Background
The State of the World’s Midwifery 2014 (SoWMy2014): A Universal Pathway. A Woman’s Right to Health [
1] took its inspiration from the United Nations Secretary-General’s Every Woman Every Child initiative [
2‐
4] to do everything possible to achieve the Millennium Development Goals (MDGs) by 2015 and work towards the development and adoption of a post-2015 agenda supportive of a continuing focus on maternal and newborn mortality and morbidity reduction.
The report was entitled
The State of the World’s Midwifery, but it used a very broad definition of midwifery (“the health services and health workforce needed to support and care for women and newborns”) and therefore provided information about a wide range of sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workers, including doctors, midwives, nurses and auxiliaries. An effective SRMNAH workforce is critical to achieve universal health coverage (UHC) although it is likely that there are significant barriers in many countries to realising effective coverage of SRMNAH care [
5].
For
SoWMy 2014, 75 middle- and low-income countries, included in the ‘Countdown to 2015’ initiative [
6], were invited to contribute to the analysis of SRMNAH needs.
SoWMy 2014 aimed to support policy dialogue between governments and their partners; accelerate progress on MDGs 4 and 5; identify developments in the three years since the
SoWMy 2011 report was published [
7] and inform negotiations for and preparation of the post-2015 development agenda. In total 73 of the 75 Countdown countries participated in
SoWMy 2014, the exceptions being Equatorial Guinea and the Philippines.
SoWMy2014 was framed around the concept of ‘effective coverage’, with quality of care, equality and equity in reaching the most vulnerable members of society as the priorities. ‘Effective coverage’ includes the dimensions of availability, accessibility, acceptability and quality of services (AAAQ) included in the right to health [
8] and the Tanahashi framework [
9]. This provides not only an effective analytical approach, endorsed and adopted by United Nations agencies, but also a framework for analysis to inform country and global actions. The AAAQ framework is also useful as it addresses supply-side (availability and quality of care) and demand-side (accessibility and acceptability) factors.
Another aim of SoWMy2014 was to be a means to catalyse action on SRMNAH services. Therefore, the study was seen as a way to collect rigorous data at country level, but also as an opportunity to encourage political buy-in for the willing contribution of often hard-to-find information, the political endorsement of best-available estimates where hard facts were not available, and a strengthening of policy dialogue on evidence, challenges, and solutions. Therefore, two main processes were used to collect data: 1) a self-completion questionnaire, which collected quantitative and qualitative data about education, regulation, professional associations, policy and planning frameworks and progress since SoWMy2011; and, 2) a one-day workshop involving national stakeholders and experts, to identify barriers and solutions for effective coverage of SRMNAH care. The workshops were considered as an important mechanism to engage a wide range of stakeholders and enable a participatory policy debate on the state of the country’s SRMNAH workforce. Based on the workshop data, the aim of this paper is to explore the barriers to, and strategies for, enabling SRMNAH services to be available, accessible, acceptable, and of quality.
Methods
The development of
SoWMy 2014 was coordinated by the United Nations Population Fund (UNFPA), the World Health Organization (WHO) and the International Confederation of Midwives (ICM). Countries participating in
SoWMy 2014 were invited to hold a one-day interactive workshop, and 36 countries did so. The objectives of the workshop were to:
-
Explain the conceptual framework and methodological approach behind SoWMy 2014 and secure buy-in to the SoWMy research process.
-
Elicit important qualitative information for the
SoWMy analysis in relation to AAAQ, to enrich the information collected using the structured questionnaire (Table
1).
-
Moderate a participatory policy debate on the state of the country’s SRMNAH workforce and strategies for strengthening it.
