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Commentary on: The Lancet Series on Midwifery – Midwifery and midwives: Lives saved and better lives built
Midwifery 30 (2014) 1107–1108
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
Commentary on: The Lancet Series on Midwifery – Midwifery and midwives: Lives saved and better lives built C.B.E. Lesley Page, PhD, Hon DSc, MSc, BA, RM, RN, HFRCM (President, Visiting Professor, Adjunct Professor)a,b,c a
Royal College of Midwives, 15 Mansfield St, W1G9NH, London, UK Midwifery King’s College London, UK c University of Technology Sydney, Australia b
Of an estimated 139 million births globally each year, an estimated 289,000 women will die during pregnancy, labour or soon after, 2.6 million will suffer stillbirths and 2.9 million infants will die in the first month of life (Renfrew et al., 2014). Behind these figures lie individual stories of lives lost, bereavement, grief, family and social disruption, economic consequences. For many women and babies, ill health and morbidity will follow birth. Poor quality maternity and new born care is a factor. While many women have no or inadequate access to any care, others are exposed to unnecessary interventions, with underuse and overuse of treatment contributing to acute and chronic clinical and psychological morbidity for an estimated 20 m childbearing women (Renfrew et al., 2014). A significant contribution of the Lancet Series on Midwifery was to highlight the problems of inadequate or lack of care and high mortality and morbidity rates in some parts of the world but also to describe over intervention, to give prominence to a problem that often seems to be in a blind spot. It sets the foundation for a global approach to the provision of high quality care. Midwifery and midwives have the potential to resolve these problems. The Lancet Series on Midwifery offers a comprehensive evidence based framework for quality based on the needs of women and infants, supported by an explicit philosophy and framed by values and consideration of the organisation of care and the characteristics of care providers. This is a framework for quality care that has the potential not only to save lives, but to build better long term health and well-being, stronger family relationships and capability to care for the baby to adulthood. The aim of the Series was to ‘examine, comprehensively and systematically the contribution that midwifery can and does make to the care of women and infants, and the health system and other conditions for it to work effectively’. This examination started with the needs and wishes of women and babies, ‘to be healthy, safe, supported and respected to give birth to a healthy baby that can thrive’ (ten Hoope-Bender et al., 2014). The application of the evidence presented could avert more than 80% of maternal and new born deaths including stillbirths. Midwifery has a pivotal, yet widely neglected part to play in accelerating progress to end preventable mortality of women and children (Horton and Astudillo, 2014). http://dx.doi.org/10.1016/j.midw.2014.09.006 0266-6138/& 2014 Published by Elsevier Ltd.
The definition of midwifery proposed is of a package of care that can be provided by a number of caregivers, with an emphasis on ensuring that women receive the complete package of midwifery. This definition may be contentious, because it is proposed that it is not only midwives who can provide this package of care, however it is a pragmatic approach to ensure effective quality care for women and babies in services which are provided by a number of personnel, and situations in which there are no midwives, or where midwives are unable to implement their full scope of practice. Nevertheless ‘midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed and regulated’ (Renfrew et al., 2014) and integrated into a functioning health system as part of a multidisciplinary team (ten Hoope-Bender et al., 2014). The crucial part that midwives play is very clear. Importantly, this framework takes us beyond ‘a focus on essential and emergency interventions for the minority to skilled care for all’ to emphasising and arguing convincingly of the need for improvement in the quality of care alongside universal coverage. The approach described will provide lifesaving skills more effectively, but also ‘identifies the value of promoting and supporting the normal processes of pregnancy, birth, post partum and the early days of life, and of strengthening women's own capabilities to care for themselves and their families’. It highlights the important balance that midwifery brings to the care of mothers and infants, preventing expensive and potentially harmful interventions (ten Hoope-Bender et al., 2014). There is evidence of the effectiveness of midwifery and midwives, particularly when working in systems of care where there is continuity, where services are integrated across communities and facilities. Much of this evidence is based on high and middle income countries but modelling the scaling up of midwifery, particularly when family planning is included, could avert many maternal and infant deaths. The inclusion of specialist care in the scenarios resulted in a greater number of deaths being prevented (Homer et al., 2014). Where will the Lancet Series on Midwifery take us? How can we use the Series, which offers a quality framework (Renfrew et al., 2014), modelling of the effect of scaling up midwifery
1108
C.B.E. Lesley Page / Midwifery 30 (2014) 1107–1108
