Making the Case to Policy-Makers: We Need to Invest in Midwives

This week the State of the World’s Midwifery 2014 (SOWMY 2014) Report was launched, showing the current challenges and needs of scaling up midwifery services around the world. The report outlines the situation in 73 countries (these countries account for 92% of global maternal and newborn deaths and stillbirths), investigating whether the midwifery workforce is sufficient to meet the universal need for sexual, reproductive, maternal and newborn health.

Only four of these countries are on track, showing the great need to invest in midwives to meet global goals and targets of ending preventable maternal mortality and preventable newborn deaths.

Student midwives in Nigeria. Photo Credit: Lindsay Mgbor/Department for International Development
Student midwives in Nigeria. Photo Credit: Lindsay Mgbor/Department for International Development

How do we make the point to policy-makers?

At the International Confederation of Midwives Congress, Jim Campbell, Director at Integrare and one of the authors of the SOWMY 2014 Report, held a workshop where midwives, health professionals and academia gathered to discuss ways in which to make the case to policy-makers of the need to invest in midwives.

“You need to show the data and the numbers,” explained Campbell, as policy-makers will look at the costs and the benefits. He further encouraged the group to understand the best way to collect data. Various methods of calculating the need of midwives were investigated, including the sensitivity of the method to account for the needs: geographical distribution, fertility rates, roles of other health workers, and more.

In Afghanistan, for example, there is a good basic healthcare system, however, due to the system not taking into account variations in demand across the country, midwives are overworked, overwhelmed and burned out. An Afghani participant in the workshop explained that there is a 35% drop out rate, 12 months after a midwife has graduated. Therefore, the retention and education of the midwifery workforce must be taken into account when making policy recommendations.

The SOWMY 2014 Report is a great tool to start making recommendations based on data. For countries to plan efficiently, the report states that the following data on the midwifery workforce should be collected: headcount, percentage of time spent on key interventions within sexual, reproductive, maternal and newborn health, roles, age distribution, retirement age, length of education, enrollments into, attrition and graduation from education, and voluntary attrition from the workforce.

What are the recommendations?

There is not a one-size fits all. Instead the recommendations need to be linked to context-specific data with a needs-based approach. Countries need different kinds of investments to meet the targets, as the needs of each country is different. It is important to ensure that recommendations are grounded in the needs of each setting.

The SOWMY 2014 Report does provide some general key messages regarding the investment in midwives.

To assist with these policy recommendations, Family Care International has created a toolkit for using evidence from the State of the World’s Midwifery 2014 Report to create policy change at the country level. Download the toolkit in English, French and Spanish!

Investing in midwifery is more than human resources

To ensure that midwives are able to provide women-centered care, have access to appropriate skills, resources and support, the investment must go beyond midwifery education. To ensure that the policies are implemented and that the commitments are prioritised, women have to be included in policy-making. The rights of women must be strengthend in society as a whole and needs to be a priority throughout sectors to ensure the targets of ending preventable maternal and newborn deaths are met.

Stay tuned!


Birthing in Afghanistan: State of the World’s Midwifery 2014 report

Last week, I wrote a post suggesting that the lives of mothers and babies in Afghanistan are showing signs of improvement. That was prior to the launch of the second State of the World’s Midwifery (SoWMy) report at the International Confederation of Midwives (ICM) 30th Triennial Congress. The report, coordinated by UNFPA, ICM and WHO but involving stakeholders from around the world, is a response to Millennium Development Goal 5 and provides an evidence base for the state of midwifery in 73 low- and middle-income countries.


Included in the report is a two-page country profile for each of the 73 ‘Countdown to 2015’ countries included in the report. The country profiles are data rich – the first half deals with ‘where are we now?’ and the second half looks at ‘what might 2030 look like?’.

