Human Resources for Maternal Health: Midwives, TBAs, and Task-Shifting

"Pregnancy is not a disease, a woman should not die of pregnancy…it doesn't need a new drug…it doesn't need research – we just need skilled workforce at different levels," argued Seble Frehywot, assistant research professor of Health Policy and Global Health at George Washington University, at the Global Health Initiative's second event of the Advancing Policy Dialogue on Maternal Health Series.

Research shows that increased access to skilled health workers during pregnancy and delivery, including midwives and other practitioners, can significantly reduce maternal mortality in developing countries. One solution to the current human resource crisis is to expand, and in many cases, acknowledge, the skills and responsibilities of non-physician health workers.

Task-Sharing: Who, What, and How

"There are too many preventable deaths…if we look at the data, quality maternal health services are not available," argued Frehywot, as she presented the following evidence:

• Countries that have the highest maternal mortality rates are those that also have the greatest worker shortage.
• In Africa, for every 10,000 births, only 2 physicians and 11 nurses or midwives are present at delivery.
• According to the World Health Organization, there needs to be at least 53 skilled health care workers (nurses, doctors, midwives) per 10,000 births to meet Millennium Goal 5 which seeks to reduce maternal deaths by 75 percent by 2015.

There are four common types, or levels, of task-shifting:"All [task-shifting] needs to be done through a sound regulatory framework…it is very important to match tasks that are needed at the ground level with the competency needed to back it up," maintained Frehywot. Task-shifting is not a reduction of care, it is a redistribution of tasks according to the person's skills, rather than their roles explained Frehywot. Regulation of these roles helps to standardize systems that are already taking place in the field. Regulatory issues such as the scope of practice, standard of care, training, licensure, and supervision must be addressed to ensure safe and high-quality treatment. Additionally, political buy-in and commitment from the Ministry of Health, medical universities, and professional councils and associations are necessary for long-term development, argued Frehywot.

Policies for scaling-up human resources should start at the district level, as these localized hospitals are geographically closest to the need, argued Frehywot. "If one really wants to decrease the maternal mortality ratios, especially by 2015, this is where most of the people live." Highlighting the momentum of several global initiatives, Frehywot advocated for continuous community engagement and the need to ensure safe, high quality health care when scaling-up health workers.

Applying Task-Shifting in Afghanistan

"Maternal mortality ratios in Afghanistan are the second highest in the world," declared Jeffrey Smith, regional technical director for Asia at Jhpiego. In 2002, when Smith arrived in Afghanistan, there were limited health workers, most with out-of-date skills, and no functional schools for training. "The most important decision made early in the reconstruction [of] Afghanistan was that midwives would be the backbone of the reproductive health workforce and they would be empowered with the skills to perform the tasks necessary for provision of basic emergency obstetric care," shared Smith.

Making the case for task-shifting, Smith discussed the importance of empowering health workers on the front line so that they may provide services in the most peripheral areas. "Task shifting should not be a temporary fix until we have more doctors," argued Smith, as this framework disenfranchises a cadre of health workers and fails to build long-term solutions for human resources. Instead, Smith advocated for the "Health Center Intrapartum Care Strategy" that makes midwives the foundation of care and includes strategies for training, staffing, and linkages to the overall health system.

In this post-conflict setting, task-shifting began as an emergency approach. However, it rapidly became a development strategy for professionalizing the workforce and rebuilding the health system. Afghanistan's Ministry of Public Health was imperative to the success of scaling up midwives as they clearly defined from the beginning what was needed and who would provide care, taking steps to ensure that the midwifery schools maintained legitimacy and received formal accreditation.

"Keep it clinical and keep it local," shared Smith. The midwifery schools made efforts to recruit individuals from the provincial level, teaching specific life-saving skills applicable in the field. This framework has successfully retained 86% of its graduates, and many of the women report that the program has provided them with a sense of community and ownership. "We need to be sure that midwives are empowered professionally," argued Smith, "so that they are trained competently and can retain their skills throughout their professional lives".

Building a Sustainable Health Workforce

"We invite the maternal health community to take advantage of the incredible momentum that human resources for health is having right now," shared Pape Gaye, president and CEO of Intrahealth. While there are many issues within the health system that need to be strengthened, Gaye maintained that "we must pick our battles" and advocated for an emphasis on scaling-up the training and availability of midwives.

In order to scale-up midwives for maternal health we must avoid the same old traps, particularly the lack of donor coordination shared Gaye. "If we do a better job of improving coordination we will start solving the problem." Additionally, Gaye discussed the implications for training generation "Y," emphasizing the importance of including new technologies available for training, including PDA's and e-learning courses.

Performance outcomes and training are the two key pillars of effective scale-up, shared Gaye. In order to have training programs with sustainable outcomes, variables such as job expectations, motivation, and organizational support must be addressed "or you will be throwing money out of the window," maintained Gaye.

Task-shifting also requires legal support and the endorsement from medical associations to help legitimize this new health system framework. "This is not simple work; you really need to have a systems approach. What we seek in the end is good integration. Integration across systems, integration across roles, courses, learning processes, and training for maximum adaptability," shared Gaye.

Drafted by Calyn Ostrowski and edited by Gib Clarke.