strengthening community midwifery in sindh through sustainable initiative of community midwives

7/27/2019 Strengthening Community Midwifery in Sindh Through Sustainable Initiative of Community Midwives

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DRAFT

Strengthening Community Midwifery in SindhThrough Sustainable Initiative of Community Midwives

May 2012

Imtiaz Kamal , RN;RM; MASecretary General, NCMNH

President, Midwifery Association of Pakistan

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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.


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Acknowledgment.

A debt of gratitude is owed to a lot of individuals. They are too many to bethanked individually for their cooperation and worthy openness. collect andTAUHs financial assistance is very much appreciated, without which itwould not have been possible to collect and document this much neededinformation.

There are a some individuals who went out of their way to provide supportand guidance as and when needed.

Special thanks are due to:

Dr. Nabeela Ali, for her valuable feed back through out , and for faith andtrust 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; AnadilKhan and Sara Haider for their very valuable assistance in compilation ofdata which proved to be a bigger challenge than envisaged; Ali Raza forthe final formatting of the report to compensate for my half baked computerskills.

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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 .212. 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.......23CMWs Curriculum .24

The Faculty .24

Quality of training .....25Teaching /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..

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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 ....5114.Instutionalisation of CMW 5215. Impact of Devolution on the Vertical grammes .. 54

PART IIAnalytical Observations , Challenges and Recommendations .56

1. System at the District Level ....572. District Midwifery Committee ..57

Part III12 Rules and Regulations Governing Midwifery Education and Practice.61

Rules and Regulation for midwifery training and practiceLegal aspects of midwifery practiceCode of Conduct . 73.

Part IV1. 12 Point Action Plan . 782. Recommendations .... 86

List of Tables

Table 1 : Number ofPublic sectorSchools Training Midwives in Sindh (byCategory) 32

Table 2 : Number ofPrivate sectorSchools Training Midwives in Sindh 32Table 3 : Numbers of CMWs admitted and Numbers Graduated Since 2009 ..33Table 4 : Numbers of Community Midwives Graduated , Deployed, Awaiting

Deployment . ....33

AnnexesAnnex 1 : Sources of informationAnnex 2 : Competencies of the midwifeAnnex 3 : Historical background of midwifery in PakistanAnnex 4 : Situation Analysis of Midwifery Education in Sindh

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List of ACRONYMS

AMAN : Association of Mothers and NewbornB.Sc : Bachelor of ScienceCMW : Community Midwife

EmONC : Emergency Obstetric and neonatal CareDoH : Department of HealthDMC : District Midwifery CommitteeDOPW : Department of Population WelfareEDO : Executive District Officer FHT : Female Health TechnicianFP : Family PlanningFWV : Family Welfare Visitor FWW : Family Welfare Worker IMR : Infant Mortality RateLHV : Lady Health Visitor

LHW : Lady Health Worker MAP : Midwifery Association of PakistanMCH : Mother and Child HealthMNCH : Mother Newborn and Child HealthMMR : Maternal Mortality RatioMoH : Ministry of HealthMoPW : Ministry of Population WelfareNMR : Neonatal Mortality RateNCMNH : National Committee for Maternal and Neonatal HealthOb/Gyn : Obstetrics and GynaecologyPHC : Primary Health Care

PHS : Public Health SchoolPMA : Pakistan Medical AssociationPNC : Pakistan Nursing CouncilPTS : Preliminary Training SchoolRHC : Rural Health CentreRM : Registered MidwifeRN : Registered NurseSBA : Skilled Birth AttendantSOGP : Societies of Obstetricians and Gynaecologist of PakistanSOM : School of MidwiferySON : School of NursingTBA : Traditional Birth AttendantUNICEF : United Nations Childrens FundUNFPA : United Nations Population FundWHO : World Health OrganisationKPK : Khayber Paktoon Khuan

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Prologue

This document reflects a most exciting and positive development. The midwife isappearing on the scene of maternal and neonatal health.. Almost all those ,connected with maternal and neonatal health in any way, have demonstrated akeen 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 agenuine interest in the standards of education and training of midwives. The desireto improve the situation is apparent from the number of studies and surveys doneto 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 reflectsevidence based planning. The goal is to take skilled care to every woman ingeneral and to the rural woman in particular , wherever she chooses to deliver herbaby. Investing in midwives is a quantum leap in the national efforts to reducematernal and neonatal morbidity and mortality.

There is light at the end of the tunnel

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Definition of A Midwife

A midwife is a person who, having been regularly admitted to a midwifery educationalprogramme, duly recognised in the country in which it is located, has successfullycompleted the prescribed course of studies in midwifery and has acquired the requisitequalifications to be registered and/or legally licensed to practise midwifery. The midwife isrecognised as a responsible and accountable professional who works in partnership withwomen to give the necessary support, care and advice during pregnancy, labour and thepostpartum period, to conduct births on the midwifes own responsibility and to providecare for the newborn and the infant. This care includes preventative measures, thepromotion of normal birth, the detection of complications in mother and child, theaccessing of medical care or other appropriate assistance and the carrying out ofemergency measures. the midwife has an important task in health counseling andeducation, not only for the woman, but also within the family and the community. This workshould involve antenatal education and preparation for parenthood and may extend towomens 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)


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Executive SummaryIntroduction

