As we build back health systems in the wake of COVID-19, we urgently need more investment to help transform care. The global stats were bleak before the pandemic and the shockwaves leave the vulnerable at most risk. Each day in 2017, 810 women died from preventable causes related to pregnancy and childbirth. And each year, there are more than two million stillbirths, and a further two and a half million newborns die in first 28 days of life. This accounts for 47% of all under-5 child deaths. 99% of these deaths happen in low & middle income countries (LMICs), especially for the poorest families. And most are preventable

The unique insight, patient rapport, and frontline experience of midwives is central to improving quality of care and ending preventable maternal and newborn deaths. Below are three examples of this in action.

1. Identifying key enablers and barriers in Kangaroo Mother Care (KMC)

Maura Daly is a midwife who did a MsC in Public Health for Development at LSHTM in 2017 and was a co-first author on this publication. This qualitative was work embedded within a Wellcome Trust funded eKMC project in The Gambia, and explored perceptions of female relatives (aunties / grandmothers) of hospitalised neonates <2000g towards small and sick newborn care, particularly KMC. 

Why is it important?

This work identifies key barriers and enablers for female relatives to support mothers and act as substitute KMC providers for hospitalised preterm and small newborns in a West African urban setting.

The insights we gained were used during the implementation of KMC as standard care at the Edward Francis Small Teaching Hospital in The Gambia (2017) and helped to promote family centred care on the neonatal unit and elsewhere in The Gambia. The voices of these women have the power to identify and address barriers and enablers for more widespread adoption of KMC as a life-saving intervention for small, vulnerable newborns.

2. Key contributions to the Every Newborn – BIRTH Study 

The EN-BIRTH study was conducted in five hospitals involving midwives, researchers and women in Bangladesh, Nepal and Tanzania. The findings from EN-BIRTH have important implications for how midwives, and other maternal and newborn health experts are:

• Measuring progress for the Sustainable Development Goals, especially related to Every Newborn targets, to reduce ~5.4 million stillbirths, newborn and maternal deaths.
• Improving measurement of coverage and quality of maternal and newborn care in routine facility registers and in population-based surveys.

Recent related EN-BIRTH papers with first authorship contributions from midwives include.

• Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study

Why is this important? 

Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH but there are no standardised data collected in large-scale measurement platforms. The EN-BIRTH study assessed the validity of measurement of coverage and quality for uterotonics among other newborn indicators. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. To address these, midwives need further data sources such as local audits—as well as service readiness or health facility assessments monitoring drug quality, stock management and provider practices. Standardisation of register design and implementation could help midwives improve data quality and data flow from registers into health management information reporting systems, especially given the pressures on frontline staff and the imperative to avoid any unnecessary reporting burden. 

• Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

Why is this important? 

Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The EN-BIRTH study assessed the validity of measurement of RMNC among other indicators. We found that specific questions, with stratification by mode of birth, women’s age and ethnicity, are important to identify those mistreated during care and to prioritise action. Improvements in measurement of more tangible events (privacy, companionship, separation) in large-scale household surveys linked to other data sources (such as service readiness surveys) are needed. Specific indicator measurement testing including validity for experience of newborn care (e.g. skin-to-skin contact as a proxy for zero separation) could also be assessed for potential use as a tracer indicator of RMNC in different information systems. Improvements to these data could also support midwives and other professionals to understand if improving experience of care for vaginal births may help curb rising caesarean section rates. 

3. Wise words: The lessons learned from midwives

By Prof Wendy Graham

On this International Day of the Midwife 2021, I would like acknowledge lessons learnt over 20 years ago from the incredible midwives in two district hospitals in Ghana. Throughout my own long career, the wise words from two such individuals have stuck with me (perhaps in part as they were called Alice and Florence – the names of my own daughters). These midwives embraced and contributed to a research project on improving maternity care, providing rich observations and feedback, alongside their heavy clinical load in an under-resourced hospital setting.

Two of their phrases in particular have been regular flashbacks during my subsequent research and are as relevant today as they were two decades ago. One phrase – “book no lie”- was coined by Alice as a poignant lesson about the importance of maintaining case notes and, how in the context of clinical audit, as she noted “if it was not written down, it was not done” – the book does not indeed lie. She realised immediately that the empty or incomplete record was both a marker of poor practice and a target for quality improvement. This remains an important lesson for the next generation of practising midwives and for those relying on registers and records for service delivery and research. The second phrase – from Florence - “audit is like holding-up a mirror” captures the importance of (literally) reflective practise and highlights the challenges in resource-settings where there is limited routine feedback to gauge the quality of the care being provided. Florence’s words are echoed in the title of paper we published on this particular project, and warrant repeating today. Midwives remain at the forefront of calling for a “mirror to be held up” to their own practises and for all women and babies to receive respectful care.