Mohammad Abou El-Ardat1*, Naima- Imširija-Galijašević1, Lana Lačević-Mulahasanović1, Đenana Šaldo1, Fahira Imamović1, Arzija Pašalić2 Vedran Đido2
1Clinic for Gynecology and Obstetrics, Clinical Center of the University of Sarajevo
2University of Sarajevo, Faculty of Health Studies in Sarajevo
*Corresponding Author: Mohammad Abou El-Ardat, Clinic for Gynecology and Obstetrics, Clinical Center of the University of Sarajevo.
Abstract
Introduction: Midwives are globally recognized as health professionals who specialize in the care of women in labor with a vital role in maternal and newborn health care. Midwives specialize in the care of women in labor and play a key role globally in managing normal vaginal birth, caring for pregnant women including supporting women and their families, providing consultations, managing normal birth for low-risk pregnant women and helping them maintain a healthy pregnancy. Despite the fact that the midwifery profession is an autonomous profession, in some countries there are many struggles to achieve recognition within its formal scope of work. The role of the midwife/midwife remains unclear in many countries due to poorly articulated policies and a lack of regulatory frameworks, which results in a lack of public clarity regarding the role of the midwife.
Objective: The purpose of this expert report is to present the role of the midwife in protecting the health of mothers before, during and after childbirth, to clearly define their role and importance, and the need to improve midwifery as a profession in order to reduce the number of caesarean sections.
Results: In the Law on Health Care of the FBiH and the Law on Nursing and Midwifery of the FBiH, the role of the midwife is insufficiently defined and she is not given sufficient authority to work. For childbirth in BiH, in addition to midwives, a doctor must always be present. In European and foreign countries, the role of the midwife is put in the foreground during childbirth, so there are also hospitals where women give birth and are cared for by midwives. Midwife-led care, an approach that is already widely practiced in developed countries; however, it is a relatively new approach in lower-income countries. In midwife-led care, a midwife who is well known to the mother provides care for the low- risk pregnant woman during antenatal care, delivery and the postnatal period, rather than being cared for by different medical staff led by an obstetrician. The primary focus of care led by midwives is to support a healthy physiological pregnancy and birth and to empower women to give birth naturally with little or no regular intervention.
Conclusion: It is very worrying for midwifery as a profession that there is currently a lack of visibility of midwives in practice within their scope of practice in Bosnia and Herzegovina. More research is needed on demonstrating the value of midwives as a primary role in the context of midwifery practice in Bosnia and Herzegovina.
Keywords: midwives, role, health, promotion, profession, Bosnia and Herzegovina
Introduction
During pregnancy, midwives assume multifaceted responsibilities aimed at ensuring the health and well-being of both mother and baby. Their role encompasses providing comprehensive prenatal care, including routine screenings, health assessments, and educational support to expectant mothers. Lunze et al. emphasize the importance of midwives in implementing innovative prenatal care approaches, such as group antenatal care models, to enhance maternal and newborn health outcomes [1]. Additionally, midwives play a crucial role in promoting maternal nutrition, monitoring fetal development, and addressing any emerging concerns to mitigate risks during pregnancy. In the labor and delivery process, midwives serve as skilled attendants, offering continuous support and care to women throughout childbirth. Their competencies encompass various aspects, including monitoring maternal and fetal well-being, providing pain management techniques, and facilitating the progression of labor. Karp et al. underscore the significance of quality improvement initiatives in labor and delivery settings, aiming to enhance the safety and satisfaction of childbirth experiences under midwifery care [2]. Moreover, midwives are trained to recognize and respond to obstetric emergencies promptly, ensuring timely interventions to optimize maternal and neonatal outcomes. Postpartum care marks a critical phase in which midwives continue to play a pivotal role in supporting women during the transition to motherhood. Their responsibilities encompass monitoring maternal recovery, providing breastfeeding support, and addressing any postpartum complications or concerns.
