As we've heard, enabling workforce is a key element to building a philosophy of care that empowers women. In this lesson, we review the research on impact and cost the scaling up the midwifery workforce. Equity, universal coverage, and human development are central principles of the global goal to deliver high quality maternity care. Critical to this goal is a workforce that can deliver accessible healthcare to those who live with the most limited resources, or who are marginalized, or disenfranchised due to race, ethnicity, religion, displacement, economic status, or education. Nurses and midwives collectively represent the largest healthcare workforce globally, as well as the most socio culturally diverse. Therefore, we are well positioned to deliver the most culturally congruent care, a key factor to promoting health equity. The qualifier to that, of course, is the fact that nursing and midwifery education also needs to promote, and protect diversity, and student enrollment so that the workforce mirrors the population being cared for. And as we discussed in module one, this is not been the case historically in the US, and we are now struggling to rectify that imbalance. In an evaluation of the relationship between human resources and health, Speybroeck and colleagues reported a direct association between health worker density and maternal infant and child survival. Such that the density of nurses and midwives had a significant independent effect on reducing maternal mortality, and this was not equaled by the density of doctors. In other words, infusing the workforce with more nurses and midwives in particular led to improved outcomes for mothers. And as we've referenced throughout this course, evidence abounds for the positive effects of scaling up midwifery. Homer and colleagues in the 2014 Lancet series showed that scaling up midwifery interventions from baseline in 78 countries could significantly reduce maternal and neonatal deaths, as well as stillbirths. Using the lives saved tool, a modeling tool developed to estimate deaths averted by in this case midwifery scale up, researchers applied scale up models of modest a 10% increase, substantial 25% increase, and universal a 95% increase. They based this modeling on services that cover the scope of midwifery care, including prepregnancy, antenatal, labor, birth, postpartum care, and family planning. They also compared the case of a stagnant or deteriorating system where population continued to grow but no additional resources access or staffing were put in place. This was all modeled over a 15-year period between 2010 and 2025. You can see from this graph the change in mortality by Human Development Index status. This includes low HDI countries, the Blue Bar on the left of each scale up scenario. Low moderate HD countries represented by the pink bar in the middle. And moderate high HDI countries represented by the green bar on the right. As you can see, deaths averted by scaling up midwifery are substantial in all scenarios, while the do nothing option resulted only increased mortality. Even the most modest scale up scenario showed significant gains especially for low HDI countries. The authors conclude that midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care resulted in an increased number of death is being prevented. Meaning that midwifery care has the greatest effect when it is provided within a functional health system with affective referral and transfer mechanisms to specialist care. In a similar analysis that focused on the cost of care, Bartlett and colleagues in 2014 also used the lives saved tool to model maternal fetal in newborn outcomes, and the concurrent cost of scaling up midwifery, an obstetric services. Again, including family planning, and this was in 58 low and middle income countries. The authors reported that increasing midwifery alone or integrated with obstetrics is more cost effective than scaling up obstetric alone. When family planning was included, the midwifery model was almost twice as cost effective as the obstetric model at 2,200 US per death averted versus 4,200 US. The most effective strategy was the most comprehensive, increasing midwives obstetricians and family planning could prevent 69% of total deaths under universal scale up, yielding a cost per death prevented of just 2,100. Further, that midwifery benefits are relevant across the entire continuum of prepregnancy, prenatal labor and delivery, and postnatal care. Not just the birth event alone, which is where the contribution of obstetrician is most impactful. Finally, including family planning reduced the number of likely births, and thus deaths, and increase the cost of effectiveness of the entire package. So while the evidence is clear and substantial in regard to the impact and cost of scaling up midwifery, nurses and midwives cannot deliver click care in isolation. To achieve universal access and health equity among vulnerable populations, partnership and collaboration are necessary about the policy and practice level. In a 2015 systematic review, Dawson and colleagues investigated strategies that have improved the quantity, quality, and relevance of the nursing and midwifery workforce, especially in terms of serving of vulnerable populations. Their findings, based on analysis of 36 studies reported that the following factors are effective ways to improve workforce capacity. Policy strategies at the national and state level that first increase supply, and coverage of nursing and midwifery staff. And the second are designed to support full scope practice. Resource management strategies that expand nurses and midwives roles, including things like task shifting and tasks sharing, management of staff distribution and the skills mix. Appropriate workloads, working with supervision, and adequate performance remuneration, including incentive pay. Education and training strategies designed to assist nurses and midwives in the performance of new or expanded roles and prepare nurses for inclusive practice. Finally, collaboration strategy is between nurses, midwives, another health providers, and organizations across sectors and with stakeholder communities, and individuals as well. All of these strategies lead to an increase in the number of well-trained and motivated nurses and midwives. Greater access to nursing and midwifery health services, increased information, essential medicines, and diagnostic technologies. And importantly, a reduction in the cost of care, making nursing and midwifery health services more affordable to those suffering financial hardship.
