We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with effective referral and transfer mechanisms to specialist care.
Introduction
Midwifery is one effective means to promote the health and wellbeing of women of childbearing age and their newborn infants and families, with a potentially rapid and sustained effect on population health outcomes1 through the provision of maternal and newborn interventions. The interventions known to be effective in improving health outcomes, such as antenatal corticosteroids for women in preterm labour2 and midwife-led care,3 have been detailed in the Cochrane Library and the Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health.4 This last review4 identified 56 essential interventions that, when implemented in packages relevant to local settings, were most likely to save lives, especially in low-income and middle-income populations. As part of this Lancet Series about Midwifery, Mary Renfrew and colleagues1 re-examined the effective interventions that have been shown to improve maternity-related outcomes for women and newborn infants, and showed that midwifery, as delivered by midwives and others with midwifery skills, can deliver most effective maternal and newborn health interventions, including the elements (also known as signal functions) for basic emergency obstetrics and neonatal Care (BEmONC; ie, assisted delivery, removal of retained products, manual removal of the placenta, administration of oxytocic drugs, antibiotics, and anticonvulsants, and neonatal resuscitation).1 Interventions, including blood transfusions or caesarean section capacity (indicative of comprehensive EmONC [CEmONC]), are classified as specialist (ie, that require the input of a medical practitioner with advanced skills in obstetrics and advanced medical equipment and medicines). Renfrew and colleagues'1 definition of midwifery is used in this and all other articles in this Series.
The practice of midwifery is defined as “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, post partum and the early weeks of life. Core characteristics include optimising normal biological, psychological, social, and cultural processes of reproduction and early life, timely prevention, and management of complications, consultation with and referral to other services, respecting women's individual circumstances and views, and working in partnership with women to strengthen women's own capabilities to care for themselves and their families”.1
The effect of scaling-up midwifery and the associated interventions provided by midwifery services is not presently known. We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled-up in 78 countries classified by Human Development Index (HDI).
Key messages
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Midwifery can deliver most effective maternal and newborn health interventions, and can enable access to specialist and comprehensive emergency care when necessary.
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Universal coverage of these interventions will result in reductions in maternal deaths, stillbirths, and neonatal deaths in 78 countries classified according to the HDI.
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In countries in the lower HDI tertile, maternal mortality would decrease by 27% with a modest (10%) increase in coverage of the interventions delivered by midwifery, including family planning, over a 15-year period (2% per year on present baseline estimates), by 50% with a substantial coverage increase (25%), and by 82% with universal coverage (95%). We noted similar reductions on stillbirths and neonatal deaths.
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Family planning alone also contributed to substantially decreasing deaths, since fewer women are exposed to the risk of maternal death. The full scope of midwifery practice should include family planning.
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In addition to the estimation of mortality, morbidity, quality of life, and wellbeing should also be measured to provide more detailed evidence on the full effect of midwifery.
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At all HDI levels, about 30% of maternal deaths could be averted by midwifery, with an additional 30% averted with the addition of specialist medical care.
HDI=human development index.
Section snippets
Measurement of maternal and child health outcomes
An estimated 15–20 million women are affected every year by substantial morbidity as a result of childbirth,5, 6 affecting not only the woman, but also her baby, other children, and members of the broader community. To determine the full effect of midwifery on women and newborn infants, biological (ie, morbidity and mortality), financial, social, and psychological outcomes would need to be measured.1 Poor maternal health contributes to economic hardship, with potentially longer-term outcomes,
Coverage of maternal and newborn health interventions
Regardless of the challenges associated with measurement, to improve outcomes, sufficient coverage of maternal and newborn interventions is required. The Countdown to 2015 for maternal and child survival tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5 in 75 high-burden countries21, 22, 23, 24, 25, 26 and has shown that the overall coverage of several components of midwifery is low, such as satisfaction of family planning needs (54%), four or more antenatal
Will an increase in coverage of midwifery avert deaths?
