EVOLVING A NATIONAL VISION AND

STRATEGIC FRAMEWORK FOR MIDWIFERY

IN PAKISTAN

Summary
 Objectives of the Provincial Consultation
To build a consensus on the long-standing issues of the Midwifery Profession
• There is an acute shortage and lopsided balance within the Human
Resources for Health
• WHO recommends 4 nurses/midwives for each doctor indicating an
8-fold shortage.
• To meet the need Pakistan requires 0.874 million additional nurses
and midwives.
• Enhancing the status of the midwifery professions by raising their
level with high quality of education.
• Considering midwifery as a distinct profession.
• Enforce regulatory mechanisms including legal protection for the
betterment of the midwives and the women they serve.
 BACKGROUND AND RATIONALE
§ The Strategic Framework has been developed by the Federal Ministry of
National Health Services, Regulation and Coordination, with the support
of the Health Services Academy, United Nations Population Fund, World
Health Organization and Midwifery Association of Pakistan.
§ The framework is largely based on the recommendations of the WHO
Global Strategic Directions for nursing and midwifery (SDNM) 2021-2025
and the Midwifery Services Framework of the International
Confederation of Midwives with the focus on creating a separate
professional distinction and identity for Midwifes, producing them in
sufficient numbers and competence enabling the, to contribute to UHC
attainment
Requirement of Nurses and Midwives / Lady Health Visitors by 2030
Additional
Projected Required Nurses
Requirement
Population WHO / Midwives / Existing in
Area In 2030 standard LHVs 2019 (Gap till 2030)
Pakistan 280 million 3.34/1000 986,543 114,520 872,038
Sindh 65.3 million 3.34/1000 217,993 21,664 194,318
Punjab 144.5 million 3.34/1000 483,206 71,575 411,631
Balochistan 17 million 3.34/1000 57,412 2,740 54,672
Khyber-Pakhtunkhwa 45.5 million 3.34/1000 151,907 13,672 138,235
Islamabad Capital 3.34/1000
2.7 million 9,169 1,201 7,968
Territory
Azad Jammu and 3.34/1000
17.2 million 57,638 1,600 56,038
Kashmir
Gilgit/Baltistan 2.8 million 3.34/1000 9,218 57 9,161
 MIDWIFERY IN PAKISTAN
• In Pakistan Maternal Mortality Survey (PMMS) of August 2020, the
maternal mortality rate in the country has decreased to 186 per 100,000
live births
• Currently, one in 16 children die before reaching their first birthday while
the stillbirth rate in the country is 43.1 per 1000 births.
• Current midwives, nurse midwives, and LHVs registered with Pakistan
Nursing Council 41,263 as of Dec 2021
 Fiscal Measures and Policy Imperatives
§ The MoNHRSC prepared a PC-I for PKR 29 million for the strengthening of the nursing and midwifery
sub-sector.
§ The Federal component has been approved by the CDWP at a cost of over PKR 8 billion over a period
of 5 years to enhance the status of the nursing and midwifery professions by raising their level of
education
§ The policy implications from the framework for quality maternal and newborn care and the effect of
life-saving interventions fall within the scope of midwifery practice
§ Competent midwives can play a huge role in rectifying this situation if properly trained and regulated
§ There is a need for better regulation at Federal level along with a Code of Conduct and scope of
practice for the development of the Midwifery profession
§ The provincial governments need to put in their share of costs to build the profession uniformly
across the country
 Current situation
§ A nurse can study up to PhD level and expect to reach at Grade 20
§ However, a midwife starts her career in grade 9 and usually retires
in the same grade having no career pathway or opportunities for
growth
§ In 2012, the B.Sc. Midwifery (BScM) started in the private sector
and was only reserved for nurses already holding nursing and
midwifery diplomas
§ Posts of Midwifery Tutors are lying vacant. The seats are mostly
occupied by the MBBS doctors
 THE NATIONAL VISION FOR THE MIDWIFERY
STRATEGY DEVELOPMENT FOR PAKISTAN

To ensure that every woman in need receives the requisite

midwifery care, by skilled, well-educated, licensed, well-
regulated, autonomous, and confident midwifery professionals,
regardless of any consideration, towards the coveted goal of
achieving UHC by 2030 in Pakistan, leaving no one behind.
 Domains of the Pakistan Midwifery Strategic Framework

Leadership, Practice/Service
Advocacy and
Governance and Education Delivery/Scope of Financing
Networking
Regulation practice

