Midwives, Task Sharing, and Family Planning: Experiences from Florida to West Africa
By Sara Stratton, Senior Technical Advisor, Family Planning, HP+
Each year as May 5 approaches, I’m reminded of the importance of midwives to women and families around the world. My second daughter was delivered by midwives who had been employed by a large OB/GYN practice in central Florida to serve lower-income women. Recognizing the complexities that many of these women face in their lives, the midwives were brought on to help them navigate their way through pregnancy and childbirth. They were an important part of the practice, working with the obstetricians and gynecologists to take the lead with clients on certain tasks where they were most knowledgeable.
This distribution of tasks worked well in the practice and for the clients it served, and I was fortunate to be the recipient of their care. The time they spent with me, my husband, and my older daughter demonstrated their approach to pregnancy and childbirth as a normal process of life and the partnership they strove to establish with their clients and the community. The experience I had is not uncommon for many women in the world, but for women in less-developed countries, access to such care is often not possible.
This year, the theme for the International Day of the Midwife, celebrated on May 5, is "Midwives, Mothers and Families: Partners for Life!" The word “partners” is key: midwives know the value of partnering with their clients and their clients’ families and communities. But another important partner, sometimes overlooked, are the other health workers that midwives routinely work with as they deliver well-woman, pregnancy, childbirth, and postpartum care. Midwives, working as part of a broader cadre of health workers, are able to take on a range of tasks to help distribute the load, especially in health systems understaffed by doctors, nurses, and other health professionals. In turn, they can share tasks with other cadres, such as community health workers, to allow them more time to concentrate on midwifery services (UNFPA, 2014; Family Care International, 2014).
This type of partnership is referred to as task shifting or sharing. While sharing or shifting tasks has created much debate over the years, it’s clear in this time of limited resources that distributing responsibilities within the health system can benefit everyone. It could certainly benefit countries like Malawi, where 3,420 midwives are struggling to do the work of what should be dispersed across 23,637 (WRA, 2017), or Niger where there is only one midwife per 10,000 people, or Senegal where a total of 5,254 midwives means four for every 10,000 people (WHO, 2010).
According to the World Health Organization, “task shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly-qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health” (WHO, 2008). Task sharing is when the usual providers retain the task, but involve or expand it to other cadres of health workers (WHO and IBP, 2017). Task shifting and sharing can help ensure clients receive the right service, from the right provider, at the right time.
Family planning is considered one of the key interventions for which task shifting and sharing can help to optimize a strained health workforce and improve access to maternal and newborn health (WHO, 2012). We know that a comprehensive sexual and reproductive health and rights package includes access to contraception and that provision of contraceptives is within midwives’ scope of practice in most countries. The question is often: Which contraceptives can midwives deliver and how is the midwife cadre defined? Globally, WHO recommends midwives and auxiliary midwives provide all contraceptive methods except permanent ones (tubal ligation and vasectomy). But country context is important.
Take West Africa. Despite the clear global guidelines for task shifting, in West Africa (particularly francophone West Africa) this practice has been met with resistance. For women, this poses a challenge since the region has very low ratios of health workers to clients (WHO, 2006) and a strong slant towards medicalization of family planning services (Ouagadougou Partnership, 2012; Konaté, 2015). What this has meant is that only highly-trained health workers have been authorized to provide contraception to women and men. Often these health workers are in more urban areas leaving women in rural areas underserved.
We know that the greater number of providers—midwives included—who can offer family planning methods enables access and availability to contraception. Expanding partnerships among health workers by sharing tasks with other cadres—including nurses and community health workers—will benefit women, couples, providers, and the health system as a whole. Midwives are already an important part of this equation.
Sara Stratton is an HP+ senior technical advisor for family planning with Palladium and a family planning advocate. She celebrates midwives for their important contribution to sexual and reproductive health of women and men worldwide on May 5, but also every day. Sara looks forward to continuing to strengthen partnerships with midwives to ensure more women and couples have access to family planning services and contraceptives, allowing them to freely decide when and how many children to have.