Assessing long-term impacts of trained midwives on health outcomes

We were commissioned by the Department for International Development (DFID) to carry out a baseline study to understand long-term impacts of diploma midwives on health outcomes in Bangladesh.  Broadly the objectives of this study are to set the baseline to understand long-term impact, of the new midwifery cadre on maternal and newborn health in Bangladesh, and to suggest suitable strategies to effectively develop, deploy and utilise them in achieving better maternal and newborn health outcomes.  The study incorporated a mixed methods approach. This included a quantitative survey for households and midwives in service and focus group discussions with both midwives still in the diploma programme and those appointed at public health facilities. Key findings revealed the need for more emphasis is needed to create a distinct identity and enabling environment for this newly created health workforce.  The study also found that the midwives are highly motivated and have adequate knowledge and skills. However, there are some bottlenecks and concerns that, if unaddressed, may derail the success of this programme.

Challenges

Historically, Bangladesh did not have a dedicated midwifery workforce. After trying various initiatives to create dedicated workforce for midwifery care over the last few decades, the Government of Bangladesh with support from development partners has started to develop a cadre of trained midwives. Developed in line with international standards, a three-year diploma education in midwifery was launched nationwide in December 2012. At the time of our baseline study in 2018, first two batches of the midwives who had completed diploma were recruited by the Public Service Commission and deployed in the public sector health facilities. Therefore, this was an ideal time to conduct a comprehensive study involving both demand and supply side to understand baseline status and also to identify key challenges that the programme was facing at an early stage.

Our approach

Our study design employed a mixed methods approach with three key components:

1. policy landscaping through desk review and key informant interviews;
2. user surveys which included mothers and children and providers which are the midwives; and
3. focus group discussions and case studies.

The objective of user (household) survey is to set the baseline status of key maternal and neonatal health indicators in areas where midwives are deployed to compare the results with a follow-up survey. This will help in understanding effectiveness of having diploma midwives, by comparing the results of key indicators of this user survey with future surveys. Each of the components either solely or jointly facilitated in reaching the research objectives.

Outcomes

Survey findings and evidence from previous nationwide surveys showed a positive trend in most of maternal, neonatal, and reproductive health indicators. Further efforts are required to create a distinct identity for the new cadre of midwives and for better integration into the existing health system. With adequate training and knowledge, many midwives are unable to perform midwifery tasks due to lack of authorisation from supervisors, lack of equipment and supplies, and due to delay in filling vacant position of nurses.

In the presence of different cadres of health care providers operating in field, an awareness among the community is needed for mothers to be informed, seek out and learn to trust these relatively younger midwives vis-a-vis  older health care providers for midwifery services. An enabling environment needs to be created for these by briefing senior health workers and physicians on the exact job description of a midwife, equipping facilities with appropriate functioning equipment and supplies, and properly managing and supervising midwives.

To ensure growth of this profession, there needs to be a clear career trajectory for midwives. To capture the progress of these midwives, additional research including a follow-up survey, if possible with the same cohort of midwives for which consent has already been taken, would be beneficial to this programme. This is further discussed in a peer review journal article.

Additional research, including a follow-up study with the same cohort of midwives to capture the career progression would be beneficial to this programme.

Photo credit: Developing Midwives Project, Brac James P Grant School of Public Health, BRAC University