PHOTO: Isaac Quesada on Unsplash
PHOTO: Isaac Quesada on Unsplash

More midwives could save millions of lives

Embargoed until: Publicly released:
Peer-reviewed: This work was reviewed and scrutinised by relevant independent experts.

Simulation/modelling: This type of study uses a computer simulation or mathematical model to predict an outcome. The original values put into the model may have come from real-world measurements (eg: past spread of a disease used to model its future spread).

Increasing the number of midwives and their level of care could reduce birth-related deaths by two thirds in low and middle income countries over the next 15 years. Too few midwives, along with poor training and support, result in inadequate care for pregnant women and their babies. This modelling study says even modest improvements in midwife provision could have significant impacts in reducing mother and baby deaths.

Journal/conference: The Lancet Global Health

Link to research (DOI): 10.1016/ S2214-109X(20)30397-1

Organisation/s: The University of Sydney, Burnet Institute, Novametrics, UK, Works Health Organisation, Switzerland

Funder: This study was funded by New Venture Fund. It was conducted by researchers from Novametrics Ltd. World Health Organisation, United Nations Population Fund, University of Sydney and Burnet Institute, Melbourne.

Media release

From: The Lancet

Study estimates multinational investment in midwives could save 4.3 million lives per year by 2035

·      About two-thirds of maternal deaths, newborn deaths and stillbirths could be prevented by 2035 if the current level of professional midwife healthcare was scaled up to an extent where a range of interventions such as family planning, diabetes management, assisted delivery and breastfeeding support were delivered worldwide.

·      Even a modest increase in the provision of care by midwives of 10% every five years would avert around a fifth of maternal and neonatal deaths and 14% of stillbirths globally by 2035, according to this new modelling study.

·      Greater investment in midwives in low-to-middle income countries could improve the survival of mothers and babies but, to realise this potential, midwives need sufficient training, to be part of a supportive and skilled team, and work in an environment with adequate water, sanitation and medical supplies.

A new modelling study published in The Lancet Global Health journal estimates that scaling up the provision of midwife-led care across the world could potentially reduce maternal deaths by 67%, newborn deaths by 64% and stillbirths by 65% if midwives were enabled to provide a range of interventions from family planning to post-natal care. This could equate to saving 4.3 million lives per year by 2035.

Improving the health of mothers and newborn babies remains an important priority on the international agenda and there has been an increasing awareness around the role of midwives in addressing this need.

This new study provides evidence for the potential impact of scaling up midwife delivered healthcare and calls for greater investment in the profession, not only to increase the numbers of midwives but to improve their education, training, regulation and working environment.

Lead author Dr Andrea Nove from Novametrics Ltd., UK [1], says: “Supported by appropriate professional education, regulation and improved working environments, it is possible to achieve a substantial increase in the level of provision of essential interventions delivered by midwives. This could save millions of lives. However, there are numerous barriers to fulfilling this level of scale-up, particularly in low to middle income countries. These include inequitable distribution of qualified midwives, poor transport links, lack of supplies and equipment and, in some countries, a lack of trust from the public. There is need for greater recognition of the importance of supporting and enabling this service to reach its potential.” [2]

The new study follows a past report on midwifery in The Lancet [3] and uses the Lives Saved Tool (LiST) which models the deaths that could be avoided, assuming a specific uptake, effectiveness and impact of a range of interventions. Using an updated version of LiST, the current study aimed to provide a more accurate estimate of the impact of increasing the provision of midwife healthcare around the world.

The study used the LiST to model effects on mortality at a country level of about 30 essential interventions which can be delivered in their entirety by competent and enabled midwives. These were treatments, responses and procedures that can be provided before conception, in antenatal care, during labour and birth and after birth, such as family planning, hypertension screening, induction of labour and the use of antibiotics for newborn sepsis [4].

Four scenarios were used to demonstrate the effects of changes in the level of provision of midwife healthcare around the world. These were a modest increase of 10% every five years in the coverage of interventions, a substantial increase by 25% every five years, an increase that would reach 95% of coverage by 2035 (universal coverage), and a decrease in coverage by 2% every five years such as might occur if investment in midwives did not keep pace with population growth.

