Midwifery 2030: A woman's pathway to health. What does this mean?

© 2015 The Authors. The 2014 State of the World's Midwifery report included a new framework for the provision of woman-centred sexual, reproductive, maternal, newborn and adolescent health care, known as the Midwifery2030 Pathway. The Pathway was designed to apply in all settings (high-, middle- and low-income countries, and in any type of health system). In this paper, we describe the process of developing the Midwifery2030 Pathway and explain the meaning of its different components, with a view to assisting countries with its implementation.The Pathway was developed by a process of consultation with an international group of midwifery experts. It considers four stages of a woman's reproductive life: (1) pre-pregnancy, (2) pregnancy, (3) labour and birth, and (4) postnatal, and describes the care that women and adolescents need at each stage. Underpinning these four stages are ten foundations, which describe the systems, services, workforce and information that need to be in place in order to turn the Pathway from a vision into a reality. These foundations include: the policy and working environment in which the midwifery workforce operates, the effective coverage of sexual, reproductive, maternal, newborn and adolescent services (i.e. going beyond availability and ensuring accessibility, acceptability and high quality), financing mechanisms, collaboration between different sectors and different levels of the health system, a focus on primary care nested within a functional referral system when needed, pre- and in-service education for the workforce, effective regulation of midwifery and strengthened leadership from professional associations. Strengthening of all of these foundations will enable countries to turn the Pathway from a vision into reality

Unravelling the impact of soil types on zinc, iron, and selenium concentrations in grains and straw of wheat/Amblyopyrum muticum and wheat/Triticum urartu doubled haploid lines

The concentration of mineral nutrients in plants is associated with bioavailabilities of soil mineral nutrients, which are regulated by various soil physio-chemical properties. A pot experiment was conducted to investigate the effects of soil type on grain and straw zinc (Zn), iron (Fe) and selenium (Se) concentrations of wheat/Amblyopyrum muticum and wheat/Triticum urartu doubled haploid lines. A set of 42 treatments in a factorial combination with 21 genotypes and two soil types collected from Ngabu and Chitedze Research Stations in Malawi was laid in a randomised complete block design (RCBD) in three replicates. Pre-experiment soil Zn and Fe were extracted using DTPA extraction method followed by analysis with inductively coupled plasma-mass spectrometry (ICP-MS). Aqua-regia hotplate acid digestion was used to extract soil Se and analysis was done using ICPM-MS. Grain and straw samples were digested using nitric acid digestion (HNO3) and analysed using ICP-MS. Soil analysis results showed that the two soils had the same textural class (Sandy clay loam), but different mineral concentrations, pH levels and percentage organic matter. Analysis of variance revealed a ~two-fold higher Zn concentration in grains grown in low pH, high Zn soils (Chitedze soils) compared to grains grown in high pH, low Zn soils (Ngabu soils). Variation in grain Zn concentration was associated with the genotypes (p = 0002), soil type (p = <0.0001), and their interaction (p = 0.035). Grain Fe was 1.3-fold higher in low pH than in high pH soils, and it was influenced by genotypes (p = < 0.0001) and soil type (p = <0.0001). Grain Se was highly associated with soil type (p = <0.0001), and it was 30-fold higher in high pH than in low pH soils. Straw Zn was generally higher in plants grown in Chitedze soils than Ngabu soils, whilst straw Se was higher in plants grown in Ngabu soils than Chitedze soils. The findings demonstrate the significance of soil physio-chemical properties for mineral accumulation and distribution to plant parts, thus informing future breeding programs on importantconsiderations on crop genetic biofortification with the three mineral element

Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: Addressing the post-2015 agenda

© 2018 The Author(s). Background: In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce. Methods: The State of the World's Midwifery report 2014 used a broad definition of midwifery ("the health services and health workforce needed to support and care for women and newborns") and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework. Results: Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation. Conclusions: The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued

A descriptive analysis of midwifery education, regulation and association in 73 countries: The baseline for a post-2015 pathway

