Call the Midwife: A Conversation About the Rising Global Midwifery Movement
On 23 March 2015, the Wilson Center Maternal Health Initiative convened this dialogue, in partnership with the Maternal Health Task Force (MHTF) and the United Nations Population Fund (UNFPA).
The world is about to hit a “turning point” in maternal and newborn health, said Laura Laski, chief of the sexual and reproductive health at UNFPA, at the Wilson Center on March 23. “In terms of strengthening the new health system for achieving the MDGS or any other goals, we have to focus on the human resources for health.” In particular, midwives.
Midwives as a way to push global maternal health efforts over the top was the theme of a day-long symposium at the Wilson Center in cooperation with UNFPA, the Swedish government, Midwives4All, and the Maternal Health Task Force. Some of the day’s more than a dozen panelists shared midwifery successes in their own countries, while others discussed international initiatives to improve the number and quality of midwives.
Two of the symposium’s four panels focused on the importance of building a global midwifery workforce and the tools and innovation needed to do so. Jessica Koval, an international program manager at Direct Relief, a maternal health NGO, said confident, skilled, and well-equipped midwives are just as important to global maternal and newborn health as technical and pharmaceutical innovations.
Midwives’ intimate understanding of communities can inform policymakers and provide a critical bridge between physicians and patients, said Frances Day Stirk, president of the International Confederation of Midwives. “Midwives tend to be where women are. They are more accessible to women and, in many parts of the world, they work in poor geographic areas and environments where many other providers fear to tread.”
This makes them critical to making progress in the 73 countries that make up 92 percent of all maternal and newborn deaths in the world. “Only 4 out of these 73 countries already have the workforce which enables us to respond effectively to the needs of pregnant women and newborns,” said Luc de Bernis, a technical adviser for the UN Population Fund in Geneva. In such a human resource crisis, midwives provide a way forward.
A History of Positive Returns
A new series of articles in The Lancet explores the history of midwifery and why it is so critical to maternal and newborn health. Holly Kennedy, one of the contributing authors and a professor of midwifery at Yale University, said the first paper of the series defines midwifery not just as a profession or set of skills, but rather a collection of philosophy, values, practice, and organization of care.
The role of the midwife has declined in modern maternal health care systems, however, in part due to the perception that midwives lack professional skills. Such thinking has led to a self-fulfilling prophecy, said Stirk, as many countries with great need have discarded midwives, rather than provide them training, even as research suggests that educated midwives have the potential to cost-effectively fulfill 87 percent of the essential interventions or services needed by mothers and newborns.
Midwifery has been shown to reduce maternal and newborn mortality, increase birthweight, and even have positive psycho-social outcomes like reducing anxiety and post-partum depression, said Kennedy. In less developed countries, just a 10 percent increase in effective midwifery care by 2030 is projected to reduce maternal mortality by 27 percent, while a 25 percent increase could reduce mortality by 50 percent. This projection has been tested in Burkina Faso, Cambodia, Indonesia, and Morocco, four countries that have seen maternal mortality declines as they increase midwifery services.
The skilled midwifery workforce is dangerously low in some countries, said de Bernis. If the world stays on its current trajectory, only eight percent of skilled workers needed to fulfill essential interventions in maternal and newborn health will be met by 2030, he said. However, increased investment in building and sustaining the midwifery workforce, along with efforts to increase family planning, could lead to meeting 31 percent of unmet need in the workforce over the same time period.
Direct Relief has partnered with the International Confederation of Midwives to develop a standardized midwife kit for low resource settings. When combined with midwives who know how to use it, the kit, which includes medical instruments, catheters, gloves, sanitary products, medicines, and other pharmaceuticals, can reduce maternal and newborn deaths by 62 percent, Koval said. So far, Direct Relief has provided kits to graduates of midwifery programs in crisis areas like Sierra Leon, Liberia, and areas of the Philippines damaged by Typhoon Haiyan.
