“This is real,” said Franka Cadée, President of the International Confederation of Midwives (ICM). “And we can no longer get around it. And we can no longer linger.” She spoke at a recent Wilson Center event, in partnership with the United Nations Population Fund (UNFPA) and Johnson & Johnson, launching a new study, Impact of Midwives, published in The Lancet Global Health. If any other intervention could have the same impact as midwives or midwifery, it would be implemented worldwide immediately, she said.

This study—led by UNFPA, ICM, and the World Health Organization (WHO)—is part of a series of publications leading up to the 2021 State of the World’s Midwifery report. It provides new estimates on the potential impact of midwives on reducing maternal and neonatal mortality and stillbirths. This publication is particularly timely as the world faces the COVID-19 pandemic and its effects on women and girls, including diminished access to sexual and reproductive health (SRH) services. As the world reveres the importance of essential health workers, like midwives, they continue to work “as the front-line workers they are, risking their lives to save others,” said Anneka Knutsson, Chief of the SRH Branch of UNFPA.

Saving Lives and Sustaining Livelihoods

The study focused on the 88 countries that account for 95 percent of maternal and infant deaths worldwide. It then identified 31 “midwife-delivered” essential interventions and estimated the number of maternal deaths, newborn deaths, and stillbirths that would occur in these countries between now and 2035 if coverage of these services remained the same. The authors then compared this baseline to four scenarios: a modest scale-up (a 10 percent increase in service coverage every five years), a substantial scale-up (a 25 percent increase every five years), universal coverage (at least 95 percent service coverage by 2035), and attrition (a 2 percent decrease every five years).

The findings were striking, said Cadée. Even the least ambitious scale-up scenario, the modest option, would produce significant results, decreasing maternal and newborn deaths by approximately 20 percent and saving 1.3 million lives per year by 2035. If the universal coverage scenario were achieved, 4.3 million lives could be saved each year by 2035.  Such an approach could avert two-thirds of maternal deaths and more than 6 in 10 newborn deaths and stillbirths. By identifying the midwifery interventions, such as access to modern methods of contraception, that could have the largest impact on these 88 countries, the study provides critical guidance to policymakers and strengthens the evidence base midwives and advocates can use to make a case for greater investments in midwifery.

“Investing in midwives is investing in women,” said Chunmei Li, Director of Global Community Impact at Johnson & Johnson, “Investing in midwives is investing in children and the future of humanity.” The benefits of this investment provide a “double return,” saving lives while also sustaining the livelihoods of midwives and the families they serve, said Petra ten Hoope-Bender, Technical Advisor for SRH at UNFPA, Geneva. This return on investment could be especially pronounced in humanitarian and fragile settings, where 60 percent of preventable maternal deaths and 45 percent of preventable neonatal deaths occur, said Jihan Salad, SRH Specialist at UNFPA, Jordan.

Strengthening Midwifery

A passionate belief that midwifery is the best approach to save and improve the lives of women, newborns, and their families is not enough to ensure the best return on investment, said Elizabeth Iro, Chief Nursing Officer at WHO. Using good data is key. With that data, stakeholders must now focus on translating the study’s findings into practice, said Andrea Nove, Technical Director at Novametrics and lead author of this study. This process is not as simple as it appears, said Iro, as interventions must be adapted to meet the specific needs of each country, given their current landscape of midwifery practice and regulation.

What’s more, to increase access to midwife services, aspects of the practice must be improved. Midwives face many barriers in their day-to-day practice, including issues related to gender inequality and increased exposure to violence, said Salad. “We cannot achieve universal access if we do not address the problems in midwifery education and practice.” This could involve ensuring that every midwife is educated according to the standards set by ICM; regulating the use of the term, “midwife;” appointing a chief midwife in each country; including midwives in maternal health policy conversations; and promoting pay equity. “In the last year, we’ve had a lot of clapping, a great amount of clapping,” said Cadée, referring to the increased recognition midwives and other health care workers have received in the wake of COVID-19. “Wonderful. But clapping does not buy bread.” 

The Importance of Collaboration

In order to implement these changes, collaboration is key. This begins in the health sector. Although midwives provide a wide range of services, some patients require a higher level of care. Midwives must work with other health care providers, such as doctors and nurses, to ensure continuity of care in these scenarios. By working with doctors and nurses to refer patients, midwives can ensure that a country’s health resources are being allocated efficiently, with women receiving the appropriate level of care for their needs, said ten Hoope-Bender.

Similarly, others in the health care profession must respect midwives and recognize their contribution to women’s health. Because midwives are with women from pre-pregnancy to the postpartum period, they provide a level of holistic care that is often not possible in other settings. Additionally, in countries where maternal health resources are especially limited, midwives can help fill gaps in care. In many countries, nobody’s attending the birth, said Nove. “And so it’s not about taking work away from nurses and doctors,” she said. “It’s about making sure that every woman is attended by someone who knows what they’re doing.”  

Collaboration must extend to the women and communities being served. Putting information in the hands of women, so that they can make decisions about their own health care is crucial, said ten Hoope-Bender. Similarly, it is important for communities to be educated on the benefits of midwifery. This allows them to take ownership of midwifery efforts in their areas and find the most appropriate solutions to their problems, said Salad.

Although much work needs to be done to achieve the potential outcomes outlined in the Lancet study, they are indeed attainable, said Nove. Several countries have previously achieved the 10 percent service increase reflected in the modest scale-up scenario, and the substantial scale-up scenario is feasible if countries undertake concerted efforts to prioritize midwifery services, said Nove. “If we implement this evidence, the world would look brighter, not just for midwives and women,” said Cadée, “but for humanity.”