Strengthening Midwifery: A Smart Investment

The world has made enormous progress in women’s, children’s and adolescents’ health. But it has not been enough to ensure high-quality universal health care for every mother, newborn, child and adolescent everywhere.

COVID-19 has exacerbated this. The pandemic swept the globe in a few weeks, and, in a few months, halted or reversed much of the progress made over decades. As ever, the hardest hit are the most vulnerable communities.

In particular, the delivery of essential sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services has been disrupted and resources reallocated, putting vulnerable women, children and adolescents at higher risk of disease, disability and death from preventable and treatable causes:

 ·     Recent WHO data from 135 countries shows that between January and April of this year 35% of countries reported disruptions across RMNCAH and nutrition services

·     Foetal outcomes have worsened, with a significant increase in the rate of stillbirths in low- and middle-income countries

·     12 million women have been affected by disruptions to family planning services, leading to 1.4 million unintended pregnancies

 The value of midwifery

Midwives are critical in protecting the health and wellbeing of mothers and newborns. As specialists in maternal and neonatal physiology, midwifery expertise lies in accompanying women and families through pregnancy and childbirth with the additional capacity of recognising and managing emergency complications with appropriate referral to the next level of care if needed. However their value extends across the reproductive health spectrum. As care providers they enable effective, accessible and comprehensive family planning and sexual health services, respond to gender based violence, avert deaths from unsafe abortions and morbidity from malaria and other illnesses in pregnancy and provide ongoing psychosocial support.

Despite the risks during the pandemic, midwives have continued to provide care, even when centralised health care services faltered and when governments failed to give them PPE. They have continued to play a central role in advocating for the health and wellbeing of women and ensuring high-quality care reaches birthing women where they live, often at great risk to their own safety. They have proved crucial to COVID-19 mitigation strategies and the delivery of health care for all, as well as providing a voice for girls’ and women’s health and reproductive rights.

Despite their worth, there are now 900,000 fewer midwives than the number required to provide global SRMNCAH services by 2030.

The need for investment

Investment is therefore urgently needed. Midwifery is one of the most cost-effective means of achieving full sexual and reproductive health coverage while accelerating the human rights agenda by ensuring a direct route to reproductive freedom for women giving birth. It reduces infections, and has the capacity to end preventable maternal mortality and newborn deaths, leading to healthier lives. Investment in midwifery will increase gender equity and a new infusion of jobs to support economic development.

Numerous studies have borne this out:

·     A Lancet Global Health study shows how midwives avert 67% of maternal deaths, 64% of neonatal deaths and 65% of stillbirths.

·     Investing in midwifery education, with deployment to community-based services, could yield a 16-fold return in lives saved and costs of caesarean sections avoided.

·     The UNFPA’s 2021 State of World’s Midwifery report shows that, where allowed to perform the full scope of practice and quality of care, midwives can meet more than 90% of reproductive health needs, saving 4.3 million lives annually by 2035. Investment will produce a “triple gender dividend”: a health dividend, where new jobs provide opportunities to attain universal health coverage; a gender equity dividend, where women receive income, education and autonomy; and a development dividend, where new jobs fuel economic growth.

Midwifery and equity

Globally, 16 million women were displaced in 2017 and the number living within 50 km of armed conflict increased from 185 million in 2000 to 265 million in 2017. Women and girls living in these settings frequently lack access to essential SRMNAH services. Yet midwives are more likely than other SRMNAH workers to be posted to, and remain in, humanitarian and fragile settings throughout a crisis.

The need for midwives in these settings is vital. Their value can be found in all three phases of the emergency management cycle: preparedness, response and recovery.

Midwives deserve higher pay

Despite their value, midwives are among the health profession’s lowest-paid. Given that the gender pay gap is higher in health care than in other sectors, this means that midwives suffer from double jeopardy pay disparity. Once occupation and working hours are accounted for, the pay gap is estimated to be 11%.

Not surprisingly, midwives often report that their pay is insufficient to live on and that they depend on another source of income to survive. Many leave the profession early, further eroding an already insufficient workforce. 

Midwives deserve pay that is equal and commensurate with their responsibilities – to save lives and protect livelihoods.

Urgent call for investment

Financial investment is urgently needed to strengthen the midwifery workforce. Meanwhile, greater investment in midwifery education and training, service delivery and leadership is also critical. Governments must not only prioritize this funding but take concrete steps to include midwives in determining health policies.

A follow-up paper to State of the World’s Midwifery 2021 is due shortly, which will further highlight the return on investments that midwifery can provide in accelerating coverage of SRMNCAH services to reach mothers, newborns, adolescents and girls everywhere.

Delay must no longer be accepted. The time for action and investment is now.

Key Partners

The International Confederation of Midwives (ICM)

The World Health Organization

United Nation Population Fund