'The evidence is strongly in favour of midwives as the main providers'--says The Lancet; The Lancet has published a landmark series of articles on 'Maternal Survival' that show strong support for expanding midwifery: Elizabeth Duff reports from the launch.
The ICM's response
The ICM, represented at the launch held at the University of London, welcomed the majority of the proposals and in particular the emphasis on skilled attendance at birth and the scaling up of midwifery, along with creating enabling environments. ICM commends the view that investment in multi-skilled community workers is an unhelpful option compared to investment in midwifery services.
As regards the recommendation for facility-based birth, ICM maintains its position that women have a right to make an informed decision to give birth at home and midwives who elect to provide professional services for women in their homes should be able to do so within a nation's health service. However, community-based healthcare facilities with midwife-led maternity services are a viable option, as midwives can practice basic emergency obstetric care and make timely referrals to district level for comphrehensive emergency obstetric care when necessary. This reduces the barrier of distance between women and the clinic, and may contribute to the retention of midwives who can work closer to home and families.
The five articles
The five papers that form The Lancet Maternal Survival Series present the evidence for prioritising the health centre and midwifery strategy and detail the action required for its roll-out, including immediate actions for governments and donors. The authors warn that, without political commitment and investment into this approach, substantial declines in maternal mortality are unlikely in the next 10-20 years, and the fifth Millennium Development Goal--to reduce maternal mortality by 75% by 2015--will not be met.
The first paper, 'Maternal mortality: who, when, where and why', in detailing the causes of maternal deaths, points out that 'most pregnant women die in labour, delivery, or during the 24-hour period after delivery, mainly from severe bleeding and hypertensive disorders. Midwives have the skills to prevent 88-98% of these deaths but currently, over half the world's women deliver their babies without professional care.'
The second paper, 'Strategies for reducing maternal mortality', makes projections, using data from Bangladesh, which suggest that teams of midwives and assistants working in health centres can increase the proportion of women receiving professional care by 40% by 2015. The authors note that professional care will also benefit infants as midwives have the skills to resuscitate newborns, ensure they are kept warm, detect infections and promote early breastfeeding.
'Going to scale with professional skilled care' is the third paper, by Marge Koblinsky and others, who state that the immediate priority for governments and donors should be to invest in the training, deployment and retention of skilled attendants, especially midwives: 'The sheer lack of staff and facilities is the most substantial barrier to progress in many developing countries. Retention of workers is a major part of the supply problem.... Governments need to invest in efforts to retain staff, improve working conditions, and offer incentives for good quality care'.
Cost issues are addressed by the fourth paper in the series: 'To make the health centre strategy work, health care fees for mothers need to be removed and where insurance schemes exist, maternity care should be included in the benefits package ... Funds also need to be made available to the poorest women to assist with costs of transport to a health facility.'
The final paper recommends that the Partnership for Maternal, Newborn and Child Health is the best placed agency to lead the efforts to ensure safe motherhood. Director of The Partnership, Francisco Songane, who was present at the launch, stated: 'Birth in a safe, professional environment should no longer be a privilege of the rich. Decision-makers must act now to ensure that every delivery is a safe delivery--and that mothers need not pay with their lives when giving birth.'
Continuing professional education for midwives was an early focus of discussion, raised by Sue Jacob of the Royal College of Midwives, and continued by Marge Koblinsky of the University of Southampton, UK.
There was also further debate on costs to families as a barrier to access: Ann Starrs, Family Care International, proposed that families are helped with strategies to save for costs of care in the same way as they do to buy seed for planting
Antony Costello, of the UK Institute of Child Health, was concerned about the 'one-size-fits-all' strategy, suggesting that in countries with very high maternal mortality a different approach may be needed. He compared situations in Malawi and Bangladesh, pointing out the high risks of PPH and infection, and proposing that widespread use of low-cost pharmaceuticals, i.e. misoprostol and antibiotics, may be the answer, as he believes is the case in Bangladesh. Responses to this included the reaction that too much antibiotic use will spread resistance and misuse of misoprostol can be dangerous.
Read the articles in the maternal, neonatal and child survival series at www.thelancet.com/collections/neonatal_survival