Abstract

“They are often accommodated in the most awful insanitary conditions, with no running water and these conditions are not limited to isolated rural areas. What's worse, it may be unsafe, especially for those doing 24-hour shifts.” Frances McConville, midwifery expert at the World Health Organization (WHO) in Geneva, is not describing soldiers, but midwives in some of the world's poorest and most unstable regions.

In a way, these health workers are the warriors on the front-line of health care, battling to ensure that women survive childbirth and that babies are born safely even in the most marginalized areas.

Midwifery, a practice so ancient that it features in early Egyptian and Roman scrolls, is seeing a long awaited increase in global attention. Decades of neglect of the role of midwives, either because of the over-medicalization of pregnancy care or a lack of resources, has left a legacy of high rates of maternal and newborn mortality in developing countries. While these rates have fallen in recent years, more progress must be made in Asia and sub-Saharan Africa, where fewer than 50% of all births are assisted by a skilled birth attendant.

Now, grassroots, government and international initiatives are coming together to put midwives at centre stage in reproductive health programmes in countries like Ethiopia and Somalia. But for these efforts to succeed, investment in midwifery must be sustainable, covering more than just the initial training.

In 2011, the United Nations Population Fund (UNFPA) published a report – The state of the world's midwifery 2011: delivering health, saving lives – that offered a comprehensive look at midwifery around the globe. The report was “incredibly revealing” says McConville. Its analysis of 58 countries showed that there was a global shortage of an estimated 350 000 midwives, at least a third of whom were needed in the world's poorest countries.

Regional efforts to improve midwifery have increased with the launch this year of the Confederation of African Midwives Associations to advocate for better education and regulation of midwives.

Midwifery has come to the fore since maternal and newborn health were made the focus of two of the Millennium Development Goals (MDGs). And there is another reason for renewed attention: the world is facing an acute shortage of health-care workers. Overall, WHO estimated in 2006 that the world needs 4.2 million more health workers, with 1.5 million of those needed in African countries alone.

Increasing the number of skilled health workers is even more important now that countries are striving towards universal health coverage. The growing support for task shifting, in which duties are redistributed so that doctors and nurses are not overburdened, has also created a greater demand for workers with midwifery skills, says McConville.

However, midwifery experts say that for a profession that is so old, it is remarkably poorly understood. “Midwives do far more than just catch babies,” says Petra ten Hoope-Bender, a director for reproductive, maternal, newborn and child health at the Instituto de Cooperación Social Integrare, a research institute in Spain. The impact midwives have is not just on pregnancy outcomes, as is often assumed, she says, but extends to newborn care, breastfeeding, family planning, and sometimes also cervical and breast cancer screening.

Nevertheless, “in developing countries especially, midwives are often at the bottom of the ladder of the health system,” says ten Hoope-Bender. She argues that midwives should be at the heart of the continuum of care, whether in terms of screening women for HIV infection, tuberculosis and malaria or of detecting early signs of noncommunicable diseases through routine antenatal checks, such as measuring blood pressure and testing for diabetes.

The linkages with infectious and chronic diseases could allow midwifery programmes to seek funding from HIV infection or tuberculosis programmes, for instance, says Dr Luc de Bernis, senior maternal health adviser at UNFPA, who is coordinating the development of the State of the world's midwifery 2014 report.

Another reason why midwifery has been sidelined, says ten Hoope-Bender, is the focus on emergency obstetric care and facility-based childbirth, which have been at the heart of efforts to achieve the MDGs. But “when midwifery is in place, there is much less need for emergency interventions because problems requiring prompt attention are managed or referred before they become a life-threatening complication,” she says.

Training is now a major focus in midwifery, and – for women in poor countries – the new generation of midwives can't come soon enough. This is essential in Somalia, where a woman has a 1 in 16 chance of survival beyond her reproductive years. According to Achu Lordfred, senior reproductive and maternal health adviser with UNFPA in the east African country, “the severe shortage of skilled health personnel with obstetric and midwifery skills means that most women have their babies delivered by traditional birth attendants. But when complications arise, these women either die or develop debilitating conditions, such as obstetric fistula, or lose their babies.” Since 2007, UNFPA has set up seven midwifery schools in Somalia that have trained 125 midwives to date, while two more schools are to be opened by the end of the year.

Ethiopia is making progress with training too. Since 2008, the number of midwives there has increased by 3000 to 4700, says Dorothy Lazaro, a midwifery specialist at UNFPA Ethiopia. The increase is due to government efforts to establish more midwifery training institutions, but ensuring quality control remains a challenge.

Ethiopia is currently testing mentorship schemes so that more experienced midwives can make sure that recent graduates have the right practical skills, Lazaro says.

Globally only 30% of practising midwives have completed a full three-year training course; only 25% of those who are fully trained meet International Confederation of Midwives (ICM) competencies; and only 15% of nurses who undertake midwifery duties meet the ICM core competencies, according to The state of the world's midwifery 2011 report.

“These data show that while we are seeing significant increases in the coverage of skilled birth attendants, the existing cadre of midwives cannot possibly be providing the quality of care that women need,” says McConville.

Increasing training is an important first step, but ensuring that midwives stay in the profession, especially in remote areas, is difficult. In the United Republic of Tanzania, for instance, says ten Hoope-Bender, a year after graduation, about 50% of women are no longer working as midwives. Incentives do not need to be monetary, says Mwansa Nkowane, nursing and midwifery technical officer at WHO. Among the top factors that count when it comes to retaining midwives are: decent housing, transport, career development and access to schools.

More research on the benefit that midwives provide will also be critical to improving midwifery, says ten Hoope-Bender, one of a group of researchers working on an upcoming midwifery series in The Lancet, the first time the journal devotes a series to this subject.

Little quantitative research on the impact of the care delivered by midwives has been conducted because much of this impact is qualitative in nature (i.e. gauged by the woman's experience of childbirth), says de Bernis.

In many resource-poor settings, childbirth is often assisted solely by traditional birth attendants. When midwives are hired in an attempt to make childbirth safer and reduce the risk of complications, traditional birth attendants may feel excluded and develop antagonism towards midwives, he says.

Increasingly, however, evidence shows that traditional birth attendants can play a vital role in improving maternal health if they work in harmony with midwives. In Indonesia, for instance, traditional birth attendants are offered financial incentives to refer pregnant women to midwives.

In a community-based midwife-led unit, for instance, traditional birth attendants could undertake basic tasks under the supervision of a midwife. “This ensures that hospitals only see the women who need treatment for a pregnancy or childbirth complication,” says ten Hoope-Bender. Understanding that pregnancy is not an illness is vital, says McConville. “Midwifery is often conflated with nursing because most midwives begin their training as nurses, but there is an important distinction between a sick person receiving treatment and a healthy woman giving birth.”

Midwives are a pillar of reproductive health programmes and it is crucial to understand their role in the health system and support them, says McConville. “These workers are proud to be midwives; you don't go into midwifery if you don't want to help other women. There is an element of love here. We are clinicians, but this is about loving and caring for other women, their babies and their families at a very special time in their lives.”

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