The State of the world's midwifery 2014 - A universal pathway. A woman's right to health

Publication date: 2014

REPRODUCTIVE HEALTH PREGNANCY CHILDBIRTH POSTNATAL THE STATE OF THE WORLD’S MIDWIFERY 2014 A UNIVERSAL PATHWAY. A WOMAN’S RIGHT TO HEALTH STEERING COMMITTEE Co-chairs: Frances Day-Stirk, Laura Laski, Elizabeth Mason. Members: Jean Barry, Benedict David, Luc de Bernis, Peter Johnson, Louise Holly, Tina Lavender, Gillian Mann, Betsy McCallon, Anders Molin, Arulkumaran Sabaratnam, Carole Presern, Simon Wright. CORE GROUP Coordinator: Luc de Bernis Members: Jim Campbell, Catherine Carr, Sheena Currie, Caroline Homer, Petra ten Hoope-Bender, Peter Johnson, Zoë Matthews, Fran McConville, Nester Moyo, Mwansa Nkowane, Grace Omoni, Francisco Pozo-Martin, CN Puradane, Amani Siyam, Laura Sochas. COUNTRY SURVEY, DATA ANALYSIS AND TECHNICAL SUPPORT UNFPA: Luc de Bernis, Susana Edjang. Secretariat: ICS Integrare, University of Southampton, University of Technology Sydney: Aferdita Bytyqi, Jim Campbell, Vincent Fauveau, Stephanie Fletcher, Maria Guerra-Arias, Caroline Homer, Sofia Lopes, Zoë Matthews, Joanne McManus, Andrea Nove, Francisco Pozo-Martin, Anna Rayne, Hishiv Shah, Laura Sochas, Andrew Tatem, Petra ten Hoope-Bender. Technical contributions: Edson Araújo, Deborah Armbruster, Albert Arnó, Patsy Bailey, Jean Ball, David Benton, Ismat Bhuiya, Ties Boerma, Jim Buchan, Amos Channon, Asiful Haidar Chowdhury, Laurence Codjia, Mario Dal Poz, Kim Dickson, Gilles Dussault, Tim Evans, Lynn Freedman, Sennen Hounton, Louise Hulton, Marge Koblinsky, Teena Kunjumen, Mandy La Fleur, Thierry Lambrechts, Christophe Lemière, Jacqueline Mahon, Adriane Martin-Hilber, Laura Matthews, Allisyn Moran, Sarah Neal, Juliette Puret, Kathrin Radke, Charlotte Renard, Rachel Sanders, Susheela Singh, Jeff Smith, Ann Starrs, Wim Van Lerberghe, Marie Washbrook. Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff, and the people that coordinated, completed, and verified responses to the State of the World’s Midwifery country survey. In particular, thanks to the country focal points: Hissani Aboubacar, Kodjovi Edotsè Adjeoda, Anna af Ugglas, Jamil Ahmed, Guy C. Ahialegbedzi, Arlette Akoueikou, Fernanda Alves, Mary Nana Ama Brantuo, Nazira Artykova, Zulfiya Atadjanova, Amalia Ayala, Farid Babayev, Radouane Belouali, Jeannette Biboussi, Zainab Blell, Malin Bogren, Edith Boni Ouattara, Rayana Bou Haka, François Busogoro, Gillian Butts-Garnett, Felister Bwana, Jean-René Camara, Alicia Carbonell, Jose Manuel Carvalho, Rene Alberto Castro, Ahmed Chahir, Maria José Costa, Thierno Ousmane Coulibaly, Hirondina Cucubica, Evelyne Degraff, Pilar de la Corte Molina, Saliou Dian Diallo, Sadio Diarra, Aicha Djama, Dudu Dlamini, Javier Dominguez, Dat Van Duong, Marie Sheyla Durandisse, Musu Duworko, Henriette Eke Mbula, Hala El Hennawy, Kerstin Erlandsson, Nicole Eteki, Mahamat Malloum Fatime, Feruza Fazilova, Rustini Floranita, Monica Fong, Daniel Frade, Paul Francis, Suzie Francis, Dina Gbenou, Rodolfo Gomez, Kemal Goshliyev, Raymond Goula, Nada Hamza, Fredrica Hanson, Sharifullah Haqmal, Gilbert Hiawalyer, Grace Hiwa, Bang Thi Hoang, Aboubacar Inoua, Bakary Jargo, Theopista John Kabuteni, Elizabeth Kalunga, Leonard Kamugisha, Selly Kane Wane, Trevor Kanyowa, Bahtygul Karryeva, Stoelle Patricia Keba, Magdy Khaled, Zareef Khanza, Kyu Kyu Khin, Eunyoung Ko, Ibroh Kouboura Abba Moussa, Alhagie Kolley, Sathyanarayana Kundur, Busisiwe Kunene, Mohammed Lardi, Joyce Lavussa, Dorothy Lazaro, Ana Leitão, Amadou Ouattara Liagui, Ornella Lincetto, Elvira Liyanto, Jean-Pierre Lokonga, Fernanda Lopes, Achu Lordfred, Juliana Lunguzi, Primo Madra, Yolande Magonyagi, Agnes Makoni, Sarai Bvulani Malumo, Margaret Mannah-Macarthy, Lucy Sejo Maribe, Michel Mbemba Moutounou, Pauline McNeil, Yordanos Mehari, Willam Michel, Michaela Michel-Schuldt, Happiness Mkhatshwa, Kuban Monolbaev, Maria Mugabo, Khin Aye Myint, Azzah Nofly, Daphrose Nyirasafali, Geoffrey Okumu, Mohamed Boubacar Ould Abdel Aziz, Taiwo Oyelade, Haydee Padilla, Anchita Patil, Jiong Peng, Sano Phal, Zulfiya Pirova, Philderald Pratt, Maria Quaresma Dos Anjos, Ginette Josia Rabefitia, Nargis Rakhimova, Thabelo Ramatlapeng, Masy Harisoa Ramilirijaona, Rabiatu Sageer, Mahamoud Said, Geneviève Saki-Nekouressi, Elfeky Samar, Aminata Seguetio, Olive Sentumbwe, Alejandro Silva, Nurgul Smankulova, Sokun Sok, Gracia Subiria, Areej Taher, Fatim Tall, Kabo Tautona, Afrah Thabet, Meera Thapa Upadhyay, Luwam Teshome, Augusto Viegas, Chumen Wen, Souleymane Zan, Aoua Zerbo, Assefash Zehaie. A full list of the names of all those who contributed is available on page 198 of this report. COMMUNICATIONS AND MEDIA: Cole Bingham, Amy Boldosser- Boesch, Julie Cornell, Adam Deixel, Christian Delsol, Etienne Franca, Rachel Haynes, Louise Holly, Ian Hurley, Cathrin Jerie, Omar Kasrawi, Mandy Kibel, Etienne Leue, Ann LoLordo, Joy Marini, Brigid McConville, Patrick McCrummen, Lori Lynn McDougall, Lothar Mikulla, Michelle Park, Sruti Ramadugu, Charlene Reynolds, Alanna Savage, Marta Seoane Aguilo, Ann Starrs, Petra ten Hoope-Bender, Veronic Verlyck, Julia Wiklander. DESIGN, LAYOUT AND PRINTING: Prographics, Inc. TRANSLATIONS: Michel Coclet, Mohammed Khawam FINANCIAL SUPPORT: Bill & Melinda Gates Foundation, Foreign Affairs, Trade and Development Canada, Johnson & Johnson, Maternal and Child Health Integrated Program, United States Agency for International Development, Ministry of Foreign and European Affairs (France), Norwegian Agency for International Development, Swedish International Development Cooperation Agency, United Nations Population Fund. Our appreciation is extended to ICS Integrare and Prographics, Inc. for their support in the research, development, writing and production of the report, and all accompanying materials. CONTRIBUTORS AND ACKNOWLEDGEMENTS Cover photos (left to right): Viviane Fortaillier, Viviane Fortaillier, ICM/Liba Taylor, Save the Children ABBREVIATIONS AND ACRONYMS AAAQ availability, accessibility, acceptability and quality AVD assisted vaginal delivery B-EmONC basic emergency obstetric and newborn care C-EmONC comprehensive emergency obstetric and newborn care CHW community health worker CMDP Community-based Midwifery Diploma Programme EC emergency contraception EmONC emergency obstetric and newborn care GIS geographic information system GPS Global Positioning System HCPAs health-care professional associations HRH human resources for health ICM International Confederation of Midwives ICN International Council of Nurses ISCO International Standard Classification of Occupations MDG Millennium Development Goal MMR maternal mortality ratio NMR neonatal mortality rate MNH maternal and newborn health NGOs non-governmental organizations PMNCH The Partnership for Maternal, Newborn & Child Health SRMNH sexual, reproductive, maternal and newborn health SoWMy State of the World’s Midwifery STIs sexually transmitted infections TBA traditional birth attendants UNFPA United Nations Population Fund UHC universal health coverage WHO World Health Organization CHAPTER 1 INTRODUCTION 1 About this report .3 CHAPTER 2 THE STATE OF MIDWIFERY TODAY 5 Evidence of progress .5 Availability .12 Accessibility .16 Acceptability .22 Quality .24 Summary .31 CHAPTER 3 MIDWIFERY2030 33 Looking towards 2030 .33 Drivers of health, health systems and health financing .34 Midwifery2030: A pathway for policy and planning .36 Realizing the pathway .36 Building from country findings .42 Midwifery2030: Inspiring global action .45 CHAPTER 4 COUNTRY BRIEFS 49 How to read the country brief .50 State of the World’s Midwifery Country Survey Respondents 198 References 201 Annexes 205 1 Glossary .205 2 General methodology .208 3 Methodology for modelling effective coverage of the essential interventions for sexual, reproductive, maternal and newborn health care .209 4 Estimating women’s and newborns’ need for the 46 essential interventions .212 5 Decision rules.216 6 Mapping of subnational distributions of populations, women of reproductive age, pregnancies and live births .217 7 Tasks within the scope of midwifery professionals according to the International Standard Classification of Occupations .218 BOXES 1 Three-year direct-entry midwifery education introduced as Bangladesh recognizes professional midwives .7 2 Examining the midwifery workforce through the lens of effective coverage .10 3 The geography of SRMNH: advances in geo-information systems .17 4 Emergency obstetric and newborn care: from designation to readiness .19 5 Reaching the poorest 40% .20 6 Country actions in Afghanistan, Sierra Leone and Togo .21 7 Respectful care in maternity services .22 8 Ensuring acceptability of service through accountability .25 9 Drivers and changes in health .35 10 Protecting the public: a renewed paradigm .40 11 The impact of investing in family planning .44 12 Midwives: a “best buy” for primary health care .45 TABLES 1 ACTIONS reported by countries that relate to the BOLD STEPS identified in SoWMy 2011 .6 2 Reasons why women do not seek care or feel uncomfortable about seeking care .23 3 How Midwifery2030 responds to the key findings from SoWMy 2014.42 4 Global initiatives and objectives in sexual, reproductive, maternal, newborn and child health .48 FIGURES 1 Key indicators for maternal and newborn health and the health workforce in 73 of 75 Countdown countries .2 2 Pregnancies in 73 countries (1950-2099) .8 3 Number of sexual, reproductive, maternal and newborn health visits needed, by WHO region [2012] .8 4 Midwifery workforce: Projected need of full-time equivalent workers to deliver sexual, reproductive, maternal and newborn health services .9 5 Midwifery workforce: Distribution in 73 countries, and by WHO region .11 6 Midwifery workforce: roles and tasks .12 7 Midwifery workforce: headcount versus full-time equivalent .13 8 Percentage leaving the workforce voluntarily each year, by cadre .14 9 Perceptions among survey respondents of the comparative attractiveness of a career as a midwife (73 countries) .15 10 Average monthly starting salary per cadre of health worker (international $ purchasing power parity, 2012) .15 11 Minimum number of births to be conducted under clinical supervision .26 12 Regulation and licensing of midwives .28 13 Functions and responsibilities of regulatory bodies .29 14 B-EmONC signal functions: midwives’ authorized and actual roles .29 15 Functions of professional associations open to midwives .30 16 Midwifery workforce: from availability to quality .32 17 Projected change in population need for SRMNH visits between 2012 and 2030, by WHO region .34 18 Key features of first-level and next-level midwifery care .37 THE STATE OF THE WORLD’S MIDWIFERY 2014 A UNIVERSAL PATHWAY. A WOMAN’S RIGHT TO HEALTH Foreword ii Executive Summary iii ii THE STATE OF THE WORLD‘S MIDWIFERY 2014 Foreword Ban Ki-moon Secretary-General of the United Nations The world has reached a turning point for women’s and children’s health. We can now celebrate the fact that maternal, neonatal and child mortality rates are at their lowest levels in history. We are poised for even greater progress thanks to the Every Woman Every Child initiative, our progress toward achieving the Millennium Development Goals, as well as the ongoing discussions regarding a set of global sustainable development goals to succeed the Millennium Development Goals after their target completion date of 2015. This report links two specific areas of focus that I care deeply about: first, maternal and newborn health, and second, the overarching principles and values of the post-2015 development agenda, providing new evidence for decision-makers. The midwifery workforce, within a supportive health system, can support women and girls to prevent unwanted pregnancies, provide assistance throughout pregnancy and childbirth, and save the lives of babies born too early. With leadership and resources, the world can prevent the vast majority of avoidable yet tragically common losses of life and address the vicious cycle of impoverishment that ensues. The State of the World’s Midwifery 2014 documents growing momentum since the first call to action in the 2011 report. Every year, more governments, professional associations and other partners are acting on the evidence that midwifery can dramatically accelerate progress on sexual, reproductive, maternal and newborn health and universal health coverage. I fully support the Midwifery 2030 vision articulated in this report. This vision is within reach of all countries, at all stages of economic and demographic transition. Its implementation will help governments to deliver on women’s right to health, ensure that women and newborn infants obtain the care they need, and contribute to our shared, global ambition to end preventable maternal and newborn deaths. I commend this report to all those interested in joining the United Nations as we work towards the Midwifery 2030 vision and improve the future of women’s and children’s health. iiiEXECUTIVE SUMMARY Executive Summary SoWMy 2014’s main objective, agreed at the 2nd Global Midwifery Symposium held in Kuala Lumpur in May 2013, is to provide an evidence base on the state of the world’s midwifery in 2014 that will: support policy dialogue between governments and their partners; accelerate progress on the health MDGs; identify develop- ments in the three years since the SoWMy 2011 report was published; and inform negotiations for and preparation of the post-2015 develop- ment agenda. SoWMy 2014 focuses on 73 of the 75 low- and middle-income countries that are included in the “Countdown to 2015” reports. More than 92% of all the world’s maternal and newborn deaths and stillbirths occur within these 73 countries. However, only 42% of the world’s medical, midwifery and nursing personnel are available to women and newborn infants (hereafter ‘newborns’) in these countries. Midwifery is a key element of sexual, reproduc- tive, maternal and newborn health (SRMNH) care and is defined in this report as: the health services and health workforce needed to support and care for women and newborns, including sexual and reproductive health and especially pregnancy, labour and postnatal care. This enables analysis of the diverse ways in which midwifery is delivered by a range of health-care professionals and associate professionals. SoWMy 2014 has been co-ordinated by the United Nations Population Fund, the International Confederation of Midwives and the World Health Organization on behalf of government repre- The State of the World’s Midwifery (SoWMy) 2014: A Universal Pathway. A Woman’s Right to Health takes its inspiration from the United Nations Secretary-General’s Every Woman Every Child initiative and his call to action in September 2013 to do everything possible to achieve the Millennium Development Goals (MDGs) by 2015 and work towards the development and adoption of a post-2015 agenda based on the principle of universality. It has been widely acknowledged that investing in a proficient, motivated midwifery workforce has a great impact on maternal and newborn health. (Jhpiego/Kate Holt) sentatives and national stakeholders in the 73 countries and 30 global development partners. Tangible progress has been made in improving midwifery in many countries since the SoWMy 2011 report: 33 of the 73 countries (45%) report vigorous attempts to improve workforce retention in remote areas; 20 countries (28%) have started to increase recruitment and deployment of mid- wives; 13 countries (18%) have prepared plans to establish regulatory bodies; and 14 (20%) have a new code of practice and/or regulatory frame- work. Perhaps the most impressive collective step forward is the improvement in workforce data, information and accountability, reported by 52 countries (71%). The evidence and analysis in SoWMy 2014 is structured by the four domains that determine whether a health system and its health workforce are providing effective coverage, i.e. whether women are obtaining the care they want and iv THE STATE OF THE WORLD‘S MIDWIFERY 2014 need in relation to SRMNH services. These four domains are: availability, accessibility, acceptabil- ity and quality. Availability: SoWMy 2014 provides new esti- mates of the essential SRMNH services needed by women and newborns. This need for services, in each country, can be converted into the need for the midwifery workforce. Midwives, when educated and regulated to international standards, have the competencies to deliver 87% of this service need. However, midwives make up only 36% of the reported midwifery workforce: not all countries have a dedicated professional cadre focused on sup- porting women and newborns. Instead there is diversity in the typologies, roles and composition of health workers contributing to midwifery ser- vices, and many of these workers spend less than 100% of their time on SRMNH services. The new evidence on diversity presented in SoWMy 2014 can inform policy and planning. Firstly, the availability of the midwifery workforce and the roles they perform cannot be deduced from job titles. Secondly, the full-time equivalent midwifery workforce represents less than two thirds of all workers spending time on SRMNH services. Therefore, any analysis comparing or correlating the midwifery workforce with SRMNH outputs/outcomes should take full-time equivalent staffing as the measure of availability. The evidence identifies opportunities to: align job titles, roles and responsibilities; strengthen linkages between education and employment: improve efficiency; and assess and reduce high levels of turnover and attrition. In particular, progress is required on the identity, status and salaries of midwives, removing gender dis- crimination and addressing the lack of political attention to issues which only affect women. Accessibility: Although nearly all of the 73 countries recognize the importance of finan- cial accessibility and have a policy of offering at least some essential elements of SRMNH care free of charge at the point of access, only 4 provide a national “minimum guaranteed benefits package” for SRMNH that includes all the essential interventions. Gaps in the essential interventions include those known to reduce the four leading causes of maternal mortality: severe bleeding; infections; high blood pressure during pregnancy (pre-eclamp- sia and eclampsia); and unsafe abortion. Lack of geographical data on health facilities and midwifery workers precludes reliable assess- ment of whether all women have access to a health worker when needed. Improving acces- sibility requires making all urban and rural areas attractive to health workers, and ensuring that all barriers to care, including lack of trans- portation, essential medicines and health-care workers, are removed. Acceptability: Most countries have policies in place to deliver SRMNH care in ways that are sensitive to social and cultural needs. However, data on women's perceptions of midwifery care are scarce, and countries acknowledge the need for more robust research on this topic. Contributors to the SoWMy 2014 workshops noted that the issue of acceptability is strongly linked to discrimination and the status of Not all countries have a dedicated professional cadre focused on supporting women and newborns. (Mamaye Sierra Leone) vEXECUTIVE SUMMARY women generally, both as service users and health workers. Quality of both care and care providers can be increased by improving the quality of midwifery education, regulation and the role of professional associations. SoWMy 2014 indicates that although the curricula in most countries are appropriate and up-to-date, pervasive gaps remain in education infrastructure, resources and systems, particularly for direct-entry midwifery programmes. Nearly all of the 73 countries have a regulatory infrastructure for midwifery, with prescribed standards for midwifery education, including in the private sector. Quality of care would be further strengthened by licensing/re-licensing systems that KEY MESSAGES 1 The 73 Countdown countries included in the report account for more than 92% OF GLOBAL MATERNAL AND NEWBORN DEATHS AND STILLBIRTHS but have only 42% OF THE WORLD'S MEDICAL, MIDWIFERY AND NURSING PERSONNEL. Within these countries, workforce deficits are often most acute in areas where maternal and newborn mortality rates are highest. 2 ONLY 4 OF THE 73 COUNTRIES have a midwifery workforce that is able to meet the universal need for the 46 essential interventions for sexual, reproductive, maternal and newborn health. 3 Countries are endeavouring to expand and deliver equitable midwifery services, but COMPREHENSIVE, DISAGGREGATED DATA for determining the availability, accessibility, acceptability and quality of the midwifery workforce ARE NOT AVAILABLE. 4 Midwives who are educated and regulated to international standards can provide 87% OF THE ESSENTIAL CARE needed for women and newborns. 5 In order for midwives to work effectively, FACILITIES NEED TO BE EQUIPPED TO OFFER THE APPROPRIATE SERVICES, including for emergencies (safe blood, caesarean sections, newborn resuscitation). 6 Accurate data on the midwifery workforce enable countries to plan effectively. This requires A MINIMUM OF 10 PIECES OF INFORMATION THAT ALL COUNTRIES SHOULD COLLECT: headcount, percentage time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce. 7 Legislation, regulation and licensing of midwifery allow midwives to provide the high-quality care they are educated to deliver and thus protects women’s health. High-quality midwifery care for women and newborns saves lives and CONTRIBUTES TO HEALTHY FAMILIES AND MORE PRODUCTIVE COMMUNITIES. 