Saturday, May 1, 2010

Shortage of midwives; situations, solutions and concerns

This is a guest blog post by Atf Gherissi who is a midwife in Tunisia. Atf wrote this discussion paper as one of the events of the Virtual International Day of the Midwife 5 May 2010. The French version of this paper can be found here.

Shortage of midwives; situations, solutions and concerns-Practice and Education Highlights on the midwifery situation in some regions

According to my modest experience and contributions in francophone African countries and in the Arab countries, whether for ICM, UNFPA and EMRO, I would like to share the following information and ideas regarding midwifery services and profession.

In the francophone African countries

An electronic survey has been conducted in 2007 by the FASFACO (Fédération des Associations de Sages Femmes d’Afrique Centrale et de l’Ouest) and supported by UNFPA among its member associations. A questionnaire sent to 13 midwifery associations was filled by 9 of them. Despite its limits, this survey highlights a serious shortage of midwives with ratios very far from WHO norm (1/5000 population).

Shared and discussed during the first FASFACO midwifery session held alongside the 5th SAGO (Société Africaine des Gynécologues Obstétriciens) in Kinshasa in 2007, with UNFPA and ICM support, these results opened a debate that raised the following issues regarding midwifery services and profession in Central and West Africa:

  • Disparity of Midwifery Curricula in terms of access and duration
  • Proliferation of Midwifery Schools (private and public) with no regard to the norms of quality of Education
  • Decreasing quality of Midwifery education comparatively to previous batches (tutoring, number of students not in adequacy with the education infrastructure)
  • Midwives gathered in the city as the result of an inadequate management of human resources (work environment, motivation, isolation) and absence of willing to practice inside the country
  • Absence of Midwifery career plan. As a result, midwives, demotivated, abandon the profession
  • Insufficient number of midwives trained per year : 115/9 countries
  • Creation of health facilities in the community without recruitment of qualified professionals

Operational recommendations derived from the discussions and mainly focused on the need to revise and harmonize midwifery curricula, to develop career plans for midwives, and to improve Education, Training and Work environment for midwives. Other recommendations emphasized on the need for establishing human resources plans and for identifying means to ensure adequate midwives distribution in the provinces (incitative measures, compulsory professional training with fixed duration). Another key recommendation concerned the vital need for strengthening partnerships between Midwives and the Community to re-establish the trust relation with women.

In the Arab countries

The situation should be the same but with an important difference in addressing midwifery education as an indirect entry program in conformity with the Anglophone education system knowing that in the francophone African countries, this education is mostly direct entry.

The strategy of assigning professionals with multiple profiles to provide SRH services to women mostly in remote areas looks to be a definitive option while it has to be considered as a transitional option meanwhile the country will be covered with enough certified midwives. These professionals count certified midwives, nurse midwives, auxiliary midwives, community midwives, nurses MCH, non physician clinicians…… In Tunisia, because of the sudden shortage of certified midwives during the Independence year (1956), the MoH provided 6 months intensive obstetrics training to 11 nurses who were the first qualified midwives in the country but having a title of auxiliary midwives. This option has been stopped in 1979 as the country was covered by certified midwives whom the direct entry education program was launched since 1967.

Among the negative outcomes of such a strategy, it is important to highlight that these professionals are not always hired such as in Yemen where midwives are trained but don’t work once certified. The Yemen Midwifery Association developed a project with the support of USAID to train these midwives to serve women as private providers of maternal care.

The other negative outcome is that all of them have in common their assignment but are different by their background and by the quality of the services provided. In some countries, it happens that these professionals work in the same health setting, but in a conflict situation which alienates more the credibility that each of the system, the setting and themselves, don’t have enough in the community supposed to be served. Moreover, no bridging is planned to ensure a scale up for these professionals and, of course, no career plan exists.

I would like to come back to the point related to the direct/indirect midwifery program. Talks with midwives from the UK, Australia and the US make clear that being graduated nurses, they keep their nurse identity but once graduated midwife, they keep the new identity and “have nothing more to do with nurses”. This is not the case in the Arab countries where there are mostly nurse midwives. There, midwives face two constraints: nurse domination and male domination as most of the nurses are men even if a balance is emerging since a few years. As an example, in the UAE, a long struggle conducted to create a midwifery association could only set a midwifery section under the nurse association. In Palestine, midwives can’t move freely without being merged with nurses. Recently, a midwife created there a national midwifery committee hoping that they will be able to create their own midwifery association.

