DRAFT

Strengthening Community Midwifery in Sindh Through Sustainable Initiative of Community Midwives May 2012

Imtiaz Kamal , RN;RM; MA

Secretary General, NCMNH President, Midwifery Association of Pakistan

Disclaimer: This study/report is made possible by the generous support of the American people through the United States Agency for international Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc and do not necessarily reflects the views of USAID or the United States Government. 1

Acknowledgment.

A debt of gratitude is owed to a lot of individuals. They are too many to be thanked individually for their cooperation and worthy openness. collect and TAUHs financial assistance is very much appreciated, without which it would not have been possible to collect and document this much needed information. There are a some individuals who went out of their way to provide support and guidance as and when needed. Special thanks are due to: Dr. Nabeela Ali, for her valuable feed back through out , and for faith and trust in me for this challenging assignment; Dr. Sahib Jan Badar Director , MNCH and her entire staff particularly Dr.Gul , Dr.Manzoor and Mr Shafiq, for their full cooperation. and availability ; Nasim Abbasi and Mehmooda Afroz for their help with field activities; Anadil Khan and Sara Haider for their very valuable assistance in compilation of data which proved to be a bigger challenge than envisaged; Ali Raza for the final formatting of the report to compensate for my half baked computer skills.

Table of Contents

Page #

List of Acronyms .4
.

Prologue

..5

Definition of a Midwife ..6 Executive Summary ...7 Part 1 BACKGROUND of Consultation ..12 Specific Objective.....15 B. Methodology.....16 C. Background of the Emergence of the Community Midwife (CMW)...18 1. Categories of midwives .. 18 D. COMMUNITY MIDWIFERY Initiative .....20 E. Literature Review ...21 1. South Asia .21 2. Pakistan .. 21 Maternal Neonatal and Child Health PC 1 . .21 Guidelines for Deployment of CMWs..22 3. Other Documents Reviewed ....23 Existing status of the graduated CMWs and their training institutions.......23 CMWs Curriculum .24 The Faculty .24 Quality of training .....25 Teaching /learning resources and methods of teaching....27 The Students.....27 4. Evaluation of Teaching / Learning Outcome... 30 5. A Positive Development ....31 6. Number of Schools Training Community Midwives ..31 7. Deployment of Community Midwives .34 8. Potential acceptability of the CMW by the community...34 9 MIS for MNCH : Monitoring and Supervision of CMWs. (Tools).37 10. Observations on the Monitoring and Supervisory Tools..42
..

Flow of information ..44 11. Challenges. For Consideration in the Future ....45 12. Meeting the Challenges: ...48 Establishing a District Management System .,48 13 Technical Supervision of the practising midwives ....51 14.Instutionalisation of CMW 52 15. Impact of Devolution on the Vertical grammes .. 54
.

PART II Analytical Observations , Challenges and Recommendations .56 1. System at the District Level ....57 2. District Midwifery Committee ..57

Part III 12 Rules and Regulations Governing Midwifery Education and Practice.61 Rules and Regulation for midwifery training and practice Legal aspects of midwifery practice Code of Conduct . 73 . Part IV 1. 12 Point Action Plan . 78 2. Recommendations .... 86

List of Tables
Table 1 : Number of Public sector Schools Training Midwives in Sindh (by Category) 32 Table 2 : Number of Private sector Schools Training Midwives in Sindh 32 Table 3 : Numbers of CMWs admitted and Numbers Graduated Since 2009 ..33 Table 4 : Numbers of Community Midwives Graduated , Deployed, Awaiting Deployment . ....33

Annexes
Annex 1 : Annex 2 : Annex 3 : Annex 4 : Sources of information Competencies of the midwife Historical background of midwifery in Pakistan Situation Analysis of Midwifery Education in Sindh

List of ACRONYMS AMAN B.Sc CMW EmONC DoH DMC DOPW EDO FHT FP FWV FWW IMR LHV LHW MAP MCH MNCH MMR MoH MoPW NMR NCMNH Ob/Gyn PHC PHS PMA PNC PTS RHC RM RN SBA SOGP SOM SON TBA UNICEF UNFPA WHO KPK : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Association of Mothers and Newborn Bachelor of Science Community Midwife Emergency Obstetric and neonatal Care Department of Health District Midwifery Committee Department of Population Welfare Executive District Officer Female Health Technician Family Planning Family Welfare Visitor Family Welfare Worker Infant Mortality Rate Lady Health Visitor Lady Health Worker Midwifery Association of Pakistan Mother and Child Health : Mother Newborn and Child Health Maternal Mortality Ratio Ministry of Health Ministry of Population Welfare Neonatal Mortality Rate National Committee for Maternal and Neonatal Health Obstetrics and Gynaecology Primary Health Care Public Health School Pakistan Medical Association Pakistan Nursing Council Preliminary Training School Rural Health Centre Registered Midwife Registered Nurse Skilled Birth Attendant Societies of Obstetricians and Gynaecologist of Pakistan School of Midwifery School of Nursing Traditional Birth Attendant United Nations Childrens Fund United Nations Population Fund World Health Organisation Khayber Paktoon Khuan

Prologue

This document reflects a most exciting and positive development. The midwife is appearing on the scene of maternal and neonatal health.. Almost all those , connected with maternal and neonatal health in any way, have demonstrated a keen desire to identify what needs to be done to prepare competent midwives. That midwives save lives needs no proof only acceptance. There seems to be a genuine interest in the standards of education and training of midwives. The desire to improve the situation is apparent from the number of studies and surveys done to collect evidence on various aspects of educating and deploying community midwives. Many lessons have been learned, shared and disseminated. Hopefully, the available information will make the next PC-1 a document which reflects evidence based planning. The goal is to take skilled care to every woman in general and to the rural woman in particular , wherever she chooses to deliver her baby. Investing in midwives is a quantum leap in the national efforts to reduce maternal and neonatal morbidity and mortality.

There is light at the end of the tunnel

Definition of A Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwifes own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. the midwife has an important task in health counseling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to womens health, sexual or reproductive health and child care. A licensed midwife may practise in any setting including the home, community, health facilities or as a self employed professional.

( For competencies of a midwife see Annex 2)

Executive Summary Introduction The Maternal Mortality Ratio (MMR), of Pakistan at 276 per 100,000 live births, is the highest in South Asia. Sindhs MMR at 314 is the second highest in the country. Women who die are poor and from rural areas for whom skilled care at birth is unavailable or inaccessible. 61 % deliveries take place at home conducted by unskilled care providers. Midwifery has not had the opportunity in Pakistan to be recognized as a vital profession nor has the midwife acquired a professional status. The Government of Pakistan has directed many efforts in the past to provide maternity care to the women in general and to the rural women in particular. This included training various types of midwifery personnel both licensed and not formally registered but allowed to conduct deliveries. i.e the Traditional Birth Attendant (Annex 3). It was to make skilled care accessible to the rural women that a PC-1 was prepared in 2006-7(1). The Community Midwifery Initiative was conceived , planned and implemented with a target to train 1200 CMWs. The National Maternal ,Newborn and Child Heath(MNCH), programme had a substantial portion of CMW training component. UNICEF and PAIMAN ( Pakistan Initiative for Mothers and Newborns) took the lead. PAIMAN trained and deployed 2000 CMWs. More development partners contributed to achieve the target . Sindh needed almost 2000 CMWs. As the initiative took off the ground, work started on various aspects of evaluating the process. Studies were carried out to evaluate the capacity of the training institutions , quality of training and Acceptability of CMW in the community. A study was carried out last year on Accessibility of midwives in the community. (12) MNCH in Sindh recruited the first batch in 2008 which graduated in 2009 and was deployed in 2011. Two more batches have been trained and are awaiting deployment. Two batches are under training. One batch will graduate by the end of 2012. Like any new venture, CMWI is facing some challenges. To strengthen this initiative and to make it a sustainable programme, health authorities of Sindh requested USAIDs Technical Assistance Unit of for Health (TAUH) for assistance to improve access to quality MNCH services at the community level through sustainable CMW Initiative in Sindh. TAUGH engaged a consultant to honour this request . To achieve this objective a plan was implemented to review and analyse available information and also up date it. The plan comprised : a Situation Analysis of CMW Education in Sindh ; Review of the Available Literature on CMWs ; Visits to training Institutions ; Meetings with all stake holders including the policy makers, planners, implementers, administrators, trainers, facilitators, students, clinical 8

supervisors ( doctors and midwives) and focal persons who are the watch dogs of MNCH In the districts(16) Findings and analytical Observations Note : For details please see the twin of this report which is a complete document by itself on Situation Analysis of Midwifery Education in Sindh. 1. Institutions: Most teaching Institutions are fairly well equipped. Some are waiting to be equipped once resources become available. Some beautiful newly built schools are empty because the SNE has to be approved.(8) 2. Faculty: Most teachers are teaching midwifery on ad hoc basis because there are no designated posts for midwifery teachers. Teaching standards of both classroom teaching and practical training need a lot of improvement because they are in the hands of teachers who are trained to teach nursing which is a disease centered discipline. There are no qualified midwifery teachers in Pakistan. Efforts are being made to fill the gap with ToT Workshops. (13) The faculty of the schools training both nurses and midwives are over worked. 3. Students: Students are a mixture of married and unmarried, young and not so young, some who left school a couple of years ago and those who have been out of school for a decade or more. The policy of making midwifery training a residential training has not worked. Almost all the married students are day scholars. It affects their attendance hence their learning. Only a few students demonstrated real interest in midwifery. Teachers are almost unanimous in their observation that the stipend of Rs. 3500 per month is a major attraction for most of the students. 4. Quality of teaching/Learning : Lecture is the most commonly used method of teaching with occasional demonstration in the class room or in skill lab. For the clinical instruction use of check lists for skill development and skill evaluation is not common. The quality of teaching requires a great deal of improvement.(9) It is ironical that this programme has been implemented in an environment with many gaps.(3) These gaps were identified more than a decade ago but nothing was done to improve the situation. The major gap was lack of teachers qualified to teach midwifery. In eleven years no efforts were made to train midwifery teachers. 5. Outcome of teaching/learning: So far three batches of CMWs have been trained. A total of 1359 students were admitted, 1287 appeared for their final examination, 832 (61%) have successfully completed their training . The failure/drop out rate of 39 % is a point of concern and needs looking into carefully. 6. Deployment: Of the three batches trained, so far one batch has been deployed. The delay in deployment is due to the time taken by the Examination Board to Issue diplomas, and then by PNC to issue the license to practice. 9

The Deployment Guidelines prepared by TRF are awaiting endorsement of the government. They need to be looked at critically before endorsement. There are many technical inaccuracies and operational issues that need to be corrected and modified before endorsement. Deployment guidelines should not include Selection Criteria and training and examination etc. Deployment begins when the CMW has completed all those steps. This is specified in the objectives of the assignment. ( Annex 1- page 5). Also there is a lot of midwifery in the deployment guidelines. That was not needed. Moreover there are inaccuracies in the content related to midwifery. Just a couple of examples of the content that needs to be corrected: Cord round the neck is given as an obstetrical emergency. This is easily managed by the midwife hence it is not an emergency. An other statement of technical inaccuracy is , Retained placenta in the first. Second and third stage of labour. Similarly there are operational issues e.g , A CMW needs a a small place of not more than 4x6 feet in a room near the exit door for establishing her Work Station but in the sketch for the Work Station ( Annex-C page 28 ) there is a table, a chair , a stool, a screen and a shelf . Will this all fit in a space of 4x6 feet. Also when the pregnant women or post natal women come for preventive services they will need space. If the Work Station is in the corner of a room occupied by the family, can CMW provide services in the same room?(2) 7. Supervision and Monitoring : Much effort and expense has been invested in the monitoring tools developed by TRF. It is a set of 10 tools entitled MIS System for CMWs.(15). Two forms are for use by the supervisors and 8 for use by CMWs . While some of the documentation is necessary, much of it when documented will never be used for any purpose. The amount of writing is very demanding . In addition the pile of forms and registers is very cumbersome and intimidating. These tools need to be looked at carefully . Documentation should be minimized to the information which will be used purposefully. 8. Acceptability and Accessibility of CMWs n the Community The CMWs are fairly well accepted in the community but the expectations of the community are somewhat higher than the services she is trained to render (10). This will have to be dealt with during the advocacy efforts. Accessibility of the CMW to the community depends on the awareness of the community about the presence of CMW in the community.(12) This will have be given publicity on the lines of what was done for LHWs. 9. Rules and Regulations for Midwifery Practice To provide legal; protection to the midwife and to the community she serves, Rules and Regulations for Midwifery Practice and a Code of Conduct have been drafted. The document will be forwarded to PNC for legal processing before approval. Until its finalisation it is suggested that Sindh Health authorities select the essential dos and donts for the guidance of community midwives. 10

Twelve point Action Plan for immediate attention ( For justification please see full text) 1. Strengthening practical training of CMWs to ensure the achievement of expected levels of competence. 2. Plannig and implementing regular diploma courses to qualify midwifery teachers for the future. And for one or two years short ToTs can continue to be given to build the capacity of the current tutors teaching midwifery. 3. Approval of separate budget and separate faculty for schools of midwifery 4. Appointment and training of clinical instructors 5. Closer collaboration between the school, hospital administration and Nursing and medical staff of Ob/Gyn Unit. 6. Improving the examination system and without any delay introducing testing of midwifery skills. Through OSCE. 7. Establishing a small committee to review the Rules and Regulations for Midwifery Practice and select the basic ones to guide the CMW for her permissible functions 8. Midwifery should not be mandatory for female nurses. They should have the choice to specialize in midwifery or in any other area of health care. 9. Reducing the long delay in deployment due to delay between the students passing her final examination and getting her license. 10. Equipping the schools with required resources particularly human resources 11. Developing a career structure for midwifery personnel without having to become a nurse to move up the professional ladder. 12. Pakistan Nursing Council revert to its original name , Pakistan Nurses, Midwives and Heath Visitors Council

Recommendations for the near future

1. For Pakistan Nursing Council: A standard, competency based curriculum for all categories of midwives. Clearly defined Scope of Work of the midwife with Rules and Regulation for Midwifery Practice and a Code Of Conduct. Disallow large teaching hospitals for medical students to have schools of midwifery 11

Strengthen the inspection and examination systems. Develop Mechanisms to cut down on delays in the registration process of midwives..

The Provincial Health Departments: Develop a five year human resource plan, for training midwifery personnel. Establish a District Body to mange at the district level, selection training, deployment and supervision of CMWs Design a strategy, for replacing TBAs and Dais with trained CMWs Either make CMW a part of the health system like the Lady Health Workers or let them be self employed but regulate their practice Develop regular diploma programmes to train midwifery teachers.

Develop a career structure for the midwives to allow for continuous professional growth Develop CMWs Work Place into a Birthing Station to offer the woman a choice of place of delivery

Maternal, Newborn and Child Health programme:

Select a few schools of midwifery and assist them to develop into Centers of Excellence. Use these to train midwifery tutors through mentorship .

Strengthen the system for monitoring of midwifery training. Ensure that the focal persons fulfil their obligation in this regard.

Focus on faculty development for the new schools 12

Encourage already trained and licensed nurse midwives to opt for midwifery and train them as tutors and clinical instructors.

Select a few maternity homes in the private sector to provide practical experience to the students providing them recognition through a logo indicative of quality services

The National Committee for Maternal and Neonatal Health ( NCMNH) and Midwifery Association of Pakistan: 1. Organise a common platform comprising obstetricians, paediatricians and midwives in collaboration with the Societiy of Obstetricians and Paediatricians, and Midwives of Pakistan for proper understanding of the role of midwives in obstetrical care and in saving lives.

2. Recommend that to eliminate the confusion between the term dai and midwife the professional midwife be called Qaabila,(the Arabic word for midwife, used in Iran and Afghanistan also) .

3 IF ACCEPTABLE Midwifery be called Qbaaleh,(the Arabic word for midwifery, The schools preparing professional midwives be called Madrassa-al-Qabaaleh, and Colleges of advanced midwifery be called Kuliaat-al- Qabaaleh, (college of midwifery ) For facilitating action, it is recommended that : UNFPA , UNICEF , WHO ,DFID and TAUH: Discuss the above recommendation with the decision makers in the health sector and the directorate of nursing in Sindh Through a consultative process with various stake holders develop guidelines and provide assistance for the implementation of the agreed upon recommendations.

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PART 1 A. BACKGROUND of Consultation Pakistan is the 6th most populous country in the world. Its Maternal Mortality Ratio (MMR, at 276 per 100,000 live births, is the highest in South Asia The urban ratio is 175 and rural is 319. The provincial ratios are: Punjab 227; Khyber Pakhtunkhwa 275; Sindh 314; and Balochistan 785. Most of the women who die are poor and from rural areas for whom skilled care at birth is unavailable or inaccessible. 64 per cent of deliveries occur at home and are attended by Traditional Birth Attendants (TBAs) or family members. Skilled Birth Attendants (SBAs) conduct 31 per cent of all deliveries and only 5 per cent of home births.(14) Specific Objective To improve access to quality MNCH services at the community level through sustainable CMW Initiative in Sindh. It is a historical fact dating back to 1751 that well trained, supervised ,supported and authorized midwives are the key to making motherhood safe. Unfortunately in Pakistan training professional midwives has not been a priority of the Government. Even though , midwives of various categories (nursemidwife LHV, pupil midwife) were being trained, majority of them were from urban areas. They got trained and stayed in cities , excepting those who were employed in BHUs, The skilled maternity care offered by licensed midwives did not reach the rural communities where 80% of the births were taking place conducted by Dais and TBAs(3). In all fairness the LHVs and Pupil Miwives do provide services in the urban and peri urban areas and the city slums, hence serving the disadvantaged and marginalized population. The training standards have remained poor. The non nurse midwife has absolutely no opportunities for professional growth and development. Nursing, which comprises mostly curative care, progressed and almost engulfed midwifery. Nursing training is for four years. Three years of nursing and one year of midwifery *. Nurses education and Career Pathways received a lot of assistance. Until the turn of the century hardly any contribution was made by the development partners to improve midwifery education in Pakistan In 2003 The development partners started to take interest. UNFAP experimented with one group of midwives in 2004 in Mansehra under the PRISM project. It did not get approval of the health authorities for continuation.

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In 2005 the Government of Pakistan decided to train 12,000 Community Midwives (CMWs). A curriculum developed in 2003 for the PRISM project was enriched for this 4th category of midwives.. UNICEF supported one group in 2006. Pakistan Initiative for Mothers and Newborns (PAIMAN) JSI/USAID also started training CMWs in 2006., committed to train 2000 CMWs and honoured its commitment. PAIMAN went about it in a very scientific way. Its first activity was to assess the capacity of the schools which were to train midwives (5.) Gaps were identified and planning was designed to fill those gaps. UNICEF and UNFPA also participated in this venture.. In the public sector the first PC-1 (1) was approved which was for January 2007 to June 2012. The national programme for Maternal, Neonatal and Child Health (MNCH) includes a large component of training of CMWs. This was a new venture for the health authorities. Five years along the way, it was realized that the vision and the practical did not quite match. Some of the requirements to enroll as a student were found difficult to implement. e.g Originally, midwifery training was required to be a residential course and rightly so because babies do not take appointments for coming into the world. The midwife has to be there to receive them at all hours of the day and the nigh. This requirement was very difficult to implement because of an other requirement i.e One of the selection criteria is ,Female , preferably married. In Pakistani culture can a married female with children and family responsibilities, particularly from rural areas stay away from home and live in a hostel? It was envisaged that this category of midwifery personnel will be self employed, hence a sustainable source of maternity services to the community. Further discussions of this strategy identified the need for the CMWs to remain articulated to the health system for at least three years. Hence she became the responsibility of the health authorities with financial implications. It was expected that the CMW will establish her own work place ( to be called a birthing station or any other similar name) , to function as a 24/7 available maternity care provider She was to provide ante, intra, and post natal care and preventive services both in the community and in her static facility. Later the debate started that she will not have a birthing station but only a small area called Work place,.She will provide certain preventive services from her Work place but will deliver babies in the homes only. Certain changes were instituted in the planned activities. The CMWs were to be launched and helped to settle as practising midwives in the community after training. All was implemented in varying degrees in one way or the other, some on time and some later than planned.

15

The missing link was the, National Guidelines for Deployment. of Licensed CMWs These got developed 3 years after the training started. (2) By this time many batches had graduated. The deployment design planned and followed by PAIMAN for the CMWs trained in the districts supported by PAIMAN was expected to become the national design but it did not work that way. Health authorities were assisted by the DFID funded, Technical Resource Facility (TRF) to develop Deployment Guidelines. There is enough evidence that Induction of this new cadre of CMWs is facing many challenges. The main ones are : Quality of training which is being affected by many factors including the capacity of the trainers; the development of midiwifery skills and evaluation of their midwifery competencies; supervision of practising CMWs and back up support to them for EmONC ; their accessibility to the communities; establishing and maintaining their credibility as competent maternity care providers more skilled than their main competitor, the TBA; acceptance, affordability and utilization of her services by the community ; and lack of rules and regulations governing the practice of midwifery. All of the above information, now available, has highlighted the positives, identified certain areas requiring strengthening and need for thorough immediate, midterm and long range planning. Upon the request of the health authorities of Sindh,Technical Assistance Unit for Health ( TAUH) of USAID, in Pakistan, contracted a midwifery specialist to provide technical assistance for addressing the above challenges..

