EXECUTIVE SUMMARY

Building a healthworkforce tomeet the needsof women,newborns andadolescents
everywhere

THE STATEOF THEWorld’sMidwifery
2021

Dedicated to all healthworkers who have losttheir lives to Covid-19

Sexual, reproductive, maternal, newborn and adolescenthealth (SRMNAH) is an essential component of the
Sustainable Development Goals (SDGs). Improving
SRMNAH requires increased commitment to, andinvestment in, the health workforce. This report focuses
primarily on midwives because they play a pivotal role
within the wider SRMNAH workforce.
Following the universality principle of the SDGs, Stateof the World’s Midwifery 2021 (SoWMy 2021) represents
an unprecedented effort to document the whole world’s
SRMNAH workforce. This approach acknowledges that
not only low-income countries struggle to meet needs
and expectations, especially in these difficult times, andthat there are many paths to better SRMNAH: examplesof good practice can be found in all countries, and allcountries should be held to account.
The development and launch of SoWMy 2021 was led by
the United Nations Population Fund (UNFPA) in partnershipwith the World Health Organization (WHO) and theInternational Confederation of Midwives (ICM), with thesupport of 33 organizations. It builds on previous reports
in the SoWMy series in 2011 and 2014, and includes many
countries not previously tracked.

The global SRMNAH worker shortage
In many countries, workforce planning andassessment of the workforce’s ability to meet theneed for health-care services is hampered by poor
health workforce data systems. Based on the available
data, SoWMy 2021 estimates that, with its current
composition and distribution, the world’s SRMNAH

workforce could meet 75% of the world’s need foressential SRMNAH care. However, in low-incomecountries, the workforce could meet only 41% of
the need. Potential to meet the need is lowest in theAfrican and Eastern Mediterranean WHO regions.
The SoWMy 2021 analysis indicates a current global
needs-based shortage of 1.1 million “dedicated
SRMNAH equivalent” (DSE) workers. There areshortages of all types of SRMNAH workers, but thelargest shortage (900,000) is of midwives and thewider midwifery workforce. Investment is urgently
needed to address this shortage.
At current rates, the SRMNAH workforce is projected
to be capable of meeting 82% of the need by 2030:
only a small improvement on the current 75%. The
gap between low-income countries and high- andmiddle-income countries is projected to widen by
2030, increasing inequality.
To close the gap by 2030, 1.3 million new DSE worker
posts (mostly midwives and mostly in Africa) need tobe created in the next 10 years, of which 750,000 will
be midwives.
At current rates, only 0.3 million of these are expected
to be created, leaving a projected shortage of 1 million
DSE posts by 2030.
In addition to these shortages, the evidence points
to the need to invest in improving quality of careand reducing the incidence of disrespect and abusetowards SRMNAH service users.

Lucia Sumani, a student midwife
stationed at Balaka District
Hospital, Malawi, conducts anantenatal check.
© Bill & Melinda Gates Foundation/
Paul O'Driscoll.

Why invest in midwives?
Since the first SoWMy report in 2011, the body of evidence
demonstrating the return on investment in midwives hasgrown. It indicates that investing in midwives facilitates
positive birth experiences and safe and effective
comprehensive abortion services, improves healthoutcomes, augments labour supply, favours inclusive andequitable growth, facilitates economic stabilization, andcan have a positive macroeconomic impact.
The Covid-19 pandemic has shone a light on theimportance of investing in primary health care formeeting population health needs. Midwives are essential
providers of primary health care and can play a majorrole in this area as well as other levels of the healthsystem: in addition to maternity care, they provide awide range of clinical interventions and contribute tobroader health goals, such as addressing sexual andreproductive rights, promoting self-care interventions
and empowering women and adolescent girls.
The analysis in this report indicates that fully educated,
licensed and integrated midwives supported byinterdisciplinary teams and an enabling environment
can deliver about 90% of essential SRMNAH
interventions across the life course, yet they accountfor less than 10% of the global SRMNAH workforce.

Bold investments are needed
For midwives to achieve their potential, greater investment
is needed in four key areas: education and training; healthworkforce planning, management and regulation andthe work environment; leadership and governance; andservice delivery. Figure 1 provides a summary of theinvestments needed in each of these areas.

Figure 1

Summary of investments needed to enablemidwives to achieve their potential

INVEST IN
Health workforce planning,management and regulationand in the work environment
Health workforce data systems
Health workforce planning approaches that reflect theautonomy and professional scope of midwives
Primary health care, especially in underserved areasEnabling and gender-transformative work environments
Effective regulatory systems

INVEST IN
High-quality educationand training of midwives
Educators and trainers
Education and training institutions

INVEST IN
Midwife-led improvements
to SRMNAH service delivery
Communications and partnerships
Midwife-led models of care
Optimized roles for midwives
Applying the lessons from Covid-19

INVEST IN
These investments should be considered at country, regionaland global levels by governments, policy-makers, regulatory
authorities, education institutions, professional associations,international organizations, global partnerships, donoragencies, civil society organizations and researchers.
The need to invest in the production and deploymentof SRMNAH workers is not confined to countries with aneeds-based shortage. Many countries, including somehigh-income countries, are forecast to have insufficient
SRMNAH workers to meet demand by 2030.

