3. INTRODUCTION
• The global maternal mortality ratio has dropped by 44% over the past 25
years, from an estimated 385 maternal deaths per 100 000 live births in
1990 to 216 per 100 000 in 2015.
• However, in terms of actual numbers it is estimated that 303 000 women
died while giving birth in 2015;
• 99% of these preventable maternal deaths occur in low- and middle-
income countries.
• Similarly, the global neonatal mortality rate fell from 36 deaths per 1000
live births in 1990 to 19 in 2015, but 2.7 million neonatal deaths still occur
each year.
• The UN Global Strategy for Women’s, Children’s and Adolescents’ Health
(adopted as part of the new Sustainable Development Goals for 2016–30)
highlights the urgent need for further progress to be made, and for this to
be based on gender responsive, equity driven and rights based
approaches with increasing emphasis on quality of midwifery care
4. Introduction
• Midwives are also deeply frustrated by the realities they
experience that constrain their efforts.
• Importantly, they express how they are hindered through a
lack of voice in creating the change and delivering the
creative solutions they know which are so badly needed.
• These experiences are universal across the information
collected regardless of whether midwives care for women
and newborns in high-, middle- or low-income countries.
• “power, agency and status” is important for midwifery
personnel if progress is to be made in delivering quality
care
5. Experiences of midwives
• 2,470 midwives were involved in the survey
Experiences of disrespect, subordination and
gender discrimination.
7. Socio-cultural barriers:
• harassment, unsafe accommodation, social isolation
• 37% of all the midwives in the survey have experienced
harassment at work, with many describing a lack of security and
fear of violence.
• A significant number of respondents, say that disrespect in the
workplace “extends to harassment – verbal bullying and, at times,
physical and sexual abuse”.
• This affects their “feelings of self-worth and their ability to provide
quality care”.
• Other barriers to providing quality care include living in inadequate
and unsafe accommodation leading to isolation from family
support, and difficulties in managing paid employment with
domestic and childbearing responsibilities
8. Economic barriers:
• salaries not comparable, not enough for basic needs
• Economically, the midwives reported low salaries that are not
comparable with similar professions and are sometimes not enough
to live on.
• One fifth of those who participated depend on another source of
income to survive, which adds to the pressure and exhaustion that
they experience.
• Yet many still place ethical values of care above salary levels, for
example the midwives in one country “aim to get fully trained and
gain experience in public sector hospitals even though we know
that the salaries are much lower than the private sector”
• Others felt that because midwifery does not come high on the
political agenda there is inadequate resourcing of midwifery
services and that “the vital role of midwifery is not recognized,
and therefore funding is not sufficient”
9. Professional barriers:
• lack of opportunity for leadership is
disempowering Professionally, 89% of
respondents reported that a clear understanding
of what midwifery involves is critical for change
to take place.
• Concerns were also expressed over the perceived
devaluing of midwifery combined with the
increasing medicalization of birth.
• Others felt that the lack of leadership
opportunities for senior midwifery staff
10. Listen to Voice of midwives
• We must listen to the voices of midwives to improve quality
of care Writing about the Global Maternal Newborn Health
Conference held in Mexico in 2015,Richard Horton (Editor-
in-Chief, The Lancet), notes that we need the right leaders,
and to invest in more midwives.
• “There are certainly successes to celebrate globally. But
there are terrible failures too.
• , globally, midwifery personnel have an in-depth awareness
of what is needed to improve quality of care,
• yet their voices are rarely heard and subsequently key
issues are absent from the international, national or local
policy dialogue.
11. VOICE OF MIDWIVES,
• Ghana: “Supportive policies are absent or weak. Midwives are not consulted at
policy level.”
• Liberia: “We have no influential person at policy-maker level who is eager for
midwives rights and responsibility and benefits. We are not fully empowered
because of lack of basic human needs.”
• Nigeria: “Poor remuneration for midwives and lack of career path as a midwife.”
• Rwanda: “The population does not know the role of midwives.”
• Uganda: “One of the problems is the high level of corruption that means money
allocated to health services is not used as specified [at all levels] and in the past
health workers have been poorly paid/delayed to be paid and even unpaid.
• There is often an absence of equipment or drugs as some have been directed to
medical staff’s private clinics/business as it means they get more income as people
pay for the services rendered.
• Here medical care is seen as a business, people open a drug shop or clinic as
income generation
12. Conditions at work and how midwifery
personnel feel at work
• in places of work midwifery personnel sometimes feel
unsafe, unsupported, disrespected and unable to provide
care in people’s homes.
