| 4. In which ways is the initiative creative and innovative?
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In 1995, MOH engaged regional and international consultants to identify the need of nation nurse-midwifes in maternal health services in Oman. A national strategy was formalised to Omanise the nursing and healthcare providers in Oman, including the nurses-midwifes professions. A pilot run of midwifery course was conducted for eight Omani nurses. The pilot run was analysed and evaluated which became the basis of future implementation of the whole project.
1999– Official launch of the midwifery course in Oman Institute of Health (later renamed as Oman Nursing Institution).
2001 – setting up of Omani Nursing and Midwifery Council (ONMC) as a critical body for setting standards for high-quality nursing and maternity care. This will ensure that all trained and qualified nurses and nurse-midwifes from Oman are able to develop their individual practice to keep themselves both safe and effective practitioners in a dynamic healthcare environment. This is an important benchmark in the history of nursing and midwifery in Oman. ONMC was established in 2001 by a Ministerial Decree (67/2001) with a view to promoting professionalism in the nursing services, education and practice. The Council had representation from the Sultan Qaboos University, Armed Forces Medical Services, Royal Oman Police, Diwan Medical Services and MoH (nursing Service and nursing education). Once the nursing profession was running smoothly under the purview of MOH, ONMC was subsequently abolished.
2006 - Directorate of Nursing was changed and expanded to Directorate of Nursing & Midwifery Affairs in 2006 by Ministerial Decision no. (122). A regulatory section was launched to look into registration & licensing. Another section was also launched to look into setting standards for high quality nursing & midwifery care.
2009 –Scope of Midwifery Practice was developed and implemented Nurse-midwifes scope of work developed and implemented
2013- Finalisation of the new career pathway for nurse-midwifes
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The stakeholders are the Ministry of Health, sister institutions such as the Sultan Qaboos Hospital and Armed Forces Hospital, Omani nurses, citizens and residents of Oman. The Ministry of Health is the man stakeholder as the custodian of primary and tertiary health care services in the Sultanate with the mission to improve access to health services and ensure equity in health services availability and utilization, improve the quality of health care and promote health care human resources development so as to achieve Omanisation and optimum utilisation of health manpower. The number of nurses increased by 18% and reached a figure of over 9,000 by End-2005, and then to over 14,000 by End-2011. The yearly growth rate of nursing workforce is about 4.3%.
Most importantly, the Omani women have accessed to primary healthcare services provided by professionally trained medical practitioners and Omani nurses-midwifes especially in women health issues such as pregnancies, deliveries and birth spacing.
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| 6. How was the strategy implemented and what resources were mobilized?
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The education budget for the training of Omani nurses-midwifes is embedded within MOH budget. However the cost of preparing the Midwifery post nursing program costs about RO 6,000/= (about USD$15,500). Although the amount may be small, the manpower and efforts galvanised to make this initiative a success was immerse and it cannot be measured in dollars and cents alone. A lot of background work was also done by staff from MOH and other sisters’ institutions such as the Royal Hospital and Sultan Qaboos Hospital as well as international experts from World Health Organisation (WHO).
No efforts are spared in improving the health of the women in the Sultanate which recognises that the health of women is of crucial importance; not only for themselves, their children, families and communities, but also for their wider society. They are the custodians of their country’s future through the bearing and rising of a healthy and well educated next generation. Childbearing and maternity services are enhanced with proper education and training through MOH public training department so that these women are aware of the issues that would face in preparing for pregnancies and childbirth.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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a. Attaining the MDG - Reduction in maternal and infant mortality rate. Oman has been successful in reducing the maternal mortality rate in childbirth from 27.3 (per 100,000 live births) in 1991 to 15.9 in 2011, a reduction of more than 205% and Infant Mortality Rate of 29 (per 1000 live births) in 1990 to 9.5 in 2011, about more than 71% reduction.
b. Reduction in home deliveries- In 2006, home delivery was about 20% but by end of 2012, almost 99% of all births in the sultanate were done at health institutions attended by professional Omani nurse-midwifes or healthcare practitioners.
c. Effective communication between pregnant mothers and their Omani nurse-midwifes, promote the importance of nurse-midwifes professions. Omani nurses-midwifes are able to communicate easily to their nation women and involve them their care. This empowers women’s right to be in decision making process of the care provided.
d. More holistic Omani nurse-midwifery professional healthcare and systems, with specialised skills and knowledge to cater to cases in the rural communities. With proper integrated maternity care services, health problems among mothers including anaemia, multi-pregnancies, and complication of pregnancies including low birth weight, stillbirths and in some areas congenital anomalies can be detected early and prevented. Midwifery encompasses care of women during pregnancy, labour, and the postpartum periods, as well as care of the newborn. It includes measures aimed at preventing health problems in pregnancy, the detection of abnormal conditions, the procurement of medical assistance when necessary, and the execution of emergency measures in the absence of medical help. The Omanis trust this initiative as evident from the high utilisation of services and education that the mothers received from the Omani nurse-midwifes. Every woman has access to Antenatal care services which are offered in all parent institutions after a confirmed pregnancy. The average number of visits to all healthcare institutions is 6.1 per pregnancy. Today, hospital deliveries represent more than 99% of the total as compared to about 80% in the 2006.