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 thecountry. Women who die are poor and from rural areas for whom skilled care atbirth is unavailable or inaccessible. 61 % deliveries take place at home conductedby unskilled care providers. Midwifery has not had the opportunity in Pakistan to berecognized as a vital profession nor has the midwife acquired a professionalstatus.The Government of Pakistan has directed many efforts in the past to providematernity care to the women in general and to the rural women in particular. Thisincluded training various types of midwifery personnel both licensed and notformally 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 wasprepared in 2006-7(1). The Community Midwifery Initiative was conceived ,planned and implemented with a target to train 1200 CMWs. The NationalMaternal ,Newborn and Child Heath(MNCH), programme had a substantial portionof CMW training component. UNICEF and PAIMAN ( Pakistan Initiative for Mothersand Newborns) took the lead. PAIMAN trained and deployed 2000 CMWs.More development partners contributed to achieve the target . Sindh neededalmost 2000 CMWs. As the initiative took off the ground, work started on variousaspects of evaluating the process. Studies were carried out to evaluate thecapacity 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 inthe community. (12)

MNCH in Sindh recruited the first batch in 2008 which graduated in 2009 and wasdeployed in 2011. Two more batches have been trained and are awaitingdeployment. Two batches are under training. One batch will graduate by the end of2012.

Like any new venture, CMWI is facing some challenges.To strengthen this initiative and to make it a sustainable programme, healthauthorities 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 aconsultant to honour this request .

To achieve this objective a plan was implemented to review and analyse availableinformation and also up date it. The plan comprised : a Situation Analysis of CMWEducation in Sindh ; Review of the Available Literature on CMWs ; Visits totraining Institutions ; Meetings with all stake holders including the policy makers,planners, implementers, administrators, trainers, facilitators, students, clinical

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supervisors ( doctors and midwives) and focal persons who are the watch dogs ofMNCH In the districts(16)Findings and analytical Observations

Note : For details please see the twin of this report which is a completedocument by itself on Situation Analysis of Midwifery Education in Sindh.

1. Institutions: Most teaching Institutions are fairly well equipped. Some arewaiting to be equipped once resources become available. Some beautiful newlybuilt schools are empty because the SNE has to be approved.(8)

2. Faculty: Most teachers are teaching midwifery on ad hoc basis because thereare no designated posts for midwifery teachers. Teaching standards of bothclassroom teaching and practical training need a lot of improvement because theyare 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. Effortsare 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 soyoung, some who left school a couple of years ago and those who have been outof school for a decade or more. The policy of making midwifery training aresidential training has not worked. Almost all the married students are dayscholars. It affects their attendance hence their learning.Only a few students demonstrated real interest in midwifery. Teachers are almostunanimous 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 methodof teaching with occasional demonstration in the class room or in skill lab. For theclinical instruction use of check lists for skill development and skill evaluation is notcommon. The quality of teaching requires a great deal of improvement.(9)It is ironical that this programme has been implemented in an environment withmany gaps.(3) These gaps were identified more than a decade ago but nothingwas done to improve the situation. The major gap was lack of teachers qualified toteach midwifery. In eleven years no efforts were made to train midwifery teachers.

5. Outcome of teaching/learning: So far three batches of CMWs have beentrained. A total of 1359 students were admitted, 1287 appeared for their finalexamination, 832 (61%) have successfully completed their training . Thefailure/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 beendeployed. The delay in deployment is due to the time taken by the ExaminationBoard to Issue diplomas, and then by PNC to issue the license to practice.

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The Deployment Guidelines prepared by TRF are awaiting endorsement of thegovernment. They need to be looked at critically before endorsement. There aremany technical inaccuracies and operational issues that need to be corrected andmodified before endorsement.Deployment guidelines should not include Selection Criteria and training and

examination etc. Deployment begins when the CMW has completed all thosesteps. 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 roundthe neck is given as an obstetrical emergency. This is easily managed by themidwife hence it is not an emergency. An other statement of technical inaccuracyis , Retained placenta in the first. Second and third stage of labour. Similarlythere are operational issues e.g , A CMW needs a a small place of not more than4x6 feet in a room near the exit door for establishing herWork Station but in the

sketch for the Work Station ( Annex-C page 28 ) there is a table, a chair , a stool, ascreen and a shelf . Will this all fit in a space of 4x6 feet. Also when the pregnantwomen or post natal women come for preventive services they will need space. Ifthe Work Station is in the corner of a room occupied by the family, can CMWprovide services in the same room?(2)

7. Supervision and Monitoring : Much effort and expense has been invested inthe monitoring tools developed by TRF. It is a set of 10 tools entitled MIS Systemfor CMWs.(15).Two forms are for use by the supervisors and 8 for use by CMWs . While some ofthe 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 offorms and registers is very cumbersome and intimidating. These tools need to belooked at carefully . Documentation should be minimized to the information whichwill be used purposefully.

8. Acceptability and Accessibility of CMWs n the CommunityThe CMWs are fairly well accepted in the community but the expectations of thecommunity 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 theCMW to the community depends on the awareness of the community about thepresence of CMW in the community.(12) This will have be given publicity on thelines of what was done for LHWs.

9. Rules and Regulations for Midwifery PracticeTo provide legal; protection to the midwife and to the community she serves,Rules and Regulations for Midwifery Practice and a Code of Conduct have beendrafted. The document will be forwarded to PNC for legal processing beforeapproval. Until its finalisation it is suggested that Sindh Health authorities selectthe essential dos and donts for the guidance of community midwives.

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Twelve point Action Plan for immediate attention( For justification please see full text)

1. Strengthening practical training of CMWs to ensure the achievement ofexpected levels of competence.

2. Plannig and implementing regular diploma courses to qualify midwiferyteachers for the future. And for one or two years short ToTs can continue tobe 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 andNursing and medical staff of Ob/Gyn Unit.

