MISSING MIDWIVES MISSING MIDWIVES Save the Children works in more than 120 countries. We save children’s lives. We fi ght for their rights. We help them fulfi l their potential.
ACKNOWLEDGEMENTS
This report was written by Kathryn Rawe, Advocacy Offi cer, Save the Children UK, with support from Sarah Williams, Health Adviser, Save the Children UK; and from Kate Kerber, Newborn Health Adviser, and Joy Lawn, Director of Global Evidence and Policy, at Save the Children USA/Saving Newborn Lives. Thanks are also due to Nouria Bricki, Lara Brearley, Simon Wright, Patrick Watt and Kitty Arie.
Published by Save the Children UK 1 St John’s Lane London EC1M 4AR UK +44 (0)20 7012 6400 savethechildren.org.uk
First published 2011
© The Save the Children Fund 2011
The Save the Children Fund is a charity registered in England and Wales (213890) and Scotland (SC039570). Registered Company No. 178159
This publication is copyright, but may be reproduced by any method without fee or prior permission for teaching purposes, but not for resale. For copying in any other circumstances, prior written permission must be obtained from the publisher, and a fee may be payable.
Cover photo: Katsina, northern Nigeria. Uleima, holding her baby boy, has been trained by hospital staff in ‘kangaroo mother care’, a technique of providing warmth and comfort to premature babies through skin-to-skin contact, as an alternative to an incubator. (Photo: Pep Bonet/Noor)
Typeset by Grasshopper Design Company Printed by Stephen Austin Ltd CONTENTS
FOREWORD v
SUMMARY vii
1. INTRODUCTION 1
2. MIDWIVES SAVE LIVES 7
3. THE MIDWIFE SHORTAGE 16
4. FILLING THE GAPS 21
5. CONCLUSION AND RECOMMENDATIONS 26
NOTES 28 iv MISSING MIDWIVES and thehighestdeathrateofnewborn babiesintheworld. Trainee midwives inAfghanistan, where there isadrasticshortage ofmidwives,
MATTS LIGNELL/SAVE THE CHILDREN foreword v the world needs midwives now more more the world needs midwives now , governments have to invest in midwives, and this challenge lies with world and this challenge lies with world in midwives, to invest have governments ,
Frances Day-Stirk Frances Midwives of College Royal Research Development, and Practice of Learning, Director of Midwives International Confederation Vice-President, leaders. The challenge is for all of us – charities, like Save the Children, professional professional the Children, Save like all of us – charities, The challenge is for leaders. and – to require and civil society College of Midwives, the Royal like organisations, and to deliver to act, countries, in donor or receiving with our governments, work in and children the women to do for going you What are families. this change for countryyour today? than ever It is unacceptable that women and their babies continue to die in childbirth and their babies continue in the It is unacceptable that women 21st century and other midwifery-skilled lack of access to midwives because of health for time and it is now far too long for spoken been have of words Volumes workers. The solution is simple: actions and strategies. different This report rightly draws attention to that worldwide shortage, because midwives are are because midwives shortage, attention to that worldwide draws This report rightly particularly health, a country’s improving and for and families, communities vital for to achieving the key are Midwives with high maternal and child mortality. in areas approach As we 4 and 5 on child and maternal mortality. Goals Millennium Development A country is judged by cit. highlights the defi the Children that Save it is propitious 2015, the maternal and child health services and by its women, and treats for it cares the way educate and recruit, to leaders need to commit investment World them. for it provides has the government that in countries where know We as a priority. midwives retain improving on the effect it has had a dramatic essential midwifery in services, invested mortalitymaternal and newborn statistics. Globally, we know that there is a shortage of midwives, and there is little doubt of the is there and is a shortage that there of midwives, know we Globally, the all over their families and communities and babies, on women impact this is having from year every and millions of babies who die of women The tens of thousands world. of this. evidence childbirth-related causes are FOREWORD vi MISSING MIDWIVES Keeku’s baby daughterdiedtwo monthslater from diarrhoea. infected intheuterusanditspread intoherbodyandkilledher.” died immediately afterwards. Doctorssaidthattheplacentabecame drive from here Shewasgiven onpublictransport… blood, but she her stomach, we rushedher tothehospital, whichisanhour and ahalf “So whenKeeku shivering started andcomplainingofterrible painin don’t have any female healthworkers visitingthisarea. There are nohealthfacilitiesordoctorsavailable inthisvillage. We didn’t show any signsofcomplications. Shehadherbaby athome. “During herpregnancy Keeku anddelivery wasperfectly normaland Ratni, explainswhathappened. Pakistan. Shewas25years old. Herbaby diedtoo. Hermother-in-law, Keeku diedtwo days athomeinhervillage aftergivingbirth who diedinchildbirth. daughter-in-law, Keeku, Ratni grieves for her
ALIXANDRA FAZZINA summary vii EVERY YEAR EVERY MORE THAN WOMEN 2 MILLION GIVE BIRTH COMPLETELY ALONE 1
3 More than More 2
means that many women and babies die from die from and babies women means that many 4
The International Journal of Gynecology and Obstetrics of Gynecology The International Journal
No mother, anywhere in the world, should have to risk her life and that of her baby by by of her baby and that risk her life to should have in the world, anywhere No mother, give 48 million women year But every childbirth without expert through going care. midwiferybirth who has recognised skills. without someone present “The single most critical person for effective care at the time of care effective critical person for “The single most birthmidwife” is the SUMMARY The global shortage of 350,000 midwives This September, world leaders will meet in New York at the United Nations General York leaders will meet in New world This September, global strategy the launch of the UN Secretary-General’s on from One year Assembly. on their commitments. will assess progress they health, and children’s on women’s use this meeting to build on the must of rich and poor countries alike Governments ll the global further global strategy steps to fi of the foundations take and urgently c specifi to make is calling on governments the Children Save shortage. health worker and deploying paying training, recruiting, action towards concrete commitments and take and political support for awareness With growing and health workers. midwives more is the crucial now opportunities change this year, for and key maternal and child health, matter. midwives why the world moment to show Stopping women and children dying in childbirth is a moral imperative. Recruiting, Recruiting, dying in childbirth and children is a moral imperative. Stopping women of the Millennium training and supporting is also critical to the achievement midwives (MDG 4) and maternal two-thirds child deaths by Goals to reduce Development mortality three-quarters (MDG 5). by Save the Children has frontline experience of the power of midwives to save lives lives to save of midwives experience of the power has frontline the Children Save in midwives; trained have we where example, for in Niger and Angola, our work from run clubs we where Leone, and in Sierra college; run a midwife we where Afghanistan, 24-hour emergency to provide health centres upgraded and have women pregnant for behind us the reasons has shown the world Our experience around during delivery. care and in it on both a local level the shortage and what can be done to address of midwives terms of international political action. 2 million women give birth completely alone, without even a friend or relative present present a friend or relative without even birth alone, give completely 2 million women moments of their lives. making these some of the most dangerous to help them, with the right skills, a health worker by be prevented complications that could easily 358,000 maternal deaths annually, are There the right equipment and the right support. newborn Millions more than 800,000 babies die during childbirthand more each year. midwives attended by routinely If births were rst month of life. the fi lost in are lives of 1.3 million the lives and skilled birth support, attendants with the right training and 3). (see page could be saved babies a year newborn LUCA KLEVE-RUUD MISSING MIDWIVES
“Nabuth wouldn’t breast-feed and became weaker and weaker every day. Messalina [a health worker] has followed me both during the pregnancy and after the birth, and she was the one who insisted I go to the hospital with the baby. “We didn’t really have money for the bus ticket, but Messalina insisted. I am very thankful that she was clear and persuasive. Save the Children’s health worker saved my baby’s life. I am incredibly thankful.” Teresa, Mozambique viii 1 introduction 1 INTRODUCTION
Every mother will remember the feelings of anticipation, excitement, fear and joy she had before she gave birth. Everyone can imagine “I was in labour what a pregnant woman – a friend, a sister, a wife or partner – will for almost fi ve go through as she approaches one of the most signifi cant moments days, and in the of her life. Now imagine giving birth without anyone in the room end, the child with any midwifery training – it can become a dangerous event. came out of my womb dead. No mother, anywhere in the world, should have to risk her life and that of her baby by I didn’t have going through childbirth without expert care, but every year 48 million women give birth without someone with the proper medical skills present.5 Each year there are 358,000 the assistance of maternal deaths,6 and 814,000 newborn babies die during childbirth.7 A million more a birth attendant babies are lost earlier in delivery – stillborn but having been alive in the mother’s womb – only my family hours or even just minutes earlier.8 More than 3 million babies die before they are a helped me.” month old.9 Liknesh, Ethiopia Complications that kill hundreds of thousands of women and babies in developing countries are managed effectively in richer countries by a midwife or health worker with the right skills, the right equipment and the support of a health system. Women in the poorest countries are least likely to have a skilled attendant during birth, are much more likely to lose their newborn, and are most likely to die themselves during childbirth.
