Figures & Tables
Figures
- FIGURE 1
Timeline of Development of Midwifery Profession in Bangladesh
Abbreviations: BMS, Bangladesh Midwifery Society; BNMC, Bangladesh Nursing and Midwifery Council; BSc, Bachelor of Science; DGNM, Directorate General of Nursing and Midwifery; DNS, Directorate of Nursing Services; GOB, Government of Bangladesh; ICM, International Confederation of Midwives; MISP, Minimum Initial Service Package; MSc, Master of Science; PhD, Doctor of Philosophy; RCM, Royal College of Midwives; SRHR, sexual and reproductive health and rights.
- FIGURE 2
Growth in Midwifery Education Institutions and Students in Midwifery Diploma Program in Bangladesh, 2013–2022
- FIGURE 3
Sexual, Reproductive, Maternal, Neonatal, and Adolescent Health Services by Midwives in Bangladesh, 2018–2022
Source: United Nations Population Fund program data.
- FIGURE 4
Percentage of Total Births Attended by Midwives in 378 Subdistrict Hospitals in Bangladesh
Source: United Nations Population Fund program data.
- FIGURE 5
Total Births in 294 Subdistrict Hospitals With at Least 4 Midwives, Bangladesh
Source: National health information system.
- FIGURE 6
Eclampsia and Postpartum Hemorrhage Cases Treated by Midwives, July 2021 to December 2022, Bangladesh
- FIGURE 7
Midwives' Use of Evidence-Based Practices Before and After Introduction of Midwifery Service in 2 Teaching Hospitals in Dhaka, Bangladesh
Tables
- TABLE 1.
Indicators for Government-Deployed ICM Standard Midwife Service Delivery Data Gathered by National DHIS2
Indicators Definition/Operational Definition ANC by midwives ANC 1 1st visit: at 4 months/16 weeks. ANC 2 2nd visit: at 6–7 months/24–28 weeks. ANC 3 3rd visit: at 8 months/32 weeks. ANC 4 4th visit: at 9 months/36 weeks. Maternity care by midwives Births by midwives Normal delivery is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Adolescent delivery (aged 15–19 years) Clients who have normal delivery at the age of 15 to 19 years. PPH coming from community PPH cases coming from the community and managed and not referred. PPH coming from community initial management and refer Number of PPH cases coming from the community referred after initial stabilization. Eclampsia managed locally at facilities with cesarean delivery capacity Eclampsia cases coming from the community managed without referral at facilities with cesarean capacity. Eclampsia initial management and refer Number of eclampsia cases coming from the community and provided with the initial management and referred. Newborn resuscitation Neonatal resuscitation with Ambu bag. PNC by midwives Care of mother and newborn from 2 hours after delivery, up to 6 weeks. Contraceptives by midwives IUCD The IUCD is a small flexible device inserted into the uterine cavity to prevent pregnancy. Injection Contraceptive injection is a temporary family planning method for women in Bangladesh. Oral pill/other Oral contraceptive pills prevent pregnancy. First trimester abortion by midwives Abortion is either medical or surgical and may be performed without a pregnancy test if menstruation is delayed. PAC by midwives Services that are provided after spontaneous or induced abortion. VIA screening Positive Number of VIA tests performed by midwives with number of positive cases. Negative Number of VIA tests performed by midwives with number of negative cases. GBV Violence against women is defined as any act of GBV that results in or is likely to result in physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty whether occurring in public or in private life. Cases Number of GBV cases seen by the midwives. ↵Abbreviations: ANC, antenatal care; GBV, gender-based violence; ICM, International Confederation of Midwives; IUCD, intrauterine contraceptive device; PAC, postabortion care; PNC, postnatal care; PPH, postpartum hemorrhage; VIA, visual inspection of the cervix with ascetic acid.
