Scaling up care by midwives must now be a global priority
Authors: Mary J Renfrew, Address Mauakowa Malata
Journal: The Lancet Global Health (2020)

Midwives have the potential to save lives of women and children at a scale unmatched by other health interventions. In The Lancet Global Health, Andrea Nove and colleagues1Nove A Friberg IK de Bernis L et al.Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.Lancet Glob Health. 2020; (published online Dec 1.)https://doi.org/10.1016/S2214-109X(20)30397-1Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar estimated that 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths in the 88 low-income and middle-income countries accounting for the vast majority of these deaths could be averted. The solution? Universal provision of care by midwives who meet international standards and are integrated into health systems in the context of multidisciplinary teams. Nove and colleagues use the Lives Saved Tool for their modelling study to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up. The authors used four scenarios of intervention coverage: increase by a modest amount (10% every 5 years), increase by a substantial amount (25% every 5 years), increase by the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). Even the less ambitious increases would substantially avert deaths. A substantial increase in coverage could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, whereas a modest increase in coverage could still avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths. The challenge is that only four of the 73 Countdown countries have a midwifery workforce able to provide the scope of care needed,2UN Population FundThe state of the world's midwifery 2014: a universal pathway. A woman's right to health. UN Population Fund, New York, NY2014Google Scholar while stillbirths and maternal and newborn mortality and morbidity rates remain outrageously high. Scaling up access to international-standard midwives would substantially reduce these rates, accelerating progress towards universal health coverage and the Sustainable Development Goals. These new findings build on and strengthen existing evidence on the impact of quality midwifery care in averting deaths and improving health and wellbeing outcomes.3Homer CSE Friberg IK Dias MAB et al.The projected effect of scaling up midwifery.Lancet. 2014; 384: 1146-1157Summary Full Text Full Text PDF PubMed Scopus (162) Google Scholar, 4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar They should command the attention of the global community in the same way that a new drug or innovative technical intervention would. There is serious and longstanding under-investment in international-standard midwifery.5WHOUN Population FundInternational Confederation of MidwivesUNICEFFramework for action: strengthening quality midwifery education for Universal Health Coverage 2030.https://apps.who.int/iris/bitstream/handle/10665/324738/9789241515849-eng.pdf?ua=1Date: 2019Date accessed: June 17, 2020Google Scholar Gender, social, professional, and economic disempowerment of midwives and the women they care for all contribute to this.6Filby A McConville F Portela A What prevents quality midwifery care? A systematic mapping of barriers in low and middle income countries from the provider perspective.PLoS One. 2016; 11e0153391Crossref PubMed Scopus (97) Google Scholar Midwives are predominantly women, and their work is with women and their newborn infants. In an equal society, this should be a strength but given the persistence of patriarchal structures in society and outdated medical hierarchies of power, it is a profound limitation. As a result, midwives in too many countries remain poorly educated, remunerated, and supported, and many are overworked, some even overwhelmed.8Sandall J Soltani H Gates S Shennan A Devane D Midwife-led continuity models versus other models of care for childbearing women.Cochrane Database Syst Rev. 2016; 4CD004667PubMed Google Scholar Research funding preferentially supports either technological solutions to obstetric emergencies7Miller S Abalos E Chamillard M et al.Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.Lancet. 2016; 388: 2176-2192Summary Full Text Full Text PDF PubMed Scopus (403) Google Scholar or the implementation of less skilled workers to care for mothers and their infants,4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar leaving a crucial knowledge gap for decision makers. Global, regional, and national plans for improving the health of women and their infants are too often developed without recognition of the key contribution of midwives to safe quality care, or the engagement of senior midwives in decision making. Health workers who do not have the full scope of midwifery competencies cannot provide the quality care or save the lives that international-standard midwives do.4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar Understanding why this is the case requires knowledge of the multiple components that make midwifery so effective. Midwives who are educated to standards set by the International Confederation of Midwives (ICM) and are integrated into health systems can provide skilled, knowledgeable, safe, respectful, and compassionate care for childbearing women, newborn infants, and families across the continuum from pre-pregnancy to the early weeks of life, including family planning.4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar Midwives can optimise normal physiological processes, strengthen women's own capabilities, provide interventions for women and neonates that both prevent and treat complications, and enable timely access to multidisciplinary services for those who need them. This model of care promotes continuity across community and facility settings, relationship-based care, local community knowledge and resilience, and equitable, individualised care that responds to clinical, psychological, social, and cultural needs. This scope and quality of care can improve more than 50 health and wellbeing outcomes, reducing mortality and preterm birth and improving maternal and newborn health and wellbeing, breastfeeding, and attachment, as well as cost-effectiveness.4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar, 8Sandall J Soltani H Gates S Shennan A Devane D Midwife-led continuity models versus other models of care for childbearing women.Cochrane Database Syst Rev. 2016; 4CD004667PubMed Google Scholar In 2014, Horton and Astudillo wrote that "midwifery has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children".9Horton R Astudillo O The power of midwifery.Lancet. 2014; 384: 1075-1076Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar These new findings underscore that and demand investment in the education, deployment, and support of midwives at a scale that reflects the magnitude of their impact. 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. But 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 midwives10Mattison CA Lavis JN Wilson MG Hutton EK Dion ML A critical interpretive synthesis of the roles of midwives in health systems.Health Res Policy Syst. 2020; 18: 77Crossref PubMed Scopus (4) Google Scholar and on an overarching focus on the quality of health care. The first joint WHO, UN Population Fund, UNICEF, and ICM global consensus for action5WHOUN Population FundInternational Confederation of MidwivesUNICEFFramework for action: strengthening quality midwifery education for Universal Health Coverage 2030.https://apps.who.int/iris/bitstream/handle/10665/324738/9789241515849-eng.pdf?ua=1Date: 2019Date accessed: June 17, 2020Google Scholar identified evidence-based actions. 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.5WHOUN Population FundInternational Confederation of MidwivesUNICEFFramework for action: strengthening quality midwifery education for Universal Health Coverage 2030.https://apps.who.int/iris/bitstream/handle/10665/324738/9789241515849-eng.pdf?ua=1Date: 2019Date accessed: June 17, 2020Google Scholar Midwives educated to international standards are a powerful solution to ending preventable deaths of women and newborn infants, while also helping mother-baby dyads to thrive. It is time to acknowledge and dismantle the intersectional barriers that perpetuate low-quality care and deny women and newborn infants the rights to life and health. The evidence demands decisive action now, and at a global level not seen before, to ensure all women and newborn infants have access to quality care by midwives. We declare no competing interests. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling studyMidwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. Full-Text PDF Open Access