Health System Strengthening Through Professional Midwives in Bangladesh: Best Practices, Challenges, and Successes

Abstract

In 2008, a cadre of professional midwives was introduced in Bangladesh. Since then, 120 midwifery educational programs have been established. There are 2,556 midwives serving at 667 government health facilities, and there are more midwives working in nongovernmental organizations and the private sector. This case study documents the process of establishing a midwifery profession with distinct midwifery expertise in Bangladesh and aims to guide other low- and middle-income countries in best practices and challenges. We describe the national administrative groundwork for the profession's launch, roll-out of an education program aligned with the International Confederation of Midwives, national deployment, enabling environments in deployment, and the professional association. Bangladesh's professional midwives' roles in humanitarian response and the COVID-19 pandemic are also discussed. The first and final authors were closely involved in supporting the government's establishment of the profession, and their direct experience is drawn upon to contextualize the topics. In addition, the authors conducted a desk review of documents that supported the profession's integration into the health system and documented its results. Both routine program data and existing research studies were reviewed. Outcomes show that midwives are deployed to 95% of government subdistrict hospitals. About 50% of these hospitals are fully staffed with 4 midwives, and within the hospitals, midwives are in charge of 90% of the maternity wards and attend 75%-85% of the births. Since the midwives' deployment, significant quality improvement for most World Health Organization indicators has been found, along with increases in service utilization. The experience of establishing a new midwifery profession in Bangladesh shows that it is possible for a lower middle-income country to introduce a globally standard midwifery profession, distinct from nursing, to improve quality sexual, reproductive, maternal, newborn, and adolescent health services in both humanitarian and development settings.

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