According to the United Nations Population Fund (UNFPA), everyday, over 800 women die during pregnancy or childbirth. Almost 90% of these deaths happen in the developing countries in Africa and Asia. Childbirth, however, is no deadly disease, and the tools for preventing maternal mortality have been available to us for years.
Maternal mortality is not just a women’s problem; its impact is felt on the family and society. There is evidence that infants who lose their mothers are much more likely to die before reaching their second birthday. Moreover, untreated complications, such as obstetric fistula, can leave long-term effects on women’s health and well-being, and keep them from being productive members of society.
It is, therefore, hardly surprising that reducing maternal and child mortality were singled out as key priorities within the Millennium Development Goals.
Among developing countries, Bangladesh has made significant improvements in this area in recent years. The maternal mortality rate has dropped from 574 in 1990, to 170 per 100,000 live births. However, compared to neighbours in the region, such as Sri Lanka (30 deaths per 100,000 live births) and Malaysia (42 per 100,000), Bangladesh still has a long way to go.
Evidence from around the world tells us that the presence of skilled birth attendants is the single most effective way to reduce maternal mortality. Skilled birth attendants can be doctors or nurses trained in obstetrics; however, in recent years professionally trained midwives have taken an increasingly important role in providing high-quality and cost-effective maternal care. Midwives have been a key to success in developing countries such as Sri Lanka and Malaysia that have achieved dramatic improvements in this area. Even in developed countries like the United States and the United Kingdom, midwives have taken on a more prominent role in maternal health.
The concept of professional midwives however, is fairly new to Bangladesh. In 2010, the government of Bangladesh made a commitment to the UN to produce 3000 midwives by 2015. The government has thus far developed curricula for midwifery, and has provided short training courses on some midwifery skills for several thousand community based birth attendants. However, a lot more still needs to be done to develop fully professional midwives who are capable of providing the range of services that these roles entail.
What does a professional midwife do?
In Bangladesh, there is still widespread confusion and lack of understanding about what a midwife actually does. In most cases, they are assumed to be the same as traditional birth attendants such as dais or dhatris – poorly educated women who lack credible information on maternity and whose interventions sometimes even cause birth complications.
A professional midwife however, is an advanced and complex medical role. A midwife does far more than just assist with birth. According to the International Confederation of Midwives, a midwife is:
“… recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the post-partum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
The key here is that the midwife provides her services in the communities, therefore making the care a lot more accessible to pregnant women.
According to experts, the assistance of professionally trained midwives significantly reduces the need for emergency interventions since problems can be detected early and managed or referred before they become life threatening. The use of midwives has been proven to reduce incidence of birth injury, trauma, and caesarean section. Midwives, therefore, not only provide a much easier childbearing experience for women, but also reduce the overall cost of maternal healthcare.
Training professional midwives in Bangladesh
One of the first initiatives to train professional midwives in Bangladesh is being undertaken by the BRAC Institute of Global Health (BIGH) at BRAC University. The three-year-long Diploma in Midwifery Programme (DMP) has been developed to train young women based on global standards of midwifery education.
DMP is a direct entry programme after students complete their higher secondary education. The 36 month long residential programme includes 155 hours of instruction. The theoretical component through classroom teaching makes up 40% of the curriculum, while 60% of the instruction focuses on lab-based and practical work through clinical and community-based learning. Moreover, the students undertake a 1 year supervised internship in selected Comprehensive Emergency and Obstetric Care (EOC) facilities in the third year of the program. Each student has to attend well over 20 deliveries to be accredited.
The DMP curriculum has been developed to provide students comprehensive knowledge and skills on maternal health. In addition to anatomy, physiology, ante and postnatal care, it includes modules on basic sciences, community health, family planning, health communication, midwifery ethics and regulatory law, microbiology and infection prevention, sexual and reproductive health rights, sexually transmitted diseases and HIV/AIDS, and advocacy and human rights in midwifery practice, among others.
The DMP programme is being run in collaboration with six local health NGOs, and all the partner organisations follow a common standard curriculum, faculty, training facilities, and assessment of the students. This ensures that a high level of quality is maintained in the instruction while adopting it to the local context of Bangladesh. Moreover, the strict focus on maintaining global standards also opens the door for students to continue further studies and advance their careers.
The first batch of 180 midwifes are expected to graduate in 2015.
Building better public health leaders at the community level
According to a 2011 Bangladesh Health Watch report, inequity in maternal health care services is particularly acute in rural areas and among the poor. Access and utilisation of professional medical care during pregnancy and birth varies widely among socioeconomic groups in Bangladesh. While most pregnant women in the upper end of the socio economic spectrum utilise professional care, among the poorest in the socioeconomic stratum, the rate of use of professional care can be less than 10%.
To address this problem, the BRAC Institute of Global Health emphasises a community-based approach in all their public health curricula. As Dr Sadia Afroze Chowdhury, the executive director of the institute stressed, to build better public health leaders you cannot just work in Dhaka.
The DMP students are recruited from remote and underserved areas of Bangladesh with high maternal and neonatal health needs. It is expected that upon graduation, the students will return to live and practice in their respective communities and bring competent and compassionate care to women who need it the most.
In order to make the DMP programme accessible, all students accepted into the programme are given a 100% scholarship which covers tuition, accommodations, meals, course materials and supplies and transportation costs for community and clinical visits. They are also given a monthly stipend of Tk500 for all 3 years.
I spoke to some of the students who are currently in the second year of the programme. Niha, a student in the DMP programme in Dinajpur, described helping fellow women and mothers in her community as the most important motivation for her studies. Her opinions were echoed by Zakia who is a DMP student in Khulna. They both displayed a strong grasp of the importance of their work and the difference they can make in their communities.
However, it was clear that attending the DMP programme was also beneficial for the students themselves. Zakia described a huge increase in her confidence since she started school. Her neighbours and relatives already look to her as an expert and approach her for help.
The students seemed proud to attend a programme of international quality, and excited about the opportunities that such a degree can open up for their future careers. Being a product of the Bangla medium schooling system, Zakia and Neha spoke little English when they started the programme a year ago. However, with the help of intensive English courses provided by BRAC University, in merely a year, they are now able to conduct their studies entirely in English.
By bringing high quality education and training to the local level, the DMP programme is truly helping to build a broad base of public health leaders among young women.
Recognition of midwives is crucial not only for better maternal health, but also for development
However, education alone, even through a world-class programme such as DMP, is not enough to ensure that professional midwifery can succeed in Bangladesh. As Dr Chowdhury pointed out, a supportive environment is needed to ensure that midwives are recognised as qualified and critical professionals. This would require official accreditation and licensing of midwives by the government.
A shift in culture within the medical community also needs to take place so that midwives are accepted in the medical community as highly skilled professionals alongside doctors and nurses. Such recognition would also create jobs and career opportunities for midwives, which is essential for this profession to be sustainable.
Development experts say that maternal mortality rates in a country tend to reflect the position of women within their culture. The better women are treated in a society, the less likely they are to die during childbirth.
Bangladesh has made considerable strides in recent years in improving the position of women in our society, which is demonstrated by rising levels of education and employment among women and girls. However, the rate of maternal mortality still remains unacceptably high, and it shows that a lot more work still needs to be done.
The development of a professional cadre of midwives can not only drastically improve the maternal mortality rate, it also allows young women to take a leadership role in solving a critical public health problem.
The BRAC Institute of Global Health has already taken a huge step forward in this regard through their DMP programme. Such an initiative deserves a supportive environment from the government and the public at large so that professional midwifery can thrive in Bangladesh.