Midwifery is one of the world’s most ancient vocations, its practitioners playing a prominent role dating back to the Bible. In much of the world, midwives continue to play an important role in maintaining the health of women and newborns.
It should come as no surprise, then, that investments in this occupation, according to the United Nations Population Fund (UNFPA), could help avert two-thirds of global maternal and newborn deaths. UNFPA, the lead UN agency working to enhance the midwifery profession, has achieved a great deal of progress in this area, helping to train more than 60,000 midwives since 2009 and supporting more than 65 countries in strengthening their midwifery workforce policies through the Maternal Health Thematic Fund, the agency’s program for improving maternal and newborn health. Much of its money comes from foreign governments and private-sector and civil society organizations.
The UN Population Fund spent more than $120 million in 2014 on maternal health services alone. Yet while it employs maternal health specialists, it does not even have a midwife on staff at its New York headquarters, conveying a subtle message, one outside expert said, that the agency is not focused enough on the profession.
Moreover, increasing the number of midwives worldwide, especially in poor countries with minimal health care systems, where midwives can make a huge difference, remains a serious problem. For starters, governments are not prioritizing the professionalization of midwifery.
As outlined in the 2014 State of the World’s Midwifery report published by the UN Population Fund, only 22 percent of countries globally have enough educated midwives to meet the basic needs of women and newborns; and 78 percent of the countries are facing serious shortages in midwifery, which will result in unnecessary deaths of women and babies.
And while the maternal mortality rate has fallen 44 percent globally since 1990, according to a November report by UN agencies and the World Bank, published in The Lancet medical journal, only nine countries achieved the UN Millennium Development Goals target of reducing the maternal death ratio by at least 75 percent between 1990 and 2015.
That would also mean that the UN’s new global goals — which begin in January and include cutting maternal deaths to fewer than 70 per 100,000 live births globally by 2030 — will require more than tripling the pace of progress, from the 2.3 percent annual improvement in maternal death ratio recorded between 1990 and 2015 to 7.5 percent a year beginning in 2016, according to a recent joint statement from the UN Population Fund, Unicef, the World Health Organization and the World Bank.
“Many countries with high maternal death rates will make little progress, or will even fall behind, over the next 15 years if we don’t improve the current number of available midwives and other health workers with midwifery skills,” said Dr. Babatunde Osotimehin, the executive director of the UN Population Fund and a Nigerian, in the statement. “If we don’t make a big push now, in 2030 we’ll be faced, once again, with a missed target for reducing maternal deaths.”
Some maternal health advocates fault governments for the inadequate number of midwives, who in addition to delivering babies, serve other vital roles such as introducing the subject of contraceptives for women whose health is impaired by too many pregnancies, discussing breast-feeding and nutrition for mothers and their babies and participating in campaigns against procedures such as female genital mutilation.
“Governments aren’t putting money where their mouth is,” said Frances Ganges, chief executive of the International Confederation of Midwives (ICM), an association that seeks to strengthen the profession globally. Noting that it is estimated that the world needs at least 350,000 midwives to meet the health care needs of women and newborns, Ganges said that in some places, midwives make less than $200 a month even after completing five years of education. If maternal health is to be a priority, she said, no one can work “for less than living wage,” including in poor countries.
Dorothy Lazaro, a UN Population Fund midwifery specialist and adviser based in Ethiopia, said that midwives, who focus their care on mothers and babies, are important in managing maternal complications such as hemorrhages and convulsions, skills that many nurses or community health workers in developing countries are not trained to handle.
Referring to the collaboration between the UNFPA and the International Confederation of Midwives through the Maternal Health Thematic Fund (with additional money contributed by foreign governments), Lazaro said that in Ethiopia, for example, only 1,275 midwives served a population of 90 million people in 2009.
The UN and the midwife confederation worked with the Ethiopian government to train 4,470 midwives and started programs in 48 training institutions, including a master’s degree program, aligned with the confederation’s curriculum standards. “So many countries that have been working with UNFPA have done exactly that,” Lazaro said.
Dr. Michel Brun, a maternal health adviser at the UN Population Fund, also noted the partnership with the ICM in carrying out training programs and setting professional standards. While the number of midwives on the ground may have increased, “the focus is on quality of care,” he said.
Lazaro of UNFPA agreed that a big concern is the lack of practical skills. Midwives “need hands-on skills . . . to save the life of the mother and baby.” Mentoring is key; often midwives are sent to health clinics without supervision. In Ethiopia, a mentoring program was established in which senior midwives support new ones for a three-week period, followed by continued support afterward.
Lazaro stressed the importance of continuing education for midwives, as “there’s always new information coming.” Many midwives also work in rural areas. “They really need to have that network,” she said.
The placement of midwives is also critical to delivering the best health care.
“Once you have your midwives well trained, then you have to deploy them in the different levels of the health system,” Dr. Brun said. For example, in a Basic EmONC (Emergency Obstetric and Neonatal Care) facility, midwives can handle rudimentary complications that can arise during childbirth without needing an obstetrician-gynecologist, he said.
“The midwives can be deployed much closer to the population” at such a facility, engaging in regular contact with community leaders and health care workers to increase awareness of pre- and post-natal complications. “This is the challenge,” he said.
