Accountability in the development of midwifery in Bangladesh

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Increasing women's access to quality midwifery services has become a focus of global efforts to realize the right of every woman to the best possible health care during pregnancy and childbirth and in the period after birth. The scope of practice of a midwife is the management of the normal physiological processes of pregnancy, labour, birth and postpartum period up to six weeks, including care of the newborn. During this time the midwife works with the pregnant woman and her family, providing highly skilled midwifery and women-centered care. The midwife as autonomous practitioner is responsible and accountable for her practice.
In Bangladesh about 194 women die per 100.000 live births due to causes related to pregnancy, childbirth and in post-partum period (Source: Bangladesh Maternal Mortality Survey BMMS 2010). Till now, the number of women giving birth at home by unskilled personnel is about 68% (Source: BMMS 2010). Midwives are considered to be the key professionals for providing skilled care for maternal health. The Government of Bangladesh has already started to educate midwives, and political leaders are committed to reduce maternal and newborn mortality and morbidity.
The development of the midwifery profession gained momentum after the Prime Minister's speech at the General Assembly of the UN in 2010 where she committed to the development and deployment of 3000 midwives by 2015 and 7000 in a few more years.
Midwives will provide services in Upazilla health complexes 24 hours 7 days a week as soon as their posts have been created. In case any complication arises, midwives will refer mothers to hospital to receive emergency services from obstetricians and other specialists, and newborns with problems will be referred to pediatricians when required.
So far, 710 midwives have been educated. Two pathways to increase the number of midwives have been developed: (a) “skill-up”of existing nurse-midwives, and (b) scaling-up by the three year direct-entry Diploma in Midwifery programme.
The Certificate in Midwifery programme, a short-term solution (skill-up) was developed jointly by the Bangladesh Nursing and Midwifery Council (BNMC), the Directorate of Nursing Services, the Directorate General of Health Services, the Obstetrical and Gynecological Society of Bangladesh (OGSB), WHO and UNFPA and commenced as a pilot project in three selected training sites in 2010. Existing nurse-midwives from the public and now also from the private sector with 2 years of working experience, aged below 45 are admitted to the training. There are 20 training centers to educate Certified Midwives all over the country.
The three-year direct entry Diploma in Midwifery education, the long-term solution (scale-up), was developed in 2012 and commenced in December 2012 with 525 students in 20 training sites. The next batch will start in December 2013.
Existing faculty are mainly senior staff nurses. The nursing colleges and institutions lack posts for nursing or midwifery instructors and nursing and midwifery lecturers. UNFPA is supporting the educational sites with training equipment.
There are several levels of accountability in regard to midwifery in Bangladesh.
Generally, accountability is the process whereby public service organizations and individuals within them are held responsible for their decisions and actions, including their stewardship of public funds, fairness, and all aspects of performance, in accordance with agreed rules and standards, and fair and accurate reporting on performance results vis-à-vis mandated roles and/or plans.
UNFPA and WHO are supporting the Government of Bangladesh to plan, implement, monitor and evaluate the midwifery programme. Regarding accountability, UNFPA has established mechanisms within the organization and in all their operations and in external partnerships. UNFPA is accountable to their donors and has to ensure that funds are used to achieve development results.
The Directorate General of Health Services oversees the midwifery programme, the Bangladesh Nursing and Midwifery Council (BNMC) is responsible to ensure quality in education and the Directorate of Nursing Services overlooks the placement of midwives. Those who are in charge of the Midwifery programme, their activities and guidance are held accountable for efficient and effective management.
Though the Bangladesh Government showed their commitment to educate midwives, so far, 710 certified midwives have been trained, the creation of the posts has not yet been done. If the posts are not created, already trained midwives will not be able to work in their field of expertise, lose their competencies and mothers and children in Bangladesh will be deprived from their right to have a safe delivery.
A midwifery act, professional rules and regulations are under development and coordinated by the BNMC. Regulations will define the scope of practice of the midwife as an autonomous professional but will also provide a code of conduct and ethics for the profession and a mechanism for complaints and discipline. In other words: the midwife receives a framework in which she will be able to offer services but at the same time she is accountable for her actions.
Finally, midwives themselves are accountable to ensure safe pregnancies and deliveries, provide quality services to their client, the pregnant woman, the women in labour or the mother and child in the post-partum period. This is based on the right of every women to be accompanied by a competent midwife.
Saving the lives of mothers and newborns through quality services of midwives, will benefit the society in human and economic development. Quality midwifery services that are coordinated and integrated within communities and are being integrated in a supportive health system will ensure that a continuum of essential care can be provided throughout pregnancy, birth and beyond.