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Reducing Maternal Mortality by Investing in Midwives: A Policy Brief to the UNFPA » Women's Courage

Reducing Maternal Mortality by Investing in Midwives: A Policy Brief to the UNFPA

March 3rd, 2011 by jennawg Leave a reply »

To: The United Nation Population Fund (UNFPA)

To Whom It May Concern:

The unacceptably high rates of maternal mortality that exist in developing countries remain a source of shame for this agency and the global medical community. The situation can be summed up in a few statistics: first, 529,000 women die annually due to complications from pregnancy or childbirth—that’s one woman per minute. Moreover, some 10 million women a year suffer from disease, injury, or infection as a result of pregnancy or childbirth (1). However, these numbers become much more meaningful with another number: by UN estimates, 80% of maternal deaths are preventable (2). Unfortunately, despite substantial opportunities for reduction, maternal mortality rates have barely changed in the past 20 years (3). I understand that you and many other UN agencies have established the Millennium Development Goals, among them MDG 5: reduce maternal mortality. This MDG sets the target reduction of MMR at 5.5% per year, but the actual annual rates of decline were less than 1% between 1990 and 2005 (4).

How can we shrink the enormous gap between goal and reality? It is well known that we have the necessary technologies to reduce to maternal mortality to extremely low levels—simply take any wealthy, Western country as an example. Given this fact, as the WHO wrote in a 2005 report, “The challenge that remains is therefore not technological, but strategic and organizational.”

A 2006 Lancet article identified the provision of intra-partum services, including emergency care, as the single biggest priority to getting on with what works and reducing maternal mortality in a meaningful way (5). Specifically, it is time to shift the focus towards providing regional maternal healthcare centers in areas with high maternal mortality. Most maternal deaths happen between labor and the first 24 hours after delivery. Because most complications related to childbirth arise as emergencies, it is simply not feasible to rely on hospitals located hours away. However, that is often what happens. A recent study found that in rural Zambia, “half of all mothers lived more than 25 km from a health facility that provided basic emergency obstetric care” (6). This is particularly unacceptable when one considers that “all five of the major causes of maternal mortality – hemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labor – can be treated at a well-staffed, well-equipped health facility” (7). This policy brief focuses on ways to make the facility mentioned above a reality.

In order to do this, the most critical area to build is human capacity. Indeed, “The most crucial impediment [to reaching MDG 5] is the large deficit of human resources for maternal survival” (9). By increasing the number of skilled birth attendants, placing them in regional intra-partum care centers, and providing them with a sustainable and well-organized referral system, we can ensure that women have basic emergency obstetric care (BEOC) immediately available and comprehensive emergency obstetric care (CEOC) when needed. My suggestions for increasing human capacity are threefold: First, increase training of midwives while focusing on quality. Second, provide the necessary human resource networks to function on a regional and national level. Third, implement Mozambique’s successful surgical-midwife program to increase the comprehensive care options in rural areas.

In 1989, the Indonesian government launched a massive national village-base midwife program. They trained and deployed some 54,000 midwives in 7 years, and continued to scale up from there. Ultimately, from the time of implementation to 2003, they saw a reduction in maternal mortality from 400 deaths to 307 deaths per 100,000 live births (8). There are many lessons to be learned from Indonesia’s example—first, that drastically increasing the number of midwives does result in a substantial reduction in mortality—and moreover, that by correcting their mistakes in the future, reductions can be greater. A major lesson from the outcome in Indonesia is that a high priority must be quality, so that women receive thorough and excellent training before they’re deployed to rural posts. The WHO has also emphasized the need for “a considerable investment in high-level basic training” for aspiring midwives, who do best in training with a 10 year base of general education (7). Despite the urgent need for more midwives, quality must not be skimped on in training programs.

