- Email: [email protected]
Midwifery – A vital path to quality maternal and newborn care: The story of the Lancet Series on Midwifery
Midwifery 30 (2014) 1105–1106
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Editorial
Midwifery – A vital path to quality maternal and newborn care: The story of the Lancet Series on Midwifery
June 2014 saw the publication of the first ever Lancet Series on Midwifery. Its aim 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 needed for it to work effectively. The series sought to reach decision-makers in health and finance, as well as practitioners, advocacy groups, and women, families and communities themselves. As authors, we wanted to identify evidence-based solutions to a range of challenges in the field of maternal and newborn health and care, in low-, middle- and high-income countries. In addition to the unacceptable rates of maternal and neonatal mortality, stillbirth, and serious morbidity, these challenges include the neglect of longer-term health and well-being outcomes for women and children, rising levels of unnecessary interventions in pregnancy and childbirth, increasing inequalities, and disrespect and abuse of childbearing women and children within the health services. Most importantly, the series sought to identify the core elements of midwifery care needed by all childbearing women, and all newborn infants, in all countries. The need for this work became apparent during the writing of ‘State of the World's Midwifery (2011)’, which exposed the limitations of existing evidence, the lack of key data, and the diverse ways in which midwifery is implemented across the world. In some countries there are no midwives at all. Instead, components of midwifery care are provided by community health workers, traditional birth attendants, doctors, nurses and others – or in fact, simply by nobody. In some countries where there are midwives, they are unable to implement the full scope of practice because of inconsistent standards of education and professional regulation, inter-professional rivalries, a lack of integration into health systems, or over-medicalised approaches. This diversity has contributed to a widespread misunderstanding of midwifery (Horton and Astudillo, 2014), and means that decision-makers are faced with conflicting information about the contribution of midwifery, and specifically of midwives. Despite the blossoming of high quality research by midwives and other colleagues in some countries in the past 25 years, there has also been significant under-investment in research in the field. To increase the quantity and quality of appropriate evidence, The Lancet provided the opportunity to prepare and publish a series of expert papers on midwifery. The Bill & Melinda Gates Foundation provided the essential funding. Identifying the right team to do the work was a first important step. As well as clinical and academic midwifery, and consumer advocacy to bring the perspectives of women, we needed the breadth http://dx.doi.org/10.1016/j.midw.2014.08.010 0266-6138/& 2014 Published by Elsevier Ltd.
and depth of knowledge from epidemiology, statistics, psychology, sociology, health policy, public health, health system development, and health economics, and the clinical disciplines of obstetrics and paediatrics. We gathered authors with these backgrounds from around 20 countries in five continents who between them had worked in scores of countries at all levels of development. Over the three years in which the series was developed, the authors met only once as a full team, conducting the rest of the work virtually. We built a shared understanding through extensive discussions on how to reconceptualise quality maternal and newborn care, and how to use the existing evidence differently. We had to find ways of conducting collective, intensive, technical work, and to manage challenges, disagreements, and several re-writes and fresh starts. We benefited from the generous input of international colleagues. Inconsistent implementation rendered midwifery impossible to evaluate only from the perspective of the work of midwives. We therefore started, as midwives do, from the needs of women and infants. We used a set of shared values to guide our decisions – a rights-based approach, inter-professional working, and the importance of positively improving health and well-being as well as reducing mortality. We were conscious of the need for rigour and quality, and for a global lens. We also knew that, for the series to make a difference, we must discuss and build consensus with external partners. Through a step-by-step and multimethod, iterative process, we analysed not only what is needed for women and newborn infants, but also how care is provided, and who should provide it. We developed theory and conceptual understanding to build a shared foundation, used statistical modelling to examine the potential impact on outcomes, and drew on practical experience from different health systems. Using this range of evidence, the four papers showed the breadth and scale of the impact that midwifery can have, and the conditions needed for midwifery to flourish and to be effective (Homer et al., 2014; Renfrew et al., 2014; ten HoopeBender et al., 2014; Van Lerberghe et al., 2014). What does the Series do? Most fundamentally, this series puts women and infants at the heart of maternal and newborn care. The quality framework that emerged from our analyses focusses unapologetically on their needs. Far from being a ‘one size fits all’ solution, the framework can be used by communities, advocacy groups, midwives and other health professionals as well as decision-makers to ensure that services meet the needs of local women, families and communities. The series provides evidence to support a system-level shift from care focussed on essential and emergency interventions for the minority to skilled care for all. It demonstrates that midwifery
1106
Editorial / Midwifery 30 (2014) 1105–1106
