Midwives make childbirth safer

4 World Health • 51 st Year, No. l, January-February 1998 Midwives make childbirth safer Anne Thompson A midwife in Namibia. Midwives ore in the front line in the struggle against maternal mortality. WHO/ A Thompson Women have always looked to other women to assist them and be with them during childbirth. Midwife means "with woman". At first , the skill and wis- dom of the midwife were handed down from mother to daughter. By the sixteenth century, Europe had clear rules governing who could be a midwife and what they could do. Their practice was regulated by the local authorities - often the church. In the last century, their education and practice were organized, profes- sionalized and incorporated into the health care system of most countries. Denmark and Sweden were able to show remarkable reductions in ma- ternal mortality through a strategy of expanding the skills and availability of midwives. In 1972, a definition of the midwife was formally agreed by WHO, the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives. The definition describes the competencies and scope of practice, as well as the criteria to be applied for recognition as a midwife. Despite the fact that it is the most natural of life events, childbirth has always carried the possibility of something going very wrong. General socioeconomic develop- ment, together with widespread availability of well0 organized mater- nity services have, however, made the death of a woman in childbirth a rare event in the industrialized world. It is not so in many other Midwives in many parts of the world are taking a hard look at their practice to see how best they can enhance their contribution to the global safe motherhood effort. parts of the world, where the risk of dying as a result of simply being pregnant can be several hundred times higher. It is really only in the past decade that people have woken up to the dimensions of the unneces- sary loss of life in childbirth. Midwives themselves were among the first to respond to the challenge issued at the launch of the Safe Motherhood Initiative, which took place in Nairobi, Kenya, in 1987. Of course, midwives had always been there, in the front line, staffing the health centres and maternity units, doing what they could to make sure that the outcome of pregnancy was safe. But with their greater awareness of the dimensions of the problem, they began to wonder what else they could do to make effective maternity services available to all women . Midwives in many parts of the world took a hard look at their practice to see how best they could enhance their contribution to the global safe motherhood effort. One of the first important conclu- sions they came to was that some- times their ability to act effectively was hampered by their training or by legislation which would not allow them to practise vital skills. They needed to be able to ensure that eclamptic fits are swiftly controlled; that haemorrhage, which kills so rapidly, is stopped; that labour which progresses too slowly is identified and dealt with before it becomes World Health • 51 st Year, No. l, Jonuory-February 1998 obstructed ; that sepsis is prevented; and that the often appalling conse- quences of unsafe abortion are man- aged effectively. Some midwives, such as those in Uganda, realized that they needed to become more in- volved in linking traditional birth attendants with the formal health system and in providing services for women in remote areas. They there- fore raised the funds to buy bicycles which would sometimes take them on 90 km journeys. Midwives ' efforts to improve their ability to manage the life- threatening complications of preg- nancy and childbirth have been stimulated by a series of triennial PreCongress Collaborative Safe Motherhood workshops run by the International Confederation of Midwives (ICM) together with WHO and UNICEF. These were designed to support midwives in their efforts to make a more effective contribution to reducing maternal deaths. The series covered wide-ranging topics such as identifying the clinical issues and learning essential life-saving skills , developing an educational framework for safe motherhood, monitoring and evaluating services, and strengthening midwives ' poten- tial for political and advocacy roles. In the periods between and since the workshops, WHO and ICM have worked together to ensure that the combined strengths of the midwives ' professional organizations world- wide and the global and regional influence of WHO continue to im- prove conditions for women and their newborn. Several countries are now training their midwives in criti- cal life-saving skills with the help of the Midwifery Education Modules which were developed as a result of the workshops. By taking part in PreCongress workshops, midwives have increased their potential for initiating change. Participation has prepared them for the role of consultants, capable of sharing their expertise and acting as a stimulus or catalyst for others eager to develop their own skills in plan- ning, delivering, monitoring and evaluating an effective maternity service which is accessible to all women. Each country has had to find its own recipe. Midwives in some countries have been trained as mem- bers of district teams in the manage- ment of obstetric complications; in other countries, midwives have increased their scope by forming cooperatives to obtain regular sup- plies of family planning materials and essential medicines. Such changes are taking place in all sec- tors - public, private and nongovern- mental. Some important lessons have been learnt in recent years . One is that the quality of the care provided is critical not only to its effectiveness but also to women 's willingness to use the services. In WHO's South- East Asia Region, a number of coun- tries are responding to this challenge Midwife listening to o baby's heartbeat in Viet Nam, as port of antenatal care. Photo Panos Pictures/S. Prague © s by field-testing the development of standards of midwifery practice for safe motherhood. The Indian Government is among several that have decided to push ahead with making midwifery skills more widely available. In the Western Pacific Region, there has been in- tense activity in several countries. For example, in Indonesia, more than 50 OOO young midwives have been trained, so that there are two mid- wives for every village. In Cambodia, after the long years of war, midwifery is being strengthened by the introduction of an improved curriculum and a major recruitment drive. In the newly independent states in the European Region , there has been a major initiative aimed at updating the practice of the mid- wives. Midwives in Africa, deeply concerned about the dimensions of the problem of maternal deaths and disability in their region, had an opportunity to pool their expertise at a meeting in Uganda which dis- cussed experience from 14 countries. Among the many issues debated were ways in which midwives could get the safe motherhood message across through drama and role-play, and by working with religious lead- ers and communities. Maternal death rates remain unacceptably high in many parts of the world. It will take the combined and sustained efforts of all members of the health care team to change them. Improvements cannot come about without the political commit- ment of the world's decision-makers and politicians. In the meantime, the world 's midwives are at work, in shanty towns and remote villages, in the labour wards of the great cities and in small, isolated health centres. Their commitment is giving women a better chance of safety at one of the most critical moments of their lives. • Ms Anne Thompson works with the Maternal and Newborn Health/Safe Motherhood unit, Division of Reproductive Health (Technical Support}, World Health Organization, I 21 I Geneva 27, Switzerland.