This year, 350,000 women will die while pregnant or giving birth. The vast majority of these deaths, a whopping 99%, will occur in low-income countries and could have largely been prevented. Based on these statistics, the world is set to drastically miss Millennium Development Goals number 4 (to reduce child death) and 5 (to improve maternal health) by 2015.
However, there is still hope. The first "State of the World's Midwifery" report, coordinated and commissioned by the United Nations Population Fund Agency (UNPFA), has found that access to midwives and other skilled birth attendants plays a crucial role in maternal and newborn health and survival. According to the report, upgrading midwifery infrastructure by 2015 could prevent an estimated 3.6 million deaths in 58 developing countries. The report highlights that the largest improvements must be made in access to competent midwives, requiring some countries to increase the number of skilled midwives tenfold. In addition, the report reveals a lack of quality and standardization in midwifery training institutions, poor regulatory structure, and fragile professional associations.
The report briefly mentions the need for midwifery services to be integrated within communities, but this point is not discussed in detail. In countries where the formal health care system often runs alongside and competes with an informal system, the introduction of a new service must have community support. “Community health strategy,” popularized in the early 2000s, recognizes that communities act as the base of their own health care delivery, especially in sub-Saharan and East Africa. Skilled service providers, including the potential midwives, may not have the same socio-cultural context as their clients and may not appreciate how their clients envision health concerns. Advice and recommendations do not carry as much weight coming from strangers, and can result in indifference and mistrust.
In Kenya, the Ministry of Health recognizes that health service users are more likely to use traditional and informal health care systems as a first point of contact; formal health care is a last resort. Unfortunately, the informal health system is, well, informal. In East Africa, pregnant women turn to traditional birth attendants, who use old, unregulated, and sometimes crude hand-me-down methods. While these women are trusted, they do not have a sophisticated way to test for HIV, lack surgical ability, and lack equipment to deal with high-risk births.
To bridge this trust gap, "community health strategy" was implemented nationwide in several low-income countries. The system allows members of a determined district to elect a Community Health Worker (CHW). This volunteer is assigned 20 households, or 100 people, and is trained in basic health practices such as recognizing pregnancy danger signs and informing people about gender-based violence. Supervised and mentored by a formally trained Community Health Extension Worker, the CHWs act as the first point of contact for health education and referral in the community. In a case such as maternal health, a peer CHW recommending a midwife bears credence. CHWs also record information such as disease occurrence and population data for their households. This information filters into powerful district and national databases, and thus allow governments to make informed decisions about the health care needs of their people, including those related to maternal health and midwives.
The UNFPA report has highlighted the need for skilled midwives, who make significant improvements in maternal health and the early development of children. However, the report overlooks the importance of community engagement. Without comprehensive and coordinated approaches to integrate this service into existing health care structures, the evidence risks never being translated into practice.
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