The need for midwives and the wider
SRMNAH workforce
Globally, 6.5 billion SRMNAH worker hours would
have been required to meet all the need for essential

Midwifery leadershipand governance
Creating senior midwife positions
Strengthening institutional capacity for midwives todrive health policy advancements

SRMNAH care in 2019. This is projected to increase to
6.8 billion hours by 2030. Just over half (55%) of theneed is for maternal and newborn health interventions(antenatal, childbirth and postnatal care), 37% is forother sexual and reproductive health interventions suchas counselling, contraceptive services, comprehensive
abortion care, and detection and management ofsexually transmitted infections, and 8% is for adolescentsexual and reproductive health interventions.

Factors preventing the SRMNAH workforce from meeting
all of the need include: insufficient numbers, inefficient
skill mix, inequitable distribution, varying levels and qualityof education and training programmes, limited qualified
educators (including for supervision and mentoring) andlimited effective regulation.
Covid-19 has reduced workforce availability. Access toSRMNAH services needs to be prioritized, and provided
in a safe environment, despite the pandemic. SRMNAH
workers need protection from infection, support to copewith stress and trauma, and creative/innovative solutions
to the challenges of providing high-quality educationand services.

Equity of access to the SRMNAH workforce

The SRMNAH workforce requires a supportive policy
and working environment, and education and training, tounderstand and meet the specific needs of these groups
and thus provide quality care that is accessible andacceptable to all.

Enabling and empowering
the SRMNAH workforce
The health workforce is on average 70% women, withgender differences by occupation. Midwives are more
likely to be women; they experience considerable gendereddisparities in pay rates, career pathways and decisionmaking power.
Only half of reporting countries have midwife leaders within
their national Ministry of Health. Limited opportunities for
midwives to hold leadership positions and the scarcity ofwomen who are role models in leadership positions hinder
midwives’ career advancement and their ability to work totheir full potential.

THE STATEOF THE

Even where workforce data are available, they are rarely
fully disaggregated by important characteristics suchas gender, occupation group and geographical location,
making it difficult to identify and address gaps inservice provision.

World’sMidwifery

Some population groups risk their access to SRMNAH
workers being restricted due to characteristics including
age, poverty, geographical location, disability, ethnicity,conflict, sexual orientation, gender identity and religion.
The voices of service users are essential for understanding
the factors that influence their care-seeking behaviour.

Access to decent work that is free from stigma, violenceand discrimination is essential to address gender-related
barriers and challenges. All countries need policies toprevent attacks on health workers.
A gender transformative policy environment will challenge
the underlying causes of gender inequities, guarantee thehuman rights, agency and well-being of caregivers, bothpaid and unpaid, recognize the value of health work and of
women’s work, and reward adequately.

2021“Left behind” groups require special attention to ensurethat they can access care from qualified practitioners.

SoWMy 2021 was prepared during the world’s struggle with Covid-19. We gratefully acknowledge thesignificant efforts made by stakeholders in many countries to provide data in the face of competing priorities,
but it is clear that health workforce data systems were a major limitation even before the pandemic.
Nevertheless, this report provides valuable new evidence to inform workforce policy and planning.
Since the first SoWMy report in 2011, there has been much progress in midwifery, including
greater recognition of the importance of quality of care, widespread accreditation systems for healthworker education institutions, and greater recognition of midwifery as a distinct profession. On the otherhand, many of the issues highlighted in the two previous SoWMy reports remain of concern, such as
workforce shortages, an inadequate working environment, low-quality education and training,
and limitations in health workforce data.
Governments and relevant stakeholders are urged to use SoWMy 2021 to inform their efforts to build
back better and fairer from the pandemic, forging stronger primary health-care systems as a pathway
to UHC and Scanfosteringa morethis code
for aequitablelink to world for all. It is hoped that the pandemic will be a catalyst forchange given
theheightened
profile of health workers. SoWMy 2021 can help make this happen.
the full
SOWMY
2021 reportat www.unfpa.org/sowmy.

United Nations Population Fund
605 Third Avenue
New York, NY 10158Tel. +1 212 297 5000
@UNFPA
United Nations Population Fund
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eISBN 9789214030935
Sales No. E.21.III.H.3

Scan this code for a link to thefull SoWMy 2021 report atwww.unfpa.org/sowmy.