October 21, 2015

Strengthening Midwifery in Mexico and Meeting Women Where They Are

Written by Sarah Blake, Maternal Health Task Force

This post originally appeared on the Maternal Health Task Force blog.


The panel discussion on Mexico’s ongoing efforts to strengthen midwifery began with an introduction from Paloma Bonfil of the Interdisciplinary Group on Women, Work and Poverty. She characterized the task of members of the National Safe Motherhood Committee’s as both a practical effort and one aimed at reorienting health services overall. While the focus of the initiative is on core steps to building a cadre of professional midwives: organizing education, deploying new professionals appropriately, and organizing health policies to support this, presenters stressed throughout that professional midwives, while fundamental to the strategy, are not the most important population affected by the initiative: women are.

In describing the challenge that Mexico now faces, Bonfil noted that while in Mexico, there is a “strong midwifery tradition, but it has always been outside of the formal health system,” and it is now concentrated among rural, indigenous community. However, she pointed out that the need for professional midwives is not limited to these settings. While most women deliver in health facilities, shortages of skilled providers at primary and secondary health facilities mean that quality of care is often in question, while the obstetric and neonatal nurses who are now trained to deliver many of the core functions of midwifery are not effectively deployed – and are, often frustrated as a result.

The presentations that followed highlighted key details of the effort to, as presenter Sharon Bissell of the John D. and Catherine T. MacArthur Foundation described it, “make midwives a ‘legitimate’ option” for women so important. Bissell pointed out that among the challenges for strengthening midwifery were the multiple discourses and perspectives that surround the idea of midwifery, noting that many do not see midwifery as a profession. She described the task of the shared effort as working toward “a tipping point” in public understanding of midwives’ roles, supportive policies, investments in midwifery training and deployment, and strong leadership guiding the way forward. With such a point, it would be possible to create a “defined path” toward expanding the midwifery workforce in order to address quality, access and use of services, and ultimately accelerating progress on improving health outcomes.

This point was further expanded by Hilda Reyes of the Centro Nacional de Equidad de Genero y Salud Reproductiva (National Center for Gender Equity and Reproductive Health) of Mexico’s Secretariat of Health, who began her presentation on the full model, pointing out that while Mexico has made major advances in maternal health outcomes over the past 40 years, MDG5 was not met, and, further, 90% of women who die from maternal causes have antenatal care in a health care institution, underscoring gaps in both quality and access to comprehensive care. Reyes and Raffaela Schiavon Ermani of Ipas  both highlighted key components of the effort to build and deploy a midwifery workforce. Reyes focused on issues such as the pragmatic challenges for establishing the new institutions and models of training that will enable a new cohort of midwives with the clinical and cultural competencies to deliver care, given that there are fewer than 100 midwives in the country. Schiavon expanded on this in her presentation, highlighting the ways that the evidence gathered and presented in the State of the World’s Midwives 2014 helps to inform discussions refining policies to support a new model of health service delivery across the continuum, noting that evidence from the SoWMy helps to describe both the scope of the problem and, looking beyond Mexico, presents some potential models for addressing these challenges. She pointed out that Mexico is far from alone in having few providers equipped with all of the core midwifery competencies, while emphasizing that building technical skills, including family planning and safe abortion, along with care during labor and delivery and for both women and newborns after a birth. In describing the key pieces of evidence from the SoWMy that have informed consultations, she pointed out that key points have always been that midwifery, while cost-effective, is not simply a substitute for more expensive care, but rather, part of a model in which skilled birth attendance is not synonymous with institutional delivery – not because, as is currently the case, institutional delivery does not always ensure quality care, but because the health system is responsive to women’s needs and preferences.

Finally, Javier Dominguez of UNFPA described key elements of the planning midwifery workforce expansion at state level and for local decision-making. He pointed to the four elements of the definition of the right to health that shape assessment of the strategy: accessibility of services, availability of workers, and quality care – which includes culturally acceptable care. In his presentation, he made clear that these elements are irreducible: if the initiative is to “transform the hegemonic system,” it is not enough to simply train midwives, but to make sure they are deployed appropriately to reach women in remote communities, and that they deliver care that is both clinically and culturally competent. He further emphasized this point in response to a question on the treatment of traditional midwives under the initiative: “We must be absolutely inclusive. Without this, this initiative will not work.” That is, to fulfill the vision of the initiative, there will be opportunities for any provider, involved in caring for women and babies to play a constructive role – including traditional midwives – who, the panelists noted, may accompany professional midwives or in other roles in community-level care and coordination.