Midwifery champion: Developing context- specific midwifery models of care for better maternal and child health

Dr. Jennifer Akuamoah-Boateng is part of a global movement supporting low- and middle-income countries (LMICs) as they transition to midwifery models of care to accelerate reductions in maternal and neonatal mortality.

In an interview with Exemplars News, Dr. Akuamoah-Boateng shared insights about how the integration of midwives into health systems in LMICs can better meet women’s health needs. With an estimated 2.2 million midwives worldwide, their role is vital – yet a shortage of nearly 1 million midwives is expected by 2030. Researchers estimate universal access to midwifery care could avert two-thirds of all maternal deaths.

Dr. Akuamoah-Boateng has served as a midwife, educator, and researcher in a variety of settings across Ghana and the United Kingdom. This experience informs her work at the Gates Foundation, where she now serves as a senior program officer on the Maternal, Neonatal, and Child Nutrition and Health team leading midwifery investments, including investments in maternal and child health in Nigeria.

Her portfolio includes a partnership with Exemplars in Global Health studying how Kenya and Senegal developed and implemented high-impact midwifery models of care. Kenya and Senegal have been recognized as exemplar countries in access to family planning and improvements in maternal and neonatal health, making these contexts a strong setting for understanding how midwives can best contribute to health systems.

Midwives are skilled health professionals who offer women services across sexual, reproductive, maternal, and newborn health care. They provide essential health care and guidance to women as they navigate a variety of critical decisions through conception, pregnancy, and birth, such as when to receive antenatal care, where to give birth, and how to care for their newborn’s health. And midwives offer this health care and guidance in a personalized manner, that includes emotional, social, and cultural support.

Researchers in a wide variety of settings have found that the care provided by midwives saves lives, nurtures healthy beginnings, and strengthens communities. Exemplars News discussed the many roles midwives play across health systems and models of care with Dr. Akuamoah-Boateng.

Could you tell us more about the role of midwives in providing high-quality, person-centered maternal and newborn care?

Dr. Akuamoah-Boateng: Evidence shows that improving access to the skilled care midwives provide, particularly for vulnerable women, is cost-effective and leads to improved outcomes for both mothers and newborns. Midwifery models of care also lead to better experiences and more satisfaction for patients. That’s because midwives serve as advocates for women in the health system. Midwives place women’s experience and needs front and center.

Could you describe more about what defines midwifery models of care and where they are used?

Dr. Akuamoah-Boateng: Midwifery models of care entail having a midwife support a woman from conception, sometimes pre-conception, providing services throughout the continuum of their pregnancy, birth, and postpartum period. In these models, sexual, reproductive, maternal, and neonatal health care is provided in a holistic manner and a personalized way.

Likely one of the oldest professions, midwives have always been common, providing services for women and mostly by women. However, global midwifery models have traditionally been defined, standardized, and implemented in higher- income contexts, especially in Europe. Consequently, even in LMICs, where midwives are present and midwifery is practiced, it is often viewed as not aligned with internationally recognized definitions or standards.

However, the European/western models of midwifery care may not necessarily be applicable everywhere. Though there are tenets and core principles of these models that need to be adhered to, LMICs need to implement midwifery models in a way that accommodates local contexts and the systems in which they are embedded.

You previously worked as a registered midwife in Ghana. Could you share more about some of your experiences providing care as a midwife and how that influenced your approach to your work today?

Dr. Akuamoah-Boateng: My experience in Ghana is the driving force of the work I do to support the movement to rollout midwifery models of care globally. I practiced in both rural and urban settings, where resources were often minimal and we often had to improvise.

This is where I came to recognize that often policies, programs, and interventions are designed on a global level with limited recognition of the context within which they are meant to be implemented. As such, programs and interventions are never scaled because the systems in which they are meant to be delivered were not taken into consideration, and the people who were meant to be at the center of the interventions were never brought along.

These experiences deeply inform and shape every aspect of my work. In my role, I prioritize the populations we aim to reach and serve, the context in which they live, and the systems within which they access care. I work via a robust co- creation process for designing interventions, supporting policies, and activities to improve health outcomes, considering systems and contextual relevance.

