Midwives Are Essential to Global Maternal and Child Health


Approximately 48 million women per year do not have a skilled attendant, such as a midwife, nurse, or physician, at their birth.1 While the proportion of births in developing regions attended by skilled personnel rose from 55% to 65% between 1990 and 2009, this still leaves 1 in 3 women who gives birth without a skilled attendant present to help her.2 This is in stark comparison to developed regions where 99% of women giving birth have 1 or more skilled attendants with them throughout their labor and birth.2 Today more than 2 million women give birth each year with no one else present: no skilled birth attendant, no family, no friends.1

It is almost unfathomable that there can be 2 million women—unique individuals with names and faces and loved ones—who have no one with them as they labor and give birth. Even more tragic is the fact that each year greater than 350,000 women die during pregnancy, birth, or in the first 6 weeks postpartum,3 and 2 million newborns die within the first 24 hours after they are born.4 Most of these women and newborns die in low-income countries, and many of their deaths are preventable. Two new reports, Missing Midwives1 and The State of the World's Midwifery 2011: Delivering Health, Saving Lives,5 recommend increasing the number of midwives in the world as one of the best ways to reduce maternal and neonatal mortality worldwide.

Save the Children's Missing Midwives1 describes the many ways in which midwives save lives, including preventing infections and asphyxia, 2 of the most common causes of neonatal death.4 The report notes that approximately 1.3 million newborn deaths could be prevented by filling the shortage of midwives in the poorest countries, which lack funding for midwife recruitment, training, and salaries. Governments must invest in educating and retaining midwives to save lives and improve health. The report concludes with 4 recommendations for governments: “support countries to recruit more midwives and health workers, ask the UN Secretary-General to host a health worker event at the UN General Assembly, make the International Monetary Fund support flexibility on public sector spending, and respect the international recruitment code of practice.”1

The State of the World's Midwifery 2011: Delivering Health, Saving Lives5 begins with an overview of the midwifery profession around the world including its development, education, regulation, and service delivery. The overview is followed by a description of the midwifery workforce, education, and policies in 58 developing countries that accounted for 58% of the world's births in 2009. A summary for each of these countries that includes key health indicators and the state of midwifery in that country is provided. Most importantly, more than half of all births worldwide occur in these 58 countries yet they have a disproportionate amount of birth-associated mortality and skilled personnel. Ninety-one percent of maternal deaths and 82% of neonatal deaths occur in these countries yet they have less than one-fifth (17%) of the world's skilled birth attendants. The State of the World's Midwifery 2011: Delivering Health, Saving Lives5 presents recommendations for governments, regulatory bodies, schools and training institutions, professional associations, international organizations, donor agencies, and civil society. These bold steps call on partners to “maximize the impact of investments, improve mutual accountability, and strengthen midwifery services.”5

Both reports discuss the Millennium Development Goals, which all United Nations member states agreed to try to achieve by 2015. Millennium Development Goal 5 to improve maternal health includes the target of reducing the maternal mortality ratio by 75%. As of 2008, the maternal mortality ratio had decreased by 34% in developing regions from 440 deaths per 100,000 births to 290.2 Millennium Development Goal 4 is to reduce child mortality and includes the target of reducing the under-5 mortality rate, of which 38% occurs during the first 4 weeks of life,4 by two-thirds. As of 2009, the global under-5 mortality rate had decreased by one-third from 89 per 1000 live births to 60.2

As the Millennium Development Goals deadline approaches, goals 4 and 5 remain far from their targets. In 2010, the United Nations General-Secretary, in conjunction with multiple partners, developed the Global Strategy for Women's and Children's Health6 to identify steps to help move closer to Millennium Development Goals 4 and 5. This document along with Missing Midwives and The State of the World's Midwifery 2011: Delivering Health, Saving Lives5 is bringing new attention to the work that is left to be done to improve maternal and child health.

Encouraging in this time of dire need are the many ways in which midwives in the United States and the American College of Nurse-Midwives (ACNM) are already working to improve maternal and child health globally. These efforts are not new. The ACNM Department of Global Outreach (DGO) has spent more than 3 decades strengthening the capacity of midwives and other health care professionals around the world. The DGO's areas of expertise include in-service clinical training development and implementation, integrated pre-service strengthening, health profession and association strengthening and community education and mobilization.7 Box 1 presents examples of the numerous strategies midwives and their professional associations, academic institutions, and nonprofit organizations can use to help improve global maternal and child health. Indeed, ACNM as well as midwives working for other agencies are working on these initiatives and many others. Midwives who want to contribute to efforts to improve maternal and child health outside the United States have many resources available to prepare them for and support global health work. Current international volunteer and job opportunities for midwives are posted at the DGO's Web site,7 and ACNM members can join the Division of Global Health.

The Chinese symbol for crisis is composed of 2 characters, one representing danger and one representing opportunity. These are appropriate descriptors of the global maternal and child health crisis. Midwives are essential to efforts to reduce the dangers mothers and their children face globally, and these dangers present opportunities for existing midwives to contribute to maternal and child health and for new midwives to be educated around the world.


Table BOX 1. . Examples of Midwifery Strategies to Improve Global Maternal and Child Health
  1. Adapted with permission from T. M. Johnson, CNM, MS, and S. Stalls, CNM, MA (written communication, July 2011).

• Strengthen long-standing liaisons with established midwifery associations throughout the world while building twinning relationships with developing associations
• Encourage active global dialogue on midwifery regulation and education, interdisciplinary collaboration, barriers, and other professional issues
• Partner with governments, institutions, and organizations to build education programs and clinical practices
• Provide training opportunities for midwives and other clinicians to support train-the-trainer education in countries in need
• Develop Web-based, mobile technology, and other innovative educational modalities to reach those without strong formal education or those in the most remote areas
• Engage in maternal and child health research, with a twinning process when applicable
• Implore legislators to remove scope of practice and other barriers so that more midwives can be educated and deployed both nationally and internationally
• Seek partnerships with international agencies, nongovernmental organizations, and other groups, to raise awareness of maternal and child morbidity and mortality issues
• Continue to promote maternal and child health as a matter of human rights