Renfrew and colleagues1 have shown that midwifery is an effective and probably cost-effective means to provide reproductive, maternal, and newborn services. Therefore, we sought to establish the effect of scaling-up such services on maternal and neonatal deaths. We aimed to estimate the effect of midwifery, as defined in this Series,1 on maternal and newborn outcomes. The two objectives to achieve this aim were to estimate maternal, fetal, and neonatal deaths averted using the Lives Saved Tool
The Lives Saved Tool
LiST is one module in the Spectrum Policy Modeling Software.31 Other Spectrum modules include HIV, demography, and family planning. LiST was selected as one tool that has the proven capacity to estimate the effect of discrete midwifery interventions, rather than a package of care as in the quality maternity framework, in The State of the World's Midwifery 2014 Report.32 In brief, the LiST model starts with a given population's current health and mortality status, and coverage of health
Effective interventions and estimation of their baseline coverage
The effective maternal and newborn health interventions were those identified in the Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health,4 and in the study by Renfrew and colleagues,1 as being able to be delivered as part of midwifery services, particularly by midwives educated to international standards and who are integrated into the health system. Specialist medical interventions were those requiring medical assistance such as blood
Deaths averted under different increased coverage scenarios
A modest increase in coverage of midwifery, including family planning, by 10% every 5 years (scenario 1) could result in a 27·4% reduction in maternal deaths in the group A countries, a 35·9% reduction in the group B countries, and a 62·7% reduction in the group C countries (table 4). Given the lower number of maternal deaths in the group C countries than in the other groups, a reduction in the absolute number of maternal deaths resulted in a larger proportional effect in group C than in group
Estimation of the additive value of specialist care
The second aim of this study was to estimate the value of adding specialist (obstetrician) care to midwifery on maternal, fetal, and neonatal lives saved. To do this, we included all activities that could reasonably be delivered by a midwife to be midwifery care,28 covering activities ranging from community-based to BEmONC-level care; these are included in the first four boxes in the framework for quality maternal and newborn care1 in this Series.
We included additional interventions deemed to
Even modest increases in coverage can save lives
Even at the lowest level of scale-up, of 10% per 5 years relative to baseline, we noted a noticeable reduction in the number of maternal and neonatal deaths, with the greatest absolute reduction in the low-HDI countries. The largest percentage reduction was seen in the moderate-to-high HDI category, possibly because the overall coverage was already high (75% of institutional births), so quality was most likely to be affected.
Analyses and reports in the past two decades25, 26, 65 have
Conclusions
We have described the range of potential benefits that full and comprehensive scale-up of midwifery can bring to communities and families worldwide, regardless of their present level of development. Although it is clear that these benefits can be very important, further critical assessment and research is required to establish how health systems and community services can be best improved and strengthened in order for midwifery to be available and accessible to all.
Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care
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Midwife-led continuity models versus other models of care for childbearing women
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Essential competencies for basic midwifery practice
2024, The Lancet Regional Health - Western Pacific
In Lao Peoples Democratic Republic, midwives are the main providers of primary reproductive, maternal, newborn, child and adolescent (RMNCAH) services. We analyzed to what extent practice regulations allow midwives to provide nationally defined essential RMNCAH services.
Stakeholder consultations and document reviews were conducted to identify the essential RMNCAH interventions and care tasks midwives are expected to provide without physicians. These were defined in: 1) the Essential Health Service Package (EHSP) and 2) 18 national standards and guidelines. We then mapped whether midwifery regulations, which provide the legal framework for clinical service provision, supported delivery of these standards to identify regulatory gaps. Data were used to update regulations.
Midwives were expected to provide 39 RMNCAH interventions without physicians, representing 1100 care tasks. Midwifery practice regulations allowed eight of 39 interventions (20.5%) and 705 of 1100 care tasks (64.1%) at baseline. Of the 31 interventions not allowed for provision by midwives, 83.9% (26) required prescribing and giving medicines, 51.6% (16) ordering and conducting diagnostics, 38.7% (12) making a clinical diagnosis, and 22.6% (7) use of non-pharmacological interventions. The Ministry of Health convened a multi-stakeholder group to revise the midwifery practice regulations, which increased the legally supported interventions and care tasks to 37 (94.9%) and 1081 (98.3%), respectively.
This novel methodology enabled systematic identification and quantification of regulatory gaps in midwifery practice and data-driven revisions. Consequently, regulatory support for delivery of primary RMNCAH interventions vastly improved. The approach can be applied to other clinical cadres, service areas and countries.
Korea Foundation for International Health Care (KOFIH) supported research operation.
There is no international standard for advanced midwifery scope of practice.
Globally, there is variance in how scope of midwifery practice is determined and regulated, with no consensus on extended or advanced scope. This can lead to under-utilised staff potential, un-met consumer need, and loss of professional skill.
