Comparison of training of Midwife in Japan and Paraguay

Introduction                                                             page      1

Background                                                                         1

Literature on midwifery training                                         8

Comparison of Japan and Paraguay                             11

Discussion                                                                         18

Conclusion                                                                         22

References

Attachment

 

I. Introduction

In many countries, maternal deaths are major health problem. World Health Organization (WHO) has recommended several strategies to reduce maternal mortality. One of strong recommendations of WHO is that of training for personnel who assist at deliveries.

Japan is one of the developed countries that have a higher maternal mortality ratio than European countries, which have also experienced a reduction in maternal mortality ratio over the past 50 years since the Second World War. Paraguay is a developing country that has higher maternal mortality ratio than other Latin American countries.

In these two countries, the midwifery education systems at university level are similar, even though there are different situations in their health services systems. WHO’s recommendations about strategies of maternal health care give a point of review to compare these two countries’ educational systems for midwives. ^{(1 – 7)}

Midwives in both countries have similar limitations on what they are allowed to do to assist at a delivery. This paper will compare the midwifery education systems of Japan and Paraguay. Similarities, differences and limitations of midwifery education and their performance in these countries will be documented and will be compared to WHO’s recommendations.

II. Background

Japan is a small mountainous island country of Asia. After World War II, Japan became the first industrialized country in Asia. The Japanese health system was organized or re-organized by help of the occupation forces (GHQ) after World War II. Paraguay is a small inland flat country of South America. It is a subtropical country, but the difference of temperature during the day and through the year is noticeable. The principal industries are agriculture and cattle breeding. Ten years ago, the autocracy of 34 years ended. This year, 1998, saw the first election of the president and the governors by democratic election.

The demographic data and health indicators for Japan and Paraguay are displayed in Table 1 and 2. The area of Paraguay and Japan is almost the same; Paraguay’s area is 1.1 times that of Japan. However, the population of Japan is 125,351,000, ⁽⁸⁾ about 25 times of the population of Paraguay which is 4,957,000. ⁽⁸⁾ The annual population growth rate (1980-1996) of Paraguay is 2.9%, ⁽⁸⁾ while that of Japan is 0.4%. ⁽⁸⁾ The life expectancy of males in Japan is 76.38, ⁽⁹⁾ and that of females is 82.85. ⁽⁹⁾ The life expectancy of males in Paraguay is 65.11, ⁽¹⁰⁾ and females is 69.48. ⁽¹⁰⁾ The Infant Mortality Rate (IMR) of Paraguay is 28 per 1,000 live births, ⁽⁸⁾ while that of Japan is 4 per 1,000 live births. ⁽⁸⁾ The Maternal Mortality Ratio (MMR) of Paraguay is 160 per 100,000 live births, ⁽⁸⁾ and that of Japan is 18 per 100,000 live births. ⁽⁸⁾ The Maternal Mortality Ratio of Japan is higher than that of European countries such as Luxembourg which is 0 per 100,000 live births and that of Switzerland and Norway is 6 per 100,000 live births. ⁽⁸⁾ The major causes of maternal deaths in Paraguay are abortion, hemorrhage, eclampsia and obstructed labor. ⁽¹⁰⁾ In Japan, eclampsia and hemorrhage are main causes of maternal deaths. The present health indicators of Paraguay are similar to those in Japan 30 - 40 years ago. ^(9,10,11,12)

The number of medical doctors per 100,000 persons in Paraguay is 49. ⁽¹³⁾ The figure in Japan is 184. ⁽⁹⁾ The number of medical doctors per 100,000 persons in Japan is much higher than that of Paraguay. However, this Japanese ratio is lower than that of European countries such as Norway, where the figure is 203 per 100,000 per persons. ⁽¹⁴⁾ The number of Public Health Nurses who usually work in the Public Health Center or municipal office per 100,000 persons in Japan is 25.1 and midwives who usually work in the Hospital is 18.8 per 100,000 population. ⁽⁹⁾ Both health staff is trained at the university level. The number of Registered Nurses and Assistant Nurses per 100,000 persons in Japan is 738. ⁽⁹⁾ The number of Registered Nurses and/or Midwives who are trained at university level per 100,000 persons in Paraguay is 12. ⁽¹³⁾ The numbers of nurses who are trained at technical level is 25 per 100,000, and the number of auxiliary nurses is 70 per 100,000 in Paraguay. ⁽¹³⁾ In Japan, the total number of nurses per 100,000 persons is 781.9. ⁽⁹⁾ In Paraguay it is 107 per 100,000 persons. ⁽¹³⁾ The number of beds per 100,000 persons in Paraguay is 158, ⁽¹²⁾ and this figure in Japan is 1329.9. ⁽⁹⁾ When a pregnant woman delivers in hospital, she usually stays there for about 7 days in Japan, and in Paraguay for 48 hours. There are enough human resources to take care of post-partum women for 7 days in Japan.