“At the time of the delivery the bleeding was too much. I felt dizzy and weak and I had a headache. I was very worried that I’d
lose my life. I know THE CHILDREN PALMER/SAVE RACHEL two women who’ve died from bleeding too much during childbirth. “The danger of giving birth is very real to me. If the midwife isn’t there you can pass away.” Tereza with her son, Baksoro, Southern Sudan
1 2 MISSING MIDWIVES EVEN LIVE TO SEE THE ENDOF THEIR FIRST DAY. BEFORE THE AGE OFFIVE, ONEIN TEN DOESNOT OF THE 8.1MILLIONCHILDREN WHO DIEEACH YEAR be registered and/orlegally licensedtopractisemidwifery”. andhasacquiredprescribed therequisite courseofstudiesin midwifery qualifi cations to inwhichitislocated,duly recognised inthecountry hassuccessfully completedthe “a personwhohaving beenregularly educationalprogramme, admittedtoamidwifery and babies. The InternationalConfederation ofMidwives (ICM)defi nes amidwife as attendantsplayMidwives andskilledbirth avitalrole insaving thelives ofmothers AND HEALTHCARE MIDWIVES, SKILLEDBIRTH ATTENDANTS woman andherbaby are given thecarethey need. andsupport Nochildisborntodie. appalling suffering theworld needsmore midwivesattendantssoevery andskilledbirth anddoesnotlive toseetheendoftheirfiduring theirbirth rst day. Of the8.1millionchildren whodieeachyear before theageoffi ve, oneintendies intowns andcities.particularly areas are much lesslikely tohave thanbetteroffwomen, services essentialmidwifery Within thosecountrieswomen from thepoorest familiesandthoselivinginrural package ofeight proven (seebox). interventions newborn deathscouldbeprevented midwives by trainingandsupporting toprovide a in thepoorest countries. New analysis by Save theChildren hasshown that38%of Around 1.3 millionbabiescouldbesaved eachyear by fi inmidwiveslling theshortage THE WORLD NEEDSMORE MIDWIVES higher level ofcare. medicines, supervision, andaplacetorefer women withcomplicationsthatrequire a ofafunctioninghealthsystemtoprovide equipment,need thesupport thenecessary attendantscannotoperateeffectivelyMidwives andskilledbirth inisolation. They to saving thelives ofmothersandbabiesmust berecognised. newborn babies. However, thesignifi attendantsmakecant contributionthatskilledbirth competing demandsfrom otherpatientsandlesstimetodedicatemothers over-stretched ahealthworker healthservice withawiderremit ismore likely tohave tobeattendedbyideal isfor acertifi every birth ed midwife, becauseinanunder-staffed, dedicated tothecare ofpregnant women, new mothersandtheirnewborn babies. The Midwives whoseeducationand trainingare are theonly peopleinahealthservice referral ofcomplicationsinwomen andnewborns”. andtheimmediatepostnatalperiod,childbirth andintheidentifi cation, managementand trained toprofi ciency intheskillsneededtomanagenormal, uncomplicatedpregnancies, an “accredited healthprofessional, suchasamidwife, doctorornurse, whohasbeen… 12
11 attendantis A skilledbirth 10 To stopthis 1 introduction 3
Lancet AROUND 1.3 MILLION BABIES COULD BE SAVED BABIES 1.3 MILLION BE SAVED COULD AROUND OF THE SHORTAGE YEAR BY FILLING EACH COUNTRIES. THE POOREST IN MIDWIVES The tool accounts for country specifi c countryThe tool accounts for specifi 13 The fi gure of 1.3 million has been calculated using ‘Lives Saved’, a modelling tool a modelling tool Saved’, ‘Lives of 1.3 million has been calculated using gure The fi high incidence of malaria – to treat and prevent malaria, which interferes with the with which interferes malaria, and prevent high incidence of malaria – to treat the placenta to the baby through nutrients and of oxygen ow fl death newborn and prematurity which can lead to stillbirth, syphilis, vulnerable to contracting tetanus who are babies, to their newborn protection is cut when their umbilical cord prematurely waters break woman’s if a infection problems breathing and avoid mature tting, fi women pregnant to prevent including anticonvulsants survive, and baby and/or a suction assisted births using forceps infection, antibiotics to treat removal and manual the uterus contract after birth, to make drugs machine, of placenta after birth properly and fed born. are they demographic and epidemiologic data, as well as current levels of intervention coverage of intervention coverage levels as current as well and epidemiologic data, demographic to the This tool has also been used to contribute saved. to estimate lives Stillbirth series of 2011, which demonstrates that many stillbirths could be prevented stillbirths which demonstrates that many could be prevented Stillbirth series of 2011, health system. with a functioning and effective 2. 2. the risk of – to reduce women pregnant for Syphilis detection and treatment 3. – to enable mothers to pass on during pregnancy immunisation toxoid Tetanus 4. the risk of of membranes – to reduce rupture premature preterm, Antibiotics for 5. babies’ lungs – to help premature labour preterm for Antenatal corticosteroids 6. – a range of interventions to help the mother Basic emergency obstetric care 7. warm kept to breathe, stimulated babies are – to ensure care Immediate newborn 8. when not breathing of babies that are the lives – to save Neonatal resuscitation Note: that is used to a consortium by of academic and international organisations, developed of selected evidence-based if the coverage deaths could be averted many model how level. to a given increased interventions were 1. 1. with in areas women pregnant for antimalarial treatment Intermittent preventive Analysis by Save the Children shows that 38% of newborn deaths could be prevented be prevented deaths could that 38% of newborn shows the Children Save by Analysis and to 99% of women midwives by provided eight interventions were if the following of maternal and child deaths. levels in the 68 countries with the highest newborns total of a this package (from through could be saved lives 1.3 million newborn deaths). newborn 3.3 million annual HOW MIDWIVES SAVE LIVES SAVE MIDWIVES HOW 4 MISSING MIDWIVES HEALTHCARE WORKERS. – PART OF A WORLDWIDE SHORTAGE OF3.5MILLION THERE IS SHORTAGEA GLOBAL OF350,000MIDWIVES change thisyear, now isthecrucialmomentto show theworld why midwives matter. awareness for maternalandchildhealthkey andpoliticalsupport for opportunities training, paying anddeploying more midwives andhealthworkers. With growing call onthemtomake specifi take stepstowards meeting theurgentchallengeoffi governments and must usethismeetingtobuildonthefoundations oftheglobalstrategy Assembly, they willbeheldtoaccountontheirprogress. Richandpoorcountry In September2011, whenworld leaderswillmeetagaininNew York attheUNGeneral 250,000 newborn babiesby 2015. commitments tosave thelives of50,000women duringpregnancyand andchildbirth 2010, by theUKgovernment makingstrong theglobalstrategy pledgedtosupport attendants,midwives andskilledbirth asdidonedonorcountry, Australia. InDecember strategy, eightdeveloping-country governments madepledgestoincrease thenumber of up progress onthehealth-related MillenniumDevelopment Goals. ofthe Aspart an ambitiousglobalwomen’s andchildren’s toinspire actionandspeed healthstrategy In September2010, launched theUNSecretary-General ‘Every Woman, Child’, Every maternal andchildhealth(MDGs45). contribution tomeetingtheinternationally agreed MillenniumDevelopment Goalson women andnewborn babies, boostingthenumbers ofmidwives would make adecisive of 3.5millionhealthcare workers. Aswell asthemoralimperative for saving thelives of of350,000midwives,There isaglobalshortage TIME FOR ACTION access toemergencyobstetriccare provided inhospitals, suchascaesarean sections. maternal deathscouldbeprevented by comprehensive care duringchildbirth, including crucial. Uptotwo-thirds ofnewborn babies’lives couldbesaved To make gains, further therole themidwife is ofthewiderhealthsysteminsupporting wrong position, orusingherbsto treat infections ratherthan seekingmedicalcare. on awoman’s belly toforce thebaby out, usingbuttertoattemptturn ababy inthe attendants usepracticesthat canbeharmfultomotherandbaby; for example, sitting Opinion isdividedover therole attendant. ofthetraditionalbirth Sometraditional birth and thequalityofcare they provide, dramatically. canvary are notcertifi ed orlicensedandasaresult theirlevel ofeducation, trainingandskills, respected, oftenolderwomen inthecommunity whohelpmotherstogive birth. They In many attendants– countriesthejobofdelivering babiesfallstotraditionalbirth AND COMMUNITYHEALTH WORKERS TRADITIONAL BIRTH ATTENDANTS c commitments andtake concrete actiontowards recruiting, 16 which is part of a worldwide shortage ofaworldwide shortage whichispart lling thehealthworker shortage. We 14 and three-quarters of andthree-quarters 17 15
1 introduction 5
MATTS LIGNELL/SAVE THE CHILDREN THE LIGNELL/SAVE MATTS ANDY HALL ANDY Dr Abhay Bang holds a Abhay Dr in in a village baby newborn India Maharashtra, 19 20 In 2010, the Indian government announced it would announced it would government the Indian In 2010, 18 Save the Children, through its global through the Children, Save sure aims to make programmes, access to a have women 640,000 more birth. give when they trained midwife A training course for community community for A training course province, in Jawzjan midwives 18-month The northern Afghanistan. the Children which Save course, practice includes extensive supports, district hospital. in a nearby is on here The session shown cervical dilation. While a qualifi ed, fully equipped midwife at every birth is the ideal, when they are are when they birth at every equipped midwife is the ideal, fully ed, While a qualifi basic training to traditional birth of supporting the option and providing not available can spot danger signs and refer so they health workers attendants and community cant difference. a signifi to health facilities can make women A partner of Save the Children’s, Dr Abhay Bang, pioneered home-based care for for home-based care pioneered Bang, Dr Abhay the Children’s, A partner of Save in breakthrough and made a real India, district in Maharashtra, in Gadchiroli newborns health which included training a community trial, The Gadchiroli lives. children’s saving like to manage problems and how in each village to identify high-risk babies, worker 57%. 70% and infant deaths by deaths by newborn reduced and infection, hypothermia been has now deaths of newborn solution to the problem This community-based India. in sites across replicated Community health workers can perform a similar life-saving role in their home villages. in their home villages. role a similar life-saving can perform health workers Community to treat women, basic advice to pregnant to give health workers community Training can problems are to a clinic if there to go and to encourage women some complications, a dramatic difference. make On the other hand, many believe traditional birth attendants can be a vital link between traditional birth attendants can be a vital link between believe many On the other hand, to the clinic to to go encouraging women giving advice, the health system, and women Some argue that providing moral support. mothers to provide and accompanying deliver ts. benefi basic training can bring great even As a result, countries have at various times put bans in place to prevent traditional birth at various times put bans in place to prevent countries have As a result, concerned that training them are Others practising or being trained. attendants from and training important the more task of recruiting, from diverts attention and resources and skilled birth attendants. midwives retaining make this model of village-level care a key part of its newborn survival strategy. It will partsurvival of its newborn strategy. a key care this model of village-level make with a combined population of 500 million people. 235 districts, out across be rolled MISSING MIDWIVES COLIN CROWLEY/SAVE THE CHILDREN COLIN CROWLEY/SAVE
Rukia certainly knows the value of a health worker. She had been Rukia and her attending regular antenatal check-ups in her local village health facility nine-day-old son, when she was told to go to the district hospital by a health worker Husseinat, in Mtwara – Rukia was showing signs of being close to giving birth, even though District Hospital, she was only seven months pregnant. After a scan showed that she Tanzania. was carrying too much fl uid in her abdomen, she was operated on and her son, Hussein, was delivered by caesarean section. After this, staff trained Rukia in ‘kangaroo care’ – a technique for caring for premature babies – which involves holding her son to her bare skin and wrapping him up so that she maintains body contact with him. And because she had access to a health worker she was also given advice and support in breastfeeding, and learned important hygiene techniques, such as washing her hands and cleaning her breasts before feeding.