• Some 37% of respondents experience harassment at work,
while 15% are rarely or never supported at work and 15%
rarely or never have good supervision.
• Consequently, a significant proportion (45%) of midwifery
respondents are exhausted and around 10% feel
traumatized, lonely, scared or angry.
• These negative feelings are likely to be the result of social,
professional and economic pressures, which often
intersect, and may run the risk of midwives developing
burnout
13. Why midwifery personnel think they
are sometimes treated badly.?
• midwifery personnel think health system issues are a significant
reason for poor conditions at work.
• For example 68% of respondents said that there were not enough
staff so that they are all overworked;
• 55% said that the health system is disorganized;
• 40% think managers are not doing their jobs properly and 43%
attribute poor conditions to lack of equipment and supplies.
• However, social barriers appear to underpin some of the
experiences of midwifery personnel with a quarter of respondents
linking the poor treatment and conditions to gender inequality and
discrimination against women;
• and 19% think that poor training adds to the low status of
midwifery personnel. Interestingly, a higher percentage of African
respondents have marked all of the above as social and professional
barriers
14. Combining work as a midwife with
family life
• One of the significant social barriers for most midwifery personnel
is the challenge of combining family, caring and reproductive
responsibilities with working life.
• The long and stressful hours of work have badly affected 40% of
respondents’ families in the survey.
• Nearly 40% of respondents feel that their house is a mess as they
don’t have enough time to clean and tidy and likewise 38% are
leaving children under 14 years alone while they work.
• Economic pressures mean that just over 20% of women have
another source of income, which must add to the time pressure
and exhaustion that they feel.
• However, the affected midwifery personnel are not entirely on their
own as 82% of respondents get some help from their families and
around 74% are being supported and helped with housework by
their husbands
15. Issues of midwives in Rural
• Midwives’ years of practice ranged from a minimum of
three to 10 years.
• Five themes emerged from the individual interview
transcripts regarding the challenges experienced by
midwives in care delivery to rural women:
• 1. Inadequate infrastructure (lack of beds and physical
space).
• 2. Shortage of midwifery staff.
• 3. Logistical challenges.
• 4. Lack of motivation.
• 5. Limited in-service training
16. Inadequate infrastructure (lack of beds
and physical space).
• “In rural areas, we have big problems with
wards and beds. Sometimes, due to
inadequate rooms and beds, anytime we have
more than three women in labour, we are
compelled to put them on mattresses on the
floor because the room can only contain three
women at a time”
17. • “But the place for HBB is too small, you see.
Sometimes you put almost 10 babies there,
and in the same place, we have to do HBB, so
it is not suitable. It is not enough. I think that
place can cause cross-infection because you
fnd one baby sucking on another baby,
sucking on its hand, on the clothes of the
other baby. I don’t like that place. Better with
the mother” (Mkunga_05
18. • “Sometimes you deliver a baby who needs
resuscitation, and you have no equipment for
resuscitation nearby, so you must run to fnd
the equipment, and the resuscitation needs to
be performed in the golden minute, one
minute to help the baby to breathe. So, it can
take more than one minute before you can
help the baby, and this is very, very
discouraging to me”
19. • “If I don’t get enough resources, I feel bad
because my work will be hindered. I will not be
able to perform my work well. So, when I have
enough resources, I can perform my work
efectively” (Mkunga_03)
• “The midwife in the labor ward is not a
permanent nurse at the site. They’ll come, you
train the midwife to understand the labor ward,
then three months later they go to another unit,
and another midwife comes who is not as skillful”
(Mkunga_06
20. Shortage of midwifery staff.
• "In this clinic, we are only three midwives manning the
maternal and child health services. We currently
handle the responsibilities of about five or more
midwives which is making us get stressed up…".
• Some participants felt exhausted due to continued care
delivery without breaks, which was causing burnout.
“We hardly take our annual leave because of the
inadequate number of midwifery staff in our facilities.
• I have not taken my annual leave for three years I have
been posted here as a midwife”
21. Lack of motivation
• All participants in this study acknowledged that
despite the workload on midwives in rural , they
were not compensated or incentivised.
• The midwives felt unnoticed and that their efforts
to deliver quality maternal and child health
services went unrecognised. “I must say that it
appears no one recognises our work in this
remote area where there is a lot of work. I have
never been paid any allowance since I started
working in this remote area for almost five years
now”
22. • “…However, I must say that our only
advantage and motivation for working in
these rural areas is that our promotions are
faster than our colleagues in the towns and
cities”. “One good thing about working in
these rural areas is that we can be allowed to
go to school for further studies with pay when
we work for at least two to three years…”.
