Strengthening midwifery in the South-East Asian region: A scoping review of midwifery-related research.

Improving sexual, reproductive, maternal, newborn, and adolescent health outcomes necessitates greater commitment to, and investments in, midwifery. To identify future research priorities to advance and strengthen midwifery, we conducted a scoping review to synthesise and report areas of midwifery that have been explored in the previous 10 years in the 11 countries of the World Health Organization's South-East Asia region. Electronic peer-reviewed databases were searched for primary peer-reviewed research published in any language, published between January 2012 and December 2022 inclusive. A total of 7086 citations were screened against the review inclusion criteria. After screening and full text review, 195 sources were included. There were 94 quantitative (48.2%), 67 qualitative (34.4%) and 31 mixed methods (15.9%) studies. The majority were from Indonesia (n = 93, 47.7%), India (n = 41, 21.0%) and Bangladesh (n = 26, 13.3%). There were no sources identified from the Democratic People's Republic of Korea or the Maldives. We mapped the findings against six priority areas adapted from the 2021 State of the World's Midwifery Report and Regional Strategic Directions for Strengthening Midwifery in the South-East Asia region (2020-2024): practice or service delivery (n = 73, 37.4%), pre-service education (n = 60, 30.8%), in-service education or continuing professional development (n = 51, 26.2%), workforce management (n = 46, 23.6%), governance and regulation (n = 21, 10.8%) and leadership (n = 12, 6.2%). Most were published by authors with affiliations from the country where the research was conducted. The volume of published midwifery research reflects country-specific investment in developing a midwifery workforce, and the transition to midwifery-led care. There was variation between countries in how midwife was defined, education pathways, professional regulation, education accreditation, governance models and scope of practice. Further evaluation of the return on investment in midwifery education, regulation, deployment and retention to support strategic decision-making is recommended. Key elements of leadership requiring further exploration included career pathways, education and development needs and regulatory frameworks to support and embed effective midwifery leadership at all levels of health service governance.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar.

BACKGROUND: Auxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar. METHOD: A qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software. RESULTS: AMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers' expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the "salt between the beans" an essential ingredient but often invisible between the beans. CONCLUSION: The trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.

Assessing the operational feasibility and acceptability of an inhalable formulation of oxytocin for improving community-based prevention of postpartum haemorrhage in Myanmar: a qualitative inquiry.

OBJECTIVE: This study assessed the potential operational feasibility and acceptability of a heat-stable, inhaled oxytocin (IOT) product for community-based prevention of postpartum haemorrhage in Myanmar. METHODS: A qualitative inquiry was conducted between June 2015 and February 2016 through focus group discussions and in-depth interviews. Research was conducted in South Dagon township (urban setting) and in Ngape and Thanlyin townships (rural settings) in Myanmar. Eleven focus group discussions and 16 in-depth interviews were conducted with mothers, healthcare providers and other key informants. All audio recordings were transcribed verbatim in Myanmar language and were translated into English. Thematic content analysis was done using NVivo software. RESULTS: Future introduction of an IOT product for community-based services was found to be acceptable among mothers and healthcare providers and would be feasible for use by lower cadres of healthcare providers, even in remote settings. Responses from healthcare providers and community members highlighted that midwives and volunteer auxiliary midwives would be key advocates for promoting community acceptance of the product. Healthcare providers perceived the ease of use and lack of dependence on cold storage as the main enablers for IOT compared with the current gold standard oxytocin injection. A single-use disposable device with clear pictorial instructions and a price that would be affordable by the poorest communities was suggested. Appropriate training was also said to be essential for the future induction of the product into community settings. CONCLUSION: In Myanmar, where home births are common, access to cold storage and skilled personnel who are able to deliver injectable oxytocin is limited. Among community members and healthcare providers, IOT was perceived to be an acceptable and feasible intervention for use by lower cadres of healthcare workers, and thus may be an alternative solution for the prevention of postpartum haemorrhage in community-based settings in the future.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study.

