Midwives 'can provide 80% of all the care women need'

Over the past several decades, the world has made substantial progress in reducing maternal and neonatal mortality.

Between 1990 and 2020 the maternal mortality ratio decreased from 244 to 152 deaths per 100,000 live births, while neonatal mortality decreased by over 50% between 1990 and 2017, declining from 37 to 18 deaths per 1,000 live births. That said, the Sustainable Development Goal (SDG) targets for maternal mortality of 70 deaths per 100,000 live births globally and 12 deaths per 1,000 live births for neonatal mortality are still considered ambitious.

One of the determining factors to achieving these goals, according to emerging research, will be whether countries can significantly improve the delivery of services to pregnant women and their newborns, including through the expansion of the number of midwives globally.

To mark International Day of the Midwife, Exemplars News spoke with Sally Pairman, Chief Executive of the International Confederation of Midwives (ICM), about how midwives can help improve health outcomes for women and reduce neonatal and maternal mortality, especially in low-resource settings.

What are some of the key challenges that midwives face in different parts of the world, particularly in low-resource settings?

Pairman: Everywhere in the world, but especially in low-resource settings, the challenge is [midwife] workforce shortages. We are short – on a very conservative estimate – at the moment some 900,000, and potentially more than a million, globally. That's having a huge impact on midwives in terms of workloads and how they actually can provide quality care. In many places, contributing factors to this shortage are lack of investment in building the midwife workforce, low status of women and midwives, poor quality pre-service midwifery education, poor deployment of registered midwives into the workforce, and lack of enabling environments to support and sustain the workforce.

There are also quite a lot of gender inequality issues and hierarchical systems within health services. There's a lack of respect towards midwives as professionals, sometimes from other health professionals, and from health service managers. Often, they're not paid, or they're very poorly paid. In some countries some midwives haven't been paid for months. There's a lack of leadership and a lack of midwives at the table where decisions are being made.

The environment that midwives are trying to work in is often not actually supportive, so we don't have resources. We haven't got enabling policies. They're not well integrated into the health system, and in many cases, of course, the health system itself is poorly functioning. There's a myriad of issues. And I would say the issues are not just in lower and middleincome countries. We are seeing some of these issues even in high-income countries, especially the workforce shortages and stressful and non-supportive work environments.

High maternal mortality rates and disparities in access to quality maternity care are persistent global health issues. How could we improve maternal health outcomes and promote equitable access to midwifery care globally?

Pairman: A big topic! I think that, first of all, it's understanding that midwives are primary health practitioners. Midwives have a scope of practice which covers from pre-pregnancy through pregnancy, labor, birth, and the postnatal period up to about six weeks after the birth. It also extends into different areas of sexual health, mainly family planning, abortion services, services for adolescents, education, and that kind of thing.

If we understand that midwives can provide a whole range of services that a woman needs through the childbirth continuum, we can put midwives in communities where women are. They can get to know their community, the women can get to know them. There's a level of trust and understanding of each other. Then those midwives are able to provide their services in those communities.

Of course, the midwives then need access and good integration into the broader health service because some of the women that they care for are going to need additional care from an obstetrician or a baby might need a neonatologist or a pediatrician. Some of those women will need medical input, but many will not.

There can be primary birthing units in small facilities, or they could be at-home (birthing) depending on their situation, but we need to take the service to where the women are. That is actually how we get better access for women because at the moment [pregnant women] sometimes don't go to [health facilities] because in many settings they are not going to get respectful care and they're frightened or it's too far, and they can't travel, and they can't afford to get there. If you actually had the midwives working in the communities, then women would come to them.

We know that service from professional midwives has got incredibly good outcomes for women and babies. It's indisputable that if you use midwives effectively according to what they can do, that we're going to significantly reduce maternal and newborn mortality. There's evidence that universal coverage of midwife-delivered interventions by 2025 could avert 67% of maternal deaths and 64% of newborn deaths and 65% stillbirths. It's pretty amazing. There's other evidence that says midwives can provide more than 80% of the care that all women will need. It's about using the resources that you've got effectively and recognizing what midwives can actually do to optimize their role and improve outcomes for mothers and babies.

Midwifery education and training play a crucial role in ensuring high-quality care for women and infants. How could we improve midwifery education, particularly in resource-constrained settings?

Pairman: There's a lot of work going into this right now. First of all, what I would say is that we should be educating midwives to be midwives and not wasting resources by requiring midwives to do a nursing qualification, then doing a midwifery qualification on top of that, when they're not going to become a nurse. Providing the education program that's going to get you to the practitioner at the other end that you want. And that means making sure that the education programs are really well designed and are building towards meeting the essential competencies of a midwife.

