1. Midwifery – key to quality care Global and national implications of The Lancet Series on Midwifery International Day of the Midwife 2015 RCM Conference Edinburgh Midwives for a better tomorrow Professor Mary Renfrew FRSE Director, Mother and Infant Research Unit @MIRU_UK Director, Scottish Improvement Science Collaborating Centre

2. The Lancet Series on Midwifery @midwiferyaction #LancetMidwifery You Tube: Midwifery Action http://www.thelancet.com/series/midwifery

3. @midwiferyaction#LancetMidwifery @midwives4all#midwives4all @MIRU_UK @maryrenfrew

4. The Lancet Series on Midwifery Background Four papers, five commentaries: June 2014 Two further papers in preparation Multidisciplinary group of 35+ specialists from 20+ countries –health systems analysts, demographers, statisticians, epidemiologists, health service researchers, social scientists, health economists, specialist midwife researchers, service user advocates, public health and policy experts, and clinical experts: midwives, obstetricians, paediatricians, other related disciplines Input from close readers/critical friends, WHO, Gates Foundation, ICM, FIGO, Lancet editors and reviewers Supported by the Bill & Melinda Gates Foundation + NORAD http://www.thelancet.com/series/midwifery www.midwiferyaction.com

5. Midwifery – key to quality care Taking another look at the evidence: the Lancet Series on Midwifery and why it matters Global and national impact and implications

6. ‘Midwifery is a vital solution to the challenges of providing high quality maternal and newborn care for all women and infants, in all countries’ ten Hoope Bender et al 2014 The Lancet

7. The Lancet Series on Midwifery Background Unacceptable rates of mortality and morbidity Longer term and psycho-social outcomes overlooked –birth is the start of the journey High rates of unnecessary interventions Inequalities in outcomes and care Care and compassion seen as less important, yet integral to system failures Disrespect and abuse of women within the health system

8. The Lancet Series on Midwifery Background Diverse discourses –emergency care, facility birth, tasks and task-shifting, essential interventions, skilled birth attendance, risk assessment, normal birth

9. The Lancet Series on Midwifery Background Diverse discourses –emergency care, facility birth, tasks and task-shifting, essential interventions, skilled birth attendance, risk assessment, normal birth Diverse approaches –focus on mortality vs health and well-being, women vs children, high vs middle vs low-income countries –focus on RCTs of specific interventions vs views and experiences –focus on systems, workforce, costs and resources

10. The Lancet Series on Midwifery Background Diverse discourses –emergency care, facility birth, tasks and task-shifting, essential interventions, skilled birth attendance, risk assessment, normal birth Diverse approaches –focus on mortality vs health and well-being, on women vs children, on high vs middle vs low-income countries, on birth vs continuum –focus on RCTs of specific interventions vs views and experiences –focus on systems, workforce, costs and resources Midwifery shown to be important –yet inconsistently implemented, unanswered questions, substantive barriers –rendered invisible in current discourse

11. Figure 2 Bhutta et al The Lancet Stillbirth Series 2011 377, 1523-1538DOI: (10.1016/S0140-6736(10)62269-6)

12. The Lancet Series on Midwifery What we learned… … we needed to ask different questions, start from a different perspective, re- examine the evidence

13. Women, babies, families Universal needs and equity

14. The Lancet Series on Midwifery Re-examining the evidence – a new lens Focus on needs of women, infants, families Human rights-based approach Drawing on diverse sources of evidence All relevant outcomes: survival, health, wellbeing Relevant to low, middle, high-income settings Long-term view: quality care and services Distinguishing between what, how and who Interdisciplinary, cross-sectoral, health systems perspective Acknowledging diverse workforce, importance of integrated services Examining the specific contribution of midwives Developing evidence-informed consensus

15. Defining midwifery ‘Skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life. Core characteristics include optimising normal biological, psychological, social and cultural processes of reproduction and early life, timely prevention and management of complications, consultation with and referral to other services, respecting women’s individual circumstances and views, and working in partnership with women to strengthen women’s own capabilities to care for themselves and their families’. Renfrew, McFadden, Bastos et al The Lancet 384, I9948, 1129 – 1145, 2014 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext

