Strong health systems start with midwives. Credit: Unsplash

By Shreya Komar
UNITED NATIONS, Aug 15 2025 (IPS)

Asia-Pacific’s midwives are a healthcare lifeline capable of delivering nearly 90 percent of essential maternal and newborn services. Yet the region grapples with severe shortages, underinvestment, and systemic neglect.

The newly released State of Asia’s Midwifery 2024 Report, released by the United Nations Population Fund (UNFPA), reveals that despite midwives’ lifesaving potential, many countries lack enough workers, face poor training and support systems, and struggle with weak policy backing. The findings underscore an urgent need to elevate midwives from auxiliary roles to central pillars of health systems across the region.

Drawing on data from 21 countries in the UNFPA Asia-Pacific (AP) region, the report was intended to assist countries in the region to meet the challenges of the health-related SDGs and the Every Woman Every Newborn Everywhere (EWENE) agenda, a global initiative focused on accelerating the reduction of preventable maternal and newborn deaths.

The report shows hundreds of thousands of maternal and newborn deaths in 2023 across the Asia-Pacific that timely midwife interventions could have largely prevented. The region faces a shortage of approximately 200,000 midwives, contributing to an annual toll of roughly 66,000 maternal deaths alone. These stark figures expose both the human cost and the systemic failure to invest in this essential healthcare workforce.

According to the report, at least five Asia-Pacific countries, including Lao PDR, Mongolia, Pakistan, Papua New Guinea (PNG) and Timor-Leste, are estimated to face needs-based midwife shortages, with Pakistan and PNG experiencing the most severe gaps.

The report projects that Pakistan and PNG will still face shortages by 2030, even if they maintain current rates of midwife graduation and full employment. Other countries, such as Afghanistan, Myanmar, and Viet Nam, are also likely to experience ongoing shortages; however, limited data prevents precise estimates of these shortages.

Beyond shortages, the report points to alarming gaps in education quality, regulatory frameworks, and leadership pathways for midwives. Many countries still struggle with limited pre-service training, scarce continuing education opportunities, weak licensing systems, and fragmented governance. Retention suffers as poor pay, inadequate infrastructure, and lack of professional recognition push midwives away, especially from rural and underserved areas.

The report also emphasizes how placing midwives in leadership roles can strengthen decision-making on policies that directly affect maternal and newborn health, improve supervision and mentoring, and ensure midwifery perspectives shape regulation, training, and service delivery.

Countries like Afghanistan, Iran, and Malaysia show how midwife-led governance can integrate professional expertise into national health strategies, ultimately enhancing the quality, reach, and effectiveness of sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) services.

Since 2021, nine countries have increased midwife availability (Bangladesh, Cambodia, Iran, Lao PDR, Maldives, Nepal, PNG, Sri Lanka and Viet Nam), four have seen decreases (Indonesia, Malaysia, Pakistan and the Philippines), and two show no significant change (Mongolia and Timor-Leste). It shows that while some nations are making progress, regional gains are uneven, and shortages can worsen without sustained investment and retention strategies.

The WHO estimates that countries with fewer than 25 doctors, nurses and midwives per 10,000 people will struggle to provide adequate primary healthcare, a threshold that, while general, offers a benchmark for minimum workforce density.

Acting on this information is imperative because midwives are the most cost-effective, accessible answer to achieving safe motherhood and newborn survival goals. As the World Health Organization notes, when well-trained and integrated, midwives can address roughly 90 percent of essential reproductive and newborn health needs. Still, the world faces a global shortfall of nearly 900,000 midwives, and many in Asia endure poor working conditions, low pay, and limited career paths. Thus, saving lives demands investing in midwifery education, fair compensation, regulation, leadership, and full integration into health systems.

Midwife supervisor Arafin Mim, who oversees a team serving over 32,500 Rohingya refugees on the remote island of Bhasan Char in Bangladesh, captures the importance of her work simply.

“I feel this profession from the corner of my heart. It’s about making a connection with a pregnant woman, building a relationship during her pregnancy.”

Mim’s dedication illustrates the commitment and resilience midwives bring to some of the world’s most challenging environments.

In UNFPA’s recent opinion piece, the Regional Director Pio Smith shares a vivid image of midwives delivering in remote Bangladesh during climate crises to describe their resilience.