(Homer et al., 2014), and analysis of case studies of effective change in some low income countries (Van Lerberghe et al., 2014), as well as specific advice on the improvement of maternal and newborn health through midwifery (ten Hoope-Bender et al., 2014)? The Series signals a change in thinking, and proposes that shifts in the systems of care are required. A further two articles are in progress, one on human rights the other on research priorities. What is apparent from the Series and the commentaries that accompany it is that the challenges ahead are considerable. Resource need will grow exponentially in some parts of the world as populations grow. The challenge of systems shift, and the cultural and values change required, are increased in the context of misunderstanding of midwifery and the role of midwives, profound inequalities, disrespect and abuse of women and midwives, limited capability and capacity, an increase in the effects of commercialisation, and the often low status of women and midwives. There are also the blind spots around human rights and the effects of the overuse of intervention. Each one of these challenges alone can be daunting; in combination effective change to develop quality may seem insuperable. The strength of the Series, the key, lies in the integration of evidence and values, the modelling and analysis that will help resolve problems not in a piecemeal way but through the use of a package. Such fundamental change is likely to be more effective, and will avoid wasted efforts. The Lancet Series in Midwifery is a unique and powerful tool that engenders thinking and debate, that should lead to further research, provides a basis for changing the way we work as individual practitioners, and for the systems change called for. Systems shift is necessary for the package of midwifery to work and for individual midwives to do their best, and to give evidence
based care, expressing in their practice clear values and philosophy. Crucial to this is an understanding of roles, multidisciplinary work and the appropriate organisation of care. Listening to women, public involvement and greater public understanding of science will be essential. Systems shift will lead to better health for populations. The health of populations is made up of the number of one, the one mother, one baby, one family and one community, where death, ill health and disability may be prevented. But the promise of the Series is this; it offers the potential not only to improve short term and long term health but to promote a good start in life, building better lives from the beginning, no matter in which part of the world birth takes place. Twitter: @MidwiferyAction, #LancetMidwifery Website: http://www.Solution98.org References Homer, C.S.E., Friberg, I.K., Dias, M.A.B., et al., 2014. The projected effect of scaling up midwifery. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14) 60790-X. Horton, R., Astudillo, O., 2014. The power of midwifery. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14)60855-2. Renfrew, M.J., McFadden, A., Bastos, M.H., et al., 2014. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14)60789-3. ten Hoope-Bender, P., de Bernis, L., Campbell, J., et al., 2014. Improvement of maternal and newborn health through midwifery. Lancet , http://dx.doi.org/ 10.1016/S0140-6736(14)60930-2. Van Lerberghe, W., Matthews, Z., Achadi, E., et al., 2014. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet , http://dx.doi.org/10.1016/S0140-6736(14) 60919-3.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
Commentary on: The Lancet Series on Midwifery – Midwifery and midwives: Lives saved and better lives built C.B.E. Lesley Page, PhD, Hon DSc, MSc, BA, RM, RN, HFRCM (President, Visiting Professor, Adjunct Professor)a,b,c a
Royal College of Midwives, 15 Mansfield St, W1G9NH, London, UK Midwifery King’s College London, UK c University of Technology Sydney, Australia b
Of an estimated 139 million births globally each year, an estimated 289,000 women will die during pregnancy, labour or soon after, 2.6 million will suffer stillbirths and 2.9 million infants will die in the first month of life (Renfrew et al., 2014). Behind these figures lie individual stories of lives lost, bereavement, grief, family and social disruption, economic consequences. For many women and babies, ill health and morbidity will follow birth. Poor quality maternity and new born care is a factor. While many women have no or inadequate access to any care, others are exposed to unnecessary interventions, with underuse and overuse of treatment contributing to acute and chronic clinical and psychological morbidity for an estimated 20 m childbearing women (Renfrew et al., 2014). A significant contribution of the Lancet Series on Midwifery was to highlight the problems of inadequate or lack of care and high mortality and morbidity rates in some parts of the world but also to describe over intervention, to give prominence to a problem that often seems to be in a blind spot. It sets the foundation for a global approach to the provision of high quality care. Midwifery and midwives have the potential to resolve these problems. The Lancet Series on Midwifery offers a comprehensive evidence based framework for quality based on the needs of women and infants, supported by an explicit philosophy and framed by values and consideration of the organisation of care and the characteristics of care providers. This is a framework for quality care that has the potential not only to save lives, but to build better long term health and well-being, stronger family relationships and capability to care for the baby to adulthood. The aim of the Series was to ‘examine, comprehensively and systematically the contribution that midwifery can and does make to the care of women and infants, and the health system and other conditions for it to work effectively’. This examination started with the needs and wishes of women and babies, ‘to be healthy, safe, supported and respected to give birth to a healthy baby that can thrive’ (ten Hoope-Bender et al., 2014). The application of the evidence presented could avert more than 80% of maternal and new born deaths including stillbirths. Midwifery has a pivotal, yet widely neglected part to play in accelerating progress to end preventable mortality of women and children (Horton and Astudillo, 2014). http://dx.doi.org/10.1016/j.midw.2014.09.006 0266-6138/& 2014 Published by Elsevier Ltd.
