Nurses and midwives key to achieving health targets in low- and middle-income countries

Around the globe, non-physician health professionals are critical to the effective delivery of care and services that protect and improve the health of their communities. This has been especially apparent during the coronavirus pandemic. 

Stephen Hodgins, an associate professor of global health, has focused on developing and strengthening community health worker programs in countries such as Nepal. He says that in low- to middle-income countries, these providers are critical not only during a time of crisis, but in the day-to-day delivery of health care in systems that are very different from what is typically experienced in Canada. 

Community health workers deliver primary care 

In nations such as Canada and the U.S., health systems are physician-centred, with doctors providing and supervising care in a hierarchical system. “While nurses play a critical role, it is understood to be distinct from that of physicians,” Hodgins explains.  

“In less wealthy countries, non-physicians including nurses, midwives and other health workers have a much broader range of tasks that include more complex care and treatments, overlapping what is often considered to be the responsibility of physicians.” Hodgins says these increased responsibilities include providing primary care, maternal care and delivery, prescription treatments and even some surgical procedures.  

This model of health-care delivery works well in low- and middle-income countries because of resources and infrastructure, says Hodgins. “In low- and middle-income countries there tends to be a ‘brain drain’ of doctors to large cities, creating an urban-rural divide in terms of access to physicians.” Hodgins points to higher paying hospital jobs and private practice opportunities as the reason. 

“Often, there are no effective policy levers available to distribute physicians to improve the population’s access to care.” In response to this, Hodgins says two categories of health facility tend to exist outside cities and hospitals: stand alone health centres and dispensaries, or health posts, generally staffed only by non-physician health workers. 

“These community health centres and health posts are where most preventive care is provided,” explains Hodgins. This includes public health programs such as immunizations, treatment for basic childhood illnesses and prenatal care, as well as some curative services.  

“Credit for improved health outcomes goes to the development of these community primary care systems and their frontline non-physician health workers.” 

Midwives improve maternal health outcomes in Malawi

Professor Zubia Mumtaz, also a global health researcher, says health centres often deliver more complex care under the supervision of a clinician–another solution to a shortfall of physician resources. 

Using Malawi as an example, Mumtaz says in addition to urban brain drain, many Malawi-trained physicians leave the country for careers abroad. “Clinicians are just one of many categories of health professionals that give care,” she says. “With education programs that take only a few months to two to three years to complete, more providers are trained and working to provide a broader range of care, when physicians aren’t available.” 

Mumtaz’s research concentrates on the impact and results of maternal health care provided by midwives, trained to provide prenatal care and assist women in childbirth. Her most recent research conducted in Malawi will be published shortly. 

The Malawi government has incentivized birthing in health facilities attended by midwives, where a woman can deliver more safely. “If a Malawian woman chooses to give birth in her own community with a traditional birth attendant, rather than at a health facility with trained professionals, she must make a payment of one goat to her chief.” As a result, Mumtaz says approximately 85 per cent of births in Malawi are conducted by a midwife. 

Mumtaz says that a clinician is available to support more complex cases, and a physician is on call for surgical procedures, such as Caesarean sections, but response time is not optimal. Midwives also do their jobs with very few instruments available to them. 

“These midwives work in pairs for a 12-hour shift, staffing rural health facilities round the clock,” she explains. “They often deliver 12 to 15 babies on each shift. Their workload is incredible.”

According to Mumtaz, despite these challenges, Malawi has seen great improvement in maternal health outcomes. The maternal mortality rate dropped from 916 deaths per 100,000 live births in 1998 to 349 deaths per 100,000 live births in 2017. “With midwives on the rural frontline, the rate of women dying during pregnancy or in childbirth has been reduced by more than 60 per cent.” 

The World Health Organization says that health workers are vital to achieving national and global goals for maternal and child health, as well as other targets such a universal health coverage, infectious and non-communicable diseases including mental health, emergency preparedness and response, patient safety and the delivery of integrated, people-centered care, and more. 

Mumtaz agrees. “These health workers are heroes. We are not sufficiently grateful to them for the work they do on the frontline.”