Implementing evidence-based practices is paramount to enhancing the quality of midwifery services. Karp et al. emphasize the importance of integrating best practices into routine care protocols, ensuring that midwives deliver high-quality, evidence-informed care to women 1098 The Role Of Midwives In Maternal And Reproductive Health Care and newborns [2]. This includes staying updated on the latest clinical guidelines, research findings, and advancements in maternal and newborn health care. Training and education play a crucial role in equipping midwives with the necessary skills and knowledge to provide quality care. Continuous professional development opportunities, such as workshops, seminars, and online courses, enable midwives to stay abreast of emerging trends and best practices in the field. By investing in ongoing education, midwives can enhance their competencies and adapt to evolving healthcare landscapes.
Furthermore, fostering a culture of quality improvement within midwifery settings is essential for driving positive change and innovation. This involves creating interdisciplinary teams dedicated to assessing and optimizing service delivery processes, identifying areas for improvement, and implementing targeted interventions to enhance patient outcomes. Engaging in collaborative partnerships with other healthcare professionals and stakeholders is instrumental in improving midwifery services. By fostering effective communication and coordination across care teams, midwives can streamline care pathways, enhance continuity of care, and improve the overall patient experience. Ultimately, enhancing the quality of midwifery services requires a comprehensive approach that addresses various facets of care delivery, including evidence-based practices, training, continuous professional development, quality improvement initiatives, and collaborative partnerships. By prioritizing quality improvement efforts, midwives can further optimize maternal and newborn health outcomes and uphold the highest standards of care [3].
Healthcare system factors, including policies, regulations, and resource allocation, can shape the delivery of midwifery services and impact their effectiveness. In some settings, restrictive regulations or policies may limit the scope of practice for midwives or hinder their ability to provide comprehensive care. Conversely, supportive policies that prioritize midwifery-led models of care and ensure adequate resources and infrastructure can facilitate the provision of high-quality midwifery services and improve maternal outcomes.
Training and education also play a critical role in overcoming barriers and enhancing the effectiveness of midwifery care. By equipping midwives with culturally sensitive communication skills, knowledge of diverse childbirth practices, and strategies for addressing social determinants of health, training programs can help midwives navigate cultural and social factors that may impact care delivery.
Additionally, ongoing professional development opportunities can empower midwives to stay informed about best practices and emerging trends in maternity care, enhancing their ability to provide effective, evidence-based care to women and families. In summary, addressing barriers and leveraging facilitators to effective midwifery care requires a multifaceted approach that considers cultural, social, and healthcare system factors. By promoting culturally competent care, addressing social determinants of health, advocating for supportive policies, and investing in midwifery education and training, stakeholders can work together to overcome barriers and create an enabling environment for midwives to provide high-quality, holistic care to women and families [3].
Law on Nursing and Midwifery in BiH regulates the activities of nurses - technicians and nurse midwives, the manner of performing and organizing activities, the standard of education and conditions for performing the activities of nurses and midwives, the rights, obligations and responsibilities of nurses and midwives, and the control of the safety and quality of work of nurses and midwives in the Federation of Bosnia and Herzegovina. Midwives, within the meaning of this law, are health workers who have completed secondary medical school in the field of gynecology and obstetrics/midwifery or a higher health school in the field of midwifery. Midwifery care includes all procedures, knowledge and skills for protecting the health of female persons before, during pregnancy, at childbirth and in the postpartum period. Midwifery care includes care for the health of female persons before, during pregnancy, at childbirth and in the postpartum period. Health and midwifery care are an integral part of the health care system and are carried out in accordance with the regulations on health care, regulations on health insurance and the provisions of this law. Health care and midwifery care are public activities and are subject to the control of compliance with education standards and quality standards [4].
In countries such as Sweden, England, the Netherlands and many others, a normal pregnancy will be managed by midwives, only in the case of some pathology, the care of the pregnancy will be taken over by a doctor-gynecologist. Most women in these countries do not even see a doctor. In England, at least half of all babies are born in the hands of midwives, including the children of Princess Kate and Meghan Markle. In Sweden and Finland, care during pregnancy is provided almost exclusively by midwives, and obstetricians are only involved in high-risk pregnancies. In the United States of America, it was determined that the states in which midwives are involved in the care of women giving birth (Oregon, Washington and New Mexico) are ranked among the best in terms of the health of mothers and babies. On the other hand, states with a small number of midwives and weak systemic involvement of them in the process of mother and baby care (Alba, Mississippi and Ohio) have significantly worse results in key indicators for mother and baby care [5].