23. Logistical issues
• The midwives felt that they were neglected by
clinic managers because they made requisitions
for the necessary supplies, but their voices were
not heard.
• “In this clinic, the challenge we face here is not
only about beds and space to put the clients but
also consumables and supplies such as gloves,
liquid soap, cotton, and gauze.
• We have always been improvising in every
procedure we perform in this clinic”
24. Limited in‐service training
opportunities
• “It is a disadvantage of working in rural areas in the north. As we
are working here, we are only able to attend few in-service training
courses, unlike our colleagues who are in the cities who have the
opportunity to attend lots of workshop training all the time”.
• “I must acknowledge that workshops have been organised by
Health Service and other bodies, but due to our number (a few
staff), we are unable to attend most of those workshops”
• they also do not have the opportunity for effective mentorship and
coaching by senior and experienced midwives in rural areas.
“…Hmmm, our problems are just too many. When you are posted
here, you are just on your own. There are no senior or more
experienced midwives here to mentor or coach us…”
25. • Some midwives expressed a desire to be more actively
involved in weekly multidisciplinary perinatal clinical
meetings to discuss and learn from neonatal mortality
and morbidities and carry out training:
• “As a midwife, it’s easy to help others if we are sitting
in a meeting, a regular meeting.
• For the meeting on wellness, we talk about how to care
for the patient in the ward. Regular and monthly
meetings of the staf of the labor ward are held,
reminding the midwife of her roles, how to help the
mother, how to help the baby so that they begin and
end labor safely with their baby.”
26. Changes that midwives would like to
see
• better pay (70%).
• professional development (53%)
• Respect – ( 36% ) from senior health staff
• value supportive supervision and being listened
to(and 32%)
• recognition and status
• information campaigns to make sure the public
knows the importance of midwifery person
• support for professional midwifery associations
27. • An increase in the availability and quality of
training, mentoring and supervision for midwifery
personnel,
• Investment in resources including more
personnel, cleaner, more hygienic and better
equipped maternity units and access to free
delivery packs.
• The formation and widespread recognition of
midwives associations, specialist midwife led
units and the Midwives Service Scheme
28. • The use of maternity support workers or less qualified
staff to do some of the less specialist tasks thereby
taking the burden from overworked midwifery
personnel.
• Social and professional awareness and recognition for
the work of midwifery personnel
• Encouragement of homebirths and natural births
within the health system, including listening to
pregnant women’s choices and upholding rights,
thereby enabling midwifeled care.
• Exchanges of learning, and roles, between midwifery
personnel and nurses and other colleagues.
29. FURTHER SUGGESTIONS FOR
CHANGES
• Ethiopia: “Further training in obstetrics so that midwives
could be allowed to conduct caesarean sections especially
in rural communities.”
• Kenya: “Create a forum for sharing experiences and getting
more involved in research work.”
• United Kingdom: “That midwives should be given as much
respect for their expertise in pregnancy and normal birth as
the obstetric doctors are given for their expertise in
abnormality of pregnancy and birth.
• Midwives should be able to practice in a truly autonomous
way.
• Micro-management does not make for good practitioners.”
30. SUGGESTIONS FROM AFRICAN
COUNTRIES FOR ENCOURAGING
CHANGE, EXTRA COMMENTS
• A profession separate from nursing and regulations specifically for
midwives.
• More jobs for midwives, to show how important they are in the
society.
• More working personnel to be employed, especially in Zambia
where graduates often wait for years before finding employment.
• In South Africa, midwives and nurses have one governing body, i.e.
South African Nursing Council (SANC). “Midwives should have their
own governing body, as essentially we are not nurses.
• We are midwives.” Encourage midwives as policy-makers.
Educational planners and researchers need to have enough
knowledge of the profession (midwife) and the scope of practice of
midwives
31. MORE EXAMPLES OF GOOD PRACTICE,
EXTRA COMMENTS
• Kenya: “In the county that I work in, trainings and professional
development programmes have been organized by the health
department through donor support. These trainings are on
emergency obstetric care.
• Once midwives are armed with such practical knowledge, it
becomes easy for them to apply this knowledge in their day-to-day
work.”
• Peru: “Having midwife managers and supervisors who are part of
the management team allows our issues to be more visible and
enables the correct decisions to be made.”