© 2016 The Author(s). Background: Education, regulation and association (ERA) are the supporting pillars of an enabling environment for midwives to provide quality care. This study explores these three pillars in the 73 low- and middle-income countries who participated in the State of the World's Midwifery (SoWMy) 2014 report. It also examines the progress made since the previous report in 2011. Methods: A self-completion questionnaire collected quantitative and qualitative data on ERA characteristics and organisation in the 73 countries. The countries were grouped according to World Health Organization (WHO) regions. A descriptive analysis was conducted. Results: In 82% of the participating countries, the minimum education level requirement to start midwifery training was grade 12 or above. The average length of training was higher for direct-entry programmes at 3.1 years than for post-nursing/healthcare provider programmes at 1.9 years. The median number of supervised births that must be conducted before graduation was 33 (range 0 to 240). Fewer than half of the countries had legislation recognising midwifery as an independent profession. This legislation was particularly lacking in the Western Pacific and South-East Asia regions. In most (90%) of the participating countries, governments were reported to have a regulatory role, but some reported challenges to the role being performed effectively. Professional associations were widely available to midwives in all regions although not all were exclusive to midwives. Conclusions: Compared with the 2011 SoWMy report, there is evidence of increasing effort in low- and middle-income countries to improve midwifery education, to strengthen the profession and to follow international ERA standards and guidelines. However, not all elements are being implemented equally; some variability persists between and within regions. The education pillar showed more systematic improvement in the type of programme and length of training. The reinforcement of regulation through the development of legislation for midwifery, a recognised definition and the strengthening of midwives' associations would benefit the development of other ERA elements and the profession generally

The involvement of midwives associations in policy and planning about the midwifery workforce: A global survey

© 2015 The Authors. Objective: a fit-for-purpose midwifery workforce is needed to respond to the current and future needs in sexual, reproductive, maternal and newborn health and to achieve universal health coverage. Evidence-based policy and planning that involves all stakeholders, including professional associations can assist with the development of such a workforce. The aim of the study was to explore how and when midwives' associations are involved in the planning processes for the midwifery workforce and which tools and approaches the associations perceived were used to support human resources for health policy. Methods: all 108 member associations of the International Confederation of Midwives were invited to participate. A questionnaire collected data including: the involvement of the association in the national planning dialogue, processes and methods for participation and engagement; mechanisms to guide and inform decision-making; and, the tools, data and evidence used to influence human resources for health policy. A descriptive analysis was conducted and comparisons were made by country group based on national income strata. Results: 73 (68%) midwives' associations participated in the study, representing 67 (71%) countries. In most (95%) countries, the planning process to determine the provision of reproductive, maternal and newborn health was centralised at the ministry of health level and included midwives' associations amongst others. Less than two thirds of associations reported involvement in planning and policy. The planning processes in which they took part were the reproductive, maternal and newborn plan (63%), the national health plan (58%), and the human resources for health plan (52%). Planning was more frequently undertaken at national than sub-national levels in middle- and low-income countries than in high-income countries. Midwives associations were often unaware of the human resources for health approaches used to calculate the number of midwives required, and reported low use of benchmarks, guidelines and supporting tools during their involvement in the planning process. Conclusion: although midwives associations were involved in planning and decision-making processes for midwifery, their participation was often limited. These associations represent a key provider group in sexual, reproductive, maternal and newborn health and as such have a greater capacity to contribute to policy development and planning and have a meaningful contribution to the achievement of the goals of universal health coverage

Indigenous knowledge of rural communities in Malawi on socio-economic use, propagation, biology, biodiversity and ecology of Uapaca kirkiana Muell. Arg

