Midwives: key rural health workers in maternity

care

B.E. Kwast

Abstract The most acceptable and attainable rural health worker for maternity care is frequently the tradifiomd birth attendant or other personnel lacking clinical skills to freaf I&threatening emergencies. when first referral level facilities are also poorly staffed and illequipped IO deal with these emergencies, this again points to the need for training of and delegation to the trainedmidwif in rural areas. Unfortunately. their number is declining in rural areas of some countries most in need, e.g., Tmuonia. Elsewhere. midwifery skills and knowledge have been integrated into basic musing educarion. but practical skills are only developed postbasically when midwife educaters are expert clinicians. The graduates of such training could be delegated responsibility for many lifesnving procedures in obstetric cure. Successful clinical experience in use of these responsibilities will earn the midwife’s needed community reputation as a trusted health worker.

training; Midwifery Keyworas: motherhood; Maternal mortality.

Safe

Every year, half a million women worldwide sacrilice their own lives in the process of giving “ew lie. Behind each death is a

vices backed up by family planning. It is in recognition of this deplorable state of affairs that the Safe Motherhood Initiative (SMI) has been launched. In 1987, the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and United Nations Fund for Population Activities (UNFPA) agreed on the common goals of: (I) reduction of maternal mortality by SO?/.between 1990 and the year 2ooo; (2) access for all pregnant women to prenatal care, to trained attendants during childbirth and to referral facilities for high risk pregnancies and obstetric emergencies: and (3) availability for all couples of information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Nevertheless, despite the intensive work of WHO and the International Federation of Gvnecoloav and Obstetrics (FIGO) on essential obstetric functions at first referral level For the prevention of maternal mortality since 1985 [I], the delegation of responslbdltles for this essential care remains a topic of controversy among professionals who, by and large, have little experience OFunderstanding of the complexities of maternal care in scattered communities where the real problems lie. But without this essential delegation, the daunting task cannot be approached.

story of individual and family suffering with far-reaching impact. Many more women who do not die are scarred for life by complications and difficulties surrounding childbirth. Yet most of these tragedies are preventable through provision of adequate obstetric ser-

Key issues bility

related to delegation of

respertsi-

Delegation tiplies training and apprenticeship; the creation of a compatible environ-

ment for the practice; mounting a controlling and monitoring system and enacting relevant legislation to implement the program. Thus, the delegation of responsibilities must be based on the followinn elements: (1) the maternal health problems in-a given co&umity; (2) the perceptions and exp&ations of women and their families regarding maternal care; (3) the health worker actually assigned to maternal care in the district health system; (4) the most reliable, cost effective type of health personnel who can be assigned to affect maternal mortalitv: and (5) the strategy for ohmnine to nro. vide-safe maternity car: .a The clinical and sociocultural causes of maternal mortality in developing countries have been extensively described. The challenges for maternal health care in preventing the major causes of premature deaths among women in these populations are: (1) to reduce the incidence of complications during pregnancy; (2) to cope with obstetric emergencies until medical aid or referral to hosoital is available: and (3) to focus on reduction of fertility which wili reduce the exaosure to the risk of maternal death. The scope of their health problems is compounded by low female literacy, rural residence, religious and cultural preferences regarding marriage and fertility and low socioeconomic status. In many cultures, the preference for a large family, and particularly for sons, contributes to perpetual childbearing. Because of their low status, women may be abandoned if a male child is not produced and this may have devastating results. Heavy worl. and overworking during pregnancy pose real risk to their life and health. In such circumstances women do not generally seek health care and especially for pregnancy related problems, because of the cultural and geographic factors which restrict access to nroviders who can attend to them adequitely. If women die because the health worker has neither the skills nor the facilities, there will be no trust and the community behavior, so crucial for the reduction of maternal mortality, will not change. Female health workers are generally

scame for cultural reasons and this contributes to the scarcity of health services for WO”C”.