6 2 midwives save lives 7
21 ed health staff. ed health staff. SAVE LIVES SAVE
In Niger, many women live too far away from a health centre to a health centre from too far away live women many In Niger, fuel helped fund an ambulance and provided so we’ve walk there, women’s Our efforts to improve other district ambulances. for bringing results. are access to better antenatal and postnatal care attended antenatal consultations in the women 25,000 In 2008, in delivered than 5,000 babies were and more support, clinics we qualifi the clinics by Globally, one in three pregnant women (35%) gives birth or a (35%) gives without a midwife women pregnant one in three Globally, higher. In some countries rates of unattended births much are skilled birth attendant. or skilled no midwife countries 59% of births have in the least developed On average, is 94% of birthsgure and in Bangladesh 76%. fi in Ethiopia the present; health worker Giving birth birth or skilled without a midwife attendant puts one of higher risk of death from and their babies at a much women during childbirth. that can happen serious complications the many midwifery with the right someone present have So it is vital to are as they complications early, training who can identify these immediately. be dealt with or referred and must often unpredictable birth almost every someone attended by is In rich countries where of these many and supplies, equipment with the right training, with a serious In poor countries dealt with easily. complications are fatal. are all too often they shortage of midwives,
2 MIDWIVES 2 MIDWIVES If complications arise the woman may be miles away from the nearest health clinic or the nearest from be miles away may If complications arise the woman nd transport fi to urgently have may family the woman’s is an emergency If there hospital. her to get help. fuel to take for money and borrow Every woman should have expert care and support when she gives birth. But the reality the reality But expert and support birth. when she gives care should have Every woman no midwife, their babies at home with means delivering women of childbirth many for electricity or light. oor in a house without running water, on a dirtylying bed or dirt fl By comparison, only 1% of women in the UK give birth or skilled in the UK give without a midwife 1% of women only By comparison, being that the birth with the most common cause so fast that happens birth attendant, cannot get to hospital in time. the woman 8 MISSING MIDWIVES have herbaby. is completed, sheplansto and where, onceconstruction Save theChildren isbuilding, outside amaternityward that Dessie, four monthspregnant, is tomeetthehealth-related MDGs. 62% by 2015, butestimatedthata£280million fundinggap must befi lled ifit ambitious targettoincrease withaskilledattendantto thenumber ofbirths government committedtotrainingthousandsmore midwives andsetan Health SectorDevelopment Programme launched lastyear, theEthiopian outawiderangeofservices.in placetoallow themtocarry Initsnew health centres andhasprogressive policiesonthepracticeofmidwives The government ofEthiopiahasbeeninvesting inbuildingandupgrading consultation, andrecovery. delivery has builtanew maternityward atthelocalhealthcentre there withrooms for are unabletogetthere intimeifthere are complications. Save theChildren The districthospitalisafour-hour drive away from Wogidi somany women been usedbefore.” blade inthemarket. We justcheckifit’s properly packed tobesure ithasn’t and herbare hands–that’s allsheusedtodeliver my children. We buythe my mother-in-law’s help,” shesays. “A bladefor cuttingthecord, cleancloths atahealthcentre.birth “So far, allmy children have beenbornathomewith Dessie from South Wollo inEthiopiahasfour children buthasnever given
CAROLINE TRUTMANN/SAVE THE CHILDREN
2 midwives save lives 9
SAVE THE CHILDREN THE SAVE
CAROLINE TRUTMANN/ CAROLINE BONET/NOOR PEP BONET/NOOR PEP A razor blade is the blade A razor some tool used by only traditional midwives, northern Nigeria. Herbs used to treat babies in newborn infection in a traditional midwife by northern Nigeria. A cloth used in the delivery in rural Ethiopia. of a baby
23 BIRTH ASPHYXIA 23% BIRTH PRETERM BIRTH PRETERM BIRTH 28% COMPLICATIONS
22 OTHER 11% OTHER SEPSIS 15% TETANUS 2% TETANUS DIARRHOEA 2% PNEUMONIA 11% CONGENITAL CONGENITAL ABNORMALITIES 8% developed lungs, or feeding diffi culties due to an under-developed digestive digestive culties due to an under-developed diffi or feeding lungs, developed system (28%) when it is born (23%) to need resuscitation WHAT DO NEWBORN BABIES DIE FROM? WHAT Birth asphyxia is responsible for more deaths in children under fi ve than malaria. than ve under fi deaths in children more for is responsible Birth asphyxia ASPHYXIA AND SEPSIS WHAT DO NEWBORN BABIES DIE FROM? WHAT rst month are: babies in the fi killers of newborn biggest The three • culties due to under- diffi breathing eg, prematurity, arising from complications • likely during delivery and is more of oxygen is deprived when a baby asphyxia, • of the blood (15%). an infection sepsis, Asphyxia causes 814,000 newborn deaths, most of which could be prevented by by most of which could be prevented deaths, causes 814,000 newborn Asphyxia midwives equipment, With the right training and and skilled birthmidwives attendants. heart in a signs of distress rate and can detect monitor the unborn baby’s able to are risk of asphyxia, is at greater able to assess whether the baby are They birth. during baby which can predict They or if it is premature. if it is small and underweight example, for to how and know delivered are when they to need resuscitation likely more babies are to a or baby a woman when to refer know They breathing. who is not help a newborn at a clinic or hospital. of care higher level 10 MISSING MIDWIVES AND STIMULATE IT TO BREATHE BYRUBBING ITSBACK ORFEET. HAVING SOMEONEPRESENT WHO KNOWS TO DRY THE BABY SOME OF THE WAYS OFPREVENTINGASPHYXIAARESIMPLE– especially duringthecriticalfi rst week oflife. to mothersinothercountries, ensuring thatmore babiesreceive thecare they need, more than30millionwomen andbabiesin18countriesare now beingextended proper hygiene, warmthandbreastfeeding. The benefi havets oftheseefforts reached for pregnant women, andeducationfor pregnant womenof abouttheimportance initiative helpsensure accesstomidwives, treatment ofinfections, tetanus immunisations identifi ed bettercare practicesandimproved tosave interventions newborn babies. The programme, launchedin2000withagrantfrom theBill&MelindaGatesFoundation, has lives ofbabiesintheirfi rst monthoflife. The groundbreaking Saving Newborn Lives Save theChildren isleadingtheway inresearch aboutwhatworks besttosave the 5,304 diedfrom sepsis. died from sepsis. InNepal, outof732,000births, 6,591babiesdied from asphyxia and similar totheUK’s totalbirths, but5,874babiesdiedfrom asphyxia and3,109babies 743,000 births. Bycomparison, inBurkinaFasothere were 721,000babiesbornin2008, 306 babiesdiedfrom asphyxia and39diedasaresult ofneonatalsepsis, from atotalof In richercountriesdeathsfrom asphyxia andsepsisare rare. very IntheUKin2008, from infection. gauze tocleanthebaby’s face, abarofsoap andaplasticsheettoprotect themother kit containsapairofgloves, two tiesfor theumbilicalcord, arazorblade, two piecesof clinicinMvoloChildren-supported gives women kittouseathome. asafe delivery The attendant. athomewithatraditionalbirth birth The trainedmidwife attheSave the oftenpreventtransport women from comingtoahealthcentre. Many women willgive In Mvolo, SouthernSudan, thedistancesfrom women’s homestoclinicandthelackof breastfeeding –isalsoimportant. of thenewborn –ensuringskin-to-skincontactwiththemotherandencouraging equipment tocutandtiethecord –canhelpprevent infection. The immediatecare a year. prevent many casesofinfection, includingneonatalsepsis, whichkills521,000newborns During anormaldelivery, thepresence ofawell-trained attendantcan midwife orbirth thebaby andstimulate ittobreathedry by rubbingitsbackorfeet. 42,000 lives ayear couldbesaved simply by having someonepresent whoknows to Some oftheways ofpreventing asphyxia are extremely simple. Itisestimatedthat to beablerefer themostseriouscomplicationstoa hospital. homes. However, tohave mostimpact, midwives ofahealthcentre needthesupport and and canbedelivered by amidwife working inthecommunity orvisitingmothersintheir thatcansaveSome oftheinterventions babies’andmothers’lives are relatively simple EMERGENCY OBSTETRICCARE 25 Clean delivery practices–for example, Cleandelivery hand-washingandusingsterile 26 24 2 midwives save lives 11 A midwife A midwife