Materials and methods
This systematic review includes a comprehensive literature search of published scientific articles, in English, from 2020 to 2024, using electronic databases considered most relevant to the topics; CINAHL, EMBASE and PubMed. In this systematic review and meta-analysis, we included studies on the role of midwives in different countries, including Thailand, the United States, Australia, Canada, the UK, the Netherlands, Bosnia and Herzegovina, Slovenia, Croatia and Serbia, to arrive at results on what the role of midwives is in these countries. Citations without abstracts and/or full text, anonymous reports, editorials, case reports, case series and qualitative studies were excluded.
Results
A midwife is a trained health professional who cares for pregnant women including supporting women and their families, providing consultation, conducting normal birth for low-risk pregnant women, and assisting them to maintain healthy pregnancies [6]. However, the role of the midwife remains unclear in many countries through poorly articulated policy and lack of regulatory frameworks resulting in a perceived lack of clarity for the midwife's role by the public [7]. In Thailand, midwives are responsible for taking care of low-risk pregnancies whereas the obstetricians manage high-risk pregnancies [8]. Nevertheless, a recent cluster survey reported that most of the births in Bangkok were assisted by obstetricians, with only 1% delivered by the midwives. In Thailand, deliveries in rural area are more likely to be assisted by obstetricians (78.6 per cent) compared to deliveries by midwives (20.4 per cent) and other healthcare providers (1%) [7]. However, women living in rural areas were delivered babies by midwives' higher rate than those who living in metropolitan area (20.4% and 10.7%, respectively).
This study was undertaken to explore Thai pregnant women's views about the role of the midwife and identify the perceptions and views of Thai pregnant women in relation to the selection of intrapartum care providers. Pregnant women's perceptions of the role of the midwife were found as being ambivalent in view of their tasks undertaken in labour and birth. Even though the midwife is able to conduct births on their own responsibility, a majority of pregnant women did not identify certain tasks such as normal vaginal delivery, placental delivery, and perineal suturing as being primarily a midwife's role. These findings were different from an Australian study which showed that conducting vaginal delivery as the part of a midwife's role was a normal practice accepted by pregnant women, while showing similarities with studies undertaken in other countries [9]. A previous study in Thailand found that 50% pregnant women indicated that midwives were qualified to conduct normal vaginal delivery and to perform placental delivery, which according to the current study would indicate perceptions have remained unchanged on a critical role/skill of midwives. In countries such as India Conducting normal vaginal delivery by the midwife despite less women indicating normal vaginal delivery as the role of the midwife, the associated elements of a midwife's intrapartum care, such as encouraging pushing, diagnosing true labour pain, and performing the vaginal examination, were largely recognised by the pregnant women to be a midwife-related skill. Although over half the women agreed that encouraging pushing would be a midwife's role, there were still just under half who believed it to also be the role of the physician. These findings represent the current view of a midwife's role in Thailand, mainly as giving support and assessing health, rather than performing normal delivery and associated tasks. Additionally, women perceived midwifery care as being provided with emotional support as opposed to the provision of physical support in labour [10]. It is of concern that there is now less clarity about the full scope of the midwife's role in intrapartum care delivery. Current Thai data reported that 82.1% of births in Thailand were attended by physicians while only 16.1% were delivered via normal vaginal delivery by the midwife while another 1.8% were assisted by other health staff. The Thai Nursing and Midwifery Council (TNMC) defined the midwife as a professional qualified to conduct normal vaginal delivery for normal pregnancies which aligned with the international definition of the midwife [6]. However, a lack of public awareness of their role may be to blame and this risk will be further increased if midwives are not able to get this message across during their everyday practice. This study shows that the work of midwives, particularly in attending normal vaginal deliveries remains invisible to many pregnant women, who have little idea about what midwives do. The International Confederation of Midwives (ICM) noted that women's main source of information about midwife care is provided by the midwives themselves [11]. Thus, accurate knowledge and understanding regarding the midwife's role during labour and birth is essential to disseminate; hence, it may be necessary to review why this message is not being received and understood by pregnant women in Thailand. Pregnant women in this study had a higher likelihood of accepting normal vaginal delivery as a part of physicians' roles rather than midwives. This phenomenon directly relates to the traditional and cultural norms of midwifery practice, where midwives are viewed as being in a subordinate position in practice and act as the physician's assistant. One reason why many women may not be aware of the scope of midwives is due to the current overloading of obstetrical practices [12]. Due to obstetrician-led care, physicians are the main care providers and have a biomedical perspective, with labour and birth being considered high-risk events; therefore, obstetric interventions are routinely performed to ensure patient