Experiences of a new cadre of midwives in Bangladesh: findings from a mixed method study

There is significant global evidence that women and their newborns receiving midwife-led care are less likely to develop complications and that scaling up professional midwifery can avert maternal deaths, stillbirths and neonatal deaths [1, 2]. Research also shows that midwifery is associated with improved health outcomes and efficient use of resources when it is provided by midwives who are well-educated, trained, licensed, regulated and integrated into a health system with effective teamwork, referral mechanisms and sufficient resources [3]. However, in 2014, only 4 out of 73 high-burden countries (countries with 92% of global maternal and neonatal mortality) had a midwifery workforce that was adequate to meet the needs and there is a consensus that more midwives are needed to improve maternal and newborn survival [4, 5]. Bangladesh is one of those countries which lacked dedicated midwives in its health workforce [6‐8].

Various initiatives have been taken in Bangladesh over the last four decades to increase the number of healthcare workers with the competencies to assist women and newborn to make pregnancy and childbirth safer. Historically, the nursing colleges have attempted to integrate and provide supplementary midwifery education to nurses to produce nurse-midwives to work in health facilities [9]. Community maternal and child health services are provided mainly by family welfare visitors (FWVs), who are trained in the country’s public health administration and training institutions, named family welfare visitors’ training institutes (FWVTIs), under direction of the Family Planning Directorate (FPD).

In the 1980s, the Ministry of Health and Family Welfare (MoHFW) provided a short training to traditional birth attendants (TBAs) to produce more than 50,000 trained traditional birth attendants (TTBAs) to assist women in their communities and supplement the work of the FWVs, especially in hard to reach areas. The programme did not achieve its intended results as studies have shown that the TTBAs continued to adhere to their traditional practices [10, 11]. Similar initiatives of training TBAs have failed in other countries as well and the World Health Organization has cautioned against plans to simplify and delegate tasks [12, 13]. In 2003 responding to the global call to provide all pregnant women with a skilled birth attendant and recognising that vast numbers of women still gave birth outside of a health facility, the MoHFW embarked on a programme to provided 6 months training to community health workers and produced around 13,000 community skilled birth attendants (CSBA). Despite large investment in this programme, the impact could not be established and there were confusions with their dual role of providing community health services and as skilled birth attendants (SBA), in addition to the questions of competency in fulfilling the definition of a SBA and the low uptake of services by the community [14, 15]

In 2010, at the 65th General Assembly of the United Nations the Prime Minister of Bangladesh announced producing and deploying dedicated midwives as an attempt to have a permanent solution to the shortage of SBAs [4, 6]. Subsequently, the curriculum and the regulatory frameworks for the diploma midwifery education and mentorship programme were developed with support from the development partners [16, 17]. The curriculum has been designed to incorporate general courses (Science and English), foundation courses (such as anatomy and pharmacology) and professional courses (from newborn complexities to maternity experience) [18]. In September 2018, 55 education and training institutes (38 government and 17 private) had 1565 available placements (975 government and 590 private) to produce diploma midwives, while the government created 2996 midwifery service posts in 1733 primary healthcare facilities across the country. In 2018, MoHFW recruited 1143 licensed midwives and deployed them in 342 health facilities (Personal communications, MoHFW and United Nations Population Fund (UNFPA)).

The objective of this paper, which is part of a larger study, was to better understand the experience of the midwives in their education programme and their first posting and to assess their knowledge and skill.

This paper is a small component of a larger study to outline the initial status of a national effort for scaling up professional diploma midwives in Bangladesh as a new and dedicated health workforce. It is too early to comment on whether scaling up diploma midwives is likely to achieve the expected outcomes. However, there is evidence that there are women willing to enter and remain in this profession. This is important as evidence exists to show that a skilled health workforce dedicated to addressing maternal and neonatal health can have important impacts [22, 23]. Previous studies have also suggested that there is high political commitment for scaling up the midwifery programme in Bangladesh and that the programme has high potential, particularly if multiple partners and stakeholders work in close collaboration [24]. Finally, our study demonstrates that a curriculum covering the internationally agreed competencies of a midwife does exist and is being implemented to produce competent professional midwives in Bangladesh.

