More than 60 percent of preventable maternal deaths and 45 percent of newborn deaths take place in countries affected by recent conflict, natural disaster, or both. Yet as Sarah B. Barnes, Project Director of the Maternal Health Initiative, observed at a recent event hosted by the Wilson Center and UNFPA, in collaboration with the Inter-agency Working Group on Reproductive Health in Crisis (IAWG) and White Ribbon Alliance, “the leading causes of both maternal and newborn death occurring in humanitarian settings are considered to be preventable if managed by skilled providers and adequate resources.”

The central role of midwives in navigating crisis and preventing these unnecessary deaths was the focus of the event.

“Midwives constitute the health workforce that can help deliver around 90 percent of essential sexual, reproductive, maternal, and neonatal health services,” said Dr. Tamar Khomasuridze, Sexual and Reproductive Health (SRH) Technical Advisor for Eastern Europe and Central Asia Regional Office at UNFPA.

Dr. Khomasuridze works to support midwives in many settings. She observed that this essential work can be accomplished when health workers are properly trained and supported by an enabling policy environment and health system. But she added that periods of conflict or disaster in humanitarian settings, midwives face several challenges affecting their role in supporting mothers and infants.

Cultural Context as a Barrier to Care

Health workers and midwives on the ground in South Sudan, Afghanistan, and Ukraine shared their particular experiences at the event. What they had in common, observed Dr. Khomasuridze, is “the fact that midwives deliver life-saving services in life-threatening conditions, for all.”

Yet each speaker acknowledged facing unique barriers to their work “The context of the crises in [these] three countries is different,” said Dr. Khomasuridze. said

Dr. Olena Samoilenko, a neonatologist working in a children’s hospital ward in Ukraine, noted that nobody abandoned the children in her country, even in wartime: “While bombs fell, while transport was collapsed – all staff, nurses, came here and stayed here. All were with our children.” 

The cultural context can sometimes create or compound barriers to the role of midwives and health workers in emergency response situations. An Afghan midwife, whose name was withheld to protect her safety, noted that the current cultural norms and rules in Afghanistan have led to increased discrimination towards mothers and midwives—as well as a reduction in the number of women seeking care.

An example that the Afghan midwife offered was the fact that all women, including midwives, their staff, and their female patients, face discrimination because they are required to always be accompanied by a male. “Yet despite these challenges,” she continued, “Afghan midwives are still the frontline health providers in many fragile settings and continue to provide constant and quality care in public and private sectors.”

Lilian Ndinda, Maternal and Child Health Coordinator for the International Rescue Committee in South Sudan, reflected on the challenge of cultural context while she worked at the Dadaab Refugee Complex in Kenya.

“Culture sometimes affects the quality of health services that are provided,” Ndinda said, noting that women need to seek several levels of approval from family members – from their father, their mother, their husband—before obtaining care. “It would take a mother several days to make the decision on whether to have a caesarean section or not,” said Ndinda. She added that the delays caused by this cultural norm also strained Kenya’s health systems as well.

Investing in Midwives

“The role of midwives in disaster preparedness is critical,” said Mushtaq Khan, Health Technical Advisor and SRH Advisor for the MENA region and Asia at the International Rescue Committee.

Yet the central role that midwives play often does not reflect this fact. For instance, a

lack of providers and training for midwives in various settings remains a challenge. Khan observed that there are a mere five midwives per 100,000 people in Afghanistan. Given the scarcity of trained professionals, he continued, how can we expect to improve maternal and neonatal child health indicators without more substantive investment?

 Another challenge is stress. Midwives often face mental strain and psychological burnout from working in these conflict settings with inadequate support. But organizations can take steps to reduce the psychological impacts. “Just as we focus on training a midwife to become a better midwife,” said Ndinda, “let’s also focus on teaching the midwife to cope with this work.”

Investing in midwives is a key piece of strengthening the health systems which are fundamental to disaster response.  “We should utilize the potential of the health workforce to strengthen health systems,” said Dr. Khomasuridze. Prioritizing the health workforce, and, in particular, midwives, within health systems will be an investment with long term positive impact.

Prioritizing Midwives in Disaster Planning

As a group, the panelists agreed that that midwives were often overlooked in planning for disaster responses. “Midwives are being discounted in numbers, no one is listening to their realities” said Angela Nguku, a midwife, and Deputy CEO of White Ribbon Alliance.

Given the impact that they have, it is critical for organizations to prioritize the needs of midwives in humanitarian responses. Yet while the need to center midwives in the response process is essential, there are a number of significant barriers to doing so.

 The Afghan midwife panelist said that instead of payment for their services, midwives in her country instead were confronted by a “fear of being attacked while working in health facilities, [as well as] a lack of female healthcare providers’ voices at the decision-making table.”

Another challenge in integrating the role of midwives in response planning is the fact that reproductive health is often not the first priority in such emergencies. Sexual and reproductive health needs are often overlooked in these crises, observed Dr. Khomasuridze. She proposed that sexual and reproductive health needs, including maternal and neonatal health, should be fully integrated and prioritized in preparedness and humanitarian responses.

The most compelling reason to do so is that emergencies do not erase these critical needs. The reality is that pregnancy and other health concerns still occur during these events. “The crisis comes and finds women when they are pregnant,” said Nguku.

Ensuring care for women in the midst of disasters requires a systemic response. Khan observed that when emergency preparedness and response planning at all levels – local, national, and international—leaves midwives out of the process, it is impossible to come up with concrete solutions.

Read more:

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