6. Improving the examination system and without any delay introducing testingof midwifery skills. Through OSCE.

7. Establishing a small committee to review the Rules and Regulations forMidwifery Practice and select the basic ones to guide the CMW for herpermissible functions

8. Midwifery should not be mandatory for female nurses. They should have thechoice to specialize in midwifery or in any other area of health care.

9. Reducing the long delay in deployment due to delay between the studentspassing 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 tobecome 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

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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

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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) andMidwifery 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 thehealth sector and the directorate of nursing in Sindh

Through a consultative process with various stake holders developguidelines and provide assistance for the implementation of the agreedupon 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 ratiois 175 and rural is 319. The provincial ratios are: Punjab 227; Khyber Pakhtunkhwa275; Sindh 314; and Balochistan 785. Most of the women who die are poor andfrom rural areas for whom skilled care at birth is unavailable or inaccessible. 64 percent of deliveries occur at home and are attended by Traditional Birth Attendants(TBAs) or family members. Skilled Birth Attendants (SBAs) conduct 31 per cent ofall deliveries and only 5 per cent of home births.(14)

Specific Objective

To improve access to quality MNCH services at the community level throughsustainable 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 motherhoodsafe. Unfortunately in Pakistan training professional midwives has not been apriority of the Government. Even though , midwives of various categories (nurse-midwife LHV, pupil midwife) were being trained, majority of them were fromurban areas. They got trained and stayed in cities , excepting those who were

employed in BHUs, The skilled maternity care offered by licensed midwives did notreach the rural communities where 80% of the births were taking place conductedby Dais and TBAs(3). In all fairness the LHVs and Pupil Miwives do provideservices in the urban and peri urban areas and the city slums, hence serving thedisadvantaged and marginalized population.

The training standards have remained poor. The non nurse midwife has absolutelyno opportunities for professional growth and development. Nursing, whichcomprises mostly curative care, progressed and almost engulfed midwifery. Nursing training is for four years. Three years of nursing and one year ofmidwifery *. Nurses education and Career Pathways received a lot of assistance.

Until the turn of the century hardly any contribution was made by the developmentpartners to improve midwifery education in PakistanIn 2003 The development partners started to take interest. UNFAP experimentedwith one group of midwives in 2004 in Mansehra under the PRISM project. It didnot 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 forthis 4th category of midwives.. UNICEF supported one group in 2006. PakistanInitiative for Mothers and Newborns (PAIMAN) JSI/USAID also started trainingCMWs 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 thecapacity of the schools which were to train midwives (5.) Gaps were identified andplanning was designed to fill those gaps. UNICEF and UNFPA also participated inthis venture..

In the public sector the first PC-1 (1) was approved which was for January 2007to 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 therequirements to enroll as a student were found difficult to implement.e.g Originally, midwifery training was required to be a residential course and rightlyso because babies do not take appointments for coming into the world. Themidwife has to be there to receive them at all hours of the day and the nigh. Thisrequirement was very difficult to implement because of an other requirement i.eOne of the selection criteria is ,Female , preferably married. In Pakistani culturecan a married female with children and family responsibilities, particularly fromrural 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. Furtherdiscussions of this strategy identified the need for the CMWs to remain articulatedto the health system for at least three years. Hence she became the responsibilityof the health authorities with financial implications.It was expected that the CMW will establish her own work place ( to be called abirthing station or any other similar name) , to function as a 24/7 availablematernity care provider She was to provide ante, intra, and post natal care andpreventive 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 smallarea called Work place,.She will provide certain preventive services from herWork 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 inthe community after training. All was implemented in varying degrees in one way orthe other, some on time and some later than planned.

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The missing link was the, National Guidelines for Deployment. of LicensedCMWs These got developed 3 years after the training started. (2) By this timemany batches had graduated.The deployment design planned and followed by PAIMAN for the CMWs trainedin 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 facingmany challenges. The main ones are : Quality of training which is being affectedby many factors including the capacity of the trainers; the development ofmidiwifery skills and evaluation of their midwifery competencies; supervision ofpractising CMWs and back up support to them for EmONC ; their accessibility tothe communities; establishing and maintaining their credibility as competentmaternity 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 forHealth ( TAUH) of USAID, in Pakistan, contracted a midwifery specialist toprovide 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 toprovide professional maternity care to pregnant women ( through out the

maternity cycle), and provide Basic Emergency Obstetric Care in case ofcomplications before making referrals when a higher level of obstetric care isessential.

Specific Objective

To improve access to quality MNCH services at the community level throughsustainable CMW Initiative in Sindh.

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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 DATABASE is being attended to by MNCH directorate. Certain other areas becameapparent for technical support. In the light of those the ToRs were revised inconsultation with Director MNCH.

Revised ToRs:

Literature review: includes national MNCH PC-I, training curriculum,

monitoring mechanism, the reports of TRF on CMWs and other relevantdocuments.

Meet with the concerned official of the Health Department and other

stakeholders to gather information required on the new role of provinceswith devolved vertical programs.

Situational analysis of current trainings including classroom & practical

trainings, capacity of training institutions and deployment status ofgraduated 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 ofthe assignment it became obvious that it will not be possible to put time lines onplanned activities . A lot depended on when a certain document(s), a particularindividual or group of individuals for meeting (s) and opportunity for field visits etcbecame available. Also certain events came up which were directly related to theassignment , but were not in the Work Plan e.g a full day seminar cum Workshopon , 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 wasdecided to have dates planned for activities but focus on the outcomes.

The Work Plan includes the following approaches to achieve the objectives of theassignment:

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 etcrelated / pertinent to national scenario of midwifery in Pakistan starting

with 1948, to trace the development of midwifery as efforts of thegovernment to provide maternity services particularly to the ruralpopulation..