Based on the available data, the report shows that:-

  • the maternal and newborn health workforce is able to meet 23% of the need in Afghanistan
  • this could decline to a shocking 8% by 2030 if the status quo remains
  • even if by 2030, the number of pregnancies were reduced by 20%, the number of midwife, nurse and physician graduates doubled, efficiency improved by 2% each year and attrition was halved in the next 5 years, the maternal and newborn health workforce is predicted to still only be able to meet 31% of the country’s need.

Anecdotal evidence from my experience living and working in Afghanistan suggests that a significant proportion of Afghan midwives have qualified in the past 5 years, are under the age of 25 and are as yet unmarried. In a few years’ time, those midwives will be married and be having their own children to care for, which may well mean for many of them, an end to work, thus negatively impacting attrition rates of the midwifery workforce.

Although this sounds rather bleak, it is important to remember that Afghanistan has just been through a period of decades of war and significant progress is being made. However, given the potential period of instability that the country may well be entering with the forthcoming elections and withdrawal of foreign troops, there will need to be an enormous and concerted effort on all levels to maintain the progress that has been made.  It was truly wonderful to see Afghan midwife Sabera Turkmani receive the Dorethea Lang Leadership Award at the ICM Congress on the same day that the SoWMy 2014 report was launched.

Midwives in Afghanistan are also women and mothers, and find themselves facing the same pressures as the women for whom they are providing care. Girls need to be free to attend school in order to train as midwives, young women need to be free to work once qualified and midwives need to be free to travel to and from their place of work safely. That’s a lot of freedom needed for Afghan midwives in a country that has a history of oppressing the freedom of women.

Fundamentally, the state of midwifery in Afghanistan rests delicately with the freedom and security that the country will provide for women over the coming years.

Learn more:

Cover image courtesy of Flickr Creative Commons

The 2014 State of the World’s Midwifery Report: A Summary

Since the establishment of the Millennium Development Goals (MDGs) 14 years ago, global leaders, organizations, and nations have been working to reduce child mortality and to improve maternal health around the world.

Unfortunately, a major barrier in reaching the health-related MDGs is the fact that not everyone has access to quality health care services – whether at a hospital or a clinic. In sub-Saharan Africa, women are 100 times more likely to die as a result of pregnancy or childbirth than a woman in an industrialized country. Around the world, 289,000 women die from childbirth complications annually, nearly 3 million newborns die in the first month of life and 2.6 million newborns are stillbirth each year.

Enter: The midwife.

Midwife: An educated, accountable health professional who possesses the skills and experience to support mothers and babies through the pregnancy, delivery and recovery stages of birth. – UNFPA

Infographic c/o UNFPA
Infographic c/o UNFPA

Educated midwives have the capability to perform nearly 90 percent of the essential care for women and newborns before, during and after delivery. Midwives teach communities (men and boys included) about important family planning techniques and products and thereby help to decrease the risk of unwanted pregnancies. In fact, investing in an educated and well-trained midwifery workforce has the potential to yield a 1,600 percent (16-fold) return on investment due to the economic benefits that arise from improved maternal and newborn health. As a result, investing in an educated midwifery workforce can single-handedly help to improve gender equality, empower women and enhance economic development.

To expand on the importance of midwives, the United Nations Population Fund (UNFPA) recently launched the State of the World’s Midwifery (SOWMy) report.

The 2014 SOWMy aims to do the following:

  • Provide an evidence base on the state of the world’s midwifery to support policy dialogue between governments and their partners;
  • Accelerate progress on the health MDGs;
  • Identify developments in the three years since the SOWMy2011; and
  • Inform negotiations for and preparation of the post-2015 agenda.

Additionally, the report highlights the importance of four key factors – the Availability, Accessibility, Acceptability, and Quality of midwifery care. It argues that countries and health systems must address each aspect of care in order to provide women and newborns with the lifesaving care they need and deserve.