ICM Guidelines
 LEADERSHIP, GOVERNANCE AND REGULATION

§ The Pakistan Nursing Council will be renamed the Pakistan Nursing and Midwifery Council
and it will be empowered to establish a separate, distinct and discrete identity for the
Midwifery profession and not obscure it as a part of Nursing
§ The mandate of the Council will transcend registration and will include a develop code of
conduct having autonomous practice for the profession while reducing the overlapping and
mix-up in the roles and responsibilities of Nurse-midwives, Lady Health Visitors, Certified
Nursing Attendants, Community Midwives and Family Welfare Workers
§ The Regulation Wing, MoNHRSC will support the provincial Midwifery colleges technically
also ensuring that all the schools/ colleges of midwifery is head by the midwife.
 EDUCATION
§ All the Registered Midwives in Pakistan will go through a 4-year course after doing in public and
private sector institutions on the newly designed curriculum
§ In case of registered nurses, a 2-year bridging program may be designed leading to a BSc in
Midwifery
§ Admissions and progression should be highly transparent, in accordance with the ICM educational
standards
§ Continuous midwifery education programs to update and upgrade midwifery knowledge and skills
§ Most of the larger schools of Nursing upgraded as Colleges of Nursing should have a separate
department for midwifery and allocate a significant proportion of seats for Midwifery
§ All the public health schools producing Lady Health Visitors in the country should be upgraded as
Midwifery Schools headed by competent Midwives instead of doctors and with enhanced seats
 MIDWIFERY SERVICES
§ In addition to their core duties, Midwives are expected to provide education to
communities on:
o Health, wellness, nutrition and hygiene
o Childbirth, breastfeeding and infant care
o Removes misconceptions and taboos relating to childbirth
o Family planning and contraception
o Adolescent reproductive health issues
o Provide referrals to specialized doctors when needed
 MIDWIFERY SERVICES AND ADVOCACY
§ The Pakistan Nursing Council / Regulations Wing MoNHSR&C will ensure uniformity
within the provinces on the provisions of the National Vision such as educating
enough midwives and nurses with competencies to meet population health needs;
creating jobs, and ensuring that midwives are supported, respected, protected,
motivated and equipped to safely and optimally contribute in their service delivery
settings, consistent with WHO recommendations.
§ Advocacy will be carried out to highlight the virtuous character of the profession
• The MoNHRSC to expedite its support for the upgraded colleges in faculty
development, provision adequate resources including, human, material and
financial support
• The Ministry will promote a rights-based approach to ensure comprehensive care
for women and neonates, devoid of any discrimination
 MIDWIFERY WORKFORCE
§ New positions of midwives to be created at all levels of the health systems including
universities, teaching hospitals, district headquarter hospitals, tehsil or sub-district
headquarter hospitals, rural health centers and certain basic health units
§ A transition plan should be prepared for carrying out the merger of several cadres
that has overlapping tasks/ responsibilities
§ The MoNHSR&C and the PNC will ensure uniformity and standardization in the
implementation of all public policies relating to Midwives across all the provinces
§ Ensure Up to date job descriptions, roles and responsibilities for midwives
§ A career structure for midwives will be immediately evolved to retain the
motivation of midwives and remove all barriers in their workplaces bringing them at
par with the nursing profession
§ Right people, right place to provide care
 FINANCING AND THE WAY FORWARD
§ Each province will develop its own Midwifery Strategy in lieu with federal strategy
remaining within this framework need to decipher the number of midwifery
professionals based on the requirement of each district by the 2030 in order to attain
universal health coverage
§ Financial estimates need to be prepared and allocations made by the provincial
governments through non-development or development expenditures (PC-Is)

§ By changing post nomenclature, Midwives will enjoy the same career pathways as
allowed to Nurses (Grade 16-20) or even higher for selection posts or Deans in
universities

§ The Provinces will devise their costed Midwifery operational plans and ensure timely
 Partnership and Networking
§ This Strategic Framework will be implemented at the provincial level by a number of technical and
development partners including:
§ MoNHRSC, Provincial Health and Population Welfare departments
§ Pakistan Nursing Council and provincial Directorates General of Nursing
§ UN agencies and funds such as WHO, UNFPA and UNICEF
§ Donors and Development Partners
§ Midwifery Association of Pakistan
§ Society of Obstetrics and Gynaecology of Pakistan
§ Jhpiego – a project of Johns Hopkins University
§ National Committee on Maternal Health
§ Health universities such as Health Services Academy
§ The Midwifery Strategy will be linked and aligned with other developments taking place in the Nursing
and Midwifery Sector and to a similar intervention dealing with the education and curriculum issues
 The Way Forward
§ This Strategic Framework will be finalized as soon as a consensus emerges with the
provincial Departments of Health, which in turn will develop and implement their
own strategies and operational plans with sustainable financing till 2030
§ The United Nations’ agencies like UNFPA, WHO and UNICEF are expected to provide
technical expertise to the provinces not only at the policy making but in its practical
implementation as well
§ All these actions are expected to pave the way for a transition to a robust Midwifery
cadre leading to spectacular successes in improving the crucial health and
demographic indicators in Pakistan

Thank You!
Topics for Discussion
• Leadership and Governance – development pathway
• Education – Readiness, preparedness (Faculty, Schools – readiness,
competence, opportunities for training, Nursing examination boards,
Clinical site readiness, International accreditation)
• Midwifery Services – Framework, Regulations (role of PNC), Structure, UHC
integration, inclusion in health information systems/HRH
• Midwifery Workforce – Career structure, Services pathway, systems
integration (Services to policy making)
• Funding –
• Partnership and Networks – National networks, International partnerships
• Bridging pathways – transition for existing midwifery programs
• Role of private sector – education and services