3. Review of specific reports pertinent to the CMW Initiative in Pakistan ingeneral and for Sindh in particular

4 Analysis of the information available about the situation regardingselection, training, deployment and supervision of CMWs and theirrelationship with the current health system

5. Situation Analysis of Midwifery Education in SindhNote : For details please see the twin of this report which is a complete

document by itself on Situation Analysis of Midwifery Education in Sindh.

6. Personal contact with maximum number of stake holders including , but notlimited to: The director and staff of MNCH in Sindh; Development Partnersassisting midwifery in Sindh; Heads of selected Training Institutions;Midwifery Tutors, currently enrolled CMW students, recently graduatedCMWs and practising CMWs.

7. Consultative meeting with: Pakistan Nursing Council; the Executive Board

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of Midwifery Association of Pakistan; the recently established UNFPAsCountry Working Group for the Development of Midwifery; Directorate ofNursing and Nursing Examination Board, Sindh

8. Prepare a Draft for the Regulatory Mechanisms of Midwifery Practice inPakistan to provide protection to the practising midwives and to thecommunity they serve.

9. 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 inPakistan. It was not in the SoW but the author considered it veryrelevant for the purpose of comparison with the present situationand future planning

11. Prepare, submit and disseminate the final report in consultation withJSI/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 interviewers14. 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 midwiferypersonnel 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 generaland to the rural women in particular date back to early fifties. There were no wellthough out plans to prepare midwives with basic midwifery competencies.

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Many categories of midwives are being trained without a proper planning of humanresource 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 femalenurses, they join the midwifery course. They by and large do notopt 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 forDiploma in Teaching Nursing. A vast majority of those currently teaching

midwifery are from this category. because there is no diploma for teachingmidwifery.

1.2The Lady Health Visitor( One year of training in midwifery followed by oneyear of training in public health). This was a legacy inherited from the BritishRaj. They were trained to beCommunity Midwives in the real sense..

1.3There 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 todeteriorate 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 ormidwives. Now they are going to be used to supervise CMWs

1.4The Midwife (15 months of training in midwifery ) This category waspreviously known as ,Pupil Midwife. No one could explain the reason forthis nomenclature. Recently the prefix Pupil was removed. With a coupleof exceptions in the private sector, very few of them have even the minimummidwifery competencies. This is the weakest category of midwiferypersonnel.

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 theseschools that they were to close with immediate effect. Seven schoolsapproached the Midwifery Association of Pakistan (MAP) for assistance.Guided by its legal advisor MAP took up the matter with PNC. The decisionfor immediate closure was reversed and the programme was extended till 2013.

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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 writtennotification has been sent to PNC by MAP. Response is awaited.

The entry requirement for all the three categories is 10 years of schoolingThey share the same curriculum which is extremely sketchy. It was last lookedat in February 1994. It is labeled ,4 th Year This midwifery curriculumsPreface ,written by the then Vice President of Pakistan Nursing Council, reads, I am pleased with revision of curriculum of Nursing.. This isreflective of the thinking of nursing leaders and a proof that midwifery is notconsidered 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 thatthe midwives do not qualify as competent Skilled Birth Attendants.(SBAs.)A vast majority comes from urban or peri -urban background. A negligibleminority is of rural background. They all train and remain in the cities exceptingthose who work in the Basic Health Units ( BHUs). Some of them reside in BHUand 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 trainedmidwives.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 ina very unusual national environment. This included: plans for and initiation ofdevolution; lack of clarity in the governance of vertical programmes implementedby the federal government, the problems of the transitional period, resourceallocation, structural adjustments , civic unrest, political instability , insurgenceof religious fundamentalism, increasing crime rate affecting the law and ordersituation and high inflation rates. All of these factors need to be kept in mindwhile evaluating or analyzing any of the plans and their implementation in thehealth 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.

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UNFPA under its PRISM project had trained a group of community midwives in2004for which PNC had designed a curriculum in 2003.In 2005 An enriched curriculum was designed (7). Originally the national targetwas to train 10,000 CMWs . It was later increased to 12,000. The goal was torecruit 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 studentswas recruited. UNICEF funded training of a group of CMWs in 2006. At the sametime PAIMAN developed the first regular programme to start the training of CMWs.Training of both the groups of UNICEF and of PAIMAN started almostsimultaneously in September 2006.PAIMAN went about it in a very organized way. It got a team of senior midwiferyspecialists 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 Midwiferytutors of international standards was recruited with ICM involvement and aneducation specialist from USA was recruited for the educational aspects of thetraining.Schools were equipped with teaching learning materials and job aids. Incentiveswere given to the administrators and trainers and stipends were paid to thestudents 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 sidethe implementation, activities started for assessment of the training Institutions (8)

evaluation of the quality of training (9) ; performance of CMWs and theiracceptability in the community. (10)

In 2005-6 a PC-1 was approved and implemented in 2007, to take MCH servicesto 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 in2008. So far three batches have graduated and the fourth and the fifth batches areunder training.

Sources of Information ( Annex 1)

Review of literature

Institutions Visited

Situation Analysis of CMWs Education in SIndh

Persons met

Meetings, seminars attended

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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 importantpiece of information was that where ever midwifery has been taken seriously, MMRhas 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 adistinct category of midwifery personnel registered as, Midwife. India and Nepalare two such examples. Their emphasis is on midwifery skills irrespective of whatthe individual providing care is called. Nepal has succeeded in bringing down itsMMR. These countries are struggling like most countries of South Asia, to getmidwifery recognized as a profession distinctly separate from nursing.

