Dr. Amal forms part of the first (of two) mobile health teams that support ten health centres in four districts in Amran. She has worked for Save the Children for two month. (Ala’a Aleryani / Save the Children)

 As part of Save the Children’s life-saving work in Yemen we are responding to the chronic lack of health workers and health facilities by providing child focused health and nutrition services in 19 sites across Amran.  Dr. Amal forms part of one of these teams that support ten health centers in four districts in Amran.  

Malnutrition levels remain critical in Yemen

Political instability, conflict, fuel shortages and high food prices have left almost 10 million people without enough to eat and 967,000 children’s lives at risk.

Malnutrition rates amongst children under-five are escalating beyond emergency levels – in some areas over a quarter of all children are malnourished.^[1]  Children across Yemen are suffering from malnutrition are more likely to become ill with diarrhoea, pneumonia, malaria, measles and AIDS.  Malnutrition compromises a child’s immunity so that an episode of illness tends to last longer or be more severe.

Chronic under-funding, mass displacement of people and a prioritization of urban over rural delivery of health services have left the most vulnerable people in remote regions without access to lifesaving care.

Currently in Yemen there is one health center per 30,000 people. After conducting a health facility assessment in Amran and Sa’ada governorates (two of the conflict-affected areas of Yemen), Save the Children found that 80% of facilities could not provide basic health services due to the lack of medical equipment, drugs, health staff, and furniture.

A Health Champion

Dr. Amal Abduallah Afre is 26 years old. She lives in Sana’a, the capital of Yemen. Her working day starts by making a 1.5 hour trip from her home in Sana’a, to the Save the Children office in Amran.

Dr. Amal is warm, open and driven. You can imagine her in her element at the health centers, commanding her space, administrating advice and barking orders. She is acutely aware of what she has compared to the little possessed by communities with whom she works and she is willing to give as much as she can to help.

“The first time I worked, I went to Gahel. I thought, yanni, this is a long distance, I was not used to the travelling but I adapt.

“Gahel is the closest place we travel from Amran – only thirty minutes. Haitha it is the furthest and is almost three hours from this place.

“The people in Sana’a, they don’t know what happens in Haitha. There are no services from the government, these people are forgotten people

“They have no education, no health services – it feels like the middle ages.”

“It takes three hours to get to Haitha and three hours to get back and we stay for four hours. While at the health centre we treat 300-400 cases.

“At first when we come to Haitha, the patients were difficult to deal with. They push each other; they want to take medicine now. The number of patients is increasing. The volunteers that work with us are really important. We need a lot of support for triage. 400 people, one health center, the people don’t know how to organize themselves. The health service is decreased if we can’t get triage under control.

“The most difficult thing I face is I can’t treat everyone in the perfect way.  I only make one visit every two weeks. These people are waiting and it is the only service.

“One patient I see in Haitha, severe malnutrition – the child had a high grade fever and test positive for malaria. The mother had 5 or 6 children with her and she told me that 3 or 4 of her children had died before reaching 6 years old from diseases. I referred the mother and child to Amran and gave them transport to get to free medical care there.

“At the outpatient therapeutic feeding you see children with no cheeks at the beginning of the week and cheeks at the end!

“For sure people are grateful. They like to give you something, something small, like breakfast – lahoh (a flatbread with a slightly spongey texture).”

Supporting families and saving lives

Medical professionals like Dr. Amal, are vital to help children survive. Without them, no vaccine can be administered, no life-saving drugs prescribed and no woman can be given expert care during childbirth.

Our mobile health teams provide general consultations; treat communicable diseases; support women with antenatal and postnatal care and work towards a safe and healthy delivery for every mother and child (assistance, education, and provision of clean delivery kits).

We also run outpatient therapeutic programs and supplementary feeding, where mothers can bring malnourished children that have been identified by the mobile teams. Here the children receive specialist food and care to help them recover.

Mobile health teams

• Until July 2012, 23,075 medical consultations have been conducted by our teams in Amran
• 11,810 children have been screened for malnutrition by our mobile health teams
• We identified 434 with severe malnutrition and over 2,500 children suffering from moderate malnutrition.
• We have also screened 8044 pregnant and lactating women.

For more information see www.everyone.org

The Health Workers Count Coalition has produced a new policy briefing on the importance of health workers for achieving Universal Health Coverage (UHC).

