Feature Story

27 March 2008

On the Front Lines of the Struggle to Save Mothers' Lives

Voices of Midwives

Nester Moyo
Originally from Zimbabwe and now Senior Midwifery Adviser, International Confederation of Midwives, The Hague

Midwifery is practiced where the women are. That means that you will find midwives in areas that are remote, often with poor housing and security. There are no incentives. Our major thrust is to strengthen midwife associations in countries. We are convinced that midwives and midwife services are low-cost, effective and high impact, improving maternal and infant mortality. Midwife associations should be included at policy level discussions with the ministry of health to improve services to mothers and their children. We are convinced if we strengthen midwife associations, they can become the lynchpin pulling together all the other stakeholders in maternal and newborn health.

Mallavarapu Prakasamma
Trained nurse/midwife and Secretary General of the Society of Midwives, India

Midwives can deliver services most cost-effectively. They are the ones present in the villages. I firmly believe that if you want to reach out to the maximum number of women and children, this is the group that you need to support. Developed and developing countries with a strong midwife cadre supported by the health system have achieved maternal and infant mortality reduction. I am here to represent the voices of the midwives. The ones who are in the field, who are to make difficult decisions in difficult situations, they are the least supported, least skilled and most demoralized. ‘Up scaling’ should not be ‘down skilling’. The government of India has recognized that these health workers need skills and has committed to having skilled birth attendants for every mother.

Budi Anna Keliat
Nurse/midwife and lecturer, who helped set up a community mental health project with local midwives in Aceh, Indonesia, following the 2005 tsunami 

After the tsunami, midwives were an entry point with the community. The mothers were under a lot of stress. They needed to have a way to handle pregnancy, new babies and children under five years. Usually maternal health only focuses on physical health. Our project deals with quality of life of the mother and the children…For example, a midwife takes care of the mother after delivery. She can help identify postpartum depression, and then we can easily take care of that mother. If you need more than simple interventions, then you refer the mother to someone who can help. Health workers are very satisfied when they can see the results within the family. Frowns become smiles. That is an incentive. Nurses and midwives must work closely to achieve their objectives within the community. Our targets should be the people in the community.

Nadia Van Camp
Trained as a nurse/midwife in Belgium, now works with Médecins Sans Frontières in Mozambique

There are midwife shortages even in Belgium. But I feel I can be more useful as a midwife in a developing country. You feel much more appreciated in the work that you do. We need to train birth attendants to more easily recognize symptoms [of complications]. There is a lack of human resources in Mozambique, and the training is not enough. It doesn’t take into account HIV -- this is a big burden on the staff…If you have one in five infected (with HIV), one in five of health staff is infected as well. Maybe even more, because they are more at risk.

I would like to see salaries increase. It will attract more people to the profession. If they go to a private business they get three times the salary. They are doing triple shifts. In hospital wards they are looking after 100 patients. It’s hard work for not a lot of salary. One of the particular problems is not international brain drain but internal: rural–urban and to the private sector.

Jeremiah Mainah
Nurse/midwife and treasurer of the National Nurses Association, Kenya

Midwifery encompasses the whole family. You’re not dealing with one person but with three individuals -- the parents and the child. Having a qualified midwife gives her (the mother) a better chance for herself and her newborn. A midwife is well-trained and doesn’t look at the pregnancyon its own. She sees the social economics of this family, what sort of food are they eating, where they live.

Nurses are the backbone of any health institution, but they have not been involved in forming policy or recognized for the work they do. We have seen a lot of brain drain in Kenya. Nurses have not been properly remunerated and suffer poor working conditions. So most of the nurses have been seeking greener pastures outside the country. I hope this forum opens up for discussion the issue of human resources for health at the country, regional and international level.

Ana De Lurdes Cala
Mid-level maternal and infant health nurse, Mozambique

I feel close to the mothers… I like to be close to life. (In Mozambique), there is a lack of health workers to cover the whole country. We can’t educate the women about their health care. Many women are still delivering outside of the hospital. The problem is the distance from the house to the hospital. They like to deliver to the community because they want to be near their family. But when there are complications they can’t resolve them if she’s in the house. So there is high maternal mortality. Infant mortality is also high. The government is doing training, but there needs to be more capacity building of existing staff. We need more nurses for all levels of maternal health.

Athaliah Bagoi
Treasurer of the Midwifery Society, Papua New Guinea

I saw it was important to be a midwife, because there were so many women who were having complications. I wanted to help other women. Most nurses after their graduation never go back for any formal training. Papua New Guinea has more than 800 languages and diverse culture, so there are cultural taboos. For example, in one culture a woman can bleed to death in front of a male midwife, because she doesn’t want to be seen by a man. Women do not come to the antenatal clinic, because they don’t want to be seen by a male officer. When there are male officers, they don’t come for delivery.

Laila Ali Fadl
Nurse/midwife and government focal point for midwife training, Sudan

While I was a nurse I noticed that women die from simple things that can be treated like haemorrhage and obstructed labour. That is why I decided to be a midwife.

Midwife training started in Sudan in 1918, and the first midwifery school was established in 1921.But until now our coverage is less than 50 per cent. In Sudan, the challenge is that the midwife profession is not that attractive. Village midwives are not part of the health system. We need more village midwives. Due to conflicts and wars village midwives have been displaced. I would like to see that midwives in future have good training and skills and a clear career pathway. We need midwives to train midwives. We need midwifery leaders to build the capacity of midwives.

Enid Mwebaze
Nurse/Midwife, Uganda

After being a nurse for 10 years, I crossed over to midwifery, because it’s more rewarding. Someone is giving life, and that is my passion. There’s a lot of hope.

The shortage of manpower affects delivery. You can’t hurry that process. You need to be beside that person giving the encouragement and support that she really needs. Because the mothers are so many -- this one is calling, that one is calling – sometimes you can’t offer that support, which frustrates. At the forum, I’m learning about scaling up and skilling up the health worker -- increasing the numbers but also increasing their skills. We are now on top of the agenda, which makes me proud.

Grace Danda
Vice-President of the Zimbabwe Confederation of Midwives

I didn’t think nursing was complete without learning midwifery. You’re really doing the hands-on work. You’re bringing out life. In Zimbabwe, with hyper-inflation and the challenging economic situation, salaries are affected. Salaries are so low. The situation is also affecting working conditions. Hand-on resources -- gloves, drugs, cotton, delivery packs -- are insufficient.

Without resources, the midwives are demotivated, and they don’t want to work. They go to greener pastures where they can get those resources and work effectively -- moving public to private, out of the country or rural to urban. There is a severe shortage of midwives when they move away. The patients are still the same number. Deliveries with skilled attendants have gone down, and with no one to continuously monitor pregnancies, maternal mortality goes up. With the declaration that is being issued, we hope for improved government support.

– Angela Walker