safety [13]. The power of the medical model within the hospital system can thus sometimes negatively influence the role of the midwife in facilitating normal vaginal delivery. Autonomy may be further reduced when midwives are required to practice strictly within their scope of practice and are required to call upon medical doctors for consultation and referral. The hierarchy of professional prestige has favoured physicians thus further decreasing midwives' autonomy in their scope of practice [14]. Being less autonomous in midwifery practice in a hospital setting may influence the perceptions of women interpreting this type of midwifery care as 'the norm'. The pregnant women, thus, recognise the midwife's role as a subordinate position, without recognition of the capacity to conduct normal vaginal delivery as a major task during labour and birth for the midwife [14]. Thus, according to ICM recommendations, it is important to promote midwifery as an autonomous profession, in order to optimise the care that midwife can provide for women and their families. The decision- making of women regarding types of birth can be influenced by the perceived reliability of healthcare professionals. However, the World Health Organization (WHO) noted that midwives are the primary providers of care [15]. Primary midwifery care sees the midwife function as the woman's primary provider through all stages of pregnancy, being the entry-point to the health care system and providing care on their own authority [16]. This could maintain a relationship that supports women in need which is the most important component to provision of holistic care. The Thai Nursing and Midwifery Council's (2019) current policy emphasises women- centred care concepts to support women's needs such as the midwife's role as a primary health care provider [13]. Enhancing the maternity care in response to women's unique needs is needed to restore women's confidence and the public image of the midwife as a primary care in intrapartal care. The invisibility of midwives found in this study suggests that the awareness of women regarding the essential roles of midwifes could be better promoted to pregnant Thai women. Table 1 provides a comparison of obstetricians and midwives across the four countries and with the United States. In Australia (in the public system), the Netherlands, and the UK, women having an uncomplicated vaginal birth usually have a midwife as the primary accoucheur (person in charge of the care). Three of the four countries had workforce models in which midwives were primary maternity caregivers across most birth settings.
Table 1. Numbers of obstetricians and midwives by country
|
USA |
AUSTRALIA |
CANADA |
NETHERLANDS |
UK |
Live births/year |
3 885 500 |
305 000 |
376 600 |
163800 |
754 000 |
Obstetricians (OB) |
35 586 |
1742 |
2213 |
931 |
2600 |
Midwives (MW) |
12 436 |
14 280 |
1740 |
3221 |
21 500 |
Total providers |
48 022 |
16 022 |
3953 |
3752 |
24 100 |
MW/OB Ratio |
0,34/1 |
8,19/1 |
0,79/1 |
3,46/1 |
8,27/1 |
In Australian private settings, there is always a midwife present, but the obstetrician is usually the primary accoucheur. Three of the four countries subsidize at least part of maternity providers' education. A UK neonatologist believed that effective integration across the care pathway leads to favorable maternal and newborn outcomes: "Integration between maternal, new-born, and infant care (midwife, health visitor, and GP) are important for ensuring safe high-quality care continuum." (A health visitor is a registered nurse or midwife who has gained additional training and qualification as a specialist in community public health for children). Current UK maternity policy includes continuity of midwife care as the key to responding to current evidence of impact on the reduction of preterm births, stillbirths, and improved women's experience [17,18]. The UK, Canada, and Australia have guidelines that describe the importance of midwifery and integration within the healthcare system. The Australian Pregnancy Care Guidelines were explicit about the role of the midwife and the evidence for continuity saying: Midwives are the primary providers of care for the woman; this may be through a team of mid-wives being responsible for the care of a small number of women (team midwifery) or a woman receiving care from one midwife or his/her practice partner (caseload midwifery) … the benefits of midwifery continuity of care when providing maternity services are well documented [19]. Dutch midwife stakeholders described the independence of midwifery as a strength in the Netherlands: "The strength of the midwifery profession in the Netherlands means midwives are independent and have a degree of power and good balance with obstetricians." Midwifery was not part of the national health care scheme in Canada when it began to achieve formal recog-nition in 1993 and is still being established in some prov-inces. Midwifery is formally recognized in 10 out of 13 provinces and territories. Stakeholders noted that where midwives are well integrated, and midwifery education programs well-established (Ontario, British Columbia, Quebec, Alberta), rates of uptake of midwifery care have increased to 20%-25% [20]. Examples of how midwifery has made differences in numerous at-risk communities, and especially in caring for Indigenous populations, were provided.…effective transfer/integration and growing strength of midwifery has been crucial to in-creasing the safety of home birth. Healthcare access was, in part, dependent upon effective collaboration, as reflected in the Australian Pregnancy Care Guidelines [19]. Collaboration also involves working within es-tablished clinical networks and systems to facil-itate timely referral and transfer to appropriate services when required … collaborative net-works within these systems are critical for en-abling access to safe effective quality services.