UHC refers to all people having access to an essential package of quality health services without the risk of financial hardship associated with paying for healthcare.

This briefing outlines why strong health workforces are essential for expanding coverage of services to those most in need and why health workers need to be considered when increasing financial risk protection and reducing inefficiencies. The briefing calls on governments to take action on health workers as part of their efforts to achieve UHC.

Download the briefing here.

Guest post: Oying Rimon, The Bill and Melinda Gates Foundation, Impatient Optimists

Around the world, frontline health workers are often the first link to lifesaving care and supplies, and in some cases they are the only link for families and communities in rural and impoverished areas. This is also where most of the world’s unmet need for family planning resides. More than 200 million women in developing countries want to delay or avoid pregnancy but lack access to modern methods of contraception.

Family planning and frontline health workers: worth the investment

In just a few short weeks, the foundation, together with the UK government and other partners, will host the London Summit on Family Planning. It will be a groundbreaking global convening of developed and developing country government and civil society leaders, who will pledge to address the contraceptive needs of an additional 120 million women in the world’s poorest countries by 2020. The summit will also focus on tackling cultural barriers to contraception and encourage countries to adopt a rights-based approach, which enables women to decide whether, when, and how many children to have. At the foundation, we often talk about how frontline health workers and family planning are extremely cost-effective strategies to save lives, and improve health and development broadly. For instance, every three seconds a child’s life is saved thanks to the care provided by a frontline worker (PDF), who can be provided basic training for as little as $300 (U.S.). Likewise, investing in family planning services has a proven cost-benefit return for both developing and developed country governments, and addressing current unmet contraceptive need could prevent one in three maternal deaths and one in four infant deaths.

A personal connection

For me, frontline health workers are not just a smart investment, but also a community I feel personally committed to. Back in the 1970s, one of my first jobs was as manager of a national family planning program in my native country of the Philippines, which included more than 4,500 outreach workers and 50,000 community-based volunteers providing information and services to couples in their neighborhoods. I met with many of these highly committed community-based workers and saw first-hand how crucial a role they played for the country’s population, nearly half of which resides in urban slums.

In the Philippines, this first-string of health providers, mostly midwives and barangay (village) health workers, fills the gaps of an overwhelmed healthcare system and provides critical health. As of 2012, contraception use in the country, which is 80 percent Catholic, is just 34 percent. Yet current political leadership is committed to bringing family planning services closer to the people. Recently, I was on a personal visit there and was pleasantly surprised to see many of the same individuals I used to know, still working for their communities–although many now qualify for senior citizen discounts!

Progress is possible

In other parts of the world, frontline workers are already doing more to provide family planning services to the poor and marginalized. For example, in Uganda, recent policy changes allow community health workers to provide injectable contraceptives to women, and have resulted in significant improvements in contraceptive access countrywide (PDF).

Frontline workers have the ability to reach those most in-need. We know that progress is possible. Yet in order to see results, frontline workers need to be adequately trained, supported, and integrated into the broader health system, and they need consistent access to cost-effective family planning supplies. Imagine the impact if we worked to prioritize policies like task shifting and training that enable frontline workers to deliver family planning services to meet the needs of millions?

The London Summit on Family Planning will aim to galvanize new financial and political commitments to ensure this progress, and convene leaders to affirm that every woman in the world deserves the opportunity to determine her own future. With the right resources and policy support, I believe there are few limits to what frontline workers can do. Empowering them with family planning knowledge and supplies, which they can deliver to women worldwide, will have an immediate and far-reaching impact. Doing so will benefit not just women themselves, but families, communities, and entire nations.

During last year’s International Conference on Family Planning, IntraHealth promoted health worker empowerment with the slogan “Family Planning: It Takes a Health Worker.” We had the phrase printed on posters and buttons, proudly displayed at our booth and on our lapels. We posited that all of the contraceptive technologies in the world will not make a difference if there are not skilled health workers to deliver them. Visitors to our booth, seeing our theme, sometimes laughed and said, “Well, technically it doesn’t take a health worker to put on a condom or promote abstinence.”

Health worker with supplies in a clinic near Dakar, Senegal.

