Midwifery education in Nepal: Training the first generation of professional midwives
Nepal plans to produce and deploy thousands of professional midwives across the health system to improve women’s access to quality maternity care. With support from Germany, midwifery education programs are now up and running – and the first graduates are already busy at work.
The nine young women in their starched white and pink uniforms were bursting with pride. It was January 2020 and the National Academy of Medical Sciences (NAMS) in Kathmandu had just graduated its first cohort of professional midwives. After three years of hard work and sacrifice, the members of the group had earned Bachelor’s degrees in Midwifery and were ready to enter the workforce as members of Nepal’s newest health cadre.
It was a joyful and celebratory day – not just for the new graduates, but also for the faculty who taught them and for the many different partners who had helped to create and support the course. The midwifery education program which produced these confident, motivated young midwives had been years in the making.
What did it take to get to this point? This article takes a look at the recent history of midwifery education in Nepal, with special attention to the contributions of German development cooperation.
A new cadre of professional midwives
The journey started back in 2006, when Nepal’s Ministry of Health and Population endorsed the creation of a new cadre of professional midwives as part of its long-term strategy for improving the health of mothers and babies in the country. Although maternal mortality had been declining, Nepal continued to face challenges in ensuring good quality maternity care, particularly in rural areas. The size and shape of the health workforce was one of the key issues: most maternity services in the country were – and still are – provided by nurses and auxiliary nurse midwives who learn basic midwifery skills as part of their pre-service training, but who do not always have the competencies and depth of experience needed to manage challenging obstetric situations on their own.
‘A lot of investments have been made in refreshing maternity skills and in training health workers to become Skilled Birth Attendants, but these have not brought the results that were hoped for,’ says Dr Laxmi Tamang, the President of the Midwifery Society of Nepal (MIDSON), explaining the government’s decision to introduce professional midwives. ‘Nepal has a high stillbirth rate and Caesarean sections are on the rise. This is where midwives come in.’
When fully educated, licensed and working as part of interdisciplinary teams, midwives can provide 90 per centof essential sexual and reproductive health services. They have the competencies needed to manage normal pregnancies and deliveries – and to detect potentially life-threatening complications which require emergency intervention.
Midwifery education: Starting from scratch
For professional midwives to be deployed in large numbers they would first need to be trained. The Ministry of Health and Population, working in close cooperation with the Nepal Nursing Council, MIDSON, UNFPA Nepal and the International Confederation of Midwives (ICM), decided to start by developing a Bachelor’s in Midwifery (BMid) course: a three-year competency-based education program aligned to international standards.
Over a period of several years, this group of partners built a ‘scaffolding’ for midwifery education, piece by piece. Academic institutions were identified to design and run the first courses. A curriculum was developed in line with ICM guidelines. Hospitals were lined up to offer clinical placements for midwifery students. Entry requirements were defined for aspiring midwives; so were the competencies expected from those about to graduate.
In 2016 Nepal’s first BMid course was launched at the Kathmandu University School of Medical Sciences (KUSMS). Programs at NAMS and at the Karnali Academy of Health Sciences (KAHS) followed in 2017 and 2018, respectively. By 2021 more than 100 students were enrolled in BMid courses in Nepal and the intake for new entrants was raised to 70 students per annum.
Supporting midwifery faculty
Since 2016 the Support to the Health Sector Program (S2HSP), which is implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), has been an important technical partner for these three institutions.
A top priority has been to train the faculty who are teaching on the midwifery courses. ‘When the BMid programs started, Nepal did not have any midwifery educators who had been trained as professional midwives,’ explains Dr Arpana Kalaunee, a technical advisor with S2HSP. ‘Most of the instructors come from a nursing or nurse-midwifery background and were accustomed to the obstetric model of maternity care.’ As an initial measure, S2HSP collaborated with UNFPA Nepal on a series of 14-day training courses to introduce midwifery faculty to the philosophy and principles of midwifery and to the midwifery model of care.