“When non-stop rain caused flooding in her village, the maternity ward, pharmacy, and storage room were submerged by water. She still continued to deliver babies, without electricity, even supporting emergency cesarean sections as needed with the doctors on call.”

The report urges governments and partners to close needs-based midwife shortages by expanding education in line with ICM standards, improving faculty and curricula, and ensuring equitable deployment. It recommends updating policies so midwives can work to their full scope, using data-driven workforce planning to create sanctioned posts, and adopting fair recruitment, deployment, and retention strategies.

Finally, it calls for empowering midwives with leadership roles in SRMNAH governance, regulation, and service improvement.

UNFPA’s Executive Director, Dr. Natalia Kanem, reminds us in a statement that “midwives are instrumental to navigating these challenges: They can provide up to 90 percent of essential services for sexual and reproductive health and bring their expertise and counsel to women wherever they are.”

Country examples such as Bangladesh, Nepal, and Cambodia offer hopeful signs. Bangladesh’s midwife-led birthing centers, Nepal’s rural midwifery deployments, and Cambodia’s regulatory reforms are exemplary, but much more action and investment are needed.

Midwives must be valued and supported as key professionals with quality education, fair pay, robust licensing, leadership opportunities, and a seat at health policymaking tables. This will result in fewer maternal and infant deaths, stronger newborn health, and more resilient healthcare systems.

IPS UN Bureau Report

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Increasing levels of violence across India due to ethnic tensions and armed insurgencies are taking their toll on women and cutting off access to crucial reproductive health services. Credit: Stella Paul/IPS

By Stella Paul
BASTAR, India, Sep 26 2014 (IPS)

Twenty-five-year-old Khemwanti Pradhan is a ‘Mitanin’ – a trained and accredited community health worker – based in the Nagarbeda village of the Bastar region in the central Indian state of Chhattisgarh.

Since 2007, Pradhan has been informing local women about government health schemes and urging them to deliver their babies at a hospital instead of in their own homes.

Ironically, when Pradhan gave birth to her first child in 2012, she herself was unable to visit a hospital because government security forces chose that very day to conduct a raid on her village, which is believed to be a hub of armed communist insurgents.

“I have seen women trying to use home remedies like poultices to cure sepsis just because they don’t want to run into either an army man or a rebel." -- Daniel Mate, a youth activist from the town of Tengnoupal, on the India-Myanmar border
In the panic and chaos that ensued, the village all but shut down, leaving Pradhan to manage on her own.

“Security men were carrying out a door-to-door search for Maoist rebels. They arrested many young men from our village. My husband and my brother-in-law were scared and both fled to the nearby forest.

“When my labour pains began, there was nobody around. I boiled some water and delivered my own baby,” she said.

Thanks to her training as a Mitanin, which simply means ‘friend’ in the local language, Pradhan had a smooth and safe delivery.

But not everyone is so lucky. Increasing levels of violence across India due to ethnic tensions and armed insurgencies are taking their toll on women and cutting off access to crucial reproductive health services.

This past June, for instance, 22-year-old Anita Reang, a Bru tribal refugee woman in the conflict-ridden Mamit district of the northeastern state of Mizoram, began haemorrhaging while giving birth at home.

The young girl eventually bled to death, Anita’s mother Malati told IPS, adding that they couldn’t leave the house because they were surrounded by Mizo neighbours, who were hostile to the Bru family.

According to Doctors Without Borders (MSF), a global charity that provides healthcare in conflict situations and disaster zones across the world, gender-based violence, sexually transmitted infections including HIV, and maternal and neonatal mortality and morbidity all increase during times of conflict.

This could have huge repercussions in India, home to over 31 million women in the reproductive age group according to the United Nations Population Fund (UNFPA).

The country is a long way from achieving the Millennium Development Goal (MDG) target of 103 deaths per 100,000 live births by 2015, and is still nursing a maternal mortality rate of 230 deaths per 100,000 births.

There is a dearth of comprehensive nationwide data on the impact of conflict on maternal health but experts are agreed that it exacerbates the issue of access to clinics and facilities.

MSF’s country medical coordinator, Simon Jones, told IPS that in India the “most common causes of neonatal death are […] prematurity and low birth weight, neonatal infections and birth asphyxia and trauma.”

