Training midwives in the developing world

If midwifery services were improved by 2015, approximately 3.6 million lives could be saved each year, says the State of the World’s Midwifery Report.

The report, which was released by UNFPA on June 20th, also indicates that unless an additional 112,000 midwives are trained and retained in supportive environments, 38 of the 58 countries will not be on track to meet the requirement of 95 percent coverage of live births by skilled attendant, a target of Millenium Development Goal 5.

GlobalPost spoke with Frances Ganges, Technical Director at the White Ribbon Alliance and a board member of the International Confederation of Midwives. She has 25 years of experience as a midwife and has spent 20 of those years working in Africa, training hundreds of midwives and midwifery tutors in Kenya, Uganda, and more than a dozen other countries. She is based in the Washington, D.C. area.

Countries like Ethiopia are looking at training thousands of new midwives with GHI funding. What does it take to train a midwife?

Thousands, that’s a huge number for any country, and when you think about it, there's a huge amount of other work that needs to be done first. It's been my experience in training many, many midwives in Africa, that many times the tutors and teachers themselves haven't been updated … some of them haven’t had continuing education in decades.

When I was working in Ghana, I saw that you can have over 100 people in one class, getting a lesson. They can go to a lab, and there will be 30 or 40 students at a demonstration. I can't imagine a school being swamped with another 100 students or 200 students. Just addressing the infrastructure of the training system to prepare for a large intake of students is enormous. I have no idea how much that costs. I know it's going to be a lot.

Are there enough midwifery experts in countries like Ethiopia to plan for these huge programs, to update the curriculum, and so on?

I would say no, because you're taking practicing midwives and taking them away from their existing work. But I think it's important to draw them from the region, because if not, you're bringing in expats, and that's not sustainable either.

Another problem is hiring these midwives once they're trained. Sometimes the funding isn’t available to hire existing midwives, let alone thousands more. And another problem is [staffing in] rural areas. Getting health care professionals to move to rural areas is a problem in every country. No one wants to be 500 miles from a city with no bank, inadequate schools for their children and then no equipment to take care of the mothers.. So what happens is that when people get a year or two of experience, they flee. I can't blame them. This poor midwife, out in the boonies, and she may have no way to get her salary for months at a time. So you need some kind of infrastructure created where midwives can be where women need them the most.

What potential do you think midwives could have to make a difference in the health systems of these countries?

I think there's a huge potential. Three years’ training is certainly a solid foundation, as long as there's adequate training for dealing with complications, because that's why women die. I think it would make a huge difference, but only if you're going to get the women out to the areas where there's a lack of facilities, a lack of infrastructure, a lack of ability to deal with complications. She also needs supplies. If she's there, she's nice and trained, she's passed her exams and is qualified, but she has no oxytocin, she has no gloves, she has no sutures, what's the point? Even the patients don’t want to go to a clinic where there's no clean toilet, there's no running water… even the mothers don't want to go there unless it's an emergency.

Why is the idea of midwifery getting so much attention now in the world of international development?

There was the UN Secretary General’s meeting [Joint Action Plan to improve maternal health] and a lot of things going on around the world in terms of advocacy for [maternal and newborn health], and I think it's time the world paid attention. So now it's great, we know the problem, but what do we do about it? One of the solutions is absolutely addressing the health worker shortage issue.

How similar are midwifery practices relatively around the world? Is each program culturally different?

I think it's relatively similar, and the International Confederation of Midwives is working on global education standards, so when you’re talking about a midwife, you’re talking about someone with the same skills. I think in virtually every country there's a traditional role in terms of traditional birth attendants, or traditional midwives, who attend women at birth, whether it's a family member, like an aunt, or someone who learned her skills as an apprentice. And then there are professional midwives in most countries. They may be called something a little different. In east and southern Africa, for example, nurses are also trained as midwives as well.

As you read about GHI, as a midwifery expert, what kind of information are you watching for to understand what’s happening?

I'm watching for more of the practical responses—working with the countries and the governments, so not just giving something to them but working for sustainable solutions. And solutions that aren't going to be overnight, — there is no magic bullet. This is a huge undertaking that is going to take years to implement. It's not a 5-yr plan. It's a 15- or 20-year plan. I welcome the idea, but … to realistically put a plan in place, I want to see it done right. Otherwise it's going to be a huge waste of resources that's going to make a difference here or there, but won't be a real change.

This interview has been condensed and edited.