Midwifery – key to quality careGlobal and national implications of

The Lancet Series on Midwifery

International Day of the Midwife 2015 RCM Conference Edinburgh

Midwives for a better tomorrow

Professor Mary Renfrew FRSEDirector, Mother and Infant Research Unit

@MIRU_UK

Director, Scottish Improvement Science Collaborating Centre

The Lancet Series on Midwifery

@midwiferyaction#LancetMidwiferyYou Tube: Midwifery Action

http://www.thelancet.com/series/midwifery

@midwiferyaction #LancetMidwifery@midwives4all #midwives4all

@MIRU_UK@maryrenfrew

The Lancet Series on MidwiferyBackground

• Four papers, five commentaries: June 2014

• Two further papers in preparation

• Multidisciplinary group of 35+ specialists from 20+ countries– health systems analysts, demographers, statisticians,

epidemiologists, health service researchers, social scientists, health economists, specialist midwife researchers, service user advocates, public health and policy experts, and clinical experts: midwives, obstetricians, paediatricians, other related disciplines

• Input from close readers/critical friends, WHO, Gates Foundation, ICM, FIGO, Lancet editors and reviewers

• Supported by the Bill & Melinda Gates Foundation + NORAD

http://www.thelancet.com/series/midwiferywww.midwiferyaction.com

Midwifery – key to quality care

• Taking another look at the evidence: the Lancet Series on Midwifery and why it matters

• Global and national impact and implications

‘Midwifery is a vital solution to the challenges of providing high quality maternal and newborn care for all women and infants, in all countries’ten Hoope Bender et al 2014 The Lancet

The Lancet Series on MidwiferyBackground

• Unacceptable rates of mortality and morbidity

• Longer term and psycho-social outcomes overlooked– birth is the start of the journey

• High rates of unnecessary interventions

• Inequalities in outcomes and care

• Care and compassion seen as less important, yet integral to system failures

• Disrespect and abuse of women within the health system

The Lancet Series on MidwiferyBackground

• Diverse discourses– emergency care, facility birth, tasks and task-shifting, essential

interventions, skilled birth attendance, risk assessment, normal birth

The Lancet Series on MidwiferyBackground

• Diverse discourses– emergency care, facility birth, tasks and task-shifting, essential

interventions, skilled birth attendance, risk assessment, normal birth

• Diverse approaches– focus on mortality vs health and well-being, women vs children,

high vs middle vs low-income countries

– focus on RCTs of specific interventions vs views and experiences

– focus on systems, workforce, costs and resources

The Lancet Series on MidwiferyBackground

• Diverse discourses– emergency care, facility birth, tasks and task-shifting, essential

interventions, skilled birth attendance, risk assessment, normal birth

• Diverse approaches– focus on mortality vs health and well-being, on women vs

children, on high vs middle vs low-income countries, on birth vs continuum

– focus on RCTs of specific interventions vs views and experiences

– focus on systems, workforce, costs and resources

• Midwifery shown to be important – yet inconsistently implemented, unanswered questions,

substantive barriers

– rendered invisible in current discourse

Figure 2

Bhutta et al The Lancet Stillbirth Series 2011 377, 1523-1538DOI: (10.1016/S0140-6736(10)62269-6)

The Lancet Series on Midwifery

• What we learned…

… we needed to ask different questions, start from a different perspective, re-examine the evidence

Women, babies, familiesUniversal needs and equity

The Lancet Series on MidwiferyRe-examining the evidence – a new lens

• Focus on needs of women, infants, families• Human rights-based approach• Drawing on diverse sources of evidence• All relevant outcomes: survival, health, wellbeing• Relevant to low, middle, high-income settings• Long-term view: quality care and services• Distinguishing between what, how and who• Interdisciplinary, cross-sectoral, health systems perspective• Acknowledging diverse workforce, importance of integrated

services• Examining the specific contribution of midwives• Developing evidence-informed consensus

Defining midwifery‘Skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life. Core characteristics include optimising normal biological, psychological, social and cultural processes of reproduction and early life, timely prevention and management of complications, consultation with and referral to other services, respecting women’s individual circumstances and views, and working in partnership with women to strengthen women’s own capabilities to care for themselves and their families’.