What category of health worker is likely to be accepted and trusted by the community to provide the skills required to reduce maternal mortality most cost effectively? The most acceptable and attainable may be within the family, or the traditional birth attendant (TBA), or the traditional healer or the comtmtnity health worker. If a health post or dispensary exists in the area and there is a female health worker, women may go there, but since results are often unsatisfactory for lack of either skills or facilities, this point of contact may be bypassed for other centers, with disastrous consequences to mother and child even if they survive. Most importantly, services need to be affordable. Whoever is the first contact needs to be backed up by a community support system for emergencies, but this will not succeed without trusted help regularly available. The definition and situation of the category of health worker enabled to deal with these challenges varies among countries. Rigid adherence to classification determining which health workers should or should not perform certain elements of essential maternity care will not benefit the SMI. While it is true that women and children suffer a disproportionately large number of deaths in rural areas, most towns and cities have equally horrendous problems. It is well

known that rural migrants to towns cluster in slums and shanties where, even in industrialized societies, health care is well below par. By the year 2000 half of the world’s population willlive in cities. It is estimated that differentials in proportions will continue to exist and that in the least developed countries 80% will still live in rural areas. This percentage is 45 for the newly industrialized and 20 for longtime industrialized nations. When addressing levels and definition of health workers, it would be more appropriate to use the term community health worker in the context of an integrated district health system which should apply to both rural and urban areas and de-

Midwrvs in mwt

pend on its population tration.

spread or concen-

Fundamental to this effort is a district health care system within a defined area for which the nehvork of health centers and hospital is accountable 121.Because the foundation of SMI is at the community level, the health centers must have the capacity to rewood to the commttnitv’s needs and be r&uIarly in touch with ii to Rain its conlide& and encourage it to sbar~responsibility for the safetv of its women. To be effective. the health c;“ter must have close links witi thecommunity it serves and the referral center it uses most. Comprising these links are: understanding of the problems to be dealt with: ability to offer practical help; readiness to provide additional relevant education; constructive criticism: tlexibilitv for accommodating to changing needs; akeptance of full share of responsibility when things go wrong;

and the confidence to make ccntact with nongovernmental oraanizations and other sect&s within the con&unity. This concept of interlinkage is crucial to the success of district heahh systems and strategies. The SMI requires team building and effective working with others to enhance the role of each through mutual respect. The district management team. consisting of leaders in the community, health centers and the hosoital, must be committed to the development’of a district health system. Delegation of resoonsibility is not “at&a! to many, but is a sine qua “on if a reduction in maternal mortality is to be achieved. It is important that cadres Hith less educational and professional education be well prepared at their own level to participate in essential team activities. Tradirional birth mendants Outside the industrialized world and China, the TBA still delivers most babies, even though this will change; with increasing “rbanization, family traditions are breaking

down and the tradition

n#“*r”i,~

‘WC,

will not be handed

SII

on.

Yet, tragic maternal outcomes have not been reduced in spite of intensive efforts to train TBAs in many countries for several decades, except in areas where they are regularly supervised by midwives. The blame cannot be attributed to the TIJAs when delegation of midwifery services to the TBA and other community health workers was allowed to occur without an efficient supervisory and referral system. The TBA, generally illiterate with no formal schooling, has had a co”rse of training that usually lasts no more than 80 hours. By definition they do not have the theoretical knowledge toextend their skills very far and cannot be expected to deal with obstetric emergencies in isolation. It is crucial that a mechanism for workinc with TBAs or women in the community beireated. Tbe fact that they are not part of the formal health system is only one reason for their isolation. Much more important is the community’s failure to accept their supervisors, who are the enrolled or registered midwives. To increase their standing-within the community, they in twn should be enabled to imorove their skills through upgrading and re&her courses. The sooner women’s organizations (of which trained midwives should be members) are recognized as equal partners in development, the more quickly the status of the trained midwife will be enhanced. Other from line workers At the same time. training of other front line maternal care personnel has not kept pace, resulting in a steady decrease in the number of births attended by a trained person in many countries. Health assistants have been trained as primary health care workers, but they are mainly men, who may often not he acceFtable to women for cultural reasons. The M in the MCH (Maternal Child Health) within primary health care is thus hardly addressed, except when women come for treatment of common complaints during pregnancy which can hwlly be considered prenatal care. Yet in :.ome cultures, in

