Commentary
DOI: 10.1111/1471-0528.12799 www.bjog.org
Quality of care and midwifery services to meet the needs of women and newborns F McConville,a DT Lavenderb a Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland b School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK Correspondence: F McConville, Technical Officer, Midwifery, WHO Policy, Planning and Programmes, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, Geneva 27, Switzerland. Email [email protected]
Accepted 28 January 2014. Please cite this paper as: McConville F, Lavender DT. Quality of care and midwifery services to meet the needs of women and newborns. BJOG 2014; 121 (Suppl. 4): 8–10.
Introduction Globally, maternal mortality has declined by 47% (from 400 to 210 maternal deaths per 100 000 live births) over the last two decades (1990–2010), but considerably greater progress will be needed to reach Millennium Development Goal 5, especially in countries experiencing conflict and high HIV incidence.1 There has been a corresponding promotion of childbirth in facilities in low-income countries, and access to skilled birth attendants (SBAs) in health facilities has risen from 55% in 1990 to 66% in 2011. Yet, as the Millennium Development Goals Report 2013 points out, 46 million of the 135 million women who had live births in 2011 delivered alone or without adequate quality of care. Improving the quality of care has dominated maternity strategies in the last decade, motivated by the desire to offer care that not only leads to improved outcomes, but also offers a good experience for women and their families. Multiple definitions have attempted to conceptualise the various attributes of quality of care, most of which have core elements. The United Nations (UN) Committee on Economic, Social and Cultural Rights states that care should be ‘Available, Accessible, Acceptable and of good Quality’.2 However, care should also be provided by competent, respectful practitioners, who are not only able to carry out specific tasks, but who also have the knowledge to support their practice. In relation to midwifery care, providing a good quality service also needs to be viewed in the context of wider reproductive health services. Quality of care is a priority for the World Health Organization (WHO). Globally, the focus on quality (not just coverage) is essential because quality is critical for
8
impact. Under the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, the Commission on Information and Accountability (CoIA) called for a process to ensure global reporting, oversight and accountability on women’s and children’s health. The CoIA recommended the establishing of an Independent Expert Review Group (IERG).3 At the annual World Health Assembly at WHO headquarters in Geneva, the 197 UN Member States debate and agree global health priorities. Central to the future direction of WHO, and the ongoing post-2015 discussion, is Universal Health Coverage (UHC) and the message of equity of access for all.4 Underpinning UHC is the need for quality of care and the unique role of community and facility-based midwifery services. This brings an unprecedented opportunity to bring together UHC, quality of care and the unique role of community-based and facility-based midwifery services in providing universal access to improved maternal and newborn health.
Skilled care at birth We should not confuse ‘midwives’ with ‘midwifery’—they are not the same. Midwifery is what matters to women and newborns. A midwife is the professional best qualified to provide midwifery, but others (nurses, doctors) also provide aspects of midwifery, varying across settings. Where the practice of midwives is constrained, or where there are no midwives, terms lose their meaning. In 2004, WHO–International Confederation of Midwives (ICM)– International Federation of Gynecology and Obstetrics (FIGO) developed a Joint Statement, which defined the SBA and agreed this to be ‘a midwife, nurse, doctor’, or other care provider. The 2004 Joint Statement clearly sets
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of care midwifery
out that an SBA is someone who has (at a minimum) 23 ‘core’ midwifery skills (ICM definition).5 In low-income countries where civil registration and vital statistics are lacking, access to an SBA (one of several proxy measures for reduction in maternal mortality) is measured through demographic health surveys. These surveys ask women whether or not they gave birth in a facility, and if so whether a midwife, nurse or doctor was with her during childbirth. Although this indicator has enabled the tracking of increased births at the health facility level, there are two major concerns: how does a woman know the profession of the persons who supported her in childbirth, and how do we know that SBAs in each setting have the 23 ‘core’ skills and abilities? A recent study in Gujarat, India, for example, showed that degree and diploma nurse-midwives are graduating with virtually no midwifery experience because they have been unable to gain practical training experience in the critical 24 hours around childbirth.6 So, are women and newborns really getting ‘skilled’ care? We think they deserve better.
