Authors: Alma Virginia Camacho, Sandra Land, Joyce E. Thompson

Transcription

1 Strengthening Midwifery in Latin America and the Caribbean: A report on the collaboration between the Regional Office for Latin America and the Caribbean of the United Nations Population Fund and the International Confederation of Midwives June 2014

2 Authors: Alma Virginia Camacho, Sandra Land, Joyce E. Thompson Edition and design: Family Care International Photo credits: Joey O Loughlin The activities described in this report were conducted in the framework of UNFPA grants RLA6U204 Strengthened national capacity to implement comprehensive midwives programs and RLAC7103 Increased national capacity to deliver comprehensive maternal health services, implemented by Family Care International between 2011 and UNFPA 2014 Strengthening Midwifery in Latin America and the Caribbean 2

3 Table of Contents i. Foreword... 4 ii. Presentation Introduction Status of Midwifery in LAC Highlights of the UNFPA/ICM Collaboration to Strengthen Midwifery in LAC ( ) Summary Indicators of Health Status, Midwifery Work Force, Education, Regulation, & Association (ERA) References Strengthening Midwifery in Latin America and the Caribbean 3

4 FOREWORD Far fewer women and their newborns die today in Latin America and the Caribbean (LAC) than two decades ago. The LAC region is on track to achieve Millennium Development Goal (MDG) 4, and advances in newborn survival have played a significant part in countries impressive reductions in child mortality. Despite significant progress on maternal health, however, the region is not expected to meet the MDG 5 target of a 75% reduction in maternal mortality between 1990 and Each year, 9,300 women die in the LAC region from causes related to pregnancy and childbirth, and 106,000 do not survive their first month of life. Most of these deaths could be prevented: every preventable death is a violation of the individual s right to life and to the highest achievable standard of health. Each death has a crushing emotional impact on surviving family members, and lost productivity and high medical costs create an enormous financial burden on survivors, communities, and national economies. Each death of a woman and her newborn during pregnancy or childbirth is also a marker of the region s profound inequalities. In LAC, most maternal and newborn deaths take place in poor, rural areas with large minority populations. Improving regional and national averages mask the enormous differences in health outcomes that exist across and within countries. In some rural communities, ten indigenous women die from childbirth complications for every non-indigenous woman who gives birth. These senseless deaths do not have to happen. The Regional Office for Latin America and the Caribbean of the United Nations Population Fund (UNFPA-LACRO) is committed to accelerating progress in saving women s and newborn lives by promoting skilled birth attendance, improving quality of care, and working to ensure every woman s access to comprehensive, timely sexual and reproductive health services. This report shares valuable evidence on human resources for health in the region. UNFPA s fruitful, continuing collaboration with the International Confederation of Midwives and national midwifery associations enables and empowers midwives to help bridge the family planning gap, to ensure that prenatal care and delivery are provided by skilled birth attendants with life-saving skills, and to address the reproductive health needs of young people. Together, we can use information in this document to better understand and improve maternal health services and to promote access to skilled care. Through this report, we are pleased to show how support for professional midwifery associations is having concrete and measurable results in the provision of quality health services before, during and after birth. Marcela Suazo Regional Director The Regional Office for Latin America and the Caribbean, United Nations Population Fund Strengthening Midwifery in Latin America and the Caribbean 4

5 PRESENTATION Evidence shows that investing in developing the capacity of health care providers translates into positive health outcomes. Over the last decade, the recognition of the professional midwife as a provider of skilled birth attendance has grown. In line with UNFPA s strategic priorities, after the launch of the first State of the World s Midwifery report in 2011, UNFPA-LACRO partnered with the International Confederation of Midwives (ICM) to strengthen the ability of midwives and other health professionals with midwifery skills to improve health outcomes for mothers and families in the region. This initiative, implemented in close collaboration with the United States Agency for International Development, the Pan American Health Organization, and Family Care International, is based on the shared vision that competent midwives and others with midwifery skills are key to the delivery of comprehensive, continuous and effective care to women, newborns, families, and communities. One of the keystones of the UNFPA-LACRO/ICM partnership is to build the institutional capacity of professional associations of midwives, regulatory bodies and educational institutions to effectively utilize evidence-based resources and tools. As national and regional capacity progressively increases, the program relies more heavily on South-to-South cooperation, which serves to multiply the initiative s impact. The report, Strengthening Midwifery in Latin America and the Caribbean: A report on the collaboration between the Regional Office for Latin America and the Caribbean of the United Nations Population Fund and the International Confederation of Midwives, , describes the actions taken by UNFPA, ICM, and partners to strengthen the role and competencies of professional midwives in LAC. It begins with an overview of the key challenges faced in the region, followed by a description of the initiative s main strategies and concluding with the partnership s key achievements and lessons learned over the last three years, and recommendations for the future. Our commitment to and investment in enhancing the leadership role of midwives has already had a profound impact: New midwifery programs were created in Haiti and Guatemala. Midwives in the LAC region can now count on an updated curriculum based on the recent ICM global standards and competencies. A cadre of trainer of trainers was formed using these competency-based midwifery education strategies. And midwifery leaders now have the tools to advocate for policies and programs to improve the sexual and reproductive health of adolescents, women, and newborns. Most significantly, much of this important work is being progressively undertaken by the two new regional midwifery networks: the Caribbean Regional Midwives Association and the Federation of Latin American Midwives. We strongly believe that this partnership is helping to build a firm foundation for the sustainable growth and development of professional midwifery in LAC, an essential step to making life-saving care more accessible to women and babies throughout the region for years to come. Dr. Alma Virginia Camacho Regional Sexual and Reproductive Health Advisor The Regional Office for Latin America and the Caribbean United Nations Population Fund Strengthening Midwifery in Latin America and the Caribbean 5