1.1. Availability |
• Strategic intelligence on the health workforce |
• Policy, regulatory and fiscal environments |
• Education, training and professional support |
• Financing supply |
• Bilateral, multilateral and regional partnerships |
1.2. Accessibility |
• Geographical, temporal and financial barriers to access |
• Stewardship, management and equitable deployment |
• Referral across health services |
• Equitable access for vulnerable groups |
• Retaining health workers |
1.3. Acceptability |
• Increasing population demand for services |
• Workforce skill-mix, competencies, socio-cultural needs |
• Responsiveness to population-specific needs |
• Oversight and accountability |
1.4. Quality |
• Patients’ interests |
• Standards, accreditation, regulation |
• Linking professional, community and consumer organizations |
• Managing patient risk |
• Workforce management, performance and monitoring systems |
UNFPA and WHO focal points in each country were invited to arrange the workshop. In each country, a list of about 25 participants was drawn up in consultation with the Ministry of Health. Those invited to the workshop included a wide range of stakeholders such as: representatives from the Ministry of Health, advisers, advocates, health service managers and leaders, SRMNAH workers, professional associations (including midwifery, obstetrics and gynaecology, nursing), education providers, regulators, international and donor organisations, non-governmental organisations, the media, the private sector and academia. Across the 36 countries (Table
2) there were about 800 participants (between 6 and 54 per workshop).
Table 2
SoWMy2014 countries (n = 36) who held a workshop, by WHO region
Benin, Burkina Faso, Chad, Congo, Democratic Republic of Congo, Côte d’Ivoire, Ethiopia, Guinea, Liberia, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sierra Leone, Tanzania, Togo, Zambia | Bangladesh, India, Indonesia, Myanmar, Nepal | Lao People’s Democratic Republic | Brazil, Haiti, Mexico | Afghanistan, Morocco, Pakistan, Somalia, South Sudan | Kyrgyzstan, Tajikistan |
Prior to the workshops, potential participants were informed about the procedures involved, the optional nature of the process and the possibility to withdraw their consent at any point. To encourage open and honest discussion, the workshops were held under ‘Chatham House Rules’ [
10] and not video or audio recorded.
Moderators facilitated the workshops using materials provided by the SoWMy secretariat. Countries were asked to address AAAQ of the SRMNAH care system in the workshops, and a series of guiding questions were used. A rapporteur attended the workshop, and took detailed notes of what was said. A written report of each workshop was produced using a template. The draft report was sent to the workshop participants so that they could check that it was an accurate record. Once they had checked the draft, the report was submitted to the SoWMy secretariat via an on-line submission system.
Data from the workshops undertaken in French, Portuguese and Spanish were translated into English. The data were then imported into a qualitative software program (N-Vivo) and a content analysis approach was used. Qualitative content analysis is an approach that goes beyond counting words or responses to interpretation and classification in categories that represent similar meaning [
11]. It is a recognised method for the subjective interpretation of the content of textual data through the systematic classification process of coding and identifying themes or patterns [
11‐
14]. It is also a recognised method of analysing documents or written responses [
15] which is particularly applicable for these workshop reports.
A content template analysis approach [
16] was used initially to explore the barriers using the AAAQ [
8,
9] and ICM’s pillars of Education, Regulation and Association [
17]. The AAAQ (availability, accessibility, acceptability, quality) framework (see Table
1) was used as a template to develop the initial codings [
16]. This process of coding [
15] ensured that the AAAQ framework was the basis for the analysis of these questions which is in keeping with the overall principles underpinning
SoWMy2014.
Discussion
Workshops were an effective way to gather cross-national information on the barriers to effective coverage of SRMNAH care. Many of the issues identified are in line with other research which highlights the challenges to quality SRMNAH care and the need to take a systematic and step-wise approach to health system strengthening [
18]. Interestingly, even though these data were provided predominately by health care professionals, policy makers from governments and professional associations, the findings support research from the perspectives of women about SRMNAH care [
19].
It is clear that some of the proposed solutions or enablers of AAAQ require differing levels of investment and effort at a range of levels. Some require attitudinal change in health workers (ensuring respectful care; involvement in professional associations), others require a reallocation or re-prioritisation of resources (HRH planning processes, incentives to work in rural areas) while others will require significant investment (curriculum development, housing in rural areas, health insurance systems). These will vary from country to country and will need identification according to need and feasibility.