During the conference, I responded — and continue to assert — that it does take a health worker, or more accurately millions of health workers, to meet the need that hundreds of millions of couples worldwide have for family planning. It takes a health worker not only to administer most modern methods of contraception but also to provide counseling and services in a holistic way, and to offer reproductive and other health services throughout the life cycle of both women and men.

A new report issued by the Guttmacher Institute and UNFPA this week, Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012, supports that notion. Guttmacher and UNFPA released the report in preparation for next month’s Family Planning Summit to be held on July 11 in London with the support of the Government of the United Kingdom and the Bill & Melinda Gates Foundation. The summit aims to mobilize new partners and more resources to address family planning needs, especially in the developing world. Labor — or salaries of health workers — currently accounts for an estimated $0.7 billion of the $4 billion spent on family planning in developing countries in 2012, but we need to invest more, globally, to ensure that health workers are there to expand access and offer services. At IntraHealth, we truly hope that the summit also will focus on the need for health workers — not only in numbers but also in training, deployment, and ongoing support.

Modern Contraceptive Methods and Health Workers

There has undoubtedly been increased international attention to family planning over the past several years, as illustrated during the International Conference on Family Planning in Kampala, Uganda, in 2009 and during the second international conference in Dakar, Senegal, in 2011. (I had the opportunity to attend and blog about both the Kampala and the Dakar conferences.) Despite this attention, however, the report documents that the annual increase in modern contraceptive users between 2008 and 2012 was significantly lower than between 2003 and 2008 — 10 million versus 20 million per year.

The Guttmacher Institute and UNFPA report outlines the grim ramifications of the unmet need for family planning. In 2012, an estimated 291,000 women in developing countries will die from pregnancy-related causes; more than one-third of these women will not have wanted to become pregnant. And approximately one-third of newborn deaths and one-fourth of later infant deaths are associated with unintended pregnancies.

The report highlights, too, the incredible benefits and potential of family planning. If all women, and all couples, worldwide could use the contraceptive methods that they want and need, unintended pregnancies would decline by two-thirds: from 80 million to 26 million. There would be 26 million fewer abortions. There would be 21 million fewer unplanned births, and 7 million fewer miscarriages. Pregnancy-related deaths would drop by 79,000. And, amazingly, there would be 1.1 million fewer infant deaths.

According to the report, 645 million women of reproductive age (15–49 years) in the developing world are now using modern contraceptive methods, up from 603 million in 2008. However, population growth accounts for about half of the increase. The overall proportion of married women using a modern method — 92 percent of all modern method users — plateaued between 2008 and 2012, at just over 50 percent. However, there were significant regional variations, with substantial increases in Eastern Africa (from 20 percent to 27 percent) and Southeast Asia (from 50 percent to 56 percent), and stagnation — or even declines—in countries in Western Africa and Central Africa, where fewer than 10 percent of married women use modern contraceptives.

To meet the global unmet need for family planning, the report calls for the “training of health workers and others involved in provision of these services” as well as improved access to high-quality services.  This includes not only training health workers to administer contraceptives but also to offer counseling and follow-up support and to recognize clients’ rights. Offering client-friendly services means that health workers have to be skilled to respect confidentiality and provide family planning services — to adolescents and unmarried individuals, too — with a nonjudgmental attitude. Tracking health workers is important, too. The report also calls for systematic data collection of indicators, including numbers of health workers and the training they receive.

Saving Lives Saves Money—and It Does Take a Health Worker

Meeting the unmet need would not only save lives: it would save money, too. Given the current global economic environment, cost-effective solutions are essential. The current level of contraceptive care in the developing world costs about $4 billion annually but saves $5.6 billion in maternal and newborn health service costs. Fully meeting all need for modern contraceptive methods would cost $8.1 billion per year but would save a total of $11.3 billion. For every dollar spent, $1.40 would be saved. Is there another cause or investment opportunity out there that provides more bang for the buck?

At IntraHealth, we know that it takes a health worker not only to offer family planning counseling and services but also to support individuals, families, and communities. While it is true that family planning can happen without health workers, one thing is sure: family planning is not happening nearly enough without them.

Follow Laura Hoemeke on Twitter, @laurahoemeke

Published on RH Reality Check

Why the world needs more midwives

May 5th marks the International Day of the Midwife, and here at Merlin we’re championing midwives working in some of the world’s toughest places.