The prerequisite The prerequisite 27 TO HAVE MOST IMPACT, MIDWIVES NEED THE SUPPORT SUPPORT THE NEED MIDWIVES IMPACT, MOST HAVE TO THE REFER TO BE ABLE TO AND CENTRE OF A HEALTH A HOSPITAL. TO COMPLICATIONS MOST SERIOUS maternal and child health aides. These antenatal groups help women prepare for childbirth, childbirth, for prepare help women These antenatal groups maternal and child health aides. A well trained, highly skilled midwife does much more than deliver babies. than deliver more does much skilled midwife highly trained, A well ANTENATAL AND POSTNATAL CARE AND POSTNATAL ANTENATAL Emergency obstetric care requires a functioning health system. In many developing developing In many functioning health system. a requires Emergency obstetric care countries In the least developed is a huge challenge. this kind of care countries providing by deliver 3% of women and only birth give in a clinic or hospital, women 35% of only of emergency obstetric in countries with adequate coverage Whereas section. caesarean is expected to be 5–15%. caesareans having the rate of women care A midwife or skilled birth attendant with the correct training, medicines and equipment medicines training, or skilled birthA midwife the correct attendant with administering including in a health centre, obstetric care basic emergency can provide of the placenta. removal and manual assisted deliveries antibiotics and anticonvulsants, in childbirth serious complications as – known more for care of The higher level alone. a midwife by – cannot be performed emergency obstetric care comprehensive out in a hospital, be carried or blood transfusion must section Births caesarean requiring including a surgeon to a midwife, staff in addition and need the assistance of other health a woman Referring the operation and a laboratoryto perform technician to match blood. help or to a telephone to call for access having in danger to a hospital often depends on transport to the clinic or hospital. to go In Sierra Leone, Save the Children runs antenatal classes – known as ‘belly woman’ woman’ ‘belly as runs antenatal classes – known Children the Save Leone, In Sierra in partnership with government-employed clubs, – and emergency referral support groups Antenatal care by midwives can identify problems and prevent some complications, and some complications, and prevent can identify problems midwives by Antenatal care blood pressure, check the woman’s Midwives necessary. where referred means cases are and against tetanus, women immunise tablets, iron signs of aneamia and give look for example, – for pregnancies can spot high-risk The midwife identify signs of pre-eclampsia. is not in a or if the baby is very baby if the small or very large, pregnancy, if it is a multiple about and advice to women information can provide A midwife delivery. position for good part of A key and teach them to spot danger signs themselves. and breastfeeding, nutrition their baby. to deliver to the health centre when to go is advising women antenatal care of a functioning health system in order to deliver emergency obstetric care explains why explains why care emergency obstetric to deliver of a functioning health system in order under rate than deaths of children falling at a slower deaths are maternal and newborn health systems and essential midwifery strengthening This underlines the need for ve. fi to matched with the infrastructure are services have midwives so that the diagnostic skills choose to prescribe. would the interventions they deliver at the heart and within a functioning health serviceworking of the community is able to Many during and after pregnancy. and support advice – before, care, to give visit women enabling them to travel midwives, for in bicycles or motorbikes invested countries have support visits and frequent to more and to provide easily more communities to remote women. pregnant more 12 MISSING MIDWIVES LOWER NEONATAL MORTALITY RATES HIGHER LEVELSOFATTENDED BIRTH GOHAND INHAND WITH NEONATAL MORTALITY RATE PER 1,000 LIVE BIRTHS 10 20 30 40 50 60 90 70 100 80 40 50 60 30 10 20 0 0 ETHIOPIA CHAD AFGHANISTAN their fi rst monthis1in200orlower. a skilledperson. Inmostofthesecountries–24themthechanceababy dyingin developed countriesandtransition economieswherewere 100%ofbirths attendedby in theirfi rst monthoflife. Attherighthandsideofgraph there isaclusterof41 thatare attendantandthenumber ofbabieswhodie attendedbybirths askilledbirth countries. below shows, Asthechart there isacorrelation between thepercentage of and theratesofnewborn deathare low. very The oppositeistrueinmany developing In richcountries, having askilledhealthprofessional present isroutine, duringchildbirth SKILLED BIRTH ATTENDANTS ANDNEWBORNDEATHS after birth. also involves checkingfor signsofinfection inthemotherandthatsheisrecovering well and show herhow tokeep thebaby safe andwarm, andtoavoid infection. Postnatal care amidwife canhelpanewAfter thebirth mothertofeed andcare for hernewborn baby, source ofprotein isvital. –thiskindofantenatalsupport the beliefthatapregnant woman shouldnoteateggs, thereby denying heranimportant where manycountry traditionalbeliefssurrounding –suchas pregnancy stillpervade attendants,put women incontactwithskilledbirth andoffer adviceonnutrition. Ina provision ofemergencyobstetriccare inhealthfacilities. stronger healthsystems, agreater number ofhealthtrainedprofessionals andbetter TANZANIA SKILLED ATTENDANCE AT BIRTH % GHANA 28 This alsorefl ects thatrichercountrieswillhave NAMIBIA VIETNAM UK 2 midwives save lives 13 29 30 1 Afghanistan 52 14 10 Somalia 33 52 9 Eritrea 28 17 8 Haiti 26 27 7 Bangladesh 24 30 6 Democratic Republic People’s Lao 20 22 5 Nepal 19 27 4 Timor-Leste 18 27 10 Burundi 42 3 Chad 34 14 45 9 Angola 42 2 Afghanistan 47 14 52 8 Chad 45 1 Ethiopia 14 6 36 7 Central African Republic 7 African Central 45 Country 44 of births Percentage attended (2005–2009) Neonatal mortality rate, per 1,000 births (2009) 6 Guinea-Bissau 46 39 5 Leone Sierra 49 42 4 Mali 50 49 3 Somalia 52 33 2 Democratic Republic of Congo 52 74
Country mortality Neonatal rate, of births Percentage per 1,000 births (2009) attended (2005–2009) THE TEN WORST PLACES FOR BIRTH ATTENDANCE FOR BIRTH PLACES WORST TEN THE COUNTRIES WITH THE WORST NEWBORN MORTALITY RATES NEWBORN MORTALITY WORST THE WITH COUNTRIES 14 MISSING MIDWIVES NIGERIA GIVEBIRTH COMPLETELY ALONE. EVERY DAY MORE THAN 3,000 WOMEN IN facility wasbecausetheirhusbandssaiditunnecessary. own. Athird ofwomen inNigeriasaidthatoneoftheirreasons for notgoing toahealth women inNigeriafacesomeof themostdangerous momentsoftheirlives ontheir fi fth. alone –andthisvariesfrom 34.5%ofthepoorest fi fth ofwomen to3%oftherichest The starkest exampleisNigeria, where around oneinfi ve women deliver theirbabies women are reluctant tobeseenifthehealthworker isaman. seek assistancewhenthey go intolabour. Even whenahealthworker isavailable, some the house–andreligious beliefs, many women are notabletoleave theirhomesto cultural practices–suchastheneedtoaskpermissionofamalerelative togo outof available anestimated2.4millionwomen gave completely alone. birth Asaresult of present, letaloneamidwife, isextremely high. Inthe40countriesfor whichdatais In somecountriesthenumber alone, ofwomen givingbirth withouteven arelative GIVING BIRTH ALONE campaigns, involve men. make sure totacklematernalandnewborn thatefforts deaths, education particularly onr ya) Percentage ofwomenalone givingbirth (year)Country THE TEN LONELIESTPLACES TO GIVEBIRTH tipa(05 5.4% 6.3% 6.5% 8.4% Ethiopia (2005) 8.9% Nepal (2006) 9.0% Kenya (2008–09) 13.1% Angola (2006–07) 11.1% Uganda (2006) 16.9% Guinea (2005) 18.6% Rwanda (2007–08) Mali (2006) Niger (2006) Nigeria (2008) 31 Sixmillionbabiesare bornevery year inNigeria, 34 32 meaningevery day 3,100 33 This highlightstheneedto 35
2 midwives save lives PEP BONET/NOOR
Aisha, from Katsina, northern Nigeria, gave birth at home without a midwife or a birth attendant. “A neighbour helped me to cut the cord with her hands and a new razor blade,” she says. Two days after the birth, Aisha’s baby, Maymuna, became very ill and couldn’t breathe properly. Aisha brought her to the hospital in Katsina where Maymuna was diagnosed with meningitis and other infections, possibly contracted when her umbilical cord was cut at home with a razor blade. After three days of treatment with antibiotics, Maymuna started to recover.