The global agenda for improving quality of care The good news is that governments, UN agencies, donors and advocates are engaged in a series of global initiatives that aim to improve the quality of midwifery services. The second Global Midwifery Symposium (May 2013 in Kuala Lumpur) united a broad-based constituency and identified seven priorities to strengthen: investment; education; deployment; being woman-centred; regulation; support to midwives and nurses associations; and the evidence base to justify increased investment.7 The UN Population Fund (UNFPA), WHO and the ICM are co-chairing a process to develop the second State of the World’s Midwifery (SOWMy) Report, 2014. Driven by UNFPA, the 2011 SOWMy Report was remarkable as it was the first time that the situation of midwifery in low-income countries had been summarised.8 2014 will also bring the much anticipated Lancet Series on Midwifery (LSM). The LSM will set out a new framework for maternal and newborn health services, based on the evidence of what women and newborns need, demonstrating the value of quality midwifery services in terms of outcomes and women’s perceptions of satisfaction. The LSM will call for significantly increased investment in research on the impact of midwifery services. 2014 saw the launch of ‘Every Newborn’ Action Plan.9 The ICM is engaged in the process and midwives are part of global consultations that are addressing the ‘how to’ improve quality of essential newborn care services at home and in facilities. To ensure that the energy and momentum continue, we will be reunited in common purpose at the 30th Triennial Congress of the ICM in June 2014.
ª 2014 Royal College of Obstetricians and Gynaecologists
Improving the quality of midwifery care To assist ministries of health, WHO is at the early stages of developing Guidance on quality of care in midwifery services through the Availability, Accessibility, Acceptability and Quality (AAAQ) lens. A preliminary meeting with experts at WHO headquarters agreed the need for multiple stakeholders to recognise the ‘core’ midwifery skills needed by all SBAs. This is to ensure the availability of quality of care for the estimated 85% of women experiencing normal childbirth, as well as the 15% of women undergoing emergency procedures—for example a woman needing a caesarean section still requires the essential care that midwives provide, and the baby will also require essential newborn care. To ensure availability of SBAs, the guidance will help countries to benchmark for, and invest in, the right teams of SBAs (midwives, nurses, obstetricians, anaesthetists and paediatricians, others) to ensure that they are in the right place at the right time with the right skills. How should midwifery services be best organised to meet the needs of women and newborns in the most economic model? Evidence from a recent Cochrane systematic review of midwife-led care versus other models of maternity care shows that women and newborns who receive midwife-led care experience positive maternal outcomes with fewer interventions, and that there is no statistical difference between midwifery-led and other models of care in fetal loss or neonatal death.10 Midwifery services need to be acceptable to women as well as to those who provide the care. Together, institutions, doctors, nurses and midwives must end the welldocumented disrespect and abuse of women who come to give birth in facilities.11 Recent research in an area of Kenya shows that disrespectful and abusive care is the second most common reason (after inaccessibility) why women will choose to avoid a health facility at the time of childbirth. Women health workers providing 24-hour midwifery care may themselves face considerable challenges. WHO is carrying out a systematic mapping of barriers to women working 24-hour shifts in maternal and newborn care. These include professional barriers (lack of supplies, equipment etc.) as well as context specific, sociocultural and economic barriers. A systematic mapping of interventions, and qualitative analysis, will follow. This work originated at the Women Deliver Conference 2013, where WHO and ICM jointly hosted a session in which the reality of midwives’ lives was explored. Speakers from Afghanistan, Nepal and Papua New Guinea12 highlighted some distressing issues, encapsulated in emerging research on ‘moral distress’. It is time to acknowledge the physically insecure, sometimes violent, and all too often economically crippling, environment in which many women are working while try-
9
McConville et al.
ing to provide care for other women. We must think beyond training because it is essential to address the all too frequent gender-based, negative institutional hierarchies that undermine professionalism and prevent women providers from giving the quality of humanised care that women, newborns and families deserve. The provision of quality of care must not become a simple mantra or abstract vision; it is a vitally important component in interventions that save lives. As we move forward we need to engage with multiple stakeholders to ensure that quality of care remains high on the maternity agenda. We also need to ensure that we use appropriate ways to evaluate the care provided; assessment should be based on pre-defined expectations and from the perspective of users and providers. 2014 provides an opportunity to really make a difference to the lives of women and their families; working together to improve quality of care is the way we can do this.
