Midwifery matters 'more than ever'

Midwifery has a crucial part to play in saving the lives of millions of women and children who die during and around the time of pregnancy, according to a major new Series, published in The Lancet.

The Series, produced by an international group of academics, clinicians, professional midwives, policymakers and advocates for and children, is the most critical, wide-reaching examination of midwifery ever conducted. It shows the scale of the positive impact that can be achieved when effective, high-quality midwifery is available to all women and their babies. Apart from saving lives, it also improves their continuing health and wellbeing and has other long-lasting benefits.

The authors also produce evidence of a trend towards the overmedicalisation of pregnancy, and the use of unnecessary interventions such as caesarean sections, in high-income and lower-income countries, with consequent hazards and costs.

According to Professor Mary Renfrew of the Mother and Infant Research Unit, School of Nursing and Midwifery, at Dundee University, Scotland, one of the Series authors, "Many of the needs of childbearing women, their babies, and families across the world are still not being met, despite long-standing recognition that women and their babies need access to which provides more than just emergency interventions for acute medical problems. Although midwifery is already widely acknowledged as making a vital and cost-effective contribution to high-quality maternal and newborn care in many countries, its potential social, economic and health benefits are far from being realised on a global scale."

Every year, nearly 300 000 women are thought to die during pregnancy, childbirth or soon after. Around 2.6 million women suffer stillbirths, and 2.9 million infants die in the first month of life. Millions more women and their families suffer long-term health, financial, and emotional problems, simply because they have not received adequate health care before, during, or immediately after pregnancy.

New estimates produced for the Series suggest that in the countries with the highest burden of infant and , over three quarters of stillbirths and maternal and newborn deaths could be prevented in the next 15 years if effective midwifery was available to all women. Even if improvements in the coverage of midwifery services were much more modest, the potential for saving lives is huge – if coverage of midwifery services increased from current levels by just a quarter, the authors estimate that the current rate of maternal deaths could be halved by 2030.

While most maternal and child deaths occur in low-income and middle-income countries, where lack of access to effective midwifery is the primary obstacle to improving mothers' and infants' health, the Series also says that overmedicalisation of pregnancy is increasingly threatening the health and wellbeing of women and their families in both high-income and lower-income countries. The Series authors argue that routine use of unnecessary interventions, including caesarean sections, limited mobility in labour, and episiotomy can have a lasting effect on mothers' and infants' health and wellbeing.

According to another of the authors, Professor Caroline Homer, of the Faculty of Health at the University of Technology, Sydney, Australia, "Both underuse and overuse of medical interventions in pregnancy contribute to short- and long-term illness for an estimated 20 million childbearing women. This not only effects their health and wellbeing, but may also result in their needing to pay for ongoing health-care costs, and on the ability of their families to escape poverty."

The return on investment from the education and deployment of community-based midwives is thought to be similar to vaccination in terms of the cost per life saved. However, according to the Series authors, the scale of the potential effect that increasing access to effective midwifery could have is yet to receive adequate international recognition. Barriers to wider uptake of the effective midwifery practices include a lack of understanding about what midwifery can do, low status of women in society, interprofessional rivalries, and unregulated private sector care for mothers' and infants' health.

To address these barriers, the Series outlines a new framework describing the characteristics of care that women, babies and families need, before, during, and after pregnancy. For the first time, the framework addresses not just what must be done for women and their families during this period, but how it must be done, where, and by whom. The authors hope that as well as providing a blueprint for progress in improving midwifery care worldwide, the framework will also be used to evaluate success, and to help build capacity in the countries most affected by maternal and infant deaths.

According to another of the Series authors, Professor Petra ten Hoope-Bender, of the Instituto do Cooperación Social Integrare, Barcelona, Spain: "Although the level and type of risks related to pregnancy, birth, postpartum and the early weeks of life differ between countries and settings, the need to implement effective, sustainable, and affordable improvements in the quality of care is common to all, and midwifery is pivotal to this approach.

"However, it is important to understand that to be most effective, a midwife must have access to a functioning health-care service, and for her work to be respected, and integrated with other health-care professionals; the provision of health care and services must be effectively connected across communities and health- care facilities."

More information: www.thelancet.com/series/midwifery

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