The Hot Topic for the forthcoming June issue of MIDIRS Midwifery Digest, focuses on the recent Lancet Series on Midwifery, which aims to address the lack of high-quality care for childbearing women, babies and families from a global perspective.
In her article, Professor Mary Renfrew, Director of the Mother and Infant Research Unit at the University of Dundee, examines why the series was needed, what it has achieved so far and why it is having such an impact, as well as considering what it might mean in a UK context. A short extract follows.
Midwifery – the key to quality care
Professor Mary Renfrew, Director, Mother and Infant Research Unit, University of Dundee
Director, Scottish Improvement Science Collaborating Centre
Principal Investigator, Lancet Series on Midwifery.
The Lancet Series on Midwifery is the most critical, wide-reaching, and high-profile examination of midwifery to date. In this paper, I will examine why the series was needed, what is has achieved so far, and why it is having such an impact. I will also consider briefly what it might mean in a UK context.
Published in June 2014, the Lancet Series on Midwifery consists of four papers – two others are still to follow – with a set of commentaries and an editorial (Renfrew et al 2014, Homer et al 2014, Van Lerberghe et al 2014, ten Hoope Bender et al 2014). Almost immediately after publication it became clear that the series was being received very positively, both within the international midwifery community, and more widely across the maternal and newborn care, sexual and reproductive health, public health, and human rights communities. The findings and recommendations have been debated widely, and are now supported by all relevant global agencies. The work of the series was supported by the Bill & Melinda Gates Foundation, and by the Norwegian aid agency, NORAD. A public campaign to support the findings of the series – midwives4all – is being led by the Swedish Foreign Ministry.
The core challenge that the series aimed to address was the lack of high quality care for childbearing women, babies and families. This manifests in different ways in different settings, for example:
In low-income countries
- Preventable mortality of women and babies, and stillbirths, remain at unacceptable levels.
In all countries
- Acute and chronic morbidity is suffered by many women and children after birth.
- Inequalities in the provision of good quality care mean that those already most vulnerable are likely to receive the worst care, with an impact on mortality as well as health and well-being.
- Some important outcomes – mental health and longer-term complications, for example – are seldom measured.
- Over-medicalisation of health systems results in escalating rates of unnecessary interventions with harmful sequelae and unsustainable use of resources.
- Attention is often focussed on specific technical solutions – hospital birth, for example, or risk screening, or the availability of emergency services – rather than the whole picture of the skilled and compassionate care needed by all women and all babies before, during and after birth.
- A lack of respectful care is commonly reported, whether manifesting as a lack of communication, conducting interventions without agreement or information, a lack of privacy, or physical or emotional abuse.
- The rights of women and children to life and to health are severely compromised as a result.
The international community was seeking solutions to these challenges, and specifically there was a need to identify approaches to inform global policy developments such as Universal Health Coverage, the post-2015 agenda, Saving Newborn Lives, and Every Woman Every Child. Many organisations and individuals working in maternal and newborn health care had direct experience of the important contribution of midwifery, but as midwifery is implemented inconsistently in many countries, many others did not, and some were unconvinced that midwifery could add value to existing services.
Internationally, care for childbearing women and infants is provided by a very diverse workforce including traditional birth attendants, community health workers, nurses, and doctors as well as midwives. There are important barriers to the implementation of high quality midwifery such as low status and lack of effective professional regulation, and professional territorialism. Even in countries where midwives are educated to international standards, their scope of practice is often limited or they find themselves practising in situations where over-medicalised care is the norm and midwifery is under-valued. There was a dearth of evidence on midwives and their impact in low-income settings, where much of the research effort has focussed on less-skilled workforce groups. These factors combined meant that the evidence was hard to interpret. There was a clear and urgent need to examine the evidence for the contribution that midwifery could make to high quality care for women, infants and families.
This was the context in which the Lancet Series on Midwifery was planned. It meant that a radical new approach was needed, both to understand the challenges and to analyse existing evidence. Around 35 authors from very diverse backgrounds and from more than 20 countries across five continents worked on the series for three years, with the involvement of global agencies and more than a dozen critical readers. We drew on this experience as well as a very diverse evidence base that included systematic reviews of interventions, meta-syntheses of studies of women’s views, case studies, modelling, and health system analysis.
The full article will appear in MIDIRS Midwifery Digest, June 2015 issue. Visit www.midirs.org/digest for details.