8 The returns on investment are a “best buy”: • Investing in midwifery education, with deployment to community-based services, could yield a 16-FOLD RETURN ON INVESTMENT in terms of lives saved and costs of caesarean sections avoided, and is A “BEST BUY” IN PRIMARY HEALTH CARE. • Investing in midwives frees doctors, nurses and other health cadres to focus on other health needs, and contributes to achieving a grand convergence: reducing infections, ENDING PREVENTABLE MATERNAL MORTALITY and ENDING PREVENTABLE NEWBORN DEATHS. The report shows that: 87% 92% INTRODUCTION vi THE STATE OF THE WORLD‘S MIDWIFERY 2014vi THE STATE OF THE WORLD‘S MIDWIFERY 2014 require the midwifery workforce to demonstrate continuing professional development. The ultimate goal of professional associations is to foster a dynamic, collaborative, fit-for-purpose, practice-ready team of health-care professionals who are responsive to the needs of women and children. Although almost all countries have at least one professional association for midwives, nurse-midwives or auxiliary midwives, their role in quality improvement could be strengthened if they were enabled to contribute to policy discussions and key decisions affecting midwifery services. There are substantial gaps in effective coverage in both the availability and quality dimensions. Reducing these gaps requires the collection and better use of workforce data and leadership to prioritize midwifery and release resources to support workforce and service planning. The minimum 10 data elements required for health workforce planning are: headcount, percentage time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce. Midwifery2030: Quality midwifery care is central to achieving national and global priorities and securing the rights of women and newborns. SoWMy 2014 has developed Midwifery2030 as a pathway for policy and planning. Starting from the premises that pregnant women are healthy unless complications, or signs thereof, occur, and that midwifery care pro- vides preventive and supportive care with access to emergency care when needed, it promotes woman- centred and midwife-led models of care, which have been shown to generate greater benefits and cost savings than medicalized models of care. Midwifery2030 focuses on increasing the availabil- ity, accessibility, acceptability and quality of health services and health services and health providers to achieve the three components of universal health coverage (UHC): reaching a greater proportion of women of reproductive age (increasing coverage); extending the basic and essential health pack- age (increasing services); while protecting against financial hardship (increasing financial protection). Central to this are an enabling policy environment that supports effective midwifery education, regula- tion and association development, and an enabling practice environment that provides access to effec- tive consultation with and referral to the next level of SRMNH services. This should be underpinned by effective management of the workforce, including professional development and career pathways. Implementing the recommendations of Midwifery2030 can lead to significant returns on investment. A value for money assessment in Bangladesh reviewing the education and future deployment of 500 community-based mid- wives ranked positively for economy, efficiency and effectiveness. The assessment calculated a beneficial impact comparable to that of child immunization, with a 16-fold return on investment and confirms that midwifery is a “best buy” in primary health care. Essential building blocks for putting the Midwifery2030 vision into practice include political will, effective leadership and midwifery “champi- ons” who will drive the agenda, supported by the current regional and international momentum for improvements to SRMNH. Midwives can offer woman-centred and supportive care that goes beyond childbirth. (World Vision/ Sopheak Kong) 1CHAPTER 1: INTRODUCTION Photo here In September 2013, United Nations Secretary- General Ban Ki-moon presented his annual report on progress towards the Millennium Development Goals (MDGs) to the United Nations General Assembly [1]. His report, A life of dignity for all, calls for all countries and the international community at large to do everything possible to achieve the MDGs by the end of 2015 and to work towards the development and adoption of a post-2015 agenda based on the principles of universality, leaving no one behind. It identifies an emerging vision that includes every woman and girl having “equal access to health services, including sexual and reproductive health and reproductive rights”, as part of the increasing momentum to realize “universal health-care cov- erage, access and affordability”, for example, in resolutions adopted by the World Health Assembly [2] and United Nations General Assembly [3]. This report, The State of the World’s Midwifery 2014 (SoWMy 2014), takes inspiration from the United Nations Secretary-General’s above-mentioned call to action, as well as his Every Woman Every Child initiative, launched in 2010 [4]. SoWMy 2014’s main objective, as agreed at the 2nd Global Midwifery Symposium held in Kuala Lumpur in May 2013 [5], is to provide an evidence base on the state of the world’s midwifery in 2014 that will: • support policy dialogue between governments and their partners; • accelerate progress on the health MDGs; • identify developments in the three years since SoWMy 2011 was published [6]; • inform negotiations for and preparation of the post-2015 development agenda. Partners at the 2nd Global Midwifery Symposium reaffirmed that the returns on investing in a proficient, motivated and supported midwifery workforce are enormous, and they committed to improving midwifery services in all regions of the world [5]. Specifically they committed to “improve the data collection and evidence base for midwifery and identify actions to address the context-specific barriers to midwifery services within coun- tries”. This report responds to that commitment by updating the 2011 report, which has proved to be a valuable source of evidence and tool for advocacy [7]. SoWMy 2014 focuses on the 75 low- and middle-income countries that are included in the “Countdown to 2015” reports (hereafter Countdown) [8]. 73 countries agreed to contrib- ute to the preparation of SoWMy 2014; Equatorial Guinea and the Philippines were unable to contribute due to emergency and scheduling com- mitments. SoWMy 2014 adds detailed information on the midwifery workforce and enabling environ- ment in each country to inform national efforts to achieve universal, sustained and equitable cover- age of the essential interventions [9] in sexual, reproductive, maternal and newborn health (SRMNH) [10] that are proven to save women’s and children’s lives. INTRODUCTION CHAPTER 1 Partners at the 2nd Global Midwifery Symposium reaffirmed that the returns on investing in a proficient, motivated and supported midwifery workforce are enormous, and they committed to improving midwifery services in all regions of the world. 2 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Preparations included collating updated data on the midwifery workforce*, midwifery education, regulation, professional associations, policy and planning frameworks, and progress since 2011. Where feasible, participating countries hosted a policy workshop exploring barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of midwifery services, and in particular the midwifery work- force. For this reason, the preparation of this report has been in many countries an impor- tant element of the national effort to improve women’s and newborn infants’ (hereafter: new- borns) access to competent health professionals. Figure 1 illustrates a selection of key indicators for the 73 countries included in the report. As shown in Figure 1, more than 92% of all maternal and newborn deaths and stillbirths [11–13] occur within these 73 countries. They are home to women giving birth to 107 million babies per year, making up 78% of the world’s total births in 2009. Yet the number of deaths in these countries is 96% of the global burden of maternal mortality, 91% of stillbirths and 93% of newborn mortality [11–15]. The Global Health Observatory indicates that only 42% of the world’s medical, midwifery and nursing person- nel are available in these 73 countries [16]. What is midwifery? SoWMy 2014 looks at the inequitable state of the world shown in Figure 1 through the lens of midwifery [17]. The definition of “midwifery” used in this report is: the health services and health workforce needed to support and care for women and newborns, including sexual and reproductive health and especially pregnancy, labour and postnatal care. This Percentage of births attended by skilled attendant <20% 20% - 49% 50% - 74% 75% - 94% 95% or over 96% global burden of maternal mortality 91% global burden of stillbirths 93% global burden of neonatal mortality73 And produce 78% of the world’s total births per year with less than countries carry 42%of the world’s midwives, nurses and physicians Key indicators for maternal and newborn health and the health workforce in 73 of 75 Countdown countriesFIGURE 1 * The SoWMy survey requested countries to submit data on all professional, associate professional and other health cadres engaged in the provision of maternal and newborn health care (whether they work in the public or private sectors). Data should however be considered as indicative of those working in the public sector. 3CHAPTER 1: INTRODUCTION includes a full package of sexual and reproductive health services, including preventing mother-to- child transmission of HIV, preventing and treating sexually transmitted infections and HIV, prevent- ing pregnancy, dealing with the consequences of unsafe abortion and providing safe abortion in circumstances where it is not against the law. This definition is wider than, for example, the Medical Subject Headings definition, introduced in 1966, which simplifies midwifery to “the practice of assisting women in childbirth” [18]. This report emphasizes that midwifery involves far more than the care of the mother during childbirth: it pro- motes woman-centred care and the well-being of women more generally [19–21] through a support- ive and preventive model of care [22,23]. Note that the terms “woman-centred care” and the “well- being of women” include, at appropriate times, the mother and her newborn child. The report generally uses the term “midwife” to include those health professionals who are edu- cated to undertake the roles and responsibilities of a midwife regardless of their educational path- way to midwifery, whether direct-entry or after basic nursing. This is aligned with the recom- mendations and standards of the International Confederation of Midwives (ICM) [24-27] and the position statement of the International Council of Nurses (ICN) [28]. For example, ICM’s Essential competencies for basic midwifery practice asks the questions “What is a midwife expected to know?” and “What does a midwife do?” and acknowl- edges that, a midwife acquires her/his knowledge and skills through different educational path- ways [26]. Where differentiation is required for analysis and explanation, for instance in Chapter 2 on the percentage of time spent providing maternal and newborn health services or on education pathways, the report uses the titles of midwife and nurse-midwife. The vocabulary of midwifery and its use in differ- ent regions of the world and in different languages is not without complexity. For instance, not all languages have a word that literally translates as mid-wife (i.e. to be “with woman”). SoWMy 2014 does not seek to promote one definition over another, nor to prescribe how countries, languag- es, professional associations and/or others define or refer to midwifery services and the midwifery workforce. The priority is to contribute to the evi- dence base — using terms that enable comparison across regions and countries — which can inform new policy dialogue and action in support of qual- ity midwifery services and the rights of women and their newborns to obtain quality health care. About this report ICM, the United Nations Population Fund (UNFPA) and the World Health Organization (WHO) co-chaired the development and launch of SoWMy 2014, with UNFPA and WHO coordi- nating on behalf of the H4+ agencies (UNAIDS, UNFPA, UNICEF, UN Women, WHO and the World Bank). Fourteen partners were convened through a Steering Committee (see acknowledge- ments). ICS Integrare, a UNFPA Implementing Partner, managed the secretariat for the Steering Committee, and led the data collection, research, writing and production of this report with sup- port from the University of Southampton (UK), the University of Technology, Sydney (Australia) and other partners (see acknowledgements). Government representatives in each of the 73 countries collaborated with UNFPA/WHO country offices and development partners in Every woman and girl should have equal access to sexual and reproductive health services. (ICM/Liba Taylor) 4 THE STATE OF THE WORLD‘S MIDWIFERY 2014 THE STATE OF MIDWIFERY TODAY completing a questionnaire available in English, French and Spanish with national stakeholders and experts. Data collection took place between October 2013 and February 2014. Of the 73 coun- tries, 37 convened a workshop, engaging more than 500 participants in policy dialogue, includ- ing staff from ministries of health and education, health-care professional associations, regulatory bodies and medical, midwifery and nursing schools (see page 198 for a list of all contribu- tors). UNFPA/WHO country offices submitted the completed questionnaire and workshop reports on behalf of countries to the secretariat through an online platform. The data collection and the report have been made possible through the contributions of many individuals and organizations. Their willingness to convene, collect, collate and analyse the data demonstrates the global commitment to mid- wifery. However, the report recognizes there are inherent limitations in a multi-country study, not least the gaps in available data in many coun- tries. That absence of data is itself a finding that presents national partners with the opportunity to take immediate action. Examples of how this spurred action in Afghanistan, Sierra Leone and Togo are provided in Box 6 in Chapter 2. Notwithstanding the limitations, the report provides new analysis and evidence to inform policy, planning and implementation: • Chapter 2 updates the evidence base and pro- vides a detailed analysis of efforts to improve the quality of midwifery in the 73 countries; • Chapter 3 explores the future challenges and opportunities facing midwifery and proposes a people-centred, woman-focused vision that can accelerate progress on universal access by 2030; • Chapter 4 includes two-page “policy briefs” for each of the 73 countries. The policy briefs are an innovative mix of 2012 data and needs-based projections for the period to 2030. Health workforce projections have been described as “a policy-making necessity” [29]. Their purpose in the briefs, mirroring previ- ous needs-based projections on the workforce requirements to deliver priority services [30–33], is to inform policy dialogue and decisions within countries on “what actions need to be taken in the near future” [29]. All needs-based projections are sensitive to the quality of data informing them and a global modelling exercise has limitations due to the standard, evidence- based parameters employed [34]. In particular, the projections are based on the rational assumption that human resources are allocated efficiently. This may not reflect the reality in a country. The briefs should therefore be used, not as a fact-sheet, but as a tool to review and improve the quality of data and policy options within countries, enabling further identification and analysis of disaggregated data to improve needs-based modelling and costing exercises. This report (in pdf, E-pub and Kindle formats) and additional information are available online at www.sowmy.org. Additional information includes the data collection instruments and the guidance given to country teams, workshop reports, and supporting background papers. An advocacy and communications toolkit on how to use the report to inform policy dialogue at the country level is also available (in English, French and Spanish). Midwives can offer woman-centred and supportive care that goes beyond childbirth. (UNICEF/Shehzad Noorani) 5CHAPTER 2: THE STATE OF MIDWIFERY TODAY to strengthen midwifery in order to come closer to (and eventually achieve) maternal survival targets and universal access to reproductive health, not only those articulated in MDG 5, but also those that may be set in the future (e.g. the Ending Preventable Maternal Mortality by 2030 targets [4] and/or achieving universal access to sexual and reproductive health and rights). It is also recognized that reducing newborn mortality is key to achieving MDG 4**; all but 4 of the 73 SoWMy countries have made progress, with an average annual rate of reduction of 1.9% since 1990 [5]. The 2014 Every Newborn: An action plan to end preventable deaths [6] is a roadmap for change. It provides guidance on interven- tions that have the highest impact - with a triple return on maternal and newborn mortality, and stillbirths [7,8]. The plan is in accordance with the principles of universal health coverage [9] and calls for qualified and dedicated midwifery personnel to provide services. High-quality sexual and reproductive health for women, ado- lescents, pregnant women and their infants is an essential feature of UHC [10] and therefore implies the development of midwifery services, a midwifery workforce and an enabling environ- ment that is fit for this purpose. Bold steps since 2011 Tangible progress has been made in improving midwifery in many countries since the SoWMy 2011 report, which outlined a series of bold steps to be taken by governments, regulatory bod- ies, midwifery and nursing schools, professional associations and international agencies. Analysis of updates from the 73 countries participating in Evidence of progress This chapter contains a broad assessment of the state of the world’s midwifery, including an account of progress since SoWMy 2011. The chapter is based mainly on 73 country respons- es to the SoWMy survey, as well as records of the national workshop discussions. The result- ing analysis gives an in-depth description of what women and newborns need in the 73 coun- tries, the characteristics of the workforce that should serve them and a detailed breakdown of what is actually available to those in need. Also included is a new assessment of the gaps in and challenges to expanding effective cover- age of the 46 essential interventions in SRMNH recommended by the Partnership for Maternal, Newborn and Child Health [1] (see Annex 4). Much has happened in the three years since the launch of SoWMy 2011. Although MDG 5* will not be reached in many countries by 2015 (19 countries have achieved this ahead of 2015 [2]), maternal mortality decline is now an estab- lished feature of development. All but 1 of the 73 countries that completed the 2014 survey have made progress in reducing their maternal mortality ratios, with an average annual rate of reduction of 3% since 1990 [2]. One rea- son for this progress is that many low-income countries have improved access to midwifery care [3]. Building on these success stories, it is widely recognized that more needs to be done CHAPTER 2 * MDG 5A: to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio; and MDG 5B: to achieve, by 2015, universal access to reproductive health. ** MDG 4A: to reduce by two thirds, between 1990 and 2015, the under-five mortality rate. THE STATE OF MIDWIFERY TODAY 6 THE STATE OF THE WORLD‘S MIDWIFERY 2014 ACTIONS reported by countries that relate to the BOLD STEPS identified in SoWMy 2011 BOLD STEPS RECOMMENDED ACTIONS TAKEN SINCE 2011 By governments (including ministries of health and finance and other government departments and leaders) • Promote midwifery as a career with appropriate terms of service. • Include midwifery and midwives in costed MNH plans, and align human resources for health plans. • Assure management competencies tools and procedures for appropriate human resource management. • Invest in active data collection and monitoring of the practising midwifery/ MNH workforce. • Promotion of midwifery at higher education levels to increase career prospects, reported by 6 countries (8%). • 18 countries (25%) report increased production of health workers (including midwives) to reduce shortages and/or deficits; 12 (16%) have opened new midwifery schools and programmes; 8 countries (11%) report new programmes, mostly direct-entry midwifery. • 33 countries (45%) report vigorous attempts to improve retention in remote areas, including the introduction of a bonding system and/ or incentives. • 52 countries (71%) report that they have data information systems. Actions in data collection include: capacity building with external technical and financial support, establishment of information coordinating bodies, revision of data tools, recruitment of data specialists, and establishment of information centres. In addition, 5 countries (7%) report that they plan to establish information systems or update existing ones. By regulatory bodies • Establish criteria for entry into the profession. • Establish educational standards and practice competencies. • Accredit schools and education curricula in both public and private education systems. • License and relicense midwives. • Maintain codes of ethics/conduct. • 51 countries (70%) report that regulatory bodies are responsible for setting education standards, and 39 (53%) report that they are responsible for the accreditation of education providers. • Revision of code of practice, putting in place new legislation and/or establishing mechanisms for relicensing reported by 14 countries (19%). By schools and training institutions • Review curricula to ensure that graduates are proficient in all essential competencies set by government and the regulatory body. • Use the ICM and other education standards to improve quality and capacity. • 19 countries (26%) report that tools and guidelines are being developed. The majority of these relate to competencies, development or updates of curricula and revision of codes of practice. • 8 countries (11%) have made positive efforts to align education with ICM global standards. By professional associations • Promote standards for in-service training and knowledge updates. • Ensure respect of patients’ rights in service delivery. • Develop the voice of and contributions by the midwifery workforce in the national policy arena. • Survey countries report that 92% of associations are performing continuous professional development. • 88% of associations in survey countries are reported to advise their members on quality standards for SRMNH care. • Survey countries report that 77% of professional associations have advised the government on the most recent national SRMNH or health policy document, and 53% have negotiated work or salary issues with their government. By international organizations, global partnerships, donor agencies and/or civil society • Encourage international forums and facilitate exchanges of knowledge, good practices and innovation. • Encourage the establishment of a global agenda for midwifery research (for the MDGs and beyond) and support its implementation at country level. • Second Global Midwifery Symposium (May 2013) brought together midwives, policymakers, and representatives of non-governmental organizations, donor partners and civil society, to discuss various issues around midwifery strengthening, showcase results and innovations and address challenges. • Lancet Special Issue on Midwifery (June 2014): aims to consolidate and improve the available knowledge on midwifery to facilitate evidence-based decision-making at country level in support of effective SRMNH services. • The H4+ including UNFPA and WHO, is providing technical support to regions and countries on midwifery workforce assessments, quality of care and national policy. • Civil society organizations are active participants in global, regional and national forums. TABLE 1 7CHAPTER 2: THE STATE OF MIDWIFERY TODAY this report shows that many of these steps have been and are continuing to be taken (see Table 1). For example, 33 of the 73 countries (45%) report vigorous attempts to improve work- force retention in remote areas since 2011. 