Pakistan continues to lag behind other developing countries in addressing the challenges of maternal and infant mortality. Despite a number of federal and provincial mother and child health programmes, the country has the world’s lowest rate of newborn survival and a maternal mortality rate that is significantly higher than the United Nations’ Sustainable Development Goals targets.  

If Pakistan is to successfully raise the standard of mother and child healthcare, then the country must welcome the role midwives can play in improving both these health indicators, says Arusa Lakhani, president of the Midwifery Association of Pakistan, MAP, and an assistant professor at AKU’s School of Nursing and Midwifery, SONAM.

“As experts in childbirth and family planning, midwives have the potential to touch every life,” says Mrs Lakhani. Midwives are now a regular participant in the majority of policy sessions and academic symposiums but there is still a lot of progress to be made in enhancing the status of the profession, she notes. Mrs Lakhani, representing MAP, has noticed an important change in the policymaking sphere:  she notes that recent discussions with the federal health ministry, provincial government as well as public and private sector bodies show that a key requirement for reforms, political will, is now present. 

In this interview, Mrs Lakhani discusses new developments in the profession and outlines areas where stakeholders need to advocate for further reform.

The most positive trend is that provinces and donor agencies are committed to launching more undergraduate programmes for midwives. At present, Pakistan has just one, two-year Post-RM bachelor’s programme in midwifery at Aga Khan University. 

Efforts are underway to launch undergraduate degree programmes in Punjab and in more institutions in Sindh. There are also talks on extending the duration of existing diploma programmes to deepen the professional experience of all graduates and to increase the prestige of the qualification.

Through MAP, I’m working with the Mother and Child Health departments in Sindh and Punjab to support new programmes that will open up opportunities for students looking to make a difference in this area. At the same time, MAP is in discussions with agencies such as the United Nations Population Fund on initiatives to support the launch of these programmes. Overall, the profession needs to move away from just offering short training courses to midwives and to invest in academic initiatives that offer credentials that go beyond those present in diploma programmes. 

On the regulatory front, the emergence of healthcare commissions in Punjab, Sindh and other provinces, which oversee private practitioners, is a significant change. We now have assertive regulators who are actively looking into cases of malpractice. This is a positive sign since it is vital to protect the public from quacks and unlicensed practitioners who lack the qualifications and experience to offer high quality care to pregnant women and children.

 

Unfortunately, there is little or no progress in this area as our educational institutions haven’t developed a formal track for midwives interested in research. Since there are no master’s programmes available in the country, there is no route for midwives to work on a thesis that can be developed into a doctoral proposal. This means that midwifery diploma holders or graduates have no choice but do a master’s in nursing to pursue an academic career.  

MAP believes that we must first launch an undergraduate degree in a public sector university to increase the number of undergraduates. As the number of graduates grows, there will be a greater incentive for universities to develop master’s programmes in midwifery, offering more career options to midwives.

I’d say there is progress on the surface but systemic issues remain. For example, you will see advertisements for hospital-based roles, mother and child centres, and midwifery schools asking for applications from degree-holding midwives. However, we’ve noticed that they are rarely hired.

There is a role for a midwife in every mother and child health centre in the country as they are the experts in normal deliveries which account for the majority of births. Similarly, every public or private hospital should have a competent midwife who can lead their antenatal clinics, labour ward but unfortunately our midwives are also under-represented here. There are so many birthing centres and midwifery schools run by doctors and nurses rather than midwives, that I often hear midwives complaining about the lack of role models to look up to.

In other countries such as Kenya, midwives run the labour rooms in major hospitals while doctors and nurses only tend to complicated cases that have been identified by the midwife. We still have a long way to go to reach that stage in Pakistan.

MAP works to promote and protect the interests of the country’s midwives and I’d say that practicing midwives feel as though they’re operating in a climate of uncertainty.

Midwives are permitted to work as independent practitioners but an ‘action first, questions later’ approach is becoming common among regulators with measures going as far as shutting down mother and child clinics without warning or notice. What we have noticed is a rising number of grievances about such arbitrary action being taken against those operating clinics.

Unfortunately, the MAP lacks the resources to support every midwife but we are advocating for stakeholders to agree on a comprehensive scope of practice defining the responsibilities of a midwife and those of other professions. This will bring together stakeholders and will be focused on principles where there is consensus already. For example, a midwife’s domain extends to the whole spectrum of normal reproduction as well as family planning services whereas the doctor should be the expert in complicated births. The skill of a well-trained midwife is recognising when birth is normal and keeping it normal but also being able to detect when a situation must be referred to a doctor.

Such initiatives have already been successful in the mental health profession. For example, psychiatrists may prescribe medicines but psychologists cannot. 

A similar set of standards will go a long way towards protecting the public and midwives and we have started working to launch a consultative process with all stakeholders in this regard.

Regulators have a right to be concerned about midwives who take on patients with complications and a scope of practice will create a conducive climate for practitioners to work in that also gives confidence to pregnant women and children. 

I’d say our focus is on taking advantage of the momentum for reform to raise the status of the profession. While it’s encouraging to be invited to more forums and roundtables there is still a perception that midwifery is a subspecialty of nursing or a ‘second choice’ profession for those who couldn’t become a nurse or a doctor.

There’s a saying that the river runs deeper than the surface image it reflects. However, in the case of midwifery, we continue to be seen as a career with limited depth and scope. 

Dealing with such a deep-rooted problem requires a vision and roadmap and we’re looking to partner with other experts in the clinical, academic and policy making spheres to start work on this. 

We’re fortunate to have the example of the progress in the nursing profession to learn from. In the 1980s, nursing was limited to diploma programmes. But it now offers doctoral programmes, has an established career sector in all streams of service and graduates thousands of students every year across the country.

I hope to bring together and work with midwives across the country so that we can raise the status of the profession and enable every midwife to excel in the quality of care they offer mothers and children.