Developing Midwives Project (DMP)

DIPLOMA IN MIDWIFERY EDUCATION

midwifery 23 11 2016

Developing Midwives Project has been implementing a three-year Diploma in Midwifery Education under James P Grant School of Public Health (JPGSPH), BRAC University (BRACU) with a vision to improve maternal and neonatal health services in Bangladesh since April 2012 with UKaid funding from the UK Government. DMP has started its second phase from October 2016 until September 2021, is called DMP-2. This project is being implemented through seven Academic Sites in six districts across the country. All Academic Sites for the Diploma in Midwifery Education was approved by the Ministry of Health and Family Welfare, Government of Bangladesh, and accredited by the Bangladesh Nursing and Midwifery Council (BNMC). The DMP-2 builds upon the achievements of DMP and taking lessons from the implementation of rather ground-breaking DMP, deepens the project design while extending the reach and scope of the project. One of the important departures for DMP-2 (from DMP-1) is that it recognizes the importance of sustainability after 2021. As such a number of elements have been built into it including integrating DMP into the regular programme of JPGSPH, BRAC University, offering post basic BSc in Midwifery and charging fee for 70% students and free education for 30% students. The DMP aims to improve the health status of communities by contributing to the reduction of maternal and newborn morbidity and mortality and to increase coverage of quality maternal and neonatal health services through the development of qualified, competent and compassionate community-based midwives who live and serve at underserved, hard-to-reach rural and urban areas of Bangladesh. Additionally, the Project aims to contribute in establishing midwifery as a profession and employment opportunities for graduate midwives.
Reducing the maternal and newborn mortality and morbidity rate with quality maternal and neonatal health (MNH) services through qualified midwives is the primary goal of this project. To achieve this goal, the project is developing a cadre of Midwives focusing young women from disadvantaged rural and urban communities with high maternal and neonatal health needs, and educates them to become competent midwives through the education programme and deploy midwives in their respective communities upon graduation. The DMP is designed with a two-pronged approach where the first prong is developing qualified midwives and the second one is developing faculty for midwifery education. This educational initiative, the first of its kind in private sector of Bangladesh, will help provide mothers and their newborns with competent and compassionate care both within the comforts of their home and in remote, rural facilities. Midwives, educated by leaders in their field through a cutting-edge curriculum adapted to the specific context and needs of Bangladesh, will gain competencies of International Confederation of Midwives (ICM) and revolutionaries’ the landscape of maternal and neonatal health in the country.

DMP Implementation Approach

To achieve its objectives the project has adopted an innovative ‘hub and spokes’ model whereinHub-and-spokes 23 11 2016 BRACU is the hub and seven Academic Sites serve as the spokes. Six out of seven Academic Sites are managed by partner NGOs with the support of JPGSPH, BRACU while BRACU directly manages Dhaka Urban Academic Site at Mirpur. These seven Academic Sites are: Friends in Village Development Bangladesh (FIVDB) and Shimantik in Sylhet; Garo-Baptist Convention-Christian Health Project (GBC-CHP) in Mymensingh; Partners in Health and Development (PHD) in Khulna; Lutheran Aid to Medicine in Bangladesh (LAMB) in Dinajpur; Hope Foundation in Cox’s Bazar; and Dhaka Urban Academic Site at Mirpur.

