Competent Bangladeshi midwives: for healthy mothers & babies

Bangladesh has insufficient qualified midwives to reduce preventable maternal and newborn mortality and morbidity, reduce unnecessary interventions in childbirth, promote and provide family planning services, and improve the quality of maternity care. Midwifery education and regulation need strengthening and the social, economic and professional barriers that prevent midwives from providing quality care across the full scope of midwifery practice must be addressed. Midwifery competence is central to effective practice and high-quality midwifery care.

By piloting and testing a global midwifery competency assessment framework, strategies for supporting competency development and maintenance can be implemented. 

Strengthening midwives has a triple impact – improving health, promoting gender equality and supporting economic growth.

Bangladesh needs 21,000 registered and competent midwives, deployed and enabled to provide quality care across the full scope of midwifery practice, if preventable maternal and child deaths and morbidity are to be reduced by 2030[1]’[2]’[3].

Social[4], economic[5] and professional[6] barriers prevent 3000 existing midwives from addressing these issues. Insufficient qualified midwife educators, inconsistent teaching and assessment of competency and no competence assessment at registration or re-licensing undermine a competent workforce

[1] Bogren et al, 2018. What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students. BMC Health Services Research. 18: 639

[2] Zamen R, Sabur MA, Khaled A and Islam S (2019). Final report: Baseline study on trained diploma midwives in Bangladesh. Oxford: Oxford Policy Management and Dhaka: Mitra and Associates

[3] Maternal Health in Bangladesh: Let’s Do It Right. Bangladesh Demographic and Health Survey Policy Brief 2014; https://dhsprogram.com/pubs/pdf/PB10/PB10.pdf. Accessed 15.10.19

[4] For example, gender discrimination, age discrimination

[5] For example, lack of resources

[6] For example, subordination to doctors and nurses, lack of professional frameworks, lack of support and lack of a distinct career pathway

Strengthening midwives has a triple impact – improving health, promoting gender equality and supporting economic growth[1].  Increased numbers and profile of competent midwives will improve maternal and newborn health including for refugees, attract more women to midwifery as a career, and enable more women to contribute economically to their communities. A competent midwife workforce meeting international standards can provide 87% of essential maternal and newborn care, helping achieve universal access to sexual, reproductive, maternal and newborn care[2].

The competence of Bangladesh midwives can be assured through processes for consistent development and assessment in pre-service education, at registration, and after registration. Bangladeshi midwives and educators will work with international partners to pilot and implement this approach to strengthening the competence of midwives in Bangladesh.

Women, midwives, regulators and the health system will benefit.

Bangladeshi society will benefit from higher quality midwives serving larger numbers of women and newborns, including in fragile settings, with improved health outcomes. More employed midwives will contribute economically to community resilience.

[1] Buchan J, Dhillon IS, Campbell J, editors. Health Employment and Economic Growth: An Evidence Base. Geneva: World Health Organization: 2017.

[2] State of the World’s Midwifery 2014; https://www.unfpa.org/sowmy; accessed 16.10.19

With our partners[1] we will drive quality and strengthen Bangladesh’s midwife workforce by piloting and testing a global midwifery competency assessment framework with students, graduates, and registered midwives, including a cohort working with the Rohingya refugees. Outcomes will include strategies for strengthening and supporting student midwives, competence assessment of midwives upon registration and mechanisms to strengthen continuing competence of practising registered midwives. There is no current mechanism for assessing the competence of overseas midwives wishing to practise in Bangladesh; this project will inform development of such a mechanism.

Partnership with the Bangladesh Midwifery Society (BMS) and the Royal College of Midwives (RCM) will support and extend capacity-development of the BMS, activities currently underway through ‘twinning’ between BMS and RCM. Focus areas may include advocacy and leadership development.

Activities:

• Complete a detailed participatory in-country stakeholder communication, engagement and analytical plan.
• Gather existing tools and processes for assessing the competence of midwifery students, midwife teachers, new graduate midwives, practising midwives (including a cohort working in humanitarian settings)
• Complete a Gap Analysis to assess and compare the current situation in regard to the development and assessment of competencies by Bangladesh midwifery educators, regulators and in-country partners with the global competence assessment process of ICM and CGFNS
• Adapt current ICM and CGFNS competence assessment tools and processes to embrace the cultural context of Bangladesh
• Prioritise implementation challenges identified in Gap Analysis, develop a strategy and action plan in collaboration with national stakeholders
• Pilot adapted competence assessment tools and processes with representative cohorts
• Modify competence assessment tools and processes
• Evaluate and analyse findings
• Develop recommendations to ICM, national and international stakeholders
• Support implementation of recommendations 

[1] Bangladesh Midwifery Society (BMS), Bangladesh; Royal College of Midwives (RCM), England; Midwifery Educators from BRAC University (Bangladesh); and UNFPA Bangladesh.

