ETHIOPIA: Midwifery Standard Manual Critical Component in Defining Care Practice, Ethics

April 2015 TheEthiopianHerald; Midwives have an important role in health and wellness promotion and education of women, their families and the community. Historical evidence has shown that midwives and the midwifery profession have made a significant contribution to the improvement of the health of women and newborns, particularly in the period of pregnancy and childbirth. Midwifery practice involves informing and preparing the women and her family for pregnancy, birth, breastfeeding and parenthood as well as family planning and infant well-being.

Quality midwifery services that are coordinated and integrated within communities and within the health system ensure that a continuum of essential care can be provided through out pregnancy, child birth and beyond. Midwifery services should ensure timely and appropriate referrals of mothers and newborns from home or health centre to the hospitals whenever they occur.

About 15 per cent of pregnant women in Ethiopia are estimated to develop obstetric complications which are potentially life-threatening. An estimated 2.6 million births occur each year. Direct obstetric complications account for 85 per cent of the deaths as well as many acute and chronic illnesses, according to Ethiopia Health Service Development Programme (HSDP 1V 2010-2015).

The Ministry of Health (MoH) has identified maternal and child health, and the achievement of MDG 4 and 5, as one of the highest priorities. The innovative approaches chosen to address these challenges included scaling up the training of midwives, and standardizing the practice.

Standardization is very important in any profession including midwifery. The primary reason for standardization is to protect the public from those who attempt to provide midwifery services inappropriately.

In line with that, the Midwifery Care Practice Standard Manual that is designed to complement the existing Nursing Care standard as part of Ethiopian Hospital Reform Implementation guideline is launched at a national workshop last month.

The Manual defines the expectation placed on registered midwives, underpinned by principles such as equity, access, and collaboration as well as emphasize women-centred care and seek to ensure that midwifery services are affordable, appropriate to local needs and sustainable over the long term.

It also promotes accountability and good quality midwifery care. Evidence suggest that when high quality midwifery services are available, the rate of skilled attendance at birth increases and there is a corresponding reduction of maternal and neonatal morbidity and mortality. The Standard also provides a monitoring framework that will ensure high quality services are maintained in the long-term.

Aster Teshome, President of Ethiopian Midwives Association (EMwA), said that, by defining the minimum standards that all Ethiopian midwives are expected to uphold, this document will promote good quality care and increase public confidence in midwifery, which in turn lead to a greater utilization of services. “By strengthening the quality and utilization of midwifery services the standards will untimely contribute to a reduction in maternal and neonatal morbidity and mortality.”

“Earlier we were unable to measure the midwifery practice due to lack of standard. “The Manual is expected to address ethical and professional practice as well as promote accountability and good quality midwifery care.”

Further more, due to the unique competencies of midwives, it is important that the profession has an independent set of standards, which work in harmony with the existing guidelines and nursing standards, to set criteria by which midwifery care practice be measured, she added.

“Not only that, it will act as externally validated criteria of best practices to which the performance of midwifery personnel can be compared. As such it is essential to guarantee pregnant mothers and mothers to get access to improved to quality midwifery and maternal health services,” she added.

According to Gobena Godana, Case Team Coordinator at MoH, “Lack of skill and knowledge resulted in unethical practice. The Manual will also serve as a critical reference for practising midwives and midwifery students,” he added that, thus, the Manual can be adopted to meet the needs of students to ensure they are equipped with the required level of knowledge and competency to implement midwifery standards when caring for patients in healthcare facilities both during clinical placements and following registration and licensing as graduates.

The Standard is based on the Scope of Practice for Ethiopia Midwives and International Confederation of Midwives (ICM) competencies. The term scope of practice refers to the rang of roles, functions, responsibilities and activities that a registered midwife is educated, competent and authorized to perform.

Historical documents have shown that professional midwifery training programmes began in Ethiopia in 1961 when the first three midwives graduated from the nurse-midwife training programme. A Human Resource for Health Strategy (2009-2020) developed in 2009 targeted to train 8,635 midwives, by the year 2015. The midwives to be trained and deployed is expected to increase to 9,866 by 2020.

Presently, the number of midwifery training institutions has increased from five in 2000 to 46. Now, 18 universities are offering midwifery training at Bachelors degree level. All states, except Gambella have midwifery training institutions. The private sector is contributing substantially to the training of midwives as eight private institutions of which 17 per cent are providing midwifery training. Seven institutions are providing training at the diploma level while one is providing both diploma and degree courses.

The data obtained from EMwA shows a substantial increase in the number of midwives from 1,275 in 2008 to 4,725 in 2012. Now, the majority of them or 95.6 per cent, are providing midwifery services in various hospitals and health centres while the rest are working as managers. However, despite male midwives are more qualified than their female counterparts as most of them have bachelor’s degree. There are more female midwives-3,662 than male midwives – 1,063.

Today, we know how to prevent and manage pregnancy -related complications and there is increasing recognition that pregnant women should be assisted by professional midwives with the necessary skills. drugs, supplies equipment and back-up, particularity during and immediately following birth.

Yet, there are not enough qualified midwives to manage the estimated number of pregnancies, the subsequent number of births and the fifteen percent of births that generally result in obstetric complications in the country. Data from the Ethiopia Midwifery Data Base and records from the Accelerated Midwifery Training Programme shows that the estimated 4,725 midwives are for a population of 85 million giving a ratio of 1: 17,989. WHO recommends a ratio of one midwife for a population of 5,000. The current numbers show that there is a critical shortage of midwives to provide maternal and neonatal services to the growing population of women of childbirth age.

Shortage of midwifery services providers able to provides killed attendance at birth and emergency obstetric care particularly in rural settings; is a major human resource challenge that cannot be addressed by government alone.

Although the number of midwives in Ethiopia is increasing steadily, and evidence show that even though 70 per cent of the midwives are satisfied with the type of work they do, poor working conditions, low salaries, lack of supervision and lack of opportunities for career development are the main demotivating factors.

In addition to these, opportunities for education and transfers are the driving forces for change of employment. But, lack of access to further education leads to lack of opportunities for better employment, promotion and salary increment. These multiple indicators are markers for dissatisfaction among the midwives.

Scaling up training of mid-level health providers including midwives and ensuring that they are working in a conducive environment is a priority for both the government and development partners as to HSDP 1V( 2010-2015).


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