In all countries that have achieved dramatic improvements in maternal mortality, professionally trained midwives have been a key to success. They play an essential role in achieving the Millennium Development Goals to reduce maternal and newborn mortality. Yet today, the training of midwives is inconsistent and the profession of midwifery often garners little recognition, meager income, and limited career opportunities. These factors contribute to the acute shortage of these valuable health workers.

The midwife shortage

Maternal mortality and morbidity cannot be reduced without midwives and others with midwifery skills. Yet the numbers of these skilled providers have not significantly increased, and have even started to decline in some countries, because of migration, deaths from AIDS-related illnesses, and dissatisfaction with pay and working conditions.

Midwives, who are overwhelmingly women, typically endure low status, poor pay and a lack of support despite the enormous responsibility they bear. Those who work within communities at the primary care level, where they are needed most, often receive the least respect and support from the health system. Gender biases frequently contribute to the problems facing midwives.

When they are properly trained, empowered and supported, midwives in the community offer the most cost-effective and high-quality path to universal access to maternal health care. Yet midwives are in short supply in many developing countries – WHO estimates some 350,000 are urgently needed worldwide. In particular, countries with high rates of maternal mortality need assistance to recruit, train and support professional midwives.

In 2011, UNFPA and 30 partners published the State of the World’s Midwifery 2011: Delivering Health, Saving Lives. The report, the first of its kind, surveyed 58 developing countries that together account for 91 per cent of the world’s maternal deaths. The State of the World’s Midwifery Report found that up to 3.6 million lives could be saved each year in 38 of the countries surveyed, if an additional 112,000 more health workers with midwifery skills were practicing in communities and backed up by a functioning health system. More than half of those skilled health workers are needed in the eight countries that contribute 56 per cent of all maternal deaths.

What midwives do

Pregnancy, whether planned or unintended, is often a key entry-point into the health system, and midwives can provide a welcoming gateway. They often introduce women to the health system and ensure that women and their babies receive a continuum of skilled care during pregnancy, childbirth, and in the important days and weeks after birth.

The basic services midwives routinely provide to protect the health of the mother and baby include:

  • Caring for women during pregnancy, childbirth and the postnatal period
  • Treating complications due to miscarriages and/or unsafe abortions
  • Providing newborn care
  • Providing pre-pregnancy advice and health education
  • Recognizing and addressing problems in the woman and newborn before, during and after childbirth
  • Offering general health information, including reproductive health care and family planning
  • Assisting women to successfully breastfeed
  • Referring women and newborns for higher level care when complications arise during pregnancy and childbirth
  • Providing additional health services in communities such as immunizations and treatment of common illnesses

Giving midwives more responsibility and protection

In some cases, basic emergency life-saving functions, such as vacuum extraction, manual removal of placenta, or manual vacuum aspiration of retained products could effectively be delegated to midwives or specially trained nurses if adequate facilities were available and relevant policies were in place, including support and protection for the providers.

In Mozambique, senior nurses trained to perform Caesarean sections have achieved outcomes as good as those performed by specialist obstetricians. The training was part of an effort to make emergency obstetric care available at the lowest levels of the health system possible, particularly in rural areas where distance may be a significant barrier to care.

However, this is occurring in very few places, even though experienced midwives argue that they have the requisite skills and would not hesitate to take on greater responsibility if they were so authorized.