The definition of midwifery proposed is of a package of care that can be provided by a number of caregivers, with an emphasis on ensuring that women receive the complete package of midwifery. This definition may be contentious, because it is proposed that it is not only midwives who can provide this package of care, however it is a pragmatic approach to ensure effective quality care for women and babies in services which are provided by a number of personnel, and situations in which there are no midwives, or where midwives are unable to implement their full scope of practice. Nevertheless ‘midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed and regulated’ (Renfrew et al., 2014) and integrated into a functioning health system as part of a multidisciplinary team (ten Hoope-Bender et al., 2014). The crucial part that midwives play is very clear. Importantly, this framework takes us beyond ‘a focus on essential and emergency interventions for the minority to skilled care for all’ to emphasising and arguing convincingly of the need for improvement in the quality of care alongside universal coverage. The approach described will provide lifesaving skills more effectively, but also ‘identifies the value of promoting and supporting the normal processes of pregnancy, birth, post partum and the early days of life, and of strengthening women's own capabilities to care for themselves and their families’. It highlights the important balance that midwifery brings to the care of mothers and infants, preventing expensive and potentially harmful interventions (ten Hoope-Bender et al., 2014). There is evidence of the effectiveness of midwifery and midwives, particularly when working in systems of care where there is continuity, where services are integrated across communities and facilities. Much of this evidence is based on high and middle income countries but modelling the scaling up of midwifery, particularly when family planning is included, could avert many maternal and infant deaths. The inclusion of specialist care in the scenarios resulted in a greater number of deaths being prevented (Homer et al., 2014). Where will the Lancet Series on Midwifery take us? How can we use the Series, which offers a quality framework (Renfrew et al., 2014), modelling of the effect of scaling up midwifery
1108
C.B.E. Lesley Page / Midwifery 30 (2014) 1107–1108
(Homer et al., 2014), and analysis of case studies of effective change in some low income countries (Van Lerberghe et al., 2014), as well as specific advice on the improvement of maternal and newborn health through midwifery (ten Hoope-Bender et al., 2014)? The Series signals a change in thinking, and proposes that shifts in the systems of care are required. A further two articles are in progress, one on human rights the other on research priorities. What is apparent from the Series and the commentaries that accompany it is that the challenges ahead are considerable. Resource need will grow exponentially in some parts of the world as populations grow. The challenge of systems shift, and the cultural and values change required, are increased in the context of misunderstanding of midwifery and the role of midwives, profound inequalities, disrespect and abuse of women and midwives, limited capability and capacity, an increase in the effects of commercialisation, and the often low status of women and midwives. There are also the blind spots around human rights and the effects of the overuse of intervention. Each one of these challenges alone can be daunting; in combination effective change to develop quality may seem insuperable. The strength of the Series, the key, lies in the integration of evidence and values, the modelling and analysis that will help resolve problems not in a piecemeal way but through the use of a package. Such fundamental change is likely to be more effective, and will avoid wasted efforts. The Lancet Series in Midwifery is a unique and powerful tool that engenders thinking and debate, that should lead to further research, provides a basis for changing the way we work as individual practitioners, and for the systems change called for. Systems shift is necessary for the package of midwifery to work and for individual midwives to do their best, and to give evidence
based care, expressing in their practice clear values and philosophy. Crucial to this is an understanding of roles, multidisciplinary work and the appropriate organisation of care. Listening to women, public involvement and greater public understanding of science will be essential. Systems shift will lead to better health for populations. The health of populations is made up of the number of one, the one mother, one baby, one family and one community, where death, ill health and disability may be prevented. But the promise of the Series is this; it offers the potential not only to improve short term and long term health but to promote a good start in life, building better lives from the beginning, no matter in which part of the world birth takes place. Twitter: @MidwiferyAction, #LancetMidwifery Website: http://www.Solution98.org References Homer, C.S.E., Friberg, I.K., Dias, M.A.B., et al., 2014. The projected effect of scaling up midwifery. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14) 60790-X. Horton, R., Astudillo, O., 2014. The power of midwifery. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14)60855-2. Renfrew, M.J., McFadden, A., Bastos, M.H., et al., 2014. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet, 23 june 2014. http://dx.doi.org/10.1016/S0140-6736(14)60789-3. ten Hoope-Bender, P., de Bernis, L., Campbell, J., et al., 2014. Improvement of maternal and newborn health through midwifery. Lancet , http://dx.doi.org/ 10.1016/S0140-6736(14)60930-2. Van Lerberghe, W., Matthews, Z., Achadi, E., et al., 2014. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet , http://dx.doi.org/10.1016/S0140-6736(14) 60919-3.