2. Pakistan

The available literature about midwifery is very limited. For the purpose of thisassignment all the available reports referenced in the text were reviewed and theirfindings have been utilized in the analytical review. For Sindh ,fortunately a reportdating back to 2000 was available (3) and has been used as a basic reference totrack the improvements in midwifery education and practice in the last decade. Allthe other documents are related to CMWs education, their acceptance in andtheir accessibility to the community.The two most significant documents for the present situation are the PC-1, (1) andthe Deployment Guidelines.(2)

2.1 MNCH PC-1 (1)Developed in 2005-6, it was the first ever document in the public sector, in thehistory of Pakistan which focused on midwifery.

Vision of National MNCH Programme

The Government of Pakistan recognizes and acknowledgesaccess to Essential Health are as a basic human right.MNCHs vision is of a society where women and childrenenjoy the highest attainable levels of health snd no familysuffers the loss of a mother or child due to the preventable ortreatable causes. The Government of Pakistan henceforth

pledges to ensure availability of high quality Maternal,Newborn and Child Health services to all, especially for thepoor and the disadvantaged.(16)

This PC-1 reflects the tremendous amount of time, money and effort that musthave been invested in its preparation . Main objective of the project was toachieve MDGs 4 and 5 i.e to reduce maternal, neonatal and child mortality and

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morbidity. Total cost of the project for Sindh was Pak Rs.3.247 billion. 50% of itsfunding was from DFID and 50 % from the government of Sindh. According to theDirector MNCH, only 25% of the funds have been released so far. Release offunds 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 necessitatedby the experiences during its implementation for example : the communitymidwifery training was planned to be residential course but it was found verydifficult to implement this requirement because of the criteria of preference formerit candidates. The need for preparing competent faculty before starting traininga large number of community midwives should have been done. Only thoseschools should have been selected which at support of the institutions with a largenumber of normal deliveries.

A lot of lessons must have been recorded by the implementers. Now that theduration 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 becritically reviewed. It is strongly recommended that the areas identified during thereview, the lessons learnt and experiences of those who implemented it at theoperational level and at the technical level should be pooled and used fordeveloping the new PC-1.

2.2 Guidelines for Deployment of CMWs.(2)

The official Deployment Guidelines Should have been ready before the first batchof CMWs graduated. Since PAIMAN was the first project to start CMWs training , itdeveloped guidelines and with the support of the provincial governments,implemented them in the districts supported by PAIMAN. It was hoped that thosewill 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 gonethrough a rigorous process to be finalized. They are now available and awaitingendorsement of the health authorities.

The Deployment Guidelines prepared by TRF are awaiting endorsement of thegovernment. They need to be looked at critically before endorsement. There aremany technical inaccuracies and operational issues that need to be corrected andmodified before endorsement.Deployment guidelines should not include Selection Criteria and training andexamination etc. Deployment begins when the CMW has completed all thosesteps. 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

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of examples of the content that needs to be corrected: Cord round the neck isgiven as an obstetrical emergency. This is easily managed by the midwife hence itis not an emergency. An other statement of technical inaccuracy is , Retainedplacenta in the first. Second and third stage of labour. Similarly there areoperational 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 herWork Station but in the sketch forthe Work Station ( Annex-C page 28 ) there is a table, a chair , a stool, a screenand a shelf . Will this all fit in a space of 4x6 feet. Also when the pregnant womenor post natal women come for preventive services they will need space. If theWork Station is in the corner of a room occupied by the family, can CMW provideservices 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 toIssue 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 institutionsincluding practical training.

There are five studies available about the status of the institutions trainingmidwives and quality of midwifery training. Two of these were conducted beforeCMWI 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 theprivate 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. Onewas conducted in 2005 by Population Council on training institutions (8) and oneon quality of training in 2010 by HLSP( 9)The most recent study is the one conducted in April May 2012 commissioned byTAUH. Recently documented information about the status of all the institutionstraining CMWs in Sindh(13) provides enough evidence about the state ofmidwifery education. The bottom line is that midwifery as a profession and themidwife as a professional have a long way to go . Both require much attention andaction.

The findings of the studies and information available from other sources aresummarized below:

3.2. CMWs Curriculum (7)

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As mentioned earlier, a special curriculum was designed for CMWs It wasdeveloped by a doctor. It went through a very rigorous exercise of more than onereview by nurses and midwives and then got finalized. It was approved by thePakistan Nursing Council (PNC.)

When implemented ,the strengths and weaknesses of the curriculum becameapparent. It covered the content but It was not competency based. It did notprovide the required guidance to the tutors who were nursing instructors withinsufficient 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. Thecontent needs to be enriched, protocols need to be developed, evaluation methodsneed to be strengthened and above all teaching /learning strategies have to bedefined . A user friendly, competency based curriculum can help the trainers toimprove their teaching and training approaches.

More than a year ago, Technical Resource Facility (TRF) contracted a Britishmidwife supported by an advisory group, to revise the curriculum. It becameavailable by the end of March 2012. In April, TRF held a review meeting which theauthor attended. The midwifery educators agreed that In its present form theCurriculum is not suitable for implementation in Pakistan. A report has been sentto TAUH.

3.3. TheFaculty.

In the past and at present , nursing Instructors are teaching midwifery on ad hocbasis.(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 midwiferytutors. So far no efforts have been made to have a proper cadre of qualifiedmidwifery tutors with a career path.By and large the schools do not have enough midwifery faculty..In the midwiferyschools which are a part of schools of nursing , the tutors who are teachingmidwifery are also responsible for teaching the nursing students.

Many schools are using LHVs as trainers without giving them any further training inObstetrics or in Educational Technology.

MNCH, the development partners and the government have tried to build thecapacity of the teachers through short courses and Workshops. This has had alimited impact. Some of those who attended these workshops were not midwiferytutors. Some got transferred to other departments because almost 100% areregistered nurses.