In Japan, some type of medical insurance covers 99.7 % of the population. ⁽⁹⁾ About 65.5 % of the population are covered by social insurance, and 34.5 % by national insurance. ⁽⁹⁾ In Paraguay, about 14% of the population is covered by medical insurance. ⁽¹⁴⁾ There is no national medical insurance in Paraguay.

The total literacy rate of Paraguay is 92%, 94% for males and 91% for females. ⁽⁸⁾ The Primary School enrollment rate for both males and for females in Paraguay is 89%. ⁽⁸⁾ The percent of Primary School children reaching grade 5 in Paraguay is 71%. ⁽⁸⁾ The Secondary School enrollment rate of males in Paraguay is 38%, and for females it is 40%. ⁽⁸⁾ In Japan, it is possible to say that the total literacy rate is near 100% except for mental diseases and handicapped persons, because the Primary School enrollment rate is 100%, ⁽⁸⁾ and almost 100% of Japanese children reach Secondary School. ⁽⁸⁾

The Paraguayan Gross National Product (GNP) is US$2,010 per capita, ⁽¹⁵⁾ and the Japanese GNP is US$37,850 per capita. ⁽¹⁵⁾ The Paraguayan economic situation is not as serious as the least developed countries in the world (LLDC), however in South America it is one of poorest countries. The percentage of total health expenditure per GNP of Japan is 6.5%, ⁽¹⁶⁾ and for Paraguay it is around 7.4%. ⁽¹³⁾ The percent of total health expenditure per total government expenditure of Paraguay is 4.3%. ⁽⁸⁾ About income distribution, in Paraguay the lowest 20% earns 2.3% of total income and the highest 20% earns 62.4% total income. ⁽¹⁵⁾ In Japan the lowest 20% earns 8.7% of total income and the highest 20% earns 37.5% of total income. ⁽¹⁶⁾

The percentage of the population with access to safe water in Paraguay is 60%, while the figure in Japan is 97%. ⁽⁸⁾ The percent of population with access to adequate sanitation in Paraguay is 41%, while Japan the figure is 85%. ⁽⁸⁾

The Japanese health system is decentralized at the municipal level. Every municipal office employs public health nurses. In addition, the regional office establishes a public health center for each 100,000 population. In Japan, safe motherhood care consists of routine services offered in municipal office, public health centers and private hospitals/clinics. Almost 30 years ago, the maternal health care system was established under the Maternal & Child Health Law. Pregnant women should register their pregnancy at the municipal office. The municipal office prepares the health record card and booklet for use during pregnancy, and until the child is three years old. These cards and booklets are used as references. Even if the pregnant women and the mother with child move to another region of Japan, these references are available.

In Paraguay, the Ministry of Public Health is developing a decentralized health system under the National Health System Plan. The maternal information system was implemented in 1996 in the national hospital and in some regional hospitals with the support of Pan American Health Organization (PAHO) and United Nations Children’s Fund (UNICEF). However this system does not function adequately due to a lack of human resources and funding, and a lack of information and training. Maternal and child health care is one of the most important programs in Paraguay, as it is in other developing countries. In addition, the Ministry of Public Health has undertaken some training programs for acute respiratory infection (ARI) control, diarrhea control, breast feeding promotion and training of Traditional Birth Attendants. But the training programs cannot reduce the maternal mortality ratio (MMR) until referral management and emergency care services improve.

In Japan, midwives also hold a license as a registered nurse. Mainly midwives work in the obstetric department of hospitals. However, sometimes they work in the non-obstetric department as registered nurses.

In Paraguay, midwives work only in the obstetric department or obstetric hospitals/clinics. They have no relationship with the general nursing department at the regional hospital level at the national level of the Ministry of Public Health. At the health post level, where only auxiliary midwives and/or auxiliary nurses work, the health care programs are integrated. Even auxiliary midwives perform as auxiliary nurses doing immunizations, treating ARI and managing diarrhea control programs. In the region of Paraguay where I worked, where there is a population of about 140,000 population, there are 43 health facilities including the regional hospital. Among 43 health facilities, there are only 26 facilities with auxiliary midwives. ⁽¹⁷⁾ In another 14 health facilities, there is only an auxiliary nurse. There are licensed nurses and/or licensed midwives in only 3 health facilities including the regional hospital. ⁽¹⁷⁾ Thus, many facilities lack trained midwives.

