State of the World's Midwifery - How to use the SOWMY 2014 country briefs (English)

Publication date: 2014

50 THE STATE OF THE WORLD‘S MIDWIFERY 2014 HOW TO USE THE SOWMY 2014 COUNTRY BRIEFS WHAT WOMEN AND NEWBORNS NEED (2012) Percentage of 46 RMNH Essential Interventions included in minimum health benefits package, 2012 Covered WORKFORCE AVAILABILITY (2012) FINANCIAL ACCESSIBILITY GEOGRAPHICAL ACCESSIBILITY Not covered MIDWIFERY EDUCATION3 MIDWIFERY REGULATION PROFESSIONAL ASSOCIATIONS4 Minimum high-school requirement to start training Years of study required to qualify (rounded) Standardized curriculum? Year of last update Minimum number of supervised births in curriculum Number of 2012 graduates/as % of all practising midwives % of graduates employed in MNH within one year Legislation exists recognizing midwifery as an autonomous profession A recognized definition of a professional midwife exists A government body regulates midwifery practice A licence is required to practise midwifery A live registry of licensed midwives exists Number of EmONC basic signal functions that midwives are allowed to practise (out of a possible 7) Midwives allowed to provide injectable contraceptives/intrauterine devices Year of creation of professional associations Roles performed by professional associations: Accessed a SBA Did not access a SBA No data on rural/ urban SBA PRE-PREGNANCY (all women of reproductive age) ANTENATAL (pregnancies x 4) BIRTH POSTNATAL (newborns x 4) BIRTH ANTENATAL (pregnancies x 4) PRE-PREGNANCY (all women of reproductive age) POST-PARTUM (births x 4) PRE-PREGNANCY ANTENATAL BIRTH POSTNATAL BIRTH ANTENATAL PRE-PREGNANCY POST-PARTUM <0.09 0.10-0.19 Continuing professional development Advising or representing members accused of misconduct Advising members on quality standards for MNH care Advising the Government on policy documents related to MNH Negotiating work or salary issues with the Government Number of births with a skilled birth attendant (SBA)2 Country classification of staff working in MNH1 Time spent on MNH % 0 0.20-0.49 0.50-0.99 >10.001.50-1.991.00-1.49 2.00-2.49 2.50-10.00 = = = = APPROX. Estimate of met need (national aggregate) based on available data. workforce time available workforce time needed na = not applicable; – = missing datana = not applicable; – = missing datana58 THE STATE OF THE WORLD‘S MIDWIFERY 2014 In 2012, of an estimated total population of 154.7 million, 111.2 million (72%) were living in rural areas and 43.2 million (28%) were women of reproductive age; the total fertility rate was 2.2. By 2030, the population is projected to increase by 20% to 185.1 million. To achieve universal access to sexual, reproductive, maternal and newborn care, midwifery services must respond to 4.3 million pregnancies per annum by 2030, 66% of these in rural settings. The health system implications include how best to configure and equitably deploy the SRMNH workforce to cover at least 359.8 million antenatal visits, 57.6 million births and 230.2 million post-partum/postnatal visits between 2012 and 2030. BANGLADESH 78,049,000 family planning visits 20,361,000 routine visits 3,257,000 skilled birth attendance 13,029,000 routine visits ESTIMATED MET NEED = 41% 78% (n=36) 22% (n=10) Midwives 0 100 Midwives, auxiliary 14,377 100 Nurse-midwives 18,684 20 Nurses na na Nurses or nurse- midwives, auxiliary na na Clinical officers & medical assistants 9,036 – Physicians, generalists 53,603 – Obstetricians & gynaecologists 802 100 0 1,000,000 2,000,000 3,000,000 N u m b er o f liv e b ir th s Rural Urban Grade 12+ 3 20 0/na No 6 Yes Yes Yes Yes/Yes – Yes 2010 Yes Yes Yes Yes Yes, 2012 Yes 5,090,000 PREGNANCIES A YEAR = HOW MANY EPISODES OF CARE? Number and distribution of pregnancies (2012) First page: Where are we now? The first page of the country brief can be used to discuss the extent to which the workforce is currently able to deliver SRMNH services for all women and newborns who need them. Proxies for availability, accessibility and quality are presented to facilitate these discussions. All data are from 2012. WHAT DO WOMEN AND NEWBORNS NEED? The brief starts by showing some of the indicators of need that must be met if universal coverage is to be attained. The number of pregnancies, their geograph- ical distribution, and the volume of services that must be provided are displayed in this section. Other needs include the provision of sexual and reproductive health services, including addressing unmet need for family