Investment in midwives could save 4.3 million lives per year by 2035

Scaling up global midwife-led care could reduce maternal deaths by 67%, newborn deaths by 64% and stillbirths by 65%, according to a new modelling study published in The Lancet Global Health.

Greater investment in midwives — to increase numbers; improve education, training, regulation and working environment across family planning to post-natal care — could equate to saving 4.3 million lives per year by 2035.

Lead author Dr Andrea Nove said, “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.”

Following a past report in The Lancet, the new study uses an updated version of the Lives Saved Tool (LiST) to model avoidable deaths by assuming a specific uptake, effectiveness and impact of a range of interventions.

The effects on mortality of about 30 essential interventions — which can be delivered in their entirety by competent and enabled midwives — were modelled for 88 countries. 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.

Four scenarios were used to demonstrate the effects of changes in the level of provision of midwife health care:

1. A modest increase of 10% every five years in the coverage of interventions.
2. A substantial increase by 25% every five years.
3. An increase that would reach 95% of coverage by 2035 (universal coverage).
4. A decrease in coverage by 2% every five years such as might occur if investment in midwives did not keep pace with population growth.

In addition to country-level modelling, the study placed countries into three categories 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.

The researchers estimated that relative to the current provision of health care 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. 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.

Conversely, a small decrease (of 2%) in the provision of midwife-delivered health care 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 said, “Midwives, especially in developing countries, are at the core of primary health care. 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.”

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.

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