International virtual confidential reviews of infection-related maternal deaths and near-miss in 11 low- and middle-income countries - case report series and suggested actions.

BACKGROUND: Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement. METHOD: An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework. RESULTS: Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections. CONCLUSION: Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.

The State of the World's Midwifery 2021 report: findings to drive global policy and practice.

The third global State of the World's Midwifery report (SoWMy 2021) provides an updated evidence base on the sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workforce. For the first time, SoWMy includes high-income countries (HICs) as well as low- and middle-income countries. This paper describes the similarities and differences between regions and income groups, and discusses the policy implications of these variations. SoWMy 2021 estimates a global shortage of 900,000 midwives, which is particularly acute in low-income countries (LICs) and in Africa. The shortage is projected to improve only slightly by 2030 unless additional investments are made. The evidence suggests that these investments would yield important returns, including: more positive birth experiences, improved health outcomes, and inclusive and equitable economic growth. Most HICs have sufficient SRMNAH workers to meet the need for essential interventions, and their education and regulatory environments tend to be strong. Upper-middle-income countries also tend to have strong policy environments. LICs and lower-middle-income countries tend to have a broader scope of practice for midwives, and many also have midwives in leadership positions within national government. Key regional variations include: major midwife shortages in Africa and South-East Asia but more promising signs of growth in South-East Asia than in Africa; a strong focus in Africa on professional midwives (rather than associate professionals: the norm in many South-East Asian countries); heavy reliance on medical doctors rather than midwives in the Americas and Eastern Mediterranean regions and parts of the Western Pacific; and a strong educational and regulatory environment in Europe but a lack of midwife leaders at national level. SoWMy 2021 provides stakeholders with the latest data and information to inform their efforts to build back better and fairer after COVID-19. This paper provides a number of policy responses to SoWMy 2021 that are tailored to different contexts, and suggests a variety of issues to consider in these contexts. These suggestions are supported by the inclusion of all countries in the report, because it is clear which countries have strong SRMNAH workforces and enabling environments and can be viewed as exemplars within regions and income groups.

Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.

BACKGROUND: Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios. METHODS: For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world's maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. FINDINGS: We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly concentrated in the group B countries, which currently account for a large proportion of the world's population and have high mortality rates compared with group C. INTERPRETATION: Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. FUNDING: New Venture Fund.

[Implementation of midwifery school accreditation mechanisms in Ivory Coast, Mali and Chad.] / Mise en place de mécanismes d'accréditation des écoles de sages-femmes en Côte d'Ivoire, au Mali et au Tchad.

One strategy to improve quality of care to eliminate preventable maternal and neonatal mortality and morbidity is to improve the training of health professionals, particularly midwives. Accreditation is a mechanism designed to reinforce education programmes and institutional capacities, using a situation analysis based on predefined criteria for decision-making. This paper describes the ongoing efforts of three Francophone African countries, Ivory Coast, Mali and Chad, to establish accreditation mechanisms of midwifery schools and to describe the necessary steps to implement these measures. Political will to support and regulate this sector, adoption of the License-Master-Doctorate (LMD) system, private sector support and an independent national accreditation commission are critical components.

Current and future availability of and need for human resources for sexual, reproductive, maternal and newborn health in 41 countries in Sub-Saharan Africa.

BACKGROUND: The WHO African region, covering the majority of Sub-Saharan Africa, faces the highest rates of maternal and neonatal mortality in the world. This study uses data from the State of the World's Midwifery 2014 survey to cast a spotlight on the WHO African region, highlight the specific characteristics of its sexual, reproductive, maternal and newborn health (SRMNH) workforce and describe and compare countries' different trajectories in terms of meeting the population need for services. METHODS: Using data from 41 African countries, this study used a mathematical model to estimate potential met need for SRMNH services, defined as "the percentage of a universal SRMNH package that could potentially be obtained by women and newborns given the composition, competencies and available working time of the SRMNH workforce." The model defined the 46 key interventions included in this universal SRMNH package and allocated them to the available health worker time and skill set in each country to estimate the potential met need. RESULTS: Based on the current and projected potential met need in the future, the countries were grouped into three categories: (1) 'making or maintaining progress' (expected to meet more, or the same level, of the need in the future than currently): 14 countries including Ghana, Senegal and South Africa, (2) 'at risk' (currently performing relatively well but expected to deteriorate due to the health workforce not keeping pace with population growth): 6 countries including Gabon, Rwanda and Zambia, and (3) 'low performing' (not performing well and not expected to improve): 21 countries including Burkina Faso, Eritrea and Sierra Leone. CONCLUSION: The three groups face different challenges, and policy solutions to increasing met need should be tailored to the specific context of the country. National health workforce accounts should be strengthened so that workforce planning can be evidence-informed.

A descriptive analysis of midwifery education, regulation and association in 73 countries: the baseline for a post-2015 pathway.