15 16 MISSING MIDWIVES 5,000. only hasonehealthworker for every 6,000people, Sierra Leonehasonefor every ofhealthcare workers61 countrieswithacriticalshortage –41ofthemin Africa. Niger is2.3per1,000,health services oronehealthworker for every 435people. There are The minimum number ofdoctors, nurses andmidwives neededtodeliver essential the biggestchallengesinglobaldevelopment today. during birth. ofhealthworkersThe shortage istherefore atruly global crisisandoneof prescribed, children cannotbevaccinated, andwomen andbabiescannotbeprotected midwives andcommunity healthworkers, diseasescannotbediagnosed, drugscannotbe The healthworkforce isthebackboneofahealthsystem. Without doctors, nurses, THE HEALTH WORKER SHORTAGE more detailbelow. to thatprofession. Boththesesetsofreasons are explored in there are alsoreasons for thatare themidwife shortage specifi to ageneralhealthworker inthepoorest shortage countries. Yet ofmidwiveslead toashortage are thesamefactorsthatcontribute ofmidwivesThe 350,000shortage 3 THE MIDWIFE 4. Lack of education and training opportunities –many Lackofeducation andtrainingopportunities countrieslackeducational 4. Migrationofhealthprofessionals –skilledhealthworkers may migrateinorder to 3. Disparitiesinhealthcoverage –urbanisationhasledmany healthworkers away 2. Diffi cult working conditions –many healthworkers lackincentives.1. They are poorly Action for GlobalHealthoutlinedfi ve causesofthehealthworkforce crisis: A billionpeoplewillnever seeahealthworker. shortage of3.5millionhealthworkers.shortage to 173,800inEurope. population, inrural areas. particularly Africa trains5,100doctorsayear compared facilities andeducatorstotrain enoughhealthworkers tocover thewhole foreign healthworkers. In somecountries, includingtheUK, hasbecome dependenton thehealthservice use theirskillsinrichcountrieswhere they willbebetter paidandbettersupported. for theirfamilies. from ruralareas insearch ofbetterworking conditionsandbetteropportunities enable themtofunctionproperly. a highcaseload. Many healthfacilitieslackthebasicequipmentandmedicinesto and irregularly paid, ofstaffmeansthosewhoare andtheshortage working willhave 38 Bycomparison, intheUKthere isonehealthworker for every 119people. SHORTAGE 42
36 is part ofaworldwide ispart 40
37 Many ofthefactorsthat 41
c 39
3 the midwife shortage 17 43 46 but this standard is far from being achieved. In Rwanda, In Rwanda, being achieved. far from is but this standard 44 Uganda has 15,000 trained midwives with an estimated Uganda has 15,000 trained midwives 45 In June 2010, the International Development Secretary Andrew Mitchell launched Secretary Andrew the International Development 2010, In June the from a £5m health partnership and health workers scheme to help midwives and doctors in the world’s nurses their skills with birthUK share attendants, the NHS and The scheme aims to expand links between countries. poorest in health technology that innovations in order and share health systems, overseas all the trained doctors, of the debt to poor countries for some the UK can repay While UK training in the UK. migrated to work that have and midwives nurses that permanent the long-term solution is to ensure help, nitely institutions can defi and that they trained and supportedstaff in poor countries are to do their work, decent wages. receive The UK was the fi rst nation to produce international recruitment guidance to international recruitment rst nation to produce The UK was the fi component of the A key countries. of developing the health workforce protect 2004 Department the international recruitment of Health Code of Practice for of healthcare recruitment the active was to preclude professionals of healthcare countries. developing from professionals HEALTH MIGRATION AND THE UK AND MIGRATION HEALTH national health service (NHS) used international the UK’s In the late 1990s, to a shortage of in response boost its workforce to rapidly recruitment skilled staff. initiatives have often favoured more short-term targeted investments, such as short-terminvestments, more targeted often favoured have initiatives at the expense of drives, c vaccination or disease-specifi distributing bed-nets of enable countries to boost the number that would commitments longer-term also failed to dedicate countries have in poorer governments Many health workers. with many to health budgets and to health workers, resources enough of their own policies and plans. countries lacking national human resources Some of the reasons for the shortage of midwives mirror those listed above. A woman A woman those listed above. the shortage mirror for of midwives Some of the reasons poorly staffed, in a poorly of working faces the prospect wishing to become a midwife The World Health Organization recommends one midwife or skilled birth one midwife attendant Health Organization recommends World The women 175 pregnant every for THE MIDWIFE SHORTAGE THE MIDWIFE 5. 5. and global health – donor agencies in human resources under-investment Chronic where 400,000 babies are born in a year, there are 46 public midwives (or one midwife (or one midwife 46 public midwives are there born in a year, 400,000 babies are where 8,600 births). every for babies each year. having 1.5 million women 18 MISSING MIDWIVES and may bepaidrelatively poorly. Amidwife inLiberiaispaidaround £62amonth, pregnant women tolookafter. Shemay have for training oropportunity littlesupport equipped healthcentre inaremote oreven dangerous locationwithahugecaseloadof £300 amonth. in BurkinaFasoamidwife canexpectaround £125amonth, andinNigeriaaround during thenightsoIcan monitorher.” Ikeepafter thedelivery herinfor 24hours. Istay withher night. I’mthere. Assoon aslabourstarts Ifamotherisbleeding day. The nightwatchmancallsmeifawoman goes intolabourat the day andoneatnight, butbecauseI’mtheonly oneIwork all “If there were two ofusworking here, onecouldwork during I don’t have any urinesticks. for antenatal care.important I’msupposedtodoaurine testbut the growth ofthefoetus inthewomb –thisequipmentisvery doesn’t work properly. Idon’t have atape measure tomeasure “I don’t have astethoscopeandmy bloodpressure machine Eva, amidwife in SouthernSudan 48
47
RACHEL PALMER/SAVE THE CHILDREN 3 the midwife shortage 19 Many midwives also migrate midwives Many 50 GLOBALLY, THERE IS A SHORTAGE OF 350,000 MIDWIVES. OF 350,000 IS A SHORTAGE THERE GLOBALLY, 49 “We need proper equipment, and the buildings are not in good not in good and the buildings are equipment, need proper “We the same to share birth just given have who have Women shape. the enough beds for have don’t We space with sick patients. ground.” on the end up laying so they stages of labour, early “With electricity, we would be able to sterilise our instruments would we “With electricity, cannot we right now but other techniques, and apply properly many are There personnel. need more Also we of this. do any of us. three only are and there patients here Madame Achatou Boukar is a midwife who works at a maternity who works Madame Achatou Boukar is a midwife she explains Here district of Niger. in the Matameye centre under- is grossly centre maternity this government-funded how equipped and lacks basic amenities such as electricity and running water. Poor working conditions, particularly those in rural settings, drive midwives to take their to take midwives drive particularly in rural settings, those conditions, working Poor in urban centres, tend to be concentrated midwives Within countries, skills elsewhere. from further based but which are away health facilities are the better resourced where of urban two-thirds Leone, In Sierra most in need. who are and children the women gave when they present doctor or health professional had a midwife, they said women of rural women. one-third with only compared birth, Personal safety is a particular concern for midwives and other female health workers, in health workers, and other female is a particular safety midwives concern for Personal noted International Labour Organization has The conditions. to poor working addition often staffed Health facilities are and nurses. among midwives the high risk of violence it position and makes which puts her in a vulnerable health worker, a single female by obstetric the necessary for 24-hour coverage that health post to provide impossible for emergencies and complications in labour. There is a shortage There of opportunities in midwifery training for least developed in the is that profession, female a traditionally midwifery, challenge for An additional countries. up grow women so fewer boys, girls complete schooling than countries fewer in many is essential in girls’ education investment Increased with the necessary basic education. started to potentially training qualifi who are women to enlarge the pool of young as midwives. overseas to seek a better standard of living. of living. to seek a better standard overseas 20 MISSING MIDWIVES fi ll theirhealthworker gaps. the wagebillandemploy healthworkers isneededtoenablethepoorest countriesto A more fl exible approach by theIMFthatgives thesecountriesmore scopetoexpand increasing thenumbers ofmidwives and otherhealthworkers onthepublicpayroll. to achieve economicstability, butitcanalsohave theeffect ofpreventing countriesfrom public spending, whichincludesthepublicsectorwagebill. The rationalebehind thisis willkeep inflthe country ation low andminimisethegovernment defi cit by restricting itoftenincludesarequirement Fund(IMF)lendsmoney toacountry that Monetary Third, thepoliciesofinternationalinstitutionsmust change. When theInternational their salaries. in recruiting andtrainingnew healthworkers, whichcantake many years, andtopay governments indeveloping countriesneedalong-term guarantee inorder toinvest workers. Aidfor healthtendstobeshort-term, unpredictable andfragmented. However, give money toimprove healthinpoorcountriescouldboostthenumber ofhealth Second, achangeintheway governments internationaldonorsandrichcountry Niger, Malawi, ZambiaandBurkinaFaso. Abuja, Nigeriain2001, butby 2008justsixhadmetthistarget–Rwanda, Botswana, to thetargetofspending15%revenues onhealthattheAfricanUnionsummitin on theirhealthbudgets. are Existingefforts inadequate. African governments committed sources. First, governments inthepoorest countriesmust increase theirown spending The money topay for theseadditional healthworkers needstocomefrom anumber of estimated atbetween £25billion and community healthworkers in49ofthepoorest countriesby 2015hasbeen The costoffi lling theglobalhealthworker gap of3.5million doctors, nurses, midwives workers accountfor alargeproportion ofthepublicsectorworkforce. Personnel oftenaccountfor thebulkofhealthspending, andinmany countrieshealth available inpoorcountries’healthbudgetstopay for recruitment, trainingandsalaries. ofmidwivesUnderlying andotherhealthworkers theshortage isalackofmoney THE FUNDINGGAP 54
51 and£34billion. 53 52
4 fi lling the gaps 21 SOME OF THE SOME OF POOREST COUNTRIES ARE SUCCESSFULLY BOOSTING THE NUMBER OF MIDWIVES. This 55
58 compared with 56% in compared 56
– this progress has been insuffi cient to meet MDGs 4 and 5. However, many of many However, cient to meet MDGs 4 and 5. has been insuffi – this progress
57
the poorest countries are successfully boosting the numbers of midwives and ensuring of midwives boosting the numbers successfully countries are the poorest the increased Burkina Faso and Rwanda have Pakistan, births attended. that more are points in the period of births 20 percentage proportion a skilled person by attended by they the global average, to reach yet these countries are Although 2000 to 2008. from other countries have Ten the bottom of the rankings. up from pulled themselves have points since 1990. than ten percentage of more improvements also shown At the same time, richer countries should work on minimising ‘pull’ factors by stopping ‘pull’ factors by on minimising work richer countries should At the same time, and countries with critical shortages, from of health workers recruitment the active Code of Practice on the International Recruitment of WHO Global adhering to the practices of ethical recruitment. which sets out principles and Health Personnel, Recruiting, training and retaining more midwives is vital to saving saving is vital to midwives more and retaining training Recruiting, in the are that existing midwives as is ensuring lives, children’s work must Donors and governments countries. right places within to support countries places with a large together in developing pay poor ‘push’ factors like the reducing by shortage of midwives the unequal training and addressing improving and by and conditions, distribution of midwives.
