Investing in midwives

Pakistan observed the International Day of the Midwife on May 5, which also marked the 100th anniversary of the International Confederation of Midwives (ICM) that together with the UNFPA and the WHO organizes the day. The main objective was to ensure that the global community recognized the importance of instituting quality midwifery programmes and amplifying the life-promoting work of this virtuous profession.

The WHO has also recently set out the Global Strategic Directions for Nursing and Midwifery 2021-2025 based on an interrelated set of policy priorities designed to help countries to ensure that midwives and nurses optimally contribute to achieving universal health coverage (UHC) and other population health goals. The document uses the terms “midwife” and “nurse” as different occupational groups by appreciating the professional distinction between midwives and nurses.

The government of Pakistan is determined to achieve the Sustainable Development Goals relating to health, particularly the attainment of UHC, by the year 2030. A major impediment in this colossal undertaking is an acute shortage and lopsided balance within the Human Resources for Health (HRH). Pakistan falls within the countries with the most acute shortage of HRH. While the WHO recommends a density of at least 45 doctors, nurses and midwives per 10,000 to attain UHC with one doctor for four nurses, midwives or lady health visitors (LHVs), Pakistan in end-2017, with a population of close to 208 million, was at 14.5 and that too with a lopsided balance.

The number of doctors was almost double the number of nurses, midwives and lady health visitors combined. This indicated that between 2018 and 2030 we have to bridge the 8-fold shortage in the number of nurses, midwives and lady health visitors by producing around 800,000 of these crucial professionals.

Until now we have focused mainly on maternal, neonatal and child health (MNCH) care in addition to communicable disease control and have yet to properly address the control of noncommunicable diseases such as cancer, diabetes, cardiovascular diseases and chronic respiratory diseases. Despite this focus, however, our maternal mortality rate, infant mortality rate and population growth rate are the highest in our region signifying that we are missing some crucial link.

When we use the term midwife, it refers to a woman who assists a prospective mother in childbirth. It stands to reason that professionals belonging to this cadre are likely to play the most pivotal role in improving our critical MNCH indicators and warrant our priority attention. However, midwifery was usually lumped with nursing, disallowing the profession to develop an identity of its own. Until quite recently when diploma programmes were the norm, candidates were admitted after 10 years of schooling to a four-year nursing training, only the last year of which was devoted to midwifery. Thus, the majority of registered diploma holders had little or no experience in deliveries.

After 1952, the government began establishing public health schools offering two-year courses for LHVs focusing on midwifery and essential elements of public health. Subsequently, the government launched a cadre of community midwives, which were not of adequate quality and failed to impact our indicators. Later, the Pakistan Nursing Council allowed registered nurses to undertake a two-year Bachelors’ programme in Midwifery in the Aga Khan University Karachi and later at the Dow University of Health Sciences Karachi.

Meanwhile, in the run up to attaining UHC, the Ministry of National Health Services, Regulation and Coordination developed a PC-I for the strengthening of the nursing and midwifery sub-sector in 2019, which called for four-year degree programmes in nursing and midwifery after 12 years of schooling. However, a lot of time was taken up in apportioning the share of federal and provincial costs and subsequently a PC-I at federal level was approved, which has not taken off yet due to lack of releases in view of the Covid-19 response and other funding modalities.

What is important is that the federal and provincial governments have resolved to do away with nursing and midwifery diploma programmes and shifted to four-year Bachelors’ programme after FSc. They have also agreed to institute a two-year bridging programme for registered nurses leading to a BSc in Nursing or Midwifery will also be available.

The good news is that after an extensive dialogue with several stakeholders, an advanced draft of the Midwifery Strategy has been developed based on which each province can draw up its strategic framework and operational plan. The principal and foremost consideration of the strategy is to establish a separate, distinct and discrete identity for the midwifery profession and not obscure it as part of nursing.

The strategy also envisages reducing the overlapping in some related cadres in the health and population sectors that could be merged with the midwifery cadre after establishing the bridging programmes. Efforts will also be made to ensure that midwives enjoy the same career pathways allowed to nurses (Grade 16-20) or even higher by changing the nomenclature of certain positions, reserving certain positions manned by doctors for midwives and creating new positions. This is important as currently very low grades are allowed to midwives and lady health visitors with no opportunities for personal or professional growth.

The Pakistan Nursing Council Act should be renamed the Pakistan Nursing and Midwifery Council, while incorporating a code of conduct relating to the practice of midwifery to remove any ambiguity. The larger schools of nursing recently upgraded as colleges of nursing should apportion a significant proportion of their seats for midwifery as well, while all the 27 public health schools producing LHVs in Pakistan should also be upgraded as midwifery colleges.

The federal MoNHRSC should expedite its support for the upgraded colleges in faculty development and provision of equipment for skills laboratories, anatomy laboratories, science laboratories, IT laboratories, audiovisual laboratories, library books/journals and access to online databases to maintain a high quality of teaching. The provincial governments should also work on the upgradation of these institutions on a priority basis.

New positions of midwives will need to be created at all levels of the health system, including teaching hospitals, district headquarter hospitals, tehsil headquarter hospitals, rural health centers and basic health units where female paramedics are not available. The MoNHRSC and PNC need to ensure uniformity and standardization in the implementation of all public policies relating to midwives to establish similar job descriptions, roles and responsibilities for all the professionals.

Each province will need to decipher the exact number of midwifery professionals required by 2030 in order to attain UHC, based on an accurate needs analysis in each district within their jurisdiction. Efforts must be made to adhere to the ICM standards for accreditation, advocacy, autonomy, admissions, assessments, competence, curriculum, and midwife-led continuity of care, educational standards of care and their evaluation process including continuing education.

Moving forward these strategy elements need to be rapidly endorsed by all stakeholders as soon as practicable so that the provincial operational plans can be developed on a priority basis along with an equitable allocation of funds. Planning should be carried out realistically with achievable targets and foreseeing challenges together with the means to mitigate them. However, the bar should be set high so as not to compromise on the quality of education imparted.

These measures can enable Pakistan’s coveted dream of bringing down its indicators for maternal and child health to acceptable levels, while attaining Sustainable Development Goal No 3 encompassing Universal Health Coverage by the stipulated timeframe of 2030.

The writer is a senior public health specialist and editor-in-chief of the Public Health

Action journal of theInternational Union AgainstTuberculosis and LungDiseases.