is a vital part of providing high quality maternal and newborn care for all women and all newborn infants. It 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 unnecessary interventions. It shows that midwifery has important contributions to make to reducing maternal and newborn mortality and morbidity, to emergency obstetric and newborn care, to sexual and reproductive health, to reducing the impact of social inequalities, and to strengthening sustainable health systems in low-, middle-, and high-income countries, thereby placing it at the heart of the post2015 development agenda. It demonstrates that the impact of midwifery reaches beyond short-term clinical outcomes, to attachment, relationships, longer-term well-being, and the economic prosperity of communities. One message from this series is that all practitioners who provide components of midwifery care, whether midwives or others, need to provide high quality, respectful care that focuses on the needs of women and newborns. To make the biggest difference, we need to invest in midwives. Importantly, these should be midwives who are educated to international standards and supported by effective regulation, and who are integrated into a functioning health system as part of multidisciplinary teams. The series opens doors to new opportunities for health system design, for monitoring, for designing education curricula, and for identifying research priorities, informing new ways of seeing quality care, and enabling conversations that focus on more than the technical practices and interventions that women and newborns need. The work of the series' authors is not complete. Two papers – one on midwifery and human rights, one on research priorities – are in progress. A communications strategy is being developed to support widespread engagement of professional groups, advocacy groups and the wider public. A set of resources including films, webinars, photographs and a website, are available to support dissemination, policy development, education and implementation. The series has been strongly endorsed by many global agencies since its publication. The true value of this series will only emerge over time, however, as its findings are used and tested by the
international community of health professionals and researchers, policy makers and implementers, funders and advocates, working hand in hand with women, families and communities. We look forward to the dialogue, the sharing of ideas, and the new knowledge that will emerge. Twitter: @MidwiferyAction, #LancetMidwifery Website: http://midwiferyaction.org Films of the series: https://www.youtube.com/user/midwiferyaction References Homer, C.S.E., Friberg, I.K., Dias, M.A.B., et al., 2014. The projected effect of scaling up midwifery. Lancet, http://dx.doi.org/10.1016/S0140-6736(14)60790X, in press. Horton, R., Astudillo, O., 2014. The power of midwifery. Lancet, 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, http://dx.doi.org/10.1016/S0140-6736(14)60789-3, in press. State of the World's Midwifery, 2011. Delivering Health, Saving Lives. UNFPA 2011. 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, in press. 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, in press.
Co-ordinator, Lancet Series on Midwifery Petra ten Hoope-Bender MBAn Director, ICS Integrare, Balmes 30, 3-1, 08007 Barcelona, Spain E-mail address: [email protected] Principal Investigator, Lancet Series on Midwifery Mary J. Renfrew RM, PhD, FRSEn Professor of Mother and Infant Health, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, Scotland, UK E-mail address: [email protected]
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Editorial
Midwifery – A vital path to quality maternal and newborn care: The story of the Lancet Series on Midwifery
June 2014 saw the publication of the first ever Lancet Series on Midwifery. Its aim 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 needed for it to work effectively. The series sought to reach decision-makers in health and finance, as well as practitioners, advocacy groups, and women, families and communities themselves. As authors, we wanted to identify evidence-based solutions to a range of challenges in the field of maternal and newborn health and care, in low-, middle- and high-income countries. In addition to the unacceptable rates of maternal and neonatal mortality, stillbirth, and serious morbidity, these challenges include the neglect of longer-term health and well-being outcomes for women and children, rising levels of unnecessary interventions in pregnancy and childbirth, increasing inequalities, and disrespect and abuse of childbearing women and children within the health services. Most importantly, the series sought to identify the core elements of midwifery care needed by all childbearing women, and all newborn infants, in all countries. The need for this work became apparent during the writing of ‘State of the World's Midwifery (2011)’, which exposed the limitations of existing evidence, the lack of key data, and the diverse ways in which midwifery is implemented across the world. In some countries there are no midwives at all. Instead, components of midwifery care are provided by community health workers, traditional birth attendants, doctors, nurses and others – or in fact, simply by nobody. In some countries where there are midwives, they are unable to implement the full scope of practice because of inconsistent standards of education and professional regulation, inter-professional rivalries, a lack of integration into health systems, or over-medicalised approaches. This diversity has contributed to a widespread misunderstanding of midwifery (Horton and Astudillo, 2014), and means that decision-makers are faced with conflicting information about the contribution of midwifery, and specifically of midwives. Despite the blossoming of high quality research by midwives and other colleagues in some countries in the past 25 years, there has also been significant under-investment in research in the field. To increase the quantity and quality of appropriate evidence, The Lancet provided the opportunity to prepare and publish a series of expert papers on midwifery. The Bill & Melinda Gates Foundation provided the essential funding. Identifying the right team to do the work was a first important step. As well as clinical and academic midwifery, and consumer advocacy to bring the perspectives of women, we needed the breadth http://dx.doi.org/10.1016/j.midw.2014.08.010 0266-6138/& 2014 Published by Elsevier Ltd.