Purpose of the assignment The purpose of this assignment is to: Provide technical support to the Maternal, Newborn and Child Health (MNCH) Programme, Government of Sindh , for making CMW Initiative sustainable. Develop a system for supportive supervision and monitoring Improve the quality of CMWs training so that they are competent enough to provide professional maternity care to pregnant women ( through out the maternity cycle), and provide Basic Emergency Obstetric Care in case of complications before making referrals when a higher level of obstetric care is essential. Specific Objective To improve access to quality MNCH services at the community level through sustainable CMW Initiative in Sindh. 16

Original Scope of Work Analyses of the existing status of the graduated CMWs and their training institutions including practical training. Preparation of DATA BASE with mapping of graduated/deployed CMWs in Sindh. Practical steps to improve training component including practical training and deployment Mechanism of supportive supervision and periodic review of skills Preparation of monitoring and evaluation framework at district and provincial level Rules and regulations of CMWs practice.

When information became available, it was found that the development of DATA BASE is being attended to by MNCH directorate. Certain other areas became apparent for technical support. In the light of those the ToRs were revised in consultation with Director MNCH. Revised ToRs: Literature review: includes national MNCH PC-I, training curriculum, monitoring mechanism, the reports of TRF on CMWs and other relevant documents. Meet with the concerned official of the Health Department and other stakeholders to gather information required on the new role of provinces with devolved vertical programs. Situational analysis of current trainings including classroom & practical trainings, capacity of training institutions and deployment status of graduated CMWs in 20 districts of Sindh. Institutionalisation of mapping and deployment of graduated CMWs Review National MNCH Program monitoring/ reporting system, Prepare monitoring and reporting framework for district and provincial level and recommend how CMWs MIS can be integrated with DHIS Recommendations on rules and regulations for CMW practice Options to make CMW initiative sustainable Dissemination Meeting

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B. METHODOLOGY A structured Work Plan was prepared for three months. Within the first fortnight of the assignment it became obvious that it will not be possible to put time lines on planned activities . A lot depended on when a certain document(s), a particular individual or group of individuals for meeting (s) and opportunity for field visits etc became available. Also certain events came up which were directly related to the assignment , but were not in the Work Plan e.g a full day seminar cum Workshop on , Are CMWs Accessible in Sindh ?. The law and order situation in the city compounded the difficulties in sticking to dates on the calendar. Therefore it was decided to have dates planned for activities but focus on the outcomes. The Work Plan includes the following approaches to achieve the objectives of the assignment: 1. Review of literature about midwifery in South Asian countries 2. Review of published reports , documents, papers, minutes of meetings , discussions in various seminars, and conferences etc related / pertinent to national scenario of midwifery in Pakistan starting with 1948, to trace the development of midwifery as efforts of the government to provide maternity services particularly to the rural population.. 3. Review of specific reports pertinent to the CMW Initiative in Pakistan in general and for Sindh in particular 4 Analysis of the information available about the situation regarding selection, training, deployment and supervision of CMWs and their relationship with the current health system Situation Analysis of Midwifery Education in Sindh Note : For details please see the twin of this report which is a complete document by itself on Situation Analysis of Midwifery Education in Sindh. Personal contact with maximum number of stake holders including , but not limited to: The director and staff of MNCH in Sindh; Development Partners assisting midwifery in Sindh; Heads of selected Training Institutions; Midwifery Tutors, currently enrolled CMW students, recently graduated CMWs and practising CMWs. Consultative meeting with: Pakistan Nursing Council; the Executive Board 18

5.

6.

7.

of Midwifery Association of Pakistan; the recently established UNFPAs Country Working Group for the Development of Midwifery; Directorate of Nursing and Nursing Examination Board, Sindh 8. Prepare a Draft for the Regulatory Mechanisms of Midwifery Practice in Pakistan to provide protection to the practising midwives and to the community they serve. Based on all the findings: Suggest practical steps to improve the training programme of CMWs Draft a Future Plan of Action for the consideration of the authorities to make the CMW Initiative , a regular and sustainable part of the health system. 10. Document a Historical Perspective of Development of Midwifery in Pakistan. It was not in the SoW but the author considered it very relevant for the purpose of comparison with the present situation and future planning 11. Prepare, submit and disseminate the final report in consultation with JSI/TAUH in June, 2012. In the light of the revised TORs the following tasks were added to the work plan: 12. Adapt the existing tools for situation analysis of midwifery training 13 Train teams of interviewers 14. Collect information from all the schools training CMWs 15. Prepare the report of findings from 20 schools. 16. Review the monitoring and supervision system and suggest the flow of information from CMWSMIS to DHIS. C. Background of the Emergence of the Community Midwife (CMW) (For better comprehension of the emergence of a new category of midwifery personnel i.e The Community Midwife please see Historical Background at Annex 2 ) Pakistan s efforts to provide maternity care to the women of Pakistan in general and to the rural women in particular date back to early fifties. There were no well though out plans to prepare midwives with basic midwifery competencies. 19

9.

Many categories of midwives are being trained without a proper planning of human resource to provide maternity care to the women who need it.

1. Categories of midwives 1.1 The Nurse-Midwife (3 years of nursing followed by one year of midwifery. training) Midwifery being compulsory for promotion of female nurses, they join the midwifery course. They by and large do not opt for midwifery as a career because there is no future in midwifery . It needs to be noted that this is the only category of midwives who can study for Diploma in Teaching Nursing. A vast majority of those currently teaching midwifery are from this category. because there is no diploma for teaching midwifery. 1.2 The Lady Health Visitor ( One year of training in midwifery followed by one year of training in public health). This was a legacy inherited from the British Raj. They were trained to be Community Midwives in the real sense.. 1.3 There was only one school in Lahore in 1947. training was of very good quality. As the public health schools increased in numbers the quality of It started to deteriorate in the early seventies. In the public sector service structure there is no career pathway for them. If they want to move upwards they have to go into nursing. The only promotion for them is to become supervisors of other LHVs or midwives. Now they are going to be used to supervise CMWs 1.4 The Midwife (15 months of training in midwifery ) This category was previously known as ,Pupil Midwife. No one could explain the reason for this nomenclature. Recently the prefix Pupil was removed. With a couple of exceptions in the private sector, very few of them have even the minimum midwifery competencies. This is the weakest category of midwifery personnel. There is no future at all for this category. They get jobs in BHUs and RHCs. They get absorbed in the private sector. Some of them work as self employed. Five years ago , all of a sudden , a notification from PNC was received by these schools that they were to close with immediate effect. Seven schools approached the Midwifery Association of Pakistan (MAP) for assistance. Guided by its legal advisor MAP took up the matter with PNC. The decision for immediate closure was reversed and the programme was extended till 2013. 20

In February 2012 in a meeting of PNC the matter was brought up by MAP. According to the registrar PNC , only the public sector schools will discontinue. The private sector can continue to train this category. A request for written notification has been sent to PNC by MAP. Response is awaited. The entry requirement for all the three categories is 10 years of schooling They share the same curriculum which is extremely sketchy. It was last looked at in February 1994. It is labeled ,4 th Year This midwifery curriculums Preface ,written by the then Vice President of Pakistan Nursing Council, reads, I am pleased with revision of curriculum of Nursing.. This is reflective of the thinking of nursing leaders and a proof that midwifery is not considered a profession with its own identity(6). Schools of nursing, midwifery and public health have multiplied many fold. Midwives of all the above categories graduate annually in thousands but not all opt to practice midwifery . The standards of midwifery training are such that the midwives do not qualify as competent Skilled Birth Attendants.(SBAs.) A vast majority comes from urban or peri -urban background. A negligible minority is of rural background. They all train and remain in the cities excepting those who work in the Basic Health Units ( BHUs). Some of them reside in BHU and provide services 24/7. In their off duty time they charge for their services. Those who can reach them and afford them utilize their services. The Average rural woman remained deprived of the services of trained midwives. This led to the emergence of the new category of midwifery personnel ,The Community Midwife, with the main goal to reach the rural population

D. Introduction to the COMMUNITY MIDWIFERY ( CMW) Initiative It needs to be noted that the CMW Initiative was conceived and implemented in a very unusual national environment. This included: plans for and initiation of devolution; lack of clarity in the governance of vertical programmes implemented by the federal government, the problems of the transitional period, resource allocation, structural adjustments , civic unrest, political instability , insurgence of religious fundamentalism, increasing crime rate affecting the law and order situation and high inflation rates. All of these factors need to be kept in mind while evaluating or analyzing any of the plans and their implementation in the health sector in the last five years. This fourth category of midwives was introduced entitled, Community Midwife (CMW)Before the CMW programme was formalized, the concept existed. 21

UNFPA under its PRISM project had trained a group of community midwives in 2004for which PNC had designed a curriculum in 2003. In 2005 An enriched curriculum was designed (7). Originally the national target was to train 10,000 CMWs . It was later increased to 12,000. The goal was to recruit females from the rural areas so that they will go back to their places of residence and serve the rural population.

Foreign assistance was sought and received. In 2006 the first batch of students was recruited. UNICEF funded training of a group of CMWs in 2006. At the same time PAIMAN developed the first regular programme to start the training of CMWs. Training of both the groups of UNICEF and of PAIMAN started almost simultaneously in September 2006. PAIMAN went about it in a very organized way. It got a team of senior midwifery specialists to assess the training schools of the districts in which PAIMAN was working (5). A critical mass of master trainers from all over Pakistan. A Midwifery tutors of international standards was recruited with ICM involvement and an education specialist from USA was recruited for the educational aspects of the training. Schools were equipped with teaching learning materials and job aids. Incentives were given to the administrators and trainers and stipends were paid to the students according to the MNCH PC -1 All efforts were made to promote the success of the programme. Those who qualified were deployed and equipped to start practising . Along side the implementation, activities started for assessment of the training Institutions (8) evaluation of the quality of training (9) ; performance of CMWs and their acceptability in the community. (10) In 2005-6 a PC-1 was approved and implemented in 2007, to take MCH services to the rural areas. The national programme for Maternal, Neonatal & Child Health (MNCH) has. CMWI as a major part of this programme. In Sindh in the public sector the first batch of CMW students was recruited in 2008. So far three batches have graduated and the fourth and the fifth batches are under training. Sources of Information ( Annex 1) Review of literature Institutions Visited Situation Analysis of CMWs Education in SIndh Persons met Meetings, seminars attended

22

E. Literature Review (For list of Documents reviewed see Annex1) 1. South Asia Review included the report of, State of Worlds Midwifery (11). The most important piece of information was that where ever midwifery has been taken seriously, MMR has gone down. Sri Lanka and Malaysia are two such examples. It is interesting to note that some of the countries of South Asia do not have a distinct category of midwifery personnel registered as, Midwife. India and Nepal are two such examples. Their emphasis is on midwifery skills irrespective of what the individual providing care is called. Nepal has succeeded in bringing down its MMR. These countries are struggling like most countries of South Asia, to get midwifery recognized as a profession distinctly separate from nursing. 2. Pakistan The available literature about midwifery is very limited. For the purpose of this assignment all the available reports referenced in the text were reviewed and their findings have been utilized in the analytical review. For Sindh ,fortunately a report dating back to 2000 was available (3) and has been used as a basic reference to track the improvements in midwifery education and practice in the last decade. All the other documents are related to CMWs education, their acceptance in and their accessibility to the community. The two most significant documents for the present situation are the PC-1, (1) and the Deployment Guidelines.(2) 2.1 MNCH PC-1 (1) Developed in 2005-6, it was the first ever document in the public sector, in the history of Pakistan which focused on midwifery. Vision of National MNCH Programme The Government of Pakistan recognizes and acknowledges access to Essential Health are as a basic human right. MNCHs vision is of a society where women and children enjoy the highest attainable levels of health snd no family suffers the loss of a mother or child due to the preventable or treatable causes. The Government of Pakistan henceforth pledges to ensure availability of high quality Maternal, Newborn and Child Health services to all, especially for the poor and the disadvantaged.(16) This PC-1 reflects the tremendous amount of time, money and effort that must have been invested in its preparation . Main objective of the project was to achieve MDGs 4 and 5 i.e to reduce maternal, neonatal and child mortality and 23

morbidity. Total cost of the project for Sindh was Pak Rs.3.247 billion. 50% of its funding was from DFID and 50 % from the government of Sindh. According to the Director MNCH, only 25% of the funds have been released so far. Release of funds is the joint responsibility of the health authorities and the donor. The major part of this project is for training community midwives( CMW). The strategy for CMW training has gone through certain modifications as necessitated by the experiences during its implementation for example : the community midwifery training was planned to be residential course but it was found very difficult to implement this requirement because of the criteria of preference for merit candidates. The need for preparing competent faculty before starting training a large number of community midwives should have been done. Only those schools should have been selected which at support of the institutions with a large number of normal deliveries. A lot of lessons must have been recorded by the implementers. Now that the duration of the initial phase is going to end in June 2012, and a new PC-! is about to be developed, it is of the utmost importance that existing PC-1 should be critically reviewed. It is strongly recommended that the areas identified during the review, the lessons learnt and experiences of those who implemented it at the operational level and at the technical level should be pooled and used for developing the new PC-1.

2.2 Guidelines for Deployment of CMWs.(2) The official Deployment Guidelines Should have been ready before the first batch of CMWs graduated. Since PAIMAN was the first project to start CMWs training , it developed guidelines and with the support of the provincial governments, implemented them in the districts supported by PAIMAN. It was hoped that those will become the national guidelines but it did not work that did not happen.. The national guidelines were prepared by TRF in 2010(2). They have gone through a rigorous process to be finalized. They are now available and awaiting endorsement of the health authorities. The Deployment Guidelines prepared by TRF are awaiting endorsement of the government. They need to be looked at critically before endorsement. There are many technical inaccuracies and operational issues that need to be corrected and modified before endorsement. Deployment guidelines should not include Selection Criteria and training and examination etc. Deployment begins when the CMW has completed all those steps. This is specified in the objectives of the assignment. ( Annex 1- page 5). Also there is a lot of midwifery in the deployment guidelines. That was not needed. Moreover there are inaccuracies in the content related to midwifery. Just a couple 24

of examples of the content that needs to be corrected: Cord round the neck is given as an obstetrical emergency. This is easily managed by the midwife hence it is not an emergency. An other statement of technical inaccuracy is , Retained placenta in the first. Second and third stage of labour. Similarly there are operational issues e.g , A CMW needs a a small place of not more than 4x6 feet in a room near the exit door for establishing her Work Station but in the sketch for the Work Station ( Annex-C page 28 ) there is a table, a chair , a stool, a screen and a shelf . Will this all fit in a space of 4x6 feet. Also when the pregnant women or post natal women come for preventive services they will need space. If the Work Station is in the corner of a room occupied by the family, can CMW provide services in the same room?(2) Deployment of the three batches trained , so far one batch has been deployed. The delay in deployment is due to the time taken by the Examination Board to Issue diplomas, and then by PNC to issue the license to practice. 3. Other documents Reviewed 3.1. Existing status of the graduated CMWs and their training institutions including practical training. There are five studies available about the status of the institutions training midwives and quality of midwifery training. Two of these were conducted before CMWI was implemented. One is Situation Analysis of Midwifery Training in Sindh (3) It contains information about all the schools in Sindh. In the pub lic and the private sector. It was conducted in 2000, followed by a Strategic Plan (4). commissioned by UNICEF. The other study is an assessment of all the schools in the districts served by PAIMAN. (5) The remaining two studies are of selected schools from all over Pakistan. One was conducted in 2005 by Population Council on training institutions (8) and one on quality of training in 2010 by HLSP( 9) The most recent study is the one conducted in April May 2012 commissioned by TAUH. Recently documented information about the status of all the institutions training CMWs in Sindh(13) provides enough evidence about the state of midwifery education. The bottom line is that midwifery as a profession and the midwife as a professional have a long way to go . Both require much attention and action. The findings of the studies summarized below: 3.2. CMWs Curriculum (7) and information available from other sources are

25

As mentioned earlier, a special curriculum was designed for CMWs It was developed by a doctor. It went through a very rigorous exercise of more than one review by nurses and midwives and then got finalized. It was approved by the Pakistan Nursing Council (PNC.) When implemented ,the strengths and weaknesses of the curriculum became apparent. It covered the content but It was not competency based. It did not provide the required guidance to the tutors who were nursing instructors with insufficient background of knowledge and skills required to prepare midwives. They did not have the capacity to adjust it to their teaching/ learning activities(9). Soon after it was implemented , it became apparent that it needed updating. The content needs to be enriched, protocols need to be developed, evaluation methods need to be strengthened and above all teaching /learning strategies have to be defined . A user friendly, competency based curriculum can help the trainers to improve their teaching and training approaches. More than a year ago, Technical Resource Facility (TRF) contracted a British midwife supported by an advisory group, to revise the curriculum. It became available by the end of March 2012. In April, TRF held a review meeting which the author attended. The midwifery educators agreed that In its present form the Curriculum is not suitable for implementation in Pakistan. A report has been sent to TAUH. 3.3. The Faculty. In the past and at present , nursing Instructors are teaching midwifery on ad hoc basis.(13) The reason being that with the exception of public health schools, the midwifery schools in the public sector do not have designated posts of midwifery tutors. So far no efforts have been made to have a proper cadre of qualified midwifery tutors with a career path. By and large the schools do not have enough midwifery faculty..In the midwifery schools which are a part of schools of nursing , the tutors who are teaching midwifery are also responsible for teaching the nursing students. Many schools are using LHVs as trainers without giving them any further training in Obstetrics or in Educational Technology. MNCH, the development partners and the government have tried to build the capacity of the teachers through short courses and Workshops. This has had a limited impact. Some of those who attended these workshops were not midwifery tutors. Some got transferred to other departments because almost 100% are registered nurses. It is ,however, encouraging to note that there are now clinical supervisors of CMWs in some of the schools. This is a very positive development even though the quality of their performance and their numbers require a lot of improvement . (9) 26

There are no sanctioned posts of the clinical supervisors or clinical Instructors. Some schools have been successful in getting a hospital staff member appointed as Clinical Supervisor. Those met did not see their role as Clinical Instructors. They were given no orientation to their role . None of them has seen the curriculum or the log book. They were not at all familiar with the functions of CMW, so they were not aware of training needs of the CMWs. It must be remembered that even though trainers are at the center of training activities there are many other factors also which affect the quality of training. These require a lot of attention of the health authorities because most of them are operational issues. e.g A major problem faced by the schools is that midwifery tutors are on posts which are not regularized. They work on ad hoc basis , hence can be moved any time to an other department. Those in regular posts are Nursing Instructors, dividing their time between teaching nursing students and midwifery students. Obviously , nursing students are their priority. The teachers of midwifery need two strengths i.e Mastery over the subject and strong background in educational technology. Midwifery is largely a competency based profession with a body of theoretical knowledge. The average teacher of midwifery with gaps in both the requirements, cannot fill these gaps with short training workshops. With their own , perhaps, he tutors can minimize the gap of knowledge but cannot develop the skills required for midwifery practice. They continue to perform as class room teachers. Some of them are doing a fairly good job. 3.4. Training of CMWs : Quality of training There is enough information available about the quality of training of CMWs. In November 2010, Assessment of the Quality of Training of Community Midwives in Pakistan (9) was done by HLSP,with DIFDs financial assistance. The Assessment study was carried out in a representative sample of 10% of the 130 schools. Only 3 schools were included from Sindh. The most recent assessment of CMWs training is the ,Situation Analysis of CMWs Education in Sindh. (13) This was an exhaustive study carried out In March- April 2012,with 100% sample of schools training CMWs. The assessment tool (Annex IV) was first discussed in a meeting with the Principals of 20 Schools training CMWs and given to them to provide information. The response was very encouraging. 18 schools returned the Questionnaire. One is not functional yet . Validation was carried out on 25% of the schools. Field visits included interviews with focal persons of MNCH, the school faculty , clinical supervisors, students, and heads of the Ob/Gyn Units and administrators of the hospitals used for practical training of CMW students,. Evaluation of teaching was done by attending one or two classes in session and assessing the knowledge and teaching skills of the teacher. The evaluation was discussed with the teachers after class. 27

The information collected during the field visits proved that the responses in the questionnaires filled by the faculty of schools do not match with the information collected during the validation field visits. It seems that the responses given are , What should be, rather than , What is Note : For details please see the twin of this report which is a complete document by itself on Situation Analysis of Midwifery Education in Sindh. Major findings of these studies endorse the fact that , in spite of many efforts of the government. the UN agencies and the development partners, the quality of midwifery training is still not of acceptable standards. It requires a lot of improvement. The theoretical part of the training which is carried out in the classroom is showing fairly good results. The reason for this is that students memorise information. They manage to answer a few questions in the examination. Even if they can answer Half the questions right in the written paper and in the viva, they get through. There is no testing of skills. Clinical teaching and learning are the weakest link of the CMW training. Some of the findings of evaluation studies outline these as under: o Some of the hospitals used for training do not get enough normal deliveries to provide hands on experience opportunities to students. o Larger institutions are teaching hospitals for medical students. They have a lot of normal deliveries but they also have a large number of learners of various medical cadres. They get priority and midwifery students do not get adequate opportunity for hands on experience. o Supervisors are not aware of the needs of midwifery students because they are not familiar with the CMW curriculum. Moreover they do not have training in clinical teaching and skill development. o Midwifery tutors feel responsible for only the theoretical learning of midwifery students. o With rare exceptions , there is hardly any collaboration between the senior management of the allied hospital, the staff of the Ob/Gyn department. and faculty of midwifery schools o Midwifery students have fair amount of memorized knowledge about midwifery but they do not develop deeper understanding for critical thinking to scientifically utilize that knowledge. o Most of the CMWs pass their final examination on the strength of their theoretical learning. o Schools of nursing which are also training CMWs, students their primary responsibility. consider nursing

28

o Most students do not get the opportunity to get practical experience in providing care to the mother during labour or conduct deliveries. The students are required to document a certain number of deliveries which they observe and a certain number that they conduct. They write up even, observed deliveries , as , conducted deliveries. They also write up fictitious cases to meet the requirement to sit for their qualifying examination. This practice has not changed since the year 2000 3.5 Teaching /learning resources and methods of teaching There is a lot of improvement compared to the resources of the schools before 2005. Some of the schools are fairly well equipped with text books, manuals, and audiovisual aids . Many schools have computers and some of the tutors are computer literate. It has been recommended that all faculty needs to be made computer literate. There are some schools, however which are still in need of resources. It has been documented (9) that the teachers do not have the background of knowledge and skills to draw upon most of the resources like the manuals and printed support materials to develop their own teaching/learning plans. Same applies to the use of modern methods of teaching. Lecture still remains the most common method of teaching.(13) A very positive reaction of the faculty members of the schools visited is being demonstrated through the interest of the tutors in their own capacity building. They are asking for further guidance . 3.6. The Students Each group of CMW Students is a mixture of those who passed the matriculation examination more than a decade ago and those who passed it only a couple of years ago. There are young unmarried girls of 20 and there are married women with children. There is marked difference in the attitude of the learners. Those living in the hostel ( where one exists) are more regular in their attendance. The day scholars have problems of transport and also of family responsibilities. They are often late and find it difficult to make up for the missed classes..Some admitted that the demands of the family leave very little time for self study Most teachers are of the opinion that there are very few students who joined this course for love of midwifery. The major attraction is the Rs. 3500.00 per month being paid to the CMW students as stipend.