The government runs nationwide maternal and child health schemes such as Janani Suraksha Yojana and Janani Shishu Suraksha Karykram that provide free medicine, free healthcare, nutritional supplements and also monetary incentives to women who give birth at government facilities.

But according to Waliullah Ahmed Laskar, an advocate in the Guwahati High Court in the northeastern state of Assam, who also leads a rights protection group called the Barak Human Rights Protection Committee, women wishing to access government programmes must travel to an official health centre – an arduous task for those who reside in conflict-prone regions.

In central and eastern India alone, this amounts to some 22 million women.

There is also a trust deficit between women in a conflict area and the health workers, Laskar told IPS. “Women are [often] scared of health workers, who they think hold a bias against them and might ill-treat them.”

For Jomila Bibi, a 31-year-old Muslim refugee woman from Assam’s Kokrajhar district, such fears were not unfounded; the young woman’s newborn daughter died last October after doctors belonging to a rival ethnic group allegedly declined to attend to her.

Bibi was on the run following ethnic clashes between Bengali Muslims and members of the Bodo tribal community in Assam that have left nearly half a million people displaced across the region.

Daniel Mate, a youth activist in the town of Tengnoupal, which lies on India’s conflicted border with Myanmar, recounted several cases of women refusing to seek professional help, despite having severe post-delivery complications, due to compromised security around them.

“When there is more than one armed group [as in the case of the armed insurgency in Tengnoupal and surrounding areas in northeast India’s Manipur state], it is difficult to know who is a friend and who is an enemy,” he told IPS.

“I have seen women trying to use home remedies like poultices to cure sepsis just because they don’t want to run into either an army man or a rebel,” added Mate, who campaigns for crowd-funded medical supplies for the remotest villages in the region, which are plagued by the presence of over a dozen militant groups.

The solution, according to MSF’s Jones, is an overall improvement in comprehensive maternal care including services like Caesarean sections and blood transfusions.

Equally important is the sensitisation of health workers and security personnel, who could persuade more women to seek healthcare, even in troubled times.

Other experts suggest regular mobile healthcare services and on-the-spot midwifery training to women in remote and sensitive regions.

According to Kaushalendra Kukku, a doctor in the Kanker government hospital in Bastar, “When violence erupts, all systems collapse. The best way to minimise the risk of maternal death in such a situation is to take the services to a woman, instead of expecting her to come to [the services].”

Pradhan, who has now resumed her duties as a community health worker, agrees. “I was able to deliver safely because I was trained. If other women receive the same training, they can also help themselves.”

Edited by Kanya D’Almeida

This story originally appeared in a special edition TerraViva, ‘ICPD@20: Tracking Progress, Exploring Potential for Post-2015’, published with the support of UNFPA, the United Nations Population Fund. The contents are the independent work of reporters and authors.

Only 65 percent of Senegalese women give birth in the presence of a skilled attendant. Credit: Travis Lupick/IPS

By Doreen Akiyo Yomoah
DAKAR, Sep 24 2014 (IPS)

Diouma Tine is a 50-year-old vegetable seller and a mother of six boys. In her native Senegal, she tells IPS, motherhood isn’t a choice. “If you’re married, then you must have children. If you don’t, then you don’t get to stay in your husband’s house, and no one will respect you.”

Despite this prevailing cultural outlook, becoming a mother here is neither easy, nor safe, with only 65 percent of Senegalese women giving birth in the presence of a skilled attendant.

According to available data, 54 percent of Senegal’s 13.7 million people live in rural areas. Of these, some 3.3 million are women of reproductive age, an estimated 85 percent of who live about 45 minutes from a health facility.

The country has a worryingly high maternal mortality rate (MMR). The last government survey taken in 2005 found that 41 women died per 1,000 live births, giving the country a ranking of 144 out of 181.

“In some regions, like the Kolda and Tamba Regions, you can find up to 1,000 deaths per 100,000 live births [since] some women are denied the ability to make decisions about when to go to hospital, [and] sometimes when roads are bad it’s difficult for them to get to a health centre.” -- Gacko Ndèye Ndiaye, coordinator of the gender cell at the Ministère de la Santé et Action Sociale (Ministry of Health and Social Action)
Between 2005 and 2010, the MMR in Senegal fell from 401 to 392 deaths per 100,000 live births, representing some progress but hinting at the scale of unmet need around the country.

