In 2004, a joint statement issued by the World Health Organization (WHO), the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) identified skilled birth attendants (SBAs), such as midwives, as an effective intervention for achieving Millennium Development Goal (MDG) 4—to reduce the neonatal mortality rate (NMR)—and MDG 5, to reduce the maternal mortality rate (MMR). In 2006, the Lancet series further emphasised the use of midwives as SBAs (Koblinsky et al, 2006). More recently, the 2014 Lancet series evaluated midwives' contribution and recognised them as the backbone of maternal, neonatal and child health services, and a strong, cost-effective resource for preventing maternal and neonatal mortality (Ten Hoope-Bender et al, 2014; Homer et al, 2014; Van Lerberghe et al, 2014). The SBA is defined as a professional who has acquired midwifery skills through accredited training by a local nursing and midwifery board to assist woman safely throughout the birth process (Koblinsky et al, 2006).
However, the State of the World's Midwifery report issued by the United Nations Population Fund (2014) identified that developing countries are short of competent midwives. Based on this information, many resource-poor countries, such as Pakistan, Afghanistan, Bangladesh, Indonesia, Kenya, and Tanzania, while setting their national targets to achieve MDGs 4 and 5, have introduced a cadre of SBAs known as community midwives (CMs) (Hennessy et al, 2006; Kenya Ministry of Health, 2012; Speakman et al, 2014; Turkmani and Gohar, 2015).
Pakistan is a South Asian country in which about 12.4% of the population lives below the poverty line (World Bank, 2012). Therefore, the MMR and NMR persistently remain high. This has a major impact on the two thirds of the population living in rural areas (Jafarey et al, 2009). Women residing in rural areas and low-income urban neighbourhoods usually give birth at home assisted by a traditional birth attendant (TBA) or a relative, as these people are easily available, accessible and affordable compared to SBAs (Rukanuddin et al, 2007; Ali et al, 2008; Khan et al, 2009). TBAs are generally older women, who initially acquire their skills by self-practice or working with other TBAs (WHO, 1992). Based on experience and informally acquired knowledge, TBAs have been found to be helpful in providing emotional support and imparting health education with regard to safe delivery, but they have not played an effective role in reducing the maternal or neonatal mortality rates for their countries (Sibley and Sipe, 2006; Garces et al, 2012).
The Pakistan government, as a participant in the Millennium Summit in 2000, promised to reduce the MMR from 276/100 000, to 140/100 000, and the NMR from 54/1000 to 40/1000, by generating 12 000 CMs by 2015 in line with MDGs 4 and 5 (National Institute of Population Studies, 2008). In Pakistan, CMs are local women with 10 years of basic education, who have acquired midwifery skills with an additional 18 months of midwifery education programmes accredited by the Pakistan Nursing Council (PNC, 2006), a regulatory body for nurses and midwives. Once the CMs complete their training, they are deployed to their respective communities using standard deployment policies developed in Pakistan by policy makers, midwifery tutors and district administrators (Government of Pakistan Ministry of Health, 2006). The original policy document consists of 10 sections; this study has summarised the policy by categorising it into three phases (Figure 1). The aim of this policy document is to set out an operational framework to facilitate CMs at their workplace in Pakistan. Studies conducted in Pakistan have identified that the CMs face various challenges in the workplace (Faisel et al, 2012; Sarfraz and Hamid, 2014). It was, therefore, considered relevant to explore the experiences of CMs during the implementation of the deployment policies.
Aim
The purpose of this study is to:
Methods
Study design
This study used a qualitative descriptive exploratory design to obtain the perspectives of 11 CMs who had been deployed in communities through the National Maternal, Newborn and Child Health Programme (NMNCHP). The study was conducted in Matiari, a sub-district of Hala in the province of Sindh, Pakistan. The selected site is about 250 km north of Karachi and has a MMR of 350/100 000 live births, which is higher than the country-wide figure of 276/100 000 (National Institute of Population Studies, 2008). Moreover, 52% of the women have homebirths attended by TBAs (Global Alliance for Vaccines and Immunization, 2010).
Ethical approval
The study was approved by the Ethical Review Committee of Aga Khan University. Written consent was obtained after educating the participants about the study's purpose, the contact time required and potential risks or benefits provided to them. The participants were informed of their research rights, such as withdrawing from the study at any stage.
Inclusion criteria
The total study population consisted of 11 CMs who had successfully completed the 18-month education programme from an accredited midwifery school and were currently deployed in the Matiari community by NMNCHP, after acquiring a license from PNC to practise midwifery independently. To recruit participants, a list of qualified CMs was obtained from the director of the Matiari NMNCHP district. Eligible candidates were contacted by telephone to participate 1 week before the interview.