Renfrew, McFadden, Bastos et al The Lancet 384, I9948, 1129 – 1145, 2014http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext

Framework for quality maternal and newborn care

Renfrew, McFadden, Bastos et al The Lancet 384, I9948, 1129 – 1145, 2014http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext

Framework for quality maternal and newborn careThe scope of midwifery

• Maternal and newborn mortality, stillbirth reduced• Less preterm birth, low birthweight • Maternal morbidity reduced

– eg infections, anaemia, pre-eclampsia, perineal trauma

• Reduced interventions in labour– eg augmentation, caesarean section, blood transfusions

• Improved psycho-social outcomes – eg satisfaction with pain relief, anxiety, post-partum

depression, improved mother-baby interaction

• Increased birth spacing, contraceptive use• Increased breastfeeding initiation and duration• Shorter hospital stays, improved referrals, increased

attendance by known midwife

Impact 56 outcomes improved by midwifery

Scale of the impact of midwifery care

• Universal coverage of midwifery would result in reductions in maternal deaths, stillbirths, and neonatal deaths in 78 countries – maternal mortality, stillbirths, and neonatal deaths

reduced by around 80%

Homer, Friberg, Bastos Dias et al The Lancet 384, 1146-1157 Sept 2014

• ‘Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated, and midwives were most effective when integrated into the health system in the context of effective teamwork and referral mechanisms and with sufficient resources. There are few benefits from relying on less-skilled healthcare workers.’– Renfrew, McFadden, Bastos et al The Lancet 2014

Who should provide midwifery care?

‘These findings support a system-level shift from fragmented maternal and newborn care focused on identification and treatment of pathology to skilled care for all. Midwifery is pivotal to this approach’.

Renfrew, McFadden, Bastos et al The Lancet 2014

Quality maternal and newborn care

Midwifery – key to quality care

• Taking another look at the evidence: the Lancet Series on Midwifery and why it matters

• Global and national impact and implications

Global and national dissemination

• Resources:– Lancet webpage, www.midwiferyaction.com, You Tube films

– Global alliance and consensus building

• eg WHO, UNFPA, UNICEF, DfID, Gates Foundation, ICM, FIGO

– Endorsement by DGs of WHO, UNFPA, +++

– Discussions re Every Newborn Action Plan, Every Woman Every Child, SDGs

• Country-level developments– Translations: French, Portuguese, Dutch +++

– Informing debate, strategy, policy

• eg US, Uganda, Brazil, Mozambique, Croatia +++

• Swedish government – www.midwives4all.org: @midwives4all: #midwives4all

– Embassies supporting country-level engagement +++

– Digital campaign to launch summer 2015

Implications for the UK

• Supports policy direction of woman-centred, person-centred services – challenges risk assessment as organising principle

– evidence for the further changes needed to maternal and newborn strategy, policy, practice

• Quality framework can inform analysis, planning, education, research– eg response to Kirkup Report, review of maternity and

newborn services, planning curricula, examining mechanisms of action

• Model for analysis and planning of future quality service provision in other fields

Next steps

• Further papers– Human rights and midwifery

– Research agenda

• in collaboration with WHO, ICM, involving UNFPA, Gates Foundation, DfID+++

– Barriers to midwifery

• Ongoing engagement in global and national developments

‘Midwifery is a vital solution to the challenges of providing high quality maternal and newborn care for all women and infants, in all countries’ten Hoope Bender et al 2014 The Lancet

Lancet Series on Midwifery: authors• Endang Achadi• Chiara Ancona• Linda A Bartlett• Maria Helena Bastos• Jim Campbell• Amos Channon• Fen Cheung• Marcos AB Dias• Luc de Bernis• Vincent De Brouwere • Eugene Declercq• Deborah Delage

• Soo Downe• Vincent Fauveau• Helga Fogstad• Ingrid K Friberg• Caroline SE Homer

• Holly Powell Kennedy

• Marge Koblinsky• Jerker Liljestrand• Address Malata• Zoe Matthews• Felicia McCormick• Alison McFadden• Abdelhay Mechbal• Susan F Murray• Helen Rehr • Mary J Renfrew• Fabienne Richard• Tung Rathavay• Jane Sandall• Anna Maria Speciale• Petra ten Hoope-Bender• Sabera Turkmani• Wim Van Lerberghe• Laura Wick

Midwifery – key to quality careThank you!

m.renfrew@dundee.ac.uk@midwiferyaction

@MIRU_UK@maryrenfrew

Photos and films: magnetofilms.comArtwork: M4ID