16. Framework for quality maternal and newborn care Renfrew, McFadden, Bastos et al The Lancet 384, I9948, 1129 – 1145, 2014 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext

17. Framework for quality maternal and newborn care The scope of midwifery

18. Maternal and newborn mortality, stillbirth reduced Less preterm birth, low birthweight Maternal morbidity reduced –eg infections, anaemia, pre-eclampsia, perineal trauma Reduced interventions in labour –eg augmentation, caesarean section, blood transfusions Improved psycho-social outcomes –eg satisfaction with pain relief, anxiety, post-partum depression, improved mother-baby interaction Increased birth spacing, contraceptive use Increased breastfeeding initiation and duration Shorter hospital stays, improved referrals, increased attendance by known midwife Impact 56 outcomes improved by midwifery

19. Scale of the impact of midwifery care Universal coverage of midwifery would result in reductions in maternal deaths, stillbirths, and neonatal deaths in 78 countries –maternal mortality, stillbirths, and neonatal deaths reduced by around 80% Homer, Friberg, Bastos Dias et al The Lancet 384, 1146-1157 Sept 2014

20. ‘Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated, and midwives were most effective when integrated into the health system in the context of effective teamwork and referral mechanisms and with sufficient resources. There are few benefits from relying on less-skilled healthcare workers.’ –Renfrew, McFadden, Bastos et al The Lancet 2014 Who should provide midwifery care?

21. ‘These findings support a system-level shift from fragmented maternal and newborn care focused on identification and treatment of pathology to skilled care for all. Midwifery is pivotal to this approach’. Renfrew, McFadden, Bastos et al The Lancet 2014 Quality maternal and newborn care

22. Midwifery – key to quality care Taking another look at the evidence: the Lancet Series on Midwifery and why it matters Global and national impact and implications

23. Global and national dissemination Resources: –Lancet webpage, www.midwiferyaction.com, You Tube filmswww.midwiferyaction.com –Global alliance and consensus building eg WHO, UNFPA, UNICEF, DfID, Gates Foundation, ICM, FIGO –Endorsement by DGs of WHO, UNFPA, +++ –Discussions re Every Newborn Action Plan, Every Woman Every Child, SDGs Country-level developments –Translations: French, Portuguese, Dutch +++ –Informing debate, strategy, policy eg US, Uganda, Brazil, Mozambique, Croatia +++ Swedish government –www.midwives4all.org: @midwives4all: #midwives4allwww.midwives4all.org –Embassies supporting country-level engagement +++ –Digital campaign to launch summer 2015

25. Implications for the UK Supports policy direction of woman-centred, person- centred services –challenges risk assessment as organising principle –evidence for the further changes needed to maternal and newborn strategy, policy, practice Quality framework can inform analysis, planning, education, research –eg response to Kirkup Report, review of maternity and newborn services, planning curricula, examining mechanisms of action Model for analysis and planning of future quality service provision in other fields

26. Next steps Further papers –Human rights and midwifery –Research agenda in collaboration with WHO, ICM, involving UNFPA, Gates Foundation, DfID+++ –Barriers to midwifery Ongoing engagement in global and national developments

27. ‘Midwifery is a vital solution to the challenges of providing high quality maternal and newborn care for all women and infants, in all countries’ ten Hoope Bender et al 2014 The Lancet

28. Lancet Series on Midwifery: authors Endang Achadi Chiara Ancona Linda A Bartlett Maria Helena Bastos Jim Campbell Amos Channon Fen Cheung Marcos AB Dias Luc de Bernis Vincent De Brouwere Eugene Declercq Deborah Delage Soo Downe Vincent Fauveau Helga Fogstad Ingrid K Friberg Caroline SE Homer Holly Powell Kennedy Marge Koblinsky Jerker Liljestrand Address Malata Zoe Matthews Felicia McCormick Alison McFadden Abdelhay Mechbal Susan F Murray Helen Rehr Mary J Renfrew Fabienne Richard Tung Rathavay Jane Sandall Anna Maria Speciale Petra ten Hoope-Bender Sabera Turkmani Wim Van Lerberghe Laura Wick

29. Midwifery – key to quality care Thank you! m.renfrew@dundee.ac.uk @midwiferyaction @MIRU_UK @maryrenfrew Photos and films: magnetofilms.com Artwork: M4ID