Better working conditions needed for midwives

World Health Organisation and partners are calling for an end to the discrimination, harassment and lack of respect that hinder midwives’ ability to provide quality care to women and newborns.

"It's time to recognize the pivotal role midwives play in keeping mothers and newborns alive," says Dr Anthony Costello, Director of Maternal, Children's and Adolescents’ Health at WHO. "Their voices have gone unheard for too long, and too often they have been denied a seat at the decision-making table."

The first global survey of midwifery personnel led by WHO, the International Confederation of Midwives (ICM) and White Ribbon Alliance (WRA), "Midwives' Voices, Midwives Realities: Findings from a global consultation on providing quality midwifery care", reports findings from 2400 midwives who chose to complete an online survey in 93 countries and was funded by the United States Agency for International Development (USAID).

It reveals that too often midwives report their efforts are constrained by unequal power relations within the health system. Many midwives also face cultural isolation, unsafe accommodation and low salaries.

The organizations highlight the need to provide midwives with professional support (including better working conditions); stronger education and regulatory environments; and stronger advocacy around midwifery.

Every year, more than 300 000 women die while giving birth and 2.7 million newborns die during the first 28 days of life, many from preventable causes. Midwifery – the skilled, knowledgeable and compassionate care provided throughout pregnancy and childbirth – plays a vital role in preventing these deaths, but only when it is of quality and provided by midwives educated and regulated to international standards.

The challenges midwives face

"Just as we are all committed to the highest quality care for all women, newborns, and their families, so must we be united in our fervour to ensure that the midwifery workforce is supported by quality education, regulation, and safe working conditions," says Frances Ganges, ICM Chief Executive. "Midwives must be respected, compensated and valued as equally as other professionals."

One-fifth of midwives who answered the online survey depend on another source of income to survive, which adds to the pressure and exhaustion that they experience. Many combine the roles of work, motherhood and caring for others in their communities. The midwives reported that long and stressful hours badly affected their families, with over one-third stating they had no choice but to leave children under 14 years alone while they work.

Though most feel they are treated with respect, many midwives reported harassment at work, a lack of security and fear of violence. Disrespect in the workplace negatively affects midwives’ self-esteem and their ability to provide quality care to mothers and babies worldwide.

Professionally, many midwives are neither provided with adequate education, nor regulatory and legal support. Few national midwifery associations get the support they need to develop leadership skills. This lack of investment reinforces gender inequality and unequal power relations within the health system.

What needs to change

The partners responsible for the survey are highlighting the urgent need to address the challenges so many midwives face. Key steps include:

1. Provision of professional support. To improve working conditions for midwives and quality of care for women and newborns, midwifery professionals need salaries that adequately reflect the level of their skills and responsibilities, health insurance and social security systems, professional support networks, good living environments, and counselling services.

2. Better education and regulation. The report includes recommendations to strengthen education and regulatory environments around midwifery. Nine out of ten respondents think that recognition of midwives by the health service is important for changes to take place.

3. Advocacy for midwifery. Based on the findings of the survey, WHO, ICM, WRA, USAID, UNFPA and other partners are developing a "Global Midwifery Advocacy Strategy" aimed at addressing the barriers midwifery personnel face in order to improve quality of care. The strategy will urge global decision makers to value the evidence on the positive impact of quality midwifery care. It will encourage policy makers to draw on the expertise of midwives when making policy and strategy decisions that affect maternal and newborn care.

"Midwives are essential to providing quality, respectful maternal and newborn care. They are able to prevent and manage many complications of pregnancy and birth and play a crucial role in ending preventable child and maternal deaths," says Dr Ariel Pablos-Méndez, Assistant Administrator for Global Health and Child and Maternal Survival Coordinator, USAID. "USAID is committed to supporting and empowering their important role on the frontlines of health systems."

"If we are to achieve the Sustainable Development Goals, we must value and support midwives," says Betsy McCallon, CEO, White Ribbon Alliance. "Midwives are directly responsible for providing reproductive, maternal and newborn health services, yet they are largely absent or ignored from designing policies and programs at all levels. Today, we stand with midwives to call for investment in and respect for midwives and midwifery so that all women receive the quality and dignified care they deserve."