Midwives, the Frontline and Backbone of Maternal Health, Face Insecure Working Environments
Midwives play a critical but unheralded role in maternal health. Their skills are sometimes marginalized in otherwise well-meaning discussions about professionalizing care, or even worse, they are subject to abuse, as was discussed at the Wilson Center earlier this month. So when I found the room overflowing at a Women Deliver panel yesterday on the disempowerment of midwives and how much it undermines global efforts to increase access to care, I took that as a good sign that midwives will not be overlooked much longer.
“Midwives are the frontline and backbone” of maternal health, said Pat Brodie of the Papua New Guinea Maternal and Child Health Initiative and WHO Collaborating Center for Nursing, Midwifery, and Health Development. But recruitment of midwives has failed to keep up with the need, in part due to non-existent or low salaries, few incentives for success, little time off, and no professional training.
Gajananda Prakash Bhandari, program director at the Nepal Public Health Foundation, described how some of the profession’s challenges – such as the risks of walking long distances at night in dangerous areas or non-supportive husbands and mother-in-laws wanting women to stay close to family – can discourage women from becoming midwives. But in places where midwives have higher job satisfaction and feel secure, there’s a notable increase in their use, which means healthier mothers and children, he said. To help address these safety issues Bhandari suggested scaling up newly formed community-based security committees, which can also protect midwives from abusive family members of pregnant women.
Afghanistan is one of the least secure places in the world to be a midwife (or a woman in general, for the matter). Pashtoon Azfar, a regional midwife adviser for International Confederation of Midwives (ICM), pointed out that in the 1950s, female members of the Afghan royal family were midwives and teachers of midwives, exemplifying the level of respect for midwifery before more than three decades of war destroyed the country’s health system. In fact, the literal translation of “midwife” in the local language is “competent,” Azfar said.
However, under Taliban rule, Afghanistan suffered a shortage of female health providers, including midwives, since women were not allowed to be educated. Maternal mortality was estimated in the early 2000s to have reached 1,600 maternal deaths per 100,000 births.
Since 2002-2003, there has been a revitalization of midwifery as part of health systems strengthening efforts in Afghanistan, including a midwifery workplace development plan created by USAID with support from Jphiego. Issues of policy development, selection criteria, recruitment, education, deployment, and supervision are still being addressed through the program. But it has had positive effects on participating midwives, including increased self-confidence, more purchasing power, economic benefits to their families, a bigger presence at the policy level, and the ability to leave their homes.
“Engagement of women in this profession has led to some level of political and social empowerment,” said Azfar. “However, still there is a long way to go.”
Read the Global Health Initiative’s full coverage from Women Deliver, part of our Advancing Dialogue on Maternal Health series with the Maternal Health Task Force and UNFPA.
Photo Credit: A midwife treating a patient in Parwan Province, Afghanistan, courtesy of the World Bank.