Image c/o UNFPA
Image c/o UNFPA

Shockingly, the 73 countries profiled in the report account for 96 percent of all maternal deaths, 91 percent of all stillbirths and 93 percent of all newborn deaths, yet have only 42 percent of the world’s midwives, nurses and doctors. Even worse, no one country had a sufficient number of educated midwives and health workers to support the health of mothers and infants. The SOWMy stresses that, in order to attract others to a career in midwifery, midwives must be properly compensated for their lifesaving work.


Image c/o UNFPA
Image c/o UNFPA

Aligning with the United Nations Declaration of Human Rights’ assertion that “everyone has the right to life, liberty, and the security of person,” the SOWMy states that all mothers should have access to trained midwives, regardless of their ability to pay. The report urges countries to adopt a “minimum services benefits package” that guarantees a baseline of care for reproductive, maternal and newborn health.


Although maternal and newborn health centered policies accelerate progress, sustainable change comes from the bottom-up – from behavior change and societal acceptance. We must work together to dispel the myths and common preconceptions about midwives that inhibit women and girls from seeking their care.


Perhaps most importantly, the quality of midwife care and training must be addressed in order to most effectively decrease maternal mortality rates. Countries must recognize midwifery as a regulated profession in order to eliminate educational and infrastructural gaps – gaps that currently serve as huge barriers to the supply of skilled midwives.

Progress and Next Steps

Thanks to the first SOWMy report in 2011, the world has finally realized the incredible importance of skilled midwives. In the past three years alone, serious improvements have been documented among profiled countries:

  • 45 percent reported taking action to improve midwife retention in rural areas;
  • 71 percent reported improvement in data collection and accountability;
  • 28 percent have increased recruitment and deployment of midwives;
  • 18 percent have prepared plans to establish regulatory bodies or associations; and
  • 20 percent have a new code of practice and/or regulatory framework.

To ensure the availability, accessibility, acceptability and quality of maternal and newborn health care, policymakers, organizations and communities must champion all aspects of midwifery in the post-2015 agenda and let it be known that not only do midwives matter, but midwives save lives.

Learn more:

Cover image c/o UNFPA

Speaking to Nigeria’s Midwives

Globally 290,000 women and 3 million children die each year due to preventable causes relating to pregnancy and childbirth. In the recent State of the World’s Mothers Report, Nigeria was listed as one of the most dangerous countries in the world to have a baby.

The solution to solving maternal and newborn deaths in Nigeria is investing in midwives!

The midwives in Nigeria are working hard to save the lives of Nigerian mothers. I recently visited George’s Memorial Medical Centre in Lagos, a clinic that focuses primarily on maternal and newborn health.

Ebonolu Olukemi Dele-Isawumi

Ebunolu Olukemi Dele-Isawumi: RN, RM, PHN

Ebunolu is a midwife at George’s Memorial Medical Centre in Lagos, Nigeria. She qualified in 1993 and has been a midwife for 22 years.

Why do midwives matter?

Midwives are important because like the name implies, they stand between the woman and the unborn child to ensure that the child is delivered safely and the woman does not get any injuries in the process. Midwives monitor the woman before conception, during pregnancy and postpartum. Midwives can also educate the local people about the harmful effects of processes like child marriage, because this leads to maternal mortality as a child’s pelvis is not yet ready for birth. Apart from maternal mortality, child marriage and early pregnancy can even lead to obstetric complications like fistula which means that young girls suffer from incontinence. We can educate women about family planning and spacing their children. I think it’s important that women should have babies at their will, not because they couldn’t delay conception.

What do you think we can do to reduce these high rates?

The solutions to solving these issues are midwives. Midwives are important, there is a deficit and we need more hands on deck! Midwives need to be better paid and better valued in society. When you tell people you’re a midwife, people don’t care and they should care because we take care of Nigeria’s mothers and babies! Nigeria has a serious and dangerous shortage of midwives. With enough midwives, we can capture problems quickly and prevent so many deaths. In the swampy River Rhine areas of Lagos, there are few facilities. Pregnant women in labour can be carried on a person’s back or in a boat to get them to the nearest facility.