Monitoring how midwives are doing is also important, Dr. Brun said. The UN Population Fund set up a system to collect and analyze data, including tracking every maternal and newborn death. “The goal is to understand what happened,” he said, to learn from their failures. On the flip side, it is also vital to note good practices on the ground in specific countries, to have the “opportunity to learn from what they are doing.”
Midwives in the field largely appear satisfied with the UN’s commitment to midwifery. “They are doing a fantastic job,” Lazaro said, noting how the UN Population Fund, which focuses on resources and training for midwives, complements the work of the larger H4+ collaboration (World Health Organization, Unaids, UNFPA, UN Women, Unicef and World Bank), which oversees policy issues and standards of competency.
“Both in principal and in practice, there has been a show of commitment” by UNFPA “to midwifery as a profession,” said Ganges of the International Confederation of Midwives, based in The Hague. “They have been very supportive.”
“UNFPA has been our biggest partner in the UN agencies,” Ganges added, noting its key role in the five-year Maternal Health Thematic Fund project and its discussions with the International Confederation of Midwives on strengthening midwifery in the 22 countries of Francophone Africa, an initiative that she hopes will run through 2017. (Here is a video, in French, on midwifery in those nations.)
The countries are Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, Ivory Coast, Democratic Republic of the Congo, Djibouti, Gabon, Guinea, Madagascar, Mali, Mauritania, Morocco, Niger, Republic of Congo, Senegal, Seychelles, Togo and Tunisia.
Ganges said that Chad, Central African Republic and Burundi are among the 10 countries with the worst maternal mortality rates globally; they are also among the world’s poorest nations.
She said that the UN Population Fund also agreed this year to finance an International Confederation of Midwives study in Kenya to perform a gap analysis in midwifery education and regulation, and has financed forums on midwifery issues.
Ganges remains discouraged, however, that there is no actual midwife on staff at UNFPA headquarters in New York. “I think it should be a priority, and it doesn’t seem to be,” she said. “I think it sends a double message.”
While efforts have been underway to recruit a midwife in New York, Ganges — who told PassBlue she has offered to help with the interview process — has not seen any public announcement or bulletin. “The answer is vague or ‘I don’t know,’ ” she said. “It’s very, very disappointing.”
Lothar Mikulla, a UNFPA spokesperson, told PassBlue recently that “the recruitment process is still pending.”
Much of the agency’s financing comes from well-off European countries such as Norway. Last year, Norway contributed about $94 million, according to Fredrik Arthur, the senior adviser and ambassador for women’s rights and gender equality at the Norwegian Foreign Ministry. This “reflects overall confidence in the UNFPA mandate” and its “practical work on the ground,” he said.
How does Norway monitor the UN Population Fund’s use of funds? The country participates in board meetings three times a year and is part of the Multilateral Organisation Performance Assessment Network, a nonprofit group that monitors institutions such as the UN and its agencies. According to the network’s 2014 annual report, “UNFPA has over the last few years taken a number of initiatives aimed at strengthening the organisation’s mandate and its focus on results, and to improve accountability.”
While Arthur acknowledged that the Foreign Ministry relies on reports from such nonprofit group networks, and not firsthand accounts, UNFPA “has been given green lights,” Arthur said. “We’re satisfied.”
The UN Population Fund is not the only UN agency promoting midwifery. Unicef spent close to $145 million on maternal and newborn health programs in 2014. It distributes midwifery kits, for one, containing basic drugs, renewable medical supplies, medical equipment and basic sterilization and resuscitation equipment for health facilities to perform an average of 50 normal deliveries.
Kim Dickson, Unicef’s senior adviser on maternal and newborn health, noted in an e-mail interview that the organization worked closely with UNFPA, “according to modalities agreed upon” in the countries where they both operate.
“In Sierra Leone and Sudan, for example, UNICEF helped train midwives on how to provide support to women who are victims of female genital mutilation,” Dickson wrote. “In Indonesia, we partnered with a mobile network to broadcast educational and technical updates to midwives across the country and link village midwives with their pregnant clients.”
Acknowledging the challenges midwives face, Dickson noted that “too many countries place restrictions on what midwives can and cannot do, even within their professional domain, often with tragic consequences.”
Where there are not enough doctors available, midwives need to be allowed to perform such services as giving injections, manually removing the placenta, administering newborn resuscitation and administering antibiotics in case of infection, Dickson said. “Such interventions can help avoid further tragic deaths among mothers and newborn babies.”
Dr. Doris Chou, a co-author of the recent maternal mortality study published in The Lancet and a medical officer in the Department of Reproductive Health and Research at the World Health Organization, was optimistic about the findings.
“While the estimated decline in maternal mortality did not reach the MDG target, it remains a significant decline, and one that may not have happened if the Member States of the UN did not agree to the MDGs in 2000,” Dr. Chou wrote in an e-mail. “In other words, countries became interested in progress when it was agreed that progress would be monitored.” She agreed, however, that better data on the ground must be collected.
Indeed, is the new goal of fewer than 70 deaths per 100,000 births by 2030 realistic?
“Certainly, it is ambitious,” Dr. Chou said. “But if there is will, and a collective global commitment, yes — it is.”