PMNCH Knowledge Summaries: #14 - Save lives: invest in midwives

Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2011
Language: English only

Note: Full text and all graphs, tables and references for each Knowledge Summary are available only on the PDF version.

Each year, 350,000 women die from complications in pregnancy and childbirth, over three million newborns die, and 2.6 million babies are stillborn. Many of these deaths could be prevented by a midwife or other skilled birth attendant. However, 52 million births worldwide occur without one in attendance, while in Asia and Sub-Saharan Africa less than 50% of births are attended by someone with the right skills. Midwives save lives and provide quality care during pregnancy and childbirth. In recognition, global, regional and national initiatives increasingly focus on the training and retention of quality midwives and other skilled birth attendants.

What is the problem?

There are still too few people with midwifery skills

The worldwide shortage of skilled birth attendants has been widely recognized for several years, but the problem persists. In 2010, the Global Strategy for Women’s and Children’s Health noted that an additional 3.5 million health workers were required to improve the health of women and children substantially in the 49 lowest-income countries. In 2006, the World Health Report estimated the global shortage at 4.3 million. In 2005, WHO said an additional 334,000 midwives would be needed over 10 years to achieve 72% coverage of skilled birth attendance in 75 countries. WHO recommends one skilled birth attendant for every 175 pregnant women, but countries like Rwanda have only 1 midwife per 8,600 births. The global shortage of midwives is compounded by inequitable and inefficient distribution. Although most people in developing countries live in rural areas, most of their health workers are located in urban areas.

Recruitment, training and retention are inadequate

Shortages in skilled birth attendants are triggered by a number of factors, including lack of institutional and practical training and varying standards in midwifery education. Poor absorption into the workforce and ineffective regulation compromise service quality. Finally, poor working conditions, remuneration, support and supervision, and lack of career path, make it difficult to retain midwives, especially in rural areas.

Weak health systems hamper midwives

The MNCH Consensus notes that skilled and properly equipped birth attendants save lives. However, midwives often have to work without adequate equipment and medicines in inappropriate facilities, without the required professional support. Additionally, many countries do not have functional health information systems and/or lack health data to support effective workforce planning.

What works?

Improving numbers, distribution and quality of midwives

Professional skilled care at birth can greatly reduce maternal and neonatal mortality. Countries that have scaled up the quantity and quality of their midwives have seen drastic improvements in maternal and neonatal health. For example, the governments of Tunisia and Thailand invested in the development of high-quality midwives, which was key to the reduction of maternal mortality in those countries. While increasing numbers and improving distribution is important, improving quality of services is critical. Studies in Bangladesh and the Dominican Republic demonstrate that improving quality of care encourages more women to use services, and increases the ability of health providers to save lives.

Targeting proven life-saving interventions

Policies that promote a core set of life-saving interventions by midwives have been proven to save lives. However, while a majority of national policies identify the need to prioritize health workforce interventions to improve MNCH, many do not identify specific actions required to scale up the workforce.

Improving competency-based education

Midwifery training programs vary widely in content and quality within and across countries. Many fail to address the midwifery competencies outlined by the International Confederation of Midwives. Some programs have tried to produce more skilled birth attendants by making training courses shorter, simplifying content and reducing access to supervisory staff. However, this reduces the quality of graduating staff. Evidence shows that the opposite is needed to develop midwifery competencies, namely: more competency-based teaching, more training in clinical settings and better access to qualified staff.

Strengthening health systems to support midwives

Midwives’ capacity to provide quality services depends on the health system and its supporting mechanisms for midwifery practice.18 Midwives are best equipped to provide good-quality care when they practise in facilities with the required equipment and drugs, operate in well-organized teams and are supported by functional referral systems. This was seen in Tunisia, where studies found that service provision and uptake increased after technical facilities, support and supervision were improved. It is also supported by the reduction of maternal mortality in Thailand.

Regulating health professionals for better quality services

Licensing, registration and other standard-setting measures help governments to ensure quality of care. Reductions in maternal mortality in Thailand, Malaysia and Sri Lanka have been attributed in part to “long-term investment in midwifery training and referral hospitals; free care and a supportive system with regulation, control, and supervision of the medical and midwifery profession”.

Strengthening professional associations

Professional associations are best placed to promote the national and regional policies needed to support the training and deployment of qualified midwives. It is therefore important to strengthen the capacity of midwifery associations, to enable better integration of midwifery considerations in policies.

Global initiatives on midwives

Many global efforts have recognized a need for increased investment in midwifery and there has been a surge in commitment. Currently, 28 partners are compiling the State of the World’s Midwifery. This report will examine the numbers and distribution of health professionals involved in midwifery. It will also discuss the roles of education, regulation, professional associations, policies and external aid.


Many maternal and child deaths could be prevented by an increase in skilled birth attendance. In addition, health personnel with midwifery skills are trained to provide a continuum of high-quality sexual and reproductive health services to mothers, helping to prevent unwanted pregnancies. Increasing investment in midwifery education, deployment and retention, regulation and oversight should be a core component of national strategies to improve women’s and children’s health.

Knowledge summary 14 cover illustration