The year 2020 has been designated as the year of the nurse and midwife. Globally, midwives have been looking forward to this year to organize, plan and strategize how to shape the future of maternal health. They could not have anticipated that a pandemic would cripple the mankind.  Covid-19 has ravaged the world, infecting and killing millions in its path. The pandemic has further destroyed livelihoods, interrupted education of children, hundreds of millions of people have lost their jobs. Humans are, however, resilient, and ready to take back control of their lives by understanding how to defeat the virus through improved treatment, and the development of vaccines. Soon the pandemic will be behind us. For those of us who are involved in maternal health, this is a critical time. I would like to talk about midwifery in Bangladesh and why it is the most important resource to curve maternal and neonatal mortality and stillbirths.
I will start by sharing the groundbreaking study recently published in the Lancet, titled “Potential Impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: A lives Saved Tool Modelling Study” by Andrea Nove et al. This modeling study provides us an estimate as to the incredible impact midwives have on maternal and neonatal mortality and stillbirth prevention. The authors estimated that by increasing midwifery interventions such as family planning, diabetes management, safe birthing and breastfeeding, millions of mothers and their newborns could be saved. For example, a 25 per cent increase in coverage every 5 years of midwife-delivered interventions could avert 41per cent of maternal deaths, 39 per cent of neonatal deaths, and 26 per cent of stillbirths, equating to 2·2 million deaths averted per year by 2035. The study helps to establish the necessary actions to be taken in the coming years, as we engage in programme planning.
Global maternal health has been a topic of growing concern. Influential leaders across the globe have taken a universal oath to play a role in bettering the state of maternal health across the world. The International Conference on Population and Development (ICPD) organized by UNFPA in Cairo, in 1994, marked the monumental occasion where 179 governments pledged to drastically lower the maternal mortality rate by at least 75 per cent by the year 2015. The United Nations Millennium Summit further endorsed this goal in 2000 and vowed to mobilize resources in order to ensure achieving the goal, which was a part of the Millennium Development Goals (MDGs). However, these efforts were not sufficient, and the goals were far from being achieved.
World leaders came together again in 2015 and embarked on another set of ambitious goals, called the Sustainable Development Goals (SDGs). In terms of maternal health, the newly defined goal was to lower the maternal mortality to as low as 70 deaths per 100,000 live births globally and 140 deaths per 100,000 live births in an individual country by 2030.
Bangladesh made significant stride in improving maternal health in line with the MDGS, and in 2010, was acknowledged by the WHO to have done a commendable job in meeting targets despite various socioeconomic challenges. Despite progress, when data was gathered and analyzed, it was obvious that the government’s intensive efforts did not bring about substantial improvement in the past decade. The class who remains neglected is the uneducated, poor rural women who are unable to access quality care. Additionally, Bangladesh lacks in its supportive programmes such as delayed first birth, quality and affordable antenatal and postnatal care, family planning, birth spacing, improved access to women's education, and availability of menstrual regulation.
Then in 2010, Bangladesh witnessed a new hope, when the Prime Minister Sheikh Hasina declared at the UN General Assembly Special Session of “Every Mother Every Child” that her government will train 3,000 midwives in 5 years and will also create posts for them. The Prime Minister is a staunch proponent of maternal health, and her decisive action on this issue has made a dramatic impact. In 2013, a 3-year Midwifery diploma training programme began in the country, supported by the Government, donor groups and academic institutions such as UNFPA, DFID and BRAC University. As of August 2019, a total of 2,131 midwives are licensed in Bangladesh, and many more are in training. Currently an estimated 40 institutions are training midwives, including our organization, HOPE Foundation for Women and Children of Bangladesh. We are the sole organization that trains midwives in southeastern part of the country.
In the Cambridge dictionary, a midwife is defined as “a person, usually a woman, who is trained to help women when they are giving birth”.
According to WHO, midwifery practice encompasses care of women during pregnancy, labour, and the postpartum period, as well as care of the newborn. It includes measures aimed at preventing health problems in pregnancy, the detection of abnormal conditions, the procurement of medical assistance when necessary, and the execution of emergency measures in the absence of medical help
Midwifery is one of the oldest professions, dating back to Egyptian and Roman scrolls. Unfortunately, this profession has been largely neglected in recent times, mostly in part due to the over medicalization of pregnancy care, and a lack of resources for educating recruiting midwives. Midwives, when trained and educated to internationally accepted standards, have the competencies to deliver 87per cent of essential services for women and newborns. Not only are they fully competent to care for women and their newborns, but they can do so at a much lower price point. They could avert 80per cent of all maternal deaths, still births, and neonatal deaths.
The benefits of deploying and utilizing midwives are that they can work in the remote, rural areas and in smaller villages. They can work as skilled birth attendants and form relationships with the families, and the community people. They are affordable, and most importantly, they place the mother in the centre of the continuum of care. At HOPE Foundation, our midwives work within the community involving not only the mothers, but also the community members and other essential resource persons that mothers might require services from in case of complicated pregnancies. This model of care we coined the “Golden Chain” which implies unbroken pregnancy care from conception to birth. We establish midwife-led birth centers in the rural areas, where their services are most needed.
Golden Chain is a holistic model of care realizing that maternity care does not just involve the delivery of a baby. It includes pre-conception health of the woman, health and nutrition while pregnant, adequate prenatal care and monitoring for complications, safe delivery, postpartum care of new mother and newborn, breastfeeding, care of infant and consequent family planning choices including contraception, or decision to have another baby. Timely referral of a high-risk mother is also included in the Golden Chain concept.
Covid-19 has created unprecedented challenges for the midwives who are working on the frontlines in midwife- led birth centres in rural villages. While many clinics and hospitals initially shut their doors due to the pandemic, the midwives continued providing critical care to women and their babies.
Approximately 11,000 maternal deaths, 74,000 neonatal deaths and 79,000 stillbirths are reported annually in Bangladesh. Most of these happen in the rural areas of the country, and the majority of the deaths are preventable by providing women centered care in midwife-led birth centers, in collaboration with others in the community. Midwifery care can significantly reduce cesarean sections and other morbidities by promoting safe natural birth.
UNFPA cites: "Investing in midwifery education, with deployment to community-based services, could yield a 16-fold return on investment in terms of lives saved and costs of caesarean sections avoided, and is a “BEST BUY” IN PRIMARY HEALTH CARE”.
In order to achieve the maternal health target of the SDGs, we must invest in educating more quality midwives and deploying them to rural areas, creating opportunities for them to practice midwifery with an entrepreneurial zeal. We must support them in providing the “Golden Chain” model of care through midwife-led birth centers. Large development agencies and business enterprises must put resources into midwifery education and practice. It is not only a job of the Government, but also a collective responsibility of all of us.

The writer is the President and Founder of HOPE Foundation for Women and Children of Bangladesh, Cox’s Bazar. He can be reached at [email protected]