Queenette Nwanekezie

Mrs. Queentte Nwanekezie: RN, RM BSc in Health Education and Administration

Queenette is the Head of Nursing and Midwifery at George’s Memorial Medical Centre. She qualified in 1994 and has been a midwife for 20 years.

Why do midwives matter?

Midwives are extremely important, they take care of the world’s mothers! Midwives are important before, during and after pregnancy. They are important with subjects like women’s health, conception, pregnancy, birth and family planning. Midwives have first-line contact with expectant or non-expectant mothers in dispensing information about contraception, discussing the different types and helping the woman to choose the best form of contraception for her. Midwives build relationships with women, which is of the utmost importance.

Why do you think Nigeria has such high maternal and newborn deaths?

Child marriage means girls aren’t physically ready to have babies. Cultural beliefs about using midwives and vaccinating babies also lead to high maternal and newborn deaths. Some women prefer to use traditional birth attendants, who are not skilled. Even when there are health care facilities available, the lack of education means that women might still opt to not use them. Of course, other factors like poor transport and poverty mean some women either have their babies at home without a skilled health worker or only see a midwife at delivery.

What do you think we can do to reduce these high rates?

We need equity in the distribution of medical infrastructures. We also need to make maternity services more accessible. Investing in midwives, educating the local people about the benefits and government support is essential. If you’re going to war, you need a gun. If you’re going to save lives, you also need to be equipped too. We also need to create a forum for midwives to share experiences, and we need to provide more courses for midwives to sharpen the skills they have, and to learn new skills. Nobody wants to hear a midwife, but midwives should be heard because our voices matter.

Midwives are extremely important. When mothers and newborns are healthy, this has a massive impact on the community. Healthy mothers and healthy newborns can break the cycle of poverty and change the status quo for women and girls. Gender inequality will persist if the needs of mothers and babies are not made a priority. Midwives are the key to unlocking the potential of mothers and newborns.

Midwives are special, they save lives in a way that no superhero can. No mother should die in childbirth, and no baby should be born only to die. Having access to maternity care shouldn’t be a lottery depending on where you live. Midwives matter to me, to you, to mothers and newborns and to whole communities across the globe. The world needs more midwives and now is the time to act. When we stand up for midwives, we stand up for mothers and newborns around the world. Let’s stand up for the people who take care of the world’s mothers and newborns. Let’s stand up for midwives!

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Quote of the day, 1 June 2014. #ICMLive

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Choosing the Path of Midwifery

This month we celebrated International Day of the Midwife – a day that not only highlights the critical work of midwives, but also rallies stakeholders across the world to invest in the future of midwifery. Thanks to their expertise, all counties have seen dramatic improvements in maternal mortality, yet we are still short in achieving the Millennium Development Goal to reduce maternal and newborn mortality. To achieve this, we not only need more midwives, but professionally trained ones.

In 2011, the United Nations Population Fund (UNFPA), published The State of the World’s Midwifery report which surveyed 58 countries and revealed a global shortage of an estimated 350 000 midwives – a third of which were needed in the world’s poorest countries. The second of its kind will be published this year and will examine availability, accessibility and quality of the midwifery workforce, including profiles of 73 countries.

Midwives face many challenges, from working in unsanitary conditions to lack of necessary equipment and medicine. And they do much more than deliver babies. The impact of midwives extends to newborn care, breastfeeding, family planning, and sometimes breast and cervical cancer screening. All the more reason to place midwives at the center of the continuum of care.

Investments in midwives can help prevent a significant number of the nearly 290,000 maternal deaths and three million newborn deaths that occur each year due to the lack of trained health workers. With such a global need, it is inspiring to meet those who are undeterred by the challenges ahead. One such woman recognizes not only the need, but the reward that comes from providing support to mothers and babies.