3
4 5
6
7
Disclosure of interests
8
The authors alone are responsible for the views expressed in this commentary and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
9
Funding
10 11
The author received no funding for this paper. &
References 12 1 United Nations. The Millennium Development Goals Report 2013, New York: United Nations; 2013. [www.undp.org/content/dam/ undp/library/MDG/english/mdg-report-2013-english.pdf]. 2 Economic and Social Council, Committee on Economic, Social and Cultural Rights (2000). The right to the highest attainable standard
10
of health (article 12 of the International Covenant on Economic, Social and Cultural Rights). UN, 22nd Session, Geneva, 25 April - 12 May 2000, General Comment No.14. World Health Organization. Keeping promises, measuring results: Commission on information and accountability for Women‘s and Children‘s Health. Geneva: WHO; 2011 [http://www.every womaneverychild.org/images/content/files/accountability_commission /final_report/Final_EN_Web.pdf]. WHO (2013). 10 facts on Universal Health Coverage. [www.who.int/ features/factfiles/universal_health_coverage/en/index.html]. World Health Organization. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva: WHO; 2004 [www.who.int/maternal_child_adolescent/ documents/9241591692/en/index.html]. Sharma B, Ramani KV, Hildingson I, Kyllile C. Confidence in selected midwifery skills: self-assessment by students just before graduation in one province of India. Presentation given by Bharati Sharma at the “Developing WHO Guidance in Quality of Care in Midwifery Services” meeting, October 23–24, 2013. The Second Global Midwifery Symposium. Strengthening quality midwifery care. Making strides, addressing challenges. May 26–27, Kuala Lumpur, Malaysia. UNFPA. State of the World’s Midwifery Report 2011: Delivering Health, Saving Lives. New York: UNFPA; 2011 [www.unfpa. org/sowmy/report/home.html]. Healthy Newborn Network (2013) Every Newborn Action Plan (ENAP) [http://www.everynewborn.org/every-newborn-action-plan/]. Soltani H, Sandall J. Organisation of maternity care and choices of mode of birth: a worldwide view. Midwifery 2012;28:146–9. Browser D, Hill K. Exploring Evidence for Disrespect and Abuse in Facility-based Childbirth. Report of a Landscape Analysis. USAID TRAction Project, Harvard School of Public Health, September 20 2010. [www.coregroup.org/storage/documents/elluminates/Respectful_ Care_at_Birth_9-20-101_Final.pdf]. Brodie P. ‘Midwifing the midwives’: addressing the empowerment, safety of, and respect for, the world’s midwives. Midwifery 2013; 29:1075–6.
ª 2014 Royal College of Obstetricians and Gynaecologists
DOI: 10.1111/1471-0528.12799 www.bjog.org
Quality of care and midwifery services to meet the needs of women and newborns F McConville,a DT Lavenderb a Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland b School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK Correspondence: F McConville, Technical Officer, Midwifery, WHO Policy, Planning and Programmes, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, Geneva 27, Switzerland. Email [email protected]
Accepted 28 January 2014. Please cite this paper as: McConville F, Lavender DT. Quality of care and midwifery services to meet the needs of women and newborns. BJOG 2014; 121 (Suppl. 4): 8–10.
Introduction Globally, maternal mortality has declined by 47% (from 400 to 210 maternal deaths per 100 000 live births) over the last two decades (1990–2010), but considerably greater progress will be needed to reach Millennium Development Goal 5, especially in countries experiencing conflict and high HIV incidence.1 There has been a corresponding promotion of childbirth in facilities in low-income countries, and access to skilled birth attendants (SBAs) in health facilities has risen from 55% in 1990 to 66% in 2011. Yet, as the Millennium Development Goals Report 2013 points out, 46 million of the 135 million women who had live births in 2011 delivered alone or without adequate quality of care. Improving the quality of care has dominated maternity strategies in the last decade, motivated by the desire to offer care that not only leads to improved outcomes, but also offers a good experience for women and their families. Multiple definitions have attempted to conceptualise the various attributes of quality of care, most of which have core elements. The United Nations (UN) Committee on Economic, Social and Cultural Rights states that care should be ‘Available, Accessible, Acceptable and of good Quality’.2 However, care should also be provided by competent, respectful practitioners, who are not only able to carry out specific tasks, but who also have the knowledge to support their practice. In relation to midwifery care, providing a good quality service also needs to be viewed in the context of wider reproductive health services. Quality of care is a priority for the World Health Organization (WHO). Globally, the focus on quality (not just coverage) is essential because quality is critical for
8
impact. Under the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, the Commission on Information and Accountability (CoIA) called for a process to ensure global reporting, oversight and accountability on women’s and children’s health. The CoIA recommended the establishing of an Independent Expert Review Group (IERG).3 At the annual World Health Assembly at WHO headquarters in Geneva, the 197 UN Member States debate and agree global health priorities. Central to the future direction of WHO, and the ongoing post-2015 discussion, is Universal Health Coverage (UHC) and the message of equity of access for all.4 Underpinning UHC is the need for quality of care and the unique role of community and facility-based midwifery services. This brings an unprecedented opportunity to bring together UHC, quality of care and the unique role of community-based and facility-based midwifery services in providing universal access to improved maternal and newborn health.
