Midwives play a central role in maternal and newborn health. So, it is fitting that their efforts took the spotlight at a two-day event – The 5^th Global Midwifery Symposium – held during the first ever International Maternal and Newborn Health Conference (IMNHC) in May 2023 in Cape Town, South Africa.

“Access to skilled midwives creates a brighter future for mothers and babies,” observed Dr. Julitta Onabanjo, Director of the Technical Division of the United Nations Population Fund (UNFPA), during her opening remarks at the event. The Symposium was attended by some 300 people and culminated with the launch of the Global Call to Action & Commitment to midwifery, to renew commitment to support, strengthen, and promote midwifery models of care.

The Midwifery Symposium was convened by UNFPA, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the International Confederation of Midwives (ICM), as well as an additional 19 global partners from civil society, academia, private sector, professional bodies, and donors. “We’re calling on the world to invest and not to rest,” said Dr. Onabanjo.

This investment is needed to face the critical global deficit of midwives—a shortage of 900,000 midwives worldwide and 500,000 midwives on the African continent alone. Even a 10 percent increase in midwifery coverage every five years would avert 22 percent of maternal deaths, 23 percent of neonatal deaths, and 14 percent of stillbirths, saving 1.3 million lives per year by 2035.

Weaving Midwives into Larger Structures of Care

Midwives are also key to the goal of universal health coverage, and they are essential to the Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP) initiatives. Midwives educated and regulated to ICM’s standards and integrated into well-functioning health systems can provide 87 percent of essential care for women and newborns. Midwives offer care across the childbirth continuum, in homes, communities, and hospitals. Yet, they make up only 10 percent of the health workforce.

To realize their lifesaving potential, midwives need education and training to international standards. There must also be an increase in midwifery leadership in policy and programming. These steps will allow midwives to be fully integrated, paid, protected, respected, and professionally developed.

“Midwives are a critical component to women’s survival and empowerment. Yet, midwives face many challenges and strong impediments exist to quality midwifery service delivery due to inadequate numbers, distribution, poor quality of education, regulations, and workforce policies,” said Geeta Lal, Senior Technical Advisor Maternal Health and Midwifery at UNFPA.

Midwifery has become a centerpiece of EPMM within UNFPA, along with family planning, and social and gender norms, said Lal. Ninety percent of the world’s midwives are women and the critical role of women in the health workforce is often overlooked, which has a monumental effect on both midwives and the women in their care.

“If you look at how midwives are treated in a country, you will know how women are treated in that country,” observed Franka Cadée, a midwife and the President of ICM.

A Formal Role for Government

The two days of the Symposium were packed with technical expertise, lived experience, and a deep appreciation and respect for birthing people and the midwives who support them. Several themes arose in the proceedings, primarily focused on the importance of investment in education and training, midwifery leadership and career progression, and the unique role and impact of midwives to improve maternal and newborn health outcomes.

Formal investment and infrastructure from government for midwives was one important strand of the discussions. This can lead to tangible reductions in maternal mortality, as well as pathways for advancements for midwives.

Zambia offers a unique perspective on this question. The country has seen sharp decline in maternal deaths since 2010, from 709 maternal deaths per 100,000 live births to today’s 270 maternal deaths per 100,000 live births. During the same period, increased coverage of skilled births attendants has risen from 40 to 80 percent.

All this success is due to the inclusion of midwives, said Dr. Lakson Kasonka, Former Permanent Secretary of Zambia. Midwifery was recognized by the government, which has led to increased training and capacity building. And when midwives are given recognition and respect, he added, they can rise to the occasion. Dr. Lakson also noted that Zambia must continue to invest in training and create supportive policies to help midwives understand that they are key players in the reduction of maternal mortality: “Special recognition of midwifery will help to ensure that no woman dies while giving life.”

Seeking Improvements in Quality of Care and Coverage

Midwives are uniquely situated to serve certain populations and communities in times of crisis if they have the proper training and resources available. Of course, this also requires structures and processes to ensure there are enough midwives to support a community.

Pakistan is experiencing an acute shortage of midwives, noted Naila Yasmin, Sexual and Reproductive Health Analyst at UNFPA, Pakistan. Midwives are often overshadowed by nurses and lack the opportunity for advancements in their careers. Yet, she added, Pakistan has established a midwifery strategic plan and midwifery-led care plan, which will hopefully help advance the education and skill training needed for midwives working in such complex contexts.

Neha Mankani, a midwife in Pakistan, and the Southeast Asia Regional coordinator for the PUSH Campaign, said that during 2022 floods in Pakistan, UNFPA estimated that 75,000 women were pregnant and delivering within 2 months of the event.

“I went into the field to see what was happening and what the needs were,” continued Mankani. “I had never seen anything like this. Where there had been villages, there were miles and miles of water and the only way we could get around was in boats. We saw maternal and neonatal deaths and morbidities because there was no one in these communities who could service these women. The community midwives should have been around, but they couldn’t be found.”