Nancy Termini
Nancy Termini

Nancy Termini grew up in Philadelphia and attended McGill University in Montreal. Studying Arabic Language and International Development Studies, Nancy had no plans on midwifery school. Now 26, she has returned to Pennsylvania and has begun prerequisites to apply for a 3-year BSN-MSN bridge program at the University of California, San Francisco. She also plans to apply to Georgetown and Frontier Universities. I had a chance to sit down with Nancy to learn how she chose this path, what challenges she may face, and how she hopes to make an impact in the world.

Girls’ Globe: How did you first learn about midwifery?

Termini: I was always aware of midwives growing up, but only through stories and in the stereotypical old-fashioned, folk-remedy sense. I learned about midwives as a modern and vibrant vocation when I began working for the Population Council – an international NGO confronting critical health and development issues, such as improving reproductive health. That’s where I learned of the critical role that midwives play in delivering care to women all over the world.

Girls’ Globe: What was it about midwifery that inspired you to go back to school?

Termini: I was first attracted to the holistic nature of midwifery. I loved that it is an ancient art and science that involves caring for the whole woman, not only during childbirth but throughout her reproductive life cycle. I also began to realize how important the direct, interpersonal nature of health care is to me. Midwives are so broadly qualified that there were many aspects of their work I found inspiring and am passionate about.  I’ve met midwives who do everything from teaching, to providing well-woman care, delivering babies, conducting research, and leading college health programs.

Girls’ Globe: Trained midwives have skills in so many areas, what will be the most difficult aspect of midwifery school for you?

Termini: I imagine that a challenging aspect of midwifery school will be learning how to guide women through a process that I myself have never experienced, as I don’t yet have children. I think it will require an added layer of focus and empathy, and I’m sure I’ll learn as much from the women I work with as they will from me.

Girls’ Globe: Midwives are sometimes faced with difficult situations, such as health scares with mother or child, domestic abuse, and so on. How can you prepare yourself for what is ahead?

Termini: To gain experience with some of these situations in a lower-pressure role, I’m working as a doula as I apply to my graduate programs. Since Doulas focus on the emotional wellbeing of the parents, rather than the clinical, I hope that I can gain some comfort and familiarity with navigating challenging situations before it becomes my responsibility to direct them. I’m particularly looking forward to working with survivors of abuse, and plan to take specialized training so that I can better engage with their needs and experiences.

Girls’ Globe: With a worldwide shortage of properly trained midwives, do you have any ideas of where you would like to focus your work?

Termini: I’d like to work both domestically and abroad. It’s important to me that I work in the community I live in, but I’m also committed to supporting women in developing countries, whether it be working to train or support local midwives, or doing research. I’d also like to learn from midwife models abroad, in countries where midwifery is a much older and more institutionalized medical tradition than it is in the U.S.

Girls’ Globe: What are some of the challenges you see in midwifery?

Termini: Globally, midwives face a lot of legal and social barriers when it comes to their scope of practice – in which their ability to provide the range of services for which they are capable is constrained. Also, in the U.S., I think that midwives are often thought of as being anti-doctor, or anti-conventional medicine. This is definitely not the case, but it’s a social and institutional challenge that domestic midwives have to continually engage with. On an individual level, I’ve learned from a lot of midwives that working in labor and delivery is fulfilling but can be highly demanding in the long run, physically and emotionally – although there are obviously unique rewards.

Girls’ Globe: It sounds like you have had the opportunity to meet many midwives already. What has inspired you about those you’ve connected with?

Termini: When I began to be interested in midwifery, I spoke to about a dozen midwives who were either colleagues, friends-of-friends, or whom I cold called. I also had the pleasure of attending the 2013 American College of Nurse Midwives Conference. Across the board, the midwives I spoke with were passionate, smart, interesting women who had done a huge diversity of things and were all passionate about helping women to have healthy, fulfilling, reproductive lives. It’s such a supportive and exciting community, and everyone I spoke with was happy to share their experiences and engage with me to help me on my way there.