6 1. Introduction Since 2011, following the launch of the first The State of the World s Midwifery report (UNFPA et al, 2011), the Regional Office for Latin America and the Caribbean of the United Nations Population Fund (UNFPA-LACRO) has partnered with the International Confederation of Midwives (ICM) to bolster midwifery leadership in education, regulation, and association to improve the health of women and families in Latin America and the Caribbean (LAC). Efforts to strengthen the contribution of midwives and others with midwifery skills were based on recommendations from a workshop held in Panama in 2011 and are consistent with the global UNFPA strategy of investing in midwifery. Other collaborating partners include the Pan American Health Organizations/World Health Organization (PAHO/WHO), the United States Agency for International Development s Maternal and Child Health Integrated Program (USAID/MCHIP), and Family Care International (FCI). This report seeks to present an overview of the status of midwifery in the (LAC) region as well as a summary of the activities to strengthen midwifery conducted in the framework of the UNFPA-LACRO/ICM partnership since The objective is to highlight the lessons learned from this rich collaboration so that decision-makers, program managers and midwives can implement similar initiatives in the future and in other contexts. i. Regional Situation of Millennium Development Goals (MDGs) 4 & 5 In LAC, maternal mortality decreased by 40% between 1990 and 2013 (WHO, 2014). Unfortunately, at the current rate of decline, the region will not meet MDG 5 by In 2013, the maternal mortality ratio (MMR) in LAC was estimated at 85 per 100,000 live births, representing 9,300 maternal deaths (WHO, 2014). In addition, it is estimated that there are Strengthening Midwifery in Latin America and the Caribbean 6

7 approximately 20 cases of morbidity for every maternal death. Seventeen countries 1 in the LAC region had MMRs above the regional average (PAHO, 2013). The most frequent causes of maternal deaths in LAC are hemorrhage, hypertension, indirect causes, direct causes and unsafe abortion (Say et al, 2014). The large majority of maternal deaths are preventable. Six countries Bolivia, Ecuador, Guatemala, Guyana, Haiti, and Paraguay were prioritized within the scope of this collaboration because of the large numbers of maternal and/or neonatal deaths. [See Section 4, Tables 4:1 and 4:2 for 2012 statistics]. LAC has made great strides in reducing infant mortality over the last decade; however, neonatal mortality has not fallen at the same pace as the overall infant mortality rate. Many countries need to accelerate the reduction in neonatal mortality if they are to achieve MDG 4. Each year more than 106,000 newborns die in the first 28 days of life. The average neonatal mortality rate was estimated at 10 per 1000 live births in Thirteen (13) 2 countries had neonatal mortality rates above the average. Infections and asphyxia are the most frequent direct causes of death. Low birth weight is often a predisposing cause. As noted in the most recent report on child mortality, children that die before 28 days of life often suffer from disease and conditions that are readily preventable or treatable with proven, cost-effective interventions (UNICEF, 2013). ii. Focus on the Skilled Birth Attendant with Emphasis on Professional Midwives As the global health community and advocates sought strategies to address the need for skilled care for childbearing women and their newborns [see Section 4, Table 4:3], a new type of health care provider, the skilled birth attendant (SBA), has emerged. Whereas a range of health professionals with a variety of titles provide childbearing care, the prototype of the SBA is the professional midwife (WHO, WHR 2005). Unfortunately, serious problems with quality of care remain. For instance, even though 80% of births reported in LAC occur in health facilities, the quality of care in deliveries is often less 1 Bolivia, Brazil, Colombia, Dominica, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Panama, Paraguay, Peru, St. Kitts and Nevis, Suriname, and Venezuela 2 Bolivia, Colombia, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Paraguay, St. Vincent, Suriname and Trinidad Strengthening Midwifery in Latin America and the Caribbean 7