One of the Millennium Development Goals (MDGs) is to achieve universal access to reproductive healthcare by 2015, but it is increasingly clear to health workers and policy makers that Senegal will not reach this target.

This year’s State of the World’s Midwifery Report produced by the United Nations Population Fund (UNFPA) projected that Senegal’s population was set to increase by 59 percent to 21.9 million by 2030.

“To achieve universal access to sexual, reproductive, maternal and newborn care, midwifery services must respond to one million pregnancies per annum by 2030, 53 percent of these in rural settings,” the report stated, adding that the health system must be configured to cover some 66 million antenatal visits, 11.7 million births, and 46.7 million post-partum and postnatal visit from 2012 to 2030.

This past May, on the International Day of the Midwife, former Prime Minister Aminata Touré called attention to a gap of 1,336 midwives in the country, setting in motion a government-sponsored recruitment drive to rapidly increase the number of trained birth attendants.

The midwife shortage is felt most severely in rural areas: the Matam region in eastern Senegal, for instance, has only 14 midwives for a population of nearly 590,000, while Tambacounda, to the south of Matam, has only 38 for a population of about 670,000.

Senegal has both ‘sage-femmes’ (fully trained midwives), and ‘matrones’, direct-entry midwives who deliver the vast majority of babies in Senegal but lack proper education, and often learn their trade on site, sometimes spending less than six months in a clinical training setting before being taking up posts in rural areas.

“There is kind of a crisis in education,” Kaya Skye, executive director of the African Birth Collective, tells IPS.

“Matrones learn how to take blood pressure, but they don’t understand what that means. [With matrones] there is an urgency to get the baby out as soon as possible [and] an overuse of drugs, which is […] another cause of mortality,” she explained.

In fact, Touré stated during a speech on May 12 that 60 percent of maternal deaths in the country could have been avoided with “sufficient personnel, a suitable medical platform, [and] democratic access to women’s health services, notably the disadvantaged in remote areas.”

Gacko Ndèye Ndiaye, coordinator of the gender cell at the Ministère de la Santé et Action Sociale (Ministry of Health and Social Action), and a midwife by trade, tells IPS that numbers alone don’t tell the whole story.

“There are disparities between different areas,” she asserted. “In some regions, like the Kolda and Tamba Regions, you can find up to 1,000 deaths per 100,000 live births [since] some women are denied the ability to make decisions about when to go to hospital, [and] sometimes when roads are bad it’s difficult for them to get to a health centre.”

The National Agency of Statistics and Demography’s 2011 health indicators report found that over 90 percent of urban births are assisted by a trained assistant, but that number falls to just half for rural births.

Skye’s African Birth Collective works to fill these gaps, and recently built the Kassoumai Birth Centre in the Kabar village of the southern Casamance region to meet the needs of mothers and midwives.

According to Skye, “Traditional midwives said they wanted their own place to practice; that they didn’t feel welcome in government clinics. There was nothing in Kabar for women – they were giving birth in the showers behind their houses.”

Although the government does provide training for midwives, building this centre was “about creating infrastructure that is outside of government protocols and facilitating that dialogue where the traditional midwives can say ‘We do it this way’,” Skye says.

A long colonial history and post-colonial education in Senegal has meant that the Western obstetric model has been dominant.

Grassroots efforts, including the work of ENDA Santé, the health division of an international NGO called Environmental Development Action in the Third World, are helping to foster a better balance between Westernised birthing techniques and traditional methods.

The African Birth Collective and ENDA Santé have translated the educational manual ‘A Book for Midwives’ into French, giving birth attendants in Francophone West Africa access to crucial information, such as the case for non-supine positions, and inverted resuscitation methods.

For women like Tine, the pride that comes from being a mother will always outweigh the dangers and complications of pregnancy and childbirth.

But if the government of Senegal scales up its efforts to improve health services, it can remove the fear factor altogether, and make a strong contribution towards global efforts to ensure the health and safety of every mother.

This story originally appeared in a special edition TerraViva, ‘ICPD@20: Tracking Progress, Exploring Potential for Post-2015’, published with the support of UNFPA, the United Nations Population Fund. The contents are the independent work of reporters and authors.