GAPS 4 FILLING THE 4 FILLING 2000 these countries is to tackle inequality – ensuring that The other big challenge for most vulnerable and the poorest, and skilled birth reaching midwives attendants are Through reach. easiest to and not just those that are and children, women most remote is contributing to the efforts of the the Children Save work, its global programme access to have women that 640,000 more sure aiming to make by countries, poorest need. they care get the postnatal and that they birth, give when they trained midwives Although there has been progress globally in increasing the number of births the number with a in increasing globally has been progress Although there in 2009, attended skilled attendant – 65% of all births were was adopted by the World Health Assembly in May 2010. in May Assembly Health World the was adopted by 22 MISSING MIDWIVES and newborn babies. and treat pregnant women has beentrainedtoadvise to anexpectant mother. She basic healthcare kitonavisit rural Pakistan, her carrying Momal, ahealthworker in half amillionnewborn children. health facilities. The schemeprovided tonearly 3millionfamiliesand services ambulances for emergencyobstetriccare; in andestablished24-hourservice than 10,000healthworkers, 80%ofwhomwere women; donatedlife-saving was launchedin2004. Over sixyears theUS-fundedproject trainedmore One suchproject wasthePakistanInitiative for MothersandNewborns, which to work inthecommunity. recruit andtrainmidwives, attendants female healthvisitorsandskilledbirth The country’s progress tonationalinitiatives hasbeendueinalargepart to age offi ve dropped from to90inthesameperiod. 112per1,000births from 18%in1999to39%2007. The number ofchildren dyingbefore the Pakistan increased with askilledattendantpresent theproportion ofbirths PAKISTAN –MAKINGPROGRESS, FACING CHALLENGES nearly twicethatinBalochistan. and whethersheisrichorpoor. rateinPunjabis The newborn mortality newborn’s shewasborn depend onwhere inthecountry chancesofsurvival Healthcare inPakistan isdistributedunequally, meaningthatamotherandher schoolstotrain12,000midwives.community midwifery £91 millionbetween 2008and2013. thebuildingof DFIDhassupported UK’s for InternationalDevelopment Department (DFID), which committed Health programme by internationaldonors, hasbeensupported includingthe More recently the government ofPakistan’s new Maternal, Newborn andChild foremost priority. 59 61
Tackling theseinequalitiesmust bePakistan’s 60
ALIXANDRA FAZZINA 4 fi lling the gaps 23
A mother gets advice from advice from A mother gets healthcare a community in and a midwife volunteer Indonesia. Aceh, KULLWADEE SUMNALOP/SAVE THE CHILDREN THE SUMNALOP/SAVE KULLWADEE 63 , Save the Children Save ,
62 Women on the Front Lines of Health Care: State of the world’s mothers 2010 State of the world’s Lines of Health Care: on the Front Women Source: Source: Between 1991 and 2007, the percentage of Indonesian births skilled by attended the percentage 1991 and 2007, Between both its Indonesia also lowered 32% to 79%. from than doubled, personnel more 390 maternal than 40% – from mortality more maternal and newborn rates by and from birthsdeaths per 100,000 live in 1989 to an estimated 228 in 2007, births deaths per 1,000 live to 19 during the same period. 32 newborn To keep the newly trained midwives motivated, the programme includes a the programme motivated, trained midwives the newly keep To its strategy has adapted in response mechanism and the government feedback system for the referral and improving modifying the training curriculum by emergency obstetric care. The midwives provide outreach and reproductive health services, immunisations immunisations health services, and reproductive outreach provide The midwives birthing a small room of them have Many nutrition. about proper and information at their home or clinic. INDONESIA – A MIDWIFE IN EVERY VILLAGE IN EVERY MIDWIFE INDONESIA – A in Indonesia who die in childbirth halved than of women has more The number in the investment of the government’s as a result largely years, last two the over died as a as 19,500 women as many In 1989, village’ programme. in every ‘midwife is 9,600. that number now, or childbirth; during pregnancy of complications result village ed 54,000 new trained and certifi Indonesia selected, years, seven Over 80,000. to approximately of midwives bringing its total number midwives, 24 MISSING MIDWIVES
MATTS LIGNELL/SAVE THE CHILDREN Afghanistan. A traineemidwife in training budgets. her baby. Allowing midwives totraindirectly canbeviewed asamore effi cient useof If someoneistrainedsolely asamidwife, alltheirwork isfocused onthemotherand and midwives whoare alsoqualifi ed nurses canbedivertedtoperform othertasks. midwives, choicedoesnotexist. thedirect entry This meanstrainingtakes longer as amidwife. Inmany countriesinthedeveloping worldof withacuteshortages nurse andthendoanadditional year andahalfinmidwifery, oryou cantraindirectly Training isakey issue. IntheUKifyou wanttobeamidwife, you canfi rst trainasa remove theplacenta, stopthebleeding andsave thenew mother’s life. placenta hadnotdetachedcompletely duringbirth. Madeenawasabletosafely had beenbleedingheavily for several hoursaftergivingbirth. The woman’s One nightwhenshewasonduty, a40-year-old woman cametotheclinicwho working inaremote community ofJawzjan, neartheborder with Turkmenistan. Madeena graduatedfrom collegeinOctober2009 andisnow themidwifery their villagestowork asmidwives aftergraduation. women onthecoursecomefrom different villagesandare required togo backto practical training, aswell asextensive practiceinanearby districthospital. Allthe Afghanistan.northern The 18-monthcoursegives women boththeoretical and Save theChildren isrunningamidwife collegeinShiberghan, Jawzjan province, in skilled personnelincreased from 6%to19%between 2003and2006. The percentage ofwomen inruralAfghanistanwhose deliveries were attendedby midwives are beingtrainedeachyear. intheirown villagesandcommunities.them inservice Anadditional 300to400 are now employed by thegovernment andNGOsacross thecountry, mostof and deploy midwives toruralareas. About2,400midwives have beentrainedand ofPublicHealthlaunchedaprogramme torapidly6 to31aftertheMinistry train Since 2002, schoolsinAfghanistanhasincreased thenumber from ofmidwifery reaching theageoffi ve. a onein11lifetime riskofmaternalmortality, andonechildinfi ve diesbefore ratesamongthehighestinworld.and childmortality Afghanwomen face Afghanistan isoneoftheriskiestplacesfor mothersandbabies, withmaternal AFGHANISTAN –MIDWIFE TRAINING COLLEGES Source: Women on theFront LinesofHealthCare: Stateof theworld’s 2010 mothers , Save theChildren
4 fi lling the gaps 25 PEP BONET/NOOR PEP The maternity ward in a The maternity ward in northernmedical centre Nigeria. 67 65 In a follow-up focus group with midwives who with midwives group focus In a follow-up 66
64 took part in the scheme, more than half indicated that they would be happy to be happy would than half indicated that they more took part in the scheme, after the scheme has ended. in their rural facility even working continue Save the Children is working in Nigeria as part is working of the Partnership Reviving the Children for Save and Child Health Maternal Newborn in NorthernRoutine Immunization Nigeria, newborn of maternal, the quality and availability which aims to improve Initiative, Katsina and Zamfara. northernand child health facilities in three states – Yobe, The programme reaches a population of more than 10.7 million people, roughly roughly than 10.7 million people, a population of more reaches The programme 7% of the total population. The initiative involves deploying newly qualifi ed, unemployed and retired midwives midwives and retired unemployed ed, qualifi newly deploying involves The initiative service is in a rural setting One year’s to health facilities in rural communities. to licensed being fully before graduated basic midwives mandatory newly for to been deployed have than 2,600 midwives More practise midwifery in Nigeria. The project in rural communities. many the country, 652 health facilities across a giving each midwife by and equipment, supplies improving includes plans for delivery book and a clean and safe ‘mama kit’ containing a personal health record the scheme has already a short-term solution, provide to Designed initially kit. due to its success. years to three two been extended from To overcome the challenge of staffi ng primary healthcare facilities in remote rural ng primary facilities in remote healthcare challenge of staffi the overcome To and child newborn the highest risk of maternal, have communities where areas, Service of Nigeria launched the Midwives Scheme. government the federal death, NIGERIA’S MIDWIVES SERVICE SCHEME – ENCOURAGING – ENCOURAGING SCHEME SERVICE NIGERIA’S MIDWIVES DISTRIBUTION EQUAL What all these solutions have in common is that they take political will and a sensible take in common is that they What all these solutions have The investment. reliable by backed strategy with long-term vision, human resources and job satisfaction at the heart well-being of the put the midwives’ must projects in the world of midwives the number that increasing These examples show project. right up to national policy. the local level from investment needs focused Encouraging an even distribution of midwives throughout a country a throughout is essential to make distribution of midwives Encouraging an even the support need. they have and children women most vulnerable that the poorest, sure to have likely more much are in urban areas is that women in most countries The trend only Yet had 2,100 midwives. Côte d’Ivoire In 2004, expert birth. support give when they the population live despite the fact that half of the cities, outside of 300 of them worked in rural areas. 