In Japan, midwives who work in the hospitals and clinics receive about US$2,500 to US$3,500 per month as a salary, included allowances for extra hours and night shifts. Usually, teachers who work in public primary school receive almost the same amount of salary as midwives. But both receive higher salary depending on the years of working experience.

In Paraguay, licensed midwives receive about US$400 to US$500 per month, if they work for one shift, which is between 6 and 8 hours. Auxiliary midwives receive between US$250 and US$350 per month, they work usually for 8 hours per day at the level of health post. The teachers who work in public primary school receive around US$500, if they work for 2 shifts, one in the morning and one in the afternoon. Usually the teachers receive better salary than auxiliary midwives and auxiliary nurses in Paraguay, if they have the same number of years of working experience. The social status of a licensed nurse and/or midwife is considered better than the social status of a teacher.

Literature on midwifery training

WHO and UNICEF organized the first collaborative pre-congress safe motherhood workshop that was held in 1987. In this workshop the vital interventions were identified as needs to reduce maternal mortality and morbidity. ⁽¹⁾ At least 585,000 women die from the complications of pregnancy and childbirth every year in the world. ⁽²⁾ 99% of these deaths occur in developing countries. ⁽³⁾

WHO has been developing the Mother-Baby Package program since 1994.

"Most pregnancy-related complications can be effectively prevented or managed without recourse to sophisticated and expensive technologies or drugs. Experience has shown that maternal and neonatal mortality can be reduced when communities are informed about danger signs and symptoms, and quality health services are available and accessible including a referral system to manage complications at a higher level of the health care system." ⁽⁴⁾

WHO listed the following essential obstetric skills/functions that should be available at first level or referral health facility as: 1) surgical obstetrics/cesarean section, suction curettage for incomplete abortion, 2) anesthesia, 3) medical treatment (for anemia, sepsis, shock, eclampsia), 4) blood replacement, 5) manual procedures and labor monitoring (manual removal of placenta, vacuum extraction, partograph), 6) management of women at high risk (maternity waiting homes), 7) family planning support (insertion of IUD, tubal ligation or vasectomy). ⁽¹⁾

In the first ICM/WHO/UNICEF Pre-Congress Workshop as the 21^st International Confederation of Midwives (ICM) congress in 1987, the participants recommended that midwives should be able to do the following: 1) manual removal of placenta and retained products, 2) prescribe/use antibiotics for the treatment of sepsis, 3) initiate and monitor blood-loss replacement for the management of severe hemorrhage, 4) administer medications to control eclampsia, 5) sedate and monitor the women with severe pre-eclampsia or eclampsia. ⁽¹⁾

Also at the second collaborative Pre-Congress Workshop as 22^nd ICM Congress in 1990, the participants suggested that essential obstetric functions be included in the midwives’ curriculum and that midwives be prepared in managing their expanded roles. ⁽¹⁾ In the pre-congress workshop in 1993 the participants discussed how to assess quality of midwifery care and to start a process whereby that assessment can be developed and used by midwives to reduce maternal and perinatal mortality and morbidity. ⁽³⁾

In the Pre-Congress Workshop in 1996, the participants recommended the following strategies for strengthening life-saving skills capacity in midwifery include: 1) drawing up a plan of action involving all people concerned indicating what is to be done, by whom and how to do it, including timelines, 2) developing life saving skills programs at a national level, 3) preparing midwife teachers with the capacity to transmit life-saving skills, 4) changing the midwifery curriculum at basic and continuing education levels, 5) ongoing monitoring and evaluation of the process and its eventual impact on maternal mortality and morbidity. ⁽¹⁾

In 1996, only 53 % of deliveries in developing countries were attended by a skilled attendant person. WHO suggests that having skilled attendants present at delivery is one of the key interventions for reducing maternal and perinatal mortality. In 1998, WHO suggested that a Skilled Birth Attendant should attend all deliveries. Skilled Birth Attendants are defined by the WHO as trained midwives, nurses, nurse/midwives or doctors who have completed a set course of study and are registered or legally licensed to practice. The WHO’s definition of skilled birth attendants does not include traditional birth attendants, including those who have been trained. ⁽⁴⁾