8 than optimal (PAHO, 2008). Furthermore, some countries reporting a high percentage of trained personnel also have high MMRs. In 2011, UNFPA-LACRO carried out a rapid assessment of skilled birth attendants by direct observation and in selected countries to address this concern. The observation teams gathered information that addressed who (title & credentials) provided childbearing care and how skilled these attendants were in providing prenatal, intrapartum, newborn and early postpartum care. The outcomes of the SBA rapid assessment suggested that not all the health professionals observed (generalist physicians, auxiliary and registered nurses, midwives, and obstetricians) had the needed competencies to provide high quality care and save lives (Thompson JE et al, 2013). The rapid assessment highlighted the need to develop competencies among health care providers in the region. The assessment s recommendations also served as the basis for the UNFPA-LACRO/ICM collaboration which was developed and rolled out over a four-year period. iii. Professional Midwives and at Risk Populations Whereas midwifery development is viewed as an effective strategy to increase skilled birth attendance, it can also be important in other areas of work, especially those that directly address improving access to quality care for mothers and newborns among vulnerable populations. Presentations at the 4th ICM Regional Conference Professional Midwifery of the Americas in 2013 highlighted the contributions that midwives have made introducing intercultural models of care in maternal health services in Ecuador and Peru, as well as the midwife s critical role in improving adolescent reproductive health, preventing unsafe abortion, and promoting family planning. iv. Models of Childbearing Care in the LAC Region There are several models of childbearing care in the LAC region. In countries including Colombia, Cuba, Dominican Republic and Venezuela, in which there are no professional midwives, childbearing care is provided primarily by physicians within institutions, supported by teams of professional and/or auxiliary nurses, sometimes with post-basic education in maternal and newborn health. In contrast, countries with professional midwifery, such as Chile, Costa Rica, Ecuador, Paraguay, Peru, Argentina, Uruguay and the English-speaking Caribbean, a Strengthening Midwifery in Latin America and the Caribbean 8

9 combination of institutional and community-based professional midwifery care is provided by an obstetric team or in collaboration with physicians. There are also several countries in the region that have a combination of institutional obstetric care provided primarily by physicians and/or specialist nurses with some midwifery competencies, and certified traditional or indigenous midwives in the community. Examples of this model of care include Bolivia, El Salvador 3, Guatemala, Haiti, Honduras, Mexico, Nicaragua, and Panama. However, during the past decade, Nicaragua trained 500 nurse-midwives, Bolivia is introducing nurse-midwives, and Mexico is preparing direct entry midwives along. Similar plans are in place in Guatemala. In any model of childbearing care, there is a need to enhance the competencies of all providers in order to improve the quality of sexual and reproductive health care given. 2. Status of Midwifery in LAC i. Titles used in LAC for midwives and others with midwifery skills Numerous titles are used in LAC for midwives and others with midwifery skills who provide childbearing care in the region. 4 These encompass those with and without essential midwifery competencies. The list includes auxiliary and registered nurses, such as specialists; professional, lay and traditional midwives; and generalist physicians and obstetricians. Certified, registered and/or licensed are sometimes used with the title. Many of these titles are expanded to address level of education, especially of the midwives, and reflect the history of the development of midwifery in those countries. The diversity of titles, curriculums and education requirements makes cross-country comparisons difficult. Thus, it is difficult to assess the impact of type of provider on coverage and quality of services. 3 The ministry of health of El Salvador began upgrading registered nurses with midwifery competencies in See Petterson, 2005; Thomson JE et al, 2012; and recent country midwifery profiles (UNFPA, ICM, FCI ). Strengthening Midwifery in Latin America and the Caribbean 9

10 ii. Summary Profile Data from Selected LAC Countries Life-Saving Skills of Midwives in the Region The SBA diagnostic assessment indicated that many of the providers (midwives, nurses, and generalist physicians) attending births lacked essential life-saving skills. However, the midwifery country profiles, completed in , found that in most countries, professional midwives were either authorized legally or allowed to perform (with no prohibitions) essential life-saving procedures with the exception of assisted delivery (forceps or vacuum extraction). These essential skills are taught and authorized in the 18 countries represented (Table 1). Each of these life-saving skills are included in the evidence-based ICM Essential Competencies for Basic Midwifery Practice (2010; amended 2013), and therefore are expected of every professional midwife. Table 1 Country Report of Life Saving Skills by Midwives and Others with Midwifery Skills Country Start IV Antibio Oxytox MagSO 4 Argentina Yes Yes Yes Yes No No No Yes Yes Bolivia Yes Yes Yes Yes No Yes Yes Yes Yes Brazil Yes Yes Yes Yes No No No Yes Yes Chile Yes Yes Yes Yes No Yes No Yes Yes Costa Rica Yes Yes Yes Yes No Yes Yes Yes Yes Ecuador Yes Yes Yes Yes No Yes Yes Yes Yes Guatemala Yes Yes Yes Yes No Yes Yes** Yes** Yes** Guyana Yes Yes Yes Yes No No No Yes Yes Haiti Yes Yes Yes Yes No/Yes Yes Yes Yes Yes Jamaica Yes Yes Yes No No No Yes Yes Yes Mexico DE Yes Yes Yes Yes No Yes Yes Yes Yes Mexico NM Yes Yes Yes Yes No No Yes Yes Yes Panama Yes Yes Yes Yes No Yes No Yes Yes Paraguay Yes Yes Yes Yes No Yes Yes Yes Yes Peru Yes Yes Yes Yes No Yes Yes Yes Yes Puerto Rico Yes Yes Yes Yes No Yes No Yes Yes St. Lucia Yes Yes Yes Yes No No No Yes Yes Trinidad & Yes No Yes No No No No Yes Yes Tobago Uruguay Yes Yes Yes Yes No Yes* n/a Yes Yes* Source: Country Midwifery Profiles, *= midwives can perform this skill if physician not available. **= nurses can perform this skill if certified. Forcep or Vac. Manual Remove Placenta MVA Bimanual Uterine Compres. NB Resus. Strengthening Midwifery in Latin America and the Caribbean 10

