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A Midwife Crisis

This blog entry was originally posted on the CapacityPlus blog.

“If we want to stop these women and babies dying, we need to invest in skilled care,” declared Flavia Bustreo, assistant director-general of family and community health at the World Health Organization. Bustreo’s declaration came on the heels of the release of the WHO’s State of the World’s Midwifery 2011: Delivering Health, Saving Lives. In an effort to facilitate the strengthening of midwifery education and service delivery, the report features data collected from 58 developed and developing countries and makes recommendations on how to improve access to midwives.  

Midwifery challenges

The term “midwife” literally means “being with the woman.” Midwifery care is essential in improving maternal health, reducing the likelihood of a woman’s death during childbirth, and reducing newborn deaths. The State of the World’s Midwifery report notes that 358,000 women and 3.6 million newborns die each year from complications in the neonatal, delivery, and postnatal periods. The report clearly cites that these deaths are largely preventable.
Like other health cadres, there is a severe shortage of skilled midwives, especially in sub-Saharan Africa. The report’s Millennium Development Goal gap analysis found that 111,880 additional midwifery personnel are needed to achieve 95% coverage for births in the 58 countries featured in the report by 2015. Those countries facing the most severe shortages include Cameroon, Chad, Ethiopia, Guinea, Haiti, Niger, Sierra Leone, Somalia, and Sudan. In these countries the midwifery workforce needs to increase by six to 15 times. Not only are these and many other countries facing shortages of midwives, but within most countries, the maldistribution of skilled midwives between urban and rural communities greatly contributes to the number of deliveries without a skilled birth attendant. 
Also contributing to health worker shortages are lengthy lag times between graduation of midwives and initial employment. Like other cadres, midwives are not immune to hiring and retention challenges fueled by poor working conditions, insufficient remuneration, an absence of support and supervision, and the lack of a career path. 

Investments in relevant, quality midwifery education

Investments in scaling up the midwifery workforce must go beyond increasing numbers to focus on providing relevant, quality education for midwives. Simply increasing the numbers of providers may not have the desired effect in reducing maternal and newborn illness and deaths. Midwifery educational programs must thoroughly address midwifery competencies, especially those relevant to country epidemiology and resources. The shortage of faculty and tutors needs to be addressed, including tapping into the experience of midwives practicing in the community, and the curricula should provide both adequate scientific knowledge and clinical practice.
The State of the World’s Midwifery report offers several action items for stakeholders to improve midwifery education in their countries. These include investments in midwifery training programs and curricula to ensure they meet essential competencies set by governments and regulatory bodies, as well as compliance with education standards set by the International Confederation of Midwives. Investments in accreditation of midwifery education are also vital to ensure training programs meet acceptable quality standards. Furthermore, it is important to ensure that both public and private education programs have sufficient numbers of highly qualified teaching faculty so they may offer the level of instruction and guidance needed. Finally, the report urges stakeholders to consider the promotion of service delivery research and increasing support for midwifery leadership.

Demography and midwifery

The United Nations recently forecasted that population growth will accelerate and the world’s population will reach 10.1 billion by the end of the century. Regions with steady growth include West and Central Africa—coincidentally the same areas with the greatest shortages of midwives. Not only are midwives scarce now, but those shortages are projected to worsen as population growth outstrips the increase in the number of midwives. The WHO report specifically cites that the production of midwives in Francophone African countries in particular is not adequate for the projected rises in numbers of births. It is vital we use the evidence in the State of the World’s Midwifery 2011 and take steps so that every woman and every newborn has access to quality midwifery services.