WHO recommends that skills-based training may be required in obstetric surgery, anesthesia, newborn care, laboratory’ support and blood transfusion services. ⁽⁵⁾ In Northern European, there were few medical professionals less than a century ago. Implementation of the skills such as better aseptic techniques, antibiotics and oxytocics use, blood transfusion, safe operative delivery and management eclampsia, brought lower rates of maternal mortality and newborn deaths. ⁽⁵⁾ At the government level, legislation to promote the role of midwives should be reviewed and amended to allow midwives to perform life-saving interventions and to prescribe medication. ⁽¹⁾

About 40 % of all pregnant women have some complications during pregnancy, and about 15 % of pregnant women need obstetric care to manage complications. Such complications are often sudden in onset and unpredictable. ⁽⁴⁾ However, WHO found the risk approach was not effective in ensuring the rational use of maternal health service, when WHO reviewed the Maternal Health and Safe Motherhood Research Program in 1992. Usually risk assessment systems are based on physical characteristics such as height, parity and age to classify pregnant women as high risk or low risk. However, with these criteria many pregnant women are classified as high risk, because many of them are under 18 years old and/or have had more than four children. ⁽⁷⁾ These factors do not predict eclampsia or hemorrhage as fatal risks of maternal death, although they may show indirectly the probability of risk. ⁽⁷⁾

Even if the risk assessment worked effectively, higher level referral health facilities are not able to receive all pregnant women with any complication. Also many cases of perinatal complications can not be solved without suitable equipment and skilled birth attendants including obstetricians. ^{(5, 6)}

IV. Comparison of midwifery training in Japan and Paraguay

In Japan, midwifery education is undertaken as professional level education. Graduate level of midwifery education follows on 3 - 4 years of nursing education at a professional nursing institute or university. As a prerequisite to nursing education, 12 years of basic education is required. Midwifery education consists of one year of specialized education after this basic nursing education. In Japan, there are multiple courses of basic nursing education. The most common is a 3-year course of nursing education in a nursing college. The alternative is a 4-year course of nursing education in the university. In some universities, it is possible to complete a midwifery component, during the 4 years of nursing education. One must pass a national licensing exam to be a midwife after graduating from the university or the institute in Japan.

In Japan, auxiliary-nursing education exists despite opposition from nurses with more advanced degrees, such as registered nurses, midwives and public health nurses. The prerequisite for auxiliary nursing education is 9 years of basic education. However, most students of auxiliary nursing institutes are high school graduates, having completed 12-year of basic education. Auxiliary nursing education lasts 2 to 3-years, depending on the curriculum. After graduating from an auxiliary nursing institute, one must pass a regional licensing exam. If one wants to become a registered nurse, it is possible to study in a nursing college for 2 or 3-years of nursing education, depending on the curriculum. If one has 12 years of basic education, one can continue to study immediately in the nursing college after graduating from the auxiliary-nursing institute. However, for auxiliary nurses with only 9-years basic education, 3 years of working experience, as an auxiliary nurse is required.

In Paraguay, there are two levels of midwives; a university level trained midwife and an auxiliary level. For university trained midwives, 12-years of basic education before nursing or midwifery education is required. Those educated at university level are called "licensed midwives". This type of midwife receives one year of midwifery education after 4-years nursing education. An alternative path is 4-years midwifery education without nursing education. There is no national licensing exam. In Paraguay when one receives a degree of graduation from a midwifery university, one becomes a "licensed midwife".

The other type of midwife in Paraguay, an auxiliary midwife, is trained for 10 months. Before this, 10 or 12 months of nursing education are required. For auxiliary nursing education, 9-years basic education is required. However, until a few years ago, basic nursing education was not required as part of auxiliary midwife education. So, some midwives who are working currently are not trained in nursing. Like university level midwives, auxiliary midwives do not take a national licensing exam. When they graduate from the institute, they are referral to as auxiliary midwives. A table of comparison of midwifery training in Japan and Paraguay is attached as Table 3.

In Japan, the Ministry of Public Health has a responsibility for management of the midwifery license. However, depending on the institute, the Ministry of Public Health or the Ministry of Education, controls midwifery education. (Table 5) In Paraguay, registration and midwifery education are under the authority of the Ministry of Public Health. (Table 5)

In Japan, the midwives are trained at least 120 hours about basic midwifery study, 120 hours about diagnosis and techniques of midwifery, 20 hours about community maternal health and 160 hours for hands on clinical practice. They have to assist at least 10 cases of normal deliveries during the clinical practice. ⁽¹⁸⁾ Among 10 hands on practices, at least 3 hands on practices are required to perform episiotomies without suturing. Medical doctor undertakes suture. About manual removal of placenta, if a midwifery student assists a delivery with complication of placenta in a hand in practice, the student observes what an instructor or medical doctor perform. (Table 4)

In Paraguay, at the university level, a midwifery student has to practice more than 20 normal deliveries as hands on practice. To practice manual removal of placenta is not required even at university level in Paraguay. However, episiotomies and suturing are required for university level education. Also a midwifery student practice an intravenous injection at the university level. However, for auxiliary level, none of these skills are trained in hands on clinical practice.