It is ,however, encouraging to note that there are now clinical supervisors of CMWsin some of the schools. This is a very positive development even though thequality of their performance and their numbers require a lot of improvement . (9)

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There are no sanctioned posts of the clinical supervisors or clinical Instructors.Some schools have been successful in getting a hospital staff member appointedas 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 curriculumor 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 trainingactivities 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 areoperational issues. e.g A major problem faced by the schools is that midwiferytutors are on posts which are not regularized. They work on ad hoc basis , hencecan be moved any time to an other department. Those in regular posts areNursing Instructors, dividing their time between teaching nursing students andmidwifery students. Obviously , nursing students are their priority.

The teachers of midwifery need two strengths i.e Mastery over the subject andstrong background in educational technology. Midwifery is largely a competencybased profession with a body of theoretical knowledge. The average teacher ofmidwifery with gaps in both the requirements, cannot fill these gaps with shorttraining workshops.

With their own , perhaps, he tutors can minimize the gap of knowledge but cannotdevelop the skills required for midwifery practice. They continue to perform asclass 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 CommunityMidwives in Pakistan (9) was done by HLSP,with DIFDs financial assistance.The Assessment study was carried out in a representative sample of 10% of the130 schools. Only 3 schools were included from Sindh.

The most recent assessment of CMWs training is the ,Situation Analysis ofCMWs Education in Sindh. (13) This was an exhaustive study carried out InMarch- April 2012,with 100% sample of schools training CMWs. The assessmenttool (Annex IV) was first discussed in a meeting with the Principals of 20Schools training CMWs and given to them to provide information. The response

was very encouraging. 18 schools returned the Questionnaire. One is notfunctional yet . Validation was carried out on 25% of the schools. Field visitsincluded interviews with focal persons of MNCH, the school faculty , clinicalsupervisors, students, and heads of the Ob/Gyn Units and administrators of thehospitals used for practical training of CMW students,. Evaluation of teaching wasdone by attending one or two classes in session and assessing the knowledgeand teaching skills of the teacher. The evaluation was discussed with the teachersafter class.

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The information collected during the field visits proved that the responses in thequestionnaires filled by the faculty of schools do not match with the informationcollected 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 completedocument 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 thegovernment. the UN agencies and the development partners, the quality ofmidwifery training is still not of acceptable standards. It requires a lot ofimprovement. The theoretical part of the training which is carried out in theclassroom is showing fairly good results. The reason for this is that studentsmemorise information. They manage to answer a few questions in theexamination. Even if they can answer Half the questions right in the written paperand 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 ofthe 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 ofvarious medical cadres. They get priority and midwifery students do not getadequate opportunity for hands on experience.

o

Supervisors are not aware of the needs of midwifery students because theyare not familiar with the CMW curriculum. Moreover they do not havetraining 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. andfaculty 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, consider nursing

students their primary responsibility.

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o Most students do not get the opportunity to get practical experience in

providing care to the mother during labour or conduct deliveries. Thestudents are required to document a certain number of deliveries which theyobserve 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 qualifyingexamination. 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 before2005. Some of the schools are fairly well equipped with text books, manuals, andaudiovisual aids . Many schools have computers and some of the tutors arecomputer literate. It has been recommended that all faculty needs to be madecomputer 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 ofknowledge and skills to draw upon most of the resources like the manuals andprinted support materials to develop their own teaching/learning plans. Sameapplies to the use of modern methods of teaching. Lecture still remains the mostcommon method of teaching.(13)

A very positive reaction of the faculty members of the schools visited isbeing demonstrated through the interest of the tutors in their own capacitybuilding. They are asking for further guidance .

3.6. The Students

Each group of CMW Students is a mixture of those who passed the matriculationexamination more than a decade ago and those who passed it only a couple ofyears ago. There are young unmarried girls of 20 and there are married womenwith 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..Someadmitted that the demands of the family leave very little time for self studyMost 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 monthbeing paid to the CMW students as stipend.

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Outputs

30

202

59%

18

5%

122

36%

2008 -2009

Passed

Passed after more than

one attempt

dropped out

Total342

Appearedforfinal exam

273

65%

149

35%

2009 -2010

Passed

dropped out

Total422

Appearedfor final

exam

339

65%

184

35%

2010-2011

Passed

dropped out

Total 531

Appearedfor

final exam


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1359 1287

832

61%

527

39%

220

612

-100

100

300

500

700

900

1100

1300

1500

Total

Admitted

Appeared

for finals

1287

Passed 832 Dropped out

527

Deployed

220

Waiting to

be deployed

612

31

Admitted, Qualified and Deployed (2009 2011)


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4Evaluation ofTeaching / Learning Outcome

As mentioned earlier ,reports are available of the evaluation of training institutionsand of knowledge and skills of CMWs. These reports are of studies/surveysbased on responses to questions asked. One report( 9) provides some information

about the skills of the CMWS. where the researchers have observed theperformance of the CMWs . They used OSCE and found that the levels ofcompetence of the CMWs, in the required skills to practice safe midwifery, by andlarge, was quite deficient. It is due to the fact that most of the midwifery is beingtaught in the classrooms.

There is a mixture of ranking of the knowledge and skills of the students and of theteachers. It is of great concern that the CMWs are ( and will be) practisingmidwifery, dealing with two lives with inadequate knowledge and skills. Midwiferypractice requires high levels of competence and mental capacity for quickdecision making. These cannot be learned in the classroom.

Internal methods of evaluation comprise occasional written tests. There is nointernal evaluation of the skills of the student CMWs.

