Midwives – Unsung Heroines of the Safe Motherhood Challenge
Throughout most of human history and in most places, women who helped other women through the dangerous and profound act of childbirth were accorded deep respect. In France, they were called ‘wise women’. In Norwegian, they were ‘earth-mothers’. The English word, midwife, is derived from words meaning ‘with’ and ‘woman’.
In all countries that have achieved dramatic improvements in maternal mortality, professionally trained midwives have been a key to success. They have an essential role in achieving the Millennium Development Goals to reduce maternal and newborn mortality. Yet today the profession of midwifery often garners little recognition, meager income, and limited career opportunities. These factors contribute to the acute shortage of these valuable health workers.
UNFPA has begun using the expression ‘midwives and others with midwifery skills (MOMS)’, to mean ‘skilled birth attendant’. This change reflects a recognition of the unique skills, roles and responsibilities midwives bring to delivery care, and to the central role that midwives play in making motherhood safer. The term ‘skilled birth attendant’ encompasses the definition of a midwife, but is more generic and broader. It also includes nurses, physicians and others who have been trained in proficiency in midwifery skills. Traditional birth attendants who lack formal professional training are not considered skilled birth attendants in the calculation of the Millennium Development Goal 5 target.
Maternal mortality and morbidity cannot be reduced without midwives and others with midwifery skills. Yet the numbers of these skilled providers have not significantly increased and have even started to decline in some countries, because of migration, deaths from AIDS-related illnesses, and dissatisfaction with pay and working conditions.
Midwives, who are overwhelmingly women, typically endure low status, poor pay and a lack of support in spite of the enormous responsibility they bear. Those who work within communities at the primary care level, where they are needed most, often find the least respect and support from the health system. Gender biases contribute to the problem.
When they are properly trained, empowered and supported, midwives in the community offer the most cost-effective, low-technology, high-quality path to universal access to maternal health care. Yet midwives are in short supply in many developing countries – WHO estimates some 700,000 are urgently needed. Countries with high rates of maternal mortality, in particular, need assistance to recruit, train and support professional midwives.
Pregnancy, whether planned or unintended, is often a key entry-point into the health system, and midwives can provide a welcoming gateway. They often introduce women to the health system and ensure that women and their babies receive a continuum of skilled care during pregnancy, childbirth, and in the important days and weeks after birth.
In particular, the midwife provides essential care during delivery, often with little support and under the adverse conditions. The practice of midwifery calls for great stamina, physical and mental strength and the ability to be flexible and ready for the unexpected: an un-booked birth, undiagnosed twins, or complications of pregnancy, to name a few. Many obstetricians and gynaecologists readily acknowledge that they learned their midwifery skills from midwives.
The basic services midwives routinely provide to protect the health of the mother and baby include:
- Care for women during pregnancy, childbirth and the postnatal period
- Treat complications due to miscarriages and/or unsafe abortions
- Pre-pregnancy advice and health education
- Newborn care
- Recognizing and addressing problems in the women and newborn before, during and after childbirth
- Offering general health information, including reproductive health care and family planning
- Assisting women to successfully breastfeed
- Referring women and newborns for higher level care when complications arise beyond their scope of practice and capabilities
Midwives provide quality, culturally acceptable care to help keep women and newborns safe. They sometimes offer prenatal care, which can be especially valuable in helping a woman plan her delivery.
In countries with strong midwifery services, midwives play an important preventative role, by offering immunizations, health education, family planning information and promotion on many aspects of healthy lifestyles.
Midwives can also foster a dialogue with female community leaders about the needs of pregnant women, and ways of mobilizing support for them. In particular, professional midwives can build on the relationship that communities often have with traditional birth attendants. Although TBAs do not have the training to deal with life-threatening problems, their cooperation can be very helpful in convincing families of the benefits of professional care, early referral or institutional delivery when complications arise or seem likely.
In some cases, midwives assume community leadership in dealing with women’s issues more broadly. In Mauritania, for example, it was a group of midwives who discovered and brought to light high rates of sexual violence in their society.
In some cases, emergency life-saving functions, such as vacuum extraction, manual removal of placenta, or manual vacuum aspiration of retained products could effectively be delegated to midwives or specially trained nurses if adequate facilities were available and relevant policies were in place, including support and protection of the providers. However, this is occurring in very few places, even though experienced midwives argue that they have the requisite skills and would not hesitate to take on greater responsibility if they were so authorized.
In Mozambique, senior nurses trained to perform Caesarean sections have achieved outcomes as good as those performed by specialist obstetricians. The training was part of an effort to make emergency obstetric care available at the lowest levels of the health system possible, particularly in rural areas where distance may be a significant barrier.
UNFPA has long given high priority to the need for skilled care at birth, as part of a three-pronged strategy to reduce maternal mortality. Within this area, midwives hold a very special and central position for UNFPA, as the Executive Director said in her 2006 World Health Day message. As part of its support for professional midwives over many years, UNFPA has been a regular partner with WHO, UNICEF and others, for example in supporting the International Confederation of Midwives’ Regional and Triennial Congresses, first launched at the beginning of the Safe Motherhood Initiative in 1987.
Since 2006, UNFPA has emphasized the need to strengthen quality midwifery care within the community as a way to reach impoverished, remote or marginalized communities. Ideally, midwives should live in and receive support from the community.
In early 2006, UNFPA sponsored a consultative workshop in New York to find out, from midwives all over the world, what barriers they face and what kinds of support they need. The workshop brought together representatives of midwifery, from both North and South, and from countries with transitional economies, with key UNFPA country and HQ staff.
Among the group were three Swedish midwives, who are being supported by the Swedish development agency (SIDA), and working in UNFPA Country Offices in Bangladesh, Bolivia and Mozambique. Sweden has a long tradition of valuing midwives as an integral part of the public health system.
Later in the year, UNFPA co-sponsored in Tunisia the first-ever International Forum on 'Midwifery in the Community', a gathering of midwives and public health experts from 25 countries to raise awareness and generate guidance on strenthening the worldwide cadre of community midwives.