Why we need to fix the global shortage of midwives
Millions of lives could be saved each year if we properly invested in midwifery, a new report has found. Jointly prepared by the United Nations Population Fund (UNFPA), the World Health Organization (WHO), the International Confederation of Midwives (ICM) and partners, the 2021 State of the World’s Midwifery report estimates a global deficit of 900,000 midwives — one-third of the globally-needed midwifery workforce.
“The findings demonstrate the importance and effectiveness of midwives as core members of the sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workforce,” United Nations Deputy Secretary-General Amina Mohammed writes in the foreword to the report. “They have been instrumental in helping to drive tangible progress towards several goals and targets of the 2030 Agenda for Sustainable Development.”
Yet too often the vital work of midwives is overlooked and underinvested in. This is to the detriment of midwives themselves and to millions of mothers and children who face ill health and injury or even death as a result of gaps in the system.
Such issues are not new. As the WHO notes in a press release, the State of the World’s Midwifery Report 2014 raised similar alarm bells yet “progress over the past eight years has been too slow. The analysis in this year’s report shows that, at current rates of progress, the situation will have improved only slightly by 2030.”
The WHO underscores the vital importance of the role midwives play. “Midwives do not just attend births. They also provide antenatal and postnatal care and a range of sexual and reproductive health services, including family planning, detecting and treating sexually transmitted infections, and sexual and reproductive health services for adolescents, all while ensuring respectful care and upholding women’s rights,” they state. “As numbers of midwives increase, and they are able to provide care in an enabling environment, women’s and newborns’ health improves as a whole, benefitting all of society.”
The multifaceted impact of midwives in the healthcare system is patent, yet the deficit is fuelled by gender bias. “Gender inequality is an unacknowledged driver in this massive shortage,” states the WHO. “The continued under-resourcing of the midwifery workforce is a symptom of health systems not prioritising the sexual and reproductive health needs of women and girls, and not recognising the role of midwives — most of whom are women — to meet these needs. Women account for 93 percent of midwives and 89 percent of nurses.”
India is no stranger to gender bias in its healthcare system, as Health Issues India has covered at length in the past such as on International Women’s Day this year. As with all observances for more than a year now, that occasion — and, indeed, this week’s International Day of the Midwife — falls during COVID-19 and the 2021 State of the World’s Midwifery report does not shy away from this.
“In the face of COVID-19 restrictions and overburdened health systems, midwives have become even more vital for meeting the sexual and reproductive health needs of women and adolescents,” Mohammed writes. “Midwives deserve to be celebrated for their courageous and often dangerous work during the crisis, which has helped to reduce the risk of virus transmission among pregnant women and their infants by enabling many births away from hospitals, either at home or in a midwifery unit or birth centre.”
Appropriate, robust investments in midwifery are needed. Among the key takeaways from the report, summarised by the WHO, is that “fully resourcing midwife-delivered care by 2035 could avert 67 percent of maternal deaths, 64 percent of newborn deaths and 65 percent of stillbirths. It could save an estimated 4.3 million lives per year.”
India bears a substantial burden of the world’s maternal mortality rate, although progress has been made. “Maternal Mortality Ratio (MMR) of India for the period 2016–18, as per the latest report of the national Sample Registration system (SRS) data is 113/100,000 live births, declining by seventeen points, from 130/ 100,000 live births in 2014–16,” according to UNICEF. “This translates to 2,500 additional mothers saved annually in 2018 as compared to 2016. Total estimated annual maternal deaths declined from 33,800 maternal deaths in 2016 to 26,437 deaths in 2018.” In terms of infant mortality, India has similarly made progress — “in 2019, the infant mortality rate in India was at about 28.3 deaths per 1,000 live births, a significant decrease from previous years” according to Statista. Yet, nonetheless, the death toll is unacceptably high. As reported last year by IndiaSpend, “across India, there were 721,000 infant deaths in 2018, as per the United Nations’ child mortality estimates. That’s 1,975 infant deaths every day, on average, in 2018.”
The reasons why are manifold. In the case of maternal mortality, UNICEF outlines that “coverage of life-saving health interventions and practices remains low due to gaps in knowledge, policies and availability of resources. In a few areas there is a gap between the rich and the poor and an urban and rural divide. Access to health services is often dependent on a families’ or mother’s economic status and where they reside.” Systemic issues within India’s healthcare system, such as poor infrastructure, inequity, poor sanitation, and malnutrition can be attributed as the causes of infant deaths — often due to preventable diseases such as diarrhoea and sepsis.
India does grapple with a shortage of midwives too. As IndiaSpend reported last year, “India has 1.7 nurses per 1,000 population, 43 percent less than the World Health Organization norm (three per 1,000). This includes nurses, midwives, women health visitors and auxiliary nurse midwives. Overall, India has 3.07 million registered nursing personnel, [the] government told the Rajya Sabha on March 3, 2020.”
Investments in midwives can save many of the lives lost among mothers and children. India, to its credit, has taken steps. The UNFPA highlights the Government of India’s Midwifery Initiative. As outlined by the Government in the report
“Its [the Initiative’s] aim is to create a cohort of Nurse Practitioners in Midwifery, capable of providing positive birth experiences to women by promoting physiological birth (thus reducing over-medicalisation), providing respectful maternity care, and decongesting higher level health facilities by providing services in midwife-led care units. The focus is on ensuring empowerment and improved career progression for midwives. India has identified seven National Training Institutes of Excellence for training midwifery educators. In 2019, the Ministry of Health and Family Welfare initiated midwifery educator training at one of these Institutes. Post-training, midwifery services will initially be provided in tertiary and secondary health facilities; in subsequent phases it will be made available in primary health centres as part of a comprehensive primary healthcare package.”
A roadmap has been developed for the Initiative by the Government, following a study conducted in concert with the WHO. “The roadmap includes a curriculum, scope and standards of practice, advocacy toolkits and learning resource packages for both the Midwifery Educator programme and the Nurse Practitioners in Midwifery programme, with the objective of raising midwifery education and service provision to global standards,” the Government’s submission to the report explains.
In an especially dark period, we have been reminded of why it is important to invest in our healthcare systems and midwives are a core component. The latest report underscores this and why bold investments need to be made. “For midwives to achieve their potential, greater investment is needed in four key areas: education and training; health workforce planning, management and regulation and the work environment; leadership and governance; and service delivery,” the report states. Greater representation of women in the healthcare workforce at higher levels of governance is also badly needed. And protection for those on the front line — viciously highlighted by the pandemic — must be enhanced and inclusive of the needs of all irrespective of gender.
“Midwives play a vital role in reducing the risks of childbirth for women all over the world, but many have themselves been exposed to risk during the COVID-19 pandemic,” commented WHO Director-General Dr Tedros Adhanom Ghebreyesus. “We must learn the lessons the pandemic is teaching us, by implementing policies and making investments that deliver better support and protection for midwives and other health workers. This report provides the data and evidence to support WHO’s longstanding call to strengthen the midwifery workforce, which will deliver a triple dividend in contributing to better health, gender equality and inclusive economic growth.”
The State of the World’s Midwifery 2021 can be accessed here.