11 Midwifery Scope of Practice The minimum scope of practice for a professional midwife includes pre-conception, prenatal, intrapartum, postpartum, newborn and family planning services. In some countries midwives also attend other aspects of sexual and reproductive health, including the prevention of unsafe abortions. However, midwives in some countries are not authorized to practice certain skills that are considered essential by ICM competency guidelines. Some examples include the inability to prescribe contraceptive methods (Argentina, St. Lucia and Uruguay), repair an episiotomy (Trinidad & Tobago), and manually remove the placenta (Argentina, Guyana and St. Lucia). Strengthening Midwifery Toolkit (SMTK) Rapid Assessment We assessed the regulatory environment in selected LAC countries to measure the level of development of the midwifery profession in the region. We used the Rapid Assessment Tool from the Strengthening Midwifery Toolkit (PAHO/WHO, 2011). As can be seen in Table 2, there is significant variation across countries. Countries with the strongest enabling regulatory environments for the practice of midwifery include Chile, Costa Rica, Jamaica, Peru, and St. Lucia; the weakest include Argentina, Bolivia, Brazil, Guatemala (which is just developing its professional midwifery program), Mexico, Paraguay, and Puerto Rico. The strongest midwifery pre-service education development and support programs are in Chile, Costa Rica, Haiti, Paraguay, Puerto Rico, St. Lucia and Uruguay. Several of these same countries require ongoing continuing professional development (CPD) for re-licensure. Strengthening Midwifery in Latin America and the Caribbean 11

12 Table 2 Comparison of Rapid Assessment Scores by Country & Indicator Group 6 Country 1-2 REG 3,5, 8,9,10 PSE 4-11 PSC Argentina /39 Bolivia /39 Brazil /39 Chile /39 Costa Rica /39 Ecuador /39 Guatemala /39 Guyana /39 Haiti /39 Jamaica /39 Mexico /39 Mexico /39 (NM) Panama /39 (SN) Paraguay /39 Peru /39 Puerto /39 Rico St. Lucia /39 Trinidad y /39 Tobago Uruguay /39 Source: Country Midwifery Profiles, STD The Code under each indicator is as follows: REG = items pertaining to midwifery regulation PSE = items pertaining to pre-service midwifery education PSC = items pertaining to midwifery practice and standards of care STD = items pertaining to midwifery staffing & deployment CPD = items pertaining to continuing professional development CPD Total score N = 39 maximum 5 These data are from the direct entry midwives in Mexico only who carry a certificate to practice but are not yet legally recognized. The nurse-midwife scores are much higher but they do not, with few exceptions, practice fullscope midwifery including attending births. 6 There is a maximum rating of 3 points for each item, with a rating of 0 if no activity up to 3 for maximum activity. If each of the 13 items were rated at the highest score of 3, the maximum total points would be 39. Strengthening Midwifery in Latin America and the Caribbean 12

13 Midwifery staffing and deployment planning needs further attention. Only Chile, Costa Rica, Guyana, and Uruguay have this type of such planning in place. Also, several countries lack or have weak midwifery practice standards for maternal and newborn health. Countries including Bolivia, Guatemala, Guyana, Paraguay, Puerto Rico, and St. Lucia must strengthen these standards. It is important to note that countries are working on improving items with low scores, and sharing their efforts with other countries in regional meetings. This rapid assessment suggests that countries with the weakest overall level of development of professional midwifery are Bolivia 7, Brazil, Guatemala, Guyana, Paraguay and Puerto Rico, though the reasons are different in each country. The countries with the strongest overall midwifery development include Chile, Costa Rica, Jamaica, Peru, St. Lucia and Uruguay. iii. Midwifery Association Development At the beginning of this initiative, we compiled an inventory of midwifery and other relevant professional organizations that would need to be considered in efforts to provide support for midwifery development in the region. This inventory included organizations which have an interest in and/or responsibility for: professional development of midwives and others with midwifery skills registration, certification and/or licensure of midwives and others with midwifery skills approval, accreditation or other regulation of midwifery education programs In developing this inventory, emphasis was given to organizations and associations in priority countries and to organizations which could partner with them to support development. While the focus in the first year was on professional associations, some of which also serve as the regulatory bodies in their own country, planned work on regulation beginning in 2014 will involve partnering with additional organizations in some countries. 7 On February 25, 2014, the Ministry of Health signed Resolution Ministerial No that authorized the formal registration of nurse-midwives that will allow these university prepared professionals to practice as nursemidwives in the country. Until this time, the nurse-midwifery graduates returned to nursing posts. Strengthening Midwifery in Latin America and the Caribbean 13

