The state of midwifery in small island Pacific nations

Midwifery education in Pacific Island countries: A discussion paper

BACKGROUND

The aim for 95% maternal health care coverage and zero-unmet need for family planning in Pacific Island countries by 2030 could be achieved by strengthening the midwifery workforce. To enable health services to provide accessible, locally acceptable, and high-quality care, the midwifery workforce must be regulated and educated to global standards and supported to practice in enabling environments. In 2019, around 64,000 live births occurred in Pacific Island countries, yet information regarding the state the midwifery workforce and midwifery education is limited.

AIM

Using data from recent reports and country case studies, this paper provides an overview of the current midwifery education situation in Pacific Island countries and discusses strategic directions for strengthening quality midwifery education and therefore quality midwifery care provision in Pacific Island countries.

DISCUSSION

Six Pacific Island countries have midwifery curricula, all post-nursing programs, although few offer midwifery education programs on a regular annual basis. Current programs do not meet ICM Global Standards for Midwifery Education. Critical areas for strengthening include making underpinning philosophical frameworks, the vision for midwifery education, and program intended learning outcomes explicit in curricula documents and ensuring integration of these in program implementation. Fortunately, five of six midwifery education programs are under processes of renewal and strengthening against global, regional, and national standards.

CONCLUSION

Strengthening the midwifery workforce in the Pacific to meet maternal and newborn health targets can be achieved through supporting the existing midwifery education programs to meet global standards. Strengthened midwifery education programs in Pacific Island countries offer an opportunity to meet each country's maternal and newborn health targets.

Quality newborn care in East New Britain, Papua New Guinea: measuring early newborn care practices and identifying opportunities for improvement

BACKGROUND

Renewed attention and investment is needed to improve the quality of care during the early newborn period to address preventable newborn deaths and stillbirths in Papua New Guinea (PNG). We aimed to assess early newborn care practices and identify opportunities for improvement in one province (East New Britain) in PNG.

METHODS

A mixed-methods study was undertaken in five rural health facilities in the province using a combination of facility audits, labour observations and qualitative interviews with women and maternity providers. Data collection took place between September 2019 and February 2020. Quantitative data were analysed descriptively, whilst qualitative data were analysed using content analysis. Data were triangulated by data source.

RESULTS

Five facility audits, 30 labour observations (in four of the facilities), and interviews with 13 women and eight health providers were conducted to examine early newborn care practices. We found a perinatal mortality rate of 32.2 perinatal deaths per 1000 total births and several barriers to quality newborn care, including an insufficient workforce, critical infrastructure and utility constraints, and limited availability of essential newborn medicines and equipment. Most newborns received at least one essential newborn care practice in the first hour of life, such as immediate and thorough drying (97%).

CONCLUSIONS

We observed high rates of essential newborn care practices including immediate skin-to-skin and delayed cord clamping. We also identified multiple barriers to improving the quality of newborn care in East New Britain, PNG. These findings can inform the development of effective interventions to improve the quality of newborn care. Further, this study demonstrates that multi-faceted programs that include increased investment in the health workforce, education and training, and availability of essential equipment, medicines, and supplies are required to improve newborn outcomes.

The interplay of structural and external factors for strengthening midwifery education in Indonesia

OBJECTIVES

This study aimed to identify the barriers to and enablers of the strengthening of midwifery education in Indonesia. Indonesia has a long history of midwifery education. In 1996, midwifery education in Indonesia had a three-year direct-entry pathway leading to a higher education level to meet international standards. The quality of midwifery education is deemed essential for preparing competent midwives.

METHODS

A qualitative design was undertaken in 12 midwifery schools in eight cities in six provinces involving 37 participants. Data were gathered using in-depth interviews. Data were analysed using thematic analysis.

RESULTS

Several intertwined factors were found to play a vital role in midwifery education. This article focuses on results on "structural and external factors", a theme which contained three sub-themes: "the structures of midwifery programmes", "midwifery accreditation impacts on midwifery education", and "the Midwifery Act".

CONCLUSION

The structure of midwifery programmes, the accreditation of midwifery programmes, and establishment of the Midwifery Act contribute to the strengthening of midwifery education in Indonesia. This study highlights the challenges faced and the scheme required to strengthen midwifery education in producing competent newly graduated midwives who improve the midwifery workforce in Indonesia.

Achieving Universal Health Care in the Pacific: The need for nursing and midwifery leadership. Review Paper

The quality of healthcare services and outcomes in the Pacific vary widely, with some countries enjoying some of the world's longest life expectancies, others have high rates of maternal and child mortality and relatively low life expectancy. Nurses and midwives make up more than two thirds of the regional regulated healthcare workforce. This paper argues that if countries are to meet Universal Health Coverage  nursing and midwifery leaders need to be explicitly involved in shaping policy  at the highest levels of government to optimise individual and community health both now and in the future. Using United Nations 2019  declaration towards building a healthier world, this paper provides a rationale for inclusion of these leaders  into national and regional decisionmaking forums related to health policy to provide an informed voice in ministerial deliberations on health policy. We suggest that following several comprehensive regional and global studies, South Pacific Chief Nursing and Midwifery Officer Alliance  and the newly developed Pacific Heads of Nurses and Midwifery provide a vehicle for this to occur. As outlined in the WHO Strategic Directions, it is now time to embed Chief Nurses in national and regional health policy development.