Skilled care at birth We should not confuse ‘midwives’ with ‘midwifery’—they are not the same. Midwifery is what matters to women and newborns. A midwife is the professional best qualified to provide midwifery, but others (nurses, doctors) also provide aspects of midwifery, varying across settings. Where the practice of midwives is constrained, or where there are no midwives, terms lose their meaning. In 2004, WHO–International Confederation of Midwives (ICM)– International Federation of Gynecology and Obstetrics (FIGO) developed a Joint Statement, which defined the SBA and agreed this to be ‘a midwife, nurse, doctor’, or other care provider. The 2004 Joint Statement clearly sets
ª 2014 Royal College of Obstetricians and Gynaecologists
Quality of care midwifery
out that an SBA is someone who has (at a minimum) 23 ‘core’ midwifery skills (ICM definition).5 In low-income countries where civil registration and vital statistics are lacking, access to an SBA (one of several proxy measures for reduction in maternal mortality) is measured through demographic health surveys. These surveys ask women whether or not they gave birth in a facility, and if so whether a midwife, nurse or doctor was with her during childbirth. Although this indicator has enabled the tracking of increased births at the health facility level, there are two major concerns: how does a woman know the profession of the persons who supported her in childbirth, and how do we know that SBAs in each setting have the 23 ‘core’ skills and abilities? A recent study in Gujarat, India, for example, showed that degree and diploma nurse-midwives are graduating with virtually no midwifery experience because they have been unable to gain practical training experience in the critical 24 hours around childbirth.6 So, are women and newborns really getting ‘skilled’ care? We think they deserve better.
The global agenda for improving quality of care The good news is that governments, UN agencies, donors and advocates are engaged in a series of global initiatives that aim to improve the quality of midwifery services. The second Global Midwifery Symposium (May 2013 in Kuala Lumpur) united a broad-based constituency and identified seven priorities to strengthen: investment; education; deployment; being woman-centred; regulation; support to midwives and nurses associations; and the evidence base to justify increased investment.7 The UN Population Fund (UNFPA), WHO and the ICM are co-chairing a process to develop the second State of the World’s Midwifery (SOWMy) Report, 2014. Driven by UNFPA, the 2011 SOWMy Report was remarkable as it was the first time that the situation of midwifery in low-income countries had been summarised.8 2014 will also bring the much anticipated Lancet Series on Midwifery (LSM). The LSM will set out a new framework for maternal and newborn health services, based on the evidence of what women and newborns need, demonstrating the value of quality midwifery services in terms of outcomes and women’s perceptions of satisfaction. The LSM will call for significantly increased investment in research on the impact of midwifery services. 2014 saw the launch of ‘Every Newborn’ Action Plan.9 The ICM is engaged in the process and midwives are part of global consultations that are addressing the ‘how to’ improve quality of essential newborn care services at home and in facilities. To ensure that the energy and momentum continue, we will be reunited in common purpose at the 30th Triennial Congress of the ICM in June 2014.
ª 2014 Royal College of Obstetricians and Gynaecologists
Improving the quality of midwifery care To assist ministries of health, WHO is at the early stages of developing Guidance on quality of care in midwifery services through the Availability, Accessibility, Acceptability and Quality (AAAQ) lens. A preliminary meeting with experts at WHO headquarters agreed the need for multiple stakeholders to recognise the ‘core’ midwifery skills needed by all SBAs. This is to ensure the availability of quality of care for the estimated 85% of women experiencing normal childbirth, as well as the 15% of women undergoing emergency procedures—for example a woman needing a caesarean section still requires the essential care that midwives provide, and the baby will also require essential newborn care. To ensure availability of SBAs, the guidance will help countries to benchmark for, and invest in, the right teams of SBAs (midwives, nurses, obstetricians, anaesthetists and paediatricians, others) to ensure that they are in the right place at the right time with the right skills. How should midwifery services be best organised to meet the needs of women and newborns in the most economic model? Evidence from a recent Cochrane systematic review of midwife-led care versus other models of maternity care shows that women and newborns who receive midwife-led care experience positive maternal outcomes with fewer interventions, and that there is no statistical difference between midwifery-led and other models of care in fetal loss or neonatal death.10 Midwifery services need to be acceptable to women as well as to those who provide the care. Together, institutions, doctors, nurses and midwives must end the welldocumented disrespect and abuse of women who come to give birth in facilities.11 Recent research in an area of Kenya shows that disrespectful and abusive care is the second most common reason (after inaccessibility) why women will choose to avoid a health facility at the time of childbirth. Women health workers providing 24-hour midwifery care may themselves face considerable challenges. WHO is carrying out a systematic mapping of barriers to women working 24-hour shifts in maternal and newborn care. These include professional barriers (lack of supplies, equipment etc.) as well as context specific, sociocultural and economic barriers. A systematic mapping of interventions, and qualitative analysis, will follow. This work originated at the Women Deliver Conference 2013, where WHO and ICM jointly hosted a session in which the reality of midwives’ lives was explored. Speakers from Afghanistan, Nepal and Papua New Guinea12 highlighted some distressing issues, encapsulated in emerging research on ‘moral distress’. It is time to acknowledge the physically insecure, sometimes violent, and all too often economically crippling, environment in which many women are working while try-
9
McConville et al.