e. More Omani nurse-midwifes - The success of the programme has motivated many young Omani nurses to take midwifery education, which encouraged the MOH to expand to cover major governorates of Oman. When it was officially launched in 1999, there were 18 nurses. In 2012, the number of nurses who progressed to be nurse-midwifes increased to 56 which is more than 300% increase in enrolment. Today, there are about 619 Omani autonomous midwife practitioners in sultanate. Though the number is still relatively small, it is still significant in providing continuous and profession neo-natal care to the Omani women especially in the interior regions.
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| 8. What were the most successful outputs and why was the initiative effective?
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Since this initiative was implemented in 1999, several levels of monitoring and evaluation means were also put in place to ensure the quality midwifery care and to ensure that standards of practice are followed. After being deployed as nurse-midwifes, these professionals are subjected to annual audit of their competencies and performance by their supervisors as part of the maternity quality assurance process. Based on the performance report, action plan is developed aiming to improve their skills.
Moreover, a peer review team during their regional visits evaluate the midwifery practice. The transparency, objectivity and approaches of peer reviews are becoming more effective in changing practice and defining safe quality of care.
In addition, MOH also adopted the Millennium Development Goal Indicators and WHO Primary Health care strategy for nursing and midwifery which outlined the following 5 Key results Areas (KRA) with core indicators. By adopting international indicators, MOH will be able to ascertain its weakness in the provision of maternity services and take a more pro-active approach to provide a holistic healthcare service for the women in Oman.
• Strengthening of health systems and services - Nursing and midwifery services-led models form the basis of PHC reforms, especially in the areas of universal coverage and leadership for health.
• Nursing and midwifery policy and practice - Nurses and midwifes play a proactive part in ensuring that the health policies, plans and decisions affecting their professions are country-specific and in keeping with the principles of inclusive leadership, effective governance and regulated practice.
• Education, training and career development -Institutional capacity enhanced for the intake and production of suitably skilled
• practitioners to provide comprehensive people-centred services
• Nursing and midwifery workforce management - Policy-makers create an enabling environment for the nursing and midwifery workforce to meet changing health needs.
• Partnership for nursing and midwifery services -Active, systematic collaboration is encouraged among nursing and midwifery organizations and with community-based organizations, health professional groups and governments.
Furthermore, the formation of the Obstetrics and Gynaecological Technical Committee which advises the Under-Secretary of the Minister of Health and performs an essential and very much needed role in clinical governance, also provides another level of evaluation for this initiative. Its mandate involves reviewing and revising the necessary clinical guidelines and protocols, is setting minimum safety and operating standards for each level of the health care system, advises on staffing levels, drugs, equipment and other commodities and identifies weaker hospital systems requiring additional support.
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| 9. What were the main obstacles encountered and how were they overcome?
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a. Obstacles from Obstetricians
Due to the lack of scope of practice, most Obstetricians were not fully aware of the roles of the Omani Autonomous nurse-midwifes. Some even viewed the local nurse-midwifes as invading their work and not competent. The Directorate of Nursing and Midwifery Affairs at the Ministry of Health decided to involve the Obstetricians in the development of a national scope of work for the Omani nurse-midwifes so that they had a sense of responsibility and ownership on craving the critical roles for the local nurse-midwifes. In so doing, the Obstetricians welcome the local nurse-midwifes and even viewed them as competent professionals capable of complementing the Obstetrician’s own work. Hence eradicating the mistrust between the Obstetricians and the local nurse-midwifes. The Scope of Midwifery Practice: Standards and Competencies were developed in 2009.
b. Public perception
An increasing educated Omani population result in increasing expectations about health care and the provision of maternity services.Initially, the local women did not trust the competencies of the local trained nurse-midwifes. They preferred their deliveries be handled by the expatriate Obstetricians and nurses in private maternity care. Not only do the Omani nurse-midwifes have to prove themselves but they also have to demonstrate to the Omani women the value of midwifery as a profession capable of providing maternity care in its own right. Overtime with lots of public awareness programmes and the experiences of the local nurse-midwifes especially serving the interior regions, the Omani women started trusting these nurse-midwifes and acknowledge their professionalism and competencies.
c. Career path for local nurse-midwifes
Although the nurses who opted to be trained as nurse-midwifes did not received any additional allowance. However, overtime the issue of career progression for this nurse-midwifes who are experienced and highly trained pose a challenge to the profession when they started comparing their job scope with that of the nurses. To address this matter, a national taskforce was formed in 2012 to develop a career pathway taking into consideration nurse-midwifes professional growth and scope of practice. This comprehensive career path will provide better prospects and remunerations for all nurses who opted to become nurse-midwifes. The new career path is in the approval stage and would be implemented in the near future.
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