Safe Delivery – Role of a novice midwife

[1].According to UNICEF (2011), for everyday 1,000 women die in the world during the childbearing process, out of this, 99% casualties occur in the developing countries [2].  In Pakistan, the MMR is 276/100,000 which is the highest among South Asian countries [2].One of the major reasons for high mortality rate is unsafe deliveries conducted by novice and inexperienced midwives or “dais”[3].

Recently the issue of whether a novice midwife should or should not conduct the delivery has been widely debated in our country. It is an important burning issue because a human life is at risk.[4,5,6] This paper will describe various reasons for which novice midwives should not conduct deliveries. These reasons include:  lack competency among novice midwife to tackle complex situation, insufficient training at midwifery schools, and unavailability of resources at work place.

First of all, novice midwives lack competency to deal with complex clinical situations because they lack extensive clinical training under competent supervision. Competency can be gained through knowledge, skills and integrated theoretical concepts in clinical setting [7]. In Pakistan, novice midwives unable to perform competent and confident care as their training do not expose them to the skills which are required for safe practice e.g., antenatal, intranatal and postnatal care [3]. It is believed that lack of exposure leads to confusion in newly qualified midwife to perform in clinical environment. According to Pakistan Nursing Council criteria for midwives training, they need to conduct 25 independent deliveries; nonetheless, this is often ignored due to incompetency of student midwives skills in the subject. Moreover lack of-supervision from experienced staff might result in more anxiousness in novice nurse. A usual method for assigning tasks to new midwives is that a supervisor would brief the group about their roles and responsibility and would disappear from the scene. This leaves new midwives totally unsupervised and when they need guidance there is no one to whom they can refer to. [8].

Another important point to consider is that training method being followed in midwifery schools is traditional and flawed by imbalance of practical and theoretical approach; furthermore faculty is not updated on current development in the field [9]. In our country, most of the midwifery programs are based on old method of classroom teaching and learning. Moreover, average span of education curriculum is just 15 to 18 months. Therefore, such programs are not well directed to provide requisite training to these young girls to perform the role of midwife [3]. On social ground, as most of aspirant midwives belong to low to middle income class where they are not socially active and could face discomfort while discussing reproductive health and conducting physical examination of sensitive parts of the body such as vagina and breast. Faculty for midwifery program is usually experienced midwives, however, they are academically not qualified and average qualification is between intermediate to bachelors in nursing. According to a study, only 46% of theory tutors were trained, whereas, none of the clinical trainer received training of trainer (TOT) or any orientation [9]. With this quality of trainers, how can we expect that a novice nurses would be able to have enough knowledge to carry out a safe delivery. Therefore, they are not well versed with recent development in the subject. This seems to have direct impact on the quality of midwives who are produced from these schools. I strongly believe that training program should be evenly focused on theory and practical approach. Unfortunately, in our scenario, training program is more focused on theory based curriculum and lacks integral clinical / hands-on experience which is essential to boost confidence to enhance knowledge.  According to a study, 60% of the Principals admitted that clinical hands on training provided by their schools/institutes are not in conformity with the standards set by Pakistan Nursing Council [9].

Finally, unavailability of physical, human, and economic resources has adverse effect on newly qualified midwives. It is possible that most of the midwifery schools in Pakistan do not have healthcare infrastructure like laboratory, radiography, maternity wards, libraries and access to latest research material. This might result in adverse effect in the quality of students graduated from these schools. Majority of the schools lack equipment in the skill lab and there were none or very few teaching aids. Overall 1 of the 13 skill lab met about 70% requirement, which indicates how poorly our institutes are equipped to provide health care education [9]. As far as human resource is concerned, it is very likely that tutor student ratio is higher than recommended. Studies suggest that in some school ratio is 2:40 and eventually its effect the quality of tutor as well as the student [9]. By virtue of a third world developing country, Pakistan lacks economic resources especially in the field of education, and midwifery schools are also not spared from this dilemma. It is most likely that there is no or minimum support for government and health authorities to improve the quality of education for health care professionals.

