By Thérèse Delvaux and Vincent De Brouwere (Woman & Child health research centre, ITM)
In 2011, the following summary kicked off the UNFPA report “The State of the World’s Midwifery “, the first of its kind: “Increasing women’s access to quality midwifery services has become a focus of global efforts to realize the right of every woman to the best possible health care during pregnancy and childbirth. It is a responsibility of governments and their political leaders and an investment that is key to reducing maternal and newborn mortality and morbidity. In addition to saving lives and preventing disability, the benefits of quality midwifery services extend to all members of society in far reaching ways, including contributing to a country’s human and economic development.”
In 2014, this statement is still more than valid.
The new Lancet series on Midwifery shows the scale of the positive impact that can be achieved when midwifery is implemented effectively and explores in detail the health system conditions needed to realise these outcomes. Examples are given from countries where midwives have helped reduce deaths among mothers and infants.
The Series consists of four separate papers that have been developed collaboratively by a multidisciplinary group of clinical, academic, research, policy, advocacy and other experts from around the world. Together, the papers address key issues on the role of midwifery in the world today, and challenge much of the current thinking and attitudes about it among health professionals and decision makers.
The series puts forward an evidence-based framework for action on what childbearing women and newborn infants actually need, rather than what they often get.Midwifery interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths.
The Lancet articles together adopt a human rights-based approach and promote a long-term view, aiming for effective solutions and quality care and services, as opposed to quick-fix and unsustainable options. It is also clear that many countries have a long way to go before offering quality woman-centred delivery care to every woman. Indeed, there are two interrelated challenges: reaching the required quantity (a coverage of 75% in 2035 would require an increase of the stock of midwives to 299 661— a net growth per year of nearly 6%) and quality (competent woman-centred, available and accountable midwives). The latter cannot be really addressed if the first challenge is not met.
The Institute of Tropical Medicine (ITM) (Vincent De Brouwere, Fabienne Richard, Maternal and Reproductive Health Unit, Public Health Department) has been involved in Paper 3 (Experience of strengthening of health systems and deployment of midwives in countries with high maternal mortality). The ITM contribution is rooted in research that started in 1990 in Morocco with the development of the Unmet Obstetric Need (UON) concept. The UON became an indicator and was measured in about 20 countries (www.uonn.org) and included in the WHO Emergency Obstetric & Neonatal Care indicators in 2009. The first study on UON carried out in Morocco in 1990 revealed the weakness of hospitals in the Moroccan health system and the lack of midwives to meet the essential needs of childbearing women and their babies. This work was complemented by the development of quality emergency obstetric and neonatal care in low resource countries in parallel with the evaluation of the (midwifery) skilled care at delivery strategy in Burkina Faso (IMMPACT, 2002-07). It is also related to lessons learned from history, in particular the documentation of the success of Sweden, Denmark, Norway and The Netherlands in achieving very low maternal mortality rates at the end of the 19th century, thanks to the professionalization of childbirth with a network of competent midwives.
Quality midwifery requires providing access to skilled birth attendance in the global South through midwifery training and an increase in skilled workforce. It also helps avoid the over-medicalization of obstetric services in the North (and to some extent in the South), where many countries display high rates of labor induction, unnecessary episiotomies and increasing cesarean section rates (of more than 20-25%). This over-medicalization of obstetric services has inspired recent trends to avoid unnecessary interventions and promote more humane delivery services including delivering in smaller maternity units and at home. It is about keeping a human rights and patient–centered approach during the whole delivery process, increasing participation and ownership, empowering women and couples during this very important event rather than the provider taking all decisions without any involvement of the patient. An Australian documentary,“The face of birth”, illustrates this trend and shows how some women appreciate delivering at home. It also shows that for instance in the UK women who have a normal pregnancy (i.e. without any complication) can easily choose to deliver in smaller maternity houses or at home.
In Belgium, only a minority of women opt for home deliveries by midwives so far. Obstetric units led by midwives for normal deliveries are emerging and represent an interesting (but still limited) initiative.
In conclusion, this Lancet series has the merit to bring (more) evidence about the effectiveness and efficiency of a midwifery strategy to improve maternal and newborn outcomes. The Series is relevant both for the North and the South and shows that programmes in the field of maternal and newborn care should be evidence-based and follow a rights-based approach as well as a long term perspective in order to meet the needs of women and couples. Let’s hope the world pays attention.