BACKGROUND: An estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar. METHODS: A mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system. RESULTS: According to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting. CONCLUSION: With the current national government's commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.

Determinants of knowledge of critical danger signs, safe childbirth and immediate newborn care practices among auxiliary midwives: a cross sectional survey in Myanmar.

OBJECTIVES: The re-emergence of community-based health workers such as the auxiliary midwives (AMWs) in Myanmar, who are local female volunteers, has been an important strategy to address global health workforce shortages. The Myanmar government recommends one AMW for every village. The aim of this study is to investigate the current knowledge of critical danger signs and practices for safe childbirth and immediate newborn care of AMWs to inform potential task shifting of additional healthcare responsibilities. METHODS: A cross-sectional survey was conducted from July 2015 to June 2016 in three hard-to-reach areas in Myanmar. Face-to-face interviews were conducted using a pretested questionnaire. RESULTS: Among 262 AMWs participating in the study, only 8% of AMWs were able to identify at least 80% of 20 critical danger signs. Factors associated with greater knowledge of critical danger signs included older age over 35 years (adjusted OR (AOR) 2.19, 95% CI 0.99 to 4.83), having received refresher training within the last year (AOR 2.20, 95% CI 1.21 to 4.01) and receiving adequate supervision (AOR 5.04, 95% CI 2.74 to 9.29). Those who employed all six safe childbirth and immediate newborn care practices were more likely to report greater knowledge of danger signs (AOR 2.81, 95% CI 1.50 to 5.26), adequate work supervision (AOR 3.18 95% CI 1.62 to 6.24) and less education (AOR 0.44, 95% CI 0.23 to 0.88). CONCLUSION: The low level of knowledge of critical danger signs and reported practices for safe childbirth identified suggest that an evaluation of the current AMW training and supervision programme needs to be revisited to ensure that existing practices, including recognition of danger signs, meet quality care standards before new interventions are introduced or new responsibilities given to AMWs.

Prevention of postpartum haemorrhage by community-based auxiliary midwives in hard-to-reach areas of Myanmar: a qualitative inquiry into acceptability and feasibility of task shifting.

BACKGROUND: In Myanmar, postpartum haemorrhage is the leading cause of maternal mortality and contributes to around 30% of all maternal deaths. The World Health Organization recommends training and supporting auxiliary midwives to administer oral misoprostol for prevention of postpartum haemorrhage in resource-limited settings. However, use of misoprostol by auxiliary midwives has not formally been approved in Myanmar. Our study aimed to explore community and provider perspectives on the roles of auxiliary midwives and community-level provision of oral misoprostol by auxiliary midwives. METHODS: A qualitative inquiry was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, auxiliary midwives, community members and mothers with children under the age of three were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. All audio recordings were transcribed verbatim in Myanmar language. Transcripts of focus group discussions were fully translated into English before coding, while key informants' data were coded in Myanmar language. Thematic analysis was done using ATLAS.ti software. RESULTS: Home births are common and auxiliary midwives were perceived as an essential care provider during childbirth in hard-to-reach areas. Main reasons provided were that auxiliary midwives are more accessible than midwives, live in the hard-to-reach areas, and are integrated in the community and well connected with midwives. Auxiliary midwives generally reported that their training involved instruction on active management of the third stage of labour, including use of misoprostol, but not all auxiliary midwives reported using misoprostol in practice. Supportive reasons for task-shifting administration of oral misoprostol to auxiliary midwives included discussions around the good relationship and trust between auxiliary midwives and midwives, whereby midwives felt confident distributing misoprostol to auxiliary midwives. However, the lack of clear government-level written permission to distribute the drug was perceived as a barrier to task shifting. CONCLUSION: This study highlights the acceptability of misoprostol use by auxiliary midwives to prevent postpartum haemorrhage, and findings suggest that it should be considered as a promising intervention for task shifting in Myanmar.