Midwifery – key to quality care
Global 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 FRSE
Director, Mother and Infant Research Unit
@MIRU_UK
Director, Scottish Improvement Science
Collaborating Centre
The Lancet Series on Midwifery
http://www.thelancet.com/series/midwifery
@midwiferyaction
#LancetMidwifery
You Tube: Midwifery Action
@midwiferyaction
#LancetMidwifery
@midwives4all
#midwives4all
@MIRU_UK
@maryrenfrew
The Lancet Series on Midwifery
Background
• 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/midwifery
www.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 Midwifery
Background
• 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 Midwifery
Background
• Diverse discourses
– emergency care, facility birth, tasks and task-shifting, essential
interventions, skilled birth attendance, risk assessment, normal
birth
The Lancet Series on Midwifery
Background
• 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 Midwifery
Background
• 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
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Midwifery shown to be important
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yet inconsistently implemented, unanswered questions,
substantive barriers
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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, reexamine the evidence
Women, babies, families
Universal needs and equity
The Lancet Series on Midwifery
Re-examining the evidence – a new lens
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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, 2014
http://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, 2014
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext
Framework for quality maternal and newborn care
The scope of midwifery
Impact
56 outcomes improved by 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
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
Who should provide midwifery care?
• ‘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
Quality maternal and newborn 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
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, personcentred 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
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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
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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 care
Thank you!
Photos and films: magnetofilms.com
Artwork: M4ID
m.renfrew@dundee.ac.uk
@midwiferyaction
@MIRU_UK
@maryrenfrew