Data collection
The data were collected in May 2013 through focus group discussions. This method is known to be appropriate and cost-effective for generating rich information through participants' interactions on the pertinent phenomena, when compared to individual in-depth interviews (Krueger and Casey, 2000). There were two focus groups consisting of 5 and 6 CMs respectively (n=11), each lasting 60–90 minutes. Both of the focus group discussions were held in Urdu, the national language of Pakistan, as preferred by the participants.
Data analysis
Qualitative content was analysed using Krueger's framework (Krueger and Casey, 2000). Based on this framework, the researcher first transcribed verbatim the participants' responses in Urdu, which were later translated into English. To ensure accuracy of the transcripts, the researcher listened to audio-taped discussions and read both the Urdu and English versions of the transcripts. The information was then summarised into codes, then grouped into categories from which themes were identified by using the inductive approach. The researcher's supervisors corroborated the authenticity of the data.
Findings
The demographic information obtained to describe the participants' profile is shown in Table 1. Following analysis of the qualitative content, one theme and four related categories emerged, illustrated in Figure 2. Participants were coded by focus group (FG) and responder (R) number.
| Variable | Number of participants | Percentage |
|---|---|---|
| Age | ||
| 18–24 years | 7 | 63.64% |
| 25–30 years | 3 | 27.27% |
| 31–34 years | 1 | 9.09% |
| Marital status | ||
| Married | 4 | 36.36% |
| Unmarried | 7 | 63.64% |
| Professional qualification | ||
| Community midwife | 11 | 100% |
| Experience | ||
| 3 months only | 11 | 100% |
| Academic qualification | ||
| Matriculation (10 years of school study) | 5 | 45.45% |
| Intermediate (passed 12th grade) | 2 | 18.18% |
| Bachelor (14 years of education) | 3 | 27.27% |
| Master (of Arts) | 1 | 9.09% |
Theme: survival as community midwives in the community
This theme represents the difficult experiences and negative influences of stakeholders that diminished the CMs' ability to continue working as a CM. Elaborating on the theme, participants used phrases like:
‘We are trapped like birds in a cage, which can't even fly.’ (FG2, R1)
These words evoke participants' sense of helplessness, disappointment and frustration in the workplace. Based on their present situation, all the participants regretted the efforts they had made to become CMs through the 18-month education programme. One participant said:
‘We have taken a diploma of a midwife [community midwife]. We have made great efforts and worked very hard, day and night, with great effort. But, in return, no one is giving us [CMs] any kind of positive response.’ (FG1, R5)
Another participant, expressing her sense of resentment, stated:
‘They [NMNCHP] have trained us as CM, we are ready to work with them [the district NMNCHP team, which is the employing agency], this [midwifery] is our profession, but for this [practising midwifery skills] we need facilities here and full support of our management.’ (FG2, R2)
Category 1: Lack of identity and recognition
In general, to secure their survival as CMs, participants were deeply concerned about acquiring a professional identity and status in the community. They were being regarded as Lady Health Workers (LHWs), instead of being identified as CMs. The basic role of the LHW is to promote maternal and child health care by means of health education and community mobilisation (Hafeez et al, 2011). Based on this identity confusion, one participant said:
‘So far no one [pregnant woman] has contacted us… When we visit pregnant women at home… they just consider us as LHWs, who go home to home to give polio vaccination to the children.’ (FG1, R5)
The study participants identified several reasons for not being recognised and acknowledged in their respective communities. The greatest blow was the lack of interest and attention given by the NMNCHP and the local district government to ensure a proper introduction of CMs to the community. One participant shared her exasperation:
‘…It's not like something would happen by only celebrating the Day of Midwives, or arranging seminars. Positive outcomes can only be achieved if something is done to promote midwives' recognition [appropriate introduction] in the community.’ (FG1, R7)
Category 2: State of helplessness
Participants felt helpless raising their concerns regarding the absence of supportive supervision from the management and the poor government initiation of independent CM practice within the assigned community. Elaborating on the skill, supervision experience and lack of support with the LHWs, one participant reported:
‘The actual support should be given to us by the LHWs… We have been working here for the last 3 months, but not a single LHW has ever come to… ask us whether we are having any problems in the community or not.’ (FG2, R3)
It is evident from these narratives that the participants felt completely left to their own devices, and did not receive any support from the professional and strategic management. While sharing the general experience of abandonment by the government, one participant stressed:
‘If they [government] have taken charge of somebody [midwives], then they shouldn't… leave them [midwives] in a state of helplessness, they [employing agency] should open a centre for them, so that the midwives can utilise their training [to practise midwifery skills] on receiving deployment.’ (FG2, R2)
Category 3: Depletion of competence and confidence
