. CONCLUSIONS: Vacuum extraction can be taught to midlevel practitioners (midwives, nurse practitioners and general physicians), thereby increasing access to emergency obstetric care especially at the periphery. This allows women to give birth closer to home in midlevel facilities when hospitals are not easily accessible or are overcrowded. Where instrumental and cesarean delivery are both available, instrumental delivery could potentially reduce the risks associated with cesarean delivery and reduce the costs of obstetric care.     

Midwifery in the 21st century. Recommendations from the Pew Health Professions Commission/UCSF Center for the Health Professions 1998 Taskforce on Midwifery.

Unprecedented changes in the delivery and financing of health care have produced angst and opportunity, criticism, and innovation. To explore the effects of these market-driven changes on midwifery, the University of California at San Francisco Center for the Health Professions convened a Taskforce on Midwifery in 1998. Consisting of eight experts from across the country, the Taskforce was charged with exploring the impact of health care system developments on midwifery, and identifying issues facing the profession and the roles midwives play in women's health care. The Taskforce answered its charge by offering 14 recommendations related to midwifery practice, regulation, education, research, and policy. The recommendations incorporate the Taskforce vision that the midwifery model of care should be embraced by, and incorporated into, the health care system in order to make it available to all women and their families. Midwives, educators, collaborators, and policymakers can use the recommendations to develop curricula, practice sites, and laws for an improved health care system that fully includes midwives and encompasses the midwifery model of care.     

Responding to Humanitarian Crises: Midwifery Care in Bangladesh

Sexual and reproductive health and rights (SRHR) is often a neglected topic of intervention in humanitarian crises despite its wide-ranging impact on women and girls’ well-being. Increasing frequency of climate-induced natural disasters calls for an urgent need to identify innovative practices for sustainable and effective humanitarian preparedness and response to ensure SRHR of affected populations. One such innovation is the empowerment of midwives in disaster response program planning and implementation. This article describes how midwives deployed to rural primary health centers provided quality SRHR services, particularly for labor and birth assistance and initial management of perinatal emergencies and referral in the aftermath of the 2022 flooding in northern and northeastern Bangladesh. Supportive supervision from physicians, adequate health care logistics and supplies, and administrative support from local health authorities created an enabling environment for the midwives. Community engagement through volunteers helped build rapport with residents and allowed patients to navigate health services. Deploying midwives as a response to climate-induced natural disaster was successful in establishing quality SRHR services. Future recommendations include systematically deploying midwives in health centers closest to the communities in locations vulnerable to climate change as part of routine health service delivery. This innovative approach clearly demonstrated that utilization of midwives during and after natural disasters could build community and health system resilience to climate change.     

MIDWIFERY IN THE 21ST CENTURY: Recommendations from the Pew Health Professions Commission/UCSF Center for the Health Professions 1998 Taskforce on Midwifery*

Unprecedented changes in the delivery and financing of health care have produced angst and opportunity, criticism, and innovation. To explore the effects of these market-driven changes on midwifery, the University of California at San Francisco Center for the Health Professions convened a Taskforce on Midwifery in 1998. Consisting of eight experts from across the country, the Taskforce was charged with exploring the impact of health care system developments on midwifery, and identifying issues facing the profession and the roles midwives play in women's health care. The Taskforce answered its charge by offering 14 recommendations related to midwifery practice, regulation, education, research, and policy. The recommendations incorporate the Taskforce vision that the midwifery model of care should be embraced by, and incorporated into, the health care system in order to make it available to all women and their families. Midwives, educators, collaborators, and policymakers can use the recommendations to develop curricula, practice sites, and laws for an improved health care system that fully includes midwives and encompasses the midwifery model of care. J Nurse Midwifery 1999;44:341–8 © 1999 by the American College of Nurse-Midwives.     