20 countries (28%) have started to increase recruitment and deployment of midwives, 13 countries (18%) have prepared plans to estab- lish regulatory bodies, and 14 (20%) have a new code of practice and/or regulatory frame- work. Perhaps the most impressive collective step forward since 2011 is the improvement in workforce data, information and account- ability, reported by 52 countries (71%). This includes the establishment of information coor- dinating bodies and information centres, and the recruitment of data specialists. Table 1 complements the evidence that the 2011 report has contributed to changing narratives about the role of midwifery [11], and there are concrete examples (see Box 1) of political support followed by policy and programme development at national level in collaboration with govern- ments, health-care professional associations, education institutions, regulatory bodies and development partners. Updating the midwifery data from the 58 countries that participated in the 2011 report is an important objective of this report, in part because it contributes to a global emphasis on Three-year direct-entry midwifery education introduced as Bangladesh recognizes professional midwives The Government of Bangladesh made headlines in 2010 when the Prime Minister Sheikh Hasina demonstrated her political commitment to midwifery by launching the training of 3000 midwives. This was a step change for Bangladesh which in the 1980s had focused attention on traditional birth attendants, and subsequently promoted a wide range of cadres including family welfare visitors, nurse-midwives and doctors. Bangladesh has recently moved to a three-year direct-entry midwifery education programme, in recognition of the value of professional midwives in reducing maternal and newborn mortality. Bangladesh is on track to reach MDGs 4 and 5, yet the Demographic Health Survey 2011 reports the maternal mortality ratio is still high at 194 per 100,000 live births, the neonatal mortality rate is 32 per 1000 and only 32% of women are attended during birth by a skilled birth attendant. This reflects a severe shortage of skilled midwifery personnel, and an extreme concentration of doctors in urban areas. In 2008 the government Directorate of Nursing Services and the Bangladesh Nursing Council, with technical assistance from WHO, jointly developed “Strategic directions for enhancing the contribution of nurse-midwives for midwifery services to contribute to the attainment of MDGs 4 and 5”. This document clearly defined two pathways for the training of midwives through the Ministry of Health and Family Welfare: (i) Certificate in Midwifery: a six-month advanced midwifery programme for existing registered nurse-midwives; (ii) Diploma in Midwifery: a new three-year direct-entry midwifery programme. WHO provided the government with the technical assistance to develop the six-month post basic course curriculum, as well as the new three- year diploma curriculum and UNFPA provide additional financial and technical assistance. UNFPA and WHO are supporting 20 training centres for the Certificate in Midwifery programme based in existing Nursing Institutes and Education centres, and the 27 Institutes providing the three-year direct-entry diploma are government funded through the multi-donor Health, Population and Nutrition Sector Development Programme. Key challenges remain. There is an acute shortage of competent teaching staff in both public and private sectors. The process of sanctioning new public sector midwife positions is underway, but needs approval to ensure the diploma midwives can practise. Coordination between the public and private sectors is essential. Importantly, much more needs to be done to provide the professional, economic and sociocultural support to enable these graduate midwives to provide the quality of care that they are committed to achieving. Bangladesh is an example of political commitment to midwifery, joint agency support to government, and public-private enterprise. Source: UNFPA and WHO. BOX 1 8 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Number of sexual, reproductive, maternal and newborn health visits needed, by WHO region (2012) FIGURE 3 information and accountability [12]. But SoWMy 2014 and this chapter do more than follow up on progress. An additional 15 countries have been added to align with the Countdown countries and, more importantly, the data provided by all participating countries are more detailed than in 2011 and represent a major step forward in our understanding of the midwifery workforce and their roles and responsibilities in providing SRMNH services. What women and newborns need In the 73 countries included in this report the annual number of pregnancies is reasonably stable at around 160 million per year [13,14]. N u m b er o f vi si ts ( m ill io n s) Eastern Mediterranean Europe Americas South-east Asia Western Pacific Africa Reproductive health visits Antenatal visits Skilled birth attendance Postnatal visits 0 200 400 600 800 1,000 1,200 1,400 Pregnancies in 73 countries (1950-2099)FIGURE 2 0 20000 40000 60000 80000 100000 120000 140000 160000 180000 N u m b er o f p re g n an ci es ( th o u sa n d s) Western Pacific 0 20000 40000 60000 80000 100000 120000 140000 160000 180000 Africa AmericasEastern Mediterranean EuropeSouth-east Asia 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2099 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000 This looks set to continue for many decades (see Figure 2). However, strikingly different demo- graphic trends are seen between world regions. Since 1990 the annual number of pregnancies has increased by 50% across African countries, which means the midwifery workforce in these countries needs to increase significantly just to maintain current levels of population coverage. In order to increase coverage of services and accelerate reductions in mortality and morbid- ity the workforce needs an even faster increase in supply of staff as well as new thinking on skill-mix and improvements in efficiency. By contrast, Asian countries are seeing reductions in the annual number of pregnancies which should allow them to determine how best to address inequitable population coverage and health out- comes, optimize the skill mix in the midwifery workforce and scale up woman-centred services. Projections and estimations of where pregnancies are occurring allow for a more accurate assess- ment of what SRMNH care is needed by women, adolescents and newborns, but this needs to be tailored to demographic and epidemiological con- texts. For example, the impact of HIV/AIDS and sexually transmitted infections will require addi- tional counselling, testing and treatment, which has implications for both the number and skill- mix of providers. Figure 3 shows an estimate of what midwifery services women and newborns need, based on recommended coverage [1] for: family planning, antenatal care (at least 4 visits), skilled birth attendance and postnatal care (at least 4 visits) in the 73 countries. From the number of visits, an additional calcula- tion estimates the total need for the package of 46 essential SRMNH interventions and multiplies this by the time required to provide those inter- ventions, as estimated by One Health [15] and experts. This enables the need for interventions to be translated into need for the midwifery work- force. Midwives, when educated and regulated to international standards, e.g. ICM and WHO [16- 20] have the competencies to deliver 87% of the estimated need in the 73 countries. 9CHAPTER 2: THE STATE OF MIDWIFERY TODAY Midwifery workforce: Projected need of full-time equivalent workers to deliver sexual, reproductive, maternal and newborn health services FIGURE 4 There is significant diversity across countries and regions in the scale and distribution of need per women of reproductive age or per pregnancy, due to different epidemiological and demographic profiles. The diversity across regions is shown in Figure 4 for both a) sexual and reproductive health services and b) mater- nal and newborn health services. Towards universal access Universal access to sexual and reproductive health care and reductions in maternal and newborn mortality are included in the MDG tar- gets. This report explores the extent to which a country’s midwifery workforce has the capacity to facilitate universal access to the 46 essential interventions for SRMNH by reference to the con- cept of effective coverage (see Box 2). Effective coverage is defined as the proportion of the population who need an intervention, receive that intervention and benefit from it [21,22]. It can be measured by the availability, accessibility, acceptability and quality of health services and of the personnel providing those services. Chapter 2 uses these four dimensions to examine the readiness of the midwifery workforce to deliver universal access. What is the midwifery workforce? Participating countries provided highly detailed information on the health workers engaged in the midwifery workforce. This includes new data on cadre names, the percentage of available working time [33] spent on SRMNH services, official roles and responsibilities, and length of education. The data demonstrate extensive cross-country variation between country cadres with similar names. Simple approaches such as the classification of skilled birth attendants according to cadre name may therefore prove ineffective. The 381 different cadres specified by coun- tries were grouped into eight broad categories: midwives, nurse-midwives, nurses, auxiliaries (midwives and nurses), associate clinicians, physician generalists and obstetricians/gyn- aecologists. These categories are constructed exclusively using each country cadre’s name, and are not a statement about cadres’ professional recognition, roles or educational pathway. The rest of this chapter focuses analysis on the eight broad categories, not the individual names pro- vided by countries. Countries also reported on non-professional cad- res: 47 countries (64%) reported the availability of community health workers (CHWs) and 20 (27%) reported the availability of traditional birth attendants (TBAs). The role of CHWs in deliver- ing some of the essential SRMNH interventions Sexual and reproductive health Maternal and newborn health Fu ll- ti m e eq u iv al en t w o rk er s n ee d ed p er 1 0, 00 0 w o m en o f re p ro d u ct iv e ag e Africa Family planning advice Eastern Mediterranean Europe Americas Western Pacific Fu ll- ti m e eq u iv al en t w o rk er s n ee d ed p er 1 ,0 00 p re g n an ci es 0 2 4 6 8 10 12 14 0 1 2 3 4 5 6 South-east Asia Family planning delivery Prevention STIs Management STIs Prevention HIV Management HIV Other reproductive health Post-partum and postnatal Birth Pregnancy Africa Eastern Mediterranean Europe Americas Western Pacific South-east Asia WHO region WHO region 10 THE STATE OF THE WORLD‘S MIDWIFERY 2014 at community level, especially in sexual health, family planning and postnatal care, is known to improve coverage and is a viable strategy as part of an integrated health service delivery network [34]. Midwives in 58 countries (79%) supervise CHWs’ and TBAs’ work concerning SRMNH, sug- gesting links between health facilities and the community, with opportunities to promote the continuum of care and to improve demand for and utilization of services. However, lack of data, combined with inconsistencies in typology, dura- tion of training, roles and proportion of available working time spent on SRMNH services, limits a comparable, cross-country analysis in this report but would be a valuable addition in future health policy and systems research. Examining the midwifery workforce through the lens of effective coverage The concept of “effective coverage” was developed by WHO in the 1970s to explore the delivery of health services. In 1978 T. Tanahashi published a conceptual framework in the Bulletin of the WHO [23], which captured the simple logic of how the domains of availability, accessi- bility, acceptability and the effectiveness of the contact between the service pro- vider and the user (i.e. quality) influences whether the population obtains health services that meet their requirements. Tanahashi argued that the simplicity of the logic could be applied to consider the effective coverage of all health services, or particular services and components of service delivery: for example SRMNH services and the midwifery workforce. Effective coverage as applied to SRMNH services and the midwifery workforce Source: Jim Campbell, ICS Integrare. Adapted from Campbell et al, 2013 [25] Colston, 2011 [22]. BOX 2 NEED AVAILABILITY ACCESSIBILITY ACCEPTABILITY QUALITY OUTCOME • How many women of reproductive age? • How many pregnancies per year? SRMNH services are AVAILABLE? SRMNH services are ACCESSIBLE? SRMNH services are ACCEPTABLE? SRMNH services provide QUALITY CARE? Outcomes are subject to the reductions in the AAAQ of SRMNH services Add the dimension of people-centred, woman-focused care, with professional teamwork and an enabled environment Woman of reproductive age seeking support through reproductive health, pregnancy, labour and birth, & postnatal follow-up • A midwife is avail- able in or close to the community • As part of an integrated team of professionals, lay workers and community health services • Woman attends • A midwife is available • As needed • Financial protection ensures no barriers to access • Woman attends • A midwife is available • As needed • Providing respectful care • Woman attends • A midwife is available • As needed • Providing respectful care • Competent and enabled to provide quality care • Woman obtains quality care for all SRMNH services • She and her baby receive quality, follow-up postnatal care CRUDE COVERAGE EFFECTIVE COVERAGE IMPACT General Comment No. 14 [24] on the right to health, published in 2000, mirrored the Tanahashi domains of availability, accessibility and accept- ability with quality as the fourth domain (AAAQ). Article 12 states that “the right to health in all its forms and at all levels contains the following interrelated and essential elements, the precise application of which will depend on the conditions prevailing in a particular State party”, before list- ing each of the AAAQ domains and the obligations for all States. The use of the AAAQ domains is therefore of immediate value for exploring effective coverage, and also reinforces the right to health. The use of the Tanahashi framework to explore human resources for health, and the AAAQ of the health workers who are at the core of ser- vice delivery, is enabling new policy insights across countries [25–28]. Similar insights have been achieved when analysing SRMNH services [22,29,30] and the midwifery workforce [31]. New opportunities have thus been created to review barriers, challenges and opportunities in the delivery of effective coverage and are comple- mentary to similar domains to measure quality of care in health systems [32]. The figure below illustrates the need to focus on measuring whether women obtain health servic- es in relation to need and how the AAAQ of the midwifery workforce influences this. This logic underpins the discussion in chapters 2 and 3. antenatal care increased postnatal care increased maternal mortality reduced neonatal mortality reduced 11CHAPTER 2: THE STATE OF MIDWIFERY TODAY Midwifery workforce: Distribution in 73 countries, and by WHO region FIGURE 5 Figure 5 shows the distribution of the midwifery workforce, in 73 countries and in each WHO region, by category of health worker (exclud- ing community cadres). This figure makes the crucial point that the percentage of time spent by each cadre on SRMNH should be taken into account when determining which cadres deliver midwifery services. Generalist physicians and generalist nurses make up a large proportion of the midwifery workforce in terms of headcount, but their contribution as full-time equivalents is reduced when multiplied by the percentage of time spent on SRMNH. Figure 5 also shows the radically different com- position of the midwifery workforce in different WHO regions, although the small number of countries in some regional groups, as well as the influence of China in the Western Pacific Region and India in the South-East Asia Region, should be noted. For example, there appear to be more midwives in the African Region, the European Region and the South-East Asia Region than in the other three regions. There is remarkable diversity across country cadres and within broad categories, particularly with respect to the percentage of time spent on the MNH component of SRMNH services, roles and responsibility, and length of education. Most country cadres in the categories for midwives, nurse-midwives, auxiliaries and obstetricians/ gynaecologists spend 100% of their time on MNH. However, in no broad category were all coun- try cadres spending 100% time on MNH, even among specialists. A much larger range exists for the generalists reported as operating within the midwifery workforce: nurses and generalist physi- cians spend 5 to 100% of their time on MNH, with nurses spending an average of 50% and generalist physicians an average of 39% of their time. This is linked to the range of responsibilities they hold, for instance in prevention, management and treat- ment of illness and disease. Another point of diversity is the extent to which each country cadre is responsible for carrying out tasks within the scope of midwifery practice. The task analysis in Figure 6 follows the International Labour Organization’s (ILO) guidance embodied in the International Standard Classification of Occupations (ISCO) [35] (see Annex 5) regarding the tasks that are within the scope of midwifery professionals. It reveals that cadre names are not always a good indicator of the way in which roles and responsibilities for midwifery services have been assigned across the workforce in each country. While there are certainly patterns, Midwifery workforce in 73 countries by cadre: FULL-TIME EQUIVALENT ON MATERNAL AND NEWBORN HEALTH Midwifery workforce in 73 countries by cadre: TOTAL HEADCOUNT 9% 5% 14% 30% 3% 22% 16% NUMBER OF COUNTRIES 73 NUMBER OF CADRES 338* NUMBER OF COUNTRIES 40 NUMBER OF CADRES 188 AFRICA 1% 8% 7% 23% 12% 43% 5% EASTERN MEDITERRANEAN NUMBER OF COUNTRIES 10 NUMBER OF CADRES 50 2% 28% 11% 40% 12% 7% AMERICAS NUMBER OF COUNTRIES 6 NUMBER OF CADRES 26 17% 24% 27% 18% 10% 1% 2% SOUTH-EAST ASIA NUMBER OF COUNTRIES 6 NUMBER OF CADRES 27 29% 57% 8% 3% 0.5% 2% EUROPE NUMBER OF COUNTRIES 5 NUMBER OF CADRES 22 25% 37% 7% 8% 18% 5% 1% 10% 45% 39% 5% 1% 1% 0.3% WESTERN PACIFIC NUMBER OF COUNTRIES 6 NUMBER OF CADRES 25 6% 5% 36% 23% 2% 22% 4% NUMBER OF COUNTRIES 73 NUMBER OF CADRES 381 REGIONALLY GLOBALLY FULL-TIME EQUIVALENT Midwives Nurse-midwives Nurses Auxiliaries Associate clinicians Physicians (general) Obstetricians/gynaecologists * Full-time equivalent figures do not include those 11% of country cadres for which percentage time spent on MNH was not reported. 12 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Midwifery workforce: roles and tasksFIGURE 6 � Since the SoWMy 2011 report countries and partners have begun to take bold steps to improve midwifery. � Projected changes in the number of pregnancies per annum provide new insights to inform the composition, skill mix, deployment and efficiency of the midwifery workforce in all regions. � Women’s need for the 46 essential SRMNH interventions can be quanti- fied: in 2012, this is estimated as 3.8 billion visits for family planning, antenatal and postnatal care and 107 million births. � Midwives, when educated and regulated to international standards, have the competencies to deliver 87% of the estimated need in the 73 countries. � Women’s need for sexual and reproductive health care also requires strong linkages with community-based service providers, with supportive supervision from midwives and other health professionals. � Countries should consider the availability, accessibility, acceptability and quality of the midwifery workforce in order to provide quality SRMNH services. � There is remarkable diversity in the typologies of health workers contributing to the delivery of SRMNH services, including significant differences between national use of cadre names and international standards for roles, education and regulation. Therefore, country cadre names do not form a strong basis for global, cross-country comparison of the midwifery workforce or grouping as skilled birth attendants. with midwives and nurse-midwives being more likely than auxiliaries to perform the full scope of midwifery practice, there are also many excep- tions. This raises concern about whether ISCO classification, which is used for international com- parison, is more often based on countries’ titles and education pathways than on the official roles, responsibilities and tasks within a country. There is also diversity within broad categories in terms of the duration of education and the education pathway. Country cadres within the broad category of midwives, and for whom the total length of clinical education was reported, trained for 1 year to 5 years; at least half trained for 3 years or more. Nurse-midwives trained for 2 to 6 years, with at least half training for 4 years or more. For those cadres that only reported post-nursing or post-college education, length of education for midwives ranged from 1 to 2 years, with at least half training 1.5 years or more, while length of education for nurse-midwives ranged from 1 to 3 years, with at least half train- ing for 2 years or more. Duration of education is relevant to international narratives on educational standards for midwives and nurse-midwives, as duration is linked to the quality and depth of study offered to students, but the data confirm significant differences between national use of cadre names and global standards on midwifery education [16] and regu- lation [18] and therefore who is entitled to use the term “midwife”. Availability The first dimension of effective coverage is availability, and is applicable to both midwifery services and the midwifery workforce (see Glossary, Annex 1). The focus in this section is the availability of the midwifery workforce. Availability depends firstly on the headcount of all workers involved in the midwifery workforce. The 73 SoWMy countries reported 7,377,083 workers who spend some proportion of their available working time providing SRMNH Evidence of progress KEY FINDINGS p er ce n ta g e o f re p o rt ed c ad re s Job description includes all midwifery tasks in ISCO 2008 guidance 0% 20% 40% 60% 80% 100% Associate clinicians Nurse- midwives Nurses Auxiliaries Physicians (general) Obstetricians gynaecologists Midwives Job description does not include all midwifery tasks in ISCO 2008 guidance 13CHAPTER 2: THE STATE OF MIDWIFERY TODAY care. However, simply correlating the reported headcount of selected cadres with health out- comes (e.g. the headcounts of midwives, nurses and doctors with the number of stillbirths, or maternal and newborn mortality, or women and adolescent girls with unmet need for fam- ily planning) is inadequate. Figure 7 shows the difference between assessing the midwifery workforce in terms of headcount versus full- time-equivalent availability. Among those country cadres for which this information was available, the full-time-equivalent workforce represents less than two thirds of all workers spending at least some time on SRMNH. Is this level of availability “enough”? If our goal is to deliver universal access to midwifery ser- vices, this question can only be answered with regards to each country’s need for midwifery services. As discussed earlier, the diversity of need, driven by a multiplicity of demographic and epidemiological factors, is not amenable to global benchmarks that promote a minimum number of health workers per 1,000 population, especially when the minimum number is often interpreted as a “target”. Workforce planning in relation to need must account for the country con- text. A needs-based analysis of the availability of the current and future midwifery workforce has been conducted for each country and is shown in the country briefs in Chapter 4. The reliability of this approach depends on 10 pieces of informa- tion that all countries should collect: headcount, percentage time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce [36]. Improving availability depends on better understanding and management of new entrants to the workforce and of existing workers who leave the workforce. Managing new entrants to the workforce must imply better management of midwifery education, as this directly determines future availability of the workforce. Enrolment, graduation and student attrition data from coun- Midwifery workforce: headcount versus full-time equivalent FIGURE 7 Note: Full-time-equivalent figures do not include those 11% of country cadres for which percentage time spent on MNH was not reported. tries are often missing or inconsistent, indicating an apparent disconnect between human resourc- es for health (HRH) management and education planning. Active management of midwifery education involves ensuring that the number of training places available, in both the private and the public sectors, is sufficient and of high enough quality to meet future needs, taking into account student selection and attrition. Management of medical and midwifery education also involves ensuring that sufficient students graduate from secondary school with skills in numeracy, literacy and sciences adequate to enrol in midwifery or medical education programmes. This was seen as a challenge in 78% of midwifery education programmes (49 out of 63). High school graduates must then be motivated to enrol in midwifery education programmes. Lack of infor- mation or negative preconceptions about careers in midwifery were reported by 9 out of 21 African countries that held a policy workshop, indicating N u m b er o f m id w if er y w o rk er s (i n m ill io n s) Full-time equivalent Headcount 0 1 4 6 7 8 3 5 2 Midwives Nurse-midwives Physicians (general) Obstetricians/ gynaecologists Nurses Auxiliaries Associate clinicians 14 THE STATE OF THE WORLD‘S MIDWIFERY 2014 the need for advocacy and better information. Once enrolled, students need practical, sociocul- tural and often financial support to remain in their education programmes. Workshop reports suggested that improving the quality of educa- tion and creating supportive environments, e.g. financial support and gender-sensitivity, could go a long way towards reducing student attrition. Pathways from education programmes to the workforce must also be better managed. Educating health workers for whom there are no jobs, or whose postings are severely delayed, is a poor use of resources. SoWMy data show that in more than half of countries, some graduates take longer than a year to join the workforce (except for obstetricians/gynaecologists) by which time their clinical skills may have deteriorated through lack of application. Workshop reports suggested a range of solutions to this problem, includ- ing: recruiting workers before their graduation; decentralizing responsibility for recruitment to subnational authorities; and better funding and enforcement of recruitment policies. Managing exits from the workforce requires a better understanding of the number of workers choosing to leave the workforce every year (see Figure 8). In more than half of such cases, data were missing on voluntary attrition, a