Countries with scarce resources, like Pakistan, mostly have poor health indicators. Maternal, neonatal and child healthcare are often compromised as a result of a lack of availability and accessibility of trained birth attendants, such as midwives. Midwives are known to be the primary healthcare provider for women during the perinatal period. Generally, they face many challenges while working in communities; and being in a pandemic can worsen their problems. Pakistan has to apply possible strategies to promote the image of midwives and midwifery profession.
The Alma-Ata Declaration highlighted the importance of primary healthcare (World Health Organization [WHO], 1978). Countries across the globe developed action plans to strengthen the provision of primary healthcare services. Ten years later, the safe motherhood initiative was launched to promote perinatal care at community and healthcare facility level (Safe Motherhood, 1997). This initiative shifted the focus from traditional birth attendants towards skilled birth attendants. Skilled birth attendants are professionals, including midwives and obstetricians, who are trained to provide antenatal, intranatal, postnatal, and neonatal care, as well as family planning services to low risk women. Furthermore, they have to be competent in order to identify, manage and refer complicated maternal and neonatal cases to the appropriate levels of care in a timely manner (WHO et al, 2004).
Being a signatory of the Alma-Ata Declaration, Pakistan developed solutions to strengthen its healthcare delivery system by preparing different cadres of skilled healthcare providers (Sarfraz and Hamid, 2014). Initially, it introduced female health visitors and gradually, community health workers were trained and deployed in rural communities of the country. Maternal, neonatal and child health (MNCH) indicators in Pakistan have been alarming as a result of various factors, including a lack of resources, economic and political unrest, and natural disasters. To strengthen MNCH services, the government of Pakistan introduced community midwives in 2006 (Ariff et al, 2010; Shah et al, 2010; Wajid et al, 2010). Community midwives are identified as independent skilled birth attendants, licensed to practice midwifery as per the defined scope of practice provided by the national regulatory body, the Pakistan Nursing Council. Community midwives are the primary healthcare providers for low risk childbearing women living in rural areas of Pakistan, where there is often no other healthcare provider. This was an initiative by Pakistan's government to invest in midwifery and promote availability and accessibility of midwives, particularly in rural communities.
Need for midwives
The literature reveals that there is a lack of investment in midwifery education, regulation and service provision in developing countries. Therefore, MNCH-related health indicators are compromised (International Confederation of Midwives [ICM] et al, 2016).
Noticing the alarming MNCH-related indicators, the State of the World's midwifery report (United Nations Population Fund [UNFPA] et al, 2014) proposed to invest in midwives and the midwifery profession, to encourage cost-effective approaches in eliminating maternal and neonatal morbidity and mortality in developing countries (Homer et al, 2014; UNFPA et al, 2014). The Lancet series on midwifery revealed that midwives could prevent 83% of maternal and neonatal deaths by providing perinatal care and family planning services to low risk women (ten Hoope-Bender et al, 2014). Literature suggests that midwifery-led models of care can improve maternal and neonatal birth outcomes by providing woman-centered, respectful maternity care throughout the perinatal period (Sandall et al, 2016). Midwives strongly believe in the physiological process of childbirth and advocate for normality, as well as minimising the use of medical and surgical interventions during labor and childbirth. Consequently, women have a satisfying childbirth experience in midwifery-led models of care (Anwar et al, 2015).
Midwifery education and practice in Pakistan
Opportunities for higher education are vital for the professional growth of midwives. In 2013, the first post-diploma nurse–midwife baccalaureate program started in a nursing school in Karachi, Pakistan. This program is offered to candidates who have completed a diploma in both nursing and midwifery. A small number of graduates have successfully received their degree and are serving in different capacities, such as midwifery tutors, clinical preceptors, principals, and midwifery technical advisors (United Nations Population Fund, 2016).
Pakistan has invested in producing a large number of diploma holder midwives. They have been trained and made accessible and available to provide MNCH services in rural communities (UNFPA et al, 2014). Diploma holder midwives do not have a career ladder; most of them gradually divert towards nursing education by doing a diploma and bachelors in nursing (Sarfraz and Hamid, 2014). Consequently, the number of practicing midwives in communities has decreased, which affects MNCH service provision in the community.
Practicing in rural communities in Pakistan is often challenging for midwives. They face hardships in providing MNCH services. They are often disrespected, and lack recognition for their image (Sarfraz and Hamid, 2014). Community members and other healthcare providers, including female health visitors, general physicians, obstetricians, nurses, and traditional birth attendants, resist acceptance of midwives' distinct role in MNCH services, and see them as competitors rather than colleagues (Sarfraz and Hamid, 2014). One reason for the professional devaluation of midwives is the result of sociocultural feminisation attached to the midwifery profession (Filby et al, 2016).