14 Argentina, Barbados, Brazil, Chile, Ecuador, Guyana, Haiti, Jamaica, Paraguay, Peru, Suriname, Trinidad and Tobago, and Uruguay have midwifery organizations which are members of ICM. Guyana and Suriname are the most recently formed. Costa Rica, Panama and St. Lucia have midwifery associations which are not yet ICM members, however, the midwifery organization of Costa Rica is currently applying for ICM membership. In several countries, the concern has been raised that the ICM-member organizations do not cover all the practicing midwives in that country. For example, in Jamaica, the midwifery association includes direct entry midwives but not nurse-midwives. In Argentina, the ICM member is a college which operates in only one province and is not national in scope. One approach being used to strengthen the professional organizations is the application of the ICM Midwifery Association Capacity Assessment Tool (MACAT) (ICM 2011). By the end of 2013, Argentina, Ecuador, Guyana, Haiti, Paraguay, Suriname, Trinidad and Tobago, and Uruguay had used the instrument as part of their strategic planning process. While it is too soon to determine the success of this approach, the feedback from the regional ICM representatives who are supporting members in this effort has been very positive. Some of the specific achievements of individual midwifery associations include: Colegio de Obstetras del Peru successfully managed and hosted the 2012 UNFPA- LAC/ICM regional meeting to roll out the ICM core competencies and standards, which included an advocacy workshop. La Federación Nacional de Obstetrices/tras del Ecuador hosted the successful Fourth ICM Americas Regional Conference with more than 1,000 participants in April Trinidad & Tobago Association of Midwives assumed primary responsibility for the early creation of the regional network of midwifery associations, the Caribbean Regional Midwives Association. By creating chapters in rural settings, the Asociación de Obstetras del Paraguay is reaching more midwives outside urban areas. Strengthening Midwifery in Latin America and the Caribbean 14

15 The first Haitian association of nurse-midwives, Association des Infirmières Sages-Femmes de Haiti, was formed with technical and financial support from the UNFPA country office, and guidance from the Canadian Association of Midwives. Midwives Association of Guyana separated from the Guyana Nurses Association to become a free-standing midwifery association. Suriname Organization of Midwives was selected to host the Fifth ICM Americas Regional Conference in iv. SWOT Analysis Based on Responses from Country Profiles This section provides a summary of the issues affecting midwifery development and expansion either positively or negatively in LAC. We describe common challenges and bottlenecks as well as exciting opportunities and innovations. It is important to note that there are sub-regional differences in the areas listed below. For instance, there are predominantly more nurse-midwives in Central America and the Caribbean and direct entry midwives in South America. The tables in Section 4 also highlight these sub-regional differences. Common Challenges and Bottlenecks Midwifery Education Lack of infrastructure and equipment for nursing and midwifery schools; e.g., teaching materials, models. Insufficient number of midwifery teachers. Lack of teacher preparation in competency-based education (CBE) strategies. Overcrowding in clinical areas leading to lack of sufficient experience to prepare competent midwives, nurses and physicians, especially in intrapartum area. Lack of financial support for midwifery programs, teachers and students. Individuals without midwifery competencies preparing new midwives. Low status of midwives resulting in limited recruitment of strong candidates to education programs. Strengthening Midwifery in Latin America and the Caribbean 15

16 Midwifery Practice and Deployment Insufficient number of midwives and others with midwifery skills available to meet the need. Low pay and low status of midwives; e.g., brain drain of health professionals in the Caribbean sub-region to resource rich countries. Lack of or insufficient investment of ministries of health in improving access to quality sexual and reproductive health services, especially for vulnerable populations. Over medicalization of birth, including extremely high rates of Cesarean sections in several countries, such as Brazil and Chile. Competition and lack of support from some physicians and nurses and their professional associations. Insufficient or poor collaboration, communication and cooperation among members of the health care team. Women unaware of professional midwifery and right to humanized childbirth with provider of their choice. Multiethnic and multicultural groups supportive of traditional birth attendants. Midwifery Regulation Governments lack of understanding of need for midwives; e.g., refusal to allow new cadres of midwives (both nurse-midwives and direct entry) to practice midwifery. Regulatory bodies limit full scope midwifery practice in some countries due to lack of knowledge of midwife s role in reducing maternal and newborn mortality and morbidity. Lack of clarity in regulatory requirements. Lack of requirement to maintain currency in midwifery practice. Strengths: Global midwifery practice norms available following ICM evidence-based competencies. Global standards for midwifery education and regulation available to all countries. Enabling regulation for midwifery practice in many countries with strong government support. Strengthening Midwifery in Latin America and the Caribbean 16

17 Professional certification and/or recognition of professional midwives who complete pre-service education based on agreed competencies. Strong interagency support to work collaboratively with ICM members to strengthen midwifery education, regulation, and associations. Sufficient CBE teachers and clinical experience to prepare competent midwives in several countries of the region. Effective and supportive midwifery associations in many countries. Growing awareness of risks of unsafe abortions in some contexts. Regional networks of midwives created with strong leadership dedicated to strengthening midwifery. Opportunities: Professional midwives recognized as key providers of quality maternal, newborn, reproductive and sexual health. Professional midwives can reaffirm and link with ICPD+20 strategies. Professional midwives have a vital role to place in sexual & reproductive health, including family planning, prevention of adolescent pregnancy, unsafe abortion, and vertical transmission of HIV. Renewed government emphasis on primary health care, including midwives practicing at community level. Government commitment to prevent adolescent pregnancies and vertical transmission of HIV in many countries. Growing support for normal birth and breastfeeding. Strong external technical and financial support for strengthening midwifery from development partners. New global and regional tools for strengthening midwifery are available in multiple languages for use worldwide. Strong midwifery leaders taking active roles in developing health policies for maternal and newborn care. Strengthening Midwifery in Latin America and the Caribbean 17