Bhutan, for instance, the male health assistant with 6 months training in midwifery can cope with certain emergencies, among others manual removal of the placenta even after a strenuous 8-hour walk high into the motmtains. when the family is auite unable to bring the woman to a he&h facility. Intermediate marernal healrhcare personnel Table 1shows a number of categories of intermediate maternal health care personnel. Most of the enrolled or auxiliary nurse midwives have had full primary education and some, several years of secondary school. The duration and &tent of midwifery education varies from 3 to I2 months, or in the case of an enrolled or direct entry midwife, perhaps 28 months with 6 months basic nursine training. Unfortunately, it is known that the training of such intermediate personnel has been seriously weakened in many countries which should be a concern to all partners in the SMI. Nurse-midwives generally have the skills and could readily be provided with the means to handle a range of more complicated cases at community and health center level, but their numbers are declinina markedlv. Tanzania, for example, has seena 24% decline in the number of midwives during the past 10 years. This, coupled with the annual 3.7% population increase during the same period, has resulted in a 50% worsening of the midwife to live birth ratio from a~comfortable I:128 a decade aao to a ratio of I:251 now. In many areas these enrolled or auxiliary mid-

wives are not accepted in rural villages, often because they are too young and their unmarried status exposes them to dangers and abuse, while at the same time they are held in low esteem by the community for having broken away from the traditional way of family life. In general, however, training yet another cadre of health worker for maternal and child health instead of a fully qualitied midwife will not solve the problem of maternal mortality. They must in any case be supervised (and by whom, if the midwife is not available?) to respond effectively to questions beyond the scope of auxiliary practice. Medical assistants are a special category who have been trained for 3 years after which they can undergo a further 2-year course and advance to Clinical Officer. These men, able to perform cesarean sections. are found in Kenya, Tanzania, and Malawi. However, they may not have been specifically recruited and trained in obstetric assessment skillsand will usually rely on the profffsional midwife’s diagnostic skills. The midwife would appear to be the most reliable, cost effective type of health personnel who can be assigned to affect maternal mortality. She is a woman who has elected to lx trained, and presumably wishes to practice and accept the responsibilities of midwifery: she is not socially distanced from mothers as are many, more sophisticated health workers, and has received some of her instruction from those in tertiary services whom she sees as valuable colleagues. She has been specifically

Midniws

prepared to work in the community, to teach, fo be critically analytical, to perform the tasks required to save life in an emergency, and is invaluable as a family olannine. worker. Why is she being d&d the opportunity to function effectively? Why is she in a hospital when her skills could be put to more effective use elsewhere? Why is legislation not being created to help her function as required by SMI and To protect the public served? Why, when she does arrive at district level, is she expected to perform eflicientlv without euuioment or support? Where is ihe tertiary da&up team to help solve her problems? Has the district health system been apprised of SMI and if not, why not? Al1 these questions are key issues in delegation uf responsibilities. Table 2 shows the training and qualifications of midwives and nurse midwives. Although there is some variation among countries, certain principal patterns are apparent 131.The registered midwife is literate, usually with at least 4 years of secondary school education before her professional training, which may last from 3 to 5 years, although some are shorter. Traditionally, professional midwifery training is added as a specialty following basic oursing education. However, in the quest lo produce a multipurpose worker reoriented towards primary health care, midwifery has either been reduced to MCH or obstetric nursing in general nurse training or has been integrated into a 4year basic nursing program. As the attack on maternal mortality requires reduction and treatment of complica-