signifi- cant barrier to understanding the availability of the workforce. In many other cases it is likely that attrition was under-reported [37]. Solutions to attrition discussed during the workshops centred mainly on improving salaries and incen- tives, management and supervision, and career development pathways, including through addi- tional training. Outflows are also heavily influenced by the age distribution of the current workforce. Although an ageing workforce is most common among obstetricians/gynaecologists, other country cadres such as midwives in Ghana and aides de santé in Guinea suffer from the same problem and will experience high losses in the next 10 years due to retirement. Regrettably, this infor- mation was unavailable for 56% of all reported country cadres. Exploring the availability of midwives Midwives make up 36% of the midwifery work- force across the 73 countries: although a sizeable proportion, they are not the only type of health worker needed to deliver SRMNH services. However, their specific contribution to the physi- ological process of “normal” birth and their high degree of focus on the SRMNH continuum of care makes them essential. This implies that policymakers should pay specific attention to these cadres within overall workforce planning. Currently, the data show that further progress can be made to encourage students to choose and remain within the profession. In most of the country responses (58%) a career as a midwife is perceived to be more attractive than other professions open to people with a similar level of education (Figure 9), but almost one quarter of countries (23%) see it as less attractive. This indicates that governments, professional associations and advocates need to do more to promote the profession, a “bold step” recommendation in SoWMy 2011. Some countries have taken this step already: • In Cambodia, midwives have been officially recognized as key to the reduction of maternal Percentage leaving the workforce voluntarily each year, by cadre FIGURE 8 P er ce n ta g e o f re p o rt ed c ad re s Auxiliaries0 20 40 60 80 100 Midwives Nurse- midwives Physicians (general) Obstetricians/ gynaecologists Associate clinicians Nurses Less than 5% At least 5%; less than 10% At least 10%; less than a quarter A quarter or more Missing data 15CHAPTER 2: THE STATE OF MIDWIFERY TODAY and newborn mortality, they received a larger pay increase than other health personnel with a similar professional education, they are financially incentivized for deliveries at public health facilities, and they are given priority when the government recruits civil servants for the Ministry of Health. • In Tanzania, the White Ribbon Alliance for Safe Motherhood has targeted secondary school students, their parents, politicians, and the community in their campaign “Increasing Women’s Access to Healthcare through Promotion of Midwifery as a Career in Tanzania” [38]. Objectives included improving public perception of midwives and promot- ing midwifery as an attractive career path among secondary school students. Results were promising with 89.4% of students reached in one region saying they would recommend mid- wifery as a career. In other cases, progress has been made through media and advocacy, for example through the cre- ation of awards recognizing the work of midwives and others, such as the African Union’s Mama Afrika award [39]. Status and identity are known to influence the attractiveness of a profession, partly reflected in the accompanying salary levels within each coun- try. Countries provided detailed information on the starting salaries of health personnel, which were validated using the World Bank database on HRH salaries.* Midwives’ salaries are among the lowest in low- and lower-middle-income countries, and are comparable to auxiliary nurse-midwives’ salaries, although this varies considerably from country to country. On average, midwives are paid more than 2.5 as much in upper-middle- income countries than in lower-income countries (see Figure 10), and in countries where there is a licensing system they are better paid. Other factors associated with higher salaries for mid- wives include an association active in negotiating employment and salary issues with government. Perceptions among survey respondents of the comparative attractiveness of a career as a midwife (73 countries) FIGURE 9 Average monthly starting salary per cadre of health worker (international $ purchasing power parity, 2012) FIGURE 10 0 500 1000 1500 2000 2500 3000 M o n th ly s al ar y (i n te rn at io n al $ P P P 2 01 2) Obstetricians/ gynaecologists Physicians (general) Nurse- midwives Midwives Auxiliary nurse- midwives Auxiliary midwives Low-income countries Lower-middle-income countries Upper-middle-income countries "Midwives were recently recognized by the government as key health professionals" (Cambodia) 36% 22% 19% 19% 4% "Women’s issues are undervalued" (Nepal) "The midwife profession is loved, but the lack of career plans tends to discourage people" (Mauritania) "A profession similar to others, not specific in terms of salary or rank" (Guinea) "Society is recognizing more and more the role of the midwife" (Papua New Guinea) MUCH MORE ATTRACTIVE A LITTLE MORE ATTRACTIVE ABOUT THE SAME A LITTLE LESS ATTRACTIVE MUCH LESS ATTRACTIVE Percentage * Correspondence with Juliette Puret and Christophe Lemière, World Bank. 16 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Accessibility The second dimension is accessibility (see Glossary, Annex 1) of health services and in par- ticular the midwifery workforce. Even if there are enough health workers, adequately remuner- ated and with the competencies to provide the continuum of care that women and newborns need, accessing the care that they provide remains a problem in many countries. Women need to be active decision-makers on when they choose to access the midwifery workforce (often denied because of gender discrimination) and to be able to reach and afford the care provided, sometimes rapidly during an emergency. Improving geographical access The first dimension of accessibility is physical reach. An accessible care system is underpinned by an adequate geographical spread of facilities and health workers, backed up by good trans- port, information and communication networks. Achieving equitable deployment of the workforce depends at the very least on good information and good planning. � The availability of the midwifery workforce can only be measured by reference to full-time equivalent not headcount. � Correlating the reported headcount of the midwifery workforce with health outcomes will produce findings that are insensitive to the real availability, as the full-time equivalent midwifery workforce represents less than two thirds of all workers spending at least some time on SRMNH. � Ten pieces of information that all countries should collect on the midwifery workforce, include: headcount, percentage time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce. � Midwifery education must be actively managed to ensure that the future workforce meets the needs of future populations. � A career as a midwife is perceived to be more attractive than other professions open to people with a similar level of education, but not in all countries. � Midwives’ salaries are among the lowest for health-care professionals in low- and lower-middle-income countries. Availability KEY FINDINGS In terms of information, only 15 of the 73 coun- tries surveyed provided an accurate, current list of health facilities, of which only 6 included pri- vate sector facilities. Only 4 countries reported that they have access to geo-referenced codes for health facilities. The absence of this basic infor- mation diminishes the ability to conduct detailed analysis of supply-side constraints to respond to population need. In terms of planning, the government decides how to allocate the midwifery workforce accord- ing to both the population level and the types of facilities that exist in that country in 53 of the 73 countries. A further 13 countries base these deci- sions solely on the types of facilities that exist, and 2 solely on the population level; 4 use other methods and 1 gave no response. However, even where one of these planning approaches was fol- lowed, it was difficult for countries to cite the exact norms they were using. Of the 66 countries reporting that midwifery workforce planning is partly premised on the types of facilities that exist, 41 (62%) were able to provide at least some information about the numbers of midwifery workers allocated to each health facility. Of the 55 countries reporting that workforce planning also follows population and population-catchment areas, 39 (71%) provided at least some information about the numbers of health personnel allocated to a certain size of population (e.g. the number of physicians per 100,000 population). Given the wide diversity in some countries on the geographical distribution of need, it may be fruitful to explore the possibility of flexible plan- ning norms at the subnational level, in order to offer the best possible combination of availabil- ity, geographical accessibility and quality in each area. These could be informed by the use of an emerging set of methods in geographic informa- tion systems (GIS) (see Box 3). Global guidance on accessibility established in 1997 [46] recommends a minimum of five fully functioning emergency obstetric and newborn care (EmONC) facilities per 500,000 population. 17CHAPTER 2: THE STATE OF MIDWIFERY TODAY The geography of SRMNH: advances in geo-information systems Geographical location is all too often a key determinant of whether a woman and her newborn will survive or thrive. Geographical information has been used to explore health outcomes for hundreds of years. Perhaps the most famous example is John Snow’s epidemiological study of London’s cholera outbreak in 1854, which plotted mortality on a map alongside the cause of the disease. This was one of the earliest examples of “health data visualization”: the conversion of health datasets into figures and graphics to clarify findings for researchers and policymakers. Advances in digital technology, design and data management software are enabling a rapid acceleration in visualization. The use of Global Positioning Systems (GPS) to record locations and GIS techniques to analyse and present data is increasing. This facilitates action on “hardwiring” equity into health services [40], promoting the “fair distribution” of services and affording “priority to the worse off’ [41] i.e. for the women and children most at need. Building up layers of geographical information for strategic planning Availability of services and human resources Where comprehensive data exist on health facilities they can be used to investigate supply of services. Decentralized and devolved monitoring and planning specific to local needs is enabled by district or facility catchment area data. Flexible context-specific workforce staffing requirements can be calculated that are relevant to population need and specific to the local terrains and geographical features. All countries should therefore seek to develop and maintain an accurate list of all health facilities and health workers with GPS coordinates. Accessibility of services and human resources Using facility maps in combination with datasets on mapped pregnancies it is possible to estimate numbers of pregnancies within user-defined distances or travel times of any type of facility. Many studies have measured, mapped and modelled travel times to health facilities using a range of different approaches [43–45]. Quality of services and human resources as measured by outputs and outcomes Maternal and neonatal mortality indicators reveal huge disparities between countries. The same is true within countries, although data on this are harder to come by. However, adverse health outcomes (i.e. maternal, perinatal and neonatal mortality) can be extracted from GPS-located data in population censuses, surveys and verbal autopsies to construct outcome maps and inform targeted equity approaches in relation to health needs and the quality of the health workforce at subnational level. BOX 3 Need for midwifery services Recent technical advances in GIS mapping have allowed the production of high- resolution datasets depicting population estimates, including live births and pregnancies, in many countries of the world. These maps, based on satellite mapping, census and survey data and shown in each of the 73 country briefs in this report, can provide the basis for strategic intelligence [42] and planning, and provide denominators for subnational indicators to track progress. LAYER 1 2 3 4 Source: Andy Tatem, Jim Campbell and Zoë Matthews, ICS Integrare and University of Southampton. 18 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Although this is an established benchmark, improved information on births and preg- nancies has led to current discussion about revising these accessibility standards [47]. SoWMy findings indicate that many countries aspire to the EmONC facility readiness bench- marks and designate a high proportion of their facilities as potentially capable of providing EmONC (see Box 4). This highlights the need to encourage national and global discussion on how to improve policy, planning, accessibility and monitoring of life-saving care. More tailored guidance or using basic health geographies such as districts and country-designed benchmarks that are related to the annual volume of pregnancies or both normal and complicated births may assist. The implications of 24-hour services, requiring shifts and rotation of the midwifery workforce, must also be considered to maintain the readi- ness of EmONC facilities. In the 37 countries which held a policy workshop a number of key challenges to geo- graphical accessibility beyond information and planning were identified, including: health workers preferring not to work in rural areas; poor/expensive transport links to remote areas; insufficient clinic space for women in early labour; and inadequate referral networks. Their suggested solutions included: financial and non-financial incentives for health workers to work in remote/under-served areas; com- pulsory periods of rural service; improvements to rural facility infrastructure to make rural posting more attractive; addressing the uneven geographical distribution of training institu- tions; and the provision of maternity homes in hard-to-reach areas. Many of these suggestions are consistent with the evidence base included in WHO guidelines and recommendations [49,50]. Improving economic access Barriers to accessing care go beyond the geo- graphical location of services. Unsurprisingly, financial barriers to care are known to have a negative effect on access [51–53]. A very positive finding from the 2014 survey is that 70 of the 73 responding countries have a national “minimum guaranteed benefits package” for SRMNH, defined as “a set of health services that the government has committed itself to making available to all, free at the point of access”. For these countries the package includes a prescribed list of interventions or services as a minimum; others may be added as a part of the package, but the minimum list is guaranteed. The existence of a minimum benefits package does not mean that women and newborns have financial accessibility to all of the essential elements of SRMNH care. Only 2 countries (China and Peru) have a package that includes all 46 essential SRMNH interventions. However, a further 10 countries include all but one or two of the interventions (Brazil, Comoros, Gabon, Guinea, Lesotho, Mexico, Senegal, South Africa, Viet Nam and Zimbabwe) and 45 countries (62%) offer at least 40 of the 46 interventions. Addressing some of the most common gaps in countries’ benefits packages could save lives. Hypertensive disorders, obstructed labour and unsafe abortion have been identified as leading causes of maternal death in developing countries [54]. However, calcium supplementation and low dose aspirin to prevent pre-eclampsia, interventions for cessation of smoking, reduction of malpresentation at term with external cephalic version and safe abortion are included in fewer than half of the countries. Similarly, while preterm birth is a leading cause of newborn death [55], a quarter of countries do not include interventions to prevent preterm birth and protect preterm infants in their minimum benefits package. In particular, use of antenatal corticosteroids to prevent respiratory distress syndrome in preterm infants, continuous positive airway pressure to manage newborns with respiratory distress syndrome, and social support during labour could be included more widely. 19CHAPTER 2: THE STATE OF MIDWIFERY TODAY Emergency obstetric and newborn care: from designation to readiness Most pregnant and healthy women experi- ence a normal physiologic process and deliver healthy live babies. However, when that process does not follow a normal course, timely access to quality EmONC can become a matter of life and death. EmONC covers a package of life-saving procedures and drugs to treat complica- tions of pregnancy and childbirth. SoWMy 2014 findings indicate that almost half (44%) of country respondents reported that all the health facilities with childbirth services in their country were designated, from a policy and planning perspective, as either comprehensive (C-EmONC) or basic (B-EmONC) (i.e. all hospitals in the country are designated as C-EmONC facilities, and all non-hospitals are designated as B-EmONC facilities). However, designation as an EmONC facility, meaning that the facility could potentially provide emergency life-saving interventions if resourced with the necessary staff, equipment, drugs and supplies, is often dramatically different from the reality of whether a facility is in a state of readiness and “fully functioning”. For monitoring purposes EmONC is defined by the performance of signal functions. For an EmONC facility to be considered fully functioning, two key aspects are required: 1) it must have performed the 7 basic or the 9 comprehensive EmONC signal functions, and 2) the signal functions must have been performed within the last 3 months. The figure below uses needs assessment data across 11 countries* to show the disparity between readiness and actual provision of basic signal functions, and which signal functions are the most widely performed. It shows that assisted vaginal delivery (AVD) is the least often performed. Only 43% of health facilities reported a health worker capable of per- forming AVD via vacuum extraction or using forceps, even fewer (32%) had the minimum requisite equipment and only 14% of health facilities had performed such a procedure in the last 3 months. Countries seeking to expand the vol- ume and quality of EmONC facilities are encouraged to align policy and planning with the global guidelines on EmONC coverage [48]. Designation can be used as a policy tool to prioritize resource alloca- tion and service improvement, consistent with coverage needs. Readiness needs to be actively managed, continuously ensur- ing that health workers, equipment, drugs and supplies are all available. Monitoring of whether the facility does perform and is fully functioning can then be used as a quality improvement tool to ensure that all women and newborns have timely access if required. Percentage of facilities in 11 countries ready to perform and which did perform each signal function P er ce n ta g e o f h ea lt h f ac ili ti es Parenteral antibiotics At least 1 health worker can perform signal function 0 20 40 60 80 100 Neonatal resuscitation Parenteral uterotonics Parenteral anticonvulsants Manual removal of placenta Removal of retained products Assisted vaginal delivery Has mininum requisite drugs/equipment/supplies Ready to perform signal function Performed signal function in last 3 months Source: Patricia Bailey, Averting Maternal Death and Disability. * Data from Averting Maternal Death and Disability EmONC Needs Assessments provided by Patricia Bailey. BOX 4 20 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Other issues of financial accessibility include: low public awareness of the right to services which are free at the point of access; women’s lack of empowerment when it comes to household budget decisions; costs of services/ items not covered by the country’s benefit package (e.g. transport, drugs); and facilities lacking equipment or supplies to meet demand. Suggested solutions to these financial barriers include: prepayment schemes and safety nets/ social protection; including transport costs within the minimum benefits package; health workers supporting communities to organize cooperative community groups to facilitate transport and share costs; and improving governance, ensuring accountability and voice to clients, and addressing corruption/racketeering, e.g. by improved supervision and monitoring. Equality of access As well as physical and financial accessibility, many women face additional barriers to accessing midwifery services and the midwifery workforce which relate to their socioeconomic position or cultural group. Rich/poor and urban/rural gaps in access to care are now well documented, and in many contexts gaps are widening [56,57]. Certain regions within a country, or particular marginal- ized groups such as adolescents, migrants or tribal communities, can also be effectively excluded from care, especially reproductive health care. There is strong commitment to making equity a fundamen- tal part of the post-2015 development agenda. One proposal to measure a country’s progress towards UHC is to track the poorest 40% of the popula- tion’s access to essential health services (see Box 5) which include the continuum of SRMNH care. Reaching the poorest 40% The World Bank and WHO are in process of developing a measurement framework to track country progress towards UHC [58,59], “assessing the aggregate and equitable coverage of health services and financial risk protection.” As part of the proposed framework it is suggested that: All measures should be disaggregated by socioeconomic strata to assess the degree to which service and financial protection coverage are equitably distributed. Disaggregation would permit progress to be measured at the population level (the aggregate goal) and among the poorest 40% of the population (the equity goal). This is consistent with the measurement of equity in the Countdown to 2015 reports. An equity goal for SRMNH services will pose significant challenges for many countries. The figure below shows the coverage level for skilled attendance at birth and four or more antenatal care visits for the poorest 40% and the rest of the population in 34 countries, with countries grouped according to cover- age levels. Only four countries are reaching the equity goal for both indicators (Armenia, Colombia, Dominican Republic and Jordan): these countries have achieved overall coverage of at least 90% and have BOX 5 SRMNH coverage for the poorest 40%, grouped by overall coverage rate for 34 countries Percentage of live births with skilled birth attendant Very low Poorest 40% Low Moderate High Very high Wealthier 60% Percentage of live births for which mother had at least 4 antenatal visits 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Very low Low Moderate High Very high Note: The 34 countries have been categorized into 5 groups based on the overall level of skilled birth attendance/ at least 4 antenatal visits nationally: very low (<31%), low (31%-50%), moderate (51%-70%), high (71%-85%) and very high (>85%). 