planning. Indicative policy question: Is the policy and planning environment in the country consistent with universal coverage of SRMNH services, responsive to what women and newborns need? WORKFORCE AVAILABILITY AND MET NEED The brief then considers how many health workers are available to meet this need. The number (by headcount) of all workers reported and the percentage time each one spends on MNH services are shown. This information provides the number of available health workers by their full-time equivalent. Only by considering the number of full-time equivalent health workers can a true picture of availability be constructed. Health workers are grouped by category, while their country cadre name is provided in footnote 1. The section also provides an estimate of how workforce availability compares with need. An estimated percentage for the national aggregate summarizes the extent to which the available midwifery workforce, taking into account which health workers provide which services, has enough time to deliver the 46 essential SRM- NH interventions to all women and newborns who need them. The estimate of met need is highly sensitive to the package of care (e.g. the 46 essential interventions), the number of health workers reported, the percentage of time they spend on SRMNH services, and the roles they perform. Indicative policy questions: Have all cadres that contribute to the midwifery workforce been reported, by name and by the percentage of time each cadre spends on SRMNH services? Does the estimate of met need at the national aggregate level mask inequities, e.g. at the sub-national level, or when disaggregated by urban/rural and socio-economic strata? FINANCIAL ACCESSIBILITY Even if there are sufficient health workers, the ser- vices they provide may not be affordable. This graph shows the number of the 46 essential SRMNH inter- ventions that are included in each country’s minimum health benefits package and available free at the point of delivery, as an indication of the degree of financial protection offered to women and their newborns in accessing SRMNH care. Indicative policy questions: Is the minimum health benefits package guaranteed to all women regardless of ability to pay? Are there national plans to provide a package of SRMNH services that include and go beyond the 46 essential interventions? GEOGRAPHICAL ACCESSIBILITY Health workers, and the facility from which they work, may not be equally distributed with regards to need. This graph shows the number of births in urban versus rural areas to indicate the geographical need for SRMNH services. Where data are available the graph also shows the number of births where a skilled birth attendant was reportedly available. This provides an indicative measure of workforce accessibility. Indicative policy question: Is there a marked difference in access to the midwifery workforce in urban and rural areas and what policy measures can be taken to address this? EDUCATION, REGULATION, ASSOCIATION Education, regulation and professional associa- tions are all crucial to support health workers in delivering quality midwifery care. This section provides information on the strength of the enabling environment within a country. Indicative policy question: Is the enabling environment for quality health workers and quality health services meeting national and international standards, and if not where can progress be made? The country brief has been designed to prompt and inform policy discussions on how the composition, skill-mix, deployment and enabling environment of the midwifery workforce impacts on the delivery of SRMNH services for all women and newborns who need them. This visual guide describes the graphics on the two-page country brief and provides examples of the indicative policy questions that may arise. 51CHAPTER 4: COUNTRY BRIEFS WHAT IF… ESTIMATES AND PROJECTIONS TO 2030 The number of midwife, nurse and physician graduates doubled by 2020? PROJECTED NUMBER OF PREGNANCIES BY YEAR: URBAN VS. RURAL CHAPTER 4: COUNTRY BRIEFS Efficiency improved by 2% per year until 2030? Attrition was halved in the next 5 years (2012-2017)? CURRENT SCENARIO CURRENT TRAJECTORY MORTALITY REDUCTION5 Target by 2030Country (MMR, 2013; NMR, 2012) CURRENT SCENARIO CURRENT SCENARIO PROJECTED OUTFLOWS by International Standard Classification of Occupations (ISCO-08) PROJECTED INFLOWS PROJECTED WORKFORCE The number of pregnancies was reduced by 20% by 2030? CURRENT SCENARIO 1 2 3 4 WHAT IF. TRAJECTORY