Expanding Access to Reproductive Health Through Midwives

Summarised from Expanding Access to Reproductive Health through Midwives. Lessons learned from SEATS' MAPS Initiative. By Charlotte Houde Quimby, RNP/CMW, and Mary Lee Mantz, RNP/CMW. January 2000.

A key problem in developing countries is lack of access to contraceptives and to high-quality reproductive health care services, which are sustainable, appropriate to local cultures and sensitive to client needs. Providing this access could prevent some of the millions of unwanted pregnancies that occur each year and save the lives of millions of mothers and children.

The MAPS initiative (Midwifery Association Partnerships for Sustainability) promotes the development of midwives - a particularly underutilised resource - as a way to address the unmet needs for family planning and reproductive health care. MAPS works with midwives in the private and public sectors, through their professional associations.

MAPS strategies

While MAPS offers a flexible approach when working with these associations, according to the specific needs of each country, it consistently applies five strategies:

1. Capacity building of associations.
2. Capacity building of members.
3. Creation of a more enabling practice environment.
4. Integration of quality and sustainability.
5. Policy initiatives.

Strengthening midwifery associations allows midwives to practise more independently and to provide high-quality services. A by-product of stronger associations is also that individual midwives gain courage and strength by working together in groups towards a common cause. MAPS uses a variety of activities, such as training, advocacy and policy changes, to ensure that midwives can reach their full potential as a community-based resource. It also encourages partnerships and networking between associations, especially 'south-to-south'; this strategy involves making use of skills and resources from other developing countries instead of relying on technical assistance from the north.

MAPS' training strategies focused on improving the capacity of individual midwives, giving them new skills to become successful providers and entrepreneurs. So midwives were given training in family planning, business management skills, community mobilisation, and advice and standards on setting up in private practice.

MAPS is a Special Initiative of the Family Planning Service Expansion and Technical Support Project (SEATS II), funded by the United States Agency for International Development (USAID) and implemented by John Snow, Inc. in collaboration with its partners. MAPS is implemented by the American Collage of Nurse-Midwives (ACNM), SEATS' partner.

Since 1995, MAPS has developed and implemented subprojects in four countries - Senegal, Uganda, Zambia and Zimbabwe. It has also worked with midwifery associations in Cambodia, Eritrea and Tanzania. MAPS has experienced a tremendous growth in the interest in and demand for technical assistance with private - practice midwives. Opportunities for private midwives are expanded by the economic burden of government-sponsored health care and by the diversion of government funds to meet the burgeoning demands created by the AIDS crisis. This was the case in Zimbabwe where, before the MAPS project began, very few midwives were in private practice. Also, cultural and legal changes are making it easier for women to own property and pursue independent financial opportunities.

Despite the short-term nature of most of the subprojects, MAPS accomplished many objectives. It strengthened the capacity of associations and the skills of midwives; it helped position private midwives as change agents; and it helped midwives increase client access to, and use of, effective contraception.

MAPS learned many valuable lessons including:

· Barriers to private practice severely limit the potential contribution of midwives to reducing the unmet need for RHC services.

· RHC service delivery points are incomplete without minor curative services and immunisation capability.

· HIV/AIDS has permanently changed the service delivery environment. Midwives must know how to counsel clients affected by HIV/AIDS and, equally important, they must know how to protect clients and themselves from cross-infection.

· Basic business management skills and community mobilisation skills are critical to the viability of private midwives.

· Private midwives serve existing needs and reduce the public-sector burden.

· Private practice expands service.