21CHAPTER 2: THE STATE OF MIDWIFERY TODAY Source: Sarah Neal, Amos Channon and Zoë Matthews, University of Southampton. Country actions in Afghanistan, Sierra Leone and Togo The Midwives Association of Afghanistan capitalized on the opportunity presented by the SoWMy 2014 survey to organize two stakeholder work- shops for data collection, validation and policy discussion. Plans are already underway for a national SoWMy 2014 launch and dissemination, including round-table policy discussions and media coverage [68]. In Sierra Leone, SoWMy 2014 participants identified poor working con- ditions, inefficient deployment mechanisms, lack of motivation, and insufficient opportunities for continuous professional development as some of the problems facing the midwifery workforce. A new mapping exercise has been commissioned by the government, in partnership with UNFPA, which will collate bio-data on all practising midwives and the geographic location of the facility they are working in. Togo is another example of how the SoWMy 2014 process has strength- ened national dialogue. The Togo Midwives Association coordinated the national workshops [69]. The meetings and discussions brought results in the form of data, and helped to strengthen relationships between the Midwives Association, the Ministry of Health, UNFPA and WHO. very little inequity between the poorest 40% and the rest of the population. One important characteristic of an equity goal is that it is an absolute rather than a relative target: countries with the lowest coverage will need to make the most progress. Analysis across coun- tries with low coverage demonstrates that the recent rate of progress towards higher coverage is very poor [60]. These are countries where the infrastructure is weakest, and attempts to increase coverage of key SRMNH interventions will require sustained investments in the health system and the health workforce. Further, as inequities in coverage reduce, it is important that greater efforts are made to reduce inequities in quality [61,62]. Equity-focused approaches will be required [63–66] targeting the poorest [41,67] if both aggregate and equity goals for SRMNH coverage are to be achieved in the future. � Most countries deploy their midwifery workforce using facility-based planning or workforce to population ratios; these may be inconsistent with needs and access to care. � Human resource information systems linked to facility GIS codes would enable new insights into people’s ability to access a skilled and competent health-care provider. � The provision of EmONC services could benefit from new approaches to designate, make ready and monitor those facilities which are capable of providing life-saving care. � Countries are urged to develop a “minimum guaranteed benefits package” for SRMNH, defined as “a set of health services that the government has committed itself to making available to all, free at the point of access”. � 70 of the 73 responding countries have a national “minimum guaranteed benefits package”, but there are gaps in the essential interventions. � Many countries will face significant challenges to ensure universal coverage, especially for the poorest 40%. � Equity-focused approaches will be required that target the poorest, if both aggregate and equity goals for SRMNH coverage are to be achieved in the future. � Countries can take immediate action to improve their strategic intelligence on accessibility to the midwifery workforce. Accessibility KEY FINDINGS Clearly, strategic intelligence could be used to plan equity-focused approaches. However, not all governments have policy priorities on workforce deployment that are commensurate with population distribution and need; most countries report using facility-based planning (number of health workers per facility type) or workforce to population ratios, which are inconsistent with addressing need and areas of special need or deprivation. An example in Sierra Leone (see Box 6), triggered by discussions in the SoWMy 2014 policy workshop, highlights how countries can take immediate action to improve available data on health facilities and on where the midwifery workforce is actually practising. BOX 6 Source: UNFPA and ICM. 22 THE STATE OF THE WORLD‘S MIDWIFERY 2014 Acceptability The third dimension is acceptability (see Glossary, Annex 1). Even if care is available and accessible, effective coverage will be reduced if either the care or the midwifery workforce is unacceptable to women, their families and communities. Despite the rising proportions of women giving birth in facilities with professional health workers, there is evidence that in some instances lack of respectful care continues to be a disincentive to access (see Box 7). Acceptable care requires that all health facilities, goods and services should be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals of all age groups including adolescents, minorities, peoples and communi- ties [70]. It should be sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned. Improving accept- ability means listening to the voices of women and their communities, and building their pref- erences into policy and training initiatives and feedback loops. This aspect of service improve- ment has historically been lacking in many countries [71] but strategies are now emerging to address the problem. It is difficult to increase acceptability without understanding current public attitudes towards the midwifery workforce and their practice. Just 18 of the 73 responding countries are aware of studies on this in their country. Among these is South Africa, which reported “lack of information or being shouted [at] instead of being given clear information … being turned away from the facili- ties and delivering at the gate or on the way home … neglect and abandonment during labour or childbirth”. More robust, peer-reviewed research is needed on this important topic. The SoWMy Respectful care in maternity services White Ribbon Alliance Charter for Respectful Maternity Care All women need and deserve respectful care before, during and after pregnancy and birth. Sadly, in many countries this is not what women are receiving. The Charter for Respectful Maternity Care [72] was developed in 2011 by a group of multiple stakeholders and development partners. The Charter was in response to a 2010 landscape report by Bowser and Hill, Exploring evidence for disrespect and abuse [73], that described seven kinds of disrespect and abuse to which women and their newborns can be subjected. These range from subtle disrespect and humili- ation, through abandonment or denial of care, to detention in facilities. Many countries are faced with this issue. Some are taking positive steps to gather new evidence and throw more light on this pervasive barrier to care: • A recent study in Kenya by the Heshima project (heshima means dig- nified in Kiswahili) found that 20% of women reported feeling humiliated or disrespected during care at childbirth. Correlations were found between the women’s socio-economic status and the different categories of disrespect and abuse, with wealthier women more likely to be detained or asked for bribes, younger women more likely to experience non-confidential care, and the poorest experiencing more aban- donment [74]. • An assessment of the quality of care in pregnancy and delivery in Kanakapura Taluk, India [75] showed that lack of respect by providers was a strong disin- centive to giving birth in a care facility, and that feeling uncomfortable asking questions, being denied a birth com- panion and lack of support from care providers were strong factors in deter- ring women from seeking care in the future. 1 in 4 women reported that their provider revealed personal information they did not want others to know. This finding was consistent across public, private, basic and referral hospitals [76]. • In Tanzania, following a Discrete Choice Experiment, one of the most important factors women identified as influencing their choice of a whether to give birth in a care facility was provider attitude. The authors estimate that improving these facility characteristics would lead to a 43-88% increase in births in care facili- ties [77]. • In South Africa women reported not seeking antenatal care because health providers were so rude; they sought attention only when in labour [78]. • In Peru many women are reluctant to utilize EmONC facilities because they felt service providers paid little attention to their needs and showed little sensitivity to local culture [79]. Source: Zoë Matthews, University of Southampton and Petra ten Hoope-Bender, ICS Integrare. BOX 7 23CHAPTER 2: THE STATE OF MIDWIFERY TODAY survey asked for reasons why a woman or girl might be unable to or uncomfortable about seeking care from a midwife; a sample of the responses is provided in Table 2. In responding to the SoWMy survey most countries (79%) stated that policies are in place specifically to address how SRMNH care will be delivered in a way that is sensi- tive to social and cultural needs, for example in relation to age, ethnicity, religion and lan- guage. These include a National Sexual and Reproductive Health Policy (Malawi), the Inclusion Strategy for Gender Equality in the Health Sector (Mozambique) and the Five Year Plan for Reproductive Health (Myanmar). The Afghanistan policy highlights support of gen- der equality issues and reproductive health and rights, as well as enhancing women’s decision-making role in relation to health- seeking practices. China’s policy notes increased investment in rural and remote regions and an extraordinary commitment to the universal provision of subsidies for all those who give birth in hospitals. In Liberia, the government regards health as a basic human right and aims to ensure every Liberian will have access to Reasons why women do not seek care or feel uncomfortable about seeking care REASON ILLUSTRATIVE QUOTE/EXPLANATION Social, cultural and religious beliefs and needs are not being met in institutions Perception that institutions, and the health personnel within them, can be unfriendly or disrespectful of women’s cultural or religious beliefs. Mothers recognize that midwives are overloaded (including with non-midwifery tasks) “There is a severe shortage of midwives and the few who are there are overloaded.” Health system incentives may encourage medicalized care New financing mechanisms that favour medical interventions can encourage women to use high-level medical services in preference to midwifery care. Lack of information on the professional role of the midwife “The general public is unaware of the competency levels of a midwife.” Where women know about and prefer care by skilled midwives, they still face geographical and financial barriers “Women will prefer care from a midwife if they are in a position to do so or make choices. Some women are located in remote, hard-to-reach areas and they only have access to traditional birth attendants.” Midwifery is socially undervalued In some countries, paying for a doctor is seen to give greater social status to the family than attendance by a midwife. services, regardless of economic status, origin, religion, gender or geographical location. During country workshops the issue of accept- ability was strongly linked with (1) women’s role in society (lack of empowerment among and discrimination against women as both service users and service providers) and (2) the attitudes of health-care providers towards service users (care not being provided in a gender- or culture- appropriate way; lack of humane, woman-centred By providing humane, informed and culturally-sensitive care, midwives can encourage women to seek SRMNH services. (Jhpiego/Kate Holt) TABLE 2 24 THE STATE OF THE WORLD‘S MIDWIFERY 2014 � More robust research is needed on women’s perceptions of and attitudes towards the midwifery workforce. � Only 18 countries are aware of studies documenting public attitudes towards the midwifery workforce and their practice, which limits the understanding of acceptability. � The issue of acceptability is strongly linked to discrimination against women as both service users and providers. Further analy- sis on gendered-roles in the midwifery workforce would be valuable. � Countries are developing policies to pro- mote care that is sensitive to social, cultural and traditional needs; these policies need to be implemented and monitored. � Mobilizing citizens and providers to cham- pion greater accountability from local services and governments to deliver on their SRMNH commitments can help to ensure the conditions for delivering quality care. Acceptability KEY FINDINGS care). Suggested solutions to these issues include: women’s empowerment by improved education; improved mentoring/supervision of clinicians by regulatory bodies, professional associations and employers; and the inclusion of respectful care and sociocultural sensitivity as part of pre-ser- vice and in-service training. This suggests there is a need for further analysis of the gendered role of midwives, building on existing research [80]. Improving the acceptability of care can also be tackled by enhancing community voice, promot- ing client/provider interaction and ensuring accountability for services. Understanding the gaps in care provision, and mobilizing citizens and providers alike to call for greater account- ability from local services and governments to deliver on their SRMNH commitments, can help to ensure that the conditions are in place to deliver quality care. A number of new initiatives have promoted accountability mechanisms at local and national levels (see Box 8). Quality The fourth dimension is quality (see Glossary, Annex 1). Even if the midwifery workforce are available, accessible and acceptable to the popu- lation, poor-quality care can substantially limit their effectiveness. Evidence from settings that have provided 100% institutional care at birth shows that maternal mortality ratios can remain high unless quality is addressed [81]. There are many aspects to quality of care [82] including level of staffing, resources and work environ- ment, and many reasons for variations in quality. The competencies of the workforce are only one component of this. Nonetheless, the midwifery workforce is a valuable starting point for Midwives can empower women through education and by providing health-care information. (Jhpiego/Kate Holt) 25CHAPTER 2: THE STATE OF MIDWIFERY TODAY Ensuring acceptability of service through accountability Increasingly, activists and advocates are seeking to stimulate accountability in the delivery and monitoring of SRMNH ser- vices by calling for stronger legal, policy, regulatory, governance and financial environments. SRMNH service delivery improves when communities, clients, providers and health managers work together to review evidence of shortcom- ings and take action. Maternal Death Surveillance and Response, facility scorecards and client-provider partnerships can build momentum for change • In Ethiopia maternal death reviews are seen as a key element of the account- ability and response cycle; these form part of a new and expanding system of maternal death surveillance and response for the country. • In Sierra Leone the death review sys- tem is under improvement with the support of the First Lady of Sierra Leone, and a Maternal Survival Network is conducting high-level advo- cacy to address recommendations arising from national maternal death review data. • Facility assessments and scorecards are used by health system managers in Sierra Leone and Ghana with civil society stakeholders benchmarking the quality of care provided at their local maternity facilities. Scorecards are used by clients and providers alike to advocate for systemic changes in SRMNH service delivery. • In Malawi the powers of the district level ombudsman’s office have been extended to include the power to report inaction at facility and district levels directly to the Ministry of Health. District ombudsmen’s offices often lack inde- pendence from health facilities, although at national level powerful and effective accountability mechanisms exist. Tracking government commitments can increase accountability • In Nigeria the group Accountability for Maternal and Newborn Health has been established to track progress, facilitate transparency in SRMNH issues, and stimulate action on priori- ties and commitments. In a pioneering move for African countries, a new National Independent Accountability Mechanism has been set up to track progress on implementing the recom- mendations of the Commission on Information and Accountability for Women’s and Children’s Health and the national roadmap. • Stakeholders in Tanzania have estab- lished a Countdown Country Case Study (Countdown to 2015 group) with in-country activities which are provid- ing evidence on the progress (and lack thereof) in SRMNH care that will be fed directly into the mid-term review of the national policies for achieving MDGs 4 and 5, as well as the One Plan and the Health Sector Strategic Plan III. Supportive governance and an enabling financial environment are essential for accountability • Tracking domestic resources dedicated to SRMNH services is often difficult: reports can be difficult to obtain and flows of SRMNH financing may not be disaggregated. • Countries of the African Union pledged, through the 2001 Abuja Declaration, to allocate 15% of their overall national budget to the health sector, but only a few countries have fulfilled this pledge. Advocacy cam- paigns and community action groups are now working to keep SRMNH- related commitments in the public eye, in order to bring decision-makers and those in power to account. Civil society can call for social accountability Five African countries have launched and developed an SRMNH campaign called MamaYe, which aims to bring together all actors working in SRMNH, from local to national level, to increase and sustain the visibility of SRMNH issues. Advocacy campaigns and national websites are platforms from which evidence, advo- cacy and accountability initiatives can be linked together and shared widely with a multitude of stakeholders in each country. They allow greater publicity and dialogue in both formal and informal settings, in order to focus attention and promote action on SRMNH. Schoolgirls engage with SRMNH issues in Ghana through the MamaYe campaign. (MamaYe Ghana) Source: Adriane Martin-Hilber and Louise Hulton, Evidence for Action. BOX 8 26 THE STATE OF THE WORLD‘S MIDWIFERY 2014 considering quality of care, particularly education, competencies, skill-mix and collaborative practice. Midwifery education: still neglected SoWMy data provide strong evidence of perva- sive gaps in the infrastructure, resources and systems that affect midwifery education. The SoWMY survey collected a fair proportion of the information used by the forthcoming Rapid Midwifery Assessment Tool* to evaluate the quality of midwifery education. The tool has six sections: infrastructure; teachers, tutors and pre- ceptors; students (discussed in the Availability section above); clinical education; curricu- lum; and influencing factors (discussed in the Regulation and Policy sections below). Inadequate infrastructure is a key problem for midwifery education. Insufficient or poor-quality equipment at teaching institutions is a problem for 80% of midwife cadres, 69% of nurse-midwife cadres and 44% of nurse cadres. Lack of class- room space is perceived as a challenge to the education of 53% of midwife cadres, 43% of nurse-midwife cadres and 17% of nurse cadres. Concerns relating to teaching staff were also com- mon. Difficulties in recruiting sufficient teaching staff were reported in relation to 82% of midwife cadres, 62% of nurse-midwife cadres and 39% of nurse cadres. Similarly, difficulty in recruiting appropriately qualified teaching staff was reported in relation to 77% of midwife cadres, 62% of nurse- midwife cadres and 39% of nurse cadres. Teacher retention is also problematic. In many countries there is inadequate investment in the education of faculty and teachers are unable to update their the- oretical knowledge and/or clinical practice skills. This limits the quality of education provided, and learning is often lecture-based. This has profound implications for the ability to educate and train midwives competent to provide the full range of services needed. The greater challenges with recruiting teachers and maintaining competency in direct-entry education programmes may be due to the fact that in some countries direct-entry edu- cation for a midwife is only recently established and they are struggling to recruit from a smaller pool of qualified teachers with pedagogic skills and specialized knowledge of midwifery. In terms of the clinical practice requirement in education programmes, the number of births a midwife must conduct under supervision prior to graduation varies across countries (see Figure 11). The median reported number of supervised births required for midwives is 34, for nurse- midwives 30, and for nurses 20. Each of these medians is less than the indicative number discussed in ICM’s education standards compan- ion guidelines [16], which encourages forward planning to ensure that sufficient midwifery practical experience be factored into education pathways and suggests a median of 50 supervised births (though some students will require more for competency demonstration and others less). Difficulties in providing students with sufficient clinical experience were reported in relation to 80% of midwife cadres, 62% of nurse-midwife cadres and 61% of nurse cadres. In many settings, therefore, midwives and other professionals may graduate from their education programmes with- out enough practical experience of childbirth. Minimum number of births to be conducted under clinical supervision FIGURE 11 Minimum number of supervised births each student must complete before graduation 0 5 10 15 20 25 30 35 40 45 10–19 20–29 30–39 40–49 50 or moreFewer than 10 P er ce n ta g e o f ea ch c ad re t yp e Minimum number of supervised births each student must complete before graduation Midwives Nurse-midwives Nurses 0 5 10 15 20 25 30 35 40 45 10–19 20–29 30–39 40–49 50 or moreFewer than 10 % o f ea ch c ad re t yp e Midwives Nurse-midwives Nurses * This tool is being developed by ICM and Jhpiego for particular use in low- and middle-income countries. 