UrbanRural Midwifery professionals Nursing professionals Paramedical practitioners & medical assistants Medical practitioners, generalists Nursing professionals, associates Midwifery professionals, associates Medical practitioners, specialists (Ob/Gyn) Outflow from attrition, death and retirement Estimates of met need based on available data. Immediate increase in met need for pregnancy, birth, post-partum/postnatal care. Acceleration in met need for pre- pregnancy services from 2028 onwards. This section of the brief uses reported country data to calculate needs-based planning estimates and projections to 2030. The projections are sensitive to reported enrolment, graduation, % time spent on MNH services, age distribution, roles and attrition. In the absence of country data, standardized, evidence-based assumptions are used. The projections are indicative and should be used to verify the accuracy of country data and inform further policy discussion. Further information in the “How to read” section on page 50. 59 0 1,500,000 3,000,000 4,500,000 6,000,000 N u m b er o f p re g n an ci es 2012 • • 2015 • • • • 2020 • • • • 2025 • • • • 2030 NMR 0 150 300 450 0 25 50 M at er n al m o rt al it y ra ti o N ew b o rn m o rt al it y ra te MMR 0 35,000 70,000 105,000 140,000 2012 2030 2013 2015 2020 2025 2030 2012 2015 2020 2025 2030 M N H w o rk er s (f u ll- ti m e eq u iv al en t) 0 35,000 70,000 105,000 140,000 0 35,000 70,000 105,000 140,000 4% leak 2% leak 3.4 million 4.3 million 52% MET NEED 2030 72% MET NEED 2030 52% MET NEED 2030 66% MET NEED 2030 52% MET NEED 2030 58% MET NEED 2030 1. These health worker categories include the following country titles - Midwives: includes direct-entry diploma midwives (new cadre); Auxiliary midwives: includes junior midwives, family welfare visitors, community skilled birth attendants; Nurse-midwives: includes nurse-midwives, nurse-midwives holding a post-basic certificate in midwifery; Generalist physicians: includes MBBS; Obstetricians & gynaecologists: includes specialists in obstetrics and gynaecology; Clinical officers & medical assistants: includes sub- assistant community medical officers (SACMO). Source: SoWMy 2014 or secondary sources (WHO Global Health Observatory; government policy documents). 2. Year of data is as per most recent data available in STATCOMPILER. 3. Information refers to the midwife cadre category. 4. National associations for midwifery and nursing. 5. These are proposed targets for MMR and NMR by 2030 from the recommendations of Ending Preventable Maternal Mortality by 2030 and the Every Newborn Action Plan. 0 25,000 50,000 75,000 100,000 0 25,000 50,000 75,000 100,000 20302012 2020M N H w or ke rs (f ul l-t im e eq ui va le nt ) 10 M N H w or ke rs (f ul l-t im e eq ui va le nt ) 10 20302012 2020M N H w or ke rs (f ul l-t im e eq ui va le nt ) Available workforce projection (adjusted for skill-mix) Need projection Available workforce projection (adjusted for skill-mix): with the synergies of scenarios 2 + 3 + 4 Need projection: Scenario 1 93% MET NEED 2030 52% MET NEED 2030 B A N G LA D ESH – a brief for policy discussion Second page: What might 2030 look like? The second page of the country brief aims to prompt policy discussion on the future evolution of the midwifery workforce compared with the future scale of population need. The last section, “Estimates and projections to 2030”, compares future availability of the health workforce and future needs for SRMNH services under a variety of scenarios. Given the absence of data in some countries, this analysis should be seen as a starting point for policy discussions (including around the availability and quality of national data) rather than as a statement of fact. PROJECTED PREGNANCIES AND MORTALITY REDUCTION Achieving universal coverage means anticipating and responding to future needs. This section shows the evolution of need (expressed as the annual number of pregnancies in urban and rural areas) in the period 2012-2030. Other needs for sexual and reproductive health services will be determined by changes in the number of women of reproductive age, including the number of adolescents. The section also provides an indication of the targets for reductions in maternal and neonatal mortality, as proposed in the Ending Preventable Maternal Mortality by 2030 initiative and the Every Newborn Action Plan. These proposed targets are subject to national policy priorities and decisions. Indicative policy questions: Is there an opportunity