Edited by Kanya D’Almeida

Doctors Without Borders (MSF) says Afghanistan is “one of the riskiest places to be a pregnant woman or a young child”. Credit: DVIDSHUB/CC-BY-2.0

By Karlos Zurutuza
KABUL, Sep 16 2014 (IPS)

Nasrin Mohamadi, a mother of four, has promised herself never to set foot in an Afghan public hospital again. After her first experience in a maternity ward, she has lost all faith in the state’s healthcare system.

“The doctors said that I had not fully dilated yet so they told me to wait in the corridor. I had to sit on the floor with some others as there wasn’t a single chair,” Mohamadi tells IPS, recalling her experience at Mazar-e Sharif hospital, 425 km northwest of Kabul.

“They finally took me into the room where three other women were waiting with their legs wide open while people came in and out. They kept me like that for an hour until I delivered without [an] anaesthetic, and not even a single towel to clean my baby or myself,” adds the 32-year-old.

“Immediately afterwards the doctors told me to leave as there were more women queuing in the corridor.”

“Many rural health clinics are dysfunctional, as qualified health staff have left the insecure areas, and the supply of reliable drugs and medical materials is irregular or non-existent." -- Doctors Without Borders (MSF)
Even after she left the hospital, Mohamadi’s ordeal was far from over. The doctors told her not to wash herself for ten days after the delivery, and as a result her stitches got infected.

“I paid between 600 and 800 dollars to give birth to my other three children after that; it was money well invested,” she says.

This is a steep price to pay in a country where the average daily income is under three dollars, and 75 percent of the population live in rural areas without easy access to health facilities.

Many women have no other option than to rely on public services, and the result speaks volumes about Afghanistan’s commitment to maternal health: some 460 deaths per 100,000 live births give the country one of the four worst maternal mortality ratios (MMR) in the world outside of sub-Saharan Africa.

While this represents a significant decline from a peak of 1,600 deaths per 100,000 births in 2002, far too many women are still dying during pregnancy and childbirth, according to the United Nations.

In 2013 alone, 4,200 Afghan women lost their lives while giving birth.

The lack of specialised medical attention during pregnancy or delivery for a great bulk of Afghan women is partly responsible. Few have access to health centres because these are only reachable in urban areas. The lack of both security and proper roads forces many women to deliver at home.

This does not bode well for the 6.5 million women of reproductive age around the country, particularly since Afghanistan only has 3,500 midwives, according to the U.N. Population Fund (UNFPA)’s latest State of the World’s Midwifery report.

This means that the existing workforce of midwives meets only 23 percent of women’s needs. The situation is poised to worsen: UNFPA estimates that midwifery services in the country “will need to respond to 1.6 million pregnancies per annum by 2030, 73 percent of these in rural settings.”

Even women with access to top-level urban facilities, such as the Kabul-based Malalai Maternity Hospital, are not guaranteed safety and comfort.

For instance, Sultani*, a mother of four, tells IPS she is far from satisfied with her experience.

“I gave birth through caesarean section to my four children in this hospital but the doctors who attended to me were unskilled,” she remarks bluntly. “A majority of them had only completed three years of medical [school].

“On a scale of one to 10, I can only give Malalai a four,” she concludes.

Sultani’s opinion may be specific to her own experience, but it finds echo in various reports and studies of the country’s health system. A 2013 activity report by Doctors Without Borders (MSF) labeled Afghanistan “one of the riskiest places to be a pregnant woman or a young child” due to a lack of skilled female medical staff.

“Private clinics are unaffordable for most Afghans and many public hospitals are understaffed and overburdened,” reports the organisation, which runs four hospitals across the country.

“Many rural health clinics are dysfunctional, as qualified health staff have left the insecure areas, and the supply of reliable drugs and medical materials is irregular or non-existent,” continues the report.

This is a sobering analysis of a country that will need to configure its health system to cover “at least 117.8 million antenatal visits, 20.3 million births and 81.3 million post-partum/postnatal visits between 2012 and 2030”, according to UNFPA.

Given that contraceptive use is still scarce, reaching only 22 percent of reproductive-age women, large families continue to be the norm. Afghan women give birth to an average of six children, a practice fuelled by a cultural obsession with bearing at least one son, who will in turn care for his parents in their old age.

A lack of information about birth spacing means mothers seldom have time to fully recover between deliveries, causing a range of health issues for the mother and a lack of milk for the newborn child.

Findings from a 2013 survey conducted by the Afghan Ministry of Public Health indicate that only 58 percent of children below six months were exclusively breastfed.