The workshops highlighted issues in the supply side (availability and quality of care) in particular, as well as challenges on the demand side, e.g. in accessing the available workforce. Participants expressed concerns about deficiencies in the size and quality of the SRMNAH workforce, the rural – urban divide in terms of services and providers, and the need to recognise and utilise all SRMNAH workers to their full capacity. Change will be difficult to fully implement for all countries regardless of the solution being evident. Political will and commitment that is backed up by resources, legislative and regulatory reform and community support is required at global, national and regional levels. In line with this, the International Labour Organisation has identified the need to monitor gaps and deficits in legal coverage, availability and affordability of services as well as assess the financial deficit that needs to be closed [
20]. This will also include an assessment of the access barriers such as fragmentation of coverage. It is clearly the responsibility of governments to ensure that there is infrastructure to support an effective health workforce including housing, education, security, transport and utilities in rural areas so that there will be, in the long run, no area which is ‘hard to reach‘. It is recognised that improving living conditions for health workers and their families with investments in infrastructure and services has a significant influence on a health worker’s decision to locate to and remain in rural areas [
21].
One of the potential solutions is a reconsideration of the way services are delivered and the way care is arranged. The provision of first level SRMNAH care as close as possible to women’s homes and communities (while ensuring access to consultation and referral transportation to higher-level services) will address accessibility issues while effectively utilising the health workforce. In some contexts, it may be necessary to upgrade specific facilities (e.g. well-functioning facilities with sufficient staff) or to incentivise those facilities in order to achieve an equitable geographic distribution of services [
22]. Efficient use of health workers and collaboration with community-level lay workers and volunteers will facilitate access to cost-effective care, especially for women and families in geographically remote or urban poor settings without transportation. If referral mechanisms are available and adequately functioning, quality midwife-led care can be delivered at community level, reducing unnecessary delays and improving health outcomes [
5]. First-level midwife-led units [
23‐
27] could be established within reach of communities, supported by community health workers and traditional birth attendants who assist women to access the health system and facilitate respectful, culturally sensitive care [
28].
Many health workers globally work in difficult, unsafe, isolated and poorly equipped settings and themselves experience gender-based violence, poor salaries and working conditions and a lack of access to continuing professional development; all of which impede their ability and/or motivation to provide high-quality care [
29,
30]. Poor working conditions undermine their ability or willingness to continue practising: many choose to leave the workforce due to frustration with their position and role [
30] or because they reach an arbitrary retirement age. A recent survey of 2470 midwifery personnel who provided care to childbearing women and their newborns in 93 countries showed that while midwives were committed to providing the best quality of care for women, newborns and their families, they were frustrated by the realities they experienced that constrain their efforts [
30]. To further highlight this, a systematic review has also shown that there are significant social and cultural, economic and professional barriers that prevent the provision of quality midwifery care in low and middle income countries and these need to be addressed to bring about improvements in the quality of care [
31].
Some of the strategies to bring about improvements in the quality of care include having an enabling professional environment that will support effective education, regulation and professional association [
17]. This means that SRMNAH workers can develop meaningful relationships with women, with occupational autonomy and flexibility, so that they control, organize and prioritise their own work; have access to supportive supervision, reflect on practice with peers and colleagues, share ideas and information and optimise service provision [
29,
32,
33]. This is more likely to result in the provision of quality care (supply-side) and address demand side factors especially related to acceptability of care from the perspective of women.
It was evident that high-quality education, continuing professional development and career pathways are critical to addressing many of the AAAQ challenges especially in relation to the provision of quality care which is much needed to promote accessibility and ensure acceptability [
34]. This includes: making a career as an SRMNAH worker attractive; providing educational pathways with sufficient opportunities for clinical experience; having well-prepared faculty and appropriately resourced programmes; developing or applying accreditation systems with measurable standards and criteria; providing a safe and conducive learning environment; and facilitating community engagement to ensure that what health workers are taught meets community needs and incorporates respectful care and socio-cultural sensitivity [
35]. Quality of initial education and ongoing training and support must ensure that SRMNAH workers remain competent to do their job effectively, can gain advanced clinical skills if desired or follow leadership and management training to become SRMNAH leaders. Continuous professional development programmes will increasingly be delivered through information and communications technology using blended learning that includes eLearning and face-to-face time, potentially in education hubs, either locally or regionally. A strong and functional regulatory system is also necessary with registration and licensing, incorporation of internationally consistent standards and codes, the accreditation of education programmes and continuing professional development frameworks so that periodic re-licensing and evidence of continued competence can be monitored. Vibrant and committed professional associations can provide: a point of leadership and advocacy, lobbying for improved working conditions (including flexible hours, adequate remuneration, leave, housing, transport, safety and security); opportunities for career development, promotion and incentives for retention; access to information and evidence for enhancing practice through continuing education and research. Effective support may include twinning models between individuals or associations [
36]. Development, training and support are required to assist the sustainability of associations and to enable members to work at political and government levels and exercise advocacy both for women generally and for SRMNAH workers.