18 Innovations: A number of programs and projects to prepare or enhance the competency of midwives and others with midwifery skills in many countries. Development of regional midwifery bodies: CRMA, FLO. South-to-South cooperation for development of midwifery pre-service education. South-to-South cooperation in the Caribbean region on development and provision of continuing professional development opportunities for midwives. Opportunities to apply Train the Trainers methodology on CBE teaching, learning and assessment. 3. Highlights of the UNFPA/ICM Collaboration to Strengthen Midwifery in LAC ( ) Based on the outcomes of the SBA rapid assessment and midwifery profiles, awareness of a variety of models of childbearing care, continuing high levels of maternal and neonatal mortality and the insufficient number of professional midwives in some countries, UNFPA/ICM efforts in LAC focused on the roll out the ICM global competencies for midwifery practice and standards for education and regulation in keeping with the 2011 ICM International Definition of Midwife and Scope of Practice. 8 i. Strategic Planning Joint UNFPA/ICM initiatives to strengthen midwifery had been underway around the world for a number of years (UNFPA/ICM Investing in Midwives, 2008). In LAC, several countries, especially Guyana and Haiti, benefited from this earlier support for midwifery development. A first step in the UNFPA-LACRO/ICM collaboration was to create an Advisory Committee 8 Refer to Section 4, Table 4:4 for an overview of midwifery education, association development, and regulatory requirements in the 18 countries that completed profiles in 2013 and Strengthening Midwifery in Latin America and the Caribbean 18

19 comprised of UNFPA-LACRO, ICM regional representatives, FCI, USAID and two technical advisors. The committee provides overall guidance to the project. In November 2011, UNFPA-LACRO convened the regional meeting Promoting Midwifery in Latin America and the Caribbean: Strategic Planning for Achieving MDG 5. The meeting was planned by UNFPA-LACRO, USAID, Regional ICM representatives, the president of the new regional network in Latin America (FLO) and Family Care International (FCI). Additional support and technical assistance was provided by PAHO s Latin American Center for Perinatology, Women s and Reproductive Health (PAHO/CLAP). Forty-eight midwifery leaders and others from twenty-one countries reviewed the 2011 State of the World s Midwifery report and the ICM global standards and competencies (2010). The purpose of the meeting was to identify the strategic areas and priorities that would guide activities through These included: Strategic areas: Develop policies and programs including human resources management for quality sexual and reproductive health services. Enact legislation and promulgate regulations that support the full scope of midwifery practice. Ensure that pre service midwifery education programs prepare competent midwives for beginning practice, using CBE and the ICM global standards and competencies. Ensure that continuing education and post basic education programs are available. Support development of professional midwifery associations and regional networks. Create or strengthen partnerships among stakeholders, including professional, governmental, and donor agencies. Provide comprehensive support to priority countries for developing midwifery. Priority activities for : Implement the ICM Global Standards and competencies throughout the region. Coordinate international cooperation (UNFPA, PAHO/WHO, USAID/MCHIP) for midwifery development at country and regional levels to avoid duplication, achieve greater synergy and maximize impact of available resources. Strengthening Midwifery in Latin America and the Caribbean 19

20 Provide technical support to implement country, sub-regional and regional plans. Make continuing education programs available, including those provided virtually. Support ICM Americas regional conferences. Create midwifery networks in Latin America and the Caribbean sub-regions, including a network of university based midwifery educators. Provide tools to manage midwifery personnel resources based on country needs. Support for midwifery associations in countries, sub-regions and regions Continue to compile information (profiles) on midwifery and midwifery services in LAC, including documentation of successful experiences. Support six priority countries: Bolivia, Ecuador, Guatemala, Guyana, Haiti and Paraguay. Promote quality improvement efforts in health systems responsible for sexual and reproductive health services. Promote active participation of midwives in prevention of adolescent pregnancy. Support development of young midwifery leaders in the region. Meeting participants continued to meet in the following years to reaffirm the strategies to strengthen midwifery in the region and recommitted to enhancing collaboration with existing initiatives at country and regional levels. Each year s UNFPA-LACRO/ICM workplan included specific activities that addressed the strategic areas and priorities outlined above. Inter-agency synergy was ensured by including PAHO/WHO, USAID and FCI as collaborating partners in activities such as the CBE workshops in the Caribbean, updating the PAHO/WHO Strengthening Midwifery Toolkit (2013), and supporting the development of two regional midwifery networks: the Caribbean Region Midwives Association (CRMA) and the Federation of Latin American Midwives (FLO). A brief discussion of each of the major activities follows. The collaboration has served to strengthen midwifery throughout LAC. As of 2014, state of the art midwifery practice has become a goal for many countries. ii. Roll out of ICM Standards and Competencies There were two concrete opportunities to roll-out and discuss use of the 2010 ICM updated essential competencies and new education standards. The first was in Peru, in July 2012, as part Strengthening Midwifery in Latin America and the Caribbean 20