ing to provide care for other women. We must think beyond training because it is essential to address the all too frequent gender-based, negative institutional hierarchies that undermine professionalism and prevent women providers from giving the quality of humanised care that women, newborns and families deserve. The provision of quality of care must not become a simple mantra or abstract vision; it is a vitally important component in interventions that save lives. As we move forward we need to engage with multiple stakeholders to ensure that quality of care remains high on the maternity agenda. We also need to ensure that we use appropriate ways to evaluate the care provided; assessment should be based on pre-defined expectations and from the perspective of users and providers. 2014 provides an opportunity to really make a difference to the lives of women and their families; working together to improve quality of care is the way we can do this.
3
4 5
6
7
Disclosure of interests
8
The authors alone are responsible for the views expressed in this commentary and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
9
Funding
10 11
The author received no funding for this paper. &
References 12 1 United Nations. The Millennium Development Goals Report 2013, New York: United Nations; 2013. [www.undp.org/content/dam/ undp/library/MDG/english/mdg-report-2013-english.pdf]. 2 Economic and Social Council, Committee on Economic, Social and Cultural Rights (2000). The right to the highest attainable standard
10
of health (article 12 of the International Covenant on Economic, Social and Cultural Rights). UN, 22nd Session, Geneva, 25 April - 12 May 2000, General Comment No.14. World Health Organization. Keeping promises, measuring results: Commission on information and accountability for Women‘s and Children‘s Health. Geneva: WHO; 2011 [http://www.every womaneverychild.org/images/content/files/accountability_commission /final_report/Final_EN_Web.pdf]. WHO (2013). 10 facts on Universal Health Coverage. [www.who.int/ features/factfiles/universal_health_coverage/en/index.html]. World Health Organization. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva: WHO; 2004 [www.who.int/maternal_child_adolescent/ documents/9241591692/en/index.html]. Sharma B, Ramani KV, Hildingson I, Kyllile C. Confidence in selected midwifery skills: self-assessment by students just before graduation in one province of India. Presentation given by Bharati Sharma at the “Developing WHO Guidance in Quality of Care in Midwifery Services” meeting, October 23–24, 2013. The Second Global Midwifery Symposium. Strengthening quality midwifery care. Making strides, addressing challenges. May 26–27, Kuala Lumpur, Malaysia. UNFPA. State of the World’s Midwifery Report 2011: Delivering Health, Saving Lives. New York: UNFPA; 2011 [www.unfpa. org/sowmy/report/home.html]. Healthy Newborn Network (2013) Every Newborn Action Plan (ENAP) [http://www.everynewborn.org/every-newborn-action-plan/]. Soltani H, Sandall J. Organisation of maternity care and choices of mode of birth: a worldwide view. Midwifery 2012;28:146–9. Browser D, Hill K. Exploring Evidence for Disrespect and Abuse in Facility-based Childbirth. Report of a Landscape Analysis. USAID TRAction Project, Harvard School of Public Health, September 20 2010. [www.coregroup.org/storage/documents/elluminates/Respectful_ Care_at_Birth_9-20-101_Final.pdf]. Brodie P. ‘Midwifing the midwives’: addressing the empowerment, safety of, and respect for, the world’s midwives. Midwifery 2013; 29:1075–6.
ª 2014 Royal College of Obstetricians and Gynaecologists
