Supporting Private Community Midwifes - Possible Implications for the Well-Being of the Poor and the Quality of Public Services
March 30, 2006
Dr. Solveig Buhl
This is a summary of a very interesting in-depth analysis on the reality of community midwives provided by the Yemeni-German Reproductive Health Programme.
In February / March 2006, the Yemeni-German Reproductive Health Programme commissioned a study on the support of private community midwives (CMW). The programme wanted to have more information on whether encouraging private practice discriminates against the poor and undermines public services or whether it improves quality access to reproductive health services including the poor.
Within the continuing collaboration between the Mainstreaming Poverty Reduction Project (QVA) and CPAS, Solveig Buhl and Shoqi Maktari conducted a 10-day field study using qualitative research methods, to shed light on the questions at core of this evaluation.
In spite of the limitations of the current evaluation design there is some evidence to conclude that the Private Midwife Initiative has contributed to an improved level of RH in remote and generally underserved locations and that poor people have benefited from it. There is no robust evidence that the private CMW services make the RH services unaffordable for the poor, although the very poor might not be able to afford even low level fees.
The significance of the poverty outcome of the Private Midwife Initiative depends upon a number of factors. The most critical factors are:
- remoteness, implying distance to next public or private health facility, difficult road conditions and high transportation cost; in particular remoteness to better equipped services in case of serious emergency;
- extent and depth of poverty, i.e. in locations with low or moderate levels of poverty other private facilities compete with the offers of the project supported CMWs;
- economic and social incentives for the midwife to offer services regularly
- affordable fees and low cost medication;
- public support or private sponsoring in order to provide quality services in a sustainable manner.
Private CMW Centres have not necessarily undermined the quality of the public health facilities. On contrary, in remote locations, it is the private midwife that provides services that hitherto have not been offered by the public health system. No other private provider would offer services in too remote areas for the lack of economic gains. At the same time, the public facilities alone would probably not set enough incentives to provide quality services. Further, especially in remote areas, no clear line between “private” and “public” services can be drawn. The more transparent these private services are handled, the better for the public services and the clients, including the poor.
In the more densely populated areas close to towns where private and public services providers directly compete, the private CMW Centres are rather supplementary than satisfying a basic need.
The Private Midwife Initiative has contributed to educate women from underserved communities about reproductive health issues. But they cannot reach the men. As the study has shown there are many misconceptions, especially regarding contraception even among the clients of the CMW centres. It seems of utmost importance to include husbands and unmarried men in awareness rising.
So far, at least in the locations visited, the initiative was backed by the fathers and mothers of the CMWs. It could be considered to encourage more community participation when selecting further suitable locations and CMWs for support. This could potentially contribute to the sustainability of the approach and to greater ownership and control over the services provided. The study recommends when extending the programme, only remote and poor locations should qualify in order to attain a higher level of poverty outcome.
First General Meeting of the Midwives Association
September 2, 2004
In early June USAID/Yemen (through the Partners for Health Reform plus Project) and UNFPA collaborated with the Ministry of Public Health and Population in the organization of a national workshop in Sana'a to establish a midwives association. About 50 participants attended, representing Yemeni midwives at all levels of health services and training, the Higher Institutes for Health Sciences, the RH/FP Directorate, Department of Nursing and Midwifery, Community Midwives Training Project, the Union of Practicing Health Professions, the HSR Policy Unit, and donors.
Participants also included midwives from Lebanon, Bahrain, Indonesia and the U.S., countries with a long history of midwife associations. In addition, the General Secretary of the International Confederation of Midwives attended and encouraged Yemeni midwives in this new venture. Experiences from each of the visiting countries enriched the discussion, helped to identify obstacles and lessons. A core group of Yemeni midwives had prepared draft by-laws which were reviewed during the workshop.
USAID and UNFPA pledged their continued support to the association. The formation of this association will be a major step in the history of Yemen in assuring a voice, active participation, and recognition of the role that Yemeni midwives play in maternal child and family health.
Following the workshop, a core group of midwives worked with the Ministry of Social Affairs to officially register the association. One of the final steps was to organize the First General Assembly for the Midwives Association. This meeting took place in Sana'a on September 2.
There was standing room only as more than 120 midwives from all corners of the Republic of Yemen attended the first general meeting of the Yemeni Midwives Association at the Sheraton on September 2. The meeting was the first step and a requirement by law to establishing the Midwives Association which will represent the interests of all Yemeni midwives. Participants discussed and approved the internal regulations of the association, elected an administrative board and selected a monitoring and the inspection committee.
Attendees were eager to finally see the formation of this association which will address their development and career needs and assure them a voice in decisions about how to improve maternal and child health services. They were also keen to elect from among their members the most qualified and committed representatives to manage and lead the activities of the association.
Ms. Taiz Al-Ba'adani, representative of the Ministry of Social Affairs and Labor (MOSA&L) with a legal background, chaired the meeting together with two members of the preparatory committee, Ms. Fawzia Yousif and Ms. Suad Kassem. The Internal regulation was read, discussed and endorsed by the participants. The majority of participants endorsed the board and committee members. Under the guidance of Ms. Taiz, the chairpersons, deputy chairpersons and other assignments were appointed as required by the internal regulation. Two additional members were added by the administrative board to increase the governorate representation.
The Administrative Board
- Suad Kassed (Chairperson)
- Samia Hakim (The General Secretary)
- Fatoum Noor Aldin (The Financial Person)
- Huda Jahlan (Member - Amran)
- Salama Al-Rabooee (Member - Al Jawf)
- Samah Al-Rammah (Member - Al Baidha)
- Nabila Al-Faqih (Member - Dhamar)
- Afrah Otaifah (Member - Hajja)
- Iltaf Antar (Member - Sa'adah)
The Monitoring and the Inspection Committee
- Jamilah Yahia (Chairperson)
- Fayeza Al-Arhabi (Deputy)
- Hedaya Ahmed (Reporter)
- Saeeda Mohamed Saeed (Member)
- Aziza Othman (Member)