27CHAPTER 2: THE STATE OF MIDWIFERY TODAY Most midwifery and nursing cadres have a national curriculum that is followed by all schools (85% of midwife cadres, 64% of nurse- midwife cadres and 78% of nurse cadres). The ICM recommends that curricula be reviewed every five years [16] and this has happened for 78% of midwife cadres, 48% of nurse-midwife cadres and 28% of nurse cadres. This may reflect the increasing number of direct-entry mid- wifery programmes established in recent years. The content of these curricula is not generally perceived to be a challenge to the provision of quality midwifery education, but this is an issue for a significant minority of cadres. Among countries where there is no standard curriculum, there are national standards for assessing educa- tion quality for only 33% of midwife cadres and 38% of nurse-midwife cadres. Potential ways to improve the quality of midwifery education suggested by SoWMy workshop participants include the imple- mentation and regular review of minimum standards for curricula (aligned with ICM global standards), and the introduction of faculty development plans, including regular refresher training and formal qualifications for teachers/tutors/supervisors. Other suggestions included: improved access to simulation train- ing and equipment; regulation/accreditation of private midwifery schools (although far from all public schools are regulated or accredited either); more “hands-on” training in health facilities; and improvements in monitoring and evaluating education and training institutions. More in-service training and continuing profes- sional development are seen as good means of improving quality, and this included supportive supervision of teachers/tutors. Such invest- ments would enable improvements on a range of issues, including: productivity, competency and quality of care; accountability of service providers to service users; workforce morale; continuous professional development; effective regulation; and collaboration between different professional associations. The involvement of midwifery staff in maternal and perinatal death reviews helps to identify areas for improvement and to overcome systemic problems. Improving legislation, regulation and licensing mechanisms Supporting and protecting midwives by law (providing a legal right to practise) is an impor- tant acknowledgement of their worth. Only 35 out of the 73 responding countries (48%) have legislation recognizing midwifery as a regulated profession, and in five of these countries the leg- islation is not applied. Among the 54 countries who took part in both SoWMy 2011 and SoWMy 2014, the proportion of countries with such leg- islation has increased only slightly (from 35% to 37%). Yet progress is being made: 12 countries reported that legislation is being created. This does, however, leave 26 countries with no such legislation and none being created. In nearly all responding countries there is at least one organization with responsibility for the regulation of midwifery practice (see Figure 12). Half (51%) said that midwifery is regulated by the Ministry of Health or other government department, and a similar proportion (47%) mentioned a government-approved regulatory Midwives, when educated and regulated to international standards, are able to provide quality care and have a positive impact on sexual, reproductive, maternal and newborn health outcomes. (Jhpiego/Ali Khurshid) 28 THE STATE OF THE WORLD‘S MIDWIFERY 2014 organization such as a Board or Council. A few countries have more than one regulatory body. Just 6 of the 73 countries report having no regu- latory body whatsoever, of which 3 (Democratic Republic of Congo, Guatemala and South Sudan) said that one is being set up. The existence of a regulatory body is necessary, but not sufficient, to ensure effective regulation. Survey respon- dents were asked to state the responsibilities of their regulatory organization(s) (facilitating a comparison with ICM’s global standards [18]). Figure 13 shows that the main responsibilities currently held by regulatory organizations are: setting standards for midwifery practice; regis- tration; applying sanctions in misconduct cases; and setting ethical standards. Relatively few countries mentioned accreditation of education providers or protection of the professional title of “midwife”. Although most countries report that a regula- tory organization is responsible for the functions listed in Figure 13, information from the 37 country workshops indicates that in some coun- tries regulatory organizations do not fulfil these functions effectively, due to issues such as: lack of clear description of midwifery competencies; lack of nationally agreed standards for midwife- ry education (especially in the private sector); and lack of effective regulatory processes, e.g. due to political instability or insufficient resourc- es. Adequately resourced regulatory systems are a key priority for quality improvement. The workshop participants considered ways to tackle these issues, and suggestions included ensuring that regulation of midwifery is separate from regulation of other health professions, but with appropriate coordination. The scope of practice for different cadres in the midwifery workforce should be laid down by regu- latory mechanisms, but these are often ineffective. For instance, there are countries in which mid- wives perform some or all of the seven basic signal functions without being authorized to do so, often because they are the only health-care provider present when the need arises. The SoWMy data allow a comparison of the authorized and actual activities of midwives in relation to the seven B-EmONC signal functions as shown in Figure 14. Assisted vaginal delivery stands out as the func- tion with the most significant disparity between authorization and provision, with 19 countries stating that midwives perform this even though they are not authorized to do so. Midwives are also authorized to provide at least one type of family planning product in 71 out of the 73 countries, the two exceptions being China and Iraq. In 57 countries midwives are authorized to provide all four types listed in the question- naire: contraceptive injection, contraceptive pill, intra-uterine device and emergency contraception (EC), commonly referred to as the “morning-after pill”. Authorization does not, of course, guaran- tee availability or quality; at country level there is very little correlation between unmet need for contraception and the number of family planning products that midwives are authorized to provide. Out of the four types of contraception listed in the questionnaire, EC is the least likely to be pro- vided by midwives, although 61 of the 73 countries reported that it was. Neither women nor midwives are protected or sup- ported without appropriate regulation, registration and licensing. For the latter, licensing systems for Regulation and licensing of midwivesFIGURE 12 Percentage of 73 responding countries 0 20 40 60 80 100 Officially recognized definition of professional midwife System of licensing Midwife is a recognized and regulated profession Electronic register for licensing 88 48 53 60 77 Yes NoYes, but with conditions No, but it is being created Government department or government approved regulatory body regulates midwifery practice 29CHAPTER 2: THE STATE OF MIDWIFERY TODAY Functions and responsibilities of regulatory bodiesFIGURE 13 B-EmONC signal functions: midwives’ authorized and actual roles FIGURE 14 midwives exist in 34 of the 73 countries (47%) and are being created in a further 11 countries (15%). In all but one of the 34 countries with a licensing system, licensing is compulsory before a midwife can practise. Again, a system is a cru- cial first step, but does not guarantee effective implementation. This is illustrated by the survey, which found that only 26 of the 73 countries have a system of regular re-licensing (typically annually or every five years) and only 17 make continuing professional development a condition of re-licensing. A register of licensed midwives exists in 48 of the responding countries, of which 28 have an elec- tronic register. Among the 54 countries which took part in both SoWMy 2011 and SoWMy 2014 there has been a 40% increase in those with an electronic register. This progress is likely to con- tinue: a further 18 countries reported plans to create a register. Paper-based registers are updat- ed less frequently than electronic ones (10% of countries with a paper-based register and 43% of those with an electronic one say that the register is updated at least once a month). Improving professional associations All 73 countries except Turkmenistan reported at least one professional association, college or union which is open to midwives, nurse- midwives or auxiliary midwives. 51 of the 73 countries are represented within the ICM and 45 in the ICN, providing linkages to the global bodies and the technical support this offers. The 73 countries listed a total of 119 professional associations of which 71 (60%) were created in or after 1990; nearly all are specifically for midwives and/or nurses. In a few countries no midwifery or nursing association was men- tioned, but instead information was provided about, for example, an association for obstetri- cians which midwives and nurse-midwives are entitled to join. Although nearly all countries named associa- tions, only 60 were able to provide data on the number of members of each association. Across Percentage of 73 responding countries Setting standards for midwifery practice Registration of practising midwives Applying sanctions to midwives found to have been guilty of misconduct Setting standards for professional ethics Establishing the scope of midwifery practice Setting standards for education Investigating alleged misconduct or incompetence Ensuring the quality of education Verification of midwives joining the workforce from other countries Continuing professional development Advising government on MNH care policy Assessing competency prior to registration Protection of the professional title ‘midwife’ Accreditation of education providers Other 0 10 20 30 40 50 60 70 80 79 11 53 60 62 67 67 68 68 78 74 73 70 70 70 Number of countries Parenteral administration of antibiotics Administration of oxytocics Administration of anticonvulsants Assisted instrumental delivery by vacuum extractor Manual removal of placenta Manual vacuum aspiration for retained products Newborn resuscitation with mask Authorised and do 0 10 20 30 40 50 60 70 80 Authorised but don’t do Not authorised but do Not authorised and don’t do 30 THE STATE OF THE WORLD‘S MIDWIFERY 2014 these 60 countries nearly 670,000 members were reported (not all are midwives/nurse-midwives because some associations are also open to other cadres of health professional). Across the 50 countries that provided data on the number of members currently practising, 86% of the total membership is currently practising in-country, which suggests that, in these 50 countries, mem- bership lists are kept reasonably up to date. The “bold steps” recommended in SoWMy 2011 for professional associations included contribut- ing to the policy arena and advocating for better working conditions. Figure 15 shows that nearly all of the 119 associations play a role in continu- ing professional development, and a similar number advise members on quality standards for SRMNH care. Interestingly, 53% report being involved in negotiating work or salary issues with their government, a function that is generally the domain of a trade union. Participants in the 37 country workshops made several suggestions about how to strengthen pro- fessional associations. Associations specifically for midwives were suggested, as well as: encour- aging all midwives to join; ensuring professional associations contribute to policy discussions and key decisions affecting SRMNH services at national and regional levels; advocacy to increase the visibility of the profession and advance the rights of the midwifery workforce, e.g. improving staff welfare, security and promotion; improv- ing collaboration and cooperation between all health-care professional associations and other SRMNH stakeholders such as NGOs; and strengthening the administrative and advocacy capacity of professional associations [83]. Policy and planning The alignment and cohesion of policy and plan- ning instruments, along with data for strategic intelligence, are essential to deliver effective cov- erage of quality midwifery care. Across the 73 countries, respondents listed 276 policies, plans and legislations in place for organizing, delivering and monitoring SRMNH services (almost 4 on average per country) and all countries reported at least one policy/plan/ legislative in force. 68 countries have a national health plan (although not all used this title), 66 have a national SRMNH plan/strategy/roadmap or similar and national HRH plans are in place in 52 countries. Of the 52 countries with a national HRH plan, 39 (75%) said the MNH workforce targets in the plan are based on or linked to SRMNH service coverage targets in the national SRMNH/health plans. 25 of the 73 countries returned policy documents in support of their responses. These documents were catalogued in relation to the 2014 PMNCH/ Functions of professional associations open to midwivesFIGURE 15 Percentage of 119 associations performing each function 0 20 40 60 80 100 Continuing professional development Advising members on quality standards for MNH care Advising the government on the most recent national MNH or health policy document Advising/representing members accused of misconduct or incompetence Negotiating work or salary issues with the government. Other 92 88 48 53 60 77 An effective and clear regulatory environment strengthens the role of midwives and contributes to improving quality of care. (Jhpiego/Kate Holt) 31CHAPTER 2: THE STATE OF MIDWIFERY TODAY WHO Multisectoral Policy Compendium [51], from which it is evident that most of these 25 countries have policy foundations that span the domains of SRMNH and HRH. Of the 47 countries which reported non-profes- sional cadres, 12 submitted policy documents but only 4 submitted policies which specifically mentioned or included community health work- ers. In this particular sample, HRH policies seem not to include CHWs and their roles within the health system structure. However, some countries have developed or are in the process of developing policies specifically addressing community services and the roles of CHWs and these linkages are encouraged. Countries with national health, SRMNH and/ or HRH plans tended to report that these are recent (72% of the plans were published in or after 2009). Most are still current, covering a period up to or beyond 2014. National SRMNH plans tend to be less recent than national health plans and national HRH plans: 42%, 12% and 19% respectively were published prior to 2009. Costed plans are important in order to priori- tize service areas in a country. Out of the 276 policy documents reported, 170 (62%) contain plans that are fully costed. National health plans and national SRMNH plans are the most likely to be fully costed (71% and 70% respec- tively, compared with 60% of national HRH plans). Out of the 73 responding countries, 54 (74%) said that their existing policy documents specifically address how the country is going to improve all four elements of availability, acces- sibility, acceptability and quality of services. However, it should be noted that the existence of a policy document does not guarantee its effective implementation. Summary If our goal is to provide universal, effective coverage of midwifery services to all women and newborns, regardless of wealth, place of residence or age, we must jointly address the dimensions of AAAQ, the lack of which holds back countries and excludes parts of their populations. Many countries have moved to make the neces- sary workforce available, but much needs to be done to meet shortages and/or deficits in the number and composition of the midwifery work- force to ensure progress to universal coverage. The diversity between countries in typologies and composition of health workers contribut- ing to SRMNH services is striking, but using information from the SoWMy survey it is pos- sible to assess the roles, competencies, education and contribution of each and every cadre. As � Pervasive gaps in infrastructure, resources and systems adversely affect midwifery education. � Key challenges for quality midwifery education include the inad- equacy of secondary education, lack of teaching staff, poor quality equipment, lack of opportunities for practical training and lack of classroom space. � The number of births a midwife conducts under supervision prior to graduation varies across countries, and may be insufficient to meet competency requirements. � Nearly all responding countries have at least one regulatory body, but many lack legislation recognizing midwifery as a regulated pro- fession, clearly described midwifery competencies and education standards, and effective regulatory processes. � Nearly all countries reported having at least one professional asso- ciation open to midwives, 80% provided data on the numbers of midwives in membership and 75% knew who was currently practis- ing in-country. � Among the 54 countries which took part in both SoWMy 2011 and SoWMy 2014 there has been a 40% increase in those with an elec- tronic register of licensed midwives. � Alignment and cohesion of policy and planning instruments in SRMNH and HRH are essential to deliver effective coverage of mid- wifery services: 75% of countries said the SRMNH workforce targets in their HRH plans was linked to the national SRMNH or health plan. � Of the 276 policy documents reported, 62% contain plans that are costed, among which the SRMNH plans are more likely to be fully costed than the human resource for health plans. Quality KEY FINDINGS 32 THE STATE OF THE WORLD‘S MIDWIFERY 2014 MIDWIFERY2030 many of these workers do not spend 100% of their time on SRMNH tasks it is important to calculate the full-time equivalent workforce in each country in order to compare availability with need for services. Clearly this information, along with minimum workforce data, is required to provide strategic intelligence informing policy and planning processes. Countries can use this information to actively manage the education of the midwifery workforce, adequately remunerate those employed, and effectively promote a career as a midwife. This will ensure that the future workforce meets the needs of future populations. Countries should also press forward with plans to improve the accessibility, acceptability and quality of care. Accessibility can be addressed by using GIS and appropriate equity-based planning tools, as well as ensuring that their national “minimum guaranteed benefits package” for SRMNH includes all essential interventions. Acceptability should be recog- nized as an important element of care: steps should be taken to reduce disrespectful care and instead to promote care that is sensitive to social and cultural needs, accompanied by robust research on women’s perceptions of and attitudes towards the midwifery work- force. Finally, maternal and newborn mortality will remain high unless the quality of care is addressed. Countries should improve the qual- ity of midwifery education, regulation and association, and address pervasive gaps in order to move towards effective coverage. Figure 16 shows the gap in effective coverage from the availability and quality dimensions: the availability of all workers who participate in the midwifery workforce of the 73 SoWMy countries, and those who have the dedicated time, authorized roles, practical training and competencies to provide quality care. The constraints to coverage within these two dimen- sions are substantial (leaving aside the problems of acceptability and accessibility). Reducing this gap requires the collection and better use of data on: what proportion of avail- able midwifery workers are full-time with SRMNH services, how many students are likely to join the workforce in the future, where the health workers are located, how women and their communities feel about the services they experience, and how the HRH plan furthers SRMNH strategies. To achieve this, strong leadership is needed to prioritize midwifery and release resources to support this new approach to workforce and service planning. Midwifery workforce: from availability to qualityFIGURE 16 N u m b er o f m id w if er y w o rk er s (i n m ill io n s) Full-time equivalent Headcount 0 1 4 6 7 8 3 5 2 Full-time equivalent, all midwifery tasks Full-time equivalent, all midwifery tasks, > than 25 supervised births Midwives Nurse-midwives Physicians (general) Obstetricians/ gynaecologists Nurses Auxiliaries Associate clinicians 90% reduction 33CHAPTER 3: MIDWIFERY2030 and each requires a tailored policy response to develop context-specific health service and health workforce solutions. Figure 17 highlights the projected change in population need for key SRMNH health-care contacts, including family planning visits, four antenatal care visits, skilled birth attendance and four postnatal visits. Chapter 2 also showed the importance of under- standing whether health-care professionals are available, accessible, acceptable and able to deliv- er quality care in order for countries to ensure that women and newborns obtain the care they need. Encouragingly, 16 (22%) countries are projected to have a midwifery workforce that, by availability and skill-mix of health personnel, is potentially able to provide all women and Chapter 2 described the state of the world's midwifery based on analysis of survey, work- shop and secondary data from 73 of the 75 Countdown countries. It presented progress since 2011 and consolidated the evidence base to enable stronger policy dialogue within coun- tries on the barriers, challenges and potential policy responses. The evidence has revealed the similarities and differences across coun- tries and captured the bold steps that many are taking to strengthen SRMNH services and the midwifery workforce. This chapter builds on the evidence of where countries are today and looks ahead to where they could be in 2030. It provides decision- makers, health professionals, stakeholders and supporting partners with additional evidence- based suggestions for strengthening midwifery, improving SRMNH services and accelerating progress on both the MDGs and UHC. It focuses on how governments and their partners can work together to meet international obligations and fulfil women’s rights to sexual, reproductive, maternal and newborn services. Finally, it pres- ents Midwifery2030, which describes what fully implemented midwifery care can achieve and includes 10 goals and the policy development and planning necessary to achieve them. Looking towards 2030 As detailed in Chapter 2, the global number of pregnancies per annum in the period 2014-2030 is projected to remain constant at 160 million, but regions, countries and urban/rural commu- nities within them will face very different needs, MIDWIFERY2030 CHAPTER 3 New models of practice based on proximity of care to women and communities enable access to health services. (Jhpiego/Kate Holt) 34 THE STATE OF THE WORLD‘S MIDWIFERY 2014 newborns with at least the 46 essential interven- tions [1]. Conversely, 57 (78%) countries face projected deficits (by full-time equivalent person- nel and/or skill mix) in the midwifery workforce. In those countries where projected “met need” (the availability of the workforce compared with the need for SRMNH services) is less than uni- versal, ways to fulfil a woman’s rights to sexual and reproductive health, including maternal and newborn care, need to be developed. In the 16 countries where the projection of met need is more than 90% policy discussion must occur. For example, a country may have 100% of met need but there may be imbalances in the skill mix needed for resource efficient midwifery teams (e.g. too many physicians and not enough mid- wives). Projections of more than 90% present an opportunity to analyse: the validity of the data provided; equity of coverage; productive efficien- cy of the workforce (providing more care with the same resources); alignment between educa- tion and employment; and, looking beyond the numbers, the quality of personnel and services. It is also important to analyse whether the aggre- gate met need conceals economic, geographical or social disparities within the country (e.g. where the workforce is primarily located in major cities there will be inequitable distribu- tion and underserved groups in rural areas). The 46 essential interventions save lives and promote health [1]. However, women and newborns have a right to universal cover- age [2] which goes beyond the provision of interventions and requires new approaches to enable women to have healthy sexual and reproductive health outcomes, includ- ing healthy pregnancies and births, and to receive respectful, supportive, preventive care. The next section sets the scene for policymakers and partners in all countries to consider where on this pathway they are, and how much progress they need to make. Improvement is feasible for all communities in all countries. Drivers of health, health systems and health financing Global Health 2035: a world converging within a generation, the report of The Lancet Commission on Investing in Health published in December 2013, highlights the fact that the financial and technical capacities are now available to reduce infections, child and maternal mortality and non-communicable diseases to low levels [3]. The combination of economic growth in many low- and middle- income countries together with increasing availability of health technologies makes a “grand convergence” in health achiev- able within about two decades [3]. Investing in health could prevent around 10 million deaths by 2035 [3]; in particular, investing in women’s and children’s health will secure substantial health, social and economic ben- efits [4]. To achieve return on investment, countries will need to respond to changes in health, health system and financial drivers and the global policy landscape (see Box 9). The Global Strategy for Women’s and Children’s Health (the Global Strategy) [22], supported by the Every Woman Every Child Projected change in population need for SRMNH visits between 2012 and 2030, by WHO region FIGURE 17 P er ce n ta g e ch an g e 20 12 -2 03 0 Family planning visits -30 -20 -10 0 10 20 30 40 50 60 70 Eastern Mediterranean Europe Americas South-east Asia Africa Antenatal care, skilled birth attendance, postnatal care visits Western Pacific 35CHAPTER 3: MIDWIFERY2030 campaign [23], is focused on addressing inequal- ities and is likely to be a key driver of SRMNH through 2030. The main tools have been devel- oped as follows. In 2011, the Global Strategy’s Commission on Information and Accountability for Women’s and Children’s Health [24] high- lighted the need for better data collection and accountability from all stakeholders involved in RMNCH, which led to the creation of the inde- pendent Expert Review Group for Women’s and Children’s Health [25,26]. The Commission on Life-Saving Commodities in 2012 [27] identi- fied the essential life-saving commodities for RMNCH and delivery strategies. Finally, the 2013 Global Investment Framework for Women’s and Children’s Health [4] added a financial perspective, detailing the health, social and economic benefits (of up to nine-fold) that can be generated. Changes in the health market will affect the financing of health systems