Midwifery in Pakistan

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• Midwives are regarded as "dais" because of the lack of knowledge about the midwife's role in the community and amongst the medical profession.
• There are no regulatory mechanisms and no code of conduct for midwifery practice.
• The midwife is not comfortable with her own professional identity.

Professional Education

• There are more schools of midwifery than schools of nursing.
• There are no designated posts for midwifery teachers.
• There is an extreme shortage of qualified teachers to teach midwifery
• Midwifery students have been graduating with very little or no practical experience in delivering babies.

Professional Practice

• Midwifery is not regarded as a distinct profession, independent of nursing.
• There is an acute shortage of licensed practicing midwives in spite of the fact that thousands graduate every year.
• There are no policies or plans to utilize the trained and licensed midwives.
• Dais are occupying a large number of posts meant for licensed midwives.

Professional Development

• There are no opportunities for advancement in midwifery.
• There is no career structure for midwives.
• The midwife starts at the lowest rung of the pay scale and retires in the same grade.

Government's Role

The Government's previous efforts of Patch Work to promote safe motherhood were not effective because the plans did not include promotion of midwifery as a profession.

1. 60,000 TBAs were trained, but it made no difference to the maternal death rate
2. Lady health visitors were trained as community midwives, but they remained in towns.
3. Training in midwifery was made compulsory for promotion for the female nurses. They went through it to fulfill the requirements and so only a negligible number practice as midwives.
4. Text Box: Child birth remained by and large in the hands of the illiterate and untrained TBAsDoctors graduated in large numbers but they remained in cities.

Renaissance of Midwifery

Just at the turn of the century, action started to promote midwifery. MDGs 4 and 5 contributed to the realization that it was necessary and possible for every baby to be delivered by a skilled birth attendant, who need not always be a doctor. The government started to locate resources to strengthen the education preparation of the midwives.

The result was that:

• International agencies and bilateral donor communities responded to the government's requests for assistance.
• A maternal health policy came into being.
• Advocacy events started with the celebration of the International Day of Midwifery in 2002.
• Midwifery curriculum got revised.
• National Committee for Maternal and Neonatal Health (NCMNH) made special efforts to promote the profession of midwifery and assisted in the establishment of the Midwifery Association of Pakistan (MAP) in 2005.
• Education of the midwife started to receive attention.
• UNFPA, UNICEF and USAID made substantial contribution to improve midwifery training.
• Multi million dollar projects were developed which included: Women's Health Project, Pakistan Initiative for Mothers and Newborns, Newborn and Child Health, technical Assistance for Midwifery, Reproductive Health Project and Maternal, Newborn and Child Health (MNCH) Project. All of these projects included a midwifery component.
• Some activities got directed to provide short courses to train midwifery teachers.
• Importance of the skilled birth attendant got recognized at the highest level.
• The midwife got identified as the skilled birth attendant in the forefront.
• The President and Prime Minister demonstrated their interest in the training of midwives and in 2005 gave to the health authorities a target of 12, 000 midwives to be trained in five years.

Current Status

The midwife is gradually emerging as an important member of the maternal health team. The government, with donor assistance, is taking action to meet some of the midwifery challenges:

• Revision of the Nursing Act is in process.
• Training of midwifery teachers through short courses has started.
• A new curriculum for community midwives is being pre-tested.
• A considerable number of teaching/learning materials have become available to the teachers and the students of midwifery.
• Some of the health facilities are being strengthened.
• Courses in advanced midwifery are becoming available. They are not of the standard required but it is a start.
• A number of obstetricians are openly acknowledging the important role of midwives in making motherhood safe.
• Midwives are beginning to recognize their own identity.
• Above all, midwives now have their own professional organization which has provided them a platform for the first time in the history of Pakistan.

Challenges

• Revision of the Pakistan Nursing Act to strengthen the midwifery component in its name and text.
• Preparation and employment of competent midwifery teachers.
• Preparing skilled midwives who are capable of functioning as specialists in normal obstetrics.
• Strengthening the examination boards to enable them to improve the midwifery examination system.
• Finalization of a legal framework for midwifery practice to protect the midwife and the community she serves (MAP has the draft).
• Sensitizing the community and the medical profession about the pivotal role of the midwife in lowering maternal mortality.
• Improving midwifery education using available evidence of the existing weakness.
• Strengthening the health facilities to provide backup support to the midwife.
• Designing an educational system which provides opportunities for professional advancement to the midwife.
• Acknowledging midwifery as a profession and developing a career structure for its members.
• Designing a system to deploy and supervise the community midwife.