Midwifery in Middle Eastern and North African countries: A scoping review

BACKGROUND

While midwives are positioned as critical providers for improving sexual, reproductive, maternal and newborn health outcomes in the Middle East and North African (MENA) countries, the standards of midwifery have not been explored systematically in this region.

AIM

The purpose of this scoping review was to provide an overview of existing literature on midwifery practice, education, and regulation in MENA countries in the context of ICM standards.

METHODS

A search was conducted inclusive of English and Persian written studies published between 2000 and 2019 in CINAHL plus; Ovid MEDLINE; PubMed; Scopus; and grey literature. Title and abstract and full-text review were performed in Covidence, and data extraction and synthesis performed using NVivo 12.

RESULTS

The initial search identified 7,994 articles. Overall, 139 studies were included in the review. Although, the primary concept of most included studies was "midwifery practice", "midwifery regulation" was addressed in limited way. Approximately 90% were from Middle Eastern countries. Forty-two per cent of studies used cross-sectional designs, and most originated from Iran, Jordan, and Palestine. Diversity was found in midwifery education, practice and regulation across the MENA countries. Midwives from different nations had uneven levels of proficiency, scope of practice, and education. Midwifery curricula were aligned with ICM competencies in some countries. Most countries had midwifery associations and were members of ICM. Some countries had regulations recognising midwifery as an autonomous profession.

CONCLUSION

Midwifery practice, education and regulation in MENA countries were not always comparable with ICM standards, although some progress was evident.

Early neonatal death review from two provinces in Papua New Guinea: A retrospective analysis

AIM

To determine the causes of early neonatal death and the avoidable factors associated with these deaths among women participating in a cluster-randomised crossover trial in Papua New Guinea.

METHODS

Early neonatal deaths were identified by retrospective chart review of the Women and Newborn Trial of Antenatal Interventions and Management study participants between July 2017 and January 2020. Causes of death and avoidable factors were identified using the Perinatal Problem Identification Program system.

RESULTS

There were 35 early neonatal deaths among 2499 livebirths (14 per 1000 births). Fifty-seven percent (20/35) of deaths occurred on the first day of life. Idiopathic preterm birth was the leading obstetric cause of perinatal death (29%; 10/35). Extreme multi-organ immaturity (23%; 8/35) and hypoxic ischaemic encephalopathy (17%; 6/35) were the most common final causes of neonatal death. Forty-six avoidable factors were identified among 26 deaths, including delays in care-seeking, insufficient resources at health facilities, poor intrapartum care and immediate care of the newborn, including neonatal resuscitation.

CONCLUSION

In this study, potentially preventable causes and avoidable factors were identified in the majority of early neonatal deaths. Addressing these factors will require health system strengthening, particularly the upskilling of primary level health staff, as well as targeted health education of women and the community.

Midwifery education, regulation and association in the Democratic Republic of Congo (DRC) - current state and challenges

Background: In the Democratic Republic of Congo (DRC), maternal and neonatal health outcomes are poor and delivering healthcare services of sufficient quality is a challenge as there are only 0.6 midwives, physicians, or nurses for every 1,000 inhabitants.

Objective: To explore the current state of the midwifery profession in the DRC and to suggest suitable strategies for increasing the quality and quantity of a highly competent midwifery health workforce in the DRC.

Methods: Data were collected at a workshop with 17 key persons using three questionnaires developed by the International Confederation of Midwives, and three focus group discussions. The analysis was focusing on quantitative and qualitative content.

Results: In DRC the midwife profession is not legislated. A midwifery association is well established, but due to a lack of resources does not function optimally. Two midwifery education programmes exist: a three-year direct-entry programme resulting in a diploma in midwifery, and a 12-month postgraduate programme for nurses resulting in a certificate in midwifery. Neither of the programmes leads to a bachelor’s or master’s degree. At the institutions offering the midwifery programmes (n = 16), the educators’ academic qualifications are lower than required and there is a lack of teaching and training equipment for meeting the education needs.

Conclusions: The Sustainable Development Goal on health, and specifically the health of mother and newborn, will be difficult to meet in the DRC. We therefore suggest that (i) the midwifery education programmes be improved to meet international standards; (ii) these programmes be designed in a way that allows for an academic degree at either the bachelor’s or master’s level; (iii) the competence level of the midwifery educators be increased; and, most crucially, (iv) a regulatory structure be formed that legislates and regulates the midwifery profession and its autonomous practice.

Perinatal death audit and classification of stillbirths in two provinces in Papua New Guinea: A retrospective analysis

OBJECTIVE

To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea.

METHODS

We used data from an ongoing cluster-randomized crossover trial in 10 sites among 4600 women in Papua New Guinea (from 2017 to date). The overarching aim is to improve birth outcomes. All stillbirths from July 2017 to January 2020 were identified. The Perinatal Problem Identification Program was used to analyze each stillbirth and review associated avoidable factors.

RESULTS

There were 59 stillbirths among 2558 births (23 per 1000 births); 68% (40/59) were classified "fresh" and 32% as "macerated". Perinatal cause of death was identified for 63% (37/59): 30% (11/37) were due to intrapartum asphyxia and traumatic breech birth and 19% (7/37) were the result of pre-eclampsia. At least one avoidable factor was identified for 95% (56/59) of stillbirths. Patient-associated factors included lack of response to reduced fetal movements and delay in seeking care during labor. Health personnel-associated factors included poor intrapartum care, late diagnosis of breech presentation, and prolonged second stage with no intervention.

CONCLUSION

Factors associated with stillbirths in this setting could be avoided through a package of interventions at both the community and health-facility levels.