and the capacity of countries to meet the needs of their populations, particularly the poorest and most disadvantaged adults and adolescents [12]. Towards 2030, there will be continuing technological innovations, ris- ing incomes, enhanced consumer education and demand, increased availability of information, urbanization and an increase in weather-related natural disasters [12,28]. The interactions (among consumers, health workers and pro- viders) between the public and private health sectors and increased economic growth will also impact on access to health systems and UHC [29]. Together these changes, drivers and initiatives are creating a unique opportunity for coun- tries to make rapid progress towards realizing the universal right of access to high-quality Drivers and changes in health The main drivers and changes include: • Significant shifts in population demo- graphics and burden of disease, including: increased mobility, urban- ization [5] and ageing [5,6]. Population increases will affect the ability of many health systems to provide adequate numbers and coverage of health workers. • Progress towards UHC will be made as resources are better distributed to provide quality health services, address inequities and remove financial barriers to access, while contributing to popula- tion needs and targets [7–9]. • Non-communicable diseases [10] including diabetes, cancers, cardio- vascular diseases and depression are becoming more prevalent, and HIV and some other infectious diseases are becoming chronic conditions, as access to effective treatments increases. • Mental health problems, addictions and gender-based violence [6] are increasing. • Enhanced consumer education and demand will require commitments to: strengthening accountability, rights-based approaches, equity and empowerment; and ensuring meaning- ful participation by individuals and civil society in policymaking processes [11]. • Changes in the health market environ- ment include technological innovations, rising incomes, increased availability of information [12] and the rise of the private health sector. • Commitments in many countries [13] to sexual and reproductive health and rights [14], gender equality [15] and adolescent health [16] will enable women to participate fully in decisions related to their sexual and reproductive health and could significantly reduce discrimination against women and girls [13,14]. • Health services will increasingly use e-health and m-health technologies [17]. • Quality of care will increase in impor- tance, as will the value placed on it by consumers [3]. • Variations in the attractiveness of health careers and employment settings may affect the medium- and long-term sta- bility of the health workforce [18,19]. • Changes in official development assistance will bring in new donors including non-Development Assistance Committee countries, philanthropists and providers of funding to combat climate change [20], who will increas- ingly use trusted, effective and efficient vehicles for disbursing investments, such as The Global Fund to Fight AIDS, Tuberculosis and Malaria [21]. BOX 9 Source: Caroline Homer, University of Technology, Sydney 36 THE STATE OF THE WORLD‘S MIDWIFERY 2014 SRMNH services, with midwifery as one of its core components. Midwifery2030: A pathway for policy and planning Most women and children are healthy and need the health system and health-care providers to help them stay healthy. Midwifery2030 starts from the premise that pregnant women are healthy unless complications, or signs thereof, occur, and that midwifery care provides pre- ventive and supportive care with access to emergency care when needed. Midwifery2030 presents a coherent policy and planning pathway to guide the provision of services to women and newborns across the two continuums of SRMNH care: from sexual and reproductive health through to pregnancy and the postnatal period (as needed), and from communities to referral hospitals. Midwifery2030 focuses on increasing the AAAQ of health services and health provid- ers aligned with the three components of UHC: reaching a greater proportion of the population (increasing coverage), extending the basic and essential health package (increasing services) while protecting against financial hardship (increasing financial protection). Midwifery2030 has the following 10 goals. 1. All women of reproductive age, includ- ing adolescents, have universal access to midwifery care when needed (the first and second components of UHC). 2. Governments provide and are held account- able for a supportive policy environment. 3. Governments and health systems provide and are held accountable for a fully enabled environment. 4. Data collection and analysis are fully embed- ded in service delivery and development. 5. Midwifery care is prioritized in national health budgets; all women obtain universal financial protection (the third component of UHC). 6. Midwifery care is delivered in collaborative practice with health-care professionals, associates and lay health workers. 7. First-level midwifery care is close to the woman and her family with seamless trans- fer to next-level care (see Figure 18). 8. The midwifery workforce, in communities, facilities and hospitals, is supported through quality education, regulation and effective human and other resource management. 9. All health-care professionals provide, and are enabled to deliver respectful, quality care. 10. Professional associations provide leadership to their members to facilitate quality care through advocacy, policy engagement and collaboration. Realizing the pathway Transformative changes within countries are needed to move forward from the reality described in Chapter 2 to achieving the goals of Midwifery2030. Collaborative action is required to: • redesign models of practice to keep women and newborns at the centre of care; Midwifery2030 aims to help women and children stay healthy by increasing the quality and coverage of health services. (Guifty Banka) 37CHAPTER 3: MIDWIFERY2030 • secure an enabling professional environ- ment, including high-quality education, regulation and professional association; • secure an enabling practice environment through an effective referral network and a human resources management system that includes supportive supervision, ongoing edu- cation and a safe and supportive workplace; • enable intra- and inter-disciplinary col- laboration and teamwork at all levels, from community to tertiary level. Redesigning models of practice Midwifery2030 promotes models of practice that position women and newborns at the centre of care. Chapter 2 identified gaps in the continuum of care in many countries, particularly a lack of attention to care during pregnancy, after birth and in access to family planning. Midwifery 2030 incor- porates the full continuum of care from sexual and reproductive health through to pregnancy, birth, postnatal care and the early months of newborn life [30]. It can meet the needs of adolescent girls [16] and includes access to culturally sensitive and appropriate family planning and safe abortion (in accordance with human-rights standards [31] and when it is not against the law respectively) and post-abortion services for all women. Models of practice must promote the provision of first-level care as close as possible to wom- en’s homes and communities, while ensuring access to consultation and referral to next-level services. In order to improve access to qual- ity midwifery and obstetric care, aligned with minimum recommended coverage levels [32], it may be more effective to upgrade specific facilities (e.g. well-functioning facilities with sufficient staff) or to incentivize those facilities which achieve an equitable geographical distri- bution of services, rather than making birthing services available at all facilities. Efficient use of health workers and collaboration with community-based lay workers and volunteers can facilitate access to cost-effective care, espe- cially for women and families in geographically remote or urban poor settings without trans- portation. First-level midwife-led units [33] could be established within reach of communi- ties, supported by CHWs and TBAs who assist women to access the health system and facili- tate respectful, culturally sensitive care [34]. Models of practice must use the health workforce effectively. SoWMy 2014 shows that many cadres in the midwifery workforce spend significant proportions of their time on other tasks, result- ing in a lack of focus on SRMNH services. For First-level midwifery care Next-level* care Defining feature Close to the woman and her family, de-medicalized but professional. Secondary- and tertiary-level services with seamless transfer and inter-disciplinary collaboration and professional respect. For whom? For all women and newborn infants. For all women and newborn infants who have problems or risk factors that cannot be solved by first-level midwifery care. By whom? Best by midwives, alternatively by doctors and associate clinicians if appropriately educated and regulated. Best by a collaborative team that includes midwives, obstetricians and gynaecologists, paediatricians and other medical specialties as needed; alternatively by appropriately trained doctors, and associate clinicians (including advanced level). Where? Preferably in midwife-led units; also in hospitals with maternity units. In all hospitals. Key features of first-level and next-level midwifery care FIGURE 18 Source: Adapted from the World Health Report 2005 [43] and WHO Optimize MNH [68]. *Next-level care includes appropriate consultation, teamwork and referral and return when required or requested to secondary- or tertiary-level services. 38 THE STATE OF THE WORLD‘S MIDWIFERY 2014 the care of women and newborns who are pre- dominately healthy and considered at normal risk, a midwife who is educated (regardless of the education pathway), regulated and supported to provide care within an enabled, safe and col- laborative practice environment is likely to be the most cost-effective option. A focused and competent SRMNH workforce, with fewer cadres, is likely to be more cost-effective with regard to providing ongoing education, regulation and supervision. CHWs and TBAs will continue to be part of service delivery models in the coming years, including in those countries where there are severe deficits in the number of professional health workers. In communities where CHWs and TBAs hold a respected position they can influence women’s use of midwifery care [35,36] and can provide basic health information about healthy pregnancy, safe birth options, newborn care, nutrition, breastfeeding support, fam- ily planning and HIV prevention. Formal and informal links between the traditional birthing services in a community and the professional health services can facilitate both the effective use of available resources and access to quality, respectful care [36–38]. Such links can also open a career pathway for community workers to enter the professional midwifery cadre through appro- priate education programmes. The aims of Midwifery2030 can be achieved through midwife-led models of practice. There is strong evidence from upper-middle- and high-income countries that midwife-led models, particularly those that provide continuity of care and provider, generate significant benefits and cost savings with no identified adverse effects (33,39–42). Midwife-led care includes: continuity of care and provider; monitoring the physical, psychological and social well-being of the woman and her family; providing indi- vidualized education, counselling and antenatal care; continuous attendance during labour, birth and the immediate postnatal period; minimiz- ing technological interventions; and identifying and referring those who require obstetric or other specialist attention [43]. Midwife-led care can be delivered at community level if there is access to transport for referral to reduce unnec- essary delays [43]. Securing an enabling professional environment The goals proposed by Midwifery2030 require an enabling professional environment to support effective education, regulation and professional association [44], often identified as lacking in the survey responses from the 73 countries in this report. Many midwives around the world work in dif- ficult, unsafe, isolated and poorly equipped settings, and themselves experience gender- based violence, poor salaries and working conditions and a lack of access to continuing professional development; all of these factors impede high-quality care [45]. Poor working con- ditions undermine their ability or willingness to continue practising: many midwives choose to leave the workforce due to frustration with their position and role [46] or because they reach an arbitrary retirement age. An enabling profes- sional environment means that midwives can develop meaningful relationships with women, with occupational autonomy and flexibility, so that they can: control, organize and priori- tize their own work; have access to supportive supervision; reflect on practice with peers and colleagues; share ideas and information; and optimize service provision [45,47]. A commitment to education, regulation and association Implementing an enabling professional environment involves: 1. High-quality education, continuing pro- fessional development and career pathways, including: making a career as a midwife attrac- tive; providing educational pathways with sufficient opportunities for clinical experience; having well-prepared faculty and appropriately 39CHAPTER 3: MIDWIFERY2030 resourced programmes; developing or applying accreditation systems with measurable standards and criteria; providing a safe and conducive learning environment; and facilitating communi- ty engagement to ensure that what midwives are taught meets community needs and incorporates respectful care and sociocultural sensitivity. Quality initial and ongoing education must ensure that midwives remain competent to do their job effectively, can gain advanced SRMNH clinical skills if desired or follow leadership and management training to become SRMNH leaders. Continuous professional development programmes can increasingly be delivered through information and communications tech- nology, using blended learning that includes e-learning and face-to-face time, potentially in education hubs, either locally or regionally. 2. A strong and functional regulatory system including registration and licensing; incorporation of internationally consistent standards and codes while also meeting country- specific needs, the accreditation of education programmes and continuing professional devel- opment frameworks so that periodic re-licensing and evidence of continued competence can be monitored. Effective regulation also includes authorizing personnel to undertake specific tasks depending on the context and need, for example, prescriptive authority and providing expanded HIV services [48,49]. 3. Vibrant and committed professional asso- ciations that can provide: a point of leadership and advocacy, lobbying for improved working conditions (including flexible hours, adequate remuneration, leave, housing, transport, safety and security); opportunities for career develop- ment, promotion and incentives for retention; and access to information and evidence for enhancing practice through continuing educa- tion and research. Effective support may include twinning models between individuals or associa- tions [50,51]. Development, training and support are required to ensure the sustainability of associations and to enable members to work at political and government levels and exercise advo- cacy both for women generally and for midwives. Quality education, regulation and professional associations must be supported to ensure the sustainability of midwifery services and to build and sustain momentum for quality maternal and newborn care. Data from the country workshops in SoWMy 2014 highlighted the need for capacity building in education, regulation and association to enable them to develop, flourish and play a vital role in sustaining and supporting the goals of Midwifery2030. Box 10 outlines the regulatory devel- opments that are needed to better protect the public. Securing an enabling practice environment An enabling practice environment includes access to effective and reliable consultation and referral networks [52] as well as human resources develop- ment, management and capacity building. Access to effective consultation and referral networks First-level midwifery services need to be clear about their capability to consult with, and trans- fer women and/or newborns to, a secondary- or tertiary-level service if required, and about the processes for referral and transfer. In the coun- try-level workshops there were strong themes related to a lack of access to transport, a lack of cooperation between health care levels, poor com- Motivated and committed professional associations can influence decision- making processes, contributing towards a strengthened profession. (Jhpiego/Kate Holt) 40 THE STATE OF THE WORLD‘S MIDWIFERY 2014 munication between first-level and higher-level services, and a lack of accountability at the com- munity level. Addressing these issues requires: • community engagement to gain understanding of, and support for, transfer; • evidence-based policies, guidelines and indications for consultation and referral; • access to functional telecommunication systems (including e-health and m-health) between health service levels and between health professionals; • effective utilization of CHWs or TBAs to ensure timely referral and transfer from the community level; • education and regulation to enable specific services to be delivered at first level (e.g. prescriptive authority and HIV screening and treatment); • access to suitable, safe accommodation to await labour and birth if the most suitable place to give birth is away from home; • access to transport for women and their new- borns to next-level care, and return home when ready; • the possibility for women to be accompanied by a person of their choice if transferred to the next-level service, because social support is a critical component of effective and respectful care. Protecting the public: a renewed paradigm Professional regulation is about protecting those we serve. However, many regula- tory systems remain under-developed, outdated or, in some cases, completely absent. As a result, those who use the health services are placed at risk, and governments are denied the support of powerful tools in their efforts to secure UHC and redesign health systems. Over the next two decades governments, the professions and regulatory bodies need to modernize or put in place regula- tory models that are in step with current and future needs and proactive in secur- ing public protection at the design stage rather than focusing on approaches that address failure retroactively. In the future, regulatory frameworks must be proportionate to the level of risk. They need to provide solutions to emerging problems as and when they occur, and/or provide for pre-emptive actions so as to minimize risk of occurrence. Reacting after the fact and waiting for legislative time to change outdated laws must be the excep- tion rather than the rule. To be effective, the regulatory body needs to be a collaborator and a team player. It must understand the contribu- tions of all actors and seek to synergize opportunities for achieving public safety. Comprehensive regulatory models need to address education, practitioners and the practice environment. Standards of education and curricular content need to keep pace with the rapidly expanding evidence base, new forms of care delivery and modern edu- cational processes. These processes will often be problem-orientated and team- focused. Educational programmes need to be competency-based and modular in structure. The practitioner needs to be prepared and authorized to work to their full scope of practice according to population needs. Delegation, supervision and accountability will be clear and regulators will be proac- tive in engaging users of the services, the various disciplines involved in the matrix of care and governments to ensure that practitioners are not only properly pre- pared for their own roles but also work in a coherent manner. This provides an opportunity for regulators to work far more closely together, sharing best practice, information and data, and establishing benchmarks against which their performance will be judged. A philosophy of life-long learning and continuing competence will be instilled in practitioners from the very outset of their preparation. Regular re-licensure to practise tied to continuing competence processes will be essential. Supervisory systems need to be updated to optimize the use of technology so as to provide, even in the most remote settings, the types of support that can secure better public protection and professional devel- opment. Living in a global world where mobility is a reality requires the development of systems that balance the avoidance of unnecessary delays, overly burdensome requirements and excessive costs with the imperative of protecting the public from poorly performing individuals. To this end, the development and implementation of a regulatory dataset is needed. This will facilitate transparency and assist in the assessment, calibration and recognition of qualifications across jurisdictions. Source: David C Benton, International Council of Nurses. BOX 10 41CHAPTER 3: MIDWIFERY2030 Human resources development, management and capacity building Every country needs a minimum HRH dataset on their midwifery workforce. As described in Chapter 2 this includes: headcount, percentage of time spent on SRMNH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce. This will enable efficient workforce planning and determination of the appropriate SRMNH team [53]. It will allow the assessment and con- figuration of the most appropriate skill mix for the continuum of care, as well as the intake and deployment options to equitably deliver essen- tial SRMNH interventions at scale and quality, and the financing and investment options to achieve universal coverage and access. Reference to basic health geographies, such as districts, may also help improve services in line with need. An HRH strategy should include an assessment of a country’s health service packages, national clinical guidelines and curricula. Accurate HRH data and needs-based planning will sub- sequently inform accurate education planning and financing, including the numbers of students to be accepted into programmes, deployment opportunities and new graduate posts. Planning must take account of mobility in health labour markets, where regional and global demand for health workers may affect national supply. Performance review and development is an important component of human resources management. This will: identify the needs of individuals and services, including learning needs to maintain competence; identify the suc- cesses and challenges of their work; and allow service delivery to meet the needs and culture of the local population. Performance review and development will identify the need for continuing professional education and quality improvement. Advancing along a career path is an important component of job satisfaction. A career matrix can enable people to undertake a range of roles at different times in their career while ensuring that knowledge and skills remain in the health-care system and the professions. Developing opportunities for staff to move into other roles, including extended clinical roles, education, management or research, will require formal development options includ- ing faculty development programmes. The use of new technologies [54] can enable “virtual” schools or e-learning programmes to be estab- lished and widely accessed. Making respectful teamwork and collaboration a reality Midwifery2030 requires that collaborative SRMNH teams work effectively while keep- ing the woman and newborn at the centre of care. Failures in teamwork and communication account for the majority of sentinel events in maternity care [55,56]. Clarity and agreement about the roles and responsibilities of each team member while working to their full scope of practice will avoid unnecessary overlaps and inefficiencies. Having either too few or too many of one cadre, or too many similar cadres, will impede the full achievement of the aims of Midwifery2030, the seamless delivery of the continuum of care, and may lead to over-medicalization. Midwifery2030 means that a midwife working to the full scope of practice, including providing family plan- ning, with access to consultation and referral, can bridge the gap between the community and health services. Inter-professional collaboration in education and practice is likely to ensure that a fit-for-purpose workforce is developed [57]. Implementing inter-disciplinary teamwork and collaboration involves: learning together to create a “collabo- ration-ready” workforce; respecting and building on each other’s discipline and competencies; communicating with one another and handing over to ensure continuity and consistency; and debriefing together to learn from errors. 