The aim of this scoping review was to synthesise and map what is reported in the international literature on the advanced scope of midwifery practice.
A systematic scoping review methodology was adopted utilising Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A full search was conducted of databases including MEDLINE, CINAHL, Scopus, Google. Publications from 2019 to August 2022 that met criteria were included. Reported skills were mapped to the International Confederation of Midwives (ICM) competencies of pre-conception, antenatal, labour and birth, postnatal plus globally identified areas for midwifery investment.
28 articles met inclusion criteria. Reported skills included abortion care (n = 6), prescribing (n = 7), ultrasound (n = 2), advanced practice skills (n = 7), midwifery-led skills, primary health, post-graduate education, HIV/AIDS testing, advocacy, and acupressure (all n = 1).
This review presents a synopsis of publications describing what has been defined as advanced midwifery scope of practice in international contexts.
Establishing evidence of midwives working to the peak of professional scope is important to continue to develop professional capacity and support contemporary practice, regulation, governance, and policy while improving consumer access to equitable care. Findings aid service development, provision, and professional planning.
During the late 19th and early 20th century, several states mandated midwifery licensing requirements to improve midwives’ knowledge, education, and quality. Previous studies point to the health benefits of midwifery quality improvements for maternal and infant health outcomes. This paper exploits the staggered adoption of midwifery laws across states using event-study and difference-in-difference frameworks. We use the universe of death records in the US over the years 1979-2020 and find that exposure to a midwifery licensing law at birth is associated with a 2.5 percent reduction in cumulative mortality rates and an increase of 0.6 months in longevity during adulthood and old age. The effects are concentrated on deaths due to infectious diseases, neoplasm diseases, and suicide mortality. We also show that the impacts are confined among blacks and are slightly larger among males. Additional analyses using alternative data sources suggest small but significant increases in educational attainments, income, measures of socioeconomic status, employment, and measures of height as potential mechanism channels. We provide a discussion on the economic magnitude and policy implication of the results.
2023, American Journal of Obstetrics and Gynecology
The intrapartum period is a crucial time in the continuum of pregnancy and parenting. Events during this time are shaped by individuals’ unique sociocultural and health characteristics and by their healthcare providers, practice protocols, and the physical environment in which care is delivered. Childbearing people in the United States have less opportunity for midwifery care than in other high-income countries. In the United States, there are 4 midwives for every 1000 live births, whereas, in most other high-income countries, there are between 30 and 70 midwives. Furthermore, these countries have lower maternal and neonatal mortality rates and have consistently lower costs of care. National and international evidences consistently report that births attended by midwives have fewer interventions, cesarean deliveries, preterm births, inductions of labor, and more vaginal births after cesarean delivery. In addition, midwifery care is consistently associated with respectful care and high patient satisfaction. Midwife-physician collaboration exists along a continuum, including births attended independently by midwives, births managed in consultation with a physician, and births attended primarily by a physician with a midwife acting as consultant on the normal aspects of care. This expert review defined midwifery care and provided an overview of midwifery in the United States with an emphasis on the intrapartum setting. Health outcomes associated with midwifery care, specific models of intrapartum care, and workforce issues have been presented within national and international contexts. Recommendations that align with the integration of midwifery have been suggested to improve national outcomes and reduce pregnancy-related disparities.
Registration as an internationally qualified midwife in Australia can be challenging, as the individual must meet rigorous education and professional competency assessment standards.
The purpose of this discussion is to present an overview of the evolution of registration standards for internationally qualified midwives in Australia from 2000 to 2020 and evaluate their effectiveness in promoting internationally qualified midwives' professional integration.
Australian registration policies for internationally qualified midwives have undergone significant change over the last 20 years. In 2010, registration policy and governance moved from state or territory to national jurisdiction, then these standards were upgraded in 2014, and finally transitioned to an outcome-based assessment (OBA) program in 2020. Inconsistency and lack of transparency in established registration policies and their implementation were revealed, most notably when bridging programs for internationally qualified midwives from non-English speaking backgrounds were discontinued in Australia in 2015, despite reference in the NMBA policy as an available transition program from 2000 to 2020. The implementation of OBA in 2020, which occurred after a significant delay, complicated registration processes further with inclusion of two levels of assessment (MCQ examination and OSCE) and associated expenses.
Evidence-based strategies and regulatory adjustments are necessary to effectively register internationally qualified midwives in Australia, particularly those from non-English speaking backgrounds.