and depth of knowledge from epidemiology, statistics, psychology, sociology, health policy, public health, health system development, and health economics, and the clinical disciplines of obstetrics and paediatrics. We gathered authors with these backgrounds from around 20 countries in five continents who between them had worked in scores of countries at all levels of development. Over the three years in which the series was developed, the authors met only once as a full team, conducting the rest of the work virtually. We built a shared understanding through extensive discussions on how to reconceptualise quality maternal and newborn care, and how to use the existing evidence differently. We had to find ways of conducting collective, intensive, technical work, and to manage challenges, disagreements, and several re-writes and fresh starts. We benefited from the generous input of international colleagues. Inconsistent implementation rendered midwifery impossible to evaluate only from the perspective of the work of midwives. We therefore started, as midwives do, from the needs of women and infants. We used a set of shared values to guide our decisions – a rights-based approach, inter-professional working, and the importance of positively improving health and well-being as well as reducing mortality. We were conscious of the need for rigour and quality, and for a global lens. We also knew that, for the series to make a difference, we must discuss and build consensus with external partners. Through a step-by-step and multimethod, iterative process, we analysed not only what is needed for women and newborn infants, but also how care is provided, and who should provide it. We developed theory and conceptual understanding to build a shared foundation, used statistical modelling to examine the potential impact on outcomes, and drew on practical experience from different health systems. Using this range of evidence, the four papers showed the breadth and scale of the impact that midwifery can have, and the conditions needed for midwifery to flourish and to be effective (Homer et al., 2014; Renfrew et al., 2014; ten HoopeBender et al., 2014; Van Lerberghe et al., 2014). What does the Series do? Most fundamentally, this series puts women and infants at the heart of maternal and newborn care. The quality framework that emerged from our analyses focusses unapologetically on their needs. Far from being a ‘one size fits all’ solution, the framework can be used by communities, advocacy groups, midwives and other health professionals as well as decision-makers to ensure that services meet the needs of local women, families and communities. The series provides evidence to support a system-level shift from care focussed on essential and emergency interventions for the minority to skilled care for all. It demonstrates that midwifery
1106
Editorial / Midwifery 30 (2014) 1105–1106
is a vital part of providing high quality maternal and newborn care for all women and all newborn infants. It 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 unnecessary interventions. It shows that midwifery has important contributions to make to reducing maternal and newborn mortality and morbidity, to emergency obstetric and newborn care, to sexual and reproductive health, to reducing the impact of social inequalities, and to strengthening sustainable health systems in low-, middle-, and high-income countries, thereby placing it at the heart of the post2015 development agenda. It demonstrates that the impact of midwifery reaches beyond short-term clinical outcomes, to attachment, relationships, longer-term well-being, and the economic prosperity of communities. One message from this series is that all practitioners who provide components of midwifery care, whether midwives or others, need to provide high quality, respectful care that focuses on the needs of women and newborns. To make the biggest difference, we need to invest in midwives. Importantly, these should be midwives who are educated to international standards and supported by effective regulation, and who are integrated into a functioning health system as part of multidisciplinary teams. The series opens doors to new opportunities for health system design, for monitoring, for designing education curricula, and for identifying research priorities, informing new ways of seeing quality care, and enabling conversations that focus on more than the technical practices and interventions that women and newborns need. The work of the series' authors is not complete. Two papers – one on midwifery and human rights, one on research priorities – are in progress. A communications strategy is being developed to support widespread engagement of professional groups, advocacy groups and the wider public. A set of resources including films, webinars, photographs and a website, are available to support dissemination, policy development, education and implementation. The series has been strongly endorsed by many global agencies since its publication. The true value of this series will only emerge over time, however, as its findings are used and tested by the
international community of health professionals and researchers, policy makers and implementers, funders and advocates, working hand in hand with women, families and communities. We look forward to the dialogue, the sharing of ideas, and the new knowledge that will emerge. Twitter: @MidwiferyAction, #LancetMidwifery Website: http://midwiferyaction.org Films of the series: https://www.youtube.com/user/midwiferyaction References Homer, C.S.E., Friberg, I.K., Dias, M.A.B., et al., 2014. The projected effect of scaling up midwifery. Lancet, http://dx.doi.org/10.1016/S0140-6736(14)60790X, in press. Horton, R., Astudillo, O., 2014. The power of midwifery. Lancet, 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, http://dx.doi.org/10.1016/S0140-6736(14)60789-3, in press. State of the World's Midwifery, 2011. Delivering Health, Saving Lives. UNFPA 2011. 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, in press. 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, in press.
Co-ordinator, Lancet Series on Midwifery Petra ten Hoope-Bender MBAn Director, ICS Integrare, Balmes 30, 3-1, 08007 Barcelona, Spain E-mail address: [email protected] Principal Investigator, Lancet Series on Midwifery Mary J. Renfrew RM, PhD, FRSEn Professor of Mother and Infant Health, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, Scotland, UK E-mail address: [email protected]