29

Outputs
2 008- 20 09
T ota l3 4 2 Appearedfor final exam
122 36% 202 59% 18 5% Passed
Passed after more than one attempt

2009- 2010
T ota l 422 Appearedfor final exam

149 35% 273 65%

Passed dropped out

dropped out

20 10 -20 11
T ota l 531 Appearedfor final exam Passed dropped out

184 35%

339 65%

30

Admitted, Qualified and Deployed (2009 2011)

1500 1300 1100 900 700 500 300 100 -100 Total Admitted Appeared Passed 832 Dropped out Deployed Waiting to for finals 527 220 be deployed 1287 612 220

1359

1287 832 61% 527 39% 612

31

4 Evaluation of Teaching / Learning Outcome As mentioned earlier ,reports are available of the evaluation of training institutions and of knowledge and skills of CMWs. These reports are of studies/surveys based on responses to questions asked. One report( 9) provides some information about the skills of the CMWS. where the researchers have observed the performance of the CMWs . They used OSCE and found that the levels of competence of the CMWs, in the required skills to practice safe midwifery, by and large, was quite deficient. It is due to the fact that most of the midwifery is being taught in the classrooms. There is a mixture of ranking of the knowledge and skills of the students and of the teachers. It is of great concern that the CMWs are ( and will be) practising midwifery, dealing with two lives with inadequate knowledge and skills. Midwifery practice requires high levels of competence and mental capacity for quick decision making. These cannot be learned in the classroom. Internal methods of evaluation comprise occasional written tests. There is no internal evaluation of the skills of the student CMWs. There has been no study on the methods of evaluation of the students learning during training and of the final outcome of training regarding the achievement of Expected Levels of Competence ( ELOCs) of the student. This needs to be done just before the CMWs sit for their final examination.. The available information about the competence levels of CMWs who are deployed , has identified the need for a lot of improvement. What is documented below is the current system of evaluating the final outcome of 18 months of training as described by the Director General Nursing , the Controller of Examinations , Sindh Nursing Examination Board, and some of the midwifery tutors. The qualifying examination is conducted by the Sindh Examination Board. It comprises both written and oral examination. There is no testing of midwifery skills. Multiple Choice Questions have been introduced in the examination system but the quality of items does not meet the criteria of MCQs because those constructing them have two difficulties : They have not had proper training in Tests & Measurement Their own knowledge and skills regarding midwifery, by and large, are basically theoretical and quite limited Efforts have been made to train the examiners but it has had very limited impact. No marks are given for the written case histories of the deliveries which CMW conducted. Every one is aware of the fact that majority of these case histories are fictitious.

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Most CMWs manage to memorise the theoretical content of midwifery. They are able to give some times correct and some times partially correct answers to questions asked in the qualifying written and oral examination. A midwife can qualify to get a diploma if she can get 50% marks in the final examination. If a CMW fails in the first attempt, she can make FOUR more attempts to pass the examination. According to the Controller of Examinations, very few attempt a third time if they do not pass in the second attempt. There is no evaluation of the midwifery skills of the students in Sindh. OSCE was a part of ToT workshops, but is not being practised. The failure rate in the first attempt is quite high in majority of the schools. Not all those who fail make a second attempt. There are no examples of a third attempt. Majority of the examiners are not practising midwives. Some have not been to a labour room or in a class room for years. Some of the examiners are currently teaching midwifery. Between those who are teaching midwifery ,there is a collegial understanding to safe guard each others reputation and reputation of their school by maximizing the number of successful candidates of each other. 5 A positive Development A recent positive development which is very encouraging is that all those connected to CMW training in any way are voicing their concern that a vast majority of CMWs being trained in the public sector schools are getting their diplomas in midwifery on the strength of theoretical knowledge. This situation is the result of a combination of factors, circumstances and individuals. These include the student herself, the teachers, the clinical supervisors, the ob/gyn staff of the facility where the CMW is getting her practical training, schools administration and of the hospital, the examiners, the examination boards, and finally the regulatory body i.e Pakistan Nursing Council. It has also been recognized midwifery that Pakistan needs qualified faculty to teach

6. Number of Schools Training Community Midwives . In Sindh at present 20 schools are training CMWs and some new ones have been built awaiting budgetary sanction to start functioning. The goal is to have a midwifery school in each of the 23 district. There are some schools which are training midwives but are not recognized by PNC. Some of these use the platform of a recognized school to get their students to take the final examination. 33

According to the PC-1 (1) , in Sindh 2000 midwives are to be trained by the end of 2012. So far just over 1000 have been trained. Table 1: Number of Public sector Schools Training Midwives in Sindh (by Category)* General Education Requirement is Matriculation for ALL categories of Midwives Type of RN # LHV CMW Midwife Remarks school RM Nursing& Attached to a Hospital Most Midwifery 10 X X ___ SONs have one year midwifery school training for RNs Not attached to a hospital . Public Health 5 ___ X X ___ Borrow field practice areas. LHV school gets one of midwifery training. Pupil Attached to a hospital. Midwives ___ ___ ___ ___ One year midwifery training 0 school 18 month training. Separate *CMW 18 ___ ___ X ___ curriculum. schools *source MNCH This table reveals that there are 18 schools training CMWs. More than one category of students has impact on the practical experience of each student particularly on the number of deliveries to be conducted by each student. Table 2: Number of Private sector Schools Training Midwives in Sindh (by Category)* Type of school Nursing& Midwifery school Public Health school Pupil Midwives school *CMW schools # 12 RN RM X LHV ___ CMW ___ Midwife ___ Remarks Attached to a Hospital Most SONs have one year midwifery training for RNs Not attached to a hospital . Borrow field practice areas (40 weeks midwifery training.) Attached to a hospital. One year + midwifery training 18 month training. Separate curriculum.

__

___

___

___

___

11 6

___ ___

___ ___

___ X

X ___

*source MNCH 34

Table 3. Numbers of CMWs admitted and Numbers Graduated Since 2009.* Year A B C D E F 2009 2010 2011 Total *source MNCH A # C. # E # G# 406 422 531 1359 ___ ___ ___ 64 ___ 8 72 342 ___ 523 865 202 273 339 814 18 ___ ___ 18

G 122 149 184 455

selected and admitted, B. # Dropped out before starting training Dropped out during training D. # Appeared for final exam Passed in first attempt F. # Passed after more than one attempt If failed. Dropped out

Out put of 531 admissions is 339 CMWS i.e 64% successfully completed the training. 36% failure rate is is a point of concern. Table 4 Numbers of Community Midwives Graduated, Deployed, Awaiting Deployment.* Appeared in Final Exam 342 422 523 1287 # received Diploma 220 ___ ___ 220 # deployed 220 ___ ___ 220 waiting to be deployed _____ 273 339 612

Year

# passed

2009 2010 2011 Total *source MNCH

220 273 339 832

35

This table reveals 1287 appeared for their final examination, 832 (61%) have successfully completed their training . 220 have been deployed 612 are awaiting deployment. 6.1 Output of Schools So far three batches of CMWs have been trained. A total of 1359 students were admitted, 1287 appeared for their final examination, 832 (61%) have successfully completed their training . The failure/drop out rate of 39 % is a point of concern and needs looking into carefully.

7. Deployment of Community Midwives As can be seen from Table 4, the CMWs have to wait for a long period between graduation and deployment. There are three main reasons for the delays. Some of the reasons for delayed deployment are : The CMWs were supposed to get the basic equipment to set up a birthing station and start their midwifery practice. The health authorities trained the midwives but had not allocated resources to give a start to CMW. As the resources are becoming available they are getting deployed. The CMWs who pass their qualifying examination get their mark sheet but not diplomas . Without the diploma they cannot apply to PNC for registration. Diplomas are issued after many months ( some times after a year). The CMW either sits at home or seeks other employment , even adopts an other vocation.. One study reported that majority of those who were not deployed in the public sector were working elsewhere. Some NGOs employ them on salaries much better than what they expect to earn in the public sector CMWs are already voicing their dissatisfaction over the stipend (they called it salary ) of Rs. 2000 .00 per month which they are getting after deployment. They say that as students they got Rs. 3500.00 per month. It has not been explained to them that this is not a salary. It is a ,reporting fee or , articulation allowance and that they are expected to generate their own income by ,Fee for service The deployment guidelines have been developed by TRF. These have not been endorsed by the health authorities. As mentioned earlier, they need a critical review before endorsement.

36

8. Potential acceptability of the CMW by the community A qualitative study of the potential acceptability of the CMW for pregnancy and delivery related care in rural Pakistan (12) was commissioned by PAIMAN to Population Council in 2010. The study was carried out in 4 districts .A total of 375 individuals participated. The respondents were LHVs, TBAs, and male and female adults in the communities. Its findings are quite interesting and can prove useful for planning the next PC-1. 8.1 Responses of LHVs LHVs are the main competitors of CMWs. Obviously their responses could be biased. They felt that the CMW will have considerable difficulty in getting accepted in the community but added that a lot will depend on her behaviour. She has to meet the expectations of the community, and must have respect for local culture. They said that the community expects a lot from the trained health care providers irrespective of their qualifications. They were willing to cooperate with the CMWs on their terms. These include: o CMW could conduct deliveries after 2.00pm when the BHU closes. o CMW can refer all deliveries to LHV and get a percentage of the payment. o CMW can conduct normal deliveries herself and refer complicated deliveries to the LHV for which she will charge her fee. The last condition is interesting. What the CMW cannot manage , the LHV also cannot manage because they are both licensed midwives and are expected to function within their authorized limits. This action will only result in unnecessary delay in getting the woman to the source of appropriate services . Yet this reflects the practices of LHVs and perception of their own status as being superior to CMW. Majority of them are posing as doctors. That the LHVs are providing services for which they are not trained or authorized, is also reflected in the expectations of the community from the CMW. 8.2 Responses of TBAs TBAs also agreed that CMW will have many difficulties in getting herself established in the community. TBAs were also willing to cooperate with the CMW but for every gesture of cooperation they wanted a percentage (up to 50%) of what ever the CMW will charge the woman. Their condition were: o TBA will refer all delivery cases to CMW and be present at the time of delivery 37

o TBA will take care of the woman in the post natal period and cater for her needs ( massage, cleaning and washing etc) o If she is conducting a delivery herself she will call upon the CMW if she faces a problem. 8.3 Responses of community members and their expectations of CMWs Respondents in the community were males and females i.e husbands, mothers in law, literate and illiterate married women with children under five years of age, LHVs and TBAs. There was no difference of opinion that CMW is needed. CMW will be acceptable to the community if she meets their expectations. She wil be acceptable if she : o Is available and accessible o Is knowledgeable and competent o Should be friendly and cooperative. o Has the facilities to provide care. Regarding the care ,expectations of the community of a CMW were as if she is a medical doctor. Because the community expects her to be able to carry out diagnostic tests and use the ultrasound. A question arises here i.e are these expectations reflective of the services being provided by the LHV in some of the districts.? o Charges according to the economic condition of the family like the TBA and the LHV. The literate women were more in favour of paying the CMW for her services. The range was from Rs 100 to 1000. The general opinion favoured a range between Rs.300 to Rs 500. 8.4. Accessibility of the CMWs and their Utilisation by the Community A study of the Accessibility of CMW to the Community (12 ) funded by RAF and carried out in 9 selected districts all over Pakistan has identified certain very important positive factors which facilitate the work of the CMW as well as the constraints which limit her accessibility. Facilitating Factors (where present) are:.

CMWs reaching out to the community by home visits and motivating the pregnant women to avail of their services Free services and flexible rates of fee for service. Support from their own family members Cooperation of the health workers particularly LHWs 38

Availability of necessary equipment Self satisfaction with their work Respect shown by the community

Inhibiting Factors ( where present ) are: Community was not aware of the existence of CMW CMW were not aware of the geographical areas in which they were supposed to work. Therefore they worked only in their own neogbourhood Family restrictions to the CMWs mobility Low financial returns Transport issues Regarding introduction of the CMW in the community, previous events for launching the CMWs were held in cities in the presence of the dignitaries. The community knew nothing about this newcomer in the community. This weakness has been already recognised. by MNCH It is now planned to hold small events for individual or a small group of three or four CMWs almost at their door steps.. The CMW s should be introduced individually by name. Information should be given to the community about the need for skilled care for the mothers and the neonates and that CMWs are trained to provide that care.

9. MIS for MNCH : Monitoring and Supervision of CMWs. The currently used system comprises two types of monitoring and supervisory activities i.e Quantitative monitoring and qualitative monitoring and supervision. The quantitative monitoring is done by the supervisors of LHWs( LHS) , whose role is to collect data ( figures only) of the inventory, and numbers of mothers and children served and referrals made. The qualitative supervision is done by an LHV from the Tehsil or district hospital of the district. She is expected to provide supportive supervision to the CMW as well as evaluate her performance. In the original plans monitoring was to be done by the ob/gyn specialist of the district/Tehsil Hospital. It seems that it could not be implemented. 39

The LHV is ,however, dependent on the LHS for transport. Therefore the implementation of this system needs to be evaluated. Reporting and Monitoring Tools have been developed by TRF. Apparently their development went through a rigorous exercise of development, printing and reprinting at a considerable cost of money , time and effort. These have been printed in thousands. Midwifery tutors have been given the responsibility to train the CMWs. who have completed their midwifery training It is planned by MNCH to make these tools a part of the curriculum. CMWs under training will be taught about their use as a part of pre- service training. At present, they are being tested in three districts. NOTE: It is not clear whether these tools were pretested before printing. The author had an opportunity to attend a workshop for training of the recently graduated CMWs in the use of these tools. It seemed that the CMWs were having difficulty in understanding them. There were too many forms and a lot of information to be entered in many forms which much duplication, which seemed quite overwhelming. Ease of administration did not seem one of the qualities of those tools. The number of forms a nd their sizes are quite intimidating. In discussions with the Director MNCH it was decided that when the reports start to come in , the author will provide technical assistance in evaluating the quality of data received through these forms. It is a set of 10 tools with a Users Manual, for getting various types of data as under:

9.1The Population Chart On this wall chart the population of all the villages assigned to CMW,and their distance from s of : pregnant women ( 3.4%); births (2.9%); women in the reproductive age group (22 %); married women in reproductive age group (16%); Children under one year of age (2.7 %) children under 5 years of age (16%), are to be calculated and entered. CMW is expected to update this chart every year. It is not clear : Who will supply her with the distance of each village from her Work Station? Who will supply her the figures of population in each village every year?. Will CMW do all the calculations for her. ( there is an example of method of calculation given in the User Manual.)

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These seem unrealistic expectations from the CMW. It is felt that this Chart , should be supplied to her with the information at the beginning of each year. 9.2 A Card for the mother and the neonate The card is 13.5 X10.5 inches, printed on both sides. One side is for the pregnant woman and information about labour and its outcome. Its columns are in two colours, white for normal and pink for not normal condition. The woman is expected to visit the CMW ( or CMW to visit the woman) 13 times during the 9 months of pregnancy.. This regimen is not followed any more. 13 ante-natal visits per woman in 9 months is far too much for a CMW. She is not expected to Charge for ante natal visits. MNCH Informative Booklet (14) mentions 4 ante natal visits. The other side is for the postnatal mother and the newborn. It has columns in three colours, first column is pink,. The normal way of reporting is that one documents the normal first because it is more common. On the front of the card, this system has been followed. On the back ,PINK which is sign of danger is the first column . The next column is yellow and then green. Significance of yellow is not clear. In the yellow column there are some stars(*). The instructions say, the star means , Beemari Ki Darmiani Kaifiyat Naheen Hai. What does that mean.? It is very confusing . There are thirty entries to be made for the mother and 15 for the neonate at each visit.. There are total of 5 post natal visits. NOTE She is supposed to document post natal information for the mother and the baby even for those women whose delivery was conducted by SOME ONE ELSE. Supposing that some one else is an LHV, what then?

9.3 Daily Register. When opened for making entries its size is 34X 11 inches. Right side is for the woman and the opposite side is for the newborn. There is one horizontal row for each person and 51 columns with horizontal lines making 51 boxes. Almost every box has to be filled every day. 9.4 Partograph. In the Users Manual it says, Use of Partograph is very simple and very easy. Instructions tell the user what to do but there are no instructions about how to PLOT the information and how to INTERPRET the entries on the Partograph. There is a blank Partograph form in the user manual but no example of a filled Partograph. Unless the students have used the Partograph during training , they

41

will not know how to use it decision making. 9.5. The Referral Slips.

and the significance of using a Partograph for

It is 13 X3.5 inches and 1 inch thick set of forms. Each slip has three parts. Two of these are easily detachable. All the three parts have to be filled before referral. Two are detached and given to the patient/client to take to the hospital. One of these is for the hospital to keep and the other has to be filled by the doctor/nurse who provides services to the mother and or the neonate. This is to be given back to the patient for feed back to the midwife. The referral slips are in three colours. The green ones are for routine care e.g vaccination or ultrasound etc. The yellow one is for treatment of an ailment which is not life threatening. The Red one is for Emergencies requiring immediate medical attention. The system if it works seems a good system. The only reservation is that in case of the red slip , writing on three parts will take time. (1o pieces of information on each slip ) 9.6 Client Record Card It is a 7X5 card for documentation of family planning users. On one side there is information about the client and on the back is information about method of family planning being used. It has 12 columns to allow for a years contraceptive practice. 9.7 The stock Register All the other tools are in Urdu. The Stock register is in English . When opened to make entries it is 26X8 in size. Up to 50 items can be entered in it. There are nine columns. Entries have to be made on a separate page for each drug each item of supplies, equipment etc. One column says ,Particulars(Received / issued). The Received item has to written in Red and the issued item in Blue. This register has to be maintained in English. For drugs dispensed and supplies used, CMW will have to make daily entries. 9.8 CMW Monthly Report This tool is 11X8 inches and is the form of a writing pad, hard bound, with pages that can be detached. There are 3 white forms ,each followed by a yellow form. CMW has to fill the white and the yellow forms ,giving the same information on both the forms. and for the supervisors. Following these 6 pages there is a blank white page and a blank yellow page for the technical supervisors comments. The supervisor alsohas to write her comments twice. The three white forms and one white page with supervisors comments are to be submitted to LHS during the monthly meeting. CMW keeps the yellow pages for her record.