Improving pregnancy outcomes in low- and middle-income countries

This paper reviews the very large discrepancies in pregnancy outcomes between high, low and middle-income countries and then presents the medical causes of maternal mortality, stillbirth and neonatal mortality in low-and middle-income countries. Next, we explore the medical interventions that were associated with the very rapid and very large declines in maternal, fetal and neonatal mortality rates in the last eight decades in high-income countries. The medical interventions likely to achieve similar declines in pregnancy-related mortality in low-income countries are considered. Finally, the quality of providers and the data to be collected necessary to achieve these reductions are discussed. It is emphasized that single interventions are unlikely to achieve important reductions in pregnancy-related mortality. Instead, improving the overall quality of pregnancy-related care across the health-care system will be necessary. The conditions that cause maternal mortality also cause stillbirths and neonatal deaths. Focusing on all three mortalities together is likely to have a larger impact than focusing on one of the mortalities alone.     

NURSE-MIDWIFERY IN ST. VINCENT AND THE GRENADINES

Brian drain, the exodus of highly trained professionals from developing countries to better paying jobs in the developed world, threatens the structure of community health care in those developing countries. In the Caribbean Basin, as in many developing countries, midwives are the primary health care providers for mothers and their children. This paper describes the maternal and child health (MCH) system in the Caribbean island community of St. Vincent and the Grenadines (SVG); compares MCH indicators in SVG with those in developed and developing nations; describes the role of the nurse-midwife in the delivery of MCH services; and examines the growing problem of recruitment and retention (brain drain) of nurse-midwives. Suggestions made by the nurse-midwives of SVG will be used to explore some solutions to this major human resource problem threatening the MCH system and to identify the major obstacles to their implementation     

Nurse-midwifery in St. Vincent and the Grenadines.

Brain drain, the exodus of highly trained professionals from developing countries to better paying jobs in the developed world, threatens the structure of community health care in those developing countries. In the Caribbean Basin, as in many developing countries, midwives are the primary health care providers for mothers and their children. This paper describes the maternal and child health (MCH) system in the Caribbean island community of St. Vincent and the Grenadines (SVG); compares MCH indicators in SVG with those in developed and developing nations; describes the role of the nurse-midwife in the delivery of MCH services; and examines the growing problem of recruitment and retention (brain drain) of nurse-midwives. Suggestions made by the nurse-midwives of SVG will be used to explore some solutions to this major human resource problem threatening the MCH system and to identify the major obstacles to their implementation.     

Real and perceived threats to reproductive health: a way forward

Ten years ofter the International Conference on Population and Development finds the reproductive health community under threat from at least three sources: global initiatives, reforms of the health sector, and new financial modalities from donors and lenders. These challenges, however, mainly reflect the complete system failure in many low-income countries in providing basic reproductive health services to women, especially those who are poor and socially vulnerable. The reproductive health community can do a lot more to address the system failures and potential threats and take advantage of opportunities offered. The starting point should be an internal look at how the reproductive health community has performed in helping low-income countries. Understanding these changes and opportunities in the health sector is another important step, but understanding will only be effective if representatives of the reproductive health community in low-income countries are armed with the skills and tools needed to engage in health sector reforms, to take advantage of global initiatives and to effectively influence the implementation of new holistic forms of aid.     

Midwives and postabortion care: experiences,opinions, and attitudes among participants at the 25th Triennial Congress of the International Confederation of Midwives

Midwifery practice may not include caring for women experiencing complications from unsafe abortion, despite the importance of this care for the health and lives of millions of women around the world. This article summarizes data collected from midwives from 41 countries who attended the 25th Triennial Congress of the International Confederation of Midwives in 1999, focusing on their experiences with, and attitudes toward, the provision of postabortion care. Barriers to provision of postabortion care and factors for changes in postabortion care-related policies were explored. Midwives from developing countries, where complications from unsafe abortion present a serious public health problem, were cognizant of the need to authorize, train, and equip midwives in postabortion care, including the use of uterine evacuation of incomplete abortion with manual vacuum aspiration. Changes in policy and practice are needed throughout the world so that women will have access to quality, compassionate postabortion care services regardless of where they live. Ensuring that midwives are able to provide such services will help to reduce abortion-related morbidity and mortality.     

