About 350,000 women die while pregnant or giving birth every year, up to 2 million newborns die within the first 24 hours of life, and 2.6 million stillbirths occur annually says the United Nations Population Fund. A push to train more midwives worldwide and to increase their role in preventing the persistently high number of maternal and infant deaths in developing nations is under way, as the UN General Assembly annual debate spotlights the status of the Millennium Development Goals on Sept. 24 and the UN Population Fund focuses on maternal health at a forum on Sept. 23.
The intrinsic value of midwives in stemming maternal deaths may be gaining attention globally, but it is still not a priority in some of the world’s poorest countries, which could benefit the most from more midwives in the health sector. Training of midwives remains inconsistent, while the profession often garners little recognition, meager income and limited career opportunities — factors that contribute to the acute shortage of these health care workers.
Nevertheless, in the last few years, the UN has been a steadfast supporter of midwives, emphasizing their importance in introducing women to a health system that under optimum conditions can provide skilled care during pregnancy, childbirth and after delivery. In addition, the UN has reiterated the value of basic supplies being made available at childbirth settings, like cheap, crucial emergency medications to stop postpartum bleeding, a leading cause of maternal death. Access to safe abortions is also an important path to reducing maternal mortality.
In May, a symposium highlighted the role that midwives can play in preventing maternal deaths. Organized by the International Confederation of Midwives, the UN Population Fund, Jhpiego and the World Health Organization, the meeting took place in Kuala Lumpur, Malaysia, as part of the Women Deliver conference. More than 250 midwives attended.
The first UN report on midwifery, produced in 2011 by the UN Population Fund, documented the status of the workforce internationally. The report said that education, regulatory frameworks and developing midwifery associations are essential to strengthening midwife workers. Since 2011, midwifery training and authorization of their work and standards have improved in developing countries, but organizing them nationally is still far off.
Indeed, the report said that as many as 3.6 million maternal, fetal and newborn deaths a year could be averted if all women had access to midwives. The nations with the highest rate of maternal and newborn deaths are Afghanistan, Democratic Republic of the Congo, Ethiopia, India, Mozambique, Nigeria and Tanzania.
The role of governments and the private sector is vital to improving the midwifery workforce, but the will may be lacking. Some countries are also bucking promotion of midwives. Health officials in Bhutan, for one, have built up human development indicators that outpace India’s as they strive for 100 percent institutional (hospital or clinic) deliveries, since many women in the mountains might have to walk days to a doctor, midwife or not, if anything goes wrong with a pregnancy.
Dr. Yatta Lugor, deputy minister of health of South Sudan, said at the Malaysia conference this year that in her country, as in most developing nations, inadequate funding for health services, poor health facilities, limited human resources and not enough essential supplies and equipment rob women’s chances of avoiding maternal death. But the government is working to overcome those obstacles. “We have set a very ambitious goal to reduce maternal mortality ratio and under-five deaths by 20 percent” in the country’s health sector development plan for 2012 to 2016, among other objectives, Dr. Lugor said.
South Sudan, a new nation of 11 million people, has much work to do in this area, despite an influx of aid from other countries and the UN. It has the world’s highest maternal death ratio: about 1,900 deaths per 100,000 live births but fewer than 10 fully skilled midwives and 150 community midwives. To help alleviate the stark conditions, the UN is using midwives from its UN Volunteer corps to deploy across South Sudan to relieve the strain, says a new maternal health report from the UN.
The inability to retain workers in areas with high maternity death rates — generally, rural regions in developing countries — is a recurring problem. Skilled specialists migrate to capital cities and rich countries because they are paid more and the conditions are acceptable. The UN Population Fund says that 91 percent of maternal deaths occur in 58 of the world’s least developed countries, yet they have only 17 percent of the world’s midwives, nurses and physicians.
Uganda is a classic example. A program to increase midwifery coverage in the country’s rural areas aimed not only to encourage local students to become midwives but also for them to stay in their region instead of moving on. So far, the effort, begun in Karamoja, an outback of poor roads and few services, led to a 100 percent increase in students applying and enrolling in midwifery classes there.
In 2008, the UN Population Fund introduced the Maternal Health Thematic Fund to help strengthen national health services, enable governments to overcome obstacles and increase safe motherhood practices in developing countries. Since then, more than $60 million has been donated from Western countries to 30 developing countries for assistance, while a midwifery program began operating in collaboration with the International Confederation of Midwives.
Although the support for proper training of midwives has increased over the past decade as part of the fund, investments in midwifery are still sorely needed. One technological advance has been e-training modules to improve midwives’ skills in handling births and other complications. The modules, accessible on laptops and netbooks using software provided free by Intel, can be used anywhere anytime, with or without the Internet.
Meanwhile, basic antibiotics, the kind that most Westerners take for granted, remain some of the important tools in combating maternal deaths.