Expanding access to reproductive health through midwives[ : the MAPS initiative]

MAPS works with midwives in the private and public sectors through their professional associations. Since its beginning in 1995, MAPS has created and implemented projects in four countries in Africa -- Senegal, Uganda, Zambia, and Zimbabwe -- and assisted midwifery associations in Cambodia, Eritrea, and Tanzania. MAPS has increased access to FP/RH services by: providing services in communities where public sector services are limited or unavailable (e.g., rural areas); integrating FP into existing RH care services; reducing practice barriers; and providing health care alternatives for clients. MAPS strategies, which were tailored during implementation to specific country needs, include: capacity building of associations and their members; creation of more enabling practice environments; promotion of quality and sustainability; creation of model clinics; and development of policy initiatives. To promote sustainability, MAPS: builds association capacity for self-governance, management, training, advocacy, funding, strategic planning, and marketing; seeks to reduce barriers that prevent private midwives (PMWs) from offering a full range of services, including FP; and supports individual midwives by improving quality of care, strengthening the marketing capability of PMWs, increasing access to FP, and introducing user fees. The project facilitated outreach activities to make communities more aware of PWM services. In reaching beyond their clinics to the communities they served, midwives learned a great deal about community needs, perceptions of care, and barriers to access. MAPS included a strong training program to expand midwives' knowledge, skills, and attitudes. Training covered areas such as mobilizing communities, managing a business, keeping records of service statistics, and monitoring quality of care. During the MAPS end-of-project evaluations, midwives reported that these activities contributed greatly to their professional growth. Lessons learned included the following: (1) Barriers to private practice severely limit the potential contribution of midwives to reducing the unmet need for RH services. (2) RH service delivery points are incomplete without minor curative services and immunization capability. (3) HIV/AIDS has permanently changed the service delivery environment. (4) Basic business management skills and community mobilization skills are critical to the viability of private midwives. (5) Monitoring and long-term supervision of midwives on a sustained basis is difficult. The MAPS experience illustrates that, with adequate support, midwives can successfully expand access to RH care, reach underserved populations, and provide high-quality, integrated reproductive health services, including FP. Two areas that would benefit from continued focus are: (1) strengthening community mobilization and links with NGOs, and (2) empowering midwives by removing barriers to practice.