A table of continuing education and supervision system in Japan and Paraguay is attached as Table 5. In Japan, there is no standard norm for performance, and no specific program for continued training. Nor is there a manual of supervision and evaluation of midwifery practice under the control of the Ministry of Public Health. Usually midwives work in a hospital, very few midwives have their own clinics. Midwives who work in a hospital are trained, supervised and evaluated by the head midwife from the department of obstetrics. Midwives who have their own clinic are associated with a committee of the local obstetric association and the local public health center. Midwives receive training programs that are held in hospitals.

These midwives also individually participate in private training programs. The Japan Midwifery Association provides several continuing education courses. Some examples, include courses in management of breastfeeding, newborn care management, how to manage the midwife clinic and the role of the midwife for maternal care in hospitals. ⁽¹⁹⁾ The participants should be members of the Japan Midwifery Association. They participate in the course independently or the hospital sends the midwifery staff to the course. These courses may be paid for by the hospital, or the midwife may have to pay their own way and take the courses during vacation.

In Paraguay, there are vertical training programs, for example for breast feeding promotion and for training for TBAs. An annual conference and training programs for licensed midwives is held by the obstetric federation and faculty of medicine focusing on developing technical skills, but midwives do not have a duty to participate in these training programs. The head midwife of the regional health office supervises midwives at least twice a year. Their activities are monitored 3 times a year and evaluated once a year. This is under the local health program system of the Ministry of Public Health. They have a norm of health care service provided by the Ministry of Public Health. ⁽²⁰⁾

In both Japan and Paraguay, midwives assist only at normal deliveries. In Japan, midwives perform episiotomies in the hospital, but they don’t suture. However in Paraguay, the licensed midwives perform episiotomies and suture, depending on the situation. The licensed midwives are trained in these skills during their midwifery education in Paraguay. The auxiliary midwives do not perform episiotomies, and are not trained in this still.

In Japan, to perform manual removal of the placenta is permitted to the midwives under the supervision of medical doctor. However, this skill is not included in midwifery education. Usually an obstetrician performs this skill. A midwife improves her skills based on experience, depending on the situation. In Paraguay, licensed midwives perform manual removal of the placenta, although they are not trained formally to perform this function. Some auxiliary midwives also do this based on experience, though they too are not trained to do it.

In Japan, the midwives cannot prescribe any medication, even in emergency cases. Usually, a medical doctor does pre-prescription of medication in case of an emergency situation. The midwives use this pre-prescription to survive until a medical doctor comes, when the midwives assist in an emergency case. In Paraguay, the midwives, at both the licensed level and auxiliary level prescribe essential drugs without antibiotics. Some regional health officers even permit them to prescribe antibiotics without supervision of medical doctor depending on the situation. In the regional health office where I worked there was a radio-communication system to contact lower health facilities. ⁽¹⁷⁾ When the midwives assist an emergency case, they call a medical doctor by radio, to ask what the midwives have to do, including prescriptions. Even an Ambulance has a radio connection. When a pregnant woman is referred to a higher level of health facility by ambulance, the medical doctor gives some advice and suggestions to the midwives until they get to the hospital. However, sometimes there are no adequate drugs, no fuel for the ambulance and no way to get a hospital during the rainy season.

In Japan, for midwives, performance of intravenous injection is not permitted, even though many do actually perform this function. They do not perform the initiation of blood transfusion, even though they do the management of blood transfusion and blood-loss once initiated. In Paraguay, the midwives are not trained for the initiation of blood transfusion. However, the licensed midwives give intravenous injection, and they are formally trained to do that. The auxiliary midwives do not perform the initiation of blood transfusion or intravenous injection. However, usually in the regional hospital level, there is a nurse who is trained especially for blood donation. With the exception of this nurse, no nurse or midwife has enough experience to do that, even blood suction. In addition, at the lower health facility level, they don’t perform this skill. Also many times there is no blood bank even in the regional hospital. At higher level of health facility has to collect voluntary donation of blood.

In Japan, hypertension disorder of pregnancy is classified as a disease. Pre-eclampsia and ecplampsia are also diseases. A medical doctor has to control these cases. The midwives monitor blood pressure and other signs of pre-eclampsia and eclampsia under the orders of a medical doctor. In Paraguay, these cases should be referred to a medical doctor. However, often these patients have no access to suitable medical care. The midwives can check a vital sign, but they can not treat these serious situations.