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CMW has to make 120 entries on the white forms and repeat these on the yellow forms. That is 240 entries every month. 9.9 Check List for Supervision of Management This check list is meant for quantitative monitoring and is to be used by the Lady Health Workers Supervisor( LHS). It comprises two pages of white forms only. . Basically it is to check the inventory. But there are entries which check the performance of the midwife e.g Did she bury the placenta in a suitable manner.? Did she destroy the SHARPS in a suitable manner.? Also there is information about feed back from the community on the quality of her services and whether she is supplying free medicines etc This is qualitative monitoring which is the responsibility of the LHV. This check list does not have yellow pages. Users annual does not say any thing about the utilization of this check list. What happens to it after the information is entered is not clear. 9.10 Technical Supervisory Check List The technical supervisory check list is for qualitative monitoring and is to be used by the LHV. It comprises 8 pages of white forms only . The supervisor is to check all the documentation mentioned above in 8 tools. Check/ask/observe performance of skills and make 108 entries. Most of the questions relate to the competency of the CMW in performance of almost all the midwifery skills. From the check list one gathers that the supervisor will accompany CMW for a home visit of a pregnant woman, and of a post partum woman and also be with CMW l throughout the 4 stages. when she attends to a woman in labour. It is difficult to comprehend how the supervisor will manage that in a couple of hours That is just about the amount of time she will have available to her for one CMW. She is expected to supervise two CMWs in one day. Also she has no control over how much time she can spend with one CMW because she is tied to the LHS for transport. This check list does not have yellow pages. What happens to the Technical Supervisory Check List after the required information is entered in it is not clear. The quality of this supervision becomes questionable. The supervisor is an LHV. Her own competency level will have to be evaluated before she is assigned the task of supervising CMWs. NOTE: There is no mention of this check list in the Users Manual. 10. Observations on the Monitoring and Supervisory Tools and process 43

10.1 Recognising that a lot of time money and effort must have gone in their preparation, nevertheless one is overwhelmed by the amount of effort and time that will be required to use these tools. The purpose of mentioning the size and number of entries required in each tool Was to underscore a few points: CMW will have to document same information MANY times. She cannot carry the tools with her. When she goes home visiting and for delivering a baby. She will record information in a note book. Obviously that will be very brief. Then she will record in the register or on the form when she has the time. She is bound to write from memory. This can defeat theentire perpose of documentation. The size and number of tools require space to store. Not only that , space is needed to work on them e.g the daily Register requires a table top of at least four feet for her to open and write in it. The Deployment Guidelines state that her entire Work Place will be 6ft X 4ft. She is to go to a women who was delivered by some one else and record all the information about labour and delivery. This is rather unusual. How can she be certain about the accuracy of that information. Also any unusual development later , cannot be her responsibility. She is going to get Rs 2000 to do all that much writing. Will this information be forthcoming after the articulation allowance (they called its stipend ) is stopped.?. There is every possibility that due to the effort and time required to make the entries the data generated might not be accurate. It might become a form filling exercise. . Note : Information about maternal and neonatal deaths is not included in any of the forms or in the supervisory check lists . There is only one little box in which to tick whether the baby was born alive or dead. 10.2 Supervision of Mangement of CMW Quantitative monitoring and is to be done by the Lady Health Workers Supervisor. (LHS). She is not an employee of Health Department. Her services and the vehicle for monitoring will be borrowed from PWD. There is some incentive for the LHS but the nature of the incentive was not available. LHS has to visit more than one LHW in one visit. The technical supervisor is expected to visit two CMWs in one day. At present there were no answers for time management.

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10.3 Technical Supervision of CMW Originally a doctor from the District Hospital was going to supervise CMW. That was changed to tutor (16) . The Users Manual refers to LHV as the technical supervisor. It does not say what level of LHV. A fresh out of Public Health School LHV will not have the capacity to identify the needs of CMW for guidance . If asked for guidance she will have the same problem. The midwifery curriculum used for LHVs is 18 years old. and very sketchy. Technical supervision has to be done by a senior and experienced person. In addition the process of technical supervision is not very clear. According to one of the officials the LHV will meet the CMW in the monthly meeting and take information. CMW will consult her on the phone if she has any problem. The Users Manual gives one the impression that the technical supevisor will visit the CMW in her work place and if possible attend a delivery conducted by CMW. NOTE: See item 13 below for suggested approach to technical supervision of CMWs

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Flow of Information

PHMIS /DHIS E D O Office D M I S

MNCH

MS / Focal person

LHS

LHS

CMW

Technical Supervisor

Effort was made to find out about what happens to information after it reaches the District and the provincial level. It seems that at every level the effort is toensure that reports get prepares and forwarded to the relevant office.. 10.4 Information 10.4.1 Current practice Information received from MNCH Directorate is that they evaluate the reports of CMWs performance and then release their Stipend. No definite system has been established yet to use information for identifying areas requiring attention or using the information for further planning. A very elaborate soft ware has been designed for MNCH Information System. It is not being used yet because the computer operators and focal persons are being given training. The new monitoring tools are being pretested . The filled forms have been received from one district only ( Tando Allah Yar). They were not accessible to the author. 46 Use Of

10.4.2. Future Use Main use of information received from the CMWs should be processed for specific objectives. These should include: Pregnant women in the population being covered by CMWs Ante natal Care coverage Deliveries and their outcome Referrals made and their outcome CPR in the population Any maternal death (cause) Any neonatal death (cause)

It is however very difficult to comprehend how the copious documentation of CMW will be processed, analysed and for which purposes it will be used. 11. Challenges For Consideration in the future A critical analysis of the selection, training and deployment of CMWs has revealed certain verifiable facts . These are crucial for future planning of this very vital human resource which is central to the theme of reduction of MMR in Pakistan. The purpose of documenting these observations is to look at th situation critically and use the findings for result oriented planning. 11. 1 Meeting the Criteria for selection ( PC-I ) Female, preferably married, Permanent resident of the area from which she is applying Minimum qualification should be at least Matric, preferably with science subjects obtaining 45% marks Have experience of working in the community Should be 18- 35 The only study (9) which looked into the drop out rates reported that it had proved difficult for the average rural female to meet the criteria for selection in all the provinces. Punjab did better than other provinces. If one takes each criterion and applies it to the ground realities, one realizes that the criteria does not match the strategies outlined. Preference for married female had the following affects: The CMW training was planned to be a residential course. This was an unrealistic strategy, if preference was given to married women. It was not unexpected that they could not stay in the hostel because of their responsibilities as wives and mothers. Moreover the families did not approve of their continued absence from the home.. 47

 Their not being full time students affected their attendance, learning effectiveness and their learning outcomes. This was compounded by having to travel long distances to and fro, every day. Pregnancy could not be ruled out. Matriculation with science subjects Certain social constraints , shortage of schools for girls and the standards of education in the rural areas made it hard to find females who matched the education required for selection. It was an unrealistic criterion in a province with low female literacy rate to begin with. The original criterion was that the applicant passed her Matriculation with 45% marks. It has now been brought down to 40% marks. Age range Another criterion, influencing the performance of the students was the age range of 18 to 35. Those older than 25 had left school more than a decade ago. Going back to school and learning to learn was difficult. Experience of working in the community It would be possible in very rare situations. Only where the Lady Health Workers (LHWs) are working successfully , a woman might be a part of the Womans Group, if one exists, or the LHW herself is an applicant Otherwise with the sanctions imposed on their mobility, a rural, woman would hardly be allowed to work in the community. This, however needs proper screening of the applications to find out how many meet this criterion. It is not surprising therefore that students from urban areas also got enrolled . Some got selected due to pressure on the selection committee irrespective of whether they met the selection criteria or not. The Failure Rate is a point of concern. This needs to be investigated. Is it connected to irregular attendance? Are more failures among the married candidates. Are more failing in the written part or in Viva. Q. What attracted the candidates to apply ? According to the teachers there were students who admitted that they did not fill their application forms. There are examples of instances available that the major attraction was Rs 3,500 per month. When faced with realities the candidates and or the families realized about the time , effort and support of the family required, for a woman to educate herself. It was harder for the married women and for those, married or single, who `had been out of school for more than a decade.

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11.2 Attendance The students living at home do not attend classes regularly. They have genuine reasons. Public transport conditions and family responsibilities in the mornings are two main reasons. This poses problems for the teachers. With one exception, where it is mandatory to live in the hostel, in all other schools teachers admitted that when they do not have all the enrolled students in class. it increases their work load. Some caring teachers even take extra classes for those who miss classes. There are examples that teachers are pressurized into marking the student present to meat the requirements of attendance. 11.3 Time for practical training Midwifery schools observe the school hours of general education schools. They have classes in the morning from 8.00 till 10.00. The students are in the wards from 10.00 till 01.00pm If the class starts late ,it finishes late, then it impinges upon the time in the wards. During clinical practice, students are supposed to spend a minimum of 6 hours in the wards. Babies have a tendency to arrive in the late evening or at night. That was the main reason for making it a residential course. Day scholars do not want to stay or come back after 01.00pm. Most students refuse to be available during evenings and at night. The school day should be at least an 8 hour day. It has been discussed at many forums that the training period should be increased to two years. The last six months should be only supervised practice in providing obstetrical care., rotating in three shifts. This will be of great help. 11.4 Educational background of students According to the teachers that is the biggest challenge. Even though there are Manuals in Urdu, the technical terms and names of drugs etc have to be learned in English. Most of the students from the rural areas cannot even write their own name in English. Some have difficulty in reading and writing Urdu. Some teachers were certain that they did not study up to matriculation. This is especially true of those who used unfair means/ pressure to get admission. 11.5 Documentation of training activities Teachers are maintaining attendance register of theoretical attendance of the students. There is , however, no record of the time spent by the students i in the hospital in various units. As pointed out in an earlier document (9), no school has an academic calendar.

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11.6 Monitoring of training activities Directorate of MNCH has designed a very good system for monitopring training activities. There is a focal person in each district. His Job Description starts, Work as representative of MNCH programme in the district. (16) That means that this individual is the eyes and ears of MNCH in the district. It is his/ her responsibility to ensure that the training activities are implemented according to the schedule and that students meet the requirements of training. During field visits it was found that focal persons visit the school but they seem to have no contact with the student to find out whether they are learning what they are supposed to learn( i.e requirements of the course, particularly the practical aspects of their training. 11.7 Drop outs and failures One document reported high dropout rates before and during training.( 9). In Sindh no drop outs are recorded before training. There are very few drop outs during training. The failure rate is high Information is now becoming available that the dropouts are due to failures and

also after completing the training. A major reason given for drop outs after training is the delay in getting diploma, which results in delay in getting the license from PNC which delays the deployment. The whole process can take up to a year. With the result that the graduated midwives are taking up jobs with NGOs and in private maternity homes. Some start sort of private practice and some stay at home. This is a serious situation. This defeats the entire purpose of training community midwives. The High Failure Rate are a point of concern. This needs to be investigated. Is it connected to irregular attendance? Are more failures among the married candidates. Are more failing in the written part or in Viva.

12. Meeting the Challenges. 12.1 .Establishing a District Management System Districts deploying CMWs shall establish and follow a system for the training, utilization and supervision of the CMWs. Institutions training CMWs shall abide by the Districts governance mechanisms for the selection, training , deployment and supervision of the CMWs. While basic principles of the system will remain the same each district will have tailor the system according to its needs.

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For the Districts to plan effectively a plan for the midwifery human resource required for the next five years be chalked out according to the needs of the district based on the population of the district. An authority entitled District Midwifery Committee (DMC) should be established at the district level , headed by EDO (Health) and shall play a focal role in overseeing the training, deployment and performance of the midwife in the community. ( The existing Evaluation Committee can be modified to serve both purposes ) The DMC shall comprise: Executive District Officer Health (EDO) Representative of the concerned union council District Coordinator/focal person of MNCH District Coordinator of the National Program for PHC and FP Obstetrician/.Gynaecologist/ or Woman Medical Officer of District Headquarters Hospital ( DHQ) Principal of a School where midwifery training takes place Any other member deemed necessary by authorities. Mandatory Requirement All members shall be fully familiar with the training requirements and Scope of Work of the CMW 12.2 Functions of DMC This Committee will comprise various stake holders hence a source of liaison between health, population, LHW programme , training institutions and hospital . It will be the backbone of MNCH in the district. Utilising the Plan for Midwifery personnel for the next five years, DMC shall: 1.Finalize the Criteria and process of selection of trainees ( After analyzing the current criteria ) 2. Facilitate the training in Public Health Schools, and in Midwifery Schools 3. Facilitate examination and certification by the Nursing Examination Board. 4. Ensure orientation of the community to the role and obligation of the midwife and solicit support of the community to facilitate her acceptance by the community, the TBAs and the LHWs. 5. Ensure that the focal person of MNCH functions according to his/her defined 51

ToRs (14) 6. Ensure orientation of the midwife to the community and to near by health facilities 7. Ensure regular supply of necessary drugs, equipment, registers and forms for recording and reporting the information required for DHIS. 8. Provide support through a mechanism of : collaboration of CMWs with LHWs, Dais; supervision, mentoring and monitoring of practicing CMWs in the community. 9. Arrange, in collaboration with MNCH and Midwifery Association of Pakistan (MAP) and through other available resources, continuing education events ( Workshops, seminars etc) according to the needs of the midwives as identified by the midwives themselves and or by their supervisors. 10 Deal with any complaints received from the community about the midwife or from the midwife about constraints to her performance. Take action according to the Rules and Regulations of Midwifery Practice, keeping PNC informed of action taken. 11. Ensure that , Rules and Regulations and Code of Conduct for Midwifery Practice are followed and CMWs function within their specified limits as spelt out in the Document 12. Expedite the deployment of licensed CMWs in the area assigned to each of them. 12.3 Advocacy A Campaign, like the one for LHWs should be launched to educate the communities about the CMW programme. It should clearly explain that it will be a residential course. Only those married females should be accepted whose family gives in writing that they will abide by the rules of attendance 12.4 Written test for selection There should be a written test for selection. It should test very simple basic knowledge of English and a bit more than simple knowledge of Urdu ( Training Manuals are in Urdu) 12.5. Pregnancy during training ( For discussion and a policy decision.) If a student becomes pregnant during training ,she will have to discontinue training and pay back the stipend received till that time

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12.6. The stipend A vast majority of teachers stated that the students are not interested in midwifery. They and their families attraction is Rs. 3500 .00 per month. It is therefore suggested that the stipend should be reduced to Rs. 1000.00 during training. Education materials (books, manuals etc) food and hostel living should be provided free to the students. The articulation allowance after deployment should be increased. to Rs. 5000.00 per month and given for two years only to provide opportunity to the CMW to build her practice. 13. Technical Supervision of the Practising Midwives. Prerequisit : The technical supervisor should not be dependent on LHS for transport. Because availability of transport to LHS is sporadic. As mentioned above, the technical supervision of the practising CMWs should be done by a person who meets certain criteria. She should be: : Currently practising midwifery independently ( an SBA: senior midwife of any category, or a doctor) Involved in the teaching and training activities of midwives Fully aware of the Scope of Work and legal obligations of a midwife Interested in public health Capable of providing on the spot guidance to the CMW ( is clinically strong.) Capable of conducting audit/ verbal autopsy of any maternal or neonatal death. Have time officially allocated to travel according to her schedule. Her Supervisory Tool does not have to be very extensive. The first two or three visits will require more detailed encounter. Once she gets to know the CMW she can plan her own approach. If possible she should attend a delivery being conducted by the CMW. That can be only possible if CMW,s Work Station is used for deliveries. This individual will have to be trained to focus on : Quality of the CMWs performance ( safe deliveries) Partographs : plotting and interpretation in decision making CMWs ability to take timely decisions ( recognizing risk/danger) Referrals made: were these made with good judgment? Follow up of referred clients Regular users of contraceptives( CPR in the population served by her) 53

 Documentation ( absolutely necessary) Any maternal or neonatal death: If any , either an audit should be done immediately or arrange for one later to determine the cause ( was it an unavoidable death ?) Gaps in the knowledge and or skills of the CMW and action to be taken. CMWs Liaison with LHWs and TBAs The technical supervisor has to record the good practices of CMWs, areas where guidance was provided and actions which point to the gaps in the knowledge or skill level of the CMW. She should discuss it with EDO and the focal person decide what needs to be done.

14.Instutionalisation of CMW In the long run the CMW will have to become a part of the health system And need to be included in the human resource development plan. 14.1 Physical institutionalisation, of Mapping of CMWs AT present, the Mapping system has been designed by MNCH. There is a tool to document the details of each CMW , her license number, place of deployment, the reporting facility, names of management and clinical supervisors and number of LHWs attached to CMW. For implementation of the tool there are 6 officers in MNCH, each working as a desk officer for 4 districts. The presence of a focal person in the district provides the desk officers a direct link with CMWs. The focal person submits a report every month about the performance of the CMWs. From the current system it seems that the mapping is institutionalised fairly well. The CMW comes from a specific geographical area and she is expected to go back to that place. It is like slots are fixed for them. They are bonded to fit in the slot for at least three years. In principle this system seems to be implementable. If the next PC-1 is of the same design, this system can continue. The problems faced by the management is the fairly high attrition of CMWs. As mentioned earlier there are failures and then drop outs among the qualified midwives.

14.2 Professional Institutionalisation of CMWs.

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Eventually, the CMWs will have to be recognized as a special cadre of SBAs. Their sustainability depends on their becoming a part of the health system. Their has to be a special career lad der for them . The authorities will have to make sure that there are opportunities for their professional development and continuous growth. Otherwise, when the three year bond is over and the CMWs are no more articulated to the health system, they will be left unsupervised. It is feared that Without any supervision and or support they will practice as they please like some of the LHVs and the private practitioners.

To help the CMWs achieve a certain professional status, will be the responsibility of the professional organisation of midwives i.e Midwifery Association of Pakistan( MAP). The process has started already and a few of the CMWs have become members of MAP There have been a couple if incidences where the parents have contacted MAP because their daughter Did not get a job as promised.

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After Devolution
HEALTH MINISTER SECRETARY HEALTH

SPL : Secretary (PH))

D.G Health Services

Additional Secretaries (4)

Program Managers / Project Directors Preventive Preventive and and

Foreign Foreign Aided Aided Programs Programs (12) (12)

Deputy Secretaries (6) Section Officer (18)

In charges (2) 1. ChemicoBacteriological Lab (2) Police Surgeons Director Nursing Statutory Bodies 1. Quality Control Board 2. Nursing Examination Board 3. Sindh Medical Faculty 4. Health Foundation 6. Blood Transfusion Authority

Additional Directors Dev(2) Deputy Director Dev (3)

1 Principal Medical College

Medical Superintendents (6) Teaching Hospitals

For provincial Health Secretary, MNCH is one of the projects he has to look after. Things do not move as fast as before. Population Welfare Department has been affected more than health. They are having operational and funding problems. There have been efforts for partial merger between the Health Department and Population Welfare Department. The Population Welfare Centers were closed and 56

the Family Welfare Workers (FWWs) were placed in the primary health care facilities. This was a very good move. The PWD saved a lot of money by not having separate centers and the client got services under one roof. Apparently the problem of physical space for FWWs.was not foreseen. Efforts were made to find out what happened to the FWWs who could not be absorbed by PWD. Information was not forth coming. There were assumptions that most of them are working in private clinics( this wasnot verified). 15. A debatable Point The documents related to CMWs state that CMW will conduct home deliveries only. This had generated a heated debate during the Consultative Workshop on Deployment Guidelines in Bhurban in April 2010. Those with extenbsive field experience in maternal health felt that this is not a realistic requirement. Because: For safe delivery there are certain requirements of a place where birth is going to take place. These include: Privacy ; source of heat and light ; availability of water; clean space for delivery : and a few things required for the mother and the neonate. There are areas In Sindh in the interior, where very few homes will meet these requirements. If home delivery is imposed on the woman ,this is violation of her rights. A CMW might not be able to provide 24/7 services if she is called upon in the middle of the night and there is no chaperon available. If the CMW is away for 8 to 10 hours, she can only serve one woman. She will not be available to any other woman or child who needs her services. If she is static she can serve more than on e individual at any given time. Birthing Stations are a common solution to these problems. They are becoming Very popular for community midwifery. The bottom line is that home delivery should not be the only choice available to the mother and to the midwife. it should be a combination of both. CMW should have the option to establish a birthing Station if she so desires . The mother should have the option to deliver at home or in the Birthing Station. A policy decision is required for this.

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Part II Analytical Observations , Challenges and Recommendations. At the turn of the century three categories of midwifery personnel were being trained in Pakistan. Yet 80 % of the babies were being delivered by Dais and TBAs. There were two very comprehensive reports of studies available about the Status of Midwifery Education in Sindh and Punjab. Findings of both the studies are very similar. These were (and most of them remain till now) : There were more schools of midwifery than schools of nursing, yet hardly any practising midwives excepting LHVs. There were no posts of midwifery tutors except in Public Health Schools There were no teachers qualified to teach midwifery. Nursing tutors were teaching midwifery on ad hoc basis There were no clinical instructors. The curriculum was extremely sketchy and not competency based . Students cooked up cases and passed their final examination. The teachers, the examiners, the Examination Boards and PNC were all aware of this practice but no one objected to it. It was possible to get a midwifery diploma without delivering a single baby A midwife had no future prospects ( no career pathway)

Midwifery was not considered a profession with its own identity. These findings were disseminated widely. Even plans for improvement were made available to the policy makers and planners through a Strategy Formulation Workshop Not much has been done done between 2000 and 2007. A new cadre of midwifery personnel was introduced in the same environment for which plenty of evidence was available that it is not possible to prepare competent midwives without major improvements. The ONLY change made was that a new curriculum was designed for CMWs. This also was not a competency based curriculum. Patch work efforts were and are being made to improve the capacity of the teachers. The efforts are sincere but inadequate to fill the gaps of knowledge and skills of the teachers. Evidence is available that a vast majority of CMWs do not fulfill all the requirements of their training.. A lot of action is needed to improve the situation to prepare Competent Midwives. Queries are emerging. They do not have clear cut idea of their identity as professionals. Are they a part of the health system because they are getting Rs. 2000 per month ? Authorities call it a Stipend, CMWs call it a Salary. If it a stipend 58

then why is it Rs. 2000 when as students they were getting 3500. If it is salary then it should be much more than that. What needs to be done to improve and sustain the CMW Initiative in Sindh?