An enabling practice environment includes access to effective and reliable consultation and referral networks [
37] as well human resources development, management and capacity building. The workshops highlighted the need for every country to have a minimum dataset on their SRMNAH workforce to enable efficient workforce planning and determination of the appropriate SRMNAH team [
38]. As result,
SoWMy2014 [
1] suggests that each country should routinely collect a minimum dataset of 10 data items to enable efficient planning of the SRMNAH workforce. This minimum dataset includes: headcounts of the professions involved, percentage of time spent on SRMNAH, roles, age distribution, retirement age, length of education, enrolments into, attrition and graduation from education, and voluntary attrition from the workforce [
1]. Innovative technology can help build projections and future workforce scenarios from anticipated changes and challenges to support policy decisions and fit-for-purpose adjustments more accurately [
38]. Undertaking a comprehensive SRMNAH workforce assessment would also address the future workforce needs and assist countries to determine how to best deploy their workforce to deliver essential SRMNAH interventions at scale and quality with universal access [
38].
Performance review and development is an important component of human resources management. This will identify the needs of individuals and services, including learning needs to maintain competence, the successes and challenges of their work and allows service delivery to meet the needs and culture of the local population. Performance review and development will identify the need for continuing professional education and quality improvement. Advancing along a career path is an important component of job satisfaction. A career matrix can enable people to undertake a range of roles at different times in their career while ensuring that knowledge and skills remain in the health-care system and the professions. Developing opportunities for staff to move into other roles including extended clinical roles, education, management or research will require formal development options including faculty development programmes. New technologies [
39] can enable ‘virtual’ schools or e-learning programmes to be established and widely accessed.
Inter-professional collaboration in education and practice is likely to ensure a fit-for-purpose workforce is developed [
40]. Implementing inter-disciplinary teamwork and collaboration involves: learning together to create a ‘collaboration-ready’ workforce, and; respecting and building on each other’s disciplines and competences, communicating with one another and handing over to ensure continuity and consistency of care for women, and debriefing together to learn from errors.
The data from the workshops were an important contribution in the development of a pathway for policy and planning that is known as
Midwifery2030 [
1,
41].
Midwifery2030 is based on what women, adolescents and newborns need and want from an effective health system, it presents a coherent policy and planning vision to guide the provision of services across the two continuums of SRMNAH care: from pre-pregnancy to post-partum/postnatal and from communities to referral hospitals.
Midwifery2030 focuses on addressing supply and demand side issues through increasing the AAAQ of health services and health providers, reaching a greater proportion of the population (increasing coverage) and extending the basic and essential health package (increasing services) while protecting against financial hardship (increasing financial protection).
These workshops were conducted prior to the end of the Millennium Development Goals era and before the Sustainable Development Goals (SDGs) were instituted. Many of the SDGs clearly impact on SRMNAH and the ability of the SRMNAH workforce to provide quality care, including the goals that involve gender equity, education, poverty, hunger and water and sanitation [
42]. The SDGs highlight that a holistic, equitable and coherent outlook is needed and recognises that there are multiple dimensions, inter-linkages; cross-cutting issues and partnerships that need to be addressed. Addressing these broader issues will impact on SDG 3 and ultimately the capacity and capabilities of the SRMNAH workforce in the SDG era (2015–2030).