Table 2: Key demographics and maternal and newborn healthcare indicators in Slovenia, Croatia, Bosnia-Herzegovina, and Serbia
|
Slovenia |
Croatia |
Bosnia and Herzegovina |
Serbia |
Antenatal care provided by |
Obstetrician Gynecologist (5 out of 10 prenatal visits can be provided by a midwife) |
Obstetrician Gynecologist |
Obstetrician Gynecologist |
Obstetrician Gynecologist |
% of all live births born in facilities |
99,6 |
99 |
99 |
99,8 |
No. of midwife-led units or birth centers (% of all live births) |
0 |
0 |
0 |
0 |
% of births by cesarean |
21.3% |
26.6% |
28.2% |
31.8% |
Type of healthcare providers assisting birth |
||||
Midwife |
2128 (91,8) |
835 (78,40) |
347 (70,10) |
725 (77,10) |
Nurse |
893 (38,5) |
470 (44,10) |
232 (46,90) |
366 (38,90) |
Student (e.g. before graduation) |
373 (16,10) |
39 (3,70) |
16 (3,20) |
68 (7,20) |
Obstetrics registrar/medical resident under postgraduation training) |
434 (18,70) |
295 (27,70) |
108 (21,80) |
225 (23,90) |
Obstetrics and gynecology doctor |
1565 (67,5) |
718 (67,40) |
309 (62,40) |
689 (73,30) |
Results of this study highlight gaps in all countries (but to a much lower extent in Slovenia) for all domains of QMNC, including provision (Croatia still showing a relatively high index), experience, availability of resources, and reorganization of care. Notably, episiotomy rates remain high in all four countries, indicating routine or liberal use, which is not in line with WHO recommendations but was also reported in other countries in the IMAgiNE EURO study. Other indicators mirror unsatisfactory practices related to essential newborn care, with unsatisfactory rates of skin-to-skin contact and early breastfeeding and insufficient breastfeeding support in all four countries. In 2017, a high number of maternity facilities in each of the countries were at some point designated as "baby friendly" as part of UNICEF's Baby Friendly Hospital Initiative (BFHI). Currently, in Slovenia 86% of hospitals are BFHI designated (12 of 14 maternities), 47 in Croatia 95% of hospitals are designated (all public hospitals); while 78% of hospitals in Bosnia-Herzegovina and 85% in Serbia were "ever designated" as BFHI. However, these results show that there is room for improvement, and many key elements of the BFHI are not well implemented in the countries, especially for women undergoing planned cesarean [21].
Conclusion
The results of the above studies show that in most countries, doctors, not midwives, play the primary role in childbirth, which is probably because they trust doctors more than midwives. We can conclude from the studies that women may not choose a midwife as their primary care provider because they have private health insurance and therefore give birth in a doctor-led environment where the midwife is sometimes considered an "assistant". Therefore, there is a need to increase awareness of the importance and role of midwives in the health system and in the lives of pregnant and postpartum women.
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