Emma V. Clark, PhD (c), is a third-year PhD candidate at Vanderbilt University School of Nursing. Her research stems from her interest in how regulation of midwives (e.g., licensure, oversight of training curricula, development and enforcement of scopes of work, and requirements for ongoing practice) affect how many midwives are working in a country, the quality of maternal health care, and overall maternal health outcomes (e.g., maternal mortality and rates of postpartum hemorrhage, eclampsia, and sepsis). Regulation has been suggested as a factor that can affect maternal health outcomes1, mostly through the effects that it has on how well midwives are integrated into the health system, or how able they are to provide all the health services they are trained and authorized to provide, and have strong interprofessional collaboration (e.g., with nurses and doctors). However, no one has really attempted to quantify this relationship. This is where Clark’s research is trying to fill in the knowledge gap. She is using existing data that was collected as part of a large survey of midwives’ associations in most low- and middle-income countries, to assign a single score to a country’s midwifery regulatory environment and then look at the relationship between this score and various indicators of access, quality, and overall outcomes that are routinely collected in these countries.
The WHO reports that there were about 287,000 maternal deaths in 2020, with an estimated 95% of these having occurred in low- and lower middle-income countries2. “Each of these deaths has devastating implications for families and communities. Having a skilled birth attendant present at birth can help identify and manage complications in a timely manner, but the current global reproductive, maternal, and newborn health workforce can only meet 41% of need,” claims Clark. While midwives are an effective and efficient type of skilled birth attendant, because they can provide most of a set of high-impact interventions proven to save lives, there is a global shortage of 900,000 midwives, mostly in Africa and low-income countries.3 Many countries want to invest in midwives, both to increase numbers and to help them provide the highest quality care they can. However, there is very limited guidance available to policy makers about how specifically they can invest in midwives in ways most likely to result in improvements in maternal health. Clark’s research objective is to provide concrete guidance to policy makers that not only supports them making much needed investments in midwives, but also tells them exactly how they can invest for results. “This is so important because funding for maternal health is very limited in most countries,” states Clark.
So far, the most interesting aspect of Clark’s research is that she initially thought that a modified Delphi process was needed, or expert convening to decide if and how to weight scores for her independent variable. “I was dreading this process and I wasn’t sure that it was going to even yield helpful or reliable results,” says Clark. Surprisingly, through her work with VUSN’s Dr. Marianna LaNoue, she was able to see that she could actually do this by using a model fit predictor.
Currently there are global movements for increasing investment in midwifery. Clark’s work is part of a larger research area on the global midwifery workforce, looking to quantify midwives’ contributions to global maternal health and improve understanding of the most strategic places to invest in increasing the quantity and quality of midwives working globally. And while there is a lot of documentation on barriers to investment or ability of midwives to provide high quality, accessible care, “it’s time to start figuring out how to address these barriers and creatively using existing data sources to document what does and doesn’t work,” urges Clark.
Clark would like to acknowledge Vanderbilt University, for its generous travel funding for several international conferences, where she has been able to learn and connect with others working on the global midwifery workforce. “I am very grateful to the International Confederation of Midwives for the tremendous amount of work they did surveying all of their member midwifery associations and making the data publicly available,” concludes Clark.
- Policies for Reducing Maternal Morbidity and Mortality and Enhancing Equity in Maternal Health. https://www.commonwealthfund.org/publications/fund-reports/2021/nov/policies-reducing-maternal-morbidity-mortality-enhancing-equity
- Maternal Mortality, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
- New report sounds the alarm on global shortage of 900 000 midwives. https://www.who.int/news/item/05-05-2021-new-report-sounds-the-alarm-on-global-shortage-of-900-000-midwives