However, the supporters of this subject might claim that a novice midwife could perform safe delivery under supervision of other experienced staff nurse and with appropriate training period of 3 year i.e. bachelor’s level. They might also claim that novice midwife could be competent in delivery with enough exposure and knowledge during their training program. Advanced education for diploma midwives could enhance their competency.

Bachelors program is being conducted at developed countries as these countries have well established universities which have requisite infrastructure, educational facilities and trained faculty which are integral parts of such programs. Unfortunately, in Pakistan’s context, there is no such institute which has such facilities to conduct 3 years program. Only Aga Khan University School of Nursing and Midwifery, which has better facilities compared to other midwifery schools, has recently launched a 3 years midwifery program on pilot basis and results are yet to come. Therefore, if curriculum for midwives changes from 18 month to bachelor’s level, this will not improve the quality of graduates as they will still have to go through the traditional teaching approach without requisite educational infrastructure [3].  Secondly, due to shortage of qualified and experienced nurses in Pakistan, it is very difficult to burden supervisory function on existing staff. This will have direct impact on patient care. Moreover, in 2005 when Pakistan went through the trauma of earthquake and many pregnant women suffered pelvic fractures and other complexities, the experienced midwives were not able to provide treatment to these pregnant women, rather they were giving care to non-pregnant women [3]. This also supports my argument that without proper education, experience is not enough to give license to these midwives to carry deliveries.

Hence, in the light of above arguments, safe deliveries could be conducted by novice midwives if their level of knowledge and clinical expertise could be enhanced. In the process of delivery, prompt and critical decisions need to be taken as per the demand of the situation; however, novice midwife lacks these skills due to insufficient training. On the contrary, four years education program coupled with one year compulsory training for midwifery would improve the midwifery level. Moreover, regular workshops for midwives which focused on early detection of high risk pregnancies and early referral would improve the health needs of women in Pakistan.

References

1. Ariff S, Soofi S, Sadiq K, Feroze A, Khan S, Jafarey S, et al. Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs. [Internet]. BMC health services research. 2009. p. 319. Available from: http://www.biomedcentral.com/1472-6963/10/319
2. UNICEF. (2011). The state of the World’s Children. Retrieved from

http://www.uncief.org/SOWC2011/pdfs/SOWC-2011-statistical-tables- 2082010.pdf

1. Rukanuddin  R J, Ali  T S , McManis B.  Midwifery education and maternal and neonatal health issues: Challenges in Pakistan. American College of Midwife, 2007; 52(4) 398- 405.
2. Hassan H, Jokhio A, Winter H, Macarthur C. Safe delivery and newborn care practices in Sindh, Pakistan: a community-based investigation of mothers and health workers. [Internet]. Midwifery. 2012. p. 466–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21906857
3. Anwar S, Jan R, Qureshi R, Rattani S. Perinatal women’s perceptions about midwifery led model of care in secondary care hospitals in Karachi, Pakistan. [Internet]. Midwifery. 2014. p. e79–90. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0266-6138(13)00312-4
4. Jan R, Mohammed Y, McIntyre H. Implementing midwifery led care in Pakistan. [Internet]. The practising midwife. 2011. p. 32–4. Available from: http://openurl.ingenta.com/content/nlm?genre=article&issn=1461-3123&volume=14&issue=6&spage=32&aulast=Jan
5. International Confederation of Midwives Essential Competencies for Basic Midwifery Education (2010). Retrieved from www.internationalmidwives.org
6. Shahnaz  S.  Factors affecting the midwifery led service provider model in Pakistan.2010. The Aga Khan University Hospital for Women, Karimabad. Retrieved from http://www.agakhanhospital.org/karimabad /midiwifery.asp
7. Midwifery Curriculum. Assessment of the quality of training of community midwife in Pakistan, 2010. Retrieved from

http://www.trfpakistan.org/LinkClick.aspx?fileticket=jNucN7xoy_E%3D&tabid=240