The participants regarded competence as the possession of core midwifery knowledge and skills, and confidence as the ability to perform these skills to benefit mothers and newborns in the community. However, participants felt that they were neither competent nor confident in practising midwifery skills, identifying two reasons for this. First, they pointed out the lack of opportunities for practising midwifery skills independently during their training. Secondly, they were not able to practise for extended periods and so, over time, they had forgotten their acquired skills. The limited opportunity for CMs to practise midwifery skills combined with delayed deployment of around 2 years since attaining their qualification has greatly undermined their competence and confidence, making their survival difficult in the community. One participant reported:
‘Our training was going well. But when we were doing duties in hospital wards or labour room[s]… the LHWs and the doctors didn't pay much attention to us. When we [said], “Please make us do the deliveries along with you,” the [hospital staff] used to say that, “No, there is no need for you to see it, you just record all the things, we [hospital staff] have also learned in the same way, by writing everything and please don't share this thing with your madam [tutors].”’ (FG2, R4)
Commenting on delays in deployment, one participant shared:
‘Although we had full confidence in each other that, yes, we were able to do it [midwifery skills practice]… but as 2 years' time have passed since we completed the training, so most of the things are now going out of our minds… Even if we [CMs] remember certain things, if we do not remain in practice of midwifery skills, our hands would definitely shake while doing a certain kind of work.’ (FG1, R1)
Category 4: Unavailability of resources and financial support
Participants highlighted three issues pertaining to resources. These were: non-establishment of work stations (birthing centres); non-availability of essential equipment and drugs; and lack of financial support. Of these, the most prominent problem was non-establishment of work stations. One participant, speaking on her peer's behalf, said:
‘One bigger problem is that we have been asked to open individual centres in our home. Now tell me, if a girl is living in a two-room house with her mother, brother, and bhabhi [brother's wife], how will she get one room to open a centre? Definitely none of the family members would spare their room for the opening of the individual centre… They [project officers] just order us: “You should open the centre at your own house.” But we face a lot of challenges and problems with this… There is no base built for us yet, so, definitely, we have to face a lot of difficulties in achieving our goals.’ (FG1, R3)
The next issue pertaining to resources was the supply of equipment, medicines and birthing kits, which most participants considered important for their survival. However, according to the participants, many of them were not provided with any of these resources. One participant shared:
‘LHWs bring the antenatal and family planning cases to us. Though we don't have any kind of medicine for them here… We just examine these clients, we don't have anything to give to them.’ (FG2, R5)
Further financial hardship was suffered through unpaid salaries and non-reimbursement of official activities. One participant said:
‘I don't get any financial support from my management… I don't even get the delivery cases independently; I haven't become so famous or renowned that I would get a lot of clients and all that. So, definitely, I myself have to spend all [the] money from my own pocket.’ (FG1, R1)
A surprising revelation was that the existing government has set a fixed fee for a birthing process for CMs at 500 Pakistani rupees (approximately £3.10). The monthly remuneration was 2000 rupees (approximately £12.41), with no payment of charges for antenatal and postnatal check-ups. One participant said:
‘The NMNCHP people have told us to charge 500 rupees for the delivery from the patient, which is not enough… See we [CMs] have to do a lot of work at the time of the delivery; for instance, we monitor labour, provide all support, and we would expect to clean our ladies up following birth as part of the complete package of care.’ (FG2, R4)
Discussion
It is a key requirement of the CM deployment policies that qualified CMs should be fit for independent midwifery practice in their assigned community area. Yet, the findings of this study have revealed that none of the CMs felt ready to adopt an independent role due to the gaps in clinical training, delayed deployment, and unavailability of refresher courses. According to the participants, they completed their training 2–3 years ago, but the deployment creates a gap between learning and practice. This diminished their knowledge, skills, competence and confidence for adopting independent midwifery practice (Hughes and Fraser, 2011). Furthermore, the participants' narratives indicated that before deployment, they did not receive any refresher training or regular supportive supervision, which hindered their ability to practise as independent CMs. As a result, almost all the participants in the current study requested refresher training so that they could gain competence and confidence to become independent midwives at the time of their deployment. These findings echo the ICM (2013) policies on the essential competencies of midwifery, along with United Nations Population Fund (2014) reports and other published literature (Maclean, 2003; Mohmand, 2013; Renfrew et al, 2014).