Service Area Private Hospitals, % Public Hospitals, % FP Guidelines on FP 5 91 Staff trained on FP 28 88 Blood pressure apparatus available 95 94 Combined progestin-only oral pill 33 100 Progestin-only oral pill 11 94 Male condom 32 99 All 6 FP services 0 72 ANC Guidelines on ANC 7 61 Staff trained on ANC 26 87 Blood pressure apparatus 98 99 Hemoglobin testing capacity 82 79 Urine protein testing capacity 79 68 Iron or folic acid tablets 78 97 All 6 ANC services 2 32 Normal delivery Guidelines on emergency obstetric care 5 22 Staff trained in delivery care 16 57 Examination light 91 80 Delivery pack 94 87 Suction apparatus 89 57 Neonatal bag and mask 88 89 Partograph 22 42 Gloves 69 72 Injectable uterotonic oxytocin 72 61 Injectable antibiotic 70 59 Magnesium sulfate 45 28 Skin disinfectant 71 68 Intravenous fluids with infusion set 65 65 All 13 delivery services 0 0 Abbreviations: ANC, antenatal care; FP, family planning.
a Where midwives are deployed.
- TABLE 3.
Sample Dashboard Used by Government District Public Health Nurses to Supervise Midwives at District Hospitalsa
Hospital Do the midwives provide autonomous ANC? Are normal pregnancy cases only seen by a midwife for ANC? Is an ANC card used for every mother? Do the midwives distribute supplements (i.e., iron, folic acid, calcium)? Do the midwives provide services in consultation with doctors (if needed)? Do the midwives provide services during emergencies for initial stabilization or doctor referral? Do the midwives manage labors independently? Do at least 75% of women labor and deliver in upright and lateral positions? Do the midwives provide continuous companionship/labor support? Do the midwives ensure hydration and nutrition during labor for all women? Is the Labor Care Guide used during every delivery? Sharishabari Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Bakshiganj Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Madarganj No No No Yes Yes Yes Yes No No No No Islampur Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Malandah No No Yes No Yes No No No No No Yes Deowanganj Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Rajnagar Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Sreemangal Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Kamalganj Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Kulaura Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Abbreviation: ANC, antenatal care.
↵a This is a sample. No indicates follow-up needed.
- TABLE 4.
Comparison of Results Between Government Subdistrict Hospitals in Bangladesh: Without Midwives, With Midwives, and With Midwives and Mentors
Measure Without Midwives With Midwives Midwives and Mentors Number of facilities ready for obstetric emergencies 3 of 7 1 of 6 4 of 6 Percentage of staff who valued, felt capable of using, and used evidence-based practices 68% 81% 92% Number of evidence-based care practices used more than 50% of the time 4 of 8 6 of 8 8 of 8 Number of evidence-based practices with significantly greater use than in facilities without midwives (fixed effect logistic regression) N/A (reference group) 3 of 8 5 of 8 Midwives' competence Staff imagined that having midwives would improve service provision. Among nurses and managers, some affirmed midwives' contribution, while some felt they were too inexperienced to be autonomous. Midwives expressed having the capacity to do more but not being allowed (e.g., some were not allowed to deliver babies). Managers affirmed midwives' capacities and contribution and midwives stated they were proud to be midwives. Separate antenatal care corners Nonexistent Transitioning to staffing antenatal care corners with midwives. Antenatal care corners consistently staffed by midwives. Management of obstetric emergencies Nurses reported that they do not manage obstetric emergencies (commonly, patients were referred). Midwives expressed confidence in managing obstetric emergencies but having limited autonomy so were not able to if another staff person decided to refer. Midwives said they managed obstetric emergencies. Indicators Baseline, 2018 (N=47) Midline, 2019 (N=47) No. (%) No. (%) Separate antenatal care and postnatal care corner available 27 (57) 45 (96) Availability of oxytocin 19 (40) 38 (81) Availability of magnesium sulfate 6 (13) 38 (81) Visual inspective of the cervix with acetic acid service available 12 (26) 35 (74) Postpartum family planning service available at inpatient and outpatient 15 (32) 45 (96) Postabortion care service available 12 (26) 41 (87) Separate duty roster for midwives 1 (2) 41 (87) - TABLE 6.
Care Quality at Clinical Practice Sites Connected to Educational Institutes, 2017–2019
Major Evidence-Based Practices 2017, % (N=87) 2018, % (N=657) 2019, % (N=652) Correctness of partograph 7 51 62 Continuous companionship 67 87 94 Maintaining hydration and nutrition during labor 77 86 92 Non-supine, non-lithotomy birthing positioning 15 49 74 Delayed cord 61 76 87 Skin-to-skin contact for at least 1 hour 10 56 76
Supplemental material
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