After studying Indonesia’s example, another crucial factor is evident: supervision and support of midwives on a local and regional level (8). It’s necessary that sufficient supervision and mentoring programs are put in place to provide support to midwives, established at the beginning of their post and occurring at regular intervals. This kind of support will increase retention and can also continue the training process once midwives are established in villages. Overall, “Implementation at scale needs a sound human resource plan: a health workforce framework that considers planning, recruitment, education, deployment, and performance support of health workers” (5). While this is a bit of an overwhelming requirement, it is nevertheless essential to devote the resources to a human resource strategy to ensure sustainable, effective healthcare provision.

The final major lesson from Indonesia is the need for “access and financial support for referral to emergency obstetric-care centers” (8). Indeed, this is absolutely crucial for a midwife and intra-partum care model to work. While midwives are able to provide basic emergency obstetric care, which is sufficient for the majority of women giving birth, there are a few services out of their range, which fall under the category of comprehensive emergency obstetric care, and include c-section and blood transfusions. This agency has recommended that for every 500,000 people, there be 4 facilities offering BEOC, and 1 offering CEOC. Aiming for these ratios should be a major priority, as well as ensuring open communication and transportation between facilities. Finally, an exciting possibility to increase the number of midwives who can offer comprehensive emergency obstetric care comes from Mozambique, where a training program has been implemented to train midwives in surgical techniques. These workers, called técnicos de cirurgia, or TCs, receive at least 3 years of surgical training, with an emphasis on quality and self-sufficiency. Many go on to work in district hospitals, where they provide 92% of surgeries and have largely identical outcomes to those of medical doctors. Moreover, their retention rate was 88%, while that of doctors was 0%. The incredibly successful example of Mozambique can be mimicked in terms of quality and content to provide sustainable increases in provision of CEOC in rural areas. (9)

We have the technologies to prevent most maternal death. The focus must be on building regional personnel capacity to handle maternal health, particularly obstetric emergencies, so that all women have access to these technologies. I would also like to emphasize, as many others have, the importance of writing policy with an emphasis on immediacy and practicality. The current maternal mortality figures are shameful, and policy and implementation need to have increased support, money, and urgency behind them. A major strength in the fight to reduce maternal mortality is that we have the techniques to almost completely reduce maternal mortality and morbidity. This confers an advantage not present in many other global health problems. However, it also indicates a responsibility to do much more than what we’re doing—there is no excuse.

In Solidarity,

Jenna Wixon-Genack

Stanford University

  1. World Health Organization: “Why do so many women still die in pregnancy and childbirth?”
  2. United Nations Summit. September 20-22, 2010. New York.
  3. http://www.unifem.org/attachments/products/MDGsAndGenderEquality_1_MakingChangeHappen.pdf
  4. “What Will it Take to Achieve the Millennium Development Goals?—An International Assessment.” UNDP. June 2010. http://content.undp.org/go/cms-service/stream/asset/?asset_id=2620072
  5. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69381-1/fulltext
  6. http://biomedme.com/general/emergency-care-for-childbirth-complications-out-of-reach-for-rural-women-in-zambia_31570.html
  7. http://www.who.int/whr/2005/chap4-en.pdf
  8. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60538-3/fulltext
  9. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2007.01489.x/full


  1. wsallman says:

    This is a fabulous post. You clearly lay out the problem and the current inefficiencies in the system in place to deal with it. After, you outline credible options for attacking the issue that have evidentiary support. From your analysis, midwives really do seem to make a difference. The girl who lives next to me has a mother who is a midwife in a small town in Alaska. They do not have a major hospital within an hour of the town and she is often called out to remote parts of the town to deliver children. When she came to visit, she explained how vital this type of access for developing countries is. It really drove home the point that even her work in the U.S. with its well developed health care system was extremely important. I can only imagine that this impact would be magnified immensely in the developing world. Thanks for coming up with a well-constructed piece on the issue!

  2. kaking says:

    Hi Jenna!