Newborn care activities such as cleaning the child and measurement of weight and height are undertaken by nurses in both countries. These skills are trained in midwifery education.

In Japan, pregnant women have to pay for the cost of normal delivery care that includes hospitalization for 7 days. A Japanese medical insurance covers treatment of disease, but normal delivery is not classified as a "disease". About 90 % of institutional delivery in Japan are performed with episiotomy and intravenous injection. The Japanese medical insurance system considers these performances are required for normal delivery. The cost of a normal delivery is about US$3,000. This payment can be recovered as a present for delivery from the municipality or employer depending on the type of medical insurance. When midwives refer a pregnant woman with a complication and/or problem to a medical doctor of a higher institute, the pregnant woman pays using medical insurance, because it is not a normal delivery. In Japan, midwives may open a clinic at which they can attend normal deliveries without the presence of a medical doctor. Also, they assist at home deliveries. The midwives who have owned the clinic have a connection and relationship with an obstetrician to whom they can refer problem cases. However, most midwives work in hospitals and clinics. Usually the obstetricians assist even for normal delivery in the hospitals, but if the pregnant woman has no problem, the obstetricians may just observe the delivery by the midwives. Under the law, midwives can not perform intravenous injection and prescribe drugs even in emergency cases in Japan. In hospitals, obstetricians are available 24 hours a day. When midwives need the assistance of an obstetrician, midwives call them to do medical care. However, in an emergency case, actually midwives perform such medical services.

In Paraguay, when the midwife refers a pregnant woman with a complication and/or problem to a medical doctor or higher hospital, usually the pregnant woman has to pay the cost of transportation and treatment. But often they can’t pay. When the midwife refers such a pregnant woman with problem which midwife created, the midwife would have to pay the medical doctor or higher institute. But usually midwives also have no capacity to pay. Sometimes if people have no money, when they have a complication, they can’t reach a suitable treatment and health facility. They might return to their community and use a TBA. This would be a cause of increasing Maternal Mortality.

V. Discussion

Japan is one of the most developed countries with high level medical technology and health services. However, Japanese Maternal Mortality Ratio is 18 per 100,000 live births, which is higher than that in some European countries. In Japan, reducing the Maternal Mortality Ratio is considered the most important objective in the area of maternal and child health care.

Paraguay is a developing country, however its economic status is not as serious as the least developed countries (LLDC). The Paraguayan Maternal Mortality Ratio is 160 per 100,000 live births. This is lower than that of most of the least developed countries (LLDC). However, this ratio is higher than that of many Latin American countries.

These two countries have different situations in terms of health status and health systems and infrastructures. However, both countries face the challenges of reducing the Maternal Mortality Ratio. One of the key strategies for reducing the Maternal Mortality Ratio is midwifery education and continuing training as recommended by the WHO. In this paper, the midwifery education of the two different countries has been described.

The WHO’s materials about midwifery education and training were reviewed to give a structure for the country comparisons. The education and training of midwives in two different countries, Japan and Paraguay, have been compared with WHO’s recommendations for midwifery education and training. The results of these comparisons are described below.

In Japan, at least 4 years of nursing and midwifery education occur after 12 years of basic education to be a midwife. There is a national license exam to be certified as a midwife in Japan. In Paraguay, there is also at least 4 years of nursing/midwifery education after 12 years of basic education to be a licensed level of midwife. In Paraguay, however, auxiliary level midwives are trained for 1 year after 1 year of nursing education. Unlike in Japan, in Paraguay there is no national license exam for both levels of midwives.

Japanese midwives and Paraguayan midwives who are trained at university level have similar education and status. However, in Paraguay, auxiliary midwives or TBAs of a lower status assist in deliveries in the rural areas.

In Japan and in Paraguay, midwives are trained to assist a normal delivery and to detect complications and risks in pregnancy. In Paraguay, the risk assessment system is based on WHO’s standard. WHO stated that their standards should be modified and re-established nationally to identify risks to reduce Maternal Mortality. The major problem of the Paraguayan health services is the lack of a suitable referral system, lack of available equipment and inadequate distribution of health personnel, even if midwives do identify complications and risks in pregnancy.

In Japan, midwives are well enough trained to detect complications and risk in pregnancy. There is no national manual of midwifery performance, but hospitals establish their own manuals and criteria. In Japan, there is an effective referral system and medical doctors are available 24 hours a day. However, in Paraguay, this type of referral system is not available, and midwives have to be trained with the technical skills needed to handle emergency situations.

