Midwifery is a vital solution—What is holding back global progress?

We need look no further than midwifery for compelling evidence of gender inequalities blocking progress in global health. Despite growing evidence of the extensive impact of midwifery,1-6 midwives and the women they care for are disempowered by patriarchal structures and professional, socio-cultural, and economic barriers.7, 8 Widespread misunderstanding of the role and scope of midwifery exists at all levels of policy, health services, academia, and funders.9 The consequence is the fragmentation of care, with inevitable safety and quality gaps.8 This retards progress on universal health coverage and efforts to improve quality, equity, and dignity, and contributes to adverse outcomes including the unprecedented rise in unnecessary and unsafe interventions.10 These barriers disable the human rights of women and children, and ultimately harm families, communities, and economies.11 Science has played a part in this. Most research has focused on obstetric areas of interest: the clinical and emergency interventions needed when complications arise.1, 12 Much less research exists on enhancing the respectful, supportive, women- and newborn-centered, high-quality care for all that prevents complications and enables timely response when they arise. There is a serious lack of investment in examining the contribution that quality midwifery care can make. Community-based studies in low-income countries have focused on nonprofessional health workers with more than 100 trials, compared with a dearth of trials on professional midwives in these countries.1 Science, in this case, led predominantly by women, has also provided answers. Growing evidence using a range of methods shows that midwifery—knowledgeable, skilled, and compassionate care across the continuum from pregnancy to birth and beyond—saves lives, reduces preterm birth, promotes health and well-being, and improves sustainability.1-3, 5 While disruptive to the status quo, midwifery is a vital, bold, constructive solution to the challenges of providing high-quality care for all women, newborn infants, and their families. Why has the global community been so hesitant to act on all of the evidence on the benefits of midwifery from many different sources?1-6 We argue that the intersectionality of gender, social, professional, and economic disempowerment, fueled by powerful precedents and perverse incentives, constrains momentum.7, 13, 14 The population midwives serve, women and children, are often disempowered, discriminated against, and seen as low priority by decision-makers.15 Midwives, who are predominantly women, are subject to the same discrimination as other women in their societies.16 The work of midwives may be valued less than other health professionals, concerned with the intimacies of sexual and reproductive health and therefore contentious or ignored. Many midwives are inadequately remunerated or supported, overwhelmed by workload, and working in situations that expose them to sexual and other forms of violence. Midwives may work in less accessible, low-income areas where there are few other health professionals. Hence, they experience the exclusion associated with vulnerable communities while providing an essential service for the women and children who are likely to experience the worst outcomes.6, 17 Complicating this gender and social inequality is an underlying related professional bias.7 Health services and global agencies are often administered by public health practitioners or medical doctors who bring their own experiences and professional perspectives to decision-making. The common conflation of midwifery and nursing causes confusion about roles and responsibilities. Even in countries where midwifery is strong, midwives may have to fight for their full scope of practice and few senior leadership positions are available to midwives.7 Yet, midwifery can be transformative for women, families, communities, and health systems alike. Countries with long-established midwifery such as the Nordic countries have very low rates of maternal and newborn mortality. Countries that have strengthened midwifery as part of the health system have seen a fall in maternal mortality, and improved quality of care.3 Midwifery addresses the challenges both of "too little too late" and of "too much too soon," providing accessible and appropriate care where it is needed, be it in communities or large hospitals.18-20 High-quality midwifery makes a key contribution to reducing unacceptably high maternal and newborn mortality,21 stillbirth, and preterm birth; increasing access to care in remote and rural areas; preventing the escalating use of interventions conducted without medical indication5; reducing disrespect and abuse in childbirth22; improving early childhood development; and strengthening the sustainability of health systems. Midwives, enabled by quality midwifery education, professional regulation, embedded in an enabling health system, and working in the context of multidisciplinary teams, provide a cost-effective strategy to address these problems and more. Midwives working in this way act as powerful human rights defenders for women and children. The message is beginning to be heard. The broader concept of quality that encompasses equity, dignity, and preventive and supportive care is gaining ground, and the evidence of midwifery's contribution to evidence-informed quality strategies is being acknowledged.8, 13 Together, global agencies, governments, funders, and universities are working to strengthen the implementation of high-quality midwifery education23 and identifying ways to mobilize resources for research to examine how best to scale up more effective, compassionate, and sustainable models of care.24 The 2019 report on the Global Strategy for Women's, Children's and Adolescent's Health25 focuses on midwifery education, with a seven-step action plan for countries working toward international-standard midwifery.26 At the global and country level, evidence-informed midwifery competencies, tools for programmatic measurement and evaluation, and guidance for strengthening midwifery are being developed.27 Countries in sub-Saharan Africa (eg, Ghana, Zambia, and Somalia) and South Asia (eg, Bangladesh, Nepal, and India) are making progress on strengthening midwifery and implementing international standards. Midwives are needed in leadership positions globally, regionally, and locally to promote, prioritize, and implement this ambitious agenda. Gender equality is fundamental to the system-wide change needed; the voices of women must be heard and valued more clearly.28 Without exception, countries that have successfully strengthened midwifery in recent years such as Canada, New Zealand, Australia, the United Kingdom, and Malawi have done this by also strengthening midwifery-led academic leadership and through working in partnership with women and forming alliances with women's advocacy groups.29 Interdisciplinary support has also been key. There is a long road ahead toward the equitable implementation of quality care,30 meeting the health-related United Nations Sustainable Development Goals31 and universal health coverage. Science shows us that the journey would be considerably shortened through the implementation of midwifery that meets the international standards set by the International Confederation of Midwives. Tackling the systemic barriers that are rooted in gender inequality is fundamental to achieving this. Any opinions stated are those of the authors and not of UNICEF.

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