A few years ago, I met Wang Linyun, a nurse/midwife from Taiyuan Maternity Hospital in Shanxi, China. The photo below is a screenshot from an interview—she is expressing the utter desperation and helplessness she felt when she did not know how to help a baby experiencing childbirth complications. If a baby died or suffered a long-term disability, she blamed herself!
But one may ask, how could a nurse/midwife in a maternity ward not know what to do? To answer that, let’s look at Wang Linyun’s pathway to becoming a midwife. Like many nurses/midwives in China and elsewhere, Wang completed her 3-year general nursing education, which included few midwifery specific courses. After attending 20 supervised births at a local hospital where she was expected to “learn on the job,” she was licensed to work as an obstetric nurse (Chinese title for midwife). In short, Wang became a midwife with little midwifery education or training.
The International Confederation of Midwives (ICM) defines a midwife as someone who has successfully completed a midwifery education program, is legally licensed and has demonstrated competency in the practice of midwifery. In reality, according to the State of the World’s Midwifery 2014 report, most of the midwifery workforce globally are generalist nurses like Wang Linyun.
Currently, the maternal, newborn, child health (MNCH) workforce can include any health worker—auxiliary midwives, certified midwives, nurses, physicians. It’s a full-time practice for some, and for others MNCH may only make up 20% of their clinical practice. Some have completed general nursing with very little midwifery topics covered; others may have completed a short-term midwifery course or a 3-year midwifery program. Practice requirements similarly vary across settings. Some countries require midwifery students to attend at least 50 supervised births. In other countries, a midwife entering the workforce may have attended 30 supervised births or less and may never have encountered a complicated delivery.
As you can see, urgent improvements are needed in how midwives are educated and trained today. The stakes are too high if we don't address them. The Lancet Series on Midwifery concluded that midwives educated to international standards, who are licensed, regulated, fully integrated into health systems and working in interprofessional teams could avert over 80% of all maternal deaths, stillbirths and neonatal deaths. Additionally, good quality midwifery care improves over 50 other health outcomes.
Addressing a specific issue vs. empowering an entire cadre
With MNCH programming, we ask what the pressing challenges in maternal and child health are. The answer would likely be a condition that is the leading cause of maternal newborn death or disability, such as birth asphyxia or obstetric fistula, and we identify evidence-based solutions to address that issue. A great example is our China NRP program, that trained more than 250,000 health workers—midwives, nurses and doctors included—on how to resuscitate babies unable to breathe on their own at birth. The program reduced newborn mortality caused by birth asphyxia by over 70% in 10 years.
Such targeted initiatives have had great success in past decades. We have seen similar successes in other areas including HIV/AIDs and reducing child mortality through vaccines. However, to achieve good health for all and sustain the achievement made in areas such as reducing child mortality, we must also invest in the health workforce—the foundation of health systems.
Last year, in response to the 18 million shortage of health workers projected by the WHO, Johnson & Johnson launched the Center for Health Worker Innovation to help build a thriving frontline health workforce. As the bridge between communities and health systems, frontline health workers—especially nurses, midwives and community health workers—will be key to achieving global health goals including universal health coverage by 2030.
With that new vision, we asked the question differently, centering it around the pressing challenges experienced by the people doing midwifery work. Now, we are confronted with systemic issues such as quality of preservice education and licensing and training of staff that point to foundational improvements needed to strengthen the practice of midwifery as a whole.
Intervention opportunities along the midwifery pathway
Current gaps in midwifery education and training include:
- Curricula that is not up to global standards in breadth and depth of topics, time allocated between theoretical study and hands-on practice, and not up-to-date with current recommendations and guidelines
- Short-term, in-service trainings that focus on one specific set of clinical skills, not the full spectrum of competencies
- Evidence-based simulation training methodology is not widely adopted
- Weak licensure and re-licensure processes
The Center aims to raise the bar for midwifery education and ensure that every midwife is trained to the global standard, licensed, competent to perform her/his job, and integrated into interprofessional teams.
To that end, we are working with partners such as UNFPA, ICM, and national governments and institutions to develop tools and knowledge products, carry out cross-country research, and facilitate learning along three points in the midwifery education pathway:
- Preservice education for midwives, auxiliary midwives and nurses – to strengthen the quality of midwifery pre-service education through standardized competency-based curriculum and training of midwifery educators
- Preceptorships – to support newly qualified midwives in their transition to the workforce that include comprehensive training for preceptors and rotations for new midwives through all midwifery areas
- Licensing and Relicensing – to improve policies and regulations for accreditation and licensing and provide opportunities for continuing professional development and skills expansion
Midwifery is much more than assistance at the moment of birth. It encompasses everything from preconception consultations, labor and delivery, and post-natal care to child and adolescent health and development. While much progress has been made in addressing various gaps in MNCH care, the Center is making the case that investing in strengthening the midwifery cadre is needed for long-term sustainable impact and improved women’s and children’s health outcomes.
In doing so, we hope a nurse like Wang Linyun will never again find herself in the situation where she has all the heart to save lives but not the skills to do so, and every midwife is empowered to perform to the best of their ability.