Rationale for the Programme in the context of Bangladesh

Bangladesh has achieved quite impressive results against Millennium Development Goals (MDGs), especially in the areas of Maternal, Neonatal and Child Health (MNCH). In spite of that, there is still significant number of maternal deaths occurring every year – around 170 for each 100,000 live births. Only 42.1% of births are being attended by skill birth attendants in Bangladesh (NIPORT, Bangladesh Demographic and Health Survey, 2014). Introduction of specialized midwifery services seems to be imperative in this scenario. From this perspective, there have been several initiatives from government and development partners to introduce midwifery services in Bangladesh. To achieve the Sustainable Development Goal, Bangladesh must reduce it to 70 per 1,00,000 live births by 2030 as per its SDG commitment. The country has been identified by the World Health Organization (WHO) as one of the 57 countries facing a crisis in the supply of human resources for health (HRH). According to the State of World Midwifery Report (2011) Bangladesh with approximately 3.4 million births per year would need approximately 20,000 midwives to provide services to every birth in the country by 2015. Untrained providers are still a significant source of care for pregnant women. The draft Health Workforce Strategy commissioned by the Ministry of Health and Family Welfare (December 2015) mentioned that the current deployment of physicians, nurses and midwives is at 5.8 per 10,000 population compared to the ideal threshold of 22.8/10,000 population, which is the poorest in the WHO South East Asia region. Moreover, this threshold includes a large variety of health care providers, ranging from post-graduate specialists in the formal to dubious and unqualified practitioners in the informal sector. MMR and NMR are still very high; there are large discrepancies in maternal behaviours and outcomes among rural and urban and between different wealth quintiles. Thus four or more antenatal care visits, for example, was found among 46 percent women in urban areas and in only 26 percent of women in rural areas. About 35 percent of women in the poorest wealth quintile had received antenatal care from a medically trained provider; the corresponding proportion among women of wealthiest quintile was 88 percent; about 73 percent of the wealthiest women attended at delivery by a medically trained provider compared to only 18 percent of the poorest. To meet the goal of increasing skilled birth attendance by 50%, a more systematic approach to training that emphasizes scale and quality is clearly needed along with supportive work conditions with appropriate infrastructure and supervision at community level. It is clear that larger numbers of better qualified maternal health professionals are required who are capable and comfortable working in communities and able to help negotiate effective and timely referral to Emergency Obstetric Care (EOC). Considering women’s status and education in Bangladesh there must be an aggressive initiative to educate committed local women with a certain minimum level of education and commitment to become competent midwives who can be easily accessed at the local level.
Meanwhile, Bangladesh has committed to ending preventable child and maternal deaths by 2030. In order to achieve that, Bangladesh would need to ensure that 98 percent deliveries are conducted by skilled birth attendants and the same proportion of women attends 4 ante-natal visits. This would reduce the MMR to 59 per thousand live births by , which is achievable given the 5.63 percent decline in MMR which has already been achieved between 2001 and 2010 (Ibid 1).
Bangladesh ranks fourth among countries with high prevalence of child marriage with 66 percent of girls married before 18 years (UNICEF State of the World Children 2013). The incidence of early marriage is more common in rural (78 percent) than in urban (65 percent) areas and in slums (78 percent) than in non-slum areas (57 percent) according to Gender Statistics of Bangladesh, Bangladesh Bureau of Statistics, Government of Bangladesh, 2012. Thus 31 percent of adolescent girls in Bangladesh have begun childbearing, one in four teenagers has given birth and 6 percent are pregnant with their first child. Unfortunately, the number of adolescents who have begun childbearing has remained almost stagnant, decreasing only 3 percentage points to 30 percent in the last ten years. Such early pregnancy can cause complications during delivery resulting in morbidity and mortality for the young mothers as well as their newborn, and reduce the young mothers’ opportunities for education and employment while imposing the emotional burden of childbearing and rearing.
It is in this backdrop that the need to urgently develop the midwifery cadre in Bangladesh was recognized, spurred by a commitment from the Honorable Prime Minister of Bangladesh at the UN General Assembly in 2010, to train and deploy 3000 midwives. Introduction of this new cadre to the country’s health system is seen as a key step to achieving Sustainable Development Goals (SDGs) as midwives who are educated and regulated by international standards can provide 87 percent of essential care needed for women and newborn, potentially yielding a 16 fold return on investments in terms of lives saved and costs of caesarean sections averted (UNFPA Bangladesh, Certificate in Midwifery Education Programme Formative Evaluation Report. Dhaka, June 2015). Given that the scope of practice of a Midwife includes health counselling and information for the woman herself as well as her family and community, and may extend to women’s health, sexual or reproductive health and child care (International Confederation of Midwives, International Definition of Midwife. June 15, 2011), the impact of the midwife’s work extends far beyond the immediate events of pregnancy and childbirth.

A Strategy to Scale up the Midwifery Workforce in Bangladesh
The commitment from the Honorable Prime Minister of Bangladesh was a key component of a broader set of actions to provide universal access to maternal, newborn and child health services in Bangladesh to accelerate achievement of the health-related MDGs. To fulfill the Prime Minister’s commitment to educate 3000 midwives by 2015, a draft strategy entitled three thousand midwives by 2015: a strategy to scale-up the midwifery workforce in Bangladesh” was developed by the Ministry of Health and Family Welfare in collaboration with the JPGSPH, BRACU in 2011. The strategy outlined a systemic approach to scaling up midwifery education capacity inclusive of both the public and private sectors and with special attention to the needs of communities in greatest needs. A workshop was convened by the JPGSPH, BRACU in May 2011 and attended by high level officials from the MOHFW including the Honorable Minister and around 100 other stakeholders to discuss the national strategic plan for scaling up the midwifery workforce. There was broad agreement on the importance of the systemic approach to education and the benefits of working with core competencies of midwifery education identified by the International Confederation of Midwives (ICM). In recognition of the need to move forward on multiple fronts, there was an understanding on the benefits of a division of labour among partners according to relative comparative advantages in pursuing specific entry-points or pathways for training.

Partnerships

BRAC University has started the DMP in partnership with six non-governmental partner organizations who plays vital role to the project. Alongside there are national partners from government and non-government sectors.

  • Ministry of Health and Family Welfare (MoHFW)
  • Bangladesh Nursing and Midwifery Council (BNMC)
  • Directorate of Nursing Services (DNS)
  • Bangladesh Midwifery Society (BMS)
  • Obstetrical and Gynaecological Society of Bangladesh (OGSB)
  • BRAC

The underserved and hard-to-reach areas with the greatest maternal health needs have been identified based on maternal and neonatal mortality and morbidity data as per the Bangladesh Maternal Mortality and Health Care Survey (BMMS), Bangladesh Demographic and Health Survey (BDHS) and United Nations Development Assistance Framework (UNDAF). Adapted to the specific context and needs of Bangladesh, this programme is being pursued in close collaboration with partners from the state and non-state sectors. JPGSPH, BRACU is collaborating with the Bangladesh Nursing and Midwifery Council (BNMC), which is responsible for accreditation and registration of the midwives as a professional cadre as well as the Ministry of Health and Family Welfare (MOHFW). The programme is also engaging the Bangladesh Midwifery Society (BMS) and the Obstetrical and Gynaecological Society of Bangladesh (OGSB) to establish a strong framework of support for midwives.