Mankani and another midwife traveled to 24 former facility areas, delivered 2,000 clean delivery kits, and treated some 15,000 women, but they couldn’t find the community midwives. She noted that when they did find community midwives, they inquired why they were not able to mobilize. Mankani said that these midwives didn’t feel confident in their own abilities and felt that they might not even be allowed to practice in those conditions. They also lacked the resources they would have needed to do so. 

Pakistan has a community midwife system with around 40,000 midwives, but Mankani noted that they are often not able to provide the services they are meant to for numerous reasons: families can’t afford to pay, finding women with the secondary education required to be to trained is difficult, and midwives often lack confidence even once they are trained. Mankani pointed to a real need to improve education, empowerment, and financial investment in Pakistan.

Midwifery also has had historic challenges in South Africa. Sheila Crow, Associate Professor, Division of Nursing and Midwifery, University of Cape Town, noted that her city had a good track record on maternal deaths after moving midwifery care out of hospitals and into free standing obstetric centers a few decades ago. These centers were staffed entirely by midwives with physicians visiting once a week. The HIV crisis of the late 1980s and 1990s changed all that. “We had the highest rate of HIV in the world and that sent our [maternal death] numbers flying,” Crow recalled.

Various improvements have been made in midwifery in South Africa since the 1990’s, and Crow stressed the importance of setting up midwifery to properly integrate multi-level, quality, maternal and newborn care. “If you set it up for a conveyer belt system and expect people to be seen every five minutes,” she said, “you are not going to get the respectful care you would like to see, so there is that tension on how the services are set up and how they are financed.”

A Unique Profession

That midwifery requires its own distinctive training, education, and recognition was another essential part of the discussion. Midwives can’t simply be grouped together with nurses or physicians as healthcare providers. They must also be in leadership positions that make a difference— particularly when discussing maternal and newborn health and the role of midwives in the healthcare system. And they need fellow midwives as mentors and educators.

“If you’re not at the table, you end up on the menu,” said Margaret Manah Macarthy, National Quality Manager of Sierra Leone’s Ministry of Health and Sanitation. She has worked as a midwife throughout her career in Sierra Leone and shared with the audience that in 2010 there were only 28 midwives in Sierra Leone and most of them did administrative work.

The government then established a midwifery school and worked to rebuild the profession. Sierra Leone has experienced many crises since then, including a rebel war, Ebola, and mudslides, and each crisis has led to the loss of healthcare workers, including midwives. Manah Macarthy stressed the need for increased investment in proper salaries, quality education, a code of ethics, a standard of practice, and proper mentorship and career progression to keep the profession healthy: “An OBGYN can’t mentor me in my role. I want to be mentored by a midwife.”

Respectful maternity care was another central theme of the Symposium and is a cornerstone to quality midwifery care.

In Egypt, a career in midwifery wasn’t an option, said Merette Khalil, a Doula and an Advocacy and Communications Manager at the White Ribbon Alliance. The lack of a path into the profession led her to become a birth doula instead. As an advocate for women and girls, Khalil sees respectful maternity care as essential to midwifery care and a cornerstone of her own work: “People often don’t remember what you say to them, but they will always remember how you made them feel,” she said.

When the White Ribbon Alliance’s What Women Want campaign asked 1.2 million women and girls what they wanted in their health care, the number one response was respect. “Health systems are not immune to oppression. Unfortunately, these systems are plagued with racism, sexism, colonialism, other isms that strip women and girls of autonomy and rights when they access the healthcare system,” said Khalil. “We must act now to ensure that every woman, girl, and birthing person entering the health system will be respected.” 

Midwives in Humanitarian and Fragile Settings

Experts at the Symposium acknowledged the current polycrisis of climate related impacts, the COVID-19 pandemic, and intensified poverty and displacement. They called for accelerated action and implementation of midwifery within all aspects of maternal and newborn care across the landscape created by these crises.

“A lot of the challenges and difficulties that we see in humanitarian settings are similar to what we see in resource poor, rural, and remote areas,” said Catrin Schulte-Hillen, Sexual and Reproductive Health in Emergencies Specialist at UNFPA’s Humanitarian Country Office. She observed that one difference is that in humanitarian settings, there is an international agreement on minimum standards (though this doesn’t include midwifery), as well as the Minimum Initial Service Package (MISP) for sexual and reproductive health in Crisis Situations established by the Inter-Agency Working Group for Reproductive Health in Crises (IAWG). 

Yet defining a role for midwives in the polycrisis is essential. Midwives often move with women in fragile settings and must be recognized for the work they do. “Midwives are very carbon neutral because we give care close to women, we are with women. We often say women live far, but women don’t live far—we are far away … We need to be close to women particularly as they face humanitarian crises,” said Cadée.

Read More:

• Midwives in Humanitarian Crises Need Recognition and Investment
• State of the World’s Midwifery Report 2021: Follow the Data, Invest in Midwives
• To Achieve Universal Health Care, Invest in Nurses and Midwives