26 MISSING MIDWIVES children fulfi l theirpotential. tolivebaby survives ahealthy, productive life and every mothercanlive toseeher for themotherandhernewborn baby. Itistimetoinvest inmidwives soevery newborn woman’s life isnotonly reassuring –itcanmake thedifference between life anddeath birth. The care amidwife provides duringsomeofthemostfrighteningmoments ofa Mothers willalways remember thevitalrole thattheirmidwife played whenthey gave recruit andtrainmidwives andprovide they need. themwiththesupport the lives canbesaved ofwomen andtheirbabiesinchildbirth to efforts by concerted words ofDavid Cameron: “It’s now timetotake asimilarly radicalapproach abroad” – the lives of250,000newborn babiesby 2015. safe deliveries andsave thelives of50,000women duringpregnancy andchildbirth, and more midwives. For itspart, theUKgovernment atleast2million hassaiditwillsupport number ofmidwives from 2,050to8,635, and Rwandahaspledgedtotrainfi ve times with pledgesthatspecifi cally referred tomidwives. Ethiopiacommittedtoincrease the progress towards thematernalandchildhealthgoals, several it countriessupported midwives. When theUNlaunchedEvery Woman, toaccelerate Childstrategy Every Rich andpoorcountrieshave already for boostingthenumber shown of theirsupport cannot bemet. child deathsby two-thirds by (MDG5) three-quarters (MDG4)andmaternalmortality are recruited, trainedandsupported, theMillenniumDevelopment Goalstoreduce more placesandsave thelives ofmore women andchildren. Unlessmore midwives to address it. There isamoralimperative toputmore ofthosesolutionstowork in We know thereasons ofmidwives for theshortage andwe know whatcanbedone easily prevented by someonewiththerightskills. newborn babieswillcontinue todieneedlessly from thatcanbe complicationsinbirth The world needsmore attendants. midwives andskilledbirth Without them, women and SUPPORT,GLOBAL OPPORTUNITIES GLOBAL RECOMMENDATIONS 5 CONCLUSION AND service in 1936 that led to an 80% reduction in maternal mortality in15years. in1936thatledtoan80% reduction inmaternalmortality service They responded withnew policiesandresources andestablisheda national midwifery in government inBritainwasa togethermaternalmortality “great blotonpublichealth”. In June 2010, David Cameron wrote andLiberalswere thatthelasttimeConservatives commitments ontherecruitment andtrainingofmidwives andhealthworkers. the healthworker gap, andwe willbecampaigningfor key governments tomake specifi c the lives ofmothersandchildren. Richandpoorcountriesmust work togethertoclose recognition ofthecentralrole thatmidwives andotherhealthworkers play insaving UN General Assembly inSeptember2011, itwillbetheidealmomentfor high-level governments anddonors. When world leadersanddonorscometogetheragainatthe numbers ofmidwives andtoinspireurgently neededcommitmentsfrom further other These commitmentsmust becomeafoundation for concrete actiontoboostthe 68
69 Inthe 5 conclusion and recommendations 27 – Donor – Donor governments – Donor governments exibility on public sector on public exibility – As part of delivering on the UN Secretary-General’s Every As part on the UN Secretary-General’s of delivering – – Despite claims of fl exibility, the International Monetary Fund is still exibility, – Despite claims of fl Make the International MonetaryMake Fund support fl Woman, Every Child strategy, governments should call for a high-level political event in political event a high-level should call for governments Every Child strategy, Woman, to c commitments specifi heads of state come together to make September 2011 where gap. ll the 3.5 million health worker fi code of practice Respect the international recruitment Ask the UN Secretary-General to host a health worker event at the UN event Ask the UN Secretary-General to host a health worker General Assembly All governments shortages. with health worker discouraging public spending in countries poor countries for exible economic policies fl push for must with seats on the IMF board can expand their health workforce. so they governments, especially those in the EU and G8/20, should put health workers at the should put health workers those in the EU and G8/20, especially governments, Every country with a critical health worker work. heart development of their ongoing human resources shortage and implement an effective should be supported to develop are health workers doctors and community nurses, midwives, more plan to ensure and to serve the poorest supported and deployed paid, equipped, trained, recruited, most marginalised communities. spending critical health worker countries with from health workers recruit not actively must Health Organization Global Code World to the adhere must All governments shortages. and adopted in 2010, of Practice on the International Recruitment of Health Personnel support their health workforces. depleted countries to rebuild Support countries to recruit more midwives and health workers and health midwives Support more countries to recruit RECOMMENDATIONS to: on governments is calling the Children Save 28 MISSING MIDWIVES 10 9 8 7 6 5 4 3 2 1 NOTES 13 October2007, p1287–88, doi:10.1016/S0140-6736(07)61550-5 15 newborn babiescanwe save?’, 14 13 pregnancy_safer/topics/skilled_birth/en/index.html WHO, ICMandFIGO. Geneva, World HealthOrganization, 2004www.who.int/making_ 12 11 developed by theUNinter-agency group estimation(9%) for childmortality group estimation–41%of8.1million. for childmortality Organization andintrapartum-related neonatal deaths’,stillbirths a systemicanalysis’, monitoring/9789241500265/en/index.html UNICEF, UNFPA and The World Bank, www.who.int/reproductivehealth/publications/ 5%20May%202010.pdf internationalmidwives.org/Portals/5/2010/IDM%202010%20News%20Release%20-%20 inchildbirth’, deathsandinjury needed toreduce unnecessary 30 April 2010www. from Unicef, inthreefor births years preceding thesurvey, withthemostrecentfi totalbirths gures obtained by comparingthepercentage ofwomen whoreported ‘no one’inthiscategory wasavailabledelivery (Measure DHSdatawasaccessed7March 2011). The estimatewas system deliver?’, attended by someone with midwifery skills. attended by someonewithmidwifery Levels and Trends 2010. inChildMortality Estimatedeveloped by theUNinter-agency Lawn, JE, ShibuyaKandSteinC, atbirth:‘No cry globalestimatesofintrapartum Black, REetal(2010), ‘Global, regional in2008: andnationalcausesofchildmortality Seenote2. InternationalConfederation ofMidwives, News Release: ‘350,000 more midwives Estimatedfrom DHSdatafrom 40countriesfor whichdataonassistanceduring Unicef, Lawn, JEetal(2009), ‘Reducing intrapartum-related deathsanddisability: canthehealth Trends inMaternalMortality: 1990to2008. Estimatesdeveloped by WHO, Obaid T A (2007), ‘No woman shoulddiegivinglife’, Darmstadt, Getal(2005), ‘Evidence-based, cost-effective interventions: how many The Lives Saved Tool: www.jhsph.edu/dept/ih/IIP/list/index.html ‘Making pregnancy safer: thecriticalrole oftheskilledattendant’, jointstatement by InternationalConfederation ofmidwives, ‘The defi nition ofamidwife’, 19July, 2005 BlackREetal, seenote7; Levels and Trends 2010. inChildMortality Estimated The Stateofthe World’s Children 2011 , vol 83, number 6, June 2005, p409–17 The Stateofthe World’s Children 2011 International JournalofGynecology andObstetrics The Lancet , vol 375, issue9730, p1969–87 The Lancet , vol 365, p977–88. . were 35%of136,712,000births not . Bulletin ofthe World Health The Lancet , 107, p. S128 , Volume 370, Issue9595, notes 29 34:396.
