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Midwives: A vital and life-saving investment

Stock Photo - Indian nurses at road. Street photo, Shot at Gandhi Maidan, Patna, Bihar, India on 25.02.15 at afternoon hours. image credit: UPA GHOSH / 123rf. Nurses pictured in Patna, Bihar in 2015. Image credit: UPA GHOSH / 123rf. Midwives concept illustration.
Image credit: UPA GHOSH / 123rf

It need not be said, but is often overlooked, that public health systems benefit substantially from the work of midwives. This has been quantified to the tune of 4.3 million lives that could be saved per year by the year 2035 in new research published in The Lancet.

The paper “[estimates] that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41 percent of maternal deaths, 39 percent of neonatal deaths, and 26 percent of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22 percent of maternal deaths, 23 percent of neonatal deaths, and fourteen percent of stillbirths, equating to 1·3 million deaths averted per year by 2035. 

“Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67 percent of maternal deaths, 64 percent of neonatal deaths, and 65 percent of stillbirths, allowing 4·3 million lives to be saved annually by 2035.” 

The World Health Organization (WHO) enshrined 2020 as the International Year of the Nurse and the Midwife. It noted that “the world needs nine million more nurses and midwives if it is to achieve universal health coverage by 2030.” This latest piece of research underscores that need. 

“Supported by appropriate professional education, regulation and improved working environments, it is possible to achieve a substantial increase in the level of provision of essential interventions delivered by midwives,” said the study’s lead author Dr Andrea Nove from Novametrics Ltd.. “This could save millions of lives. However, there are numerous barriers to fulfilling this level of scale-up, particularly in low to middle income countries. These include inequitable distribution of qualified midwives, poor transport links, lack of supplies and equipment and, in some countries, a lack of trust from the public. There is [a] need for greater recognition of the importance of supporting and enabling this service to reach its potential.”

Indeed, in the words of co-author Maria Najjemba of the United Nations Population Office’s Uganda Country office, “midwives, especially in developing countries, are at the core of primary healthcare. They provide support along the continuum of care, from promotion to prevention, treatment and rehabilitation, to end-of-life care. Midwives play key roles in empowering clients, facilitating teamwork across disciplines, and providing client-centred care. Scaling up midwife delivered interventions can be a game changer that will give midwives the much-needed confidence to reach everyone and provide quality care to reduce maternal and neonatal mortalities.”

For Health Issues India earlier this year, I wrote “if the COVID-19 crisis underscores anything, it is how lost India would be without its nurses and midwives.” In May, UNICEF estimated that “116 million babies will be born under the shadow of the COVID-19 pandemic and almost a quarter of them—approximately 29 million—will be born in South Asia..Countries in South Asia with the expected highest numbers of births in the nine months since the COVID-19 pandemic declaration are: India (twenty million), Pakistan (five million), Bangladesh (2.4 million) and Afghanistan (one million). 

“The continuing rapid spread of COVID-19 across South Asia means new mothers and newborns will be greeted by harsh realities, including global containment measures such as lockdowns and curfews; health centers overwhelmed with response efforts; supply and equipment shortages; and a lack of sufficient skilled birth attendants as health workers, including midwives, are redeployed to treat COVID-19 patients.” 

India stands to gain much from increased investment in midwives and consequently fewer maternal and neonatal deaths and stillbirths. India has made progress, but important caveats exist. As Health Issues India reported last year

“India’s under-five mortality rate is 37 deaths per 100,000 births as of 2018; in 1990, the figure stood at 126 deaths per 100,000 births. This translates to an annual reduction rate of 3.5 percent. Its neonatal mortality rate has declined also, from 57 deaths per 100,000 live births in 1990 to 23 deaths per 100,000 live births in 2018. Nonetheless, significant numbers of India’s children and mothers are dying. 882,000 children under five and 143,000 children between the ages of five and fifteen died in 2018. No matter the reduction, it is clear that child and maternal mortality is still a public health challenge necessitating a robust response.” 

“Millions of babies and children should not still be dying every year from lack of access to water, sanitation, proper nutrition or basic health services,” asserted Dr Princess Nono Simelela, Assistant Director-General for Family, Women and Children’s Health at the WHO at the time. “We must prioritise providing universal access to quality health services for every child, particularly around the time of birth and through the early years, to give them the best possible chance to survive and thrive.”

Midwives are an integral part of the solution to this often-preventable crisis – and the new Lancet research does provide some cause for optimism. Professor Mary J Renfrew of the UK’s University of Dundee wrote in a linked comment for the Lancet article that “positive signs exist: global policy and guidance on human resources, education, quality care, and care in pregnancy, labour, and birth increasingly acknowledge the contribution of midwives. We are also seeing investment in the education and deployment of professional midwives in India, Malawi, Bangladesh, and Mexico.” 

Nonetheless, she says, “substantive change in the pace and scale of implementation is needed. This should be based on evidence on how to tackle the barriers to international standard midwives10 and on an overarching focus on the quality of health care…every woman and neonate should be cared for by a midwife educated to international standards and enabled to legally practise the full scope of midwifery interventions. 

“The title midwife should only be used for those educated to international standards. Midwifery leadership should be positioned in high-level national policy, planning, and budgeting. Coordination between global-level, regional-level, and country-level stakeholders is essential to align education, knowledge, research, evidence-based policy and guidance, indicators, and investment.” 

“Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study” can be accessed here.

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