42 THE STATE OF THE WORLD‘S MIDWIFERY 2014 How Midwifery2030 responds to the key findings from SoWMy 2014 KEY FINDINGS FROM COUNTRY DATA AND WORKSHOPS Midwifery2030: Lack of data to support HRH policy and planning. • highlights the need for a minimum HRH dataset on a country’s midwifery workforce. Workforce shortages and deficits in relation to pro- jected need. • recognizes the importance of making the profession and career of a midwife attractive, having quality midwifery education pathways, deployment strategies and strategies to improve retention and reduce attrition. Lack of clarity of roles and tasks and a mismatch between expected roles and readiness and capacity to undertake the tasks. • includes HRH planning to review roles, tasks and responsibilities and provide clarity. This process can focus on providing the right SRMNH services by the right provider at the right time and in the right location, and reducing duplication. Gaps in the provision of antenatal interventions in the benefits packages. • recommends models of practice to ensure that women and their newborns have access to care across the continuum. Gaps in the capacity for family planning counselling and interventions to be delivered effectively. • enables family planning to be delivered through a collaborative midwifery workforce that includes CHWs or similar cadres. Cost and geography affects accessibility to care. • advocates for first-level care to be provided close to women’s homes and communities, with referral pathways and access to transport. Disrespect and abuse as drivers of non-acceptability to women. • ensures that education incorporates respectful care and sociocultural sensitivity as part of pre-service and in-service training. • recognizes that an enabled, sufficiently resourced, safe and supportive practice environment facilitates respectful care. Limitations: • in the number of midwives educated and retained; • in the quality of education: facilities, faculty, stan- dards and clinical exposure; • having either no regulatory authority, or no regulatory authority able to fulfil its role of protecting the public; • in the ability of professional associations to advocate effectively for midwifery and SRMNH services. • is firmly grounded in the need for a commitment to education, regulation and association. • highlights the importance of an enabling professional environment to ensure that the midwifery workforce has the readiness, authority and capacity to undertake the roles for which they have been educated. TABLE 3 Building on country findings Midwifery2030 has been developed to respond to the key findings from Chapter 2 (see Table 3) and the needs of women and newborns. It is a cost-effective solution, it can engage national champions and leadership and it can make a sig- nificant contribution to global SRMNH initiatives. Responding to the needs of women and newborns Midwifery2030 is founded on the premise that women and their newborns are at the centre of SRMNH services. Chapter 2 highlighted the significant concerns raised by many countries about disrespectful and abusive care. The way in which women are treated, and perceive how they are treated, reflects the quality and accept- ability of care. A shift towards people-centred care, or more specifically, woman-centred care, is required to achieve the aims of Midwifery2030. Woman-centred care: • focuses on the individual woman’s rights, needs, aspirations, expectations and decision-making, rather than those of institution or professionals; 43CHAPTER 3: MIDWIFERY2030 • recognizes the right of a woman to have choice, control and continuity from a known caregiver or caregivers; • encompasses the needs of the baby, the wom- an’s family and other people important to the woman, as defined by her; • follows the woman from community to acute settings and back to the community; • addresses her social, emotional, physical, psycho- logical and cultural needs and expectations [58]. Woman-centred care requires an integrated approach such that women have access to appro- priate care providers at the appropriate times. Examples include: an obstetrician when there are complications, a paediatrician when the baby requires additional care, and a midwife for nor- mal pregnancy and birth. This approach focuses on which provider the woman needs at a given time, and shifts from making her meet the needs of institutions or health workers to making the system accommodate her needs. Keeping women and newborns at the centre of services also requires a focus on gender equality and the provision of respectful care in line with human rights principles, covenants and legisla- tion. Every woman has the right to be treated with dignity and respect; this is one of the seven rights of the childbearing woman [59] and is underpinned by numerous international stan- dards, including the International Covenant on Civil and Political Rights (1966, Article 2) [59]. Implementing woman-centred care means: • providing respectful care that is safe and feels safe and supportive to women, maximizing their chances of a healthy life and positive outcomes; • enabling women to choose the best and most affordable options for themselves and their families; • providing access to first-level services in the community, close to where women live, with ready access to higher-level care if needed at a cost that is affordable. Providing a cost-effective solution Midwifery2030 is an effective investment strat- egy, responding to the evidence on returns of investment from increasing family planning services [60–62], the education and deploy- ment of midwives [63] and the midwife-led care model. Box 11 describes the benefits and workforce implications of investing in fam- ily planning; Box 12 highlights the value for money and projected return on investment resulting from the education and deployment of midwives in community-based services. Midwife-led care as a model of practice has been shown to be both cost-effective and cost- saving [40,42,64]. It also offers a convincing alternative to the prevailing maternity care model [42] for women with all risks because it includes functional consultation and a referral pathway [40]. Engaging national champions and leadership Political will, champions and leaders are cru- cial to making Midwifery2030 a reality and overcoming barriers to UHC. However, some of those barriers are internal and relate to inter- professional competition and hegemony. To counter this, health-care professionals need to adopt behaviours that enable effective coopera- tion and teamwork. Health-care professional associations (HCPAs) play a critical role in providing leadership to their constituencies. In the field of SRMNH, they represent the hundreds of national asso- ciations affiliated to ICM, ICN, International Federation of Gynecology and Obstetrics (FIGO) and the International Pediatric Association (IPA). As leaders of change, HCPAs are key to improving SRMNH and thus enabling the realization of Midwifery2030. The mission statements of the four interna- tional associations are similar [72–75]. Each is directed to supporting members to achieve BOX 1.4 44 THE STATE OF THE WORLD‘S MIDWIFERY 2014 The impact of investing in family planning One of the most effective ways to improve maternal health outcomes is to reduce unmet need for family planning [60]. Additional benefits include improvements in health, schooling and economic out- comes [65]. The 2012 London Summit on Family Planning generated commitments to expand access to effective contracep- tion for an additional 120 million women and adolescents with unmet need for contraceptives in 69 of the world’s poor- est countries by 2020 [66]. The impact and return on investment is clear [61], but what are the workforce implications? Key points for policy and planning are as follows. Fewer pregnancies mean an immediate decrease in population need for maternal and newborn services in the immediate future (0-15 years). As the total fertility rate declines, there will be less need for antenatal care, skilled birth attendance, emergency obstetric care and postna- tal care. This will reduce the volume of essential interventions required, with steady decreases year-on-year, mostly within the scope of practice of mid- wives and obstetricians, thus creating opportunities to increase the quality and coverage of services. Fewer pregnancies also mean a reduction in the number of women of reproductive age in the longer term. Demographic trends are a key determinant of work- force requirements. Starting 15 years after the initial investment in family planning, and accelerating rapidly for 25 years thereafter, there will be fewer women of reproductive age and therefore a decrease in the overall need for sexual and reproductive health services. Of the 46 essential interventions for SRMNH, sexual and reproductive health services have the largest impact on health workforce requirements. All women of reproductive age need uni- versal access to sexual and reproductive health care. Not all of them will become pregnant and an even smaller number will need emergency obstetric care. Hence a greater volume of services (and the corresponding capacity of the health workforce) is required for sexual and reproductive health interventions than for emergency obstetric care. The composi- tion and skill mix of health personnel needed to deliver community-based sexual and reproductive health services, including family planning, will ideally be tailored to national settings and where needed can ensure the integration and provision of HIV/AIDS services. Girls are a central component of the wider “health workforce”. Addressing the unmet need for contraceptives and family planning requires engagement with adolescents, teachers, parents and communities who therefore all form part of the expanded “health workforce” for sexual and reproductive health. In addition, children of women who have access to family planning and health ser- vices are healthier and better educated than children of women without such access [61]. So increased family planning will reduce the number of children per woman, allowing more of them to go to school which increases the number of high-school graduates (potential health- care workers), reaps social, economic and health benefits and can reduce future demand on health services [67]. Lay workers, auxiliary midwives and pharmacists are key to meeting the need for family planning and containing costs. The Optimize for MNH [68] guidelines provide evidence for new approaches to family planning services. According to these guidelines, lay health workers can initiate and maintain the provision of injectable contraceptives, with targeted monitoring and evaluation. Auxiliary midwives can effectively provide oral contraceptives, condoms, hormonal injections, contraceptive implants and intrauterine devices. These roles could be led by women within communities, resulting in more employment opportuni- ties, and greater potential for normative change while at the same time enabling midwives, nurses and doctors to dedicate more of their time to increase the cover- age and quality of SRMNH services. Source: Jim Campbell and Laura Sochas, ICS Integrare. the best for women, children, families and their communities. They range from strengthening midwives’ associations and representing nurs- ing worldwide, to the improvement of women's health and rights, and promoting physical, mental and social health for all children. The similarities in these missions and objectives pro- vide the basis and set the example for a paradigm shift in collaborative practice. Working together will strengthen advocacy initiatives, policy cohe- sion, regulation, licensing and live professional registries, inter-professional education and con- tinuous professional development. The ultimate objective for HCPAs is to foster a dynamic, col- laborative, fit-for-purpose, practice-ready team of health-care professionals who are responsive to the needs of women and children. Contributing to global RMNCH initiatives In 2014 there is a unique opportunity to build on the current national and international momentum. Since the publication of SoWMy 2011 [76] in June 2011 several new global RMNCH initiatives have been launched to BOX 11 45CHAPTER 3: MIDWIFERY2030 Midwives: a “best buy” for primary health care The Community-based Midwifery Diploma Programme (CMDP) in Bangladesh was launched in 2013. The CMDP provides a university qualification, consistent with national education standards and ICM standards and recommen- dations [69], to students selected from areas of greatest maternal health need. It incorporates a comprehensive systems approach, combining a “hub and spoke” education model with the WHO guidelines on rural retention [70] to arrive at four core functions: 1) curriculum development and faculty development; 2) student selection; 3) evaluation and deployment; and 4) the availability of appropriately located and equipped training facilities to secure the foundations for the education model. Source: Tim Evans, Asiful Haidar Chowdhury, and Ismat Bhuiya, BRAC University. Adapted from Value for Money Assessment: CMDP. April 2013 [63] 1 The hub and spoke model ranks positively for economy, efficiency and effectiveness across curriculum and faculty development, student selection and training site development when compared with single institutions independently devel- oping their own diploma programmes. 2 The impact in terms of lives and life years saved is similar to that of child immunization. Midwives graduating in 2015, during an estimated career span of 30 years, will potentially see maternal mortality reduce from 194/100,000 to 35/100,000 live births and infant mortality from 52/1,000 to 12/1,000 live births. Over the same timespan, without the diploma midwives, these rates might drop only to 154/100,000 and 43/1,000. In total, the 500 midwives would save 36,178 lives (a total of 2,635,164 life years) at a cost of US$219 per life saved, or $3.02 per life year saved. This is similar to the cost benefit of child immunization (US$216 per death averted). 3 Investing in midwives could yield a 16.2 return on investment. Using only the number of caesarean sections (c-sections) avoided as the measure, and assuming that the increasing trend for c-sections in Bangladesh continues (for example, from 15% in 2015 to 45% in 2045), community-based midwives could reduce the rate of increase by 20% (i.e. 25% in 2045), averting 3,391 c-sections per year or 101,719 over 30 years. At a net price of US$1,264 per c-section the savings could amount to US$128.5 million over 30 years: a return of 16.2 times the total education cost of US$7.9 million. When calculated at a more modest 10% reduction of c-sections (i.e. 35% in 2045), investing in midwives would still yield a return of 6.2 times the investment. Curriculum development Low cost Less time High quality Faculty development Low cost Less time High consistency Student selection Moderate cost Moderate efficiency Efficient central selection Training site development Low cost Fast production Consistent quality ACTIVITY ECONOMY EFFICIENCY EFFECTIVENESS BOX 12 promote actions within and across countries (see Table 4 on page 48). The ambitious targets of the initiatives in Table 4 will only be achieved if they are sup- ported by political will and concerted action for change. Each of the targets requires the accelerated delivery of a health benefits package for women and newborns, but as noted in analyses for the 2006 World Health Report: “health interventions cannot be delivered with- out health workers” [83]. Midwifery2030: Inspiring global action The necessary and transformative changes required in SRMNH outcomes, backed by policy The “hub” is located in a centre of excellence at the BRAC University; the “spokes” are six independent education institutions located in rural areas of Bangladesh. Over the course of 4 years the CMDP will educate 500 students to diploma level at an estimated cost of US$5,300 per student per year. Comparable programmes in Afghanistan and Sudan are estimated to cost approximately US$7,900 and US$12,700 per student per year respectively [71]. A value for money assessment conducted in 2013 [63] reported on three areas: 1) the economy, efficiency and effectiveness of the hub and spoke model; 2) impact in terms of lives and life years saved; and 3) the return on investment (based on the reduction of unnecessary caesarean sections) [72]. Educating midwives results in good value for money. A targeted intervention for a community-based midwifery workforce ranks positively for economy, efficiency and effectiveness. It has an impact comparable to that of child immunization, and could yield a 16-fold return on investment. It is a “best buy” in primary health care. WHAT MAKES THIS POSSIBLE? 3 4 51 2 Governments and health systems provide and are held accountable for a fully enabled environment. Data collection and analysis are fully embedded in service delivery and development. Midwifery care is prioritized in national health budgets; all women are given universal financial protection. All women of reproductive age, including adolescents, have universal access to midwifery care when needed. Governments provide and are held accountable for a supportive policy environment. Investing in midwives could give a 16-fold return on investment. 87% Midwives can provide 87% of the needed essential care for women and newborns if educated and regulated to international standards. Only 4 of the 73 countries have a midwifery workforce that is able to meet universal need for the 46 essential interventions for SRMNH. Bangladesh is educating 500 midwives who can potentially save around 36,000 lives. CHALLENGE SOLUTION IMPACT PROGRESS ENSURING A HEALTHY START • maintaining your health and preparing yourself for pregnancy, childbirth and the early months as a new family • receiving at least four antenatal care visits, which include discussing birth preparedness and making an emergency plan • demanding and receiving professional supportive and preventive midwifery care to help you and your baby stay healthy, and to deal with complications effectively, should they arise means: PLANNING AND PREPARING • delaying marriage • completing secondary education • providing comprehensive sexual education for boys and girls • protecting yourself against HIV • maintaining a good health and nutritional status • planning pregnancies using modern contraceptive methods means:PLANNING AND PREPARING means: MIDWIFERY2030 A PATHWAY TO HEALTH 46 THE STATE OF THE WORLD‘S MIDWIFERY 2014 XXX MILLION LIVES COULD BE SAVED XXX MILLION LIVES COULD BE SAVED WHAT MAKES THIS POSSIBLE? 6 7 8 9 10 XXX MILLION LIVES COULD Midwifery care is delivered in collaborative practice with health-care professionals, associates and lay health workers. First-level midwifery care is close to the woman and her family with seamless transfer to next-level care. The midwifery workforce is supported through quality education, regulation and effective human and other resource management. All health-care professionals provide and are enabled for delivering respectful quality care. Professional associations provide leadership to their members to facilitate quality care provision. CREATING A FOUNDATION FOR THE FUTURE • starting to breastfeed immediately and being supported to continue breastfeeding as long as you wish • being provided with information about and support in caring for your child in the first months and years of life • receiving information about family planning so you can efficiently space your next pregnancy • being supported by the midwifery team to access child and family health services and vaccination programmes at the appropriate time means: SUPPORTING A SAFE BEGINNING • safely accessing midwifery services with the partner of your choice when labour starts • finding respectful, supportive and preventive care, provided by competent midwives who have access to the equipment and supplies they need and receiving emergency obstetric care if required • participating in decisions about how you and your baby are cared for • having the privacy and space to experience birth without unnecessary disturbance and interventions • being supported by a collaborative midwifery team in the event that you do need emergency obstetric care means: 47CHAPTER 3: MIDWIFERY2030 48 THE STATE OF THE WORLD‘S MIDWIFERY 2014 cohesion, must be informed by what is most evident: midwifery has the potential to be an enabling factor to achieve the new post-2015 targets in sexual and reproductive health and to accelerate UHC. National champions from all quarters — politi- cians, parliamentarians, men, women, boys and girls, private companies and health-care providers, professional associations, regulatory authorities, policymakers and planners — need to stand behind the move towards ensuring available, accessible, acceptable and high-quality midwifery. Many initiatives to that effect are underway and can benefit from joining forces in support of Midwifery2030 as a pathway to health and well-being and thus to the fulfilment of women’s rights. Global initiatives and objectives in sexual, reproductive, maternal, newborn and child health GUIDELINES/CAMPAIGN TARGET YEAR* ACTIONS/TARGETS Stillbirths** [77] 2020 For countries with a current stillbirth rate of more than 5 per 1,000 births, the goal is to reduce their stillbirth rates by at least 50% from the 2008 rates. For countries with a current stillbirth rate of fewer than 5 per 1,000 births, the goal is to eliminate all preventable stillbirths and close equity gaps. Preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries [16] – To improve sexual and reproductive health outcomes among adolescents by reducing the chances of early unwanted pregnancy which can result in poor health outcomes, by: • reducing pregnancy before the age of 18 years; • eliminating early and forced marriage; • addressing sexual abuse and violence against women and girls • increasing the availability and use of contraception among adolescents who want to prevent pregnancy; • reducing unsafe abortion among adolescents; • increasing the use of skilled antenatal, childbirth and postnatal care among pregnant adolescents; • preventing sexually transmitted infections, including HIV. Global plan towards the elimi- nation of new HIV infections among children by 2015 and keeping their mothers alive [78] 2015 The estimated number of new HIV infections in children is reduced by at least 85% in each of the 22 priority countries. The estimated number of HIV-associated pregnancy- related deaths is reduced by 50%. Family Planning 2020 [66] 2020 To make available affordable, lifesaving contraceptive information, services and supplies to an additional 120 million women and girls with unmet need for contraceptives in the world’s poorest countries. Global targets 2025 to improve maternal, infant and young child nutrition [79] 2025 • 50% reduction of anaemia in women of reproductive age. • 30% reduction in low birth weight. • Increase the rate of exclusive breastfeeding in the first 6 months to at least 50%. A Promise Renewed [80] 2035 All countries to lower child mortality rates to 20 or fewer deaths per 1,000 live births. Ending Preventable Maternal Mortality [81] 2030 To reduce maternal mortality ratios to fewer than 70 per 100,000 live births. Every newborn: An action plan to end preventable deaths [82] 2030 and 2035 To reduce neonatal deaths to fewer than 12 per 1,000 live births by 2030 and fewer than 10 per 1,000 live births by 2035. To reduce stillbirths to fewer than 12 per 1,000 total births by 2030 and fewer than 10 per 1,000 total births by 2035. TABLE 4 * The target years are those provided by the various global initiatives. ** The 2014 "Every newborn: An action plan to end preventable deaths" provides revised targets by 203

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