1. A System at the District Level 1.1 A human resource plan is needed for the next five years according to the requirements of the district for midwifery personnel. This should be prepared by the district health authorities with the help of provincial health authorities. 1.2 Establishment of a system in the districts for the selection, training, utilization and supervision of the CMWs. 1.3 Institutions training CMWs shall be mandated to abide by the district health authorities requirements and governance mechanisms.. It is recommended that: A District I Midwifery Committee be established for the Selection, Training , Deployment and Supervision of CMWs.( Perhaps the Evaluation Committee can be modified and named District Midiwfery Committee. Because District Midwifery will have many functions. Evaluation will be one of its functions.)

2 .District Midwifery Committee (DMC) DMC shall be an authority at the district level , headed by EDO (Health) . It shall play a focal role in overseeing the training, deployment and performance of the midwife in the community. The DMC shall comprise: EDO ( Health) Representative of the concerned union council District Coordinator/focal person of MNCH District Coordinator of the National Program for PHC and FP Gynaecologist/obstetrician or Woman Medical Officer of District Headquarters Hospital Principal of the School where midwifery training will take place 59

 A representative from the provincial health authorities 2.1 Functions of DMC Utilising the Plan for Midwifery Personnel for the next five years, DMC shall: Review the criteria for selection and finalize the selection process of the trainees including the written entry test
.

Facilitate and monitor the training in Public Health School, and in Midwifery school. Facilitate examination and certification by the Nursing Examination Board.. Facilitate licensing of CMWs by Pakistan Nursing Council. Collaborate with MNCH Directorate to post licensed CMWs in the area assigned to each of them. Ensure orientation of the community to the role and obligation of the midwife and solicit support of the community to facilitate her acceptance by the community, by the TBAs and the LHWs. Ensure orientation of the midwife to the community and to near by health facilities.

Ensure regular supply of necessary drugs, equipment, registers and forms for recording and reporting the information required for DHIS. Provide support through an established mechanism of supervision, mentoring and monitoring of practicing CMWs in the community. 10.Arrange, in collaboration with MNCH and Midwifery Association of Pakistan (MAP) and through other available resources, continuing education events (Workshops, seminars etc) according to the needs of the midwives as identified by the midwives themselves and or by their supervisors. Get information from the midwife about constraints to her performance keeping PNC informed of action taken Each member be aware of the Rules and Regulations governing the practice of midwifery and ensure their implementation. Each member accepts the responsibility of fair selection of candidates. Any other task mutually agreed upon amongst the Committee members and endorsed by the provincial authorities.

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2.2 Advocacy Function of DMC There is evidence that the Community needs to be made knowledgeable about the existence state of maternal and neonatal mortality and morbidity, the role of the CMW in saving lives. An Advocacy Campaign is needed to introduce the CMW to the community . It should have been initiated even before the licensed CMWs started to arrive in the community. It should be done as soon as possible. It is recommended that DMC ensures: A Multi-pronged well planned national campaign is planned and implemented at the local level. At the provincial level it be done through different media ( on the lines used for LHWs). . Where the CMW is already working, it can be done in an event like Mothers Day or Midwives Day. AN even can be created.The approach will be to show ,What services the CMW is offering., and role of the LHWs, TBAs and the community to support her Where it is done before the CMWs arrives the approach would be of , What services the CMW will offer, and role of the LHWs, TBAs, and the community to support her. Upon CMWs deployment her ocal promotion will include her formal introduction through a launching ceremony for her introduction to the community and to the services. She will be offering. Some suggested approaches are given below for the DMC: o Linkages to develop a network of support for the CMW, through individual contact or group meetings: with Stakeholders in health in the public and the private sector. They include: general practitioners, LHVs, TBAs, within reach hospitals and maternity homes. o Recognition of midwifes home with a standardized signboard ,a logo her name identifying the CMW,PNC issued Registration Number and one sentence to say, services offered by CMW for women and newborns and her phone number. o An open house for the women of the community to visit the Midwifes Work Station. CMW can talk to them and show them her equipment and explain her functions. Success of this advocacy drive will depend upon several factors. The most important one is the level of competence of the CMWs. 2. 3 Promoting improved standard of midwifery education: Role of DMC

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There is enough evidence that the standards of midwifery education are far from being satisfactory. A representative of DMC ( e.g Ob/Gyn specialist or Woman Medical Officer of DHQ Hospital) through regular contact with the Midwifery School in the district shall keep track of the educational activities. Contact with the students is the best way to ensure that the activities are being implemented as planned. The Log Book if used properly is a very valid and useful tool to keep track of what skills the student has developed and the level of her achievement of each skill. 2.4. Tracking the progress of the students. Focal person of MNCH in the district is a very important person. He will be responsible to visit the training school at least twice a month and meet with the faculty and the students to discuss the progress of the students. He/she will be given orientation for these monitoring visits. He/she should maintain contact with the MS and the doctor in charge of Ob/Gyn Unit of the allied hospital, to ensure that the educational activities are progressing according to the schedule and as prescribed by PNC He/She shall also discuss with the two supervisors of CMWs to stay informed of their performance.

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Part III Rules and Regulations for Midwifery Training and Practice Interpretation of terms used Practicing Midwife A licensed midwife, who is currently providing services to women during any stage of the maternity cycle and to the neonate , in a community or in a health facility. Those working in the community are called ,Community Midwives (CMW) A community midwife will be articulated to the district health system She may be employed at a health facility as a practising midwife, depending upon the policy of health authorities, to meet the health needs of the pregnant women. She may work as a self employed autonomous practitioner accountable for her own actions. Maternity Cycle (MC) Is the period that starts from conception ends 42 days after the birth of the baby.. Directorate of Mother, Neonatal and Child Health (MNCH) A project established at the federal level with a cells working at the provincial level. Emergency Obstetrics and Newborn Care (EmONC) Management of a situation in which a condition appears at any time during the entire maternity cycle, which requires immediate attention to save the life of the mother and/or the baby. Nursing Examination Board (NEB) Established at the provincial level to conduct examinations for different health cadres including Midwives. Pakistan Nursing Council (PNC) Is the statutory body responsible for issuing licenses to Nurses, Midwives and Health Visitors and maintaining updated record of the numbers trained and functioning. District Midwifery Committee (DMC) An authority established at the district level to oversee the training, deployment and performance of the midwife. District Health Information System ( DHIS) 63

A system of collection of health related data at the district level for feeding into the national statistics to be used for This should be provided by the Provincial Health Authorities. A licensed midwife, who is currently providing services to women during any stage of the maternity cycle and to the neonate , in a community or in a health facility facility. Those working in the community are called ,Community Midwives (CMW) A community midwife will be self employed but articulated to the district health system She may be employed at a health facility as a practising midwife, depending upon the policy of health authorities, to meet the health needs of the pregnant women. She may work as a self employed autonomous practitioner accountable for her own actions. Maternity Cycle (MC) Is the period that starts from conception, lasts for 40 weeks and ends 42 days after the birth of the baby.. Directorate of Mother, Neonatal and Child Health (MNCH) A project established at the federal level with a cells working at the provincial level. Emergency Obstetrics and Newborn Care (EmONC) Management of a situation in which a condition appears at any time during the entire maternity cycle, which requires immediate attention to save the life of the mother and/or the baby. Nursing Examination Board (NEB) Established at the provincial level to conduct examinations for different health cadres including Midwives. Pakistan Nursing Council (PNC) Is the statutory body responsible for issuing licenses to Nurses, Midwives and Health Visitors and maintaining updated record of the numbers trained and functioning. District Midwifery Committee (DMC) An authority established at the district level to oversee the training, deployment and performance of the midwife.

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District Health Information System ( DHIS) A system of collection of health related data at the district level for feeding into the provincial and eventually in the national statistics to be used for evaluating progress and for use in future planning.

Rules and Regulations Governing Midwifery Education and Practice

Definition of a MIDWIFE. A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. The midwife must be recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwifes own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.The midwife has an important task in health counseling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to womens health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units. She shall work in accordance with her professional competencies prescribed in these rules and regulations governing her practice. Hence the Basic Midwifery Competencies will remain the same for all categories practising midwives. They will receive specific training for their non midwifery roles and functions depending upon the environment they choose to work in. That training shall be the responsibility of the employing authorities.

NOTE: These Rules and Regulations will require a legal format to be passed by the legal system. The legal version is the need of the Pakistan Nursing Council. 65

It is strongly suggested that the version to be given to the midwife when she receives her license should be in simple English (even be translated in Urdu). The simple English version will also be used by the District Midwifery Committee. Purpose of Establishing a Regulator Mechanism for Training and Utilisation of Professional Midwives To guide the training institutions in the preparation of the midwife for her prescribed roles with defined competencies.(Annex 2) To guide the evaluating bodies ( Examination Boards) to have systems in place for valid evaluation of the knowledge and skills of the midwife before she is certified as a Skilled Birth Attendant (SBA) To guide the regulatory body about its obligations for licensing and re licensing only those certified midwives who fulfill all the requirements including up to date knowledge and skills for practising as a competent Skilled Birth Attendant. To ensure that the practising midwife functions within her legal rights as a specialist in normal obstetrics To provide legal protection to the midwife To safeguard the rights of the women served by the midwife. To define disciplinary mechanism for mal practices of midwives

The rules and regulations for midwifery practice fall under four headings: 1. 2. 3. 4. Education/Training to qualify as a midwife. License to practice as a midwife Legal aspects of midwifery practice Code of conduct

Legal Aspects of Midwifery Practice and Code of Conduct shall be printed by Pakistan Nurses Midwives and Health Visitors Council in the form of a booklet and provided to each midwife along with her license to practice. ALL Licensed midwives, irrespective of their place of work, shall be held responsible for being fully informed about and shall function within their basic rights and obligations included in this document.

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In addition: The midwives who function as Community Midwives and are articulated to the Health system of the district will work under the guidance of the District Health Authorities as Community Midwives . The midwives working in the public or the private health facilities and teaching institutions will follow the rules and regulations laid down by the respective employing authorities. The midwives who are self employed will be autonomous professionals responsible for their own actions within the rules and regulation of practice. SECTION I NOTE: Provincial Health Authorities have the right to decide on the Rules and Regulations governing the practice of midwifery. e.g In USA every State has its own licensing policies. A small committee can discuss the document and ,if not all, some selected rules can be made mandatory for the time being. PNC s action will involve a long procedure. Also the final document will be in legal language difficult to understand and interpret. The Community Midwife (CMW) PART 1: EDUCATION 1.Selection Criteria for Community Midwifes Training Note: The criteria in PC-1. have been reviewed in Item 10 above. Further discussion is needed to modify the criteria for maximum out put of the training activities. 1.1. Sex- female. 1.2. Age-18-30 years. 1.3. Education- Matriculation Certificate, or its equivalent certificate recognized in the country. 1.4. Residence- must be a permanent resident of the district and of the specific union council, from where she is applying. 1.5. Health- should have sound physical and mental health.(Medical fitness certificate from a competent authority required) 1.6. Selected by the district midwifery committee, 67

1.7. Preferably recommended by the village/ community./union council. 1.8. Has the approval of her family / husband to undergo the prescribed training following the rules of the school ( Stay in the hostel for a certain period of time for practical training. 1.9. Willing to sign a bond to practice for three years in the community. from which she is selected 1.10. Willing to serve all classes of community. 1.11. Pass the written entrance test by obtaining minimum 60 % marks. 2. Student Enrolment Directory The District Midwifery Committee (DMC) shall keep a directory of all students enrolled for training, according to a format and shall communicate the information to NEB within 30 days of the commencement of the training. 3. Training Program 3.1. Duration of training period shall be 18 months ( From many forums , suggestions are coming to increase the duration to TWO years. A policy decision is required for this change) 3. 2. Training will be conducted by Public Health Schools and Midwifery Schools approved by the Pakistan Nursing Council (PNC). 3.3. 85% attendance is required for theoretical and practical sessions as prescribed in the curriculum. 3. 4. Student shall receive a stipend , as approved by the provincial authorities, for a period of 18 months 3. 5 ..In case a students training is prolonged beyond 18 months ( for what ever reason), she shall not receive any stipend for that period. 4. Interruption in training program These interruptions can be: 4.1. Authorized interruptions- If they are availed with the permission of the competent authority/Principal of the teaching institution or M.S. of the DHQ e.g. leave for illness or any other genuine emergency. 4.2 Unauthorized interruption- If they are availed without the permission of the competent authority. Necessary action is the responsibility of the school. In both cases, the trainee will complete the missed requirements of the 68

training to the satisfaction of the competent authority. 5. Employment during training A student midwife, during the entire period of training shall not accept any employment offered by any person or agency to provide maternity care. 6. Qualifying Examination The student shall appear in the qualifying examination after fulfilling all the requirements laid down in the curriculum. The examination shall be conducted by Nursing Examination Board ( NEB) according to the rules laid down by PNC. If the student does not pass the examination in the first attempt, she will be given two more chances according to the rules specified by PNC.

Section 2 LEGAL ASPECTS OF MIDWIFERY PRACTICE 1. Certification to Practice as a Midwife The school from where the midwife receives her training is responsible for providing guidelines to the students for their certification, registration and licensing. After passing the qualifying examination, the midwife will receive a Diploma from NEB, endorsed by DMC, that she has fulfilled all the requirements and is qualified to practice as a midwife.. NEB shall issue the Diploma to successful candidates within 6 weeks of the declaration of results of the qualifying examination.. 2.Registration and Licensing by the Pakistan Nursing Council Upon receiving the Diploma, the midwife will apply to the Pakistan Nursing Council for her name to be entered in the Register of Midwives being maintained by PNC . PNC shall issue the license to the midwife within a month of her application., authorizing her to practice midwifery. The license shall be valid for 5 years. Along with the license, PNC shall:

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Provide the licensed midwife with a printed copy of the Rules and regulations for her practice and the Code of Conduct Give written instructions to the midwife for the validity period of the license , and requirements for its renewal.

2.1 Loss of license If a midwife looses her license, she should immediately report the loss to the DMC, and to PNC and apply for a duplicate upon payment of the requisite fee. 2.2 Renewal of license of an inactive midwife A midwife not practicing midwifery for health or any other personal reason for a period of two years (reflecting her inactive status) would need to renew her license (even if it is valid).To qualify for the renewal she will be required to work in a Hospital approved by PNC for training, for a period of four weeks under the supervision of its WMO , conduct at least four normal deliveries and get a certificate from the WMO of having fulfilled the requirements for re licensing. After fulfilling the requirement for the renewal, duly certified by the supervising WMO, she can apply to PNC for the renewal of her license In case of a Community midwife DMC may support her request, in writing, for renewal of license, after verifying that she has fulfilled the requirements for renewal.. 3. Suspension from practice of a CMW The DMWC has the authority to suspend a midwife from practice for a specified period for the following reasons: 1. To prevent the spread of a communicable disease from which the midwife is suffering and has been duly diagnosed by a medical authority. The period of suspension will correspond to the outer limit of the contagious period. 2. Any such complaint from the community regarding her work and/or behavior, which requires investigation. 4. Revoking of license According to the rules, PNC has the authority to revoke a midwifes license to practice. This shall be done in consultation with DMC. A midwife has the legal right to ask for justification of PNCs action.

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Section 3. Deployment of community midwife 1.Posting The qualified midwife ,holding a diploma from NEB will be posted in the Community of her origin, by the competent authority within three months of her passing the qualifying examination. She may be allowed to practice on the strength of the Diploma issued to her by NEB, while waiting for her license from PNC. She must, however ,provide a proof that she has applied for registration. In case of undue delay in her registration by PNC, DMC shall intervene to facilitate her registration. If needed she may be employed in a vacant post of a midwife, at a health facility (BHU/RHC) near her assigned area.. 3. Bond to serve the community The newly licensed midwife shall honour the bond signed at the time of selection, to work in the community for 3 years. After completing the bond period she can move to another area if she wants to. If she does not get deployed within 6 months of having qualified as a midwife then she is no more duty bound to honour the bond. If she is deployed but is unable to serve the required period of bond ,she will pay back to the government the proportionate amount spent on her training. Competencies required to practice as a midwife The basic essential competencies of a midwife which she can legally practice are given at Annex 2. These have been approved by the International Confederation of Midwives (ICM) after an exhaustive global consultative process. These will remain the same for every midwife, irrespective of whether she provides domiciliary services or works in a facility. Certain non midwifery related tasks will be additional for domiciliary midwifery practice. These can be included in the training of CMWs. These will be mainly related to interaction with community and with Lady Health Workers ( LHWs) ,and Traditional Birth Attendants ( TBAs) , and making and receiving referrals. If agreed upon and approved by PNC, certain competencies may be added to the role of the midwife to meet the local situation particularly in the remote areas. It has to be ensured that the midwife gets the required training..

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Rules that govern the practice of midwifery a. Domiciliary midwifery practice :A practising community midwife: 1. Is authorized to establish her birthing station ( Called by any name which clearly indicates that it is for maternity care). This can be a part of her residence or separate from her residence. She must ensure availability of EmONC within easy reach. For this purpose she shall establish liaison with a public or private health facility providing EmONC services. 2. Shall not give any treatment to the woman or the neonate under her care for which she has not been trained.

3. For management of any condition of the woman or the neonate under her care, which is beyond her competency level, she shall provide first aid, stabilize the condition of the mother/neonate and immediately refer the patient to the nearest appropriate facility. If referral is not possible, she may call a registered medical doctor who may have the requisite expertise l and experience to assist her in an emergency. 4 Shall only administer those drugs for which she has been trained and authorized. These are listed at Annex 11.

5. Shall use Oxytocic drugs, if indicated, during the first stage of labor strictly adhering to the protocol provided to her during her training. 6. Shall provide care to the pregnant woman through out the maternity cycle and to the neonate, according to the protocols approved by PNC. Records A practicing community midwife shall maintain all records and registers ,. using the tools supplied to her by DMC. Inspection of the premises and equipment A practicing midwife shall give the DMC or its assigned representative every reasonable facility to inspect her records, equipment and such parts of her residence as may be used for professional services.

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Protection of the community midwife 1. It is the responsibility if the DMC to provide legal protection to the midwife in cases of harassment or any other form of violence. 2. The midwife reserves the right to seek legal advice and services in case of treatment given to her by the DMC or her client or a member of the community which she feels is unfair or illegal. Alternate midwife In case of non availability of local licensed midwife due to her suspension or revoking of her license or prolonged sickness, it is the responsibility of the DMWC to notify an alternate midwife to provide back up midwifery services. Suspension of license The DMC may request PNC to suspend or revoke the license of a community midwife for any of the following reasons: 1. Unprofessional conduct which includes, but not limited to the following: a) Incompetence or gross negligence in carrying out the usual functions of a licensed midwife. b) Conviction by the DMC of a criminal offence. c) Falsifying, or making grossly incorrect, grossly inconsistent, or unintelligible entries in her record on patients or record pertaining to drugs d) Not maintaining the physical standards of her work station/birthing station as prescribed by DMC 2. Procuring a license to practice by fraud or by misrepresentation. 3. Using Oxitocic drugs for selfish reasons, to hasten the first or second stage of labor. 4. Any assistance to support or perform abortion on the basis of sex selection. 5. Withholding evidence or giving false evidence regarding the cause(s)of maternal and/or neonatal death. 6. Impersonating any applicant or acting as proxy for an applicant in any examination required under this chapter for issuing a license. 7. Impersonating another licensed practitioner or permitting/allowing any other person to use her license or the certificate for the purpose of providing midwifery services. 8. Complaints received from clients which have been certified /proven to be correct., about negligent midwifery practices

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Registration of vital events Registering vital events like live birth, stillbirth, death of the mother or the neonate are part of community midwifes responsibilities. Birth registration is the responsibility of the husband/family, but a community midwife can participate in the activity. It is her role to explain to the family about the importance of registering each birth. The midwife can facilitate by providing the form and if needed help in filling it. She can also guide the family to the office where births are registered. The midwife should keep blank copies of all the relevant forms with her. The DMWC should ensure the availability of these forms. The midwife can facilitate by providing the form and if needed help in filling it. She can also guide the family to the office where births are registered. Notification of maternal death, neonatal death or stillbirths The midwife, the family or any other person present at the time of death, can assume the responsibility of notifying the death of a mother or a new born baby to the Chairman Union Council / Municipal Corporation. Maternal Death (death of a mother) For purposes of notification ,a maternal death is defined as follows: Death of a woman due to pregnancy related causes i.e. during pregnancy, child birth or 42 days after the termination of pregnancy is a maternal death. If the death rakes place in the home while the woman was being looked after by the midwife, it is the responsibility of the midwife to complete the relevant form and submit it to the DMC. Neonatal Death (Death of a newborn) For purposes of notification ,neonatal death is defined as follows: A baby born at any stage of pregnancy who breaths or shows other signs of life after complete expulsion from the mother is a live birth. If such a baby dies within a week after birth, it is a neonatal death. The birth and the death of such of baby must both be registered. Stillbirth For purposes of notification ,neonatal death is defined as follows: A baby born after the 24 th week of pregnancy who has not at any time after being completely expelled from his mother, breathed or shown any sign of life is a stillborn baby. It does not require registration, but it must be reported in the midwifes register with cause of stillbirth described. It will be reported in DMIS for district / provincial / national statistics.

