Why is there a global shortage of midwives and what needs to be done about it?

Why is there a global shortage of midwives and what needs to be done about it?

Across the world, midwives face unsatisfactory pay, challenging working conditions and barriers to training.

(Abbie Trayler-Smith)

Every day about 810 women die in childbirth globally. Every 16 seconds a child is stillborn, and each year some 2.4 million newborn babies die. Midwives can make a difference to these shocking outcomes. But recent research shows their numbers are sorely lacking.

According to The State of the World’s Midwifery 2021 report (SoWMy 2021), the world currently needs 900,000 more midwives. This represents a third of the required global midwifery workforce. Compiled by the United Nations Population Fund (UNFPA), the World Health Organization (WHO) and the International Confederation of Midwives (ICM), the study found the world’s sexual, reproductive, maternal, newborn and adolescent health workforce (within which midwives play a pivotal role), can only meet an estimated 75 per cent of the world’s need. The shortage is worst in low-income countries, where only 41 per cent can be met. But if health services could be persuaded to recognise midwives’ roles and invest in services, by 2035 roughly two-thirds of maternal, newborn deaths and stillbirths could be averted, saving 4.3 million lives annually.

But why are many governments and funders not investing in midwives? Dr Sally Pairman, chief executive of the ICM, a membership organisation of 139 professional midwives associations from some 119 countries, says gender inequality dominates many of the problems. “There’s a very big piece here about this being a woman’s workforce caring for women,” says Pairman. About 90 per cent of the world’s midwives are women. “They experience considerable gendered disparities in pay rates, career pathways and decision making-power,” the report states.

Pairman says established hierarchies in health services can leave midwives without recognition or authority. She would like to see more midwives involved in national-level policy discussions, but says they are rarely represented at ministerial level.

Training standards vary widely between countries. A 2018-19 WHO study of midwifery educators in low- and middle-income countries (quoted in SoWMy 2021) found that of the 100 institutions that responded from 35 countries, all indicated: “Regulation of education programmes did not effectively ensure quality nor facilitate standardisation in midwifery education.”

Investment is needed in four areas to increase the number of midwives and improve outcomes, according to the report. The first is in health workforce planning and management to increase midwives’ autonomy and create a work environment free from gender-related stigma. The second is in high quality education. A third is to enable midwives to lead their own improvements, such as midwife-led models of care. And the fourth backs investment in midwifery leadership and governance.

Work in these areas has already begun. ICM has supported its members to advocate for midwifery at global, regional and local levels by providing training. It has also set standards for midwifery education, competencies and regulation.

Global public sector workers union Public Services International (PSI) has built capacity among its nurse and midwife members, particularly in Africa, to demand improved working conditions and wages. It has also lobbied members to try and prevent the ‘brain drain’ of midwives from the Global South to countries offering better pay and conditions. For example in the UK, where non-British nationals make up 12 per cent of the nation’s National Health Service (NHS) within a total of about 1.9 million employees.

In April 2021, WHO also published its Global Strategic Directions for Nursing and Midwifery (2021-2025) report, which also focused on four areas of improvement: education, jobs, leadership and service delivery. It highlighted the cracks in midwifery provision laid bare by the Covid-19 pandemic.

“We’re going to see the impact of Covid more and more,” warns Pairman. She expects newborn mortality cases will rise again in the aftermath of the pandemic. However, she is hopeful that understanding and evidence about the role of midwives is increasing, particularly midwife-led continuity of care models. “There is more interest from some of the big global funders around midwifery,” she says. “But how do we actually get all the governments behind this?”

Understaffed and underpaid in Kenya

More midwives are needed in Africa than anywhere else in the world according to SoWMy 2021. The latest Unicef data shows countries on the continent have higher rates of neonatal mortality than any other. In 2020, the average global rate of a child dying within their first 28 days of life was 17 per 1,000 live births. In Lesotho, the rate is 44.3, in South Sudan 40.2 and in the Central African Republic 38.3. Outside of Africa, only two countries had rates above 35: Afghanistan and Pakistan.