Private midwives: a new approach to family planning service delivery in Ghana

Data on 134 private sector midwives who were educated and trained in family planning service delivery by the Ghana Registered Midwives' Association (GRMA) showed that, for most, the course was the first they had received since qualifying as a midwife. Four out of five of the new family planning clients served by these midwives were first time contraceptive users. Approximately 9% of the clients were men, most of whom requested condoms. While delivering women is still the main function of the maternity homes, it is clear that family planning services have come to represent an important element of the health care the midwives provide. A follow-up study of family planning acceptors found extremely encouraging continuation rates. In addition, a survey of the women that the midwives had delivered showed that the contraceptive prevalence rate among these women was higher than the national rate. Providing family planning services through private sector midwives has been shown to be a very successful approach in Ghana, and one that has the potential to become a pillar of the nation's overall family planning delivery programme. As several other countries in Africa also have active private sector health networks, this approach holds promise far beyond its initial success in Ghana.     

Neonatal resuscitation from a global perspective

The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.     

Midwifery in the Industrialized World

Because of the successful attempt at the beginning of this century to dismantle midwifery in Canada and the United States, there is much ignorance and misunderstanding among the public and health professionals about the essential role of midwives in modern maternity services. With the renaissance of midwifery in North America, health administrators, health providers and the public need information about modern midwifery.Midwifery is primary health care for women with a focus on reproductive health. Key elements of the midwifery model of care are normality, facilitation of natural processes with the minimal amount of evidenced-based intervention, and die empowerment of the woman and the family.Scientific evidence proves that: midwives are as safe or safer than doctors for primary maternity care; using midwives greatly reduces the rates of unnecessary obstetrical interventions; midwifery services lead to considerable cost savings; midwives have more success in reaching socially disadvantaged groups; women have more satisfaction with midwife-managed care.In nearly every industrialized country outside North America, midwives provide primary maternity care, and obstetricians, generally, are hospital-based specialists providing tertiary maternity care. In Scandinavia, the Netherlands, New Zealand and other countries, all prenatal, intrapartum and post-partum care for at least 70 percent of women is provided solely by midwives. These countries have much lower obstetrical intervention rates than Canada, and have maternal and perinatal mortality rates equal to and, in some cases, better than Canada.An autonomous midwifery profession in equal standing with the medical profession is a key component of an optimal modern maternity care system.     

Midwives and women together for the family of the world: the place of research

In this paper, I explore the place of research in the theme 'Midwives and women: together for the family of the world'. I begin by examining each of the concepts involved. What is the family of the world? Midwives: what do they contribute to the family of the world? Women: what do they contribute to the family of the world? Putting midwives and women together what is the impact on the family of the world. What is the place of research and what is its impact? I build an argument to show that midwifery research covers social, cultural and political spheres. It breaks the barriers between midwives and women and helps create a true partnership where there is interactivity rather than just one-way information giving from midwife to woman. Once midwives interact with women, they are more likely to persuade them and the world around the women to change their way of doing things. By evaluating what they do using research, midwives are able to capture the safe motherhood success stories and effect replication where needed. With research, midwives become unified, assertive, and mutually supportive in order to reinforce professional identity, accountability and autonomy in the delivery of quality care for women and their families. The family of the world therefore has a ready source of care and support, leadership, knowledge and policies that have been tried and tested to be effective in contributing to the health of women and their families.     

Objectifs pour un développement durable – pour l’analyse et pour la planification en santé

Starting in the year 2000 and ending in 2015, the eight millennium development goals (MDGs) were an impressive global success, even though success varied from country to country. It was therefore logical when these ended, to develop a new set of targets with the goal of overall improvement in the context of sustainability. Development of these targets led to the setting of 17 sustainable development goals (SDGs), ending in 2030. This has led to the expression “Agenda 2030” as the “result” of the SDGs. The third SDG pertains directly to health, and includes maternal, neonatal, and child health. However, several other SDGs have a direct impact on perinatal health including: SDG 1: poverty; SDG 2: food security; SDG 4: education; SDG 5: gender; SDG 6: WASH (WAter, Sanitation and Hygiene); or SDG 16: peace. SDGs provide general directions and a structured setting, knowing that perinatal care providers, particularly in high-income countries are already responding largely to the demands.     

A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

Objective

to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

Design

systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

Setting

midwifery services in any setting in low-, middle-, and high-income countries.

Participants

midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

Interventions

task shifting to and from midwives.

Findings

thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

Key conclusions

this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

Implications for practice

evidence from the review fed into the World Health Organisation's ‘Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting’ guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.