To assess a national midwife workforce against the 2019 ICM Essential Competencies for Midwifery Practice is a global first. The ICM/CGFNS global competency assessment process to be used is based on existing tools and processes of the respective organisations. It is a new approach to credentialing midwives and has not previously been piloted at country level. This project positions Bangladesh at the vanguard of the first global assessment and credentialing framework for midwives.

For the first time, globally recognised competency assessment tools and processes will be adapted to the Bangladesh context and the development and assessment of competencies in pre-service programmes will be strengthened. For the first time international competency assessment processes will be used to inform and support the competence assessment of midwives at the point of registration and to enable the development of continuing competence assessments of practising midwives. 

The solution will strengthen the competence of the entire midwifery workforce in Bangladesh. It will enable the Bangladesh government and midwifery regulator to consider adapting the globally recognised competency assessment tools and processes to assess the competence of overseas midwives seeking to work in Bangladesh and thereby providing another opportunity to increase midwife numbers. 

Midwives meeting international standards, working in functioning health systems, can avert more than 80% of all maternal, neonatal deaths and stillbirths, improve over 50 other health-related outcomes, and increase satisfaction with care[1]’[2]. A competent midwife workforce can provide 87% of essential maternal and newborn care.

Bangladesh is significantly short of midwives and those they have face many barriers to providing competent, quality midwifery care[3]’[4]. Pregnant women face issues of access, unnecessary intervention and poor-quality care[5]. Insufficient qualified and competent midwife educators and inconsistent competency assessment processes contribute to a poor-quality midwifery workforce[6]. 

Poor quality of care is a bigger barrier to reducing mortality than insufficient access to care.

Midwives meeting international standards of competence are the first step to quality maternity care.

[1] Strengthening quality midwifery education for Universal Health Coverage 2030: framework for action. Geneva: World health Organization; 2019.

[2] Lancet Series on Midwifery, 2014

[3] Bogren et al, 2018. What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students. BMC Health Services Research. 18: 639

[4] Zamen R, Sabur MA, Khaled A and Islam S (2019). Final report: Baseline study on trained diploma midwives in Bangladesh. Oxford: Oxford Policy Management and Dhaka: Mitra and Associates 

[5] Maternal Health in Bangladesh: Let’s Do It Right. Bangladesh Demographic and Health Survey Policy Brief 2014; https://dhsprogram.com/pubs/pdf/PB10/PB10.pdf. Accessed 15.10.19 

[6] Information from in-country partners_October 2019

In its first year this project will aim to serve the current midwifery workforce in Bangladesh. This includes more than 3700 midwives in clinical practice,  approximately 1370 midwifery students, approximately 100 midwifery educators, and stakeholders from the Bangladesh Midwifery Society, the Bangladesh Nursing and Midwifery Council (the midwifery regulator), and the Ministry of Health. These are approximate numbers from the available health workforce data.

In five years, numbers will increase as more midwifery students enter midwifery education programmes, with a flow on increase to practising midwives. If credentialing processes for overseas midwives are in place within five years, there may also be an increase in numbers entering and practising in Bangladesh. 

Numerous women and their families will also be indirectly served during this project by the more equitable distribution of the midwifery workforce to rural, underserved and humanitarian areas, as well as by the improved quality of the overall midwifery workforce.

ICM envisions a world where every childbearing women has access to a midwife’s care for herself and her newborn. Women have a fundamental human right of access to midwives as the health professionals most equipped to support them with respectful, individualised and high quality care throughout the childbirth continuum. Midwives, too, have the right to be recognised, respected and supported as well-educated, regulated and autonomous health professionals to provide this essential care.

ICM demands better access for women to competent midwives and women-centred childbirth services and more investment in midwives and midwifery services.  It also deliver expertise, resources, leadership and support to its Member Associations, partners and stakeholders in these collaborative efforts.  