Kenya’s Ministry of Health has had some success in addressing infant mortality rates and improving maternity services. In 2013 it abolished maternity charges in public health facilities to prevent fees being a barrier for women to access professional care. According to the 2008-2009 Kenya Demographic Health Survey, 56 per cent of women gave birth at home. Many received assistance from a traditional birth attendant (TBA), of whom only about 20 per cent had any type of formal training in assisting births. But by 2017, the ministry credited its policy for doubling the number of women delivering in public hospitals, from 600,000 in 2013 to 1.2 million in 2015, and decreasing the country’s maternal mortality ratio from 488 to 362 per 100,000.

Midwife Jemimah Makau says she has observed this improvement since joining Emali Model hospital in Makueni County, in south-eastern Kenya in 2015, which receives support from UK charity Amref Health Africa. Makau has done outreach work in the community to educate TBAs about the importance of women delivering in hospitals.

“Nowadays we are not getting as many mothers going to the TBAs,” she says. Makau is also involved in a project to help women make their own healthcare choices, as husbands can force them to deliver at home.

However, Makau emphasises more needs to be done to ensure a midwife is actually available for women coming to hospitals. “We have shortages in our hospital,” says Makau. With three departments serving mothers and children, her team is thinly spread. “It is a challenge for us [when we have] only one midwife delivering maybe two or three mothers alone,” she says.

Makau had to pay for her midwifery qualification - no funding is available. She says the three and a half years of training was expensive. The government devolved health services to county level in 2013, which Makau says means training opportunities and salaries differ nationwide. She wants the government to take back control to make training cheaper and improve pay, which would discourage those who qualify from leaving Kenya. “What makes them [the midwives] fly to other countries the most is the challenge of poor pay,” she says.

England: “I have never seen maternity services in such a dire state”

Midwives in England are increasingly sounding alarm bells about a maternity staffing crisis. Sector-driven campaigning for more investment in maternity services began about a decade ago, with midwives warning a combination of factors is damaging care. The UK’s exit from the European Union and the Covid-19 pandemic have compounded shortages.

“I have never seen maternity services in such a dire state,” says Maddie McMahon, a volunteer for campaign group the Association for Improvements in the Maternity Services (AIMS). McMahon is a professional doula who has worked alongside midwives for 18 years. “There are women who are 28 weeks pregnant who have not yet seen a midwife,” McMahon continues. “Families who go into labour and there’s nobody to come to their home birth. Families who go into labour and are told to get in the car and drive a long way to another hospital because theirs is closed. Families in labour and the midwife in hospital is also caring for two or more other women simultaneously. No breastfeeding support and no postnatal support full stop.”

In 2018, data published by NHS England and analysed by the Royal College of Midwives (RCM) suggested that for every 30 midwives it trained that year, 29 were lost.

This was a blow for the UK government, which pledged earlier that year to train an additional 3,000 midwives over four years in England. Part of the problem is the profession’s ageing workforce – the RCM found that retirement was the biggest reason for midwives leaving the profession in 2020.

As a result, midwives say their job has become too pressurised, causing newly-trained midwives to abandon their roles. This has been exacerbated by ‘Covid burnout’ during the pandemic. Although EU-qualified midwives can still work in England, some are leaving because of other circumstances brought about by Brexit. According to an RCM survey published in October 2021, 57 per cent of midwives planned to leave the NHS by the end of that year.

In November 2021, thousands of midwives, doulas, families and healthcare professionals in more than 50 UK towns and cities held vigils to raise awareness of the problems, under the banner March with Midwives. The action received significant press coverage, and sparked a parliamentary debate in January 2022 in which the Conservative MP Siobhan Baillie called on the government to listen to the campaigners’ demands. These included improving midwives’ pay and financial support for student midwives. However, she clarified that money was not the only solution and a “culture shift” was also needed.