BACKGROUND: Education, regulation and association (ERA) are the supporting pillars of an enabling environment for midwives to provide quality care. This study explores these three pillars in the 73 low- and middle-income countries who participated in the State of the World's Midwifery (SoWMy) 2014 report. It also examines the progress made since the previous report in 2011. METHODS: A self-completion questionnaire collected quantitative and qualitative data on ERA characteristics and organisation in the 73 countries. The countries were grouped according to World Health Organization (WHO) regions. A descriptive analysis was conducted. RESULTS: In 82% of the participating countries, the minimum education level requirement to start midwifery training was grade 12 or above. The average length of training was higher for direct-entry programmes at 3.1 years than for post-nursing/healthcare provider programmes at 1.9 years. The median number of supervised births that must be conducted before graduation was 33 (range 0 to 240). Fewer than half of the countries had legislation recognising midwifery as an independent profession. This legislation was particularly lacking in the Western Pacific and South-East Asia regions. In most (90%) of the participating countries, governments were reported to have a regulatory role, but some reported challenges to the role being performed effectively. Professional associations were widely available to midwives in all regions although not all were exclusive to midwives. CONCLUSIONS: Compared with the 2011 SoWMy report, there is evidence of increasing effort in low- and middle-income countries to improve midwifery education, to strengthen the profession and to follow international ERA standards and guidelines. However, not all elements are being implemented equally; some variability persists between and within regions. The education pillar showed more systematic improvement in the type of programme and length of training. The reinforcement of regulation through the development of legislation for midwifery, a recognised definition and the strengthening of midwives' associations would benefit the development of other ERA elements and the profession generally.

Stillbirths: ending preventable deaths by 2030.

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. RESULTS: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. CONCLUSIONS: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.

Delivering the evidence to improve the health of women and newborns: State of the World's Midwifery, report 2014.

The State of the World's Midwifery Report 2014: A universal pathway, a women's right to health (SoWMy2014) was published in June 2014 and joins the ranks of a number of publications which contribute to the growing body of evidence about a global midwifery workforce that can improve maternal and child health.This editorial provides an overview of these publications that have been supported by global movements in the area of sexual, reproductive, maternal, and newborn and child health over the last four years. Background information is given on the methodology and data collection of SoWMy2014, the main findings cover the area of the availability, accessibility, acceptability and quality of midwifery services and a 2 page country brief shows the SRMNH data and workforce projections for each of the 73 "Countdown countries" that participated.SoWMy 2014 report shows that midwives can provide 87% of the needed essential care for women and newborns, when educated and trained to international standards. Midwives however, are most effective when they work within a functional health system and enabling environment.Also, a supportive team of auxiliaries, physicians and specialists is essential in order to ensure coverage of SRMNH services to women and newborns across the whole continuum of care, from pre-pregnancy through to pregnancy, childbirth and the post-natal period and from household to hospital.Based on these findings, the report puts forward a vision of Midwifery2030, a pathway for women's health and for midwifery policy and planning through the end of 2030. It promotes women-centered and midwife-led care to achieve the goal of universal health coverage for all women.

Improvement of maternal and newborn health through midwifery.

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Developing capacities of community health workers in sexual and reproductive, maternal, newborn, child, and adolescent health: a mapping and review of training resources.

BACKGROUND: Given country demands for support in the training of community health workers (CHWs) to accelerate progress towards reaching the Millennium Development Goals in sexual and reproductive health and maternal, newborn, child, and adolescent health (SR/MNCAH), the United Nations Health Agencies conducted a synthesis of existing training resource packages for CHWs in different components of SR/MNCAH to identify gaps and opportunities and inform efforts to harmonize approaches to developing the capacity of CHWs. METHODS: A mapping of training resource packages for CHWs was undertaken with documents retrieved online and from key informants. Materials were classified by health themes and analysed using agreed parameters. Ways forward were informed by a subsequent expert consultation. RESULTS: We identified 31 relevant packages. They covered different components of the SR/MNCAH continuum in varying breadth (integrated packages) and depth (focused packages), including family planning, antenatal and childbirth care (mainly postpartum haemorrhage), newborn care, and childhood care, and HIV. There is no or limited coverage of interventions related to safe abortion, adolescent health, and gender-based violence. There is no training package addressing the range of evidence-based interventions that can be delivered by CHWs as per World Health Organization guidance. Gaps include weakness in the assessment of competencies of trainees, in supportive supervision, and in impact assessment of packages. Many packages represent individual programme efforts rather than national programme materials, which could reflect weak integration into national health systems. CONCLUSIONS: There is a wealth of training packages on SR/MNCAH for CHWs which reflects interest in strengthening the capacity of CHWs. This offers an opportunity for governments and partners to mount a synergistic response to address the gaps and ensure an evidence-based comprehensive package of interventions to be delivered by CHWs. Packages with defined competencies and methods for assessing competencies and supervision are considered best practices but remain a gap.

Mapping for maternal and newborn health: the distributions of women of childbearing age, pregnancies and births.

BACKGROUND: The health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed. METHODS: This paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies. RESULTS AND CONCLUSIONS: These estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project.

Towards elimination of maternal deaths: maternal deaths surveillance and response.

Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).