in your country to address unmet need for family planning and therefore reduce the annual number of pregnancies? What is the impact of urban/rural population change on the selection, education and deployment of the midwifery workforce? What are the midwifery workforce implications to achieve the accelerated reductions in maternal and neonatal mortality by 2030? ESTIMATES AND PROJECTIONS TO 2030 This section illustrates the potential evolution of the midwifery workforce under “business as usual” assumptions and according to different policy scenarios. The first row of three graphs considers the number of health workers who will enter and exit the midwifery workforce in the period 2012 - 2030. The graph to the left illustrates how the full-time equivalent number of health workers will reduce over time, and the shaded area represents the ‘outflows’ in this period. The graph in the centre identifies the entries from national education institutions, and the third graph to the right the cumulative effect of entries and exits. ‘What if’ scenarios are presented as examples. These illustrate the potential impact of policy decisions and demonstrate the changes in met need that could be realised through four different scenarios: reducing the number of pregnancies per annum, increasing the supply of midwives, nurses and physicians, improving efficiency and reducing voluntary attrition. The bottom two graphics highlight the difference between “business as usual” and the combination of the policy scenarios. The changes in met need are based on the country data reported and a standard set of decision rules in Annex 5. Indicative policy questions: What are the opportunities to improve the efficiency and management of the current midwifery workforce? What is the turnover of the midwifery workforce today, and are there mechanisms in place to capture all exits and understand why health workers are leaving? What are the national policy priorities for the skill-mix and deployment of the midwifery workforce and how will this impact on met need? WHAT WOMEN AND NEWBORNS NEED (2012) Percentage of 46 RMNH Essential Interventions included in minimum health benefits package, 2012 Covered WORKFORCE AVAILABILITY (2012) FINANCIAL ACCESSIBILITY GEOGRAPHICAL ACCESSIBILITY Not covered MIDWIFERY EDUCATION3 MIDWIFERY REGULATION PROFESSIONAL ASSOCIATIONS4 Minimum high-school requirement to start training Years of study required to qualify (rounded) Standardized curriculum? Year of last update Minimum number of supervised births in curriculum Number of 2012 graduates/as % of all practising midwives % of graduates employed in MNH within one year Legislation exists recognizing midwifery as an autonomous profession A recognized definition of a professional midwife exists A government body regulates midwifery practice A licence is required to practise midwifery A live registry of licensed midwives exists Number of EmONC basic signal functions that midwives are allowed to practise (out of a possible 7) Midwives allowed to provide injectable contraceptives/intrauterine devices Year of creation of professional associations Roles performed by professional associations: Accessed a SBA Did not access a SBA No data on rural/ urban SBA PRE-PREGNANCY (all women of reproductive age) ANTENATAL (pregnancies x 4) BIRTH POSTNATAL (newborns x 4) BIRTH ANTENATAL (pregnancies x 4) PRE-PREGNANCY (all women of reproductive age) POST-PARTUM (births x 4) PRE-PREGNANCY ANTENATAL BIRTH POSTNATAL BIRTH ANTENATAL PRE-PREGNANCY POST-PARTUM <0.09 0.10-0.19 Continuing professional development Advising or representing members accused of misconduct Advising members on quality standards for MNH care Advising the Government on policy documents related to MNH Negotiating work or salary issues with the Government Number of births with a skilled birth attendant (SBA)2 Country classification of staff working in MNH1 Time spent on MNH % 0 0.20-0.49 0.50-0.99 >10.001.50-1.991.00-1.49 2.00-2.49 2.50-10.00 = = = = APPROX. Estimate of met need (national aggregate) based on available data. workforce time available workforce time needed na = not applicable; – = missing data52 THE STATE OF THE WORLD‘S MIDWIFERY 2014 In 2012, of an estimated total population of 29.8 million, 23.5 million (79%) were living in rural areas and 6.5 million (22%) were women of reproductive age; the total fertility rate was 5. By 2030, the population is projected to increase by 46% to 43.5 million. To achieve universal access to sexual, reproductive, maternal