"Professional Midwife led Maternal and Newborn Health Care in Bangladesh"

The joint Daily Star-UNFPA  roundtable entitled “Professional Midwife led Maternal and Newborn Health Care in Bangladesh” was held on the 28th of January in Dhaka. The roundtable highlighted the importance of professional midwives leading reproductive health care for women. Women having access to a midwife before, during and after pregnancy and delivery has shown to reduce maternal and newborn deaths significantly. Midwife-led maternal and newborn health care in Bangladesh is vital as currently more than  83,000 stillbirths, 5,200 pregnancy-related deaths of women, and 76,000 neonatal deaths  are reported annually. A majority of these deaths are preventable, simply by having a professionally educated midwife attending women and newborns.

 The roundtable was moderated by Reaz Ahmed, Assignment Editor of The Daily Star, and attended by the Honourable Member of Parliament, Professor Dr. Habibe Millat as Chief Guest. Rondi Anderson, Midwifery Specialist from UNFPA gave an overview of midwifery in Bangladesh before a panel of esteemed participants coming from relevant ministries, embassies and other reputed NGOs such as GIZ, BRAC, JHPIEGO, KOIKCA, IPA, Save the Children and many more.

Rondi Anderson termed midwives as at the frontline for reproductive healthcare globally. She said that Bangladesh is leading in the region in working towards having a midwife for every woman during her pregnancy, delivery and post-delivery period. In line with the SDGs, the Bangladeshi health sector plan calls for equity, quality and efficiency for improving the present healthcare facilities and services. She highlighted the important role midwives play in preventing maternal and neonatal mortality and morbidity, thus giving rise to the importance of identifying midwifery as a separate profession in the medical field.  In Bangladesh only 42% of deliveries are attended by skilled birth attendants, and only 38% of deliveries take place at institutions. One midwife can provide 87% of the required essential care for women and newborns and can conduct 50% of deliveries in a union. In addition they can provide post-partum family planning services. The Bangladesh government has approved 3000 posts for midwives in fulfilling its pledge to the “Every Woman Every Child” strategy of the United Nations.

Participants at the roundtable were informed by the UNFPA expert that the current maternal mortality rate (MMR) is 170 per 100,000 live births and Bangladesh must strive hard to reduce it to 70 per 1,00,000 live births by 2030 as per its SDG commitment.

Mr. Goutam Aich Sarker, joint secretary (Nursing) of the Ministry for Health and Family Welfare (MoHFW) said that though a three-year diploma course in midwifery is  offered at 38 government institutes and 14  private organisations including Brac and other NGOs, the service of midwives at rural health centres remains a challenge because of the centres' dilapidated condition.

Lawmaker Prof. Dr. Habibe Millat informed that Bangladesh has achieved a lot in the last 5 years, especially in reaching the target for child mortality (MDG 4) and eradicating polio. He said improvements are an ongoing process, but still the percentage of home deliveries stands at a staggering 63% and 58% do not even have skilled birth attendants during delivery. Child marriage is still a grave concern.  Initiatives are being taken to establish laws that will decrease the rate of child marriage. Dr. Millat further said that amongst the seven divisions in the country, the National Survey shows that the highest mortality rate is in Rajshahi; 290 per 100000, yet in the neigbouring divisions the rates are significantly lower. Further work needs to be done to understand why the numbers vary significantly from division to division.  Prof. Habibe Millat observed that the maternal and labour ward is the most neglected ward in many hospitals, even at the country's leading Dhaka Medical College Hospital. He emphasized the importance of increasing the health budget to ensure that national and global goals in the health and development sector could be achieved.

Luc de Bernis, consultant for the International Confederation of Midwives (ICM) informed the roundtable that the Bangladesh health minister had asked the ICM and UNFPA to pilot the implementation of  the Midwifery Services Framework (MSF)  in Bangladesh to ensure that newly trained midwives will be able to work in an enabling environment. He said we have to accelerate our concerted efforts to reach the SDG target of reducing maternal deaths to 70 in every 100,000 live births. A reduction in the maternal mortality ratio(MMR) here has been maintained between 2010 and 2015. But the fact remains that 50% of the pregnant women do not have access to skilled birth attendants when they are ready to give birth. He also touched upon the issue of high rate of child marriage and child pregnancy in the country. He mentioned the importance of working on women's rights and empowerment as fundamental for society and maternal and newborn health.

Frances Ganges, Chief Executive of ICM said no matter where a woman is, no matter what are the circumstances or situation is, her health and wellbeing can be improved by the care of a midwife. She stressed the necessity of women having access to midwives for respectful and quality health care and clearly stated that not even one maternal death is acceptable. Moreover she highlighted the need for maintaining global standards in midwifery education and implementation of MSF.

In her comments, UNFPA Country Representative Argentina Matavel Piccin acknowledged the importance of a strong joint approach for strengthening midwifery and maternal and newborn health in Bangladesh. She mentioned the midwifery training programme of Brac and GIZ as playing a strong role alongside the Government midwifery programme and thanked the donors such as Department for International Development (DFID), Korean International Cooperation Agency (KOICA) and the governments of the USA, Canada and Sweden for extending the needed support to the Bangladesh government. 

Momena Khatun, senior health adviser of Canadian International Development Agency (CIDA) talked about the need for follow-up and assessment of the midwife graduates after their posting in respective centres.

Dr. Jahiruddin Ahmed, interim chairperson of the department of midwifery and nursing, Brac University informed that Brac has been offering the biggest midwifery training course in the private sector since 2013 with the financial support of DFID. Their graduates are going to be deployed in hard to reach areas of the country.

Ahn Eun -Young, health specialist of KOICA pointed out that the faculty members of 3-year midwifery diploma course were nurse-midwives. She said that teachers should have required educational background to run the course.

Rowshan Ara Begum, president of Obstetrical and Gynaecological Society of Bangladesh (OGSB), advised the midwives present in the programme to listen to mothers with all their heart. She raised the importance of putting in place a monitoring mechanism for health providers including midwives. Md. Shajedul Hasan, joint secretary of Human Resource Development Unit of the MOHFW suggested a career path for the midwives.

From among the participating midwives, a fresh graduate in midwifery Tania Akhtar believes there is need for continuous in-service training and safety and security at posting locations. Salma Khatun, a certified midwife working at an upazila health centre in Sathkhira said that counselling of the pregnant women as well as their family members should be included in the curriculum.

Halima Akhter, president of Bangladesh Midwifery Society highlighted the lack of teachers and also mentioned the fact that the current teachers were recruited from nurse-midwives. 

Recommendations: 
* Deployment of midwives to rural health centres. Increase the health budget to make reaching goals possible.  
* Mobilisation of the communities in order to achieve success in healthcare programmes
* Working on the rights issue of women which is fundamental in life. 
* Maintaining global standards in midwifery education and implementation of MSF.
* Need to follow-up midwife graduates after their posting in respective centres. 
* Midwifery teachers should have required educational background to run the course. 
* Need for continuous in-service training and safety and security at posting locations.
* Counselling pregnant women as well as their family members should be included in the curriculum.