Uzbek midwives are stepping up

WHO/Malin Bring

Midwife Gulnoza Sadieva helps a new mother learn to breastfeed.

“At our hospital, we midwives are in charge of the deliveries. Previously, it was always the doctors,” says Gulnoza Sadieva, Chief Midwife at the Ferghana Oblast Perinatal Centre in Uzbekistan. Her observation reveals a positive trend: midwives are taking on a more active and responsible role in the country’s maternity units.

Talking in a subdued and soothing voice, the midwife helps a young mother place her infant on the bed next to her so she can breastfeed. The woman gave birth a few hours ago, and the smile on her face reveals that it was a happy experience.

“If it is a normal birth, we take a step back and let the woman do most of the work herself,” Gulnoza explains. “In the past, we had to do an intervention every two hours. Now we encourage the women to deliver in a vertical position; it works as a natural painkiller.”

Near-miss case reviews: giving voice to midwives, nurses and mothers

One of the tools that has had an impact on Gulnoza’s work in recent years is the near-miss case review (NMCR). The purpose of NMCRs is to improve the quality of maternal health care by reviewing cases in which women have survived severe complications during pregnancy or childbirth.

The aim is to identify areas that can be improved, and ultimately to reduce preventable maternal and perinatal morbidity and mortality. Since the women survived, no official investigations are undertaken; the audit is conducted solely to improve the knowledge and practices of the facility staff.

WHO and partner agencies introduced the NMCR methodology in Uzbekistan in 2004. In the past decade, the majority of the country’s maternity units have implemented NMCRs with support from WHO.

In the days of the Soviet Union, doctors alone performed case reviews. NMCRs give voice to midwives, nurses and, via an interview made by a staff member, the woman who experienced complications.

“My impression is that the medical staff has come a long way,” says Tinatin Gagua, an obstetrician/gynaecologist and consulting WHO expert. Together with a group of colleagues, she recently visited 5 Uzbek maternity units to review their implementation of NMCRs.

“They know how vital NMCRs are and how they change both their own work life and the lives of the women. The quality of the sessions differed from one facility to another, but what NMCRs bring everywhere is the feeling of being part of a team. That is very important in obstetrics.”

Building confidence through dialogue and learning

Calmly and with poise, midwife Dinara Kalandarova leads the session from the head of a meeting table. Seated around her are a dozen colleagues from the Republican Perinatal Centre in Tashkent – midwives, nurses and doctors alike.

Dinara gives the floor to each in turn. When the discussion gets out of hand for a moment, she gently interrupts and calls everyone’s attention back to the question at hand.

“I’ve been facilitating NMCR sessions for 7 years and really like it,” she says. “I appreciate the way we reach the truth in the near-miss cases we discuss. It is gratifying to discover missed opportunities together and find recommendations for the future.”

She feels that the teamwork in her department has improved considerably since the hospital began implementing NMCRs. The midwives have grown more confident and knowledgeable, and the recommendations have led to better work routines. One example she points to is the installation of emergency buttons in the delivery rooms, so a midwife can call for immediate help when needed.

There was initial scepticism about the NMCR process, however.

“We midwives were passive in the beginning. We were fearful of the doctors and afraid to reveal our own mistakes. With time, we have grown more self-assured. Those of us who were not so well informed about protocols have been stimulated to read and learn more,” Dinara explains.

“Nowadays, everyone contributes, we discuss openly and freely, and dig deeper to find the underlying causes of the cases.”

Focusing on quality assurance to improve NMCRs

The assessment team that conducted the review of NMCR implementation in maternity units points to a lack of systematic quality assurance for NMCRs as one of the main challenges.

“There are no officially endorsed coordinators at the regional level and no systematic reporting of the results of the sessions. The system is unsustainable if international agencies are the only ones performing quality assessments,” says Alberta Bacchi, a WHO consulting expert.

“Much can be learned from each other, though. Exchanges between the hospitals would be valuable.”

Alberta’s colleague Tinatin agrees. She adds, “What surprised me the most in our assessment, however, was seeing a midwife leading a session with such confidence. With the hierarchical medical system taken into account, I found that truly astonishing.”