For instance, in rolling out a high-impact innovation to help midwives manage postpartum hemorrhage, I draw on my early career experiences in education and clinical practice to recognize the systemic constraints that influence the delivery and access to care, along with midwives’ competencies. These experiences accentuate my engagement with the broader health system to unlock system barriers and stimulate systemic levers that drive impact at scale.

This perspective means that we are not implementing a project, we are supporting the governments to transform health systems through high impact innovations that accelerate the reduction of mortality.

One system lever we are unlocking is the Nursing and Midwifery Councils. We partner with the councils to transform midwifery pedagogy through innovative approaches to competency-based student-centered and context-specific teaching and learning.

The councils are leading the introduction of key maternal and newborn innovations into the curriculum to support systems transformation. Additionally, educational modules are being designed for continuous professional development to ensure that practicing midwives maintain clinical competencies and consistently deliver safe, high-quality care. This is an end-to- end approach to unlock system pillars and enable innovation to be delivered at scale.

As we move towards midwifery models of care, what are the challenges and gaps that need to be addressed especially in low- and middle-income countries? How are global health organizations and governments thinking about tackling these gaps?

Dr. Akuamoah-Boateng: I wish I could say that these challenges are new, but unfortunately, they are age-old challenges. These challenges existed when I was a student midwife, decades later, they continue to persist within health systems.

For example, weak regulatory and educational systems fail to equip midwives with the competencies and resources needed to confidently deliver services to women. The lack of an enabling environment in many settings prevents midwives from practicing to the full scope of their competencies. In many contexts, disrespect and abuse of women and midwives is pervasive, undermining trust in the health system and midwives’ confidence. Additionally, inadequate remuneration for midwives negatively affects motivation and contributes to the broader crisis of health worker migration. Despite this migration challenge, many midwives continue to work in some contexts on a voluntary basis or receive stipends that are so minimal, it barely covers their commute to work. These systemic challenges disincentivize access to and the provision of quality maternal and newborn health services.

Globally, midwives and midwifery models of care are being positioned as a key part of the workforce to help reduce maternal and neonatal mortality. Global momentum is driving wider implementation of midwifery models of care and strengthening midwifery services where the need is greatest. The recent launch of the position paper on the transition to the midwifery models of care and the global midwifery acceleration roadmap are examples of this momentum.

However, deliberate attempts are essential to transition from business as usual – designing global documents that don’t drive or reflect the local agenda needed to make the relevant impact. Countries are eagerly waiting for the local momentum that will shape the local agenda before we lose yet another opportunity to accelerate impact.

Health leaders should put women first, consider what it takes for her to achieve the health outcomes she needs, and then build the system around that with investments in human resources.

Can you talk about the objectives of the EGH project on midwifery models of care? What do you hope to learn and achieve?

Dr. Akuamoah-Boateng: Data. Data. Data. That is our goal. Earlier on, I mentioned how the current midwifery models that are being advocated for globally are based on evidence from high-income countries. We want to generate data to inform how we implement midwifery models of care in LMICs, and support health leaders in making informed decisions based on locally generated data. The exercise will generate evidence on successful midwifery programs in these contexts, the characteristics of these models that set them apart from others or not, and the factors that affect performance in these models, as well as how these models are leveraged for the introduction of high impact maternal and newborn health innovations. One of the ways we’re doing that is with Exemplars in Global Health research, initially examining the midwifery systems in Kenya and Senegal.

You influenced significant policy changes nationally in Ghana and then globally. What is one highlight from this period in your career that you can share with us?

Dr. Akuamoah-Boateng: I think the highlight that I most cherish is my work elevating midwives in Ghana. When I started my career as a midwife, there was no pathway for career progression, and we had no status within the health system. But the midwifery association of Ghana, a group of young midwives who wanted change, stood together in sisterhood, and completely changed this.

Now, in Ghana, you can get a bachelor’s or master's in midwifery. All regions have at least one midwifery training school. Midwives are fully embedded into the country’s public health sector. There are clear career pathways, including reaching the level of chief midwife and director of midwives at the ministry of health, which does not exist in some high-income countries. All of this was achieved with programs and advocacy led by midwives, initiated by midwives, people who have the desire to see change happen – this would be the highlight of my career.

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