The pivotal role of midwives

In Pakistan, 39% of births are attended to by skilled health personnel, a small fraction attended by qualified ones.

I am becoming acutely conscious that the 2015 dateline for the achievement of the Millennium Development Goals (MDGs) is quickly approaching. Looking at the situation in Pakistan, there is some evidence of progress on several indicators. There are, however, also areas of human development where progress, while being made, is painfully slow and uneven. One such area is MDG5, that is, maternal health. It is estimated that about 30,000 women in this country die annually because of pregnancy related causes. United Nations’ estimates put the maternal mortality ratio (MMR) at around 270/100,000 live births. The true numbers could be much higher given the context of under-registration of deaths as well as poor statistics on cause of death.

High MMR can be explained by malnutrition, obstructed labour and complications during child birth, unsafe abortions, etc, most of which can be prevented. For instance, strengthening of the primary health care system is critical if a society wants to reduce complications both during pregnancy as well as labour. Here is where trained health personnel become important, especially in their provision of antenatal care within the community.

MDG5 calls for the reduction of MMR worldwide by 75 per cent between 1990 and 2015. In the case of Pakistan, available data points to a 48 per cent reduction in maternal mortality since 1990. A good start but still a long way to go. One of the keys to achieving MDG5 is to make sure that all births are managed by skilled health professionals. Midwives are an important part of that health workforce. In fact, one of the areas of focus of global efforts presently is to increase women’s access to quality midwifery services.

We need to have a common understanding of who a midwife is. A midwife is a person who meets the International Confederation of Midwives (ICM) definition, ie, has been educated and trained to proficiency in the ICM Essential Competencies for Basic Midwifery Practice, demonstrating competency in the practice of midwifery, and is legally permitted to use this title. A midwife ideally assists a woman before and during labour, birth and postpartum. But the midwife does more than that, including handling all aspects of reproductive health and health promotion.

In Pakistan, only 39 per cent of births are attended to by skilled health personnel. A large percentage of births are also home deliveries, again with only a small fraction attended by qualified personnel. No wonder then, the relatively high rates of maternal mortality and morbidities.

Bold steps need to be taken to address this situation by all, including the government, regulatory bodies, professional associations, schools and training institutions, international organisations and civil society, etc. At the June 2010 Women Deliver Conference in Washington DC, midwives, health personnel and development partners who were gathered there made a global call. Among others, they called on governments to address vital issues such as education and training, legislation and regulation, recruitment, retention and deployment, and association.

In a few days time, the United Nations Population Fund will be launching its State of the World’s Midwifery report. It looks at the state of midwifery in 56 countries for which data is available, including Pakistan, and also proposes a set of recommendations based on what has worked in countries that have been successful in improving maternal and child health.

In conjunction with the launch of this report, it is my hope that there will be a national commitment to strengthen the health system through an invigorated and comprehensive capacity-building effort for increasing the number and quality of midwives. An extended community midwife scheme to train and deploy community midwives will also enable better access to quality services by women in rural areas.

Published in The Express Tribune, June 27^th, 2011.