Moreover, the WHO nurse chief scientist in Geneva made a presentation in a last ICM meeting, addressing nurse-midwife as a twin entity, and announced proudly the implementation of a Master in Nursing Sciences in Morocco for both nurses and midwives. The concept is clear; nurse-midwife is merged and should be kept as it is. The problem is that, fundamentally, they are different at least for two reasons: the nurse exists to care any person in a sick situation whether the midwife has been created since centuries by the woman to be with her during the happiest, most precious, physiologic sequence of her life. So, their identities are systematically and totally different. When changing hats is made easy as in the UK, US and Australia and other countries, it is not a problem. But when it is not the case, keeping them merged stifles midwifery identity and entity. The Master degree established in Morocco by the Faculté des Sciences Infirmières of the University of Montreal recorded lots of midwives happy to have a perspective to evolute and get a PhD. However, that means: exit midwifery. And they don’t have another choice.

Now, to convince the decision makers, we need to make a strong advocacy evidence based. One argument may not need evidence as training midwives through an indirect entry education program equals to have a batch after at least 5 years whether training them through a direct entry education program equals for them to have two batches available at the same time: nurses on one side and midwives on another side.

This brief analysis is certainly not exhaustive and I am sure that the discussions you will have will address others issues at least as relevant. But I would like to conclude that the midwife needs to be emancipated now more than ever in all its aspects (education, regulation, career plan, working conditions…) and then to take its own lead. Education programs should be reviewed and updated according to a paradigmatic approach that articulates the educational paradigm with the sociocultural paradigm, the disciplinary paradigm (Bertrand & Valois, 1992), (Hatem-Asmar, Fraser, Blais, 2002), and the systemic paradigm (Gherissi 2008). Such an approach should allow producing competent midwives whom services should meets women SRH needs, health system priorities and the professional rules and ambitions.

Atf Gherissi, CM, MSc, PhD. Assistant Professor, Education Sciences. High Schoold for Sciences and Health Techniques. Tunis El Manar University. Tunisia

Please feel free to leave comments and join the discussion here about this very serious problem that faces midwifery both at a local and international level.


Anonymous said...

hello Dear Mrs Stewart,
I am PhD candidate-Public health at The Montreal University, I was also a former professor at the Saint-Joseph University in Lebanon Midwifery school;
I would like to thank you for this interesting blog thru which midwives can share scientific knowledge: Nevertheless, while reading the framework of our colleague Atef Ghreissi, I was surprised, in fact I have done a large literature review as I am working on evaluative research for midwifery reinforcement, and to my knowledge there is only one framework published which is based on the the interaction of 3 systems (socio-cultural, educational and disciplinary) in which evolves a midwifery role which was developed by Hatem-Asmar in her doctoral thesis and which was published in 1997 and again in 2002 (Hatem-Asmar, M., Fraser, W., & Blais, R. (2002). Trois paradigmes pour développer un programme de formation des professionnels de la santé: le cas de la formation des sages-femmes au Québec. Ruptures, revue transdisciplinaire en santé, 9(1), 86-102)!
I would like though to have access to the theoretical underpinnings that as mentioned in the blog was developed by Atef Ghreissi, because to my knowledge , it was not identified in any article that presents the theoretical or conceptual underpinnings for the presumed systems by Mrs Atef Ghreissi!
As scientific midwifery community, It is crucial to support our transfer knowledge to the public and to present the theoretical underpinnings that stand for our scientific knowledge!
Thank you a lot for the blog, it is interesting and it raises awareness among midwives as for the central role that midwives play in the field of reproductive health!
Sabina Abou-Malham
PhD(c) public Health-Management Health care organization
Universite de Montreal

Sarah Stewart said...

Hello Sabrina, the best thing I can suggest is you contact Atf Gherissi directly - please email me and I will give you her email: sarahstewart07(at)