I”

nd

m‘,rrmity

Iare

SII

tions of pregnancy and childbearing, the argument that training in MCH nursing is sufficient does not hold. The knowledge of pathophysiology required for the diagnosis and treatment of reproductive complications. let alone the understanding of normal reproductive function needed to prevent conditions leading to maternal and infant mortality, are not, nor should they be, included in current MCH programs in nursing. But they are an essential element in midwifery practice and therefore in the training of a midwife. During her education, a nurse-midwife is prepared to prevent, assess, diagnose and treat common and uncommon complications of childbearing. and graduates should be ready to manage these situations independently. Traditionally, MCH programs have not included this ultimate responsibility for intervention. Therefore, MCH nurses arc not prepared either theoretically or practically to carry out the basic interventions of the Safe Motherhood Initiative. The integration of midwifery into nursing education is urobablv one reason why the midwifery profeision hai been beheaded of its leadershio over the last decade. Midwifery education’ is not basic education. The level of decision making and critical thinking for successful midwifery practice requires depth of knowledge, expertise in technical and communication skills and maturity in judgment 141.This is not the outcome when these elements are ostensibly integrated into basic nursing which already has so many facets that real midwifery skills are only developed postbasically. Midwife

educators must be expert clinicians. They are the teachers of registered midwives and many other cadres of midwifery personnel. The strategy for planning to provide safe maternity care needs to include a clear vision of wh”lt w want to occur in the system and the program design must be specific to the area. The content of maternal and child health requires careful delineation. In addition to growth monitoring, immunization, control of diarrhea1 disease and prevention and treatment of acute respiratory infeections, it must include prenatal care and a concerted effort to increase the proportion of births taking place under skilled supervision. Merely selecting women at high risk without a referral system in place is a denial of primary health care, since the majority of maternal deaths occur during labor and delivery. Each level in the health system ought to be addressed in setting goals based on health resources, community perceptions and needs, and feasibility in the area. We have had the technology for decades but implementation requires a willingness and political commitment to delegate responsibilities to health workers other than physicians to carry out essential obstetric services. These are more than surgical functions and many will have to be undertaken at community level, with its app:opriate placement of trained health workers. We should be cautious about packaged solutions. such as teaching all doctors to do a cesarean section without teaching them to make a critical assessment of the progress of labor. Equipping every health center with a vehicle for emergency transport, while neglecting to organize a refresher course for the midwife and give her the resources to resuscitate a woman in an emergency, would once again leave women without the care they deserve. In many countries the role of different cadres of health worker may have legal limits and to train them for a task they cannot legally perform will lead to frustration and anxiety unless enabling legislation lo broaden their role is put in place, especially as lower level health workers may have no such legal

limitations and may already these tasks.

be performing

Conelusion The SMI is almost ready to celebrate its fifth birthday and what have been its achievements -so far? Do fewer women die? How much longer must we hear that in India

one woman dies every 4 minutes as a result of pregnancy or chiidbearing? Is it not time we gave more thought to delegating responsibilities and acting to enable someone to help keep our young w&nen off the road to de&. Smallpox was eradicated because minimally trained staff were delegated responsibility for vaccines and syringes and maintaining correct

records. Child survival took off when nurses were given the job of immunizing children and entrusted with the preparation and use of vaccines and syringes. Yet today the use of ergometrine, even orally, at community level, is fraught with controversy. What country has

had the couraae to allow communitv midwives to contra eclamptic tits and pu&peral fever with drugs? This would save lives. It is not the mere “delegation of responsibilities, but also taking measures to ensure that they can be and are carried out safely and that any

problem arising is dealt with appropriately in a compassionate, understanding and tutorial manner. Only when the person in the middle receives the support she so rightly deserves, when changes in legislation are made to allow her to function etTectively, when her training is appropriate to the tasks being delegated and she has gained experience in her actual practice area, will there be a quantum leap in the reduction of maternal mortality. R.ZfereihXS

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