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b.Facility based midwifery practice . Basic midwifery competencies required for midwifery practice will remain the same. The roles of the health facility based midwife are defined by the health facility that employs the midwife, because the legal protection of the midwife is the responsibility of the employer. She shall , however , never undertake a responsibility of a task related directly to maternal and /or newborn care. for which she has not been trained. Section IV CODE OF CONDUCT I. Midwifery Relationships The Midwives: a. Develop a partnership with women. Both share information that lead to a plan of care, and both accept responsibility for the outcomes of their decision. b. Support the right of women/families to participate actively in decisions about their care. c. Empower women/families to speak for themselves on issues affecting the health of women and families within their culture/society. d. Together with women, work with policy and funding agencies to define womens needs for health services and to ensure that resources are fairly allocated considering priorities and availability. e. Support and sustain each other in their professional roles, and actively nurture their own and others sense of self-worth. f. Respectfully work with other health professionals, consulting and referring as necessary when the womans need for care exceeds the competencies of the midwife.

g. Recognise the human interdependence within their field of practice and actively seek to resolve inherent conflicts. h. Have responsibilities to themselves as persons of moral worth including duties of moral self-respect and the preservation of integrity.

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II. Practice of Midwifery Midwives: a. Provide care for women and childbearing families with respect for cultural diversity while also working to eliminate harmful practices within those same cultures. b. Midwives encourage realistic expectations of childbirth by women, within their own society, with the minimum expectation that no woman should be harmed by conception or childbearing. c. Midwives use up-to-date, evidence-based professional knowledge to ensure safe birthing practices in all environments and cultures. d. Midwives respond to the psychological, physical, emotional and spiritual needs of women seeking health care, whatever their circumstances. e. Midwives act as effective role models of health promotion for women throughout their life cycle, for families and for other health professionals. f. Midwives actively seek personal, intellectual and professional growth throughout their midwifery career, integrating this growth into their practice. III. The Professional Responsibilities of Midwives a. Midwives hold in confidence client information in order to protect the right to privacy, and use judgment in sharing this information except when mandated by law. b. Midwives are responsible for their decisions and actions, and are accountable for the related outcomes in their care of women. c. Midwives may refuse to participate in activities for which they hold deep moral opposition; however, the emphasis on individual conscience should not deprive women of essential health services. d. Midwives understand the adverse consequences that ethical and human rights violations have on the health of women and infants, and will work to eliminate these violations. e. Midwives participate in the development and implementation of health policies that promote the health of all women and childbearing families.

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IV. Advancement of Midwifery Knowledge and Practice a. Midwives ensure that the advancement of midwifery knowledge is based on activities that protect the rights of women as persons. b. Midwives develop and share midwifery knowledge through a variety of processes, such as peer review and research. c. Midwives participate in the formal education of midwifery students and ongoing education of midwives (Adopted at Glasgow Council meeting, 2008 Due for next review 2014) 1. Midwife should abide by the oath she took, to serve women and neonates irrespective of their cast, colour and creed. 2. Her personal beliefs should not influence her professional responsibilities. V. Supply and use of authorised Drugs 1 As a community midwife: a. It is her responsibility to maintain in her stock various drugs authorized for her practice. She should regularly check with DMC for the drugs provided to her (free or on nominal cost e.g. certain contraceptives) b She needs to stock antiseptics, sedatives and analgesics, local anesthetics, oxytocic preparations and approved agents for neonatal and maternal resuscitation. A complete package of drugs which a community midwife can use, has been approved by PNC . It is included in the Curriculum ( Annex 2) c. When administering authorized drugs the midwife should comply with the policies stated by the relevant authorities. 2. As a facility based midwife : d.The administration of drugs by her should be in accordance with policies and protocols of the institution. She must ,however, receive written instructions from the head of the department /institution authorizing her the use of any drugs which are not on the list provided by PMC. 3.Use of drugs by mothers taken from sources other than midwives The family/mother is responsible for drugs supplied directly to her from an allopathic or a homeopathic doctor or herbal substances from a Hakim. If the midwife has any doubts about the safety of these drugs/medicines/herbs, she should discuss it with the person who prescribed or supplied the same. She should record the advice given.Any action taken by the midwife should be recorded in the notes for the mother. 77

The midwife, however, must be mindful of the mothers rights. 4.Records and retention of records Records are an essential aspect of the midwifes practice and she must comply with the rules governing the community midwives. To maintain and improve standard of practice, the Supervisor of midwives will periodically examine the records of all community midwives. General advice on record keeping is provided at Annex 111. 5.Premises and equipments A practicing midwifes method of practice, her equipment and any part of her residence which is used for professional purposes may be inspected by a supervisor or any person duly authorized by the DMC. Approved list of equipment and devices is in Annex 1II. 6. Home births To facilitate her own work in the community, a midwife should maintain a complete and up dated list of contacts with the following professionals and services near her area of services. a) b) c) d) Names and contact numbers of accessible and reliable means of transportation (including cost) to the nearest hospital(s) Names and means of contact of accessible medical doctors (public or private) within her reach. Names and means of contact of LHWs, TBAs,Union Council and other community midwives. Names and exact location of hospital(s) for referral purposes, whether government, private, or NGO, as well as the nature of services available in each. Distance to nearest hospital /clinic.

e)

When the support of a registered medical doctor is not available nearby, the midwife should discuss the situation in advance with the family and agree on appropriate arrangements for transport and ready cash, in case of need.. 7. Information collection and data protection Registered vital events like live births, stillbirths, death of the mother or the neonate are part of community midwifes responsibilities. Birth registration is the responsibility of the husband/ family but a community midwife can participate in the activity. It is her role to explain to the family about the importance of registering each birth. The midwife should keep blank copies of all the relevant forms with her. The DMC should ensure the availability of these forms. 78

8.Change of address / name After completion of the 3 years bond period, if a community midwife moves to another place, she should notify PNC and DMC about the change in her address. Similarly, if she wants to change her name in case of marriage or divorce, she should notify PNC and DMC .. 9. Continuing educating and refresher courses The practising midwife must seek advice and guidance from the DMC as well as the Midwifery Association of Pakistan about the choices and options available for meeting her own needs to upgrade her knowledge and skills and to meet PNCs requirement for renewal of her license a.. Every midwife shall regularly attend refresher courses to upgrade her knowledge and skills, as arranged by the DMC, or the Midwifery Association of Pakistan (MAP). She must undertake at least one course in 24 months. b.. DMC may accept evidence of recent practice as community midwife out side Pakistan in lieu of the local requirements of refresher courses. c. A midwife who is unable to attend the requisite refresher courses for valid reasons, may apply in writing for relaxation in the time limit and take the course at the next available opportunity. 10.Constraint to practice If the midwife judges that there could be significant risk to the mother and or baby in the type of care the family is demanding, she should give detailed information, options for care and explain potential risks. (She should keep a detailed record of any such discussion in her register). Even if the family rejects her advice, she must try to give the best care and seek advice from her supervisor , available medical practitioner orand the designated EmNOC facility.. She should keep a record of any undesirable attitude/behavior of any client or her relative. Deal with it as best as she can but report it to her supervisor and if needed to EDO.. 11. Protection of the clients rights A midwife has to be fully aware of the fact that the client has the right to seek legal advice for any mishaps affecting the mother or the neonates safety . It should be her utmost effort to provide safe maternity services within her legal jurisdiction.

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12. Protection of midwifes rights PNC and DMC will protect the rights of midwives . The midwife reserves the right to seek legal assistance if this protection is denied to her. VI. Role of professional organisation of midwives Professional organisations also provide protection to their members. Midwifery Association of Pakistan (MAP), is the professional platform of midwives in Pakistan. It provides protection to its members and also gives opportunities for professional growth and development. It is the professional obligation of the midwife to join her professional organisation . Her membership provides strength to the organisation which continuously works for the development of the midwife and of the midwifery programme.

Part IV
1. Action Document for the Attention of Health Planners and Policy Makers, the Institutions Preparing Midwives , Bodies Certifying and Licensing Midwives and Development Partners. PRIORITY AREAS REQUIRING IMMEDIATE ATTENTION AND DOABLE SUGGESTIPONS FOR ACTION FOR THE IMPROVE,MENT OF MIDWIFERY EDUCATION AND PRACTICE IN SINDH ( Applicable at the national level) NOTE for the reader: The existing situation and its impact mentioned in this document is a statement of evidence based information. These are facts and should not be taken as criticism. The priority areas have been identified which need IMMEDIATE attention of ALL those involved in or connected to midwifery education and practice. They should share the responsibility for taking action to INITIATE CHANGE.

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TRAINING

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SITUATION 1. Majority of midwifery students are getting diplomas in midwifery with inadequate practical experience in delivering babies. There is evidence that the current standards of practical midwifery training do not meet the criteria for preparing competent midwives capable of practising as specialists in normal obstetrics.

IMPACT 1. The midwifery diploma holders either do not practice as midwives because they do not have enough confidence, or they learn midwifery skills after their training with trial and error method. Pakistans MMR at 276 (is the highest in South Asia. A major cause is lack of competent and skilled birth attendants, particularly in the community where 61 % of the births take place at home , only 5% are conducted by Skilled Birth Attendants ( PDHS 2006-7) The average woman Rural as well as urban is deprived of the essential care during the maternity cycle.

SUGGESTED ACTION 1.A directive be issued from the Pakistan Nursing Council, to the provincial Directorates of Health and Nursing, Provincial Examination Boards and all the schools of midwifery that no midwifery student should be allowed to sit qualifying examination without certified competencies in all the midwifery skills included in the midwifery curriculum. PNC should issue the Log Book already available in PNC office , (with additions and or modifications if needed) for certification of each competency. Its use should be made mandatory. If possible it should be made a punishable offence for the school and for the students to submit falsified documents to the Examination Boards for the students to qualify to sit for the final examination. .

Important: The teachers and principals of midwifery schools , hospital administrators, Provincial Examination Boards, the Examiners and Pakistan Nursing Council are all aware that the students need a lot more hands on practice than what they are getting now..

2.There are more schools of midwifery in the country than schools of nursing There are no teachers formally qualified to teach midwifery. Short courses are being given which serve as patch work. This is due to the fact that there are no training programmes for midwifery teachers. With the

2.Nursing Instructors are teaching midwifery on ad hoc basis. Some of them have duel responsibility of teaching nursing students as well as midwifery students. They went through their midwifery training because it was compulsory for

2..Selected post basic Colleges of Nursing should be equipped to prepare midwifery teachers. While these teachers are being prepared there should be continuing efforts to upgrade those teaching at present. As a short term strategy , short training courses be developed for them. As a long term strategy diploma programmes

SITUATION exception of public health schools , there are no sanctioned posts for midwifery teachers in the public sector schools of midwifery,. To be a nursing instructor there is a requirement of a teaching diploma. For

IMPACT promotion. They have limited knowledge of the subject and limited midwifery skills

SUGGESTED ACTION should be developed for teaching of midwifery. There should be one programme for preparing teaches so that every one of them is capable of 82 classroom teaching and clinical instruction Posts should be sanctioned for midwifery teachers in each school

MAN MONEY AND MATERIAL RESOURCES OF SCHOOLS SITUATION 5. Most of the midwifery schools have neither a separate faculty nor a principal or any budget. Most midwifery schools are under nursing administration and have no identity and no authority 6.The number of schools training CMWs has increased but increase in numbers of institutions is not an only sign of progress. The human resources for staffing these schools , particularly qualified teaching faculty has not received much attention. Patchwork is being done through ToTs which does not seem to have much impact. IMPACT 5. Midwifery is overshadowed by nursing. The midwife and the profession of midwifery has been a victim of neglect. SUGGESTED ACTION 5. Midwifery schools should have their own identity with their own budget. , full time faculty and principal. Nursing and midwifery should be treated as two distinctly separate professions.

6. Information about the challenges of midwifery education, for Sindh is available based on two surveys (UNICEF 2000 and TAUH 2012) The situation with its strengths , and gaps remains almost unchanged between 2000 and 2012., excepting the increased number of schools. Which has actually further deteriorated the quality of education. There are no teachers to staff these schools. Staff nurses and LHVs are being used for teaching.

6. PNC should ,on urgent footing, get all the midwifery schools evaluated. Close down those which do not meet even the minimum requirements. Give time to those which can be made functional with some improvement. Re inspect them for approval. The number of schools should be decreased (KPK has done it ) and their quality should be improved. Development partners should not provide funding for more new buildings for schools of midwifery. unless absolutely unavoidable renovation of the old ones becomes necessary. The available funds can be utilized to strengthen the school faculty.

EXAMINATION SYSTEM

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SITUATION 7 The qualifying examination of midwives comprises a couple of theory papers and a few minutes of oral examination. There is no testing of skills. An effort was made to introduce OSCE but it has not succeeded. Objective type testing has been introduced without proper preparation of examiners to construct them. Midwifery tutors are examiners. They pass each others students to cover up the weaknesses of their training. Some examiners are in administrative position and not in touch with midwifery. There is a lot of external pressure on the examiners to pass the students whether they know any thing or not

IMPACT 7. Students memorize answers from the previous examination papers. Their effort is to please the examiners. Marking depends on the examiners whims. There are instances when a student was penalised because she had more up dated knowledge than the examiner. Most students are passing their examination without meeting the requirement of training.. Examination Boards are giving them Diplomas on the strength of which PNC is issuing them the license to practice midwifery.

SUGGESTED ACTION 7. There is urgent need to improve the examination system. It should test both knowledge and skills of the midwife. Pakistan Nursing Council and all the provincial Examination Boards should be given technical assistance to train pool of examiners to conduct scientifically valid evaluation of the competencies of the midwives. Examination Boards should be held responsible for checking the competence of the examiners. It should be made mandatory that the examiners should be updated in their knowledge and skills required to practise midwifery. Maintenance of the Log Book should be made mandatory. Each skill should be certified by a responsible person when the expected level of competency is attained by the student midwife.

REGULATORY MECHANISAM FOR MIDWIFERY PRACTICE

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SITUATION 8..There are no Regulatory Mechanisms for midwifery practice. There are examples that the midwives established Birthing Stations, doctors put locks on them and told them they are not legally permitted to have a ,Clinic In 2003, the National Commission for Human Development contracted two consultants to develop a draft of Rules & Regulations and Code of Conduct for Midwifery Practice. The DRAFT was submitted to the Chairman within three months. NO action was taken to finalise the document. After many attempts of follow up, in in 2010 it was discovered that the , File was misplaced and not found.

IMPACT 8. Midwives even when practising their profession are not aware of their own rights and professional boundary lines.. That is why thousands are trained every year but are not visible.Without regulatory mechanism neither the midwives nor the women they serve have any legal protection. Those practising substandard midwifery are playing with womens lives .There are many who blatantly practice as doctors and the sign boards outside their clinics and maternity hospitals have ,Doctor written with their name. LHVs are well known for this..

SUGGESTED ACTION 8. The document , Rules and Regulations and Code of Conduct for Midwifery Practice has been reviewed, modified and updated by a consultant hired by Technical Assistance Unit for Health.. It will be forwarded to PNC through TAUH. It needs to be discussed by PNC with its executive committee and sent to the Law Ministry for finalisation and approval. Once ready, The document needs to be printed and a copy provided to each midwife when she applies for registration for the first time. The institutions employing licensed midwives should also be provided with a copy so that the midwife is treated as a midwife and not an errand boy for the doctors.This is necessary to provide legal protection to the midwife and to the women and families she serves. (See Part III)

IMPOSITION OF MIDWIFERY TRAINING ON REGISTERED NURSES 85

SITUATION 9. Previously midwifery was optional and considered a specialization. Since 1982, because of a presidential decree , EVERY Nurse has to take midwifery. Her promotion depends on it . Since she is a registered nurse , she enrolls as a midwifery student in the 4th year of her training but is utilized in various departments of the allied Hospital as charge nurse. She attends a few lectures on midwifery but gets very little practical training. She also writes up fictitious cases to fulfill the requirements of PNC. It is this category that eventually get a diploma in teaching of nursing but are pushed into teaching midwifery.

IMPACT 9. Every year thousands of nurses appear for midwifery examination and get through like all others, on the strength of some theoretical knowledge. Very few Nursemidwives choose midwifery as a profession with the exception of those who are working in the labour rooms of Tehsil or DHQ Hospital This is a complete waste of national resources which go into training the Nurse- Midwives for their benefit only.

SUGGESTED ACTION 9.Basic midwifery should be made a specialization like many other specializations available to nurses. A specialization should be required for promotion but it does not have to be midwifery. They can specialize in any other nursing discipline, like in the case of male nurses. If nurses have the option and there is an attractive future for them (like for the nurses) as midwives they will opt for midwifery Those who choose to study midwifery will obviously be self motivated, With proper training they will be REAL midwives. Those interested in teaching can get post basic training in educational technology and become better teachers and better practitioners .Their nursing background will be an added asset.

CERTIFICATIOBN AND LICENSING SYSTEMOF MIDWIVES

SITUATION 10. The certification and licensing of the CMWs after graduation can take up to one year. Though promised before training, they do not get deployed. in the public sector during that time The first delay is at the level

IMPACT 10.There is enough evidence that if not deployed soon after graduation, the CMWs drift away. Get other jobs or even change their vocation. This is not only huge financial loss to the

SUGGESTED ACTION 10. A three member committee should be appointed by the Health Secretary to find out the causes for delay of Diplomas by the provincial Examination Board. There might be some genuine reasons e.g shortage of staff. Reasons for delay at the level of 86

of the Examination Board. The results are declared but the successful candidates do not get the diploma. The Board waits for the failures to make a second attempt after three months. Then their result is declared and after that diplomas are issued. This serves as a convenient mechanism for the Board but it does a lot of damage in the form of loss of CMWs. After the CMW gets her Diploma, she applies to PNC for registration. That takes an other 3 months or more.

government but also the women who need their services ,remain deprived of them. Because the CMW needs her Licens to get deployed, PNC has established a system of issuing a provisional license for a fee. This fee is over and above the fee already paid for registration. by CMW. This is an added expense for the CMW who has not started to earn yet.

PNC also need to be analysed. When a midwife has a diploma that she has fulfilled all the requirement and is authorized to conduct deliveries, she is legally qualified. She can apply to PNC for registration and can be deployed while waiting for PNC registration. This will cut down on the attrition rate of CMWs.

REGULATORY BODY FOR MIDWIFERY

SITUATION 11.Pakistan Nursing Council (PNC) used to be Pakistan Nurses, Midwives and Health Visitors Council. Now it is only Nursing Council. All over the world nursing and Midwifery are treated as separate professions e.g ICN & ICM are two separate international platforms for nurses and midwives. Midwifery personnel of countries which do not have a separate cadre of midwives are lobbying for a distinct identity as midwives.( India and Nepal are two examples)

IMPACT 11.PNC has lived up to its name and has done a lot for nurses.. Much has been done for nursing education and career structure etc. of nurses. A nurse can study up to Ph.D level. Career wise she can go up to BPS 20. Midwifery has not received much attention because PNC focuses on nursing. Midwives are at the lowest rung of the professional ladder.

SUGGESTED ACTION 11. PNC should be renamed, Nurses, Midwives and Health Visitors Council and Nursing Acts revision be expedited to include Midwifery and Health Visiting in its text and addressed as such. A career structure be included in the Act for the midwives and health visitors with requirements of professional development at each step of promotion. The curricula for Basic Midwifery be standardized for all the categories of midwives i.e nurse midwives, LHVs, ,non nurse midwives and CMWs. A special Module be added for those who want to serve in community 87

LACK OF A CAREER IN MIDWIFERY SITUATION 12 There is no future in midwifery as a career that is why even though every nurse is a midwife , very few choose midwifery and that also not for a career. They become self employed. If a midwife wishes to advance in her career. IMPACT 12. Any midwife with a desire for professional development is forced in to leaving midwifery. She must become a nurse which is contrary to what is being practiced internationally That is why there are no midwives of substance to be seen in Pakistan. SUGGESTED ACTION 12. There should be a Midwifery Model of education and practice. Avenues should be open for midwives to move up with specialized courses related to MCNH, for professional development. Also there has to be a career structure for the professional midwife irrespective of her nursing or public health background.

2. RERECOMMENDATIONS FOR ACTION IN THE NEAR FUTURE 2.1 For improving midwifery training it is recommended that the Pakistan Nursing Council: 1. Redesign the Midwifery Curriculum and make it a standard Curriculum for ALL categories of midwives. Non midwifery related Modules can be added according to the choice of Practice Area of the midwife ( Community, Health Facility, Private Practice)

2. In consultation with the Provincial Health Departments , clearly define the parameters of midwifery practice in Pakistan ( Annex 2)

3 Disallow Hospitals attached to medical colleges to have schools of midwifery because of a large number of learners of the medical 88

category.