• Rwanda: “The continuous professional development for midwives
is improved and it increases the knowledge and skills to better
serve. The recognition of midwives in Rwanda from the Rwanda
Association of Midwiv
32. EXAMPLES OF FURTHER CHANGES
THAT RESPONDENTS WOULD LIKE TO
• Ethiopia: “Further training in obstetrics so that
midwives could be allowed to conduct caesarean
section especially in rural communities.”
• Kenya: “Create a forum for sharing experiences
and getting more involved in research work.”
Liberia: “Motivations such as scholarship should
be provided for committed midwives, including
student midwives, to study abroad in the same
field and return to your country to serve in the
midwifery institutions as there are no midwifery
educators in my country.”
33. • Srilanka : midwifery is in a mess and facing unnecessary problems.
• Uganda: “Ugandan Nurses & Midwives Council was getting support
from the Royal Collage of Midwives, but our project is finishing now
and there is no more funding. I was in a high-level meeting with top
Ugandan colleagues, to discuss midwifery supervision and the way
forward. I fear it will now all collapse.”
• United Kingdom: “That midwives should be given as much respect
for their expertise in pregnancy and normal birth as the obstetric
doctors are given for their expertise in abnormality of pregnancy
and birth.
• Midwives should be able to practice in a truly autonomous way.
Micro-management does not make for good practitioners.”
34.
35. International Confederation of
Midwives Strategic Plan 2021-2023
• ICM has and continues to also solidify its
added value to the broader landscape of
partners by contributing to improving sexual,
reproductive, maternal, newborn, child, and
adolescent health (SRMNCAH), gender
equality, and equal access to quality health
care for women and communities.
36. Strategic Priority 1:
• Drive innovation and sustainability for the future of midwifery
• Ensure a sustainable ICM, including human, social, economic, and
environmental elements
• Utilise and promote more digital and mobile tools and knowledge
management resources to reach and support midwives and their
associations (including at different stages of their professional
development, and in different country contexts, digital access, and
languages)
• Facilitate an agile ICM that is constantly learning and responding to
the needs of its members in new and improved ways
• Foster and build the next generation of midwives while leveraging
the knowledge and wisdom of older generations, fostering cross-
generational learning
37. Strategic Priority 2:
• Develop, strengthen, and support the rollout of
a new professional framework for midwifery
• Promote midwifery as an autonomous
profession with a distinct philosophy and
approach to care
• Facilitate an enabling environment for midwives
• Strengthen midwifery education, regulation,
associations, leadership, and model of care
• Synthesize and drive research, evidence, and
essential competencies for the profession of
midwifery
38. Strategic Priority 3:
• Foster a movement for midwifery, enabling and strengthening partnerships,
advocacy, and communications for midwifery, with women’s voices at the centre
• Leverage advocacy and communications to influence and educate policy-makers
and wider audiences on the impact of and need for midwives
• Utilize effective and equitable relationships to build and support the profession of
midwifery and expand the influence of ICM
• Build up partnerships between women and midwives, from the individual level, to
the community level, to the global level (women’s rights and empowerment,
woman-centred, respectful care, and gender equality)
• Support partnerships between midwives (support for MAs, mentorship, strong
regional support, twinning)
• Strengthen partnerships between midwives and other stakeholders, including
global and national policy-makers, other health professionals (obstetricians,
paediatricians, nurses), traditional caregivers, other health workers and
associations, and partners across sectors (SRHR, Women’s Rights, UHC, etc.
39. • Cross-cutting: Promote gender equality by employing a gender
lens and prioritisation across all elements of the strategic plan
• As gender equality impacts every element of the three priorities of
ICM’s newly developed strategic plan, understanding how pervasive
inequalities affect the profession of midwifery is vital to ensuring
ICM’s remit is poised to work to address these issues.
• By utilising a gender lens (e.g., examining elements of work and
their impact on women and gender equality), across all of the
strategic priorities as well as their key objectives, ICM will be better
positioned to both promote gender equality and to work to enact
processes and approaches that will help to shape the lived realities
of midwives and the women they serve in a variety of geographies.
49. • MIDWIVES ARE THE WORLD’S ORIGINAL FIRST
RESPONDERS. THEY STOOD BY US, NOW LET’S
STAND BY THEM.
• Midwives were supported and invested in by
governments all over the world. We would see
the following by 2035: 4.3 million lives saved
every year 1.9 million stillbirths averted every
year 2 million neonatal deaths averted every
year 280K maternal deaths averted every year