    Very interesting policy memo. I really liked your use of statistics at the beginning of the post so that we all know of the gravity of the situation. I also liked how you posed the question of how to shrink the gap between the MDG and the reality that maternal mortality has not declined that much. However, I think it would have been nice had you gone into more detail about why this is so. For example, what barriers have programs intended to reduce maternal mortality faced? What factors contribute to the still high rates of maternal mortality? Also, you rely heavily on the success of Indonesia’s village-based midwife program to support your policy recommendation. My only concern is about whether or not this program’s success could be replicated in other countries as well. Undoubtedly the current maternal mortality figures are shameful, as you noted, and I think you do a good job of recommending programs to rectify this injustice.

  3. laurah21 says:

    Hey Jenna,
    This is a great recommendation!
    I completely agree that it is important to build a country’s human capacity. I think I might have mentioned this in a previous comment, but what first came to mind was the example of CARE’s program in Ayacucho, Peru, with Vigilantes de la Vida, where women midwives were trained and also women to serve as cultural mediators. During the time the project was active, the maternal mortality rates were reduced by about one half.

    Another aspect to this capacity building strategy that came to mind was the need for countries to retain their health providers. As you may know, there is a huge drainage of physicians, nurses, etc, who are trained in their natives countries and later leave to work in developed countries where the pay is higher. I recently went to a medical grand rounds where a physician (Dr. Van Der Horst, I think) from UNC med school mentioned this in passing, and his suggestion was to have American institutions reimburse a country every time they hire a person from a developing country. I thought this was an excellent idea, and perhaps something that could be a follow up to your recommendations.

    Great work!

  4. kheflin says:

    Hi, Jenna!

    Great topic! First of all, I love that you’re addressing the UNFPA. They are a great and useful international organization–my personal favorite arm of the UN–so I’m happy to see that choice. This issue truly relates to UNFPA’s work, also, despite many people’s perception that they only focus on family planning in terms of contraception.

    Also, I like your example of Indonesia. The concept of midwives as a way to address the internationally atrocious rates of maternal mortality/morbidity is a great one. Midwives are great at the work they due, and it’s a shame that they are falling out of fashion in developed parts of the world. Women helping other women deliver care is an old idea, but it makes total sense; and as you note, as long as emergency medical care is within reach (where available at all), the formula is a practical one.

    Thank you for your thoughtful post!

  5. klstaves says:

    Your memo provoked a lot of interesting questions for me. While I whole-heartedly agree that task-shifting to midwives is an important element of reducing maternal mortality, your specific suggestions made me appreciate more some of the challenges associated with doing so. For example, you suggest that midwives preform best when they have already had 10 years of general education. It strikes me that some areas may struggle greatly to find a sufficient number of women with this educational background. Is strengthening the general education system, then, a necessary component of achieving MDG 5, or could we instead push more rigorous vocational training programs?

    I was also interested by your suggestion that we need to create mentoring/support systems for midwives. I have read that absenteeism is a major problem among rural healthcare providers, and I wonder if this is also common among midwives. What kind of mentoring program would you envision?

  6. sbyron says:

    Excellent policy brief! ] I wanted to point out what I felt were the strengths of your policy brief, which were its organization, style, and evidence base. The way in which you structured your brief resulted in a highly structured brief with smooth transitions between topics. Your last paragraph was particularly strong. Stylistically, your brief achieved the tone I think you were going for. You didn’t shy away from calling out the UN agencies futile efforts in pursuing lower rates of material mortality. You used charged words that helped bring a sense of urgency and obligation. Your evidence base was also well put together. You relied on relevant sources and I think the brief had a good balance of statistics/epidemiological information and your own analysis. You also provide interesting case studies that bring complexity and anchor the maternal mortality issue.

    One thing that I would have liked to have seen is you expand more on the disconnect between policy and implementation. You talked about it briefly in your last paragraph, but I think this can be expounded upon. But overall excellent policy brief.

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