In the UK we take it for granted that expectant mothers are guided through pregnancy with the help of a midwife. To give birth without a midwife present would be unthinkable, yet each year 48 million women give birth without the support of a trained midwife, and over 2.4 million of those women give birth utterly alone.

This tragically results in hundreds of thousands of women in developing countries dying from preventable causes related to pregnancy and childbirth; millions more suffer from infection and disability. More than 800, 000 newborn babies die during child birth, with over 3 million dying before they are even one month old. The majority of these lives could be saved by a skilled birth attendant.

Simply providing skilled care before, during and after childbirth can reduce the rate of maternal mortality and save the lives of newborn babies and infants. The difference one trained midwife can make, even with basic equipment is enormous. Midwives are vital, they save lives.

However many countries where Merlin works are facing a chronic shortage of midwives.

In Afghanistan, there is 1 trained midwife per 20,000 people. One guaranteed way to stem the needless loss of life we’re seeing in countries like Afghanistan is to increase the number of trained midwives in that country.

In Afghanistan, we have established a successful Community Midwife Education programme, which trains women in rural communities to be a midwife, on the basis that they will return to and help the women in their communities.

A similar programme is currently set up in Liberia. The Zwedru Midwifery Training School is helping provide Liberia with a new generation of community midwives through its free 2-year, full-time course.

These new midwives in Afghanistan and Liberia will go on to provide pregnant women in isolated rural communities with vital and life saving medical care. Midwives need more than just training to be successful – in the Democratic Republic of Congo, we also provide the community midwives with wages, supplies and communication to help them continue saving lives.

There are no quick solutions to reducing maternal mortality. We need to ensure that midwives on the ground in crisis countries get the support they need and thousands more are trained, in order to save lives. For this year’s International Day of the Midwife, help Merlin train and support more midwives and help save lives.

This Saturday, May 5, is International Day of the Midwife. It’s the prefect opportunity to acknowledge the vital work that midwives do around the world each and every day.

Catherine, who works at a special care baby unit in Nigeria, gives an insight into one day in her life in this video:

Performing miracles

Even in the most difficult circumstances, midwives everywhere are performing miracles to support safe deliveries and ensure that babies have the best start in life.

The world needs more midwives and governments need to do more to ensure that midwives everywhere are supported to do their jobs effectively.

Read our report Missing Midwives to learn more about the global shortage and the actions needed to address it.

British midwives help to Build it for Babies

This week I had the opportunity to meet up with a group of British midwives who are supporting our Build it for Babies campaign to raise funds for seven health clinics in Bangladesh.

It was impossible not to be impressed and inspired by the enthusiasm and commitment that each of the women had for providing the best possible care to mums and babies. Our discussion confirmed my assumption that being generally lovely must be part of a midwife’s job description.

Supporting midwives abroad

Watch our slideshow of midwives at work across the world

What was even more amazing was to hear that not only do the midwives do an amazing job delivering babies in the UK, but many of them are also volunteering their time to train and support midwives in other countries too.

They talked about the contrast in the midwifery services available in the UK with those available in countries like Bangladesh, Sierra Leone, Liberia and Ethiopia.

For many women in these countries only the most basic care is available at what can be the most dangerous time in the life of a mother and her newborn baby.

Missing midwives

There’s a global shortage of at least 350,000 midwives and this means that many women and babies die from complications that could be easily prevented by a health worker with the right midwifery skills, equipment and support.

By supporting our Build it for Babies campaign you can help ensure that seven new maternal health clinics in the north east of Bangladesh are fully staffed.

By doing so, you’ll help more than 3,500 newborn babies each year survive their first crucial weeks of life.

You can also show your support for #midwives and other #healthworkers on May 5 (and every day!) through your social media channels.