This project leverages the expertise of international and local partners and focuses on strengthening midwifery competence as a way to improve the education, regulation and support of midwives in Bangladesh. 

The evidence-based solution we wish to pilot will transform many lives in Bangladesh by demonstrating the link between healthy, productive families and communities and improved midwifery services. Our collective learnings from this implementation will inform both how we make this solution sustainable in Bangladesh and how we replicate and take this solution to scale in other countries.

Even in Bangladesh where midwifery is recognised as a fully-fledged profession confusion exists about the role and competency of midwives when compared with nurses and doctors providing maternal and newborn care. Midwives face social barriers shaped by cultural prejudice and and gender norms. Professional barriers include lack of recognition and autonomy in the hierachical health system. Midwives are often subordinate to nurses and prevented from practising in their full scope. Economic barriers are reflected in low or irregular salaries and personal insecurity related to lack of housing and transportation. 

Women's low status in society and high rates of maternal mortality and morbidity remain serious concerns. The status of midwives reflects that of the women they serve. Gender inequality pervades society, reflected in lower government spending and non-responsive policies on women's rights and gender equality. 

There are diverse economic partners within and outside the health sector, each with their own agenda, influencing Bangladeshi sexual, reproductive, maternal and newborn health systems. 

Vested interests of educational and regulatory institutions may hold competing visions for midwives and the midwifery profession and be resistant to potential changes to established systems and processes.

All could slow the implementation of the project. 

The process of introducing a new cadre of midwives and moving the agenda of women’s rights forward takes time and effort. Midwives are the health professionals moving the sexual reproductive health and rights agenda forward. This project supports necessary key strategies of education and regulation for midwifery to be fully integrated in the health system.

The barriers faced by midwives in Bangladesh are not uncommon internationally and ICM has resources to support Bangladeshi midwives to raise the profile of midwives and midwifery. Focused advocacy to inform policy makers, health professional colleagues and the public about the role and scope of practice of a midwife will be essential, as will evidence to show the difference that midwives can make when fully utilised. Strategies to build relationships between midwives and women, midwives and policy makers and midwives and other health professionals have seen success in other countries and can be initiated in Bangladesh.

Overcoming gender stereotypes and eliminating gender gaps will take advocacy, public policy change and government commitment. Midwifery can be promoted to girls and women as a career that assures them of education and income and supports them to fulfil their potential and succeed in life. This project can promote gender equality by raising the visibility of midwives as an autonomous and highly skilled workforce.

This project will leverage existing relationships of in-country partners with those in position to support change and overcome resistance. Successful project implementation will rely on collaboration and and 'buy-in' from key in-country stakeholders. Building collaborative relationships and understanding potential concerns or resistance will be important first steps.

CGFNS brings significant international experience with credentialing. ICM, CGFNS and our in-country partners are strongly positioned for positive change.

What is started in Bangladesh will serve as an example in other countries, so success in Bangladesh will not only ensure sustainability there but also speed of uptake elsewhere. 

The ICM/CGFNS competency assessment process for midwives is based on international best practice drawn from competency assessment of midwives and credentialing of nurses and other health professionals. This new process and tool is being piloted in Bangladesh with the intention of subsequent global implementation. 

The Tiger Challenge provides an opportunity to pilot the process with a national workforce and in a country where the midwifery profession is new and there is an acknowledged need to improve the competence of Bangladeshi midwives. 

Successful implementation in Bangladesh will provide learning that can strengthen the process and help ready it for global dissemination. There are future opportunities for midwifery educators, regulators and professional associations in other countries to seek implementation of these assessment processes. 

The current team is part-time technical advisors from CGFNS and ICM, with a volunteer international advisory committee.

The Tiger Challenge provides the opportunity for piloting with a national midwifery workforce in Bangladesh. The proposed project team includes:

1 Project Manager full time

1 in-country coordinator full time

Midwife Technical Advisor (TA) (0.6 FTE)

CGFNS Technical Advisor (0.6 FTE)

1 BMS TA (0.4)

1 RCM TA (0.2)

1 BracU TA (0.4)

Communications Team

Finance manager (PT consultant)

1 Administrator (0.5 FTE)

2 Contractors (to be decided)

International advisory group

This solution requires a team with the resources to deliver comprehensive midwifery competence education and assessment standards and systems, capacity to work with education providers, government policy makers, health sector agencies, and other health sector stakeholders. The Team has the respect of its national and international peers and the capacity to perform the activities contemplated in this project. This team has the resources to deliver this solution.

