One in every 23 people is expected to need humanitarian assistance in 2023. That is a record 339 million this year alone. During such humanitarian crises, the needs of women, newborns and adolescents are often unmet, with devastating consequences. In fact, in 2023, 58 percent of global maternal deaths, 50 percent of newborn deaths, and 51 percent of stillbirths worldwide occur in the 29 countries with a UN humanitarian response plan or regional response plan.

Given the high burden of preventable maternal and neonatal death in these settings, the need for skilled health workers is vital. Evidence reveals that midwives are more likely than other health workers to remain in humanitarian and fragile settings throughout a crisis, even in the face of challenging conditions – including risk to their personal safety. Evidence also shows that when educated and regulated according to international standards, and supported through ongoing supervision, midwives can provide approximately 90 percent of sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) care services.

At the first ever International Maternal and Newborn Health Conference (IMNHC) in Cape Town, South Africa, the importance of maternal and newborn health in humanitarian and fragile settings was not missed. The conference had a track dedicated to this important demographic. One featured program was a panel discussion organized by The Maternal Health Initiative, International Rescue Committee (IRC), and the Inter-Agency Working Group on Reproductive Health in Crises: Midwives in Humanitarian Settings: Realities of Strengthening an Essential Health Workforce. This event focused on the experiences of a midwife and researcher from Nigeria and a midwife working on the Thailand-Myanmar border.

Midwives in fragile settings are often unable to access quality pre-service education or adequate post-deployment support and many humanitarian contexts lack the regulatory frameworks and policies needed to adequately support this essential health workforce.  There is a real lack of evidence on education and regulations of midwives in humanitarian and fragile settings, said Pandora Hardtman, Chief Nursing and Midwifery Officer at Jhpiego. She added that the increased risk and stress adds to the burden placed on midwives in these settings where the mindset can become “your life or the life of the women.”

The Need for Research and Midwifery Education in Nigeria

“There is a lot of stress for midwives in Nigeria,” said Emilia Iwu, Nurse-Midwife and Senior Technical Advisor/Primary Investigator at the Institute of Human Virology in Nigeria. The presence of Boko Haram and limited resources make it very hard for midwives to provide care there.  In Northeastern Nigeria, health workers moved out from the area leaving health facilities short staffed. She added that approximately two million people are internally displaced in Nigeria, 8.3 million will need humanitarian services, and 80% are women and children: “We really need community midwives to provide services in those areas.”

Iwu shared: “In my research, I speak with many midwives, and they are faced with continuous anxiety because every day that they go to work they know the health facility might be attacked.” Midwives work long hours because they don’t want to travel home at night or travel to work early in the morning as it puts them at risk. They also don’t wear their uniforms to work because that puts them at a higher risk of being kidnapped by insurgents who feel they can put a high ransom on their heads.  

Globally, researchers often take research collected from outside humanitarian settings and then try to apply findings to fragile settings. But Iwu called for research to be done within fragile settings to really share women’s voices and allow midwives to tell their stories: “We need to show evidence from midwives’ real-life situations on what they face in their work.”

Hardtman echoed this call for better specific research. “Looking at knowledge gaps and evidence is important. It is not just about quick numbers, but about support structures for midwifery and that can bring forth illumination at multiple levels,” she said.

Iwu also noted that it is important to understand the barriers for midwives to stay in their communities, be it safety, low pay, education and training, or other factors. A longitudinal study following midwives from schooling to the workplace would be key to unlocking some of these questions and could help policy makers address these challenges. If policymakers can use evidence-based research to understand what helps midwives stay and thrive, they can better create policies to support and encourage midwives and midwifery. “Sometimes, policy makers are making decisions without the evidence,” she said.

Unique to the challenge of humanitarian settings is the political unrest and the distinctive skills of midwives as community members to be able to be in the “hot seat” and speak to and work with all the factions involved in this unrest. This not an easy place to be in, said Hardtman.

While funding for research on midwifery in fragile settings is essential, Iwu noted that it is difficult to secure the necessary funding because funders want immediate results. “When funders look at areas to focus their resources on and where it could make the most benefit, midwifery education is one major area.” It is key to understand how midwifery education is affected in areas of conflict and humanitarian response and all midwifery curricula should include emergency preparedness skills, she continued.

In Northeastern Nigeria, many women and girls are not economically empowered. So Iwu said that it is valuable to look at the impact of education in terms of their empowerment and to look at the evidence of retention to focus our efforts on keeping trained midwives working in their communities. She added that psychological factors like work-life balance, anxiety, and depression must also be considered.

Midwifery on the Thailand-Myanmar Border

There are seven refugee camps where IRC Thailand is working along the Thailand-Myanmar border. “I am responsible for three camps including the largest refugee camp, Mae La and another two camps. In Mae La camp, the total population is around 35,000 people including 8,000 reproductive aged women. In the other two camps, there are another 3,000 women of reproductive age,” said Nan Moe Pearl Pan, Reproductive and Child Health Midwife with the IRC on the Thailand-Myanmar border. “In camp settings, frontline health care providers are camp residents who are trained to become medics, nurses, midwives, community health workers, psychosocial workers, and environmental health staff. I am a certified nurse-midwife and I work to support the camp resident assistant midwives.”

Pan observed that midwives face many challenges working within the camps, including the limited capacity of camp-based assistant midwives as compared to certified midwives. Other issues include  limitations on abortion services, the long distance between the camp and Thai hospitals, and the limited phone and internet access. The COVID-19 pandemic added new difficulties to ongoing challenges related to limited pay for assistant midwives, as well as issues of language and culture. And Pan added that these midwives also need to treat non-camp residents who come to them for help.

“A priority for me is to strengthen the capacity of the camp-based assistant midwives,” said Pan. The camp-based assistant midwives are made up of camp residents who are trained by certified midwives, but they cannot perform the same services of a certified midwife. Retention is also quite difficult. Pan said that the pay for these assistant midwives is quite low, and that often women find work outside the camp as caregivers or domestic workers for far more money than the camp can provide.

Pan recounted the story of one pregnant woman who came into the camp in need of assistance, but who was not a resident. “I recently had a woman come in with her mother and her children who was having labor pains. She was abandoned by her children’s father and hadn’t been tested for HIV, so we tested her and, she was unfortunately, found positive. We then needed to refer her to the Thai hospital to receive the necessary treatment,” said Pan. The need for women and children inside the camps is significant, she said. Add in the care for non-residents, and it becomes quite difficult at times.

Investment is necessary for the antenatal care needs in the refugee camp settings. “As a midwife working with refugees living on the Thailand-Myanmar border,” observed Pan, “we need more support in capacity building to keep the midwives working in the camps to reduce maternal and neonatal morbidity and mortality though early detection and intervention of high-risk pregnancy, emergency obstetric care, and to ensure that children are fully immunized against childhood diseases.”

Hardtman closed the session with final remarks that underscored the value of hearing direct experiences from the field: “There we have it. The voices of midwives speaking for themselves in their own voices—our own realities being brought to the table.”  While sessions on maternal and newborn health frameworks have been full at IMNHC, Hardtman noted that the voice of the midwives, the nurses, and the health work force need to be shared more widely, especially because people have forgotten that midwives are the actual implementers of those frameworks and still need support. “So, take our voices to the world, understanding that the reality of midwives in humanitarian settings are globally diverse and that help continues to be needed.”