The findings of our study are broadly consistent with the social, professional and economic barriers highlighted in other studies [25, 26]. While the midwives are highly motivated and keen to make a difference, an enabling working environment is critical to their success and is still to be secured. It is concerning that 38% of the tasks reported by the midwives are unrelated to midwifery. A previous study in Bangladesh had reported that nurses used only 6% of their time in patient care because of various health systems and social factors [27]. This indicates that there is a precedence of inappropriate use of health workforce in Bangladesh, which might affect this newly deployed workforce as well. A study conducted with government health workers in Bangladesh reported a high level of dissatisfaction, including inadequate supplies and infrastructure, bad behaviour of patients and administrative problems [28]. A Cochrane review on the factors influencing the performance of skill birth attendants in low- and middle-income countries also identified access to training and supervision, staff numbers and workloads, salaries and living conditions and access to well-equipped and well-organised health facilities as the key driving factors to keep the SBAs motivated [29]. Therefore, it is possible that the current high motivational level of the midwives may not continue if these factors are not addressed.

The results from this study regarding the mean score of the knowledge test of the midwives is positive and was much higher than reported for nurses using a similar tool, which was 25.2% in a previously conducted survey [20]. Both nurses and midwives are currently in the same level (second class officer) in public service, and from the knowledge and skills assessment, there is no reason not to see these two cadres as equal. Not only were the findings of the knowledge and skills assessment reassuring, the midwives also reported to be satisfied with their education programme. Again this is another positive finding given that a previous study highlighted some gaps in education capacity and quality assurance of the midwifery programme in Bangladesh [30]. Our results showing satisfactory clinical knowledge and a high level of self-reported confidence on clinical skills suggests that some of those early concerns have been addressed. However, it is important to be mindful that this finding could be because they have just finished their programme and started their job, and therefore have not yet full experienced all the professional and personal challenges that may face them.

While, globally, the proportion of mothers giving birth at home has significantly reduced in recent years, 53% of the births in Bangladesh still take place at home and 29% and 4% take place at private and NGO sector health facilities respectively [31]. There is evidence that women living in poor and remote settings often chose services from the private sector over the public sector [32]. The diploma midwives are being deployed at the public sector health facilities that so far cover only 14% of the total births, leaving a vast majority of the birth places uncovered with this programme. While it is possible that institutional deliveries in the public sector facilities might increase because of the deployment of the midwives, it might take some time to make the cultural changes to move away from giving birth at home. Therefore, the ability for these diploma midwives to work as close as possible with women where women live will be paramount. Further, it is not clear in the current policy documents how the midwives in Bangladesh would contribute to increasing quality skilled birth attendance for home and private sector deliveries.

There are some important limitations of this study. Firstly, we have used a self-assessment tool for clinical skills instead of complex and expensive techniques like vignettes or direct clinical observation which can assess skills more objectively. However, this approach was considered as a suitable proxy to the study team as it has been used in evaluations of midwives’ skills in some other low-resource settings [33]. Secondly, some of the concepts used in this study (for example, faculty, environment, management and supervision) are quite complex, and it is possible that not all respondents understood these concepts in the same way. We have attempted to mitigate this risk by explaining these concepts clearly to the enumerators during the training. Finally, a Likert scale could have showed more variation in the responses instead of binary “yes” and “no” response for the self-reported skills questions, However, since the module for this question was already long and since this questionnaire has been successfully used in other settings, we did not change that [19, 33].

While the results presented in this paper show the new midwives deployed at the health facilities are largely motivated, some expressed dissatisfactions regarding the education programme, crucially in relation to hands-on practice and working with women at the community level; also the work many are currently performing include tasks outside and unrelated to midwifery and for which they are not appropriately educated for. The finding also indicate that the midwives seem to have a satisfactory level of knowledge and have acquired the required skills in most of the areas except history taking, but many reported not being authorised by supervisors to perform several midwifery tasks. Lack of necessary equipment and supplies at the facility is another reason for constraining the midwives from sufficiently carrying out their duties. The ambition by most midwives appears to be able to work in the public sector, though they have concerns about being transferred, this bodes well for the public health services. Many midwives however also have plans to migrate abroad in the future, raising the concern of retention.