Strengthen the inspection and examination systems and mechanisms to cut down on delays of the licensing process.

develop

5. Pakistan Nursing Council revert to its original name , Pakistan Nurses, Midwives and Heath Visitors Council.

2.2 For mobilizing midwifery personnel in Pakistan, it is recommended that The Provincial Health Departments: 1. Develop a five year plan for training midwives according to the need of the province. 2.Establish a District Management System for selection, train ing, deployment and supervison of midwives. 3 Design well thought out strategy, to be widely disseminated and implemented by the relevant authorities for replacing TBAs and Dais with trained CMWs 4. Gradually, either make CMW a part of the health system like the Lady Health Workers or let her be self employed but regulate her practice. 5. Develop a career structure for the midwives to allow for continuous professional growth so that she does not have to do nursing to move up the professional ladder.

6. Develop a diploma programme for preparing midwifery teachers

7. Develop CMWs Work Place into a Birthing Station to offer the woman a choice of place for delivery.

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2.3 To improve midwifery training , it is recommended that MNCH:

1. In collaboration with the National Committee for Maternal and Neonatal Health, and the Midwifery Association of Pakistan (MAP) select a few schools of midwifery and assist them to develop into Centres of Excellence.. Use these to train midwifery tutors through mentorship until such time that regular diploma programmes become available to train midwifery teachers...

2. Strengthen the system for monitoring of midwifery training. Ensure that the focal persons fulfil their obligation in this regard.

3.

Encourage already trained and licensed nurse midwives to opt for midwifery to come into the academic side and also to practice midwifery independently. To qualify for the shift they should meet certain special requirements in addition to their basic midwifery and any post graduate training and that PNC define these requirements and the mechanism for meeting them.

4 Develop a mechanism whereby some selected and willing maternity homes in the private sector can be utilized to provide practical experience to the students and that these maternity homes be given an incentive and accorded recognition through a logo indicative of quality services 2.4 For changing the attitude of the community and of the medical profession towards the midwife and midwifery, it is strongly recommended that the National Committee for Maternal and Neonatal Health ( NCMNH) and Midwifery Association of Pakistan ( MAP) : 1. Organise a common platform comprising obstetricians, paediatricians and midwives in collabo ration with the Societiy of Obstetricians and 90

Paediatricians, and Midwives of Pakistan for proper understanding of the role of midwives in obstetrical care and in saving lives.

2. Recommend that to eliminate the confusion between the term dai and midwife the professional midwife be called Qaabila,(the Arabic word for midwife, used in Iran and Afghanistan also) .

3 IF ACCEPTABLE Midwifery be called Qbaaleh,(the Arabic word for midwifery, The schools preparing professional midwives be called Madrassa-al-Qabaaleh, and Colleges of advanced midwifery be called Kuliaat-al- Qabaaleh, (college of midwifery ) 2.5 For facilitating action, it is recommended that : UNFPA , UNICEF , WHO ,DFID and TAUH: Discuss the above recommendation with the decision makers in the health sector, MNCH, and the directorate of nursing in Sindh Through a consultative process with various stake holders develop guidelines and provide assistance for the implementation of the agreed upon recommendations.

The most exciting outcome of this information collected and anlysed is that the midwife is appearing on the scene of maternal & neonatal health. There seems to be a genuine interest in improving the standards of education of midwives. The desire to identify gaps is apparent from the number of studies and surveys. Hopefully, the available information will make the next PC-1 a document which reflects evidence based planning.

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Conclusion
It is a comforting thought that midwifery is being talked about. A few documents are now available on the institutions giving training to CMWs, quality of training, preparation of teachers etc. A draft of the Regulatory Mechanisms for midwifery practice is ready. When approved it will a flag bearer because no other profession in Pakistan has regulated itself in this manner. There is awareness that midwives can save lives. Ths Sindh and the Punjab Governments are celebrating International Day of the Midiwfe. Above all there is a professional organisation of Midwives affiliated with the International Confederation of Midwives. There is light at the end of the tunnel

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Sources of Information A. Documents reviewed

Annex 1

1.. National Maternal, Newborn and Child health ( MNCH) PC-1 ( 2005-6 ) 2. Guidelines for the Deployment of Community Midwives, National Maternal, Newborn & Child Health Programme, Contech International, HLSP, Islamabad , ( 2010. Commissioned by TRF ) 3. Situation analysis of Midwifery Training in Sindh ( 2001, commissioned UNICEF, Sindh Office). by

4. Strategic Planning to Improve Midwifery Training in Sindh (2001, Report of a workshop funded by UNICEF) 5. Assessment of Midwifery Schools in PAIMAN Districts in Punjab and Sindh (2005 Commissioned by PAIMAN) 6 Midwifery Training Curriculum for Nurse midwives , Pupil Midwives and LHVs (last revised in 1994, Pakistan Nursing Council) 7. Curricula for Community Midwives (2003, and 2005, Pakistan Nursing Council ). 8. Training Institutions for Community Midwives in Pakistan: An Initial Assessment ( 2010, PAIMAN, Population Council ) 9 Assessment of Quality of Training of CMWs in Pakistan ( 2010 commissioned by TRF ) 10 Assessing the Potential Acceptability of a New Cadre of Community Midwives for Pregnancy and Delivery Related Care in Rural Pakistan 2010, PAIMAN, Population Council ) 11. State of the Worlds Midwifery (2011, UNFPA and International Confederation of Midwives) 12. Are Community Midwives Accessible in Punjab and Sindh ? (January 2012 . Commissioned by RAF) 13. Situation Analysis of CMW Education in Sindh. 14 Pakistan Demographic and Health survey 15. CMW MIS System (TRF) 16. An Informative Booklet for Public Health Specialists & Social Organisers 93

17. Situation Analysis for Post Devolution Health Sector Strategy of Sindh Province Government of Sindh. 18. Srtategy 2012-2020, Sindh Health Sector 17

B. Institutions visited
School of midwifery in: 1. Tando Allah Yar 2 Bin Qasim, Jam Kanda ( HANDS) 3. Jam Shoro 4. Thtta 5. Tando Mohammad Khan 6. Halla C. Persons Met for: Getting Information; Discussions; Clarifications Department of Health Mr. Hashim Raza Zaidi, Secretary Health, Sindh Dr. Feroze Memon D.G Health MNCH Directorate Dr. Sahib Jan Badar Dr. Manzoor Ahmed Dr. M Gul Mr Shafiq TAUH , Islamabad Dr. Nabeela Ali Dr Mohammad Fazal Dr. Shoaib Khan Mr Adnan Riaz Dr. Iftikhar Malla ( Sindh) Pakistan Nursing Council Ms. Nighat Durrani UNFPA Dr. Shabir Chandio ( Sindh) Dr. Mobashar Malik, Islamabad In Schools of Midwifery and allied Hospitals 20 Principals of CMW Training Schools 8. MNCH Focal persons: 94

5 Medical superintendents 20 Tutors and clinical supervisors 3 Obstetricians 2 WMOs 1 Paediatrician 21 recently graduated 21 CMWs, awaiting deployment, Tando Allah Yar 80+ Students CMWs Directorate of Nursing , Sindh Ms. Zarina Habeeb, Ms. Mehboob Sultana, Other relevant Individuals Dr. Arjumand Faisal, CEO, Arjumand and Associates, Islamabad. Dr. Director MNCH, Punjab Dr Syeda Zahida Sarwar, Deputy Director MNCH, Punjab Ms Munawar Sarwar, DG Nursing , Punjab

Ms. Basharat Naseer, Midiwfery Tutor, Lady Wellingdon Hospital School of Midwifery, Lahore Dr Nisar Ahmed Cheema, DG Health, Punjab Dr Aslam Chaudhry,, Ex. DG Health Punjab.
D.Discussions held with: The Executive Board of Midwifery Association of Pakistan The President and Consultants of the National Committee for Maternal and Neonatal Health ( NCMNH) and the Association for Mothers and Newborns AMAN) To find out about the sustainability mechanism of training midwives, held meeting with the Superintendent of the Lady Dufferin Hospital, Karachi and Principal of the School of midwifery attached to it. The school charges tuition fees from the students. Those who are motaivated to learn midwifery join this school.

E.Seminars/ Meetings attended ( only those directly related to midwifery)

1. Dissemination Seminar of the study on ,Are CMWs Accessible in Sindh?( 95

( RAF) It is a valuable study with valid observations mostly pertaining to the understanding of the role of CMWs by CMWs themselves and by the community.

2. Review Meeting on the revised CMW Curriculum ( TRF) The revised version was considered unsuitable for Pakistans needs 3 Strategic Planning meeting of MNCH ( ICM President attended This meeting) Three suggestions came out: To increase the training period to 2 years Have one universal curriculum for all cadres of midwives Focus on teacher training

4. Meetings of the Country Working Group established by UNFPA, for the development of midwifery. Core group comprises representatives of PNC, Midwifery Association of Pakistan, Aga Khan Universitys Schools of Midwifery, WHO, UNICEF, TRF and UNFPA. First step was to collect ALL the available material about midwifery in Pakistan Inspection mechanism of schools of midwifery and the examination system for final evaluation of CMWs, were two main topics of discussion. Both require massive restructuring

5 Dissemination Seminar of the work done by RAF related to midwifery. A study on the place of choice of the mothers for delivery was an eye opener for those emphasising home births. Only 22% of the mothers selected the home for their delivery.

6 A meeting of the Pakistan Nursing Council ( by request) as an observer mainly to understand the causes for delayed registration by PNC. According to PNC the delay is at the level of Sindh Nurses Examination Board (SNEB) who took more than six months to issue the diplomas. ( It is to be noted that in the agenda of a Two Day long meeting there was no item on midwifery.)

8. Upon the invitation of Director MNCH attended a meeting, of 25 individuals in Karachi, comprising principles and tutors of schools of midwifery from all over 96

Sindh. Part of the meeting was attended by the Health Secretary. The meeting was to discuss their problems. All the problems discussed were either operational matters related to shortage of resources or personal matters related to incentives. The question of CMWs training was brought up by the author and suggestions solicited for its improvement. Not much was forthcoming.

9 Dissemination Seminar of the work done by FALAH. Their successful efforts to increase the CPR in selected geographical areas are worthy of replication.

10 MMeetings in Hyderabad, with the principals and tutors of all schools to brief them bout the Situation Analysis of Midwifery Education in Sindh. Discussed in detail each item of the Questionnaire and how to respond.

11. International Day of The Midiwfe in Karachi and in Lahore. .

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Annex 2
Competencies (Required of a midwife to practice midwifery) (Finalized by ICM through a global consultative process with its member associations of midwives) The term "competencies" is used to refer to the basic knowledge, skills and behaviors required of the midwife for safe practice in any setting. Competency # 1 Basic Knowledge and Skills: 1. 2. 3. 4. Respect for local culture (customs). Traditional and modern routine health practices (beneficial and harmful). Resources for alarm and transport (emergency care). Direct and indirect causes of maternal and neonatal mortality and Morbidity in the local community. 5. Advocacy and empowerment strategies for women. 6. Understanding human rights and their effect on health. 7. Benefits and risks of available birth settings. 8. Strategies for advocating with women for a variety of safe birth settings. 9. Knowledge of the community - its state of health including water supply, housing, environmental hazards, food, common threats to health. 10. Indications and procedures for adult and newborn/infant cardiopulmonary resuscitation. 11. Ability to assemble, use and maintain equipment and supplies appropriate to setting of practice. Additional Knowledge and Skills 12. Principles of epidemiology, sanitation, community diagnosis and vital statistics or records 13. National and local health infrastructures; how to access needed resources for midwifery care. 14. Principles of community-based primary care using health promotion and disease prevention strategies. 15. National immunization programs (provision of same or knowledge of how to assist community members to access to immunization services)

Professional Behaviours - The midwife: 98

1. Is responsible and accountable for clinical decisions. 2. Maintains knowledge and skills in order to remain current in practice. 3. Uses universal/standard precautions, infection control strategies and clean technique. 4. Uses appropriate consultation and referral during care. 5. Is non-judgmental and culturally respectful. 6. Works in partnership with women and supports them in making informed choices about their health. 7. Uses appropriate communication skills. PRE-PREGNANCY CARE AND FAMILY PLANNING METHODS Competency #2: Midwives provide high quality, culturally sensitive health education and services to all in the community in order to promote healthy family life, planned pregnancies and positive parenting. Basic Knowledge of: 1. Growth and development related to sexuality, sexual development and sexual activity. 2. Female and male anatomy and physiology related to conception and reproduction. 3. Cultural norms and practices surrounding sexuality, sexual practices and childbearing. 4. Components of a health history, family history and relevant genetic history. 5. Physical examination content and investigative laboratory studies that evaluate potential for a healthy pregnancy. 6. Health education content targeted to reproductive health, sexually transmitted diseases (STDs), HIV/AIDS and child survival. 7. Natural methods for child spacing and other locally available and culturally acceptable methods of family planning. 8. Barrier, steroidal, mechanical, chemical and surgical methods of contraception and indications for use. 9. Counselling methods for women needing to make decisions about methods of family planning.

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10. Signs and symptoms of urinary tract infection and common sexually transmitted diseases in the area. Additional Knowledge of: 11. Factors involved in decisions relating to unplanned or unwanted pregnancies. 12. Indicators of common acute and chronic disease conditions specific to a geographic area of the world, and referral process for further testing/ treatment. 13. Indicators of and methods of counselling/referral for dysfunctional interpersonal relationships including sexual problems, domestic violence, emotional abuse and physical neglect. Basic Skills: 1. Take a comprehensive history. 2. Perform a physical examination focused on the presenting condition of the woman. 3. Order and/or perform and interpret common laboratory studies such as haematocrit, urinalysis or microscopy. 4. Use health education and basic counselling skills appropriately. 5. Provide locally available and culturally acceptable methods of family planning. 6. Record findings, including what was done and what needs follow-up. Additional Skills: 7. Use the microscope. 8. Provide all available methods of barrier, steroidal, mechanical, and chemical methods of contraception. 9. Take or order cervical cytology smear (Pap test) CARE AND COUNSELLING DURING PREGNANCY Competency #3: Midwives provide high quality antenatal care to maximise the health during pregnancy and that includes early detection and treatment or referral of selected complications. 100

Basic Knowledge of: 1. Anatomy and physiology of the human body. 2. Menstrual cycle and process of conception. 3. Signs and symptoms of pregnancy. 4. How to confirm a pregnancy. 5. Diagnosis of an Ectopic pregnancy and multiple fetuses. 6. Dating pregnancy by menstrual history, size of uterus and/or fundal growth patterns. 7. Components of a health history. 8. Components of a focused physical examination for antenatal visits. 9. Normal findings [results] of basic screening laboratory studies defined by need of area of the world; eg. iron levels, urine test for sugar, protein, acetone, bacteria. 10. Normal progression of pregnancy: body changes, common discomforts, expected fundal growth patterns. 11. Normal psychological changes in pregnancy and impact of pregnancy on the family. 12. Safe, locally available herbal/non-pharmacological preparations for the relief of common discomforts of pregnancy. 13. How to determine fetal well-being during pregnancy including fetal heart rate and activity patterns. 14. Nutritional requirements of the pregnant woman and fetus. 15. Basic fetal growth and development. 16. Education needs regarding normal body changes during pregnancy, relief of common discomforts, hygiene, sexuality, nutrition, work inside and outside the home. 17. Preparation for labour, birth and parenting. 18. Preparation of the home/family for the newborn. 19. Indicators of the onset of labour. 20. How to explain and support breastfeeding. 21. Techniques for increasing relaxation and pain relief measures available for labour. 22. Effects of prescribed medications, street drugs, traditional medicines and overthe-counter drugs on pregnancy and the fetus. 23. Effects of smoking, alcohol use and illicit drug use on the pregnant woman and fetus. 24. Signs and symptoms of conditions that are life-threatening to the pregnant woman; eg. pre-eclampsia, vaginal bleeding, premature labour, severe anaemia.

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Additional Knowledge of: 25. Signs, symptoms and indications for referral of selected complications and conditions of pregnancy: eg. asthma, HIV infection, diabetes, cardiac conditions, post-dates pregnancy. 26. Effects of above named chronic and acute conditions on pregnancy and the fetus. Basic Skills: 1. Take an initial and ongoing history each antenatal visit. 2. Perform a physical examination and explain findings to woman. 3. Take and assess maternal vital signs including temperature, blood pressure, pulse. 4. Assess maternal nutrition and its relationship to o growth. 5. Perform a complete abdominal assessment including measuring fundal height, position, lie and descent of fetus. 6. Assess fetal growth. 7. Listen to the fetal heart rate and palpate uterus for fetal activity pattern. 8. Perform a pelvic examination, including sizing the uterus and determining the adequacy of the bony structures. 9. Calculate the estimated date of delivery. 10. Educate women and families about danger signs and when/how to contact the midwife. 11. Teach and/or demonstrate measures to decrease common discomforts of pregnancy. 12. Provide guidance and basic preparation for labour, birth and parenting. 13. Identify variations from normal during the course of the pregnancy and institute appropriate interventions for: a. low and/or inadequate maternal nutrition b. inadequate fetal growth c. elevated blood pressure, proteinuria, presence of significant oedema, severe headaches, visual changes, epigastric pain associated with elevated blood pressure d. vaginal bleeding e. multiple gestation, abnormal lie at term f. intrauterine fetal death g. rupture of membranes prior to term 14. Perform basic life saving skills competently. 15. Record findings including what was done and what needs follow-up. Additional Skills: 16. Counsel women about health habits; eg. nutrition, exercise, safety, stopping smoking. 17. Perform clinical pelvimetry [evaluation of bony pelvis]. 18. Monitor fetal heart rate with doppler. 102

19. Identify and refer variations from normal during the course of the pregnancy, such as: a. small for dates [light]/large for dates [heavy] fetus b. suspected polyhydramnios, diabetes, fetal anomaly (eg. oliguria) c. abnormal laboratory results d. infections such as sexually transmitted diseases (STDs), vaginitis, urinary tract, upper respiratory e. fetal assessment in the post-term pregnancy 20. Treat and/or collaboratively manage above variations from normal based upon local standards and available resources. 21. Perform external version of breech presentation. CARE DURING LABOUR AND BIRTH Competency #4: Midwives provide high quality, culturally sensitive care during labour, conduct a clean and safe delivery, and handle selected emergency situations to maximise the health of women and their newborn. Basic Knowledge of: 1. Physiology of labour. 2. Anatomy of fetal skull, critical diameters and landmarks. 3. Psychological and cultural aspects of labour and birth. 4. Indicators that labour is beginning. 5. Normal progression of labour and how to use the partograph or similar tool. 6. Measures to assess fetal well-being in labour. 7. Measures to assess maternal well-being in labour. 8. Process of fetal passage [descent] through the pelvis during labour and birth. 9. Comfort measures in labour: eg. family presence/assistance, positioning, hydration, emotional support, non-pharmacological methods of pain relief. 10. Transition of newborn to extra-uterine life. 11. Physical care of the newborn - breathing, warmth, feeding. 12. Promotion of skin-to-skin contact of the newborn with mother when appropriate. 13. Ways to support and promote uninterrupted [exclusive] breastfeeding. 14. Physiological management of the 3rd stage of labour. 15. Indications for emergency measures: eg. retained placenta, shoulder dystocia, atonic uterine bleeding, neonatal asphyxia. 16. Indications for operative delivery: eg. fetal distress, cephalo-pelvic disproportion. 17. Indicators of complications in labour: bleeding, labour arrest, malpresentation, eclampsia, maternal distress, fetal distress, infection, prolapsed cord. 18. Principles of active management of 3rd stage of labour.