The study modelled the effect of changes in the level of provision of healthcare interventions delivered by midwives for 88 countries and amalgamated the results. This was also done for three groups of countries that were categorised according to their level of development. If current mortality rates persist, in these 88 countries there will be over three million stillbirths per year by 2035, three million newborn deaths per year by 2035 and over 400,000 maternal deaths per year by 2035.

Researchers estimated that relative to the current provision of healthcare by midwives, a substantial but realistic increase (25% increase every five years) in the 88 countries would result in 41% fewer deaths of mothers, 26% fewer stillbirths and 39% fewer deaths of newborn babies. In absolute numbers this would mean averting 170,000 maternal deaths, 852,000 stillbirths and 1.2 million newborn deaths per year by 2035. The reduction in deaths was estimated to be greater in the least developed countries.

Even a modest scale-up in interventions (10% every five years) delivered by midwives would result in 22% fewer maternal deaths, 14% fewer stillbirths and 23% fewer deaths of newborn babies. It is estimated this would avert 93,000 maternal deaths, 448,000 stillbirths and 718,000 newborn deaths per year by 2035.

Scaling up midwife delivered interventions to ensure universal coverage (95% coverage) by 2035 could result in a 67%reduction in maternal deaths, a 65% reduction in stillbirths and a 64% reduction in deaths of newborn babies, according to the study. Similar to the scenario of a substantial increase in coverage, these reductions would be greatest in the least developed countries. Overall, this universal scale-up could potentially avert 280,000 maternal deaths, 2.1 million stillbirths and 2 million neonatal deaths annually by 2035.

In comparison, a small decrease (of 2%) in the provision of midwife delivered healthcare would result in 34,000 more maternal deaths, 222,000 more stillbirths and 295,000 more newborn deaths per year by 2035.

Co-author Maria Najjemba from the Uganda Country office, United Nations Population Office says: “Midwives, especially in developing countries, are at the core of primary healthcare. They provide support along the continuum of care, from promotion to prevention, treatment and rehabilitation, to end-of-life care. Midwives play key roles in empowering clients, facilitating teamwork across disciplines, and providing client-centred care. Scaling up midwife delivered interventions can be a game changer that will give midwives the much-needed confidence to reach everyone and provide quality care to reduce maternal and neonatal mortalities.” [2]

In the universal coverage scenario, the authors estimate that family planning could avert the most stillbirths and deaths of newborn babies in the least developed countries. In countries with medium development, interventions during pregnancy, such as management of hypertension, might make the greatest contribution towards reducing stillbirths, while interventions during and after childbirth such as assisted vaginal delivery and management of newborn sepsis, might make the greatest contribution to reducing newborn deaths.

Writing in a linked Comment, lead author Professor Mary Renfrew (who was not involved in the study), from the University of Dundee, UK says: “These new findings build on and strengthen existing evidence on the impact of quality midwifery care in averting deaths and improving health and wellbeing outcomes. They should command the attention of the global community in the same way that a new drug or innovative technical intervention would. There is serious and longstanding under-investment in international-standard midwifery. Gender, social, professional, and economic disempowerment of midwives and the women they care for all contribute to this.”

Professor Renfrew added: “It is time to overcome the barriers and ensure all women and newborn infants have access to quality care by midwives.”

The authors note some limitations in the study. In reality, midwives provide a much wider range of interventions than included in the LiST model and the full scope of practice was not represented. Midwives play important roles in teams performing other life-saving interventions such as caesarean sections, assisted deliveries and blood transfusion. In addition, estimates in countries where midwifery is not an established profession might not hold true becauseinterventions will be delivered by other health professionals.

By estimating the impact of changes in the coverage of interventions delivered by midwives the study highlights the potential for this profession to save millions of lives each year. According to the researchers, there are many challenges to achieving this potential but their findings indicate that targeted investment in the education of midwives and the healthcare systems in which they work could make a large contribution to the health of mothers and babies.

[1] Novametrics Ltd. Is a research and analysis company specialising in health workforce

[2] Quote direct from author and cannot be found in the text of the Article.

[3] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60790-X/fulltext

[4] A list of the 30 interventions can be found in the Appendix. For an intervention to be included in the modelling study it had to be available within LiST, deliverable in its entirety by a midwife according to International Confederation of Midwives (ICM) standards and listed as an essential intervention within the ICM essential midwifery competencies or the Global Strategy for Women’s, Children’s and Adolescents’ Health

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