In Pakistan, high maternal mortality rates have always been a major concern. A major reason for maternal deaths during pregnancy and childbirth has been the use of unskilled birth attendants. These births have usually occurred in unhygienic environments, at the hands of individuals, who are not equipped to handle the normal course of pregnancy, let alone any sort of complication that may develop during pregnancy or childbirth. Therefore, achieving Millennium Development Goals (MDG) numbers four and five, i.e., reducing child mortality rates and improving maternal health, respectively have posed a considerable challenge to Pakistan’s health system.
In its quest to achieve these goals, the health system has adopted a number of initiatives, the most important of which has been the introduction of community midwives, an approach focusing specifically on the country’s rural population. The programme proposed to introduce a cadre of community-based health workers meeting the international definition of skilled birth attendants in terms of practical skills and the required knowledge. These community midwives were to be trained in conducting normal home-based deliveries under hygienic conditions, thereby increasing the proportion of skilled birth attendants throughout Pakistan. The importance of these midwives to the far-flung areas of our country cannot be underestimated.
According to the National Maternal and Neonatal Child Health Programme, the community midwives model includes the following functions: a) providing care to the pregnant woman during the maternity cycle, including care for the newborn; b) educating the mother in self-care throughout pregnancy, as well as after birth; c) monitoring the physical, social and emotional well-being of the pregnant woman; d) taking appropriate action whenever needed within the resources available, thereby making the programme self-sufficient; e) providing guidance to the community in terms of healthy living; f) identifying complications and making timely referrals to hospitals.
Training of community midwives began in 2007-08 according to a curriculum designed by the Pakistan Nursing Council (PNC). The aim was to train 600 midwifery tutors, resulting in the recruitment, training and deployment of around 12,000 midwives across Pakistan. The training course was developed with the goal of enabling community midwives to provide effective maternal and child health care independently in their communities. The acquisition of appropriate skills and knowledge on the part of these midwives is dependent on an efficient training programme. The PNC is responsible for training methods, examination procedures and the content and quality of the curriculum being taught.
An evaluation of the training conducted in September 2010 revealed the need to improve the curriculum and the examination system. The curriculum was recently revised and approved by the PNC in collaboration with the Technical Resource Facility, an organisation providing technical assistance to the health sector. The new curriculum lays emphasis on a practice-based approach in which, the entire training process and examination procedure are regularly supervised and revised to produce competent individuals. Some of the changes that need to be incorporated include: a) midwifery schools and their affiliated hospitals should be collectively considered an “institution”, with the schools managing the theoretical aspects of the training and the hospitals covering the practical component; b) the role of community midwives should be clearly defined to include independent assessment and management of pregnant women and their infants throughout the maternity cycle, as well as the post-pregnancy period; c) revision of examination rules and policies; and d) regular maintenance of log books and reorganisation of the curriculum content.
It is commendable that following the assessment, the PNC has taken steps in the right direction. All the requisite changes are being made in order to make the health care system more efficient and hopefully, these will help Pakistan achieve the relevant MDGs by the designated year.
Published in The Express Tribune, June 2nd, 2013.
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