Visit our virtual clinic to buy anything from a stethoscope to a midwife’s salary for our Build it for Babies appeal

Je salue le courage et l’abnégation de nos vaillantes sage femmes qui oeuvrent inlassablement certaines au risque de leur vie, pour le renforcement du système de santé en prodiguant des soins de qualité aux femmes et aux enfants.
je profite de votre tribune pour réitérer mon engagement ferme à défendre le noble métier de l’ensemble des professionnels de la santé en général et de celui de la sage femme en particulier en prélude à la célébration de la journée mondiale de la sage femme.
Au Niger, nombreuse sont – elles qui sans relâche contibuent contre vent et marée à soulager la souffrance de la femmes nigériennes et des enfants en situation de détresse faute de soins spécialisés.
Notons, un accent particulier doit être mis sur la formation des sages femmes, et en guise de rappel cela cette problématique a été évoqueé au 2ème forum mondial sur les ressources humaines tenu à Bangkok (Thailande) dont j’ai eu la chance de prendre part. Entre autres la motivation et la retention des agents de santé a fait l’objet de débatS.
En ce qui concerne le Niger, des efforts sont faits dans ce sens, notamment le rehaussement du saliare des tous les agents de santé, le recrutement important de sage femme, médecins et autres professionnles de santé. Cette volonté de poursuivre les efforts, afin de motivé davantage le personnel constitue un point fort pour l’atteinte des objectifs du millénaire pour le développement dans nos pays en voie de développement. Il s’agit là d’un bon exemple à suivre… pour que vive la santé.

Boubacar Thiombiano
Directeur des Ressources Humaines
Enseignant permanent à l’Ecole Nationale de Santé Publique.

“The mediocre teacher tells, the good teacher explains, the superior teacher demonstrates and the great teacher inspires.”  Midwifery education is no different from any other subject in that the quality of instruction impacts the quality of service delivery.  In the Middle East and North Africa, there are many obstacles that must be overcome to improve the midwifery education system.  One such obstacle is an updated and regulated midwifery education system.

In most Arab States midwives face challenges similar to those in many other countries: low status of women, gender issues, and being subjected to nurse and/or doctor and employer abuse or conflict. The lack of a distinctive representative body or having one that is not structured or credible has led to an undefined role for midwives in society. Moreover, in the absence of enabling legislation and practice regulation or formal recognition and support for midwives, young girls (and their families) are reluctant to pursue an education or career in midwifery.¹

In the midwifery education systems of the Middle East and North Africa, the “great teacher who inspires” is absent. In fact, the midwifery education systems are mainly training oriented and prioritize the “doing” domain of learning and memorization.  One might compare this to culinary training which consists of learning the recipes from a cookbook instead of culinary education which prepares one for writing a cookbook with new ingredients.²  Although midwifery education programmes have to be competency-based and so mostly training oriented, the concept of competence itself has to be updated to include those skills which make a midwife proficient in adjusting or adapting to a specific situation.The midwifery education system should produce competent midwives whose services meet a woman’s sexual and reproductive health needs and rights on one side, changing priorities within the health system on the other side in addition to the professional guidelines of the midwifery profession.  The education system should also ensure a minimum level of cultural sensitivity and adaptability to the needs of specific populations.Here we come to the need for a balance between these two types of education – training through memorization and repetition of behaviors and education in critical thinking and adaptability -so that midwives can develop critical thinking while continuing to develop clinical skills.

This approach has been implemented in Djibouti (with the support of EMRO, 2004-2005), in Tunisia (with the support of UNFPA-Tunis, 2008) and in Yemen (with the support of the World Bank, 2010) where the midwifery education programme and a national midwifery strategy have been updated and developed respectively. The tools developed by ICM can help facilitate and strengthen efforts to improve midwifery education and service delivery and “The State of the World’s Midwifery Report”, published by UNFPA in 2011, is another outstanding resource that deserves the attention of all stakeholders interested in improving women and newborns health.   It is important that not only other countries in the Middle East and North Africa but also countries in Europe, Asia and other areas of the world assess the number and working conditions of midwives as well as the education system that trains them so that the services provided to childbearing women can be improved.

Join ICM and WRA in celebrating and showing support for midwives and the work that they do!  Click here to learn more about WRA’s Action of the Month, “Midwives Matter”, and what you can do to show your support for midwives on the International Day of the Midwife, May 5^th.

References:

1. Ghérissi A., Brown J.M., El Adawy M. Midwifery in North Africa and the Middle East Background Paper. The State of the World’s Midwifery Report. UNFPA, 2011  http://www.unfpa.org/sowmy/resources/docs/background_papers/23_GherissiBrownElAdawy_MidwiferyNorthAfricaMiddleEast.PDF

2. Adonyi Y. Understanding Differences Between Welding Education and Training. 2012 http://letu.academia.edu/YoniAdonyi/Papers/145858/Understanding_Differences_between_Welding_Education_and_Training.