I think one of the big challenges is poorly designed curricula. Another is a lack of midwife educators – this is a really big issue because what happens is that the top student in the class gets pulled out as soon as she graduates and becomes a teacher. She doesn't have any practice space, no experience, and she also doesn't know how to teach, but she was a good student. Another important issue is lack of access for midwifery students to gaining 'hands on' practice experiences within the maternal and newborn health services. This access is crucial for students to develop the competencies of a midwife and there is only so much that can be done with simulation. Midwifery education needs to prepare midwives with theory and practice and the midwifery philosophy and approach to care if they are to attain the necessary competencies for practice.

If midwifery teachers don't have good teaching methodologies that are going to develop critical thinking skills and applied practice and competence, then we are also not going to get the outcome we need at the end. We need to really work hard on the curricula. We need to make sure that they are appropriate for the qualification for the graduate that we're looking for, that they meet the competencies. We need to do a lot more educating of educators. There's a lot of work going on with that in terms of online and distance models that can be used across different countries to try to build the competence of those educators.

In some regions, midwives face cultural, social, and legal barriers that limit their scope of practice and autonomy. How could we improve recognition of midwives' roles within healthcare systems?

Pairman: This is actually a very big issue. It goes to gender inequality, but it also goes to cultural differences and lack of understanding of what a midwife can do. I think there's a huge need for advocacy. We are really trying this right now with our PUSH campaign.

Our midwives' associations have work to do in terms of getting alongside women's groups and communities – going out to schools, getting to know the community, talking to women about midwives so that women understand what midwives can do and what they can offer them. Because if they haven't had access to midwifery care, they won't know. Often, we still have this whole hierarchy where we think an obstetrician is the best option, which of course is often not the case. Some women will need care from an obstetrician as well as a midwife, but many will not. Through advocacy we need to bring more attention to the opportunity of care from professional midwives and the difference this can bring by way of increased satisfaction with care by women and their families, as well as improved health outcomes.

SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. How could midwives contribute to achieving this goal, particularly in the context of maternal and newborn health?

Pairman: SDG 3 is a big topic for us. It goes back to what I've already said about understanding that we've now got a huge amount of evidence about the impact that care from professional midwives can make on improving health outcomes, and about the quality of care provided by professional midwives. By professional midwives, I mean midwives who are well- educated, regulated, qualified, and working to the full scope of practice.

You've got to actually build the entire system. We know already that this would make an incredible difference to outcomes. That's why we started the PUSH campaign – because we realized it's 10 years until the SDGs are supposed to be achieved and there's no chance that we're going to achieve our targets at the current pace. We know the answers. It's about how we actually get governments to invest in maternity services, and maternal and newborn health services. Then about how we help them also understand the benefits of establishing, investing in, and maintaining midwife-led services.

The WHO is actually taking this on at the moment. They have a group called STAGE – an advisory group to the Director General, Dr. Tedros. It recently set up a midwifery models of care working group, which I'm co-chairing with Professor Jane Sandall. What we are charged to do, by the end of this year, is to come up with a guidance document for governments and ministries of health about how to transition to achieve a midwifery model of care in their country. We are explaining why they should do so. And we are looking at what are all the pieces that need to be put in place to build their midwife workforce and optimize the role of these midwives in providing sustainable pregnancy and childbirth services and broader women's health services.

The role of midwives extends beyond pregnancy and childbirth to encompass sexual and reproductive health services. How could we address sexual and reproductive health needs and ensure comprehensive care for women throughout their life course?

Pairman: Again, it's about having the midwives work across their full scope of practice because that scope includes education, includes health promotion, includes family planning, and contraceptive care of women after pregnancy. It has a focus on adolescent girls in particular and includes abortion services where midwives are legally able to do that. Midwives already provide a large amount of women's sexual and reproductive healthcare through their care across the pregnancy and childbirth continuum.

Then it's about those midwives actually being able to refer women to other community-based services for family planning. For example, to sexual health clinics. If you've got a client with an STD, then the midwife may actually be able to deal with that and manage that. That's not the complete answer, but professional midwives working across their full scope of practice are a really big part of the answer in terms of what a health system needs for sexual reproductive health services.

Looking ahead, what are some of the key priorities for ICM in advancing the status of midwifery globally and improving maternal and newborn health outcomes?

Pairman: Our vision is that every woman in the world has access to care from a midwife for herself and her newborn. We've still got a huge amount of work to do. Looking forward, what we are trying to do is to really advocate for the role of the midwife. It's not about us as a profession. This is not about self-interest, but this is because we know, and the evidence supports this, that midwives will make the difference.

We want, of course, to prevent all those unnecessary deaths – those families that are left without their mothers or their children. It's unimaginable. The damage that does for generations. That's our work really – to advance the status of midwifery globally by trying to bring attention to midwives, to their role, to the services they can provide, to the outcomes they can achieve. Basically, what needs to be put in place in any country for those midwives to be able to be successful in that work? That will improve maternal and newborn health outcomes.

There are some countries that are really trying. I was just talking this morning to the Permanent Secretary of Health for Zambia. They've really picked this up and are redesigning their maternity services to utilize midwives more effectively. India is doing the same, so is Bangladesh. There are many examples of more and more countries doing that, which is really heartening.