To support these faculty as they began working with the new curriculum, S2HSP facilitated the short-term and long-term placement of international midwifery experts at KUSMS and NAMS. The visiting experts provided onsite coaching and mentoring to the midwifery faculty, and helped to revise aspects of the new curriculum as needed. During the COVID pandemic, when physical visits were not possible, midwifery educators from Bournemouth University and the Liverpool School of Tropical Medicine, both in the United Kingdom, continued to provide online support to midwifery faculty at NAMS and KAHS.
Instilling the ‘midwifery attitude’
While the midwifery model of care can be explained in a classroom, the ‘midwifery attitude’ is best learned by observing an experienced midwife at work. Here, the international midwives had a critical role to play. During clinical placements at a large maternity hospital in Kathmandu and at a district hospital in Bagmati Province, midwifery faculty and students from NAMS benefitted from the opportunity to work day in and day out alongside Margaret Walsh, a British midwife who, with support from S2HSP, was part of the faculty at NAMS from 2017 to 2020.
‘Something fell into place when the students and faculty could see how a midwife works,’ explains Walsh, reflecting back upon her experience in Nepal. ‘They had been lacking role models. Seeing a midwife in action in the context of their own community, with the women they work with – this led to a lot of ‘aha’ moments. Oh, so this is how you do it, this is how you say it.’
Putting women at the center
One of the students whom Walsh taught was Prasansha Budha Lama, who graduated from NAMS in 2020 and now works as a midwife at the Paropakar Women’s and Maternity Hospital in Kathmandu. Honored in 2020 as one of the world’s 100 Outstanding Women Nurse and Midwife Leaders, Budha Lama learned firsthand what it means to provide women-centered care: ‘Working with visiting midwives made me realise that we have to be very close to the women we are helping,’ she says. ‘We have to pay attention to every aspect of the woman’s experience and to involve her and her family members in the process of care.’ She saw how small changes – such as installing privacy curtains in maternity wards and allowing husbands and partners to be present at births – made women feel more relaxed and confident.
Maiya Shobha Manandhar, who is on the midwifery faculty at NAMS, saw this, too. ‘Margaret was very clear about the role of midwives and showed what it looks like to advocate for women,’ she explained. ‘With her help we were able to challenge some poor practices and break certain taboos.’ This positive example helped to motivate the midwifery students, according to Manandhar. ‘They are excited about the prospect of working independently in birthing units, and they have the specialised training and experience needed to do it,’ she says.
Developing clinical skills through simulation education
Another area where Germany has contributed is the introduction of simulation-based education approaches into pre-service training for professional midwives. Through a development partnership with Laerdal Medical, the world’s largest manufacturer of training manikins and patient simulators, S2HSP established a fully-equipped simulation laboratory at KUSMS and upgraded the skills lab at NAMS. More than 80 midwifery faculty and instructors on Skilled Birth Attendant courses across Nepal have been trained to integrate simulation techniques into their teaching.
New pathways into the profession
Now that the first three BMid programs are up and running (and a fourth has been approved to begin at the BP Koirala Institute of Health Sciences), attention is turning to institutionalising the midwifery model of care in Nepal’s health system. The Government of Nepal, in its Nepal Safe Motherhood and Newborn Health Road Map 2030, envisions the creation of midwife-led birthing units at hospitals which have more than 300 births per month. Staffing these will require many more professional midwives than can be produced in the foreseeable future through the BMid courses alone.
For this reason, S2HSP has been working with the Nursing and Social Security Division at the Ministry of Health and Population, and with other partners, to develop additional pathways into the profession. The first of these is a three-year certificate-level program in midwifery which will be open to existing auxiliary nurse midwives, as well as to new entrants (i.e. high school graduates); the second is a ‘bridge course’ – a 12- to 18-month supplementary training for registered nurses to retrain as midwives.
On the right track
Once these new courses are inaugurated, Nepal will be one step closer to having the human resources that are needed to establish the first truly midwife-led birthing units. Many challenges still need to be tackled, not least creating the necessary physical space within maternity hospitals and shifting clinical practice away from the obstetric model of care, but Dr Laxmi Tamang, of MIDSON, is convinced that the country is on the right track. The first professional midwives are already at work, and nurses are awakening to the possibility to retrain and join the profession. ‘The interest and motivation are there,’ she says. ‘We are bringing more and more people onto the path to midwifery.’