Japanese midwives and Paraguayan midwives who are trained formally at the university level perform episiotomies. Midwives do not do suturing in Japan, though Paraguayan midwives do perform that function. Japan could learn from Paraguay to allow midwives to suture after episiotomies.

Japanese and Paraguayan midwives are not trained about performing manual removal of the placenta at their educational institutes, even if they are capable of doing it based on experience. They may learn to perform this function in the field through experience. They receive lectures about manual removal of the placenta and may observe this procedure during education at the nursing school in both countries.

In Japan, midwives may not prescribe any medication. However, in Paraguay, midwives prescribe some essential drugs including antibiotics, if needed. In both countries, midwives perform intravenous injection. However, in Japan midwives learn this procedure through experience while in Paraguay midwives are trained formally at the university level. Japan could learn from Paraguay to allow midwives to give an intravenous injection and to suture after epiciotomies. In both countries, midwives are not prepared to initiate blood transfusion, although they undertake a control hemorrhage and manage the blood transfusion once initiated.

In both countries, the role of midwives for perinatal care is to assist at a normal delivery. If a normal delivery is defined as a delivery that is undertaken without an episiotomy or any obstetric manipulative skills, midwives of both countries perform adequately. However, when the maternal mortality ratio of both countries are compared, the Paraguayan ratio is much higher than the Japanese ratio. The cause of the higher maternal mortality ratio of Paraguay may not be in the midwife’s ability to assist at a normal delivery. If there were adequate referral systems, available equipment and available medical doctors in Paraguay as there are in Japan, the Paraguayan maternal mortality ratio might be as low as the Japanese ratio, even if Paraguayan midwifery education system is not changed.

At this moment, if there are no adequate and suitable health care service in Paraguay as there are in Japan, midwives have to replace the obstetrician to perform some medical skills for the emergency cases to reduce maternal mortality ratio. Midwives in Paraguay have to be trained in some medical skills according to WHO’s recommendations. Paraguayan licensed midwives are trained about suturing, prescription of essential drugs and intravenous injection. These technical skills should be permitted for Japanese midwifes because midwives who have their own clinics can provide more assistance for delivery in their clinics and home delivery for pregnant women. In Paraguay, midwives need to be permitted to handle emergency cases providing adequate services in the lower level of health facilities at the community level in rural area. Auxiliary midwives are almost always the first health personnel to receive a pregnant woman. Their performance is a key factor in reducing maternal mortality ratio. If midwives are not permitted to perform these technical skills, this may be one of the obstacles to reduce maternal mortality. In Paraguay, auxiliary midwives do not have the capacity to handle emergency cases after only one year of midwifery education. Their basic education status also is not sufficient to learn how to perform in emergency cases. However, the reality of the rural areas in Paraguay is that auxiliary midwives provide health care services for any pregnant women without equipment as a referral system. If the health care system and situation can not be changed to solve the problems of maternal mortality and morbidity, even auxiliary midwives should be educated by 12 years of basic education and should be trained the skills to save mothers lives.

Eclampsia and hemorrhage are principal causes of maternal death in both countries, and also sepsis is a mayor cause in Paraguay. If WHO’s recommendations were permitted for midwives in both countries, the main causes of maternal deaths would be greatly reduced.

VI. Conclusion

In both situations of Japan and Paraguay, midwives are limited in their ability to handle emergencies such as serious hemorrhage and eclampsia, even though they perform some functions based on experience. The limitations are:

They are not adequately trained to handle emergency cases.

The technical skills for the emergency cases are permitted only to medical doctors.

These procedures require adequate equipment that is not available in lower level of health facilities in developing countries such as Paraguay.

Midwives are the first health professionals to encounter these emergency cases. Midwives have to be legally permitted to perform adequately in these emergency situations. They should be trained formally 1) to identify risk signs, 2) to give intravenous injections, 3) to prescribe antibiotics and essential drugs in emergency cases, 4) to perform episiotomies and suture and 5) manual removal of the placenta.

In both countries, to perform episiotomies is permitted for midwives. In Japan, midwives should be trained formally to give intravenous injections, suture after episiotomies and manual removal of the placenta at the nursing/midwifery institutes. There is a medical doctor who is available 24 hours a day in Japan, so that it is not necessary to permit midwives to prescribe drugs. However, in Paraguay, medical doctors are not available for 24 hours a day and appropriate equipment and referral system with transportation may be lacking. Thus the skills enumerated in 1)-5) above should be permitted and trained formally for midwives, even auxiliary level of midwives.

