Recognise and Acknowledge Us: Views of Traditional Birth Attendants on Collaboration with Midwives for Maternal Health Care Services

Background. Traditional birth attendants have since ancient time provided care to pregnant women. As such, the collaboration between midwives and traditional birth attendant (TBAs) can be an essential effort towards the reduction of the maternal and neonatal mortality and morbidity rate especially in low- and middle-income countries (LMICs). This paper argues that the collaboration between traditional and formal health systems expands the reach and improves outcomes of community health care. The study is aimed at exploring the traditional birth attendant’s views on collaboration with midwives for maternal health care services at selected rural communities in South Africa (SA). Methods. The study was conducted in two rural communities in Tshwane and Johannesburg metropolitan districts from 15 June to 31 October 2021. The study followed the qualitative explorative and descriptive research design. The sampling technique was nonprobability purposive, and snowballing technique was also used to sample the key informants who are the traditional birth attendants also known as traditional healers and who provide maternal health care services in the respective communities. The access to these participants was through the gatekeepers, the Traditional Health Organisation Council (THO) council. Data collection was through semistructured in-depth interviews. Data were analysed thematically through the eight steps of Tesch. Results. Five main themes were identified which included the recognition of traditional birth attendants as enablers of collaboration, the envisaged value of the collaboration, processes required to foster collaboration, repositioning for new roles, and barriers to collaboration. Conclusion. The TBAs are ready to collaborate with the formal health care system, and all they require is for their services to maternal health care to be recognised and acknowledged.

Supporting midwifery is the answer to the wicked problems in maternity care

The film Don’t Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care.
Although life-saving when indicated, medical interventions in childbirth can be harmful when overused.1 A challenge in striking the right balance is that the bar for benefit when it comes to birth outcomes has been set at immediate survival. This approach overlooks clinical complications, such as placenta praevia or accreta associated with caesarean, and fails to value the personal autonomy of women and communities. In global settings, caesarean section rates, which are often used as a proxy to understand the safety of a maternity system, have recently come under scrutiny. Inquiries into adverse outcomes in the Shrewsbury and Telford Hospital National Health Service Trust in the UK has led to sensational media reporting and concerns about the dangers of setting caesarean section targets. This reporting has led to a focus on individual decision makers rather than faulty systems. We know a bad system will beat the best health-care provider every time
The centrality of midwives in supporting the physiological process of giving birth is at the core of this debate. Midwives have been singled out for blame when it comes to poor outcomes, with little consideration given to the fragmented models of care they work in, where they do not always have professional autonomy and respectful collaboration. This attitude creates an environment of professional and philosophical conflict that does not put women’s optimal care and needs at the centre. Relational models of care such as continuity of midwifery care, which are supported by high-level evidence as being cost effective and leading to optimal outcomes,3 are ignored. Such models have the potential to save 4·3 million lives per year, but realising this opportunity requires a deeper understanding of why they are not reaching scale.
The way we treat women during pregnancy, childbirth, and postpartum, and the institutional options of care we provide them within health systems, directly reflect the way we value women in our societies. In too many settings we are ignoring the benefits of midwifery models of care, degrading the status of midwives, and removing financing from midwifery services and education, under the guise of safety that ignores physiology and women’s chances for optimal mental and physical health.
There is a shortage of approximately a third of the midwives we need globally, which is crucial considering that midwives who are educated and regulated to international standards of care can provide 87% of essential maternity care needs and would prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths.4 Midwifery provides a 16 times return on investment.3, 5 Evidence is mounting on how midwives improve maternity care globally; yet, midwives are leaving the profession—burned out, disillusioned, and under valued.6 The latest sensationalised media reporting in the UK has demoralised midwives even more, with global impacts. As a predominantly female profession, midwives continue to be marginalised, overworked, poorly paid, and do not have decision making authority in many countries.
The aim of intervening in the physiological processes of pregnancy and birth is to improve outcomes and safety for women and babies. Commonly used birth interventions such as caesarean sections and induction, which were previously used to treat obvious complications, are used more commonly for women that are unlikely to benefit from them, and can even cause harm to healthy women. These harms contribute to gender, racial, and geographical inequities, and there is growing concern regarding generational inequities. Less concern is afforded to women suffering from birth trauma, which is higher following intervention in birth, especially when women feel poorly informed and coerced into this.10
Although high-income countries (HICs) often drive the dominant discourse when it comes to maternity care, in some low-income and middle-income countries (LMICs) women cannot access a safe caesarean section even when it is needed, demonstrating significant inequalities in maternal care. Caesarean section rates have escalated in LMICs without adequate training or access to additional skills such as anaesthetics, leading to deadly outcomes; and maternal mortality rates are up to 100 times higher in LMICs than HICs. There is increased economic hardship for communities and stretched health systems, and distrust of hospital care and health-care providers.8 Women who become pregnant after caesarean section are at a higher risk of subsequent surgery, with inadequate attention given to additive morbidity over their reproductive life course.
The use of technology and interventions in childbirth scale up quickly and are difficult to de-implement, even when there is evidence of harm. Fiscal accountability and resource-intense care that contributes to the health-care carbon footprint (10% of the US total) should be key considerations.
To meet the 2030 Sustainable Development Goals and prevent an unfolding disaster, we call for urgent action and a united voice on the four main groups of action in the Midwifery 2030 Pathway (panel).

Midwives’ knowledge and practices regarding the screening for and management of chorioamnionitis: A qualitative study

Background: Screening for chorioamnionitis, or the risk thereof, by midwives is largely lacking during antenatal care and no best practice guidelines for chorioamnionitis in South Africa was noted.

Aim: To explore and describe midwives’ knowledge and practices related to the screening and management of women who are at risk of or diagnosed with chorioamnionitis.

Setting: Public healthcare institutions in a health district in the Eastern Cape province of South Africa.

Methods: A qualitative, exploratory, descriptive and contextual research design was used. Ten midwives were purposively included in this study, and semi-structured interviews were conducted with them. The data were analysed using an adapted version of Tesch’s eight steps for data analysis.

Results: The main theme revealed that midwives lack knowledge regarding chorioamnionitis, resulting in incorrect practices including a lack of screening, misdiagnosis and mismanagement of the infectious condition.

Conclusions: Findings of this research showed that midwives lacked knowledge regarding the screening and management of women with chorioamnionitis resulting in incorrect practices in this regard. There is thus a need for midwives to update their knowledge regarding the screening and management of chorioamnionitis and training (e.g. through a short learning programme).

Contribution: Findings of this study could be used by midwives to update their knowledge regarding screening and managing women with chorioamnionitis, which is expected to translate to better practices. Moreover, study findings were synthesised with the results of a literature review study to form the basis for the development of a best practice guideline for screening and managing women with chorioamnionitis

Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study

Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios.

For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world’s maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries.

We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly in the group B countries, which currently account for a large proportion of the world’s population and have high mortality rates compared with group C.

Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions.

New Venture Fund.

Systematic review of barriers to, and facilitators of, the provision of high‐quality midwifery services in India

The Indian government has committed to implementing high‐quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high‐quality midwifery care in India.

We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high‐quality midwifery care in India.

Thirty‐two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands‐on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women’s experiences of maternity care, and improving health system infrastructure.

The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India’s plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.