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Bentiu, Unity. IOM Midwife Florence Akidi begins seeing patients early in the morning at a primary care clinic in the Bentiu Protection of Civilians Site. As part of a routine check-up she listens to the foetus' heartbeat using a fetascope. In a country where an adolescent girl is three times more likely to die in childbirth than finish primary school, there are only 307 trained midwives like Florence. Photo: IOM/Brendan Bannon

This survey shows shows that endemic sexism harms both expectant mothers and the women who care for them

Alanna Shaikh, MPH

Motherhood is still deadly for far too many women. In 2015, an estimated 303,000 women died in childbirth. Many more suffered injury, disease, or infection as a result of pregnancy. Most of these deaths could have been prevented if women had better access to medical care – family planning, prenatal care, and good care during birth and for the post-partum period. One proven way to improve access to that care is through expanding and supporting the role of midwives in medical care. A new WHO report shares the results of a global survey of midwives and looks at ways that they can bolster medical care for pregnant women.

The document, “Midwives’ Voices, Midwives’ Realities Findings from a global consultation on providing quality midwifery care,” is based a survey of 2,470 midwifery personnel who provide care in 93 countries, and a series of brainstorming workshops. The survey finds that while midwives are committed to providing the best possible care to mothers and newborns, they face institutional barriers to doing their work. These barriers range from inadequate salaries to disrespect from doctors and lack of professional education. But more than anything else, these barriers can boiled down to one thing: sexism.

Across countries and regions, the women surveyed report on gender dynamics that affect their ability to provide care. Some report not being able to travel safely to and from work at night. Others report being systematically disrespected for their gender, or harassed for their knowledge of condom use. Few midwives had support from their husbands, which served as a barrier to working night shifts. These factors make it difficult for midwives to provide care.
Gender inequality is a universal experience among midwives, experienced in both wealthy and low-income countries. Midwives, almost all of whom are women, face a strong gender dynamic. They find that their professional knowledge and opinions are disregarded because they are female. They also report harassment, bullying, and even sexual abuse. In addition to personally experiencing the impact of gender inequality, they also see its impact on their patients.

Key Points from the Survey

Concerns around the current state of midwife care varied by region. Midwives from the US and UK felt that quality of care was being compromised by the very short amount of time they had to spend with patients. Heartbreakingly, midwifery personnel from the West Bank and Gaza Strip and Yemen could not identify a single area of their work that they felt were operating satisfactorily.

Some issues, however, crossed language and country. 45% of all midwives surveyed reported feeling exhausted. 37% faced harassment at work.  More positively, 58% felt that they were treated with respect, and 77% felt that they were listened to by medical personnel. 70% of all respondents would like better salaries.

Health sector problems affect the ability of midwives to provide care. According the document, “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.” One respondent from Ghana was especially critical of the health sector, “The reputation in some hospitals is poor as they do not care for women who cannot afford to ‘pay’. Also they are ‘known’ to be rude to the ladies both verbally and physically… so women fear to deliver in hospital. 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.”

The Way Forward

The report posits better support for midwife professional associations as a feasible, effective way to improve working conditions for midwives. Establishing and strengthening these kinds of associations was consistently mentioned by survey respondents and attendees at brainstorming workshops. It also tracks closely with the WHO approach to strengthening health sectors and improving the quality of health care.

What the Report Doesn’t Say

The report mentions in passing that evidence shows the benefits of midwifery care, but does not describe or examine that evidence. It would be a stronger, more useful report if it had devoted a page to reviewing the evidence. The WHO has a resource page on midwifery that could have been referenced. For outside sources, there is a strong Cochrane review on the benefits of midwife care that is easily accessible, as well as a comprehensive document from the Lancet.

One Sentence Takeaway

Better support to midwives would mean better healthcare for mothers and babies.