There has been no study on the methods of evaluation of the students learningduring training and of the final outcome of training regarding the achievement ofExpected 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 aredeployed , 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 , theController of Examinations , Sindh Nursing Examination Board, and some of themidwifery tutors.The qualifying examination is conducted by the Sindh Examination Board. Itcomprises both written and oral examination. There is no testing of midwiferyskills.

Multiple Choice Questions have been introduced in the examination system but thequality of items does not meet the criteria of MCQs because those constructingthem have two difficulties :

They have not had proper training in Tests & Measurement

Their own knowledge and skills regarding midwifery, by and large, arebasically theoretical and quite limitedEfforts 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 CMWconducted. Every one is aware of the fact that majority of these case histories arefictitious.

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Most CMWs manage to memorise the theoretical content of midwifery. They areable to give some times correct and some times partially correct answers toquestions 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 theexamination. According to the Controller of Examinations, very few attempt a thirdtime if they do not pass in the second attempt.

There is no evaluation of the midwifery skills of the students in Sindh. OSCE wasa 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 allthose 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 areteaching midwifery ,there is a collegial understanding to safe guard each othersreputation and reputation of their school by maximizing the number of successfulcandidates of each other.

5 A positive Development

A recent positive development which is very encouraging is that all thoseconnected 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 theirdiplomas in midwifery on the strength of theoretical knowledge. This situation is theresult of a combination of factors, circumstances and individuals. These include thestudent herself, the teachers, the clinical supervisors, the ob/gyn staff of the facilitywhere the CMW is getting her practical training, schools administration and of thehospital, the examiners, the examination boards, and finally the regulatory body i.ePakistan Nursing Council.

It has also been recognized that Pakistan needs qualified faculty to teachmidwifery

6. Number of Schools Training Community Midwives .

In Sindh at present 20 schools are training CMWs and some new ones have beenbuilt awaiting budgetary sanction to start functioning. The goal is to have amidwifery school in each of the 23 district.There are some schools which are training midwives but are not recognized byPNC. Some of these use the platform of a recognized school to get their studentsto take the final examination.

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According to the PC-1 (1) , in Sindh 2000 midwives are to be trained by the end of2012. So far just over 1000 have been trained.

Table 1: Number ofPublic sectorSchools Training Midwives in Sindh (byCategory)*

General Education Requirement is Matriculation for ALL categories of MidwivesType ofschool

#RNRM

LHV CMW Midwife Remarks

Nursing&Midwiferyschool

10 X X ___ Attached to a Hospital MostSONs have one year midwiferytraining for RNs

Public Healthschool

5 ___ X X ___ Not attached to a hospital .Borrow field practice areas. LHVgets oneof midwifery training.

Pupil

Midwivesschool 0 ___ ___ ___ ___

Attached to a hospital.

One year midwifery training

*CMWschools

18 ___ ___ X ___ 18 month training. Separatecurriculum.

*source MNCH

This table reveals that there are 18 schools training CMWs. More than onecategory of students has impact on the practical experience of each studentparticularly on the number of deliveries to be conducted by each student.

Table 2: Number ofPrivate sectorSchools Training Midwives in Sindh (byCategory)*

Type ofschool

#RNRM

LHV CMW Midwife Remarks

Nursing&Midwiferyschool

12 X ___ ___ ___ Attached to a Hospital MostSONs have one year midwiferytraining for RNs

PublicHealthschool

__ ___ ___ ___ ___Not attached to a hospital .Borrow field practice areas

(40 weeks midwifery training.)PupilMidwivesschool

11___ ___ ___

XAttached to a hospital.One year + midwifery training

*CMWschools 6 ___ ___ X ___

18 month training. Separatecurriculum.

*source MNCH

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Table 3. Numbers of CMWs admitted and Numbers GraduatedSince 2009.*

*source MNCH

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

Out put of 531 admissions is 339 CMWS i.e 64% successfully completed thetraining. 36% failure rate is is a point of concern.

Table 4 Numbers of Community Midwives Graduated, Deployed, AwaitingDeployment.*

YearAppeared inFinal Exam

# passed#

receivedDiploma

#deployed

waiting tobe

deployed

2009342 220 220 220 _____

2010 422 273 ___ ___ 273

2011 523 339 ___ ___ 339

Total 1287 832 220 220 612

*source MNCH

35

Year A B C D E F G

2009 406___

64 342 202 18 122

2010 422___ ___ ___

273 ___ 149

2011 531 ___ 8 523 339 ___ 184

Total 1359 72 865 814 18 455


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This table reveals 1287 appeared for their final examination, 832 (61%) havesuccessfully completed their training . 220 have been deployed 612 are awaitingdeployment.

6.1 Output of Schools

So far three batches of CMWs have been trained. A total of 1359 students wereadmitted, 1287 appeared for their final examination, 832 (61%) have successfullycompleted their training . The failure/drop out rate of 39 % is a point of concernand 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 betweengraduation 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 birthingstation and start their midwifery practice. The health authorities trained themidwives but had not allocated resources to give a start to CMW. As theresources are becoming available they are getting deployed.

The CMWs who pass their qualifying examination get their mark sheet butnot diplomas . Without the diploma they cannot apply to PNC for

registration. Diplomas are issued after many months ( some times after ayear). The CMW either sits at home or seeks other employment , evenadopts an other vocation..

One study reported that majority of those who were not deployed in thepublic sector were working elsewhere. Some NGOs employ them onsalaries much better than what they expect to earn in the public sector

CMWs are already voicing their dissatisfaction over the stipend (they calledit salary ) of Rs. 2000 .00 per month which they are getting afterdeployment. 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 ,reportingfee or , articulation allowance and that they are expected to generatetheir own income by ,Fee for service

The deployment guidelines have been developed by TRF. These have not beenendorsed by the health authorities. As mentioned earlier, they need a criticalreview before endorsement.