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Basic Skills: 1. Take a specific history and maternal vital signs in labour. 2. Perform a screening physical examination. 3. Do a complete abdominal assessment for fetal position and descent. 4. Time and assess the effectiveness of uterine contractions. 5. Perform a complete and accurate pelvic examination for dilation, descent, presenting part, position, status of membranes, and adequacy of pelvis for baby. 6. Follow progress of labour using the partograph or similar tool for recording. 7. Provide psychological support for woman and family. 8. Provide adequate hydration, nutrition and comfort measures during labour. 9. Provide for bladder care. 10. Promptly identify abnormal labour patterns with appropriate and timely intervention and/or referral. 11. Perform appropriate hand manoeuvres for a vertex delivery. 12. Manage a cord around the baby's neck at delivery. 13. Cut an episiotomy if needed. 14. Repair an episiotomy if needed. 15. Support physiological management of the 3rd stage of labour. 16. Conduct active management of the 3rd stage of labour including: a. Administration of oxytocic b. Early cord clamping and cutting c. Controlled cord traction 17. Guard the uterus from inversion during 3rd stage of labour. 18. Inspect the placenta and membranes for completeness. 19. Estimate maternal blood loss. 20. Inspect the vagina and cervix for lacerations. 21. Repair vaginal/perineal lacerations and episiotomy. 22. Manage postpartum haemorrhage. 23. Provide a safe environment for mother and infant to promote attachment. 24. Initiate breastfeeding as soon as possible after birth and support exclusive breastfeeding. 25. Perform a screening physical examination of the newborn. 26. Record findings including what was done and what needs follow-up. Additional Skills: 31. Perform appropriate hand manoeuvres for face and breech deliveries. 32. Inject local anaesthesia. 33. Apply vacuum extraction or forceps. 34. Manage malpresentation, shoulder dystocia, fetal distress initially. 35. Identify and manage a prolapsed cord. 36. Perform manual removal of placenta. 37. Identify and repair cervical lacerations. 104

38. Perform internal bimanual compression of the uterus to control bleeding. 39. Insert intravenous line, draw bloods, perform haematocrit and haemoglobin testing. 40. Prescribe and/or administer pharmacological methods of pain relief when needed. 41. Administer oxytocics appropriately for labour induction or augmentation and treatment of postpartum bleeding. 42. Transfer woman for additional/emergency care in a timely manner. POSTNATAL CARE OF WOMEN Competency #5: Midwives provide comprehensive, high quality, culturally sensitive postnatal care for women. Basic Knowledge of: 1. Normal process of involution and healing following delivery [including after an abortion]. 2. Process of lactation and common variations including engorgement, lack of milk supply, etc. 3. Maternal nutrition, rest, activity and physiological needs (eg. bladder). 4. Infant nutritional needs. 5. Parent-infant bonding and attachment; eg. how to promote positive relationships. 6. Indicators of sub-involution eg. persistent uterine bleeding, infection. 7. Indications of breastfeeding problems. 8. Signs and symptoms of life threatening conditions; eg. persistent vaginal bleeding, urinary retention, incontinence of faeces, postpartum pre-eclampsia. Additional Knowledge of: 9. Indicators of selected complications in the postnatal period: eg. persistent anaemia, haematoma, embolism, mastitis, depression, thrombophlebitis. 10. Care and counseling needs during and after abortion. 11. Signs and symptoms of abortion complications.

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Basic Skills: 1. Take a selective history, including details of pregnancy, labour and birth. 2. Perform a focused physical examination of the mother. 3. Assess for uterine involution and healing of lacerations/repairs. 4. Initiate and support uninterrupted [exclusive] breastfeeding. 5. Educate mother on care of self and infant after delivery including rest and nutrition. 6. Identify haematoma and refer for care as appropriate. 7. Identify maternal infection, treat or refer for treatment as appropriate. 8. Record findings including what was done and what needs follow-up. Additional Skills: 9. Counsel woman/family on sexuality and family planning post delivery. 10. Counsel and support woman who is post-abortion. 11. Evacuate a haematoma. 12. Provide appropriate antibiotic treatment for infection. 13. Refer for selected complications. NEWBORN CARE (up to 2 months of age) Competency 6: Midwives provide high quality, comprehensive care for the essentially healthy infant from birth to two months of age. Basic Knowledge of: 1. Newborn adaptation to extra-uterine life. 2. Basic needs of newborn: airway, warmth, nutrition, bonding. 3. Elements of assessment of the immediate condition of newborn; eg. APGAR scoring system for breathing, heart rate, reflexes, muscle tone and colour. 4. Basic newborn appearance and behaviours. 5. Normal newborn and infant growth and development. 6. Selected variations in the normal newborn; eg. caput, moulding, mongolian spots, haemangiomas, hypoglycaemia, hypothermia, dehydration, infection. 7. Elements of health promotion and prevention of disease in newborn and infants. 8. Immunisation needs, risks and benefits for the infant up to 2 months of age. Additional Knowledge of: 9. Selected newborn complications, eg. jaundice, haematoma, adverse moulding of the fetal skull, cerebral irritation, non-accidental injuries, causes of sudden infant death.

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10. Normal growth and development of the preterm infant up to 2 months of age. Basic Skills: 1. Clear airway to maintain respirations. 2. Maintain warmth but avoid overheating. 3. Assess the immediate condition of the newborn; eg. APGAR scoring or other assessment method. 4. Perform a screening physical examination of the newborn for conditions incompatible with life. 5. Position the infant for breastfeeding. 6. Educate parents about danger signs and when to bring the infant for care. 7. Begin emergency measures for respiratory distress (newborn resuscitation), hypothermia, hypoglycaemia, cardiac arrest. 8. Transfer newborn to emergency care facility when available. 9. Record findings, including what was done and what needs follow-up. Additional Skills: 10. Perform a gestational age assessment 11. Educate parents about normal growth and development, child care. 12. Assist parents to access community resources available to the family. 13. Support parents during grieving process for congenital birth defects, loss of pregnancy, or neonatal death. 14. Support parents during transport/transfer of newborn. 15. Support parents with multiple births.

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Annex 3 Historical Background ( Efforts of the Government of Pakistan to Provide Maternity Services to the Rural Women.) Note for the reader. The purpose of documenting the historical back ground is: to:connect the CMW Initiative with the past efforts of the government; the patch work and sometimes unrealistic policies and approaches to provide maternity care to the rural women; and form the basis for evaluation of the status of midwifery education and the progress of the profession of midwifery in Pakistan in general and in Sindh in particular, since the early fifties. Some of the information has been buried in history e,g The one year training of Dais, or the difference between a certified Dai and the historical traditional birth attendant, or the part played by the religious missions in midwifery education etc. Most of the information is evidence based. Some of the information, however has been collected with the help of institutional memories of individuals and more than half a century of the authors own very deep involvement in midwifery at the national and international level. 1. The beginning The first school of midwifery in the Indian subcontinent opened in 1882 in the Mayo Hospital Lahore. Yet in 1947, the part of the subcontinent which became Pakistan there were very few schools in the public sector training midwives.. In 1948 in Sindh, there was one midwifery school in the public sector Efforts of the Pakistan Government to provide mother and child ( MCH ) services date back to early fifties. The Lady Health Visitor and the Midwife were a legacy of the British Raj,. In addition , the other category to reach the rural women ,was being trained called DAI. This was another legacy of the Birtish Raj. This woman was largely illiterate. She was attached to an MCH Center or a public health school. She was given mostly hands on training for one year according to a prescribed syllabus. She appeared in a final viva. If successful she got a certificate, got registered with the Pakistan Nurses Midwives and Health Visitors Council ( now called Pakistan Nursing Council) She was called, Sanad Yafta Dai, i.e (Certified Dai). She became a part of the health system and was appointed in a salaried, pensionable post in MCH Centers and small hospitals. The Dais also worked as private practitioners and conducted home deliveries. Because of the extreme shortage of midwives in general and of those willing to work in the rural areas, these Dais were often posted. against the posts of the licensed midwives

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They became the, Trained Maternity Care providers in the rural areas as well as in the cities. This was the beginning of the downfall of the identity of the professional midwife ,because the word Dai and Midwife became synonymous. Even the English Urdu dictionaries translate the word Midwife into Dai. When the trained midwives started to become available and the health authorities tried to implement a replacement strategy in Sindh, the Dais took to streets. It was then decided to Let Them Extinguish Themselves. The training of Dais was stopped but their Register in the Council ( which by now was called Pakistan Nursing Council), remains open till today for those who want to re register. The untrained Dai, later termed as Traditional Birth Attendant, continued to exist because there were not enough trained Dais to cope with communities needs. Eventually the world forgot about the difference between the Dai and the TBA and now the term Dai and TBA are used interchangeably. In fact there are very few even among the health care providers who know the difference. Renaissance of Midwifery in Pakistan At the turn of the century things started to move. The first ever Situation Analysis of Midwifery Training was carried out in Sindh in the year 2000. It was commissioned by UNICEF and conducted by Rahnuma Consultants, a firm headed by a nurse-midwife educator. It brought out the dismal picture of midwifery education and a state of almost complete neglect of the midwifery profession. The findings were disseminated among the stake holders with a Strategic Plan but very little solid action has been taken by any stake holder. In 2002, the first ever International Day of the Midwife (IDM) was celebrated by the National Committee for Maternal Health with the support of UNFPA. The First Lady of Pakistan was the Chief Guest. She attracted the dignitaries , various stake holders and development partners. Findings of the Situation Analysis of Midwifery Training in Sindh were once again presented. The historians would connect this event to the start of RIPPLES of SENSITISATION about Midwifery. This event was followed by some efforts of the National Commission for Human Development but these did not move very far. The only outcome was a draft of the Regulatory Mechanisms for Midwifery Practice These were to be finalisd with legal advice.. This was not done and eventually it was found that, The file was misplaced, and never found again. In 2005 the establishment of Midwifery Association of Pakistan was assisted by the National Committee for Maternal Health ( Now called National Committee for Maternal and Neonatal Health) and the Sindh Chapter of Maternal and Child Welfare Association of Pakistan. Now the midwives have a platform with extremely limited resources but it has succeeded in bringing midwife to the forefront of maternal health service 109

In 2006 a Situation Analysis of Midwifery Education in Punjab was commissioned by UNICEF, conducted by Contech International. The Principal Investigator was a Nurse Midwife Educator. Teams of investigators included midwifery tutors. Results of both the studies i.e the one of Sindh and that of the Punjab were almost 100% identical. These underscored the fact that change if any was painfully slow. The only silver lining to the cloud was that midwifery was being talked about and at long last it had caught the attention of the donors. Efforts of the Pakistan Government to provide mother and child ( MCH ) services date back to early fifties. The Lady Health Visitor , a legacy of the British Raj, was trained as the real community midwife with training in midwifery and in public health. At the time of partition there was only one school for LHV training in Lahore. The second one was opened in Karachi with WHOs assistance and expatriate faculty. At the time of partition , in Sindh, there was one midwifery school in the public sector. In December 2000, a Situation Analysis of Midwifery Training in Sindh , commissioned by UNICEF, revealed that there were 39 schools training midwives ( including Public Health Schools)as compared to ONE in 1947. Half of these were in the private sector. The standards of midwifery education were very low. In some of the private schools the students were getting some supervised practice in conducting deliveries . In the public sector schools they were used as pairs of hands and not given any opportunity to develop midwifery competencies. Some schools train direct entry midwives (known as Pupil Midwives ) . This meant that there were more schools of midwifery in Sindh, than schools of nursing . Surprisingly there were no posts of midwifery teachers in the schools training midwives, excepting in the public health schools. More over there was no trained faculty to teach midwifery.. There was very high rate of attrition among midwifery students e.g between 1994 and 1998 a total of 2293 students were admitted in 29 schools in Sindh. 437 dropped out. 1856 appeared for the qualifying examination. A total of 1050 i.e about 50%, qualified as midwives ( 900 in the first attempt, 140 in the second attempt and 10 in the third attempt). There was no record available of those who did not make it. 3. Training Schools for midwifery training The number of schools for training midwives and LHVs kept on increasing but the rural woman was still deprived of skilled care. Because of the entry requirements only urban girls qualified for admission to the LHV or midwifery courses. They got 110

trained and stayed in towns. In all fairness, they were ( and still are) the only available source to the average woman who wants a trained provider and either can not afford a doctor or due to socio-cultural reasons or sanctions on their mobility, cannot go to a health facility. 4. The Traditional Birth Attendant ( TBA) In the late seventies, another desperate effort of the government to serve the rural women, led to training of the traditional birth attendant (TBA). Some 60,000 were trained with the support of WHO and UNICEF, all over Pakistan and left in the communities unsupervised and unsupported. Promises made to them of supervision and articulation with the health system were not fulfilled. They went back to square one within six months after training. In the private sector TBA training continues even today at a smaller scale. BECAUSE THE TBA IS A REALITY & A CHALLENGE. 5. Imposition of midwifery on registered nurses In the late eighties through a presidential decree every female nurse was mandated to get midwifery training. This was made a pre-requisite for her promotion. Therefore the schools of nursing had to offer midwifery training. The trained nurse did not take the midwifery training seriously Midwives continued to be produced, yet babies continued to be delivered by Dais and TBAs at home not only in the villages but in the cities also e.g in the early eighties in Lahore 68 % babies were delivered at home mostly by TBAs 6.Quality of midwifery training in Sindh In December 2000, a Situation Analysis of Midwifery Training in Sindh , commissioned by UNICEF, revealed that in Sindh, there were 39 schools training midwives ( including Public Health Schools ) Half of these were in the public sector as compared to ONE in 1947. The other half were in the private sector, run mainly by religious missions. As the numbers of schools increased, the standards of midwifery education and training started to deteriorate.. In some of the private schools the students were getting some supervised practice in conducting deliveries . In the public sector schools they were given lectures in midwifery but used as pairs of hands , a cheap source of services in the hospital. They were not given much opportunity to develop midwifery competencies. Three categories of midwives were being trained i.e the Nurse Midwife, the pupil midwife and the lady health visitor. It needs to be noted that the same curriculum is used for all the above categories of midwives even today. It was last looked at in 1994.

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Some schools train only direct entry midwives (known as Pupil Midwives). This meant that there were ( still are ) more schools of midwifery in Sindh, than schools of nursing . Surprisingly there were no posts of midwifery teachers in the schools training midwives, excepting in the public health schools. More over there was no trained faculty to teach midwifery. Only in one school, the principal was a qualified midwifery teacher and also had a B.Sc degree from abroad. There was very high rate of attrition among midwifery students e.g between 1994 and 1998 a total of 2293 students were admitted in 29 schools in Sindh. 437 dropped out. 1856 appeared for the qualifying examination. A total of 1050 i.e about 50%, qualified as midwives (900 in the first attempt, 140 in the second attempt and 10 in the third attempt). There was no record available of those who did not make it. Many projects included womens health and MCH but none paid much attention to the education and training of midwives. 7. Categories of midwives Pakistan is now training FOUR categories of midwives 7.1The Nurse-Midwife ( 3 years of nursing followed by one year of midwifery. training) Midwifery being compulsory for promotion of female nurses, they join the midwifery course but continue to be utilized by the institutions as registered nurses. They attend a few theoretical classes, and manage to get a diploma on the strength of theoretical knowledge with or without any midwifery competencies. They by and large do not opt for midwifery as a career because there is no future in midwifery. They would make good midwives because of their age, nursing background, experience of working in various departments of health facilities , opportunities for further education up to the doctoral level, and a chalked out career path which goes up to Grade 20.Unfortunately , because of the status accorded to midwifery in Pakistan, they are not guided by any one nor are they offered any choices. They do midwifery because it is imposed on them to get up the ladder in nursing. It needs to be noted that this is the only category of midwives who can study for Diploma in Teaching Nursing. A vast majority of those currently teaching midwifery are from this category. because there is no diploma for teaching midwifery. 7.2 The Lady Health Visitor (One year of training in midwifery followed by one year of training in public health). This was a legacy inherited from the British Raj. They were trained to be Community Midwives in the real sense. . There training was of very good quality. It started to deteriorate in the early seventies.

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Public Health Schools are not attached to any hospital. The students are sent to various health facilities for field practice. They are outsiders in those institutions. They may or may not be given the opportunity for learning practical midwifery. The current situation is that majority of them pass with limited midwifery skills but most of them practice midwifery in health facilities ( BHUs, RHCs & Tehsil Hospitals) in the public and in maternity homes/hospitals in the private sector. They also practice as midwives in their own time. They set up their own clinics and pose as doctors They learn midwifery after they get their diploma in midwifery and get a job. As LHVs, there is no career pathway for them. If they want to better their prospects they have to go into nursing. This category, however enjoys better reputation and prestige than the midwife and the CMW. In the public sector service structure there is no career pathway for them. IIf they want to move upwards they have to go into nursing. The only promotion for them is to become supervisors of other LHVs or midwives. Now they are going to be used to supervise CMWs 7.3 The Midwife (15 months of training in midwifery ) This category was previously known as ,Pupil Midwife. No one could explain the reason for this nomenclature. Recently the prefix Pupil was removed. With a couple of exceptions in the private sector, very few of them have even the minimum midwifery competencies. This is the weakest category of midwifery personnel. There is no future at all for this category. They get jobs in BHUs and RHCs. They get absorbed in the private sector. Some of them work as self employed. Five years ago , all of a sudden , a notification from PNC was received by these schools that they were to close with immediate effect. Seven schools approached the Midwifery Association of Pakistan (MAP) for assistance. Guided by its legal advisor MAP took up the matter with PNC. The decision for immediate closure was reversed and the programme was extended till 2013. In February 2012 in a meeting of PNC the matter was brought up by MAP. According to the registrar PNC , only the public sector schools will discontinue. The private sector can continue to train this category. A request for written notification has been sent to PNC by MAP. Response is awaited. The entry requirement for all the three categories is 10 years of schooling They share the same curriculum which is extremely sketchy. It was last looked at in February 1994. It is labeled ,4 th Year This midwifery curriculums Preface ,written by the then Vice President of Pakistan Nursing Council, reads, I am pleased with revision of curriculum of Nursing.. This is

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reflective of the thinking of nursing leaders and a proof that midwifery is not considered a profession with its own identity. 7.4 The community midwife It needs to be noted that the CMW Initiative was conceived and implemented in a very unusual national environment. This included: plans for and initiation of devolution; lack of clarity in the governance of vertical programmes implemented by the federal government, the problems of the transitional period, resource allocation, structural adjustments , civic unrest, political instability , insurgence of religious fundamentalism, increasing crime rate affecting the law and order situation and high inflation rates. All of these factors need to be kept in mind while evaluating or analyzing any of the plans and their implementation in the health sector in the last five years. Originally the national target was to train 10000 CMWs . It was later increased to 12,000. The goal was to recruit females from the rural areas so that they will go back to their places of residence and serve the rural population.

In 2005-6 a PC-1 was approved to take MCH services to the rural areas. A new Cadre of midwifery personnel was introduced entitled, Community Midwife (CMW). A new curriculum was designed . A national Target of 12000 CMWs was set . Foreign assistance was sought and received. In 2007 the first batch of students was recruited. 8. Growth of Institutions to train Midwives. Schools of nursing, midwifery and public health have multiplied many fold. Midwives of all the above categories graduate annually in thousands but not all opt to practice midwifery . The standards of midwifery training are such that the midwives do not qualify as competent Sklilled Birth Attendants.(SBAs.) A vast majority comes from urban or peri -urban background. A negligible minority is of rural background. They all train and remain in the cities excepting those who work in the Basic Health Units ( BHUs). Some of them reside in BHU and provide services in their off duty time on fee for service basis. Those who can reach them and afford them utilize their services. The Average rural woman remained deprived of the services of trained midwives. This led to the emergence of the new category of midwifery personnel ,The Community Midwife, with the main goal to reach the rural population. Nursing received a lot of attention and foreign assistance. A career path was developed for nurses. They could move forward academically and reach the doctoral level. The first degree course was established for nursing in Pakistan and 114

now a bachelors degree has become the norm. A nurse can achieve the top grade 20 through promotion. A midwife remains a midwife ,in a low grade with no career path and no oportunities of upward movement unless she decides to become a nurse. 9.Factors Responsible for Low Standards of Midwifery Education All documents available on various aspects of midwifery education in Pakistan highlight certain crucial facts: Until the late sixties midwifery education standards were of a quality acceptable abroad. A midwife trained in Pakistan enjoyed reciprocity with UK.for nursing and midwifery licensing. Deterioration started in 1972. For almost half a century midwifery education did not received any attention in Pakistan either of the government , or of PNC , or of the development partners. The first ever Situation Analysis of Midwifery Training was carried out in Sindh, in 2000..In 2006 it was replicated in Punjab Both were commissioned by UNICEF. Results of both the studies were almost 95% identical A third third study is in the process of being conducted in Sindh. The findings so far indicate that NOTHING has changed since 2000. So far, for almost half a century It has been possible to get a diploma in midwifery without having delivered a baby. Most Nurses who enroll in midwifery training programme get their diplomas this way. Only these. nurse -midwives get opportunities for further education to become Nursing Instructors. They are now teaching midwifery with extremely limited background in the theory of midwifery and almost no experience in the practice of midwifery With the exception of a negligible few, those teaching midwifery lack the capacity to teach effectively. Most of the teaching and learning are based on rote memory. So is the final examination. Students have been writing fictitious cases for years to meet the requirement s to qualify for giving their final examination.. ALL connected to final evaluation, certification and licensing are aware of it. No one has uttered a work about this criminal act. They pass their final examination by hook or by crook. Those who decide to practice, learn midwifery AFTER graduation by trial and error. Midwifery as a profession has not been recognized in Pakistan 115

 Midwife has no identity as a professional. She is at the lowest rung of the health care providers ladder. No future. No career. No opportunities for further professional development. 10. The silver Lining It is a comforting thought that midwifery is being talked about. A few documents are now available on the institutions giving training to CMWs, quality of training, preparation of teachers etc. A draft of the Regulatory Mechanisms for midwifery practice is ready. When approved it will a flag bearer because no other profession in Pakistan has regulated itself in this manner. There is awareness that midwives can save lives. Ths Sindh and the Punjab Governments are celebrating International Day of the Midiwfe. Above all there is a professional organisation of Midwives affiliated with the International Confederation of Midwives. There is light at the end of the tunnel

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Annex 4
Situation Analysis of Midwifery Education Sindh

Tools Used: 4.1. Questionnaire 4.2. Evaluation of the Teaching Session 4.3. Interview Guides 4.3.1 Clinical Supervisors 4.3.2 Obstetrician/ WMO 4.3.3 Medical Superintendent / Focal Person 4.3.4 Students Note: A Detailed report of the Situation Analysis is available as a separate document.

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