21 of a workshop with 18 participants from 5 countries. The second was in Trinidad, in October 2013, during the initial day of meetings with 21 midwives from seven countries. These ICM core documents were also discussed in April 2013 at the ICM Americas Regional Conference in Quito, Ecuador, attended by over 1,100 midwives from 24 countries in South, Central and North America. The ICM Regional Representatives for the Americas presented the ICM global competencies and standards at this high-level event. The ICM standards for midwifery regulation were rolled out in April 2014 at a meeting organized by UNFPA-LACRO, ICM and PAHO in Uruguay with participants from 10 countries. The global regulation standards will serve to review and update midwifery regulation in LAC in Following the roll out of the ICM competencies and standards, several countries revised their existing pre-service curricula, completed a gap analysis, and updated the content based on the ICM competencies (e.g., Barbados, Bolivia, Chile, Guyana, Jamaica, Peru, Puerto Rico, St. Lucia, Trinidad & Tobago). Argentina is currently reviewing the essential competencies curriculum. In Haiti, the ICM competencies and education standards were adopted by the Ministry of Health, the new pre-service education direct entry midwifery program was designed and implemented, and the existing nurse-midwifery program updated. In 2012 planning began for a direct entry midwifery program sponsored by the Ministry of Health in Guatemala. 9 Support for the new direct entry midwifery program in Guatemala has been ongoing. The use of the ICM competencies and education standards has been central to the technical assistance provided beginning with the initial consultations in 2012 and continuing through early A Ministry of Health Commission was established to design and put into operation the proposed three year university based program for the partera técnica universitaria (technical university midwife). A key feature of the technical assistance has been coordination of support from UNFPA and USAID at both country and regional levels. Upon completion of the framework for the curriculum, the focus of technical assistance moved to developing the curriculum, working with the university selected for the first program, preparing training sites and upgrading personnel. South-to-south cooperation, currently provided by the San Martín de 9 See Section 4, Table 4:4 for overview of results of introducing ICM global standards and competencies and use the ICM association development tool, the Midwifery Association Capacity Assessment (MACAT).] Strengthening Midwifery in Latin America and the Caribbean 21

22 Porres Midwifery School in Lima, Peru, has been a feature from the beginning. The program is expected to begin admittin students by mid iii. Strengthening Midwifery Leadership, Associations, Regional Networks Strengthening Midwifery Associations In 2013, technical support was provided to new midwifery associations and to associations seeking ICM membership. As a result of these efforts, a new midwifery association was formed in Costa Rica and recognized by the National Nursing College. This association is now finalizing its application for ICM membership with support from the ICM Americas Regional Representative and UNFPA-LACRO. CRMA, mentored by the ICM regional representatives, is now mentoring small midwifery associations in the sub-region in their applications for ICM membership. CRMA is also applying for ICM membership as a group to strengthen all their member associations. This application has been included in the agenda of the 2014 ICM Council meeting in Prague, as in order to be approved, it would require a change in the ICM Constitution. Regional midwifery networks The Federation of Latin American Midwives (FLO) was formed and officially registered as a non-governmental organization in Uruguay in The primary purpose of this regional network was to establish university direct-entry preparation of midwives as a model for the region. The initial members were from universities, professional associations, scientific entities, and federations of midwives from Chile, Ecuador, Paraguay, Peru and Uruguay. In 2013 and 2014, FLO membership grew to include two additional universities from Chile, one from Argentina and one from Brazil. Membership will continue to increase with applications from Bolivia, Costa Rica and El Salvador that are currently under review. Its purpose has expanded to support and strengthen all types of midwifery education, along with midwifery associations, regulation, and practice. In 2013, FLO took on the Strengthening Midwifery in Latin America and the Caribbean 22

23 responsibility/oversight of the Young Midwifery Leaders (YML) program in Latin America and will work with CRMA to expand CBE in Latin America. The Caribbean Regional Midwives Association (CRMA) was launched in April 2012 in Trinidad and Tobago. Membership comprises midwives associations or groups in 14 countries (* denotes ICM member associations): Antigua and Barbuda, Bahamas, Barbados*, Dominica, Grenada, Guyana*, Haiti*, Jamaica*, Puerto Rico, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Suriname*, and Trinidad and Tobago*. The government of Trinidad and Tobago agreed to recognize the CRMA constitution in early 2014, and the organization is now a legal entity sited there. One main goal of CRMA is to unify midwifery in the Caribbean and to help strengthen the profession particularly in the smaller countries and where there are no midwives associations. Another main goal is to strengthen the three ICM pillars: Education, based on the core competencies, Regulation with a focus on the ICM global standards, and Associations using the ICM Midwifery Association Capacity Assessment Tool (MACAT). As such, three committees were officially formed to address each of these main areas. CRMA hosted the first CBE Trainer of Trainers (TOT) program in October In 2014, the four Trinidad and Tobago midwife teachers who participated in the TOT program were certified as Midwifery CBE Master Trainers and the CRMA Education Committee will take on the oversight of the CBE workshops for midwife teachers and preceptors throughout the region. CRMA is also preparing a review of CBE literature for publication in In 2015, CRMA will begin a TML program for the English-speaking Caribbean midwives. Table 3 provides a summary of the development of the two regional midwifery organizations, including the current officers and structure. Strengthening Midwifery in Latin America and the Caribbean 23

