and determined at the national or policy -making level. As an essential component of the maternity services, the provision and shape of the midwifery service should also be defined and determined at this level and must reflect the needs of the maternity service. Success will be im-possible without a discrete, identifiable midwifery contribution to all aspects of the development of a national strategy and plan of action for maternity care.
Midwifery should play a significant role in defining priorities for the maternity service. It is well placed to assist in defining priorities
against the resources available, and in rationalizing the provision of care to achieve optimum results.
Midwives' involvement in the full spectrum of maternity care places them in direct contact with all personnel in the service and all the oper-ational processes that support it. Midwives provide a unique knowledge of the strengths and weaknesses of the service. If policy -makers are to build into their strategies the processes to achieve cohesion, they will need to utilize midwives' experience interpreted through a national -lev-el midwifery function.
Midwifery provides an understanding of factors that affect the out-comes of differing levels and types of care and has a role in interpreting the significance of maternity care data. Midwifery can assist in
defin-ing the differdefin-ing but complementary roles of other health professionals, including doctors, and can contribute to discussions of national staffing and skill needs and decisions.
Contribution to plans for maternity services
Fig. 1 provides a framework for the systematic development of the is-sues that will shape the type of strategy and plans to meet each
coun-Fig. 1. Framework for developing a national policy, priorities and an action plan for maternity services
KEY AREAS
(providing a national midwifery perspective)
KEY AREAS Monitoring Evaluation
links between key areas to be addressed - - - centre of responsibility for developing the key areas
try's needs for maternity services. It gives key areas to be addressed at the national level in the development of policies, priorities and plans and the process for implementing them. The following list from the Mother -baby package (9) indicates some activities that should form a part of this work (Table 1):
1. definition of national policy and guidelines 2. analysis of the situation and assessment of needs 3. preparation of national action plans
4. estimation of costs of implementation 5. identification of sources of support
6. preparation of detailed implementation plans 7. implementation of interventions
8. monitoring and evaluation.
Table 1. Key areas and activities for a midwifery contribution at the national level
Key areas Activities
Maternal needs Women's health Women's and men's
reproductive health Family planning Maternity services Standards and quality Monitoring and evaluation Provision of maternity services:
national policy, priorities and action plan
Situation analysis and needs assessment
Definition of national policy and policy, priorities and ac-tion plan guidelines Estimaac-tion of costs of implementa-tion Preparaimplementa-tion of detailed implementaimplementa-tion plans Im-plementation of interventions Monitoring and evaluation
Contribution to a midwifery action plan
The concept and process of developing national action plans for nursing and midwifery are described more fully in Chapter 4. The action plan for midwifery will be an effective component of the national action plan for maternity services if:
it is developed at or supported by the national level;
it reflects national policies, priorities and plans for the provision of a maternity service aimed at improving maternal and perinatal out-comes; and
it strengthens midwifery in support of safe or safer childbirth.
Clearly, the responsibility for the national midwifery action plan lies at ministerial or policy -making level. The development of the plan re-quires a comprehensive knowledge and understanding of midwifery and the midwifery service, and the part each plays in the provision of ser-vices. This knowledge should be available through an identifiable mid-wifery function at the national level. The implementation of the plan depends on the extent to which it is realistic and accurately reflects the service and circumstances of people with midwifery skills. The mid-wifery contribution to planning has an important part to play in achieving such realism.
Resolution WHA45.5 (8) calls on Member States to take eight steps in strengthening nursing and midwifery in support of strategies for health for all. These steps can easily be recast as activities for develop-ing midwifery:
1. identifying needs for midwifery services, followed by the assess-ment of the role and utilization of midwives;
2. strengthening managerial and leadership capabilities and reinforcing the position of midwifery personnel at all levels of service, includ-ing the central and local services of health ministries and the local authorities responsible for the programmes concerned;
3. enacting legislation where necessary or taking other appropriate measures to ensure good midwifery services;
4. strengthening education in midwifery, adapting educational pro-grammes to the strategy and revising them where appropriate in or-der to meet the changing care needs of the population;
5. promoting and supporting health services research that will ensure the optimal contribution of midwifery to health care delivery;
6. ensuring appropriate working conditions to sustain the motivation of personnel and improve the quality of services;
7. ensuring the allocation of adequate resources (financial, human and logistic) for midwifery activities; and
8. ensuring that the contribution of midwifery is reflected in policies on maternity services.
Fig. 2 shows a framework for the development of a national action plan for midwifery based on these activities. It provides for a systematic and comprehensive approach to key areas that should be developed within
Fig. 2. Framework for developing a national action plan for midwifery
PROVISION OF KEY AREAS IN MATERNITY SERVICES National policy
links between key areas to be addressed - - - centre of responsibility for developing the key areas
the plan if the provision of maternity care is to benefit from the contri-bution of midwives.
Characteristics of government midwifery personnel
Ministers and policy- makers will require that the providers of a mid-wifery contribution to national policy have a comprehensive under-standing of health, maternity and midwifery services, and can interpret midwifery in terms of national policy as well as being able to identify midwifery issues in the broadest sense. While the midwifery