Representing 140 Midwives Associations in 121 countries, across six regions, the International Confederation of Midwives (ICM) is the international standard setting and professional body for midwives. It works with bi- and multi-lateral organisations, national governments, NGOs, corporations, foundations, education providers and others to strengthen the midwifery profession and midwives’ professional associations worldwide. 

The Commission on Graduates of Foreign Nursing Schools (CGFNS) is an internationally recognised, certification body, that assesses competencies and validates academic and professional credentials for nurses and others. It is ideally positioned to implement competence assessments for midwives in Bangladesh.

UNFPA works in partnership with the Bangladeshi Government, providing technical and advisory services and support. Its partners include various Government Ministries, the Parliament, United Nations Agencies, academic institutions, and civil society organisations.

Brac University is Bangladesh’s top ranked university offering offers midwifery education at five campuses across Bangladesh.

The Bangladesh Midwifery Society represents professional midwives across Bangladesh and works to strengthen midwifery nationally.

The Royal College of Midwives is the United Kingdom's only Midwifery Society: (BMS) and the (RCM) have created a twinning partnership to strengthen the National Midwifery Programme in Bangladesh.

As the global voice for midwives, ICM partners with many likeminded stakeholder organisations working for mothers and newborns. These include the WHO, UNFPA and other UN Agencies; the Every Woman Every Child (EWEC) initiative; the Partnership for Maternal, Newborn and Child Health (PMNCH); SheDecides; the White Ribbon Alliance (WRA); the Respectful Maternity Care partnership; the Quality, Equity, Dignity (QED) Network; the International Federation of Gynecology and Obstetrics (FIGO); the International Pediatric Association (IPA); the International Council of Nurses (ICN); the Bill and Melinda Gates Foundation; Laerdal Global Health; the MacArthur Foundation; the Sanofi Espoir Foundation; the World Alliance of Breastfeeding Action; Save the  Children; and many private, government, and NGO civil society groups.

ICM sets global standards and competencies (endorsed by the WHO, among others) and provides other core documents, guidelines and resources to help ensure that midwives in all countries have effective education, regulation, and strong associations. Additionally, ICM advocates to governments and others on the evidence for midwife-led care to improve maternal and newborn health outcomes if midwives work in a supportive, enabling environment where their services are integrated into a well-functioning health system.

It works with partners on several in-country projects to strengthen midwifery care.

Our solution should not be viewed in the sense of a traditional business as our primary “product” is the delivery of competency assessment systems and educational frameworks that help to increase the professionalism and capacities of Bangladeshi Midwives.

These systems and frameworks are not designed to generate income per se but rather provide a demonstrably needed program for the Bangladeshi Health Sector and the people it serves, and as such, a traditional business model is not applicable.

However, monetizing certain aspects of the system will be necessary to ensure the sustainability of the overall program.

Consideration will be given to 'selling' the Competency Assessment Tool and other supporting activities on a capitation fee basis (as part of the midwifery education tuition fees or registration/re-licensing fees) to ensure programme administrators can continue to offer competency assessments of students, for education providers, and for regulatory bodies. This would generate a constant source of revenue.

Education providers (and potentially the licensing bodies themselves) may pay a licensing fee to the competency assessment tool developers to ensure they are able to update and maintain the tools and deliver the program as international competencies are periodically updated.

Should the Bangladeshi government decide that competence assessments should be legally mandated (as is required of nurses in many jurisdictions), it would ensure the sustainability of the program and an additional and ongoing source of revenue.

See above section

The pilot process in Bangladesh will also provide an opportunity to explore options for revenue generation through the competency assessment process. 

ICM and CGFNS are both NGO non profit organisations. Each has different business models. ICM's revenue comes partly from its midwives association members, partly from overhead allocations from externally funded projects and partly from fee-for-service activities. 

Development of a sustainable revenue base is a priority for ICM. One strategy is the  planned 2020 launch of a charity linked to ICM. Others include review of the membership fee structure (for ICM Council approval in 2020 and implementation over next three years), delivery of regional conferences (3 in 2021, 3 in 2022) and international Congress (2020) and the implementation of new fee for service activities (3 pilots underway).

Funding support for a project that will have impact in Bangladesh and influence application to other countries.

Profiling through the Tiger Challenge.

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