Uapaca kirkiana Muell Arg. is one of the most popular indigenous fruit trees in the Miombo woodlands of southern Africa. An investigation into existing indigenous knowledge and socio-economic use of this fruit tree was conducted in Malawi. The survey revealed that U. kirkiana fruits contribute considerably to livelihood as a food supplement and for income generation among local communities. However, U. kirkiana trees are not widely cultivated due to lack of improved planting materials and difficulties in establishment outside their natural habitats. The results from the survey indicate that fruits are the main non-timber products that contribute to demand for domestication and the attributes preferred by the rural communities for improvement are mainly related to fruit taste and yield. Poor management and anthropogenic activities have resulted in the destruction of forest reserves and the local people do not have maximum stewardship of U. kirkiana trees in the forest reserve. The indigenous knowledge on U. kirkiana trees provides a valuable basis for domestication, propagation and improvement of fruit and tree attributes, and management issues on both co-managed and government forest reserve

Wheat value chains in Malawi: trends, gaps, challenges and opportunities

Wheat (Tritcum aestivum L.) is an important cereal crop, consumed by over 2.5 billion people globally. The current demand for wheat in Malawi is estimated to be 200,000 tonnes/year with a projected growth in consumption of 3%–6% annually. We reviewed literature and databases on wheat production, imports, processing and consumption to describe current wheat value chains in Malawi, and to identify possible future economic and food security opportunities. The current gap between the supply and demand of wheat in Malawi is large with 99% imported due to low domestic production. The main actors in the value chain include importers, millers, bakeries, biscuit manufacturers, wholesalers and retailers. In total, 45% of milled flour is utilised by commercial bakeries, 46% is distributed to rural and urban outlets and biscuit manufacturers utilise 9%. Although there is no information on wheat exports between 2016 and 2019, FAOSTAT crop database and the ITC Trade Map databases show small quantities of wheat flour exports prior to 2016. Production constraints include the lack of a national wheat development strategy, lack of stable markets, unavailability of improved varieties, low input use and limited knowledge in the management of wheat crop. Currency devaluation and limited forex reserves further affect the annual import volumes and prices of wheat flour on the domestic market. We conclude that domestic production and wider value chain opportunities could be increased through policy support, including research for development, expansion of production into non-traditional wheat growing areas, investing in irrigation and developing market systems

Diverse pre-service midwifery education pathways in Cambodia and Malawi: A qualitative study utilising a midwifery education pathway conceptual framework.

OBJECTIVES: Educated and skilled midwives are required to improve maternal and newborn health and reduce stillbirths. There are three main approaches to the pre-service education of midwives: direct entry, post-nursing and integrated programmes combining nursing and midwifery. Within these, there can be multiple programmes of differing lengths and qualifications, with many countries offering numerous pathways. This study explores the history, rationale, benefits and disadvantages of multiple pre-service midwifery education in Malawi and Cambodia. The objectives are to investigate the differences in education, roles and deployment as well as how key informants perceive that the various pathways influence workforce, health care, and wider health systems outcomes in each country. DESIGN: Qualitative data were collected during semi-structured interviews and analysed using a pre-developed conceptual framework for understanding the development and outcomes of midwifery education programmes. The framework was created before data collection. SETTING: The setting is one Asian and one African country: Cambodia and Malawi. PARTICIPANTS: Twenty-one key informants with knowledge of maternal health care at the national level from different Government and non-governmental backgrounds. RESULTS: Approaches to midwifery education have historical origins. Different pathways have developed iteratively and are influenced by a need to fill vacancies, raise standards and professionalise midwifery. Cambodia has mostly focused on direct-entry midwifery while Malawi has a strong emphasis on dual-qualified nurse-midwives. Informants reported that associate midwifery cadres were often trained in a more limited set of competencies, but in reality were often required to carry out similar roles to professional midwives, often without supervision. While some respondents welcomed the flexibility offered by multiple cadres, a lack of coordination and harmonisation was reported in both countries. KEY CONCLUSIONS: The development of midwifery education in Cambodia and Malawi is complex and somewhat fragmented. While some midwifery cadres have been trained to fulfil a more limited role with fewer competencies, in practice they often have to perform a more comprehensive range of competencies. IMPLICATIONS FOR PRACTICE: Education of midwives in the full range of globally established competencies, and leadership and coordination between Ministries of Health, midwife educators and professional bodies are all needed to ensure midwives can have the greatest impact on maternal and newborn health and wellbeing