Girls’ Globe: Do you have any advice for young women who are thinking about midwifery?

Termini: Talk to midwives! Learning about their experiences and goals can help you to decide whether it’s a field you’d like to pursue, and help you understand your own desires and goals. Attend any kind of local birth event, and if you can, take a doula workshop. They are great ways to learn about other women’s birth or midwife experiences, and to meet people who work in childbirth. There are also some excellent books and films about birth and midwifery.

Nancy is a truly inspiring example of a woman working to make an active difference in the lives of women and children. She plans to work as a full-time midwife for several years and then shift to part-time so that she may engage some of the other skills of being a midwife, such as teaching or working with at-risk groups of women. I have no doubt that the hope and care Nancy puts into helping mothers will be reflected in her own life.

If you are interested in learning more about midwifery school, visit these resources:






Midwives: The Real Unsung Heroes

There are individuals, around the world, who are saving the lives of women, children and families every day. These are no ordinary people, in fact, many call them heroes. They travel to remote villages, through crowded urban centers, across mountains and rivers to provide life saving care to mothers and families. Creativity and strength are their “super powers” as they work with limited resources under strenuous conditions.

These super heroes have saved the lives of many of my friends. Amazing individuals, most of them women, provide loving care to babies and mothers near and dear to my heart. Who are they? It’s a bird, it’s a plane, no it is:

A midwife!

Midwives are saving lives. They help prevent serious complications for mothers and their babies during childbirth. Competent midwives greatly decrease the risk of both mother and child dying during birth. After childbirth, midwives continue to support mothers and their children through care, help with breastfeeding and other comprehensive support services. Their jobs look different depending on the country where they work.

Midwives must have the right skills and the best resources in order to do their jobs effectively.

With the help of a trained midwife, women’s and families’ stories around the world are different. Death is replaced with life. A midwife can provide the essential care needed to prevent harmful and preventable complications during and after birth. Yet, more than one-third of all births take place without the care of a skilled birth attendant. The 2011 State of the World’s Midwifery report, listed nine countries with a significant shortage of trained midwives or skilled birth attendants. Many of these countries have some of the world’s highest maternal mortality rates.

We need more trained midwives and we must celebrate those tirelessly working to save mothers, children and families around the world.

In the developing world, midwives need continual training and ongoing support. To ensure this support is a reality, governments, organizations, the private and health sectors and midwives, themselves, must be involved.

Last fall, I had the privilege of visiting the Hamlin Fistula Hospital in Addis Ababa, Ethiopia. I was impressed by The Hamlin College of Midwives and their mission to train more midwives to serve in rural areas in Ethiopia where there is a significant need for maternal care.

I recently read an amazing story about how Jhpiego, an organization working to save the lives of women and children worldwide, is supporting a midwifery program in rural Ethiopia. They also work in other countries to support maternal and child health programs.

The Hamlin College of Midwives and Jhpiego are two positive examples of people and organizations working to support the incredible work of midwives.

On June 1st the International Confederation of Midwives will hold the 30th Triennial Congress in Prague. Over 3,000 midwives from around the world will gather to share their work, learn new best practices and celebrate each other! During the congress, the 2014 State of the World’s Midwifery report will be published. The world’s leading general medical journal The Lancet will feature a midwifery series. At the congress, special ceremonies will be held to recognize and honor midwives vital contributions. Let’s take the time and celebrate these amazing heroes.

There is beauty and hope reflected in the lives of women who are able to deliver safe and healthy babies.

Want to join the global conversation?

Follow @GirlsGlobe, @JNJGlobalHealth, @FHI360, @world_midwives and #ICMLive for coverage related to the upcoming International Confederation of Midwives, taking place in Prague,1-5 June 2014. Use the hashtag #SOWMY2014 and follow the launch of the 2014 State of the World’s Midwifery Report.

 Cover Photo Credit: UNAMID, Flicker Creative Commons