24 Table 3 Development of FLO and CRMA Regional Midwifery Organizations FLO CRMA Statutes since Legally registered in Uruguay Trinidad & Tobago Logo Yes Yes Webpage Planned 2014 Community of Practice in GANM Categories of members Professional midwifery organizations; midwifery education programs, PAHO/WHO Collaborating Centers. Total members plus 3 in process 13 Members added in N/A Professional midwifery organizations; individuals Office space Yes Yes Member dues Yes Yes Vision, Mission and Yes/Yes/Yes Yes/Yes/No Strategic Plan Priorities Advocacy Young Midwifery Leaders Continuing Professional Education Competency Based Education Executive Board Term Interim Executive Board Members Pres. Ana Labandera, Uruguay Pres. Marcia Rollock, Trinidad & Tobago V.P. Joel Mota Peru Sec. Luz Torres Paraguay Treas. Marcia Robalino, Ecuador Treas. Iris Vassell Murray, Jamaica Sec. Marita Harris, Barbados Committees/Commissions Education, Regulation, Advocacy (2014) Last Annual Meeting April, 2014 April, 2013 Planned Annual Meeting July, 2015 July, 2014 Source: UNFPA-LACRO and ICM collaboration, 2014 Public Relations Officer Rosie Felix, Dominica. Ethics, Education, Regulation, and Association (2012) Strengthening Midwifery in Latin America and the Caribbean 24

25 Young Midwifery Leaders In 2013, FLO took the leadership in adapting and implementing the Young Midwifery Leaders (YML) program for Spanish-speaking midwives. This program was modeled after the ICM YML program with support from the global ICM. The program was launched in Quito, Ecuador, with 12 mentees and 10 mentors from 7 countries (Argentina, Brazil, Chile, Ecuador, Paraguay, Peru, and Uruguay). The program is 18 months long, with 16 self-study modules and a leadership project. In late early 2014, three collaborating faculty members from Chile and Ecuador were added to support the mentors. FLO s Education Committee will conduct an evaluation of the program by October Based on the results, we plan to replicate the YML program in the Caribbean in The ICM core resource documents for education have informed the development of the YML programs along with human and technical resources from MCHIP. Fourth ICM Americas Regional Conference More than 1100 midwives attended the Fourth ICM Americas Regional Conference held in Quito, Ecuador in April Midwives from the following countries were present: Antigua, Argentina, Bahamas, Barbados, Bolivia, Canada, Chile, Costa Rica, Dominica, Ecuador, Grenadine, Guatemala, Guyana, Haiti, Jamaica, Peru, Puerto Rico, St. Lucia, St. Kitts & Nevis, Suriname, Trinidad & Tobago, USA, and Uruguay. This was the largest Americas ICM regional conference, supported technically and financially by UNFPA-LACRO, PAHO/CLAP, and USAID. Some of the issues addressed were adolescent pregnancy prevention, intercultural maternal health care, the midwife s role in sexual and reproductive health, and presentation of findings of the SBA rapid assessment. Midwives who were participants in the 2012 Panama meeting shared their country s strategic efforts to strengthen midwifery using the ICM global standards and competencies. During formal presentations, plenary discussions and scheduled meetings, midwifery leaders from the entire region validated the priorities underpinning the work underway to strengthen midwifery. At their annual meeting, CRMA members agreed to move ahead with a constitution and formal recognition while FLO members decided to expand their membership to other Strengthening Midwifery in Latin America and the Caribbean 25

26 organizations. These regional conferences provide a venue to showcase the many advances in midwifery in LAC as well as providing an opportunity for the development of midwifery leadership at all levels. Country Profiles Only four LAC countries Bolivia, Guyana, Haiti and Nicaragua were included in the first The State of the World s Midwifery. Viewed as an important resource to support, monitor and evaluate midwifery development in countries, in 2012 we developed profiles in additional countries, including Ecuador, Guatemala and Paraguay. In preparing the instruments for collating information in the countries, the Advisory Committee considered prior work in the region, such as Profiling Midwifery Services in the Americas (Pettersson & Stone, 2005), as well as the questionnaires used by UNFPA to prepare the country profiles in the State of the World Midwifery Report, During the first half of 2012, the methodology and instrument, Midwives and Others with Midwifery Skills (MOMS) in LAC: Country Profiles, were piloted in Uruguay, Trinidad & Tobago and Peru. The validated instrument was subsequently made available to other countries in the region and six additional countries completed profiles in A panel during the Fourth ICM Americas Regional Conference shared the experience and results from several countries generating interest in expanding the work. Eighteen countries had completed profiles by early 2014 and several others are underway. The process of preparing the country profile ideally begins by convening a group of stakeholders and experts to plan for the data collection and to complete the Situational Analysis and Identification of Needs to Strengthen Midwifery (PAHO, SMTK Module 1, 2011). This rapid assessment of midwifery with 13 items, each with a score of 0 to 3, is a qualitative measure of opinion with regards to pre-service education, regulation, staffing and deployment, quality standards and practice, as well as ongoing professional development. The instrument was adapted for use in countries without midwives but with specialist maternal and neonatal nurses. The results of this analysis allow stakeholders to begin the strategic planning process, identify strengths and weaknesses in midwifery, and agree on priorities for an action plan. It Strengthening Midwifery in Latin America and the Caribbean 26