How did you first come into contact with midwifery and what are your reflections after working with midwives most of your life? >> To me, having spent all my professional life on Women's Health and Maternal Health, I am convinced that unessential component to provide high quality care is to include and drawn the experiences of professionally trained nurse midwives in any country. That's the most cost effective way to provide high quality care where you continue to develop the care. And I would say that this started from the background I have as a Swedish obstetrician, as a medical student. Way back in 1971, I was just about to be your father for the first time and I was taking my accepted course. Who did I learn from to respect women in the delivery room and really helped make the delivery a positive and natural event, that was midwives. I where my fellow students didn't behave well, the midwife would say, we're going to talk about that outside the room after this delivery. And that we did, and that continued during my doctor's training and later on my training to be an OBGYN and even as an OBGYN specialist, the person in charge of the delivery, normal or complicated, is a midwife in Sweden and she is really the advocate of normal care and good quality care and she helps to train doctors and keep doctors in line. >> So can you talk about the most important ways of supporting midwifery to really get maximum effect out of having midwives in the country? >> Yes, so I think the first obstacle for maternal health is to have a government that really cares about maternal and newborn health in a broad sense, meaning also family planning. But once you have taken that decision that this is really a very important priority for your society, supporting mothers outside healthcare but also inside healthcare. And then you decide that midwifery is the way to go. Either you have midwifery, you want to strengthen midwifery. What you really need to make sure is that midwifery and midwives are integrated into the health system, meaning at the Health Center level, the primary healthcare level, but also the hospital level. So it doesn't go off on a tangent and be something isolated outside regular maternal newborn care. You really need to try to find ways of having a good team work around the pregnant woman and the birth and the newborn baby on the family plan situation. And there may be various obstacles for this, financial, structural, and so on. But do you really want to have a team work where the midwife is a core person in that team? And then in that context, how do you make sure that their links between primary health care, either public or private, and the hospital care? So that the woman is not sent from different stations that don't, or the staff don't relate to each other. The normal pregnancy, after all, is not a disease. This is a normal condition where you need to strengthen the woman's normal capacities to become a mother and supporter and becoming a mother for the first time. Things like breastfeeding, preparation for childbirth, and all those things. But then, as we all know, there can arise complications and how do you then as you suspect this complication, be it diabetes in pregnancy or high blood pressure, how do you then deal with that suspect complication? You follow it up, you monitor it, you diagnose it, you perhaps treat it, but how do you do that in a collaboration where many things can be dealt with by a skilled midwife, but the skilled midwife also needs to have a backstop of skilled specialist doctors behind her? And this that you don't compartmentalize it, that you don't work as different teams. Somebody does the normal enough birthing center and somebody else deals with preeclampsia, or somewhere else. This is a communicating vessel, the woman is really in the center and you do the different things. You should not stop doing prenatal care just because you have a raise blood pressure, etc., etc. So the Timer health care and the hospital care that is usually there. How can they collaborate on a continuous basis? That is really the magic source in providing a cost effective, woman centered, quality improvement of maternal newborn care. >> Great, thank you. So when you talk about cost effective, how do you see midwives? Another staff with midwifery skills as more cost effective than physician-based solutions? >> Well, there are actually scientific studies that show that the health promotion side, the things that the woman herself can do, let's say an exercise, diet and nutrition, family planning, and smoking cessation, drinking less. These are aspects where the midwife is actually superior to doctors because the doctors have a lot of medical knowledge that may actually, in a health promotion situation, work as a ballast. Also, midwives typically are closer to the woman socially and communication wise. Midwives are typically women themselves. Perhaps have children themselves and midwives knowing that they have a very clear mandate. You are authorized to deal with a normal and a certain set of complications, but beyond that, you really have to pull in an obstetrician. That means that the midwives are actually often more adhering to guidelines than doctors, who are more of individualists and see all this case is different, the whole art of Medicine if you wish. So midwives are often more accountable than doctors. I'm on not uncertain ground, but on mine ground. We shouldn't say that midwives are better than doctors, but actually the combination of midwives and doctors is the most cost effective solution. Then the other aspect that we also need to take into account is if you have a system that doesn't have nurse midwives, and now speaking of nurse midwives all the time here, that's the definition of the midwife globally. If you don't have midwives, you only have doctors, then you're very prone to over medicalization of various kinds. Just look at the C-section epidemic, we have, for instance, now a big movement against too many C-sections. Rising from women in, for instance, India. >> So if midwives are cost effective and provide high quality care with excellent outcomes, why do you think some countries have failed to integrate midwives more effectively? And what can we do to help change this? >> Well, it's a little bit about money and perhaps a little bit about power, but of course if you have too many doctors to start with, there may be a reluctance from authorities to invest in mid. Well, everything we have all these doctors, you fail to recognize that you cannot really address maternal, newborn, family planning care with only doctors. It's not only cost effective, it's not even effective because you get all this over medicalization. And you don't deal with the normal aspects. First, let's take choice of a contraceptive or let's take breast feeding, very, very important parts of maternal newborn care. But how well-equipped is in? And how much time does the average of nutrition have to deal with these issues? But we have a couple of country examples where countries that have had strongly with free have actually backtracked through the years because it has become so popular to educate obstetrician gynecologist. And then there's the financial, they're making the profit. If you let the sector be totally unregulated and make it a very profitable business, then you may have the dominance of doctors rather than midwives. >> With all your experience in different countries, can you speak to any one country that may have not had midwives in integrated in a way that now does and has been a success with that? >> Well, I, just a few years ago, spent six years working in Cambodia. And Cambodia is one of the few countries that met Millennium Goals, four, five and six, or at least the HIV aids part of Millennium Development goal, six, but it also met the maternal and the child health development goals. And They have made a very strong thrust to make sure that there is at least one or two midwives at every health center and really expanded the availability of midwifery care and then also happened to successfully convince women that it's time to come to facilities for birthing care, not give birth at home. Lets say at the turn of the century, most recently 20 years ago, they had about 15% facility births and today they are between 90, 95% and most of that is thanks to midwives at health centers. So of all the facility births 2/3 are at health centers, the primary healthcare level where there are no doctors and 1/3 is in hospitals where you have doctors. And here you really have expanded midwifery, there's lots, a long way to go to to reach, let's say quality of midwifery, as in high income countries, but they're working on it. And they find that maternal mortality and newborn mortality is falling and they have created a basis for this. So the current Minister of Health, he wants to be remembered as the Minister of midwifery.