. , p 116–19. , Seminars in Perinatalogy The State of the World’s Children 2011 Children World’s The State of the 2011 Children World’s The State of the 2011 Children World’s The State of the 2011 Children World’s The State of the The State of the World’s Children 2010 Children World’s The State of the The State of the World’s Children 2011 Children World’s The State of the Nigeria Standard DHS 2008, p9–134 http://www.measuredhs.com/pubs/pdf/FR222/ DHS 2008, Nigeria Standard Unicef (2011), Unicef (2011), Unicef (2011), Unicef (2011), Unicef (2011), Unicef (2011), The numbers of deaths are from Black R E et al – see note 7. Numbers of births are Black R E et al – see note 7. from are of deaths The numbers Lawn, J E et al (2009) – see note 1. Lawn, R E et al (2010) – see note 7. Black, Wall, S N, et al ‘Reducing intrapartum-related neonatal deaths in low and middle- deaths in low neonatal ‘Reducing intrapartum-related et al S N, Wall, Unicef, Unicef, R E et al (2010) – see note 7. Black, In 2007 the Cochrane Review looked at how training traditional birth at how attendants looked In 2007 the Cochrane Review Healthy Newborn Network, ‘Changing perceptions to save newborns’ lives’, lives’, newborns’ to save ‘Changing perceptions Network, Newborn Healthy Healthy Newborn Network, ‘Dr Abhay Bang refl ects on the importance Community of Bang refl Abhay ‘Dr Network, Newborn Healthy see note 4. with health the Children Save interviews out by carried from These examples come FR222.pdf 31 29 30 from Unicef, Unicef, from 27 28 26 income countries – what works?’ income countries – what works?’ 24 25 23 21 22 (TBAs) improved health behaviours and pregnancy outcomes. They looked at four at four looked They outcomes. and pregnancy health behaviours (TBAs) improved One cluster- TBAs 27,000 women. and nearly than 2,000 more involving studies, regarding rates in the intervention group lower cantly signifi randomised trial found a The trial in Pakistan found perinatal death rate and neonatal death rate. stillbirths, L M, Sibley reduction. with a 30% TBA training on perinatal mortality, of cant effect signifi birth attendant Traditional McNatt K and Habarta N. Diallo M M, C M, Brown A, T Sipe Cochrane Database outcomes. and pregnancy health behaviours improving training for 10.1002/14651858. DOI: CD005460. article no. issue 3, 2007, of Systematic Reviews http://apps.who.int/rhl/pregnancy_childbirth/antenatal_care/general/ CD005460.pub2. cd005460/en/index.htm 23 September 2010, http://www.healthynewbornnetwork.org/press-release/changing- 23 September 2010, perceptions-saves-newborns%E2%80%99-lives 20 Health Workers’, http://www.healthynewbornnetwork.org/press-release/dr-abhay-bang- Health Workers’, ects-importance-community-health-workers refl 19 workers in Liberia and Sierra Leone, and a traditional birth in Nigeria. attendant Leone, in Liberia and Sierra workers 18 17 16 30 MISSING MIDWIVES 45 44 43 Health MDGs 42 Health MDGs 41 40 39 38 37 36 35 34 33 32 50 49 http://www.oanda.com/ The Lancet 48 47 Unicef, katine-chronicles-blog/2010/mar/30/traditional-birth-attendants-ban; ratesfrom birth 46 2009–2013, p21 dh_digitalassets/@dh/@en/documents/digitalasset/dh_4097734.pdf healthcare professionals, December2004, www.dh.gov.uk/prod_consum_dh/groups/ www.youtube.com/watch?v=tCSmIYmPOi423 February health-workers-uk-us-worlld http://www.guardian.co.uk/global-health-workers/interactive/infographic-mortatlity-rates- global/pid/84 Sierra LeoneDHS, 2008, p122 Save theChildren, McCoy, Detal(2008), ‘Salaries andincomesofhealthworkers insub-Saharan Africa’, http://www.bbc.co.uk/tv/features/toughestplace/midwife.shtml Guardian, attendants?’,‘Should Ugandabantraditionalbirth www.guardian.co.uk/katine/ ofHealth, RepublicofRwandaMinistry cooperationstrategy,WHO country Rwanda Unicef, ofHealth, Department Codeofpracticefor theinternationalrecruitment of Action for GlobalHealth(2010), Action for GlobalHealth(2010), GlobalHealth Worker Alliance. animationonhealthworker Flo, accessedon The Guardian, ‘Which countriesare facedwitha ‘critical’ healthworker shortage?’, Save theChildren (2011), World HealthOrganization, InternationalConfederation ofMidwives, News Release–seenote4. Measure DHSdata–seenote3. UNFPA, ‘It takes two: inmaternalhealth’, menaspartners http://www.unfpa.org/public/ ofHealth(2011), Federal RepublicofNigeriaMinistry Unicef, State ofthe World’s Children The Stateofthe World’s Children 2009 The Stateofthe World’s Children SpecialEdition, 2009 , 371: 3675–81. Conversion 2011usingOANDA, intosterling on14February
State ofthe World’s 2010 Mothers No ChildBorntoDie Global Health Atlas
Health Workers the Urgently NeededtoReach Health Workers the Urgently NeededtoReach , p60 , p17 , http://apps.who.int/globalatlas/ Saving Newborn LivesinNigeria , statisticaltables, p10 notes 31 , http://www. , Saving Newborn Lives in Nigeria Saving Newborn , p119 , www.unicef.org/sowc01/pdf/ p105, , State of the World’s Mothers: Women on the front lines of on the front Women Mothers: World’s State of the State of the World’s Mothers 2010 World’s State of the , p20 , The State of the World’s Children 2011 Children World’s The State of the 2001 Children World’s The State of the More Money for Health and More Health for the Money for Health Health and More for Money More Adegoke, A and Abubakar, A, Report to PRRINN-MNCH: Programme report on Programme Report to PRRINN-MNCH: A, Abubakar, A and Adegoke, Women Deliver, ‘Celebrate solutions: the midwives services scheme, Nigeria’, Nigeria’, services the midwives scheme, ‘Celebrate solutions: Deliver, Women Federal Republic of Nigeria Ministry of Health (2011), Republic of Nigeria Ministry Federal of Health (2011), Save the Children, the Children, Save http://apps. 2006’, Workforce Atlas of the Health ‘Global Health Organization, World Save the Children (2010) the Children Save Pakistan DHS, 2006–07 Pakistan DHS, Department for International Development, ‘Training the next generation of midwives the next generation of midwives ‘Training Department International Development, for USAID, ‘About Paiman’, http://www.paiman.org.pk/aboutpaiman/overview. Paiman’, ‘About USAID, Countdown to 2015, Decade report (2000–2010) p20, http://www. Decade report (2000–2010) p20, to 2015, Countdown Unicef, Unicef, Unicef, World Health Organization, WHO Global Code of Practice on the International WHO Global Code of Practice on the International Health Organization, World Action for Global Health, ‘The IMF, the global crisis and HRH: still constraining policy still the global crisis and HRH: ‘The IMF, Global Health, Action for World Health Organization, Global Health Observatory, accessed at http://apps.who. Global Health Observatory, Health Organization, World High Level Taskforce on Innovative International Financing for Health Systems International Financing for on Innovative Taskforce High Level ‘US$40bn – UN Secretary General’s global strategy for women and children fi nancial fi and children global strategy women for UN Secretary‘US$40bn – General’s http://www.womendeliver.org/updates/entry/celebrate-solutions-the-midwives-services- scheme-nigeria/ 67 66 who.int/globalatlas/docs/HRH/HTML/Geo_occ.htm 65 63 64 62 healthcare in Pakistan’, 12 January 2009, http://webarchive.nationalarchives.gov.uk/+/http://www.dfi d. http://webarchive.nationalarchives.gov.uk/+/http://www.dfi 12 January 2009, in Pakistan’, les/asia/pakistan-maternal-health.asp gov.uk/casestudies/fi 61 php#PAIMAN 60 countdown2015mnch.org/reports-publications/2010-report 59 SOWC5.pdf 58 Recruitment of Health Personnel, http://www.who.int/hrh/migration/code/practice/en/ Recruitment of Health Personnel, 56 57 space’, http://www.actionforglobalhealth.eu/uploads/media/IMF_Paper10Reduced_02.pdf space’, 55 int/ghodata 54 (2009) les/documents/taskforce_report_EN.pdf internationalhealthpartnership.net/CMS_fi 53 estimates’, http://www.who.int/pmnch/activities/jointactionplan/100922_1_fi nancial_ http://www.who.int/pmnch/activities/jointactionplan/100922_1_fi estimates’, estimates.pdf 52 51 follow-up and supportive supervisionfollow-up of midwifery service scheme (MSS) midwives and Zamfara states Yobe to PRRINN-MNCH cluster facilities in Katsina, deployed 32 MISSING MIDWIVES 69 reproductive, maternalandnewborn healthinthedeveloping world pregnancies, andhealthy newborns – safe births The UK’s framework for results for improving 68 guardian.co.uk/commentisfree/2010/jun/03/aid-developing-world-targeted-money David Cameron, ‘Our aidwillhitthespot’, The Guardian, 3June 2010, http://www. for InternationalDevelopment Department (2010), Choices for Women: Planned . MISSING MIDWIVES
“This report from Save the Children clearly demonstrates that midwives are critical to saving the lives of mothers and newborn babies. Filling the global shortage of 350,000 midwives must be a global priority if we are to reduce the terrible rates of maternal and child mortality in the world’s poorest countries.
“Missing Midwives highlights the important role that the midwife plays within the wider health system, and lays out a range of solutions to recruit, train, support and deploy more midwives to the places where they are needed most. Save the Children tells us exactly what needs to happen both in developing countries and in terms of global political action. These recommendations cannot be ignored.
“Missing Midwives is essential reading for anyone concerned with reducing the burden of maternal and newborn deaths.”
Dr Tony Falconer President, Royal College of Obstetricians and Gynaecologists
savethechildren.org.uk