Refresher training is also a reinforcement to policy instructions for CMs in Pakistan (NMNCHP, 2011), which suggest that all CMs should be provided a 3-month refresher course and supportive supervision to boost their knowledge and skills, reduce educational deficiencies and improve their performance. The findings of this study highlight a need for the development of support for the transition from newly qualified CM to independent professional practice. This is similar to what is practised in Indonesia for village midwives (D'Ambruoso et al, 2009) or the mentorship program in Afghanistan (Turkmani et al, 2014).
Another factor challenging CMs' professional survival in the community is the unavailability of logistical and financial resources. As written in the Pakistan CMs policies (NMNCHP, 2011), the logistic resources include essential medicine, contraceptive supplies, an examination table, an office table and chair, a delivery kit, and other professional items that would allow the CM to set up her practice effectively. The financial resources refer to a monthly stipend and earnings from delivery fees. However, the findings of this study revealed that the participants received neither a complete set of resources nor any financial support. These findings are consistent with those identified in the province of Punjab in Pakistan, where resources were not provided to undertake the role of a CM in maternal and child health care (Van Lerberghe et al, 2014).
With reference to logistic resources, each CM was also expected to establish a work station (birthing centre) within her own home. This was an unrealistic expectation, as all the participants lived with extended families in one- or two-bedroom apartments, lacking basic necessities such as a washroom, running water and electricity. Therefore, without external logistic resources, the feasibility of establishing a birth station remains impossible. To overcome this challenge, the authors suggest that CMs should be provided with some space in the basic health unit (a primary health-care facility present at the union council level) to provide a maternity service, rather than being expected to establish work stations in their homes. The CMs must also have direct access and referral pathways to functional tertiary referral units such as rural health centres and district hospitals, which is not currently in place. This would embed CMs within the local health system, allowing them to build the confidence to become autonomous midwifery practitioners. It would also improve the value of CMs in their respective communities, and the acceptance of their role would provide further evidence that the use of health-system support improves maternity services and outcomes in resource-poor countries (Van Lerberghe et al, 2014).
The study participants also felt that the monetary amount fixed by NMNCHP for their stipend of 2000 rupees per month and 500 rupees per case for managing births was too low for the amount of work that they performed. Having a fixed monetary incentive negatively impacted the CMs' income growth related to the inflationary rise of costs occurring in the country. Similar findings were reported in earlier studies conducted in 18 districts of Punjab and nine districts of Sindh, Pakistan (Faisel et al, 2012). These findings revealed reduced motivation in CMs due to irregular receipt of payments. However, in order to achieve MDGs 4 and 5, the WHO (2004) and some authors (Ten Hoope-Bender et al, 2014) advocate for the provision of all necessary resources that would enable CMs to work successfully in their communities. This study recommends that CMs should be provided with freedom to fix charges for their services. This would take into account the inflationary costs, cost of the supplies and resources, community standards, and the physical and financial condition of the woman concerned.
The CM deployment policy documents suggest strategies for local district governments to market the CMs' roles within their respective communities by organising official workshops and inviting all stakeholders. However, instead of using the official recommended strategies, the local district government handed over the CMs' introduction and advertising responsibility to LHWs (community-based female health workers assigned to improve maternal and child health services). This has created confusion for members of the community regarding the two different cadres' roles and may lead to potential conflict between LHWs and CMs, a phenomenon also described by Faisel et al (2012). The current study emphasises that to facilitate the recognition of CMs, their educational status, competencies and job descriptions, they must be supported through effective supervision. Current literature advocates the marketing of CMs as skilled maternity care professionals with recognition of their intended clients (Anwar et al, 2014; Saleem et al, 2015). Teaching business skills and marketing strategies to CMs could effectively support the marketing efforts among CMs in their communities (Lalji et al, 2014; Saleem et al, 2015).
Limitations
The study has limitations in generalisability as it was conducted at one site and included the experiences of one small cohort of CMs. The commonality of the findings and circumstances mirror other studies, especially regarding the sustainability issues of the services. Another limitation was that data were collected at one point, immediately after deployment; therefore, the participants could only share limited concerns that created difficulties at the initial stages. For the future, a longitudinal prospective study over several years would be valuable in providing comparative feedback on the factors that hinder or help CM deployment in communities, and could assist in refining the deployment policies in resource-poor countries.
Conclusion
This study explored the experiences of CMs from Sindh, Pakistan, collecting baseline information about their deployment processes and policies. It has highlighted the challenges faced by CMs to survive as independent practitioners once they are deployed in the community. The findings suggest that there is a need to revise the deployment policies, processes, introduction and initiation of CM services, availability of resources, and provision of appropriate supervision and adequate remuneration for CMs. If these revisions are fully implemented, this would go some way to ensure the sustainability of CMs in communities and would substantially contribute to success in achieving MDGs 4 and 5 in Pakistan.