Nurses and midwives are essential to meeting the Millennium Development Goals (MDGs) to provide universal and more effective maternity care and safe childbirth, and to enable more children to grow up healthy and secure. The ambitious MDGs were set in 2000 and have a key monitoring milestone in 2015. Melinda Gates recently reminded the world that although the World Health Organization (WHO) reports that deaths in children aged 1–5 have decreased by 54% from 1990–2012, deaths of newborns under 28 days have not decreased as much (down 37%) (Gates 2014, Gates & Binagwaho 2014, World Health Organisation 2014). There is still a long way to go to achieving the MDGs.

By raising political awareness of these trends and challenges, Melinda Gates is also speaking to the nursing and midwifery professions and reiterating the importance of their collective global contribution to and their responsibility for reducing maternal, neonatal and child deaths. Innovative solutions are required to improve availability, accessibility, acceptability and quality of the nursing and midwifery care and services if more progress is to be made in reaching the maternal and child health MDG targets. However, a critical shortage of nurses and midwives, especially in lower and middle income countries, is hampering progress (Carr-Hill & Currie 2013). A new report on the state of the world's midwifery showed that the 73 countries included in the report accounted for more than 92% of global maternal and newborn deaths and stillbirths, but had only 42% of the world's medical, midwifery and nursing personnel. Within these countries, workforce deficits were often most acute in areas where maternal and newborn mortality rates were highest. Only four of the 73 countries had a midwifery workforce that was able to meet the universal need for the 46 essential interventions for sexual, reproductive, maternal and newborn health (United Nations Population Fund 2014 page v.).

The World Health Organization (WHO) has consistently promoted the use of evidence-based interventions to achieve universal access to health care. The delivery of these interventions depends on access to a range of different cadres of health workers who can provide appropriate and high-quality care and referral. However, in many settings, the health workforce has been slow to self-organize, adapt and innovate to improve care delivery. In addition, there has been no global evidence-based guideline addressing the optimal organization of health worker roles and responsibilities for maternal and child health care. To accelerate progress towards reaching the maternal and child health MDGs, the WHO has now produced a global guideline that is of critical importance to nursing and midwifery. The guideline: ‘Optimizing health worker roles for maternal and newborn health’ (WHO 2012), provides options for national and subnational decision-makers regarding the rational distribution of tasks and responsibilities among cadres of health workers to improve access to maternal and newborn care. The guidance is underpinned by specially commissioned systematic reviews, and the recommendations can be explored through an interactive overview (Figure 1) on the OptimizeMNH website. In addition, a video has been produced to support dissemination of the guidance (; retrieved 20 June 2014). Users can browse the guideline by:

  • Type of Recommendation – (e.g. whether the WHO recommends the intervention, or recommends against the intervention), and
  • Type of Intervention (e.g. whether the intervention is delivered during pregnancy or delivered after birth).

Figure 1. Interactive tool showing examples of task optimization recommendations for contraceptive delivery (

Download figure to PowerPoint

For each recommendation, users can also obtain more information on the justification provided by the WHO and can obtain the full text of the recommendation, including the evidence base and implementation considerations.

Synthesis of the relevant evidence and production of the WHO guideline were a substantial endeavour that required innovative methodological developments in systematic review methodology and the use of new tools:

  • For the first time, the WHO systematically incorporated synthesized qualitative findings into a guideline. This included syntheses of the evidence on barriers and facilitators to the implementation of lay health worker programmes (Glenton et al. 2013), task shifting in midwifery (Colvin et al. 2013) and doctor–nurse substitution (Rashidian et al. 2012). These syntheses were, where possible, integrated with Cochrane effectiveness reviews on the same topics.
  • A new framework (DECIDE) for assisting guideline panels in moving from evidence to a recommendation was adapted to incorporate qualitative evidence (Treweek et al. 2013, Decide Framework 2014).
  • A new tool (CERQual) was developed to assess how much confidence to place in synthesized findings of qualitative evidence (Glenton et al. 2013).

There was also a ‘first’ for The Cochrane Collaboration when the Cochrane Library published a qualitative evidence synthesis integrated with a Cochrane effectiveness review (Lewin et al. 2010, Glenton et al. 2013). The importance of these methodological developments, as well as the evidence-based guidance and its potential impact on maternal and child health, was described in more detail in an editorial published in the Cochrane Library (Gülmezoglu et al. 2013), and in an article in the Guardian newspaper (Morton 2013).

Publication of the OptimizeMNH recommendations should help nurses and midwives and their professional organizations meet the global challenge to further reduce maternal, neonatal and child deaths by better organizing their respective workforces and collaborating more actively and effectively with other cadres of health workers. The Guidance Panel made 119 recommendations: 36 for lay health workers, 23 for auxiliary nurses, 17 for auxiliary nurse midwives, 13 for nurses, 13 for midwives, eight for associate clinicians, eight for advanced level associate clinicians, and one for non-specialist doctors. For example, inserting and removing intrauterine devices and contraceptive implants by nurses and midwives was recommended for implementation. However, insertion and removal of contraceptive implants by lay health workers was only recommended in the context of further rigorous research. This rating category indicates that there were important uncertainties about the intervention being implemented by this cadre. In such instances, the implementation can still be undertaken at a large scale, provided that it takes the form of research which is able to address unanswered questions and uncertainties related both to the effectiveness of an intervention and its acceptability and feasibility (WHO 2012).

Current roles and responsibilities of different cadres of health workers vary greatly from country to country and in many cases specific cadres may be delivering care and interventions informally, without the support of formal policies and clinical supervision to protect them and their patients. The guidance serves to clarify what different cadres of health workers can reasonably be expected to do and the support they need to do it.

Nurses and midwives globally are encouraged to access the OptimizeMNH guidance (WHO 2012) and interactive tools ( and consider how best to more rationally distribute tasks, roles and responsibilities among cadres of health workers to ensure that every woman and child has access to an effective health worker and service. This involves better coordination of the task between doctors, nurses and midwives, and nurses and midwives and lay health workers. The guidance recommends different sets of task shifting between healthcare cadres dependent on the context and needs of countries. Nurses and midwives in high-income countries are also recommended to consider the option of reverse innovation by implementing recommendations for cadres of staff, interventions and services pioneered in lower income countries where significant health gains have already been made through task optimization and shifting in less complex and less costly health systems (Harris & Noyes 2012, Johnson et al. 2013).


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  2. References
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  • Colvin C.J., deHeer J., Winterton L., Mellenkamp M., Glenton C., Noyes J., Lewin S. & Rashidian A. (2013) A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery 29(10): 12111221. doi: 10.1016/j.midw.2013.05.001.
  • Decide Framework (2014) Frameworks for going from evidence to decisions about health system and public health interventions. Retrieved from on 04 June 2014.
  • Gates M. (2014) Melinda Gates: ‘You have to let your heart break’ Telegraph Newspaper 24 May 2014. Retrieved from on 04 June 2014.
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