Building Capacity
While the potential is promising and midwives require less training than doctors, they still require some education and bringing the number needed through the system is a major obstacle. “In some parts of the world, a person who is called a midwife might have three months of education,” said Stirk. “That is not a midwife in [the International Confederation of Midwives]’s eyes. A midwife is someone…who is educated, who is able to work autonomously and within a team.”
Clinics in remote areas often have limited resources and need midwives with leadership skills to handle difficult situations, said Chunmei Li, a senior manager for corporate contributions at Johnson and Johnson. “When a woman manages to get herself to a facility to give birth to a baby, it’s everyone’s responsibility to make sure she gets the best care possible,” she said. “Nurses and midwives are best positioned to identify unmet needs, come up with solutions, and implement these solutions.”
Li explained one case where a baby was born not breathing and a doctor pronounced it dead. Unable to accept the decision, a midwife had the courage to challenge the doctor and the skills to perform resuscitation which saved the baby’s life.
In partnership with Johnson and Johnson, the Maternal-Child Health Leadership Academyputs midwives through a leadership course in which they are paired with mentors to learn specific skills and best practices, from early testing for HIV during pregnancy to pre-eclampsia monitoring. “This requires everything from making sure the staff has the necessary clinical skills to better record keeping and medical equipment and supplies to clinics having running water,” said Li.
Survive and Thrive, an initiative of the American College of Nurse-Midwives, is part of a global development alliance led by USAID to bring together U.S. midwifery, obstetric, and pediatric associations, the private sector, and non-profits to improve the quality of facility-based services, said Suzanne Stalls, a certified nurse-midwife and vice president of global outreach for the college. By mentoring and training young clinicians, Stalls said they hope to improve clinical competencies and build leadership and advocacy skills. If midwives are “respected and valued,” she said, they will not only perform better, but “have confidence to share their expertise and consult policymakers.”
Innovations in Technology and Access
Embracing technology is another untapped opportunity for innovation, said Geeta Lal, senior technical advisor for strategic partnerships at the United Nations Population Fund(UNFPA). A study by the telecommunications company ITU revealed there were more than 5 billion mobile phone subscriptions in the developing world in 2014. The cost of one computer is now less than one midwifery textbook. Getting “e-learning” right is not optional in a world where children see digital platforms as the norm, said Lal. “If we don’t think of it someone else in another part of the world will.”
To that end, UNFPA has partnered with Intel to provide offline access to multimedia platforms in remote areas. “They can use a cheap projector, tablet, and solar charger – all under $500 – which serve as training modules for midwives to watch while they are doing other tasks at home,” Lal said. Jhapeigo’s e-learning modules are being used in Ghana, Kenya, Zambia, and Uganda.
Bringing e-learning to scale also requires access to an energy grid, which may necessitate political commitment from the very beginning. “Bangladesh was targeted to receive e-learning platforms because they made a clear goal to digitalize the whole country by 2020,” Lal said, holding up a tablet. “An entire generation of school children will become tech literate. They won’t carry text books, their entire curriculum will be on this.”
Digital platforms are still new, however, and Lal cautioned that more needs to be done to understand how they address fundamental causes of poverty and poor maternal health.
A Long-Term Investment
These efforts to provide adequate training and equipment to midwives can still go to waste if the demand for their services is not there. “It’s incredibly frustrating to me to educate midwives when there’s a 50 percent employment rate,” said Peter Johnson, director of global learning and nursing and midwifery at Jhpiego. Building a sustainable, educated workforce is difficult without the support of governments and donors who are more likely to fund programs that can quickly produce numbers and results. “Sometimes, the results of educating midwives won’t be seen for a decade or even longer if you look at the roots and foundation that we need to lay down.”
But Stirk remains optimistic that midwifery is a profession that will be elevated in the coming years. It is the best way to reach those areas where maternal and newborn health is worst, she said. “Midwifery is the system we have chosen, not because it is the cheapest, but because it is the best.”
Written by Linnea Bennett and Theo Wilson, edited by Schuyler Null.
Sources: International Confederation of Midwives, UNFPA.