Programme Structure

Drawing on the standards for midwifery education of the International Confederation of Midwives (ICM), the DMP is developing midwifery faculty and curricular resources. All the partner organizations are adopting common standards related to curriculum, faculty, education facilities and the assessment of competencies of midwifery students. This common standard approach facilitates greater quality in education and practice as well as permits midwifery students to advance their careers as accredited midwifery professionals. The curriculum meets the global standards for midwifery education programme. This 155-hour, full time, 36-month residential programme with appropriate instruction and supervision from qualified faculty, combines 40% of theory hours through classroom teaching with 60% of lab and practical hours through clinical and community-based practical learning. Students will gain practical experience throughout the programme, especially through a 1-year supervised internship in selected Comprehensive Emergency and Obstetric Care (EOC) facilities in the final (third) year of the Diploma in Midwifery programme. All enrolled students are provided with accommodations, meals, course materials and supplies, local transportation to and from community and clinical sites.

To fulfil the Honourable Prime Minister’s commitment to train 3000 midwives by 2015, a draft strategy entitledThree thousand midwives by 2015: a strategy to scale-up the midwifery workforce in Bangladesh” was developed by the Ministry of Health and Family Welfare in collaboration with the JPGSPH in 2011. The strategy outlined a systemic approach to scaling up midwifery training capacity inclusive of both the public and private sectors and with special attention to the needs of communities in greatest needs. A workshop was convened by the JPGSPH in May 2011 and attended by high level officials from the MOHFW including the Honourable Minister and around 100 other stakeholders to discuss the national strategic plan for scaling up the midwifery workforce. There was broad agreement on the importance of the systemic approach to training and the benefits of working with core competencies of midwifery training identified by the International Confederation of Midwives (ICM). In recognition of the need to move forward on multiple fronts, there was an understanding on the benefits of a division of labour among partners according to relative comparative advantages in pursuing specific entry-points or pathways for training.

Partnerships

The Developing Midwives Project (DMP) at the JPGSPH, BRAC University, along with six partner organizations is empowering midwives through education and career building support in underserved, hard-to-reach areas with the greatest maternal health needs.
The areas have been identified based on maternal and neonatal mortality and morbidity data as per the Bangladesh Maternal Mortality and Health Care Survey (BMMS), Bangladesh Demographic and Health Survey (BDHS) and United Nations Development Assistance Framework (UNDAF).

The partner organizations serving these areas include Friends In Village Development Bangladesh (FIVDB) in Sylhet, Garo-Baptist Convention- Christian Health Project (GBC-CHP) in Mymensingh, HOPE Foundation in Cox’s Bazar, Lutheran Aid for Medicine Bangladesh (LAMB) in Dinajpur, Partners in Health and Development (PHD) in Khulna and Shimantik in Sylhet. In addition, JPGSPH through its newly established Midwifery Programme has been implementing the programme in Dhaka in technical partnership with the Obstetrical and Gynaecological Society of Bangladesh (OGSB). All of seven Academic Sites are approved by the Ministry of Health and Family Welfare (MoHFW) and the Bangladesh Nursing and Midwifery Council (BNMC).

Adapted to the specific context and needs of Bangladesh, this programme is being pursued in close collaboration with partners from the state and non-state sectors. JPGSPH is collaborating with the Bangladesh Nursing and Midwifery Council (BNMC), which will be responsible for accreditation and registration of the midwives as a professional cadre as well as the Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP), Directorate of Nursing Services (DNS) under the Ministry of Health and Family Welfare (MOHFW). The programme is also engaging the Bangladesh Midwifery Society (BMS) and the Obstetrical and Gynaecological Society of Bangladesh (OGSB) to establish a strong framework of support for midwives.

Programme Structure
Drawing on the standards for midwifery education of the International Confederation of Midwives (ICM), the DMP is developing midwifery faculty and curricular resources. All the partner organizations are adopting common standards related to curriculum, faculty, education facilities and the assessment of competencies of midwifery students. This common standard approach facilitates greater quality in education and practice as well as permits midwifery students to advance their careers as accredited midwifery professionals. The curriculum meets the global standards for midwifery education programme. This 155-hour, full time, 36-month residential programme with appropriate instruction and supervision from qualified faculty, combines 40% of theory hours through classroom teaching with 60% of lab and practical hours through clinical and community-based practical learning. Students will gain practical experience throughout the programme, especially through a 1-year supervised internship in selected Comprehensive Emergency and Obstetric Care (EOC) facilities in the final (third) year of the Diploma in Midwifery programme. All enrolled students are provided with accommodations, meals, course materials and supplies, local transportation to and from community and clinical sites.