and newborn care, midwifery services must respond to 1.6 million pregnancies per annum by 2030, 73% of these in rural settings. The health system implications include how best to configure and equitably deploy the SRMNH workforce to cover at least 117.8 million antenatal visits, 20.3 million births and 81.3 million post-partum/postnatal visits between 2012 and 2030. AFGHANISTAN 1,573,000 PREGNANCIES A YEAR = HOW MANY EPISODES OF CARE? 10,953,000 family planning visits 6,291,000 routine visits 1,085,000 skilled birth attendance 4,341,000 routine visits ESTIMATED MET NEED = 23% 83% (n=38) 17% (n=8) Midwives 3,500 100 Midwives, auxiliary na na Nurse-midwives na na Nurses na na Nurses or nurse- midwives, auxiliary na na Clinical officers & medical assistants na na Physicians, generalists 4,200 12 Obstetricians & gynaecologists 400 100 0 300,000 600,000 900,000 N u m b er o f liv e b ir th s Rural Urban Grade 10+ 2 25 –/– No 7 Yes Yes No Yes/Yes 95% Yes 2005 No Yes Yes Yes Yes, 2010 No Number and distribution of pregnancies (2012) WHAT IF… ESTIMATES AND PROJECTIONS TO 2030 The number of midwife, nurse and physician graduates doubled by 2020? PROJECTED NUMBER OF PREGNANCIES BY YEAR: URBAN VS. RURAL CHAPTER 4: COUNTRY BRIEFS Efficiency improved by 2% per year until 2030? Attrition was halved in the next 5 years (2012-2017)? CURRENT SCENARIO CURRENT TRAJECTORY MORTALITY REDUCTION5 Target by 2030Country (MMR, 2013; NMR, 2012) CURRENT SCENARIO CURRENT SCENARIO PROJECTED OUTFLOWS by International Standard Classification of Occupations (ISCO-08) PROJECTED INFLOWS PROJECTED WORKFORCE The number of pregnancies was reduced by 20% by 2030? CURRENT SCENARIO 1 2 3 4 WHAT IF. TRAJECTORY UrbanRural Midwifery professionals Nursing professionals Paramedical practitioners & medical assistants Medical practitioners, generalists Nursing professionals, associates Midwifery professionals, associates Medical practitioners, specialists (Ob/Gyn) Outflow from attrition, death and retirement Estimates of met need based on available data. Immediate increase in met need for pregnancy, birth, post-partum/postnatal care. Acceleration in met need for pre- pregnancy services from 2028 onwards. This section of the brief uses reported country data to calculate needs-based planning estimates and projections to 2030. The projections are sensitive to reported enrolment, graduation, % time spent on MNH services, age distribution, roles and attrition. In the absence of country data, standardized, evidence-based assumptions are used. The projections are indicative and should be used to verify the accuracy of country data and inform further policy discussion. Further information in the “How to read” section on page 50. 53 0 500,000 1,000,000 1,500,000 2,000,000 N u m b er o f p re g n an ci es 2012 • • 2015 • • • • 2020 • • • • 2025 • • • • 2030 NMR 0 150 300 450 0 25 50 M at er n al m o rt al it y ra ti o N ew b o rn m o rt al it y ra te MMR 0 1,100 2,200 3,300 4,400 2012 2015 2020 2025 2030 2013 2015 2020 2025 2030 2012 2015 2020 2025 2030 M N H w o rk er s (f u ll- ti m e eq u iv al en t) 0 1,100 2,200 3,300 4,400 0 1,100 2,200 3,300 4,400 11% leak 5.5% leak 1.3 million 1.6 million 8% MET NEED 2030 14% MET NEED 2030 8% MET NEED 2030 12% MET NEED 2030 8% MET NEED 2030 12% MET NEED 2030 1. These health worker categories include the following country titles - Midwives: includes midwives; Generalist physicians: includes generalist physicians; Obstetricians & gynaecologists: includes obstetricians & gynaecologists. Source: SoWMy 2014 or secondary sources (WHO Global Health Observatory; government policy documents). 2. Rural/urban SBA coverage is not available. Figure refers to rural/urban births only. 3. Information refers to the midwife cadre category. 4. National associations for midwifery and nursing. 5. These are proposed targets for MMR and NMR by 2030 from the recommendations of Ending Preventable Maternal Mortality by 2030 and the Every Newborn Action Plan. 0 6,000 12,000 18,000 24,000 0 6,000 12,000 18,000 24,000 20302012 2020M N H w or ke rs (f ul l-t im e eq ui va le nt ) 20302012 2020M N H w or ke rs (f ul l-t im e eq ui va le nt ) Available workforce projection (adjusted for skill-mix) Need projection Available workforce projection (adjusted for skill-mix): with the synergies of scenarios 2 + 3 + 4 Need projection: Scenario 1 31% MET NEED 2030 8% MET NEED 2030 A FG H A N ISTA N – a brief for policy discussion

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