On May 5^th, people all over the world celebrate the difference
midwives make in saving the lives of mothers and babies.  International Day of
the Midwife is about spreading awareness of the need for midwives and the impact
they have on maternal and child health. It is also about advocating for
government commitments to improve maternal and neonatal health by raising the
number of midwives, and increasing funding and legislative support for
midwifery.  These efforts are not just a means to advance a professional
occupation, but are an opportunity to advance the status of girls and women
everywhere and have a positive impact on the lives of everyone in their
communities.

350,000 women and 3 million neonates die each year as a result of mostly
preventable circumstances.  Ninety-nine percent of maternal deaths occur in
developing countries and sixty percent of these maternal deaths happen in only 6
countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic
Republic of Congo.

Every woman, everywhere, should have the right to a safe childbirth
experience.  This includes the right to deliver where, with whom, and how she
wants.  Whether a woman wants to give birth in a hospital, health facility, or
at home, she should have access to skilled care during, before and after
childbirth.  But inequities of qualified care continue to exist throughout the
world, in both developed and developing countries.  In many countries, midwifery
services are underfunded because of budget cuts and as a result of market-driven
policies.  Other countries have not yet made the decision to provide any funding
for midwifery services.

And yet midwives are key to achieving the reduction of maternal and neonatal
mortality and morbidity called for MDGs 4 and 5.  There is a shortage of 350,000
midwives globally.  If this shortage was addressed, more than one million babies
each year could be saved.  With more educated, competent midwives working in a
regulated system and the legislation to back it up, a huge difference can be
made in the lives of mothers, children and the families with whom they are
connected.

But governments need to do their utmost to support this system by supporting
midwifery education, legislation and regulation of the midwifery profession.  In
places where governments have already made commitments to improving the status
and number of midwives, such as in Malaysia, Sri Lanka and Thailand, we find
proof that by supporting midwives there is a reduction of maternal and child
mortality and morbidity and society as a whole is supported.

The International Confederation of Midwives has established global standards
on the education, competencies, and regulation of the midwifery profession as a
guide for governments and associations (available here).
These standards make it easier to educate midwives, ensuring that individuals
seeking care from midwives receive competent treatment and inspiring confidence
in the midwifery profession as a career choice.

On the International Day of the Midwife, we demonstrate our commitment to
supporting midwives with mothers, colleagues and partners worldwide.  The White
Ribbon Alliance for Safe Motherhood and the International Confederation of
Midwives are natural partners in the fight to improve the number, status and
working conditions of midwives around the world for the benefit of mothers and
babies and their families.

Join us in asking for governments and individuals to celebrate midwives:
Download the ICM’s resource packet to learn what you can do to celebrate IDM or click here to learn more about WRA’s Action of the Month: Midwives Matter.

The size of the nursing-midwifery school classes in Tanzania is rapidly shrinking, and the shortage of midwives is felt throughout the country. According to the 2010 Tanzania Demographic Health Survey, only half of births in Tanzania are attended by skilled health personnel. For every 100,000 births in Tanzania, almost 800 women die needlessly in child birth. Most of these are avoidable with access to care and skilled health workers.

The White Ribbon Alliance in Tanzania (WRATZ) is working hard to reduce maternal mortality and to bring the issue of the shortage of midwives to the forefront of the political agenda. As part of this work, WRATZ is working to promote midwifery as a profession and to improve the status and working conditions of midwives. This includes working to improve the public perception of midwives and the need for improved working conditions.  An example of these efforts is a short film, “What I Want Is Simple“, which is airing on Tanzania national television and radio spots.

Recently, with the financial support of the Health Policy Project, WRATZ organized a public hearing on this issue. Those in the audience were asked if they would choose nursing and midwifery as a career for their children. Of the one thousand people in attendance, only thirteen raised their hands in approval, which led to an in-depth discussion on the subject. Among other findings, it was revealed that students were hesitant to apply to midwifery schools due to the bad timing of acceptance letters. They had to make an enrollment decision for all the other schools a long time before the midwifery schools finalized their acceptance process.

Armed with this knowledge, civil society can now advocate with the Ministry of Health and Social Welfare and the Ministry of Education and Vocational Training of Tanzania for the necessary changes and timing adjustments to be made so that more students will be encouraged to join the depleting cadre of midwives.