An enabling environment is important for midwives, to broaden the horizon of their scope of practice (Novea et al, 2018). They require ongoing support and acknowledgement by their supervisors to become confident. Midwives in Pakistan do not have sufficient professional development opportunities, which makes them unskilled to manage the current pandemic (Cadée et al, 2020). Continuous professional education training is required to keep them updated about recent developments in the field. Furthermore, they need supportive supervision and necessary resources including personal protective equipment, medical surgical supplies, and an appropriate work setting, in order to practice efficiently.
Additionally, midwives need to acquire skills and maintain their services as independent practitioners.
Midwives and the pandemic
Coronavirus (COVID-19) has affected the health and wellbeing of individuals and service provision across the globe. No matter the state of the pandemic, healthcare providers have to work at the front lines. Similarly, midwives have to be actively involved in providing quality maternity care and conducting safe deliveries. They are expected to maintain the dignity of women and newborns and provide compassionate care at all times (American College of Nurse–Midwives, 2020).
Worldwide, evidence is coming to light related to the prevention and management of the novel coronavirus. Evidence-based guidelines relating to antenatal, intranatal, postnatal and neonatal care are also being developed (ICM, 2020). As the COVID-19 outbreak was unexpected, Pakistan, like other countries, lacked preparedness for it. It was anticipated that MNCH services might be compromised, as midwives seem to be less prepared than other healthcare providers to manage cases during the pandemic (Cadée et al, 2020; OCHA, 2020). Their service provision may be affected and they are a risk of being exposed to COVID-19 while providing maternity care. Moreover, midwives may also suffer from mental health problems as a result of working under pressure and being unable to cope with long and busy schedules. Midwives are prone to psychological issues from long and busy shifts (Walton, 2020) and a fear of COVID-19 (Gold, 2020).
People in Pakistan appreciate close family interactions and large gatherings. Staying home because of lockdown during the pandemic can have negative consequences on people's health. Parent-child and family interactions may be affected and the rights of women and their babies may be violated. Globally, since the outbreak of the pandemic, domestic violence against women and girls has intensified reaching to 243 million (United Nations, 2020). The number of cases is increasing every day in countries including the United Kingdom, Canada, the United States of America, Spain and France (United Nations, 2020). This situation can pose a risk of domestic violence, abuse and neglect for women, girls and children in Pakistan, leading to a wide range of mental health issues.
Pakistan has a domestic violence prevention and protection act, a national plan of action on human rights, and a policy for development and empowerment of women. It is important to consider these alongside international guidelines.
Solutions need be planned and implemented to support midwives' physical and mental health, and facilitate the provision of safe MNCH services. There is a need to build the capacity of midwives to promote healthy parent-child and family interactions. Being in close contact with women in communities, midwives need to learn skills to identify cases of domestic violence. They need to develop competency in assessing, managing and referring cases to experts in a timely manner. In addition to this, they need to be skilled in advocating for the rights of their clients.
Possible solutions
Midwives in Pakistan can be supported by offering higher education undergraduate and postgraduate degree programs, particularly in midwifery. Such opportunities for higher education may promote professional development and recognition of their role as skilled birth attendants. The government should include midwives in the national healthcare service structure and support them similarly to other skilled healthcare providers, such as female health visitors, nurses and doctors.
During the pandemic, pregnant women might not deliver in a facility and they may approach midwives for homebirths or birthing centre births. Therefore, to promote the health and wellbeing of both midwives and women, the government should equip midwives with personal protective equipment and related resources.
The midwifery services framework aims to provide an understanding of the midwife's role to improve the health and wellbeing of women and children by using practical, cost-effective approaches (Novea et al, 2018). Pakistan's national health ministry can apply the midwifery services framework to initiate, develop, strengthen, monitor and/or evaluate midwifery services to meet MNCH needs. This framework can be used to promote midwives' scope of work and strengthen their role in the community by providing an enabling environment.
Continuous online professional development opportunities should be designed for midwives by using mobile-friendly applications. This will help midwives to upgrade competencies by reviewing recent evidence-based guidelines at their preferred time. They should be provided with online updates about COVID-19 and its effects on maternal and child health. They need to be trained to guide parents on healthy parent-child and family interactions during lockdown and isolation. In addition, capacity building sessions on identification and first-line management related to violence, skills to promote healthy parenting, and awareness about promoting respectful maternity care by following human rights principles during the pandemic can be offered to midwives (WHO, 2020).
A business skills training module should be made part of the national diploma midwifery curriculum (Lalji et al, 2014; Ali et al, 2015). Such training will enhance midwives' entrepreneurship skills and thus, will enable them to plan and execute their services successfully.
Conclusions
Midwives are skilled birth attendants, able to provide MNCH services in Pakistan. They are significant contributors in achieving MNCH-related indictors in the country. They have to be counted as part of the national professional healthcare team. Considerable opportunities for higher education, professional support and an enabling environment is essential to promote their services. Supportive facilitation can empower midwives and help them gain confidence to practice independently according to their defined scope of practice. Respect and recognition of their unique role is important to empower them as skilled birth attendants.