At the higher level of health facilities, appropriate equipment for surgery and anesthesia with adequately trained staff are required. Accessibility of adequate health care for the high-risk pregnant women is also important.

Midwifery education and training is one of the key methods to reduce the maternal mortality. Midwives are trained adequately to assist in normal deliveries in Japan and Paraguay. However, they have no capability to handle emergency case for example serious hemorrhage and eclampsia. Even though they perform in the emergency cases based on practice, they are not trained formally, and are not permitted legally to initiate blood transfusion and intravenous injection.

These situations have to be changed formally and legally to create an environment for increased survival of high-risk pregnant women. Accessibility, adequate equipment, a functioning referral system and capacity of higher level of health facility to handle emergency cases should be improved. With more training of midwives, they should be able to perform functions usually reserved for an obstetrician to save mothers lives. With these changes, midwives will not replace obstetricians, but would provide better services for mothers where there is no medical doctor available. The performance of obstetricians and midwives can be improved to provide efficient and effective health care services for mothers, when the referral system functions, accessibility to health services exists and functioning equipment is available.

VII. Reference

WHO/ICM/UNICEF, Strengthening Midwifery within Safe Motherhood, Geneva: WHO, 1996.

WHO, World Health Day, Safe Motherhood, Maternal Mortality (WHD 98.1), http://www.who.int/whday/en/pages1998/whd98_01.html, August 21, 1998.

WHO, Midwifery Practice: Measuring, Developing and Mobilizing Quality Care, Geneva: WHO, 1993.

WHO, World Health Day, Safe Motherhood, Ensure Skilled Attendance at Delivery (WHD 98.6), http://www.who.int/whday/en/pages1998/whd98_06.html, August 6, 1998.

WHO, Mother-Baby Package: Implementing safe motherhood in countries, Geneva: WHO, 1996.

WHO, World Health Day, Safe Motherhood, Every pregnancy Faces Risk (WHD 98.5), http://www.who.int/whday/en/pages1998whd98_05.html, August 21^st, 1998.

C. Rooney, Antenatal care and maternal health: How Effective is it? A review of the evidence, WHO/MSM/92.4, WHO, Geneva, 1992.

UNICEF, The state of the world's children 1998. New York: Oxford University Press, 1998.

Health and Welfare Statistics Association, Kokumin Eisei no Doko (The state of the Japanese national health). Tokyo: Health and Welfare Statistics Association, 1997.

Ministerio de Salud Publica y Bienestar Social de la Republica del Paraguay, Direccion General de planinficacion, Paraguay Indicadores de Mortalidad. Asuncion: Ministerio de Salud Publica y Bienestar Social, 1993.

Ministry of Public Health, Kosei Hakusho (The state of Japanese national health & livelihood). Tokyo: Ministry of Public Health, 1997.

Ministerio de Salud Publica y Bienestar Social de la Republica del Paraguay, Metas Regionales para alcanzar la salud de todos en el ano 2000 a traves de la estrategia de Atencion promaria de la Salud. Asuncion: Ministerio de Salud Publica y Bienestar Social, 1995.

Concejo Nacional de Salud, Ministerio de Salud Publica y Bienestar Social de la Republica del Paraguay, Direccion General de Planificacion y Evaluacion, Analysis del sector salud del Paraguay. Asuncion: Ministerio de Salud Publica y Bienestar Social, 1998.

Roeme MI, National Health Systems of the World. New York: Oxford University Press, 1991.

The World Bank, World Development Indicators 1998 CD-ROM, http://www.cdinet.com/dec/wdi98/new/countrydata/countrydata.html. October 7, 1998

The World Bank, World Development Report 1993, Investing in health, New York: Oxford University Press, 1993.

Mayumi Onishi, Informe Final del Project Fortalecimiento de la Salud Comunitaria en Caazapa, Asuncion: JICA, 1998.

The Ministry of Public Health, Shin Karikyuramu Tenkai Gaido Bukku No. 13 (Guideline of new curriculum development No. 13). Tokyo: The Ministry of Public Health, 1996.

The Japan Midwifery Association, Heisei 10 nendo Nihon Josanpu-kai Kousyukai Semina nittei-hyo (Training programs in 1998). Tokyo: The Japan Midwifery Association, 1998.

Ministerio de Salud Publica y Bienestar Social de la Republica del Paraguay, Manual de Programacion Estrategia Local de Salud. Asuncion: Ministerio de Salud Publica y Bienestar Social, 1994.

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