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8. Potential acceptability of the CMW by the community

A qualitative study of the potential acceptability of the CMW for pregnancy anddelivery related care in rural Pakistan (12) was commissioned by PAIMAN toPopulation 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 femaleadults in the communities. Its findings are quite interesting and can prove usefulfor planning the next PC-1.

8.1 Responses of LHVs

LHVs are the main competitors of CMWs. Obviously their responses could bebiased. They felt that the CMW will have considerable difficulty in getting acceptedin the community but added that a lot will depend on her behaviour. She has tomeet 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 providersirrespective of their qualifications.

They were willing to cooperate with the CMWs on theirterms. 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 alsocannot manage because they are both licensed midwives and are expected to

function within their authorized limits. This action will only result in unnecessarydelay in getting the woman to the source of appropriate services .

Yet this reflects the practices of LHVs and perception of their own status as beingsuperior to CMW. Majority of them are posing as doctors. That the LHVs areproviding services for which they are not trained or authorized, is also reflected inthe expectations of the community from the CMW.

8.2 Responses of TBAsTBAs 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 ofcooperation they wanted a percentage (up to 50%) of what ever the CMW willcharge the woman. Their condition were:

o TBA will refer all delivery cases to CMW and be present at the time of

delivery

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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 inlaw, 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 wilbe 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 thecommunity expects her to be able to carry out diagnostic tests and use theultrasound.

A question arises here i.e are these expectations reflective of the servicesbeing 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 favoureda 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 andcarried out in 9 selected districts all over Pakistan has identified certain veryimportant positive factors which facilitate the work of the CMW as well as theconstraints which limit her accessibility.

Facilitating Factors (where present) are:.

CMWs reaching out to the community by home visits and motivating thepregnant 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

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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 weresupposed 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 forlaunching the CMWs were held in cities in the presence of the dignitaries. Thecommunity knew nothing about this newcomer in the community. This weaknesshas been already recognised. by MNCH It is now planned to hold small events forindividual or a small group of three or four CMWs almost at their door steps.. TheCMW s should be introduced individually by name. Information should be given tothe community about the need for skilled care for the mothers and the neonatesand 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 supervisoryactivities i.e Quantitative monitoring and qualitative monitoring and supervision.

The quantitative monitoring is done by the supervisors of LHWs( LHS) , whose roleis to collect data ( figures only) of the inventory, and numbers of mothers andchildren served and referrals made.The qualitative supervision is done by an LHV from the Tehsil or district hospitalof the district. She is expected to provide supportive supervision to the CMW aswell as evaluate her performance. In the original plans monitoring was to be doneby the ob/gyn specialist of the district/Tehsil Hospital. It seems that it could not beimplemented.

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The LHV is ,however, dependent on the LHS for transport. Therefore theimplementation 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 andreprinting at a considerable cost of money , time and effort.These have been printed in thousands. Midwifery tutors have been given theresponsibility to train the CMWs. who have completed their midwifery trainingIt is planned by MNCH to make these tools a part of the curriculum. CMWsunder 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. Theauthor 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 havingdifficulty in understanding them. There were too many forms and a lot ofinformation to be entered in many forms which much duplication, which seemedquite overwhelming. Ease of administration did not seem one of the qualities ofthose 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 tocome in , the author will provide technical assistance in evaluating the quality ofdata received through these forms.

It is a set of 10 tools with a Users Manual, for getting various types of data asunder:

9.1The Population Chart

On this wall chart the population of all the villages assigned to CMW,and theirdistance from s of : pregnant women ( 3.4%); births (2.9%); women in thereproductive 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%), areto 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 thebeginning of each year.

9.2A 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 itsoutcome. Its columns are in two colours, white for normal and pink for notnormal condition. The woman is expected to visit the CMW ( or CMW to visit thewoman) 13 times during the 9 months of pregnancy.. This regimen is notfollowed any more. 13 ante-natal visits per woman in 9 months is far too muchfor a CMW. She is not expected to Charge for ante natal visits. MNCHInformative 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 onedocuments 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 thefirst column . The next column is yellow and then green. Significance of yellowis not clear. In the yellow column there are some stars(*). The instructions say,the star means , Beemari Ki Darmiani Kaifiyat Naheen Hai. What does thatmean.? It is very confusing .

There are thirty entries to be made for the mother and 15 for the neonate at eachvisit.. 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 ONEELSE. 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 thewoman and the opposite side is for the newborn. There is one horizontal row foreach person and 51 columns with horizontal lines making 51 boxes. Almostevery 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 toPLOT 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 filledPartograph. Unless the students have used the Partograph during training , they

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will not know how to use it and the significance of using a Partograph fordecision making.

9.5. The Referral Slips.

It is 13 X3.5 inches and 1 inch thick set of forms. Each slip has three parts. Twoof these are easily detachable. All the three parts have to be filled beforereferral. 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 thedoctor/nurse who provides services to the mother and or the neonate. This is tobe 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.gvaccination or ultrasound etc. The yellow one is for treatment of an ailment whichis not life threatening. The Red one is for Emergencies requiring immediatemedical attention.

The system if it works seems a good system. The only reservation is that in caseof the red slip , writing on three parts will take time. (1o pieces of information oneach slip )

9.6 Client Record Card

It is a 7X5 card for documentation of family planning users. On one side there isinformation about the client and on the back is information about method offamily planning being used. It has 12 columns to allow for a years contraceptivepractice.

9.7The 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