Still, this is an improvement from a decade ago and represents small but hopeful changes in the arena of women and children’s health. The same government survey found, for instance, that “stunting among children has decreased by nearly 20 percent from 60.5 percent in 2004 to 40.9 percent in 2013.”

Dr. Nilofar Sultani, who practices at the Malalai Maternity Hospital, tells IPS that medical assistance in Afghanistan has improved “significantly” over the last ten years.

“There are more health centres, and [they are] far better equipped. The number of skilled doctors has also grown,” explains Sultani, a gynaecologist.

But the most important change, she says, has been in women’s attitude towards medical care. “Before, very few women would come to the hospitals but today, the majority of women come forward on their own. They’re slowly losing their fear [of] doctors,” notes Sultani, adding that health centres are among the very few places where Afghan women can feel at ease without the presence of a man.

Edited by Kanya D’Almeida

Midwives assume the role of the doctor and replaces the more clinical hospital setting with holistic and homeopathic methods. Credit: Bigstock

By Lorraine Farquharson
NEW YORK, Jan 27 2014 (IPS)

It was a long and hard 10 hours of labour.

“Don’t give up,” Carolina Pinheiro recalls her doula urging, as she provided both physical and emotional support.“If you feel safer in a hospital then do that, but there should not be an assumption that hospitals are safer than home. " -- Carolina Pinheiro

Pinheiro says she chose at-home birthing with midwife assistance because she wanted a safe environment, plus the gentle care the method provides, which included exercise stretches, a foot massage and aromatherapy.

Since Pinheiro could not sit up to eat during the 10 hours, yet still needed strength to push, the doula squeezed “fresh green [kale and fruit] juice” for her and constantly brought jugs of water.

“A doula is recommended if a mother chooses the at-home [birth], because she comes to your house and guides you through until the time is right for the midwife to come,” Pinheiro tells IPS.

Pinheiro’s baby was positioned feet-down, and it took three hours to turn him around. “Usually, pushing should last two to three hours,” she says.

“If I was in a hospital they would not allow me to push so long and suggest a C-section. I didn’t want that,” she adds. “My doula and I agreed to invite the midwife over only when the time felt right.”

In Pinheiro’s view, the midwife assumes the role of the doctor and replaces the more clinical hospital setting with holistic and homeopathic methods. “So there is no medication during pushing. She just guided me holistically in the positions that I could try,” Pinheiro says.

Even as women in the United States spend 98 billion dollars a year on hospitalisation for pregnancy and childbirth, the country’s maternal mortality rate has doubled in the past 25 years, to around 15 deaths per 100,000 births. Currently, the U.S. ranks 50th in the world in terms of maternal mortality, among the bottom of the most developed countries.

“My midwife took care of me through my entire pregnancy and was there by my side all along, so I knew I would feel safer,” said Pinheiro. She said that having the midwife carry out the delivery at home also made her feel more private. “If you are in a safe environment, you will be fine.”

Sandra Londino, a licensed midwife who runs a private practice in Ithaca, New York, says more than 90 percent of births with obstetricians occur in hospitals. For the most part, the use of modern technology proved effective in the early detection of complications and providing faster solutions, but there are drawbacks as well.

Londino says that when women ask questions about the birth and delivery, they are too often “brushed off” or they are not told the truth.

“Many just agree to an epidural [spinal anesthesia] or a quick C-section just because the doctor says so,” she adds. “Perhaps it is due to money and power, because we don’t see physiological births any more. There are hardly normal births in this country.”

Many women who first chose midwifery for pre-natal and birthing assistance are now opting for at-home birthing with therapeutic guidance from a doula, a phenomenon that grew 41 percent from 2004 to 2010, according to Londino.

Saraswathi Vedam, chair of Home Birth at the American College of Nurse-Midwives, says that this method is increasingly within the mainstream.

“One can always change their mind and go to the hospital,” Vedam says. “Women just enjoy the comfort and continuing care from someone who they feel a more personal relationship with, such as a midwife.”

Results of a survey show that expectant mothers chose an at-home birth in order to avoid unnecessary interventions and to have more control over her birthing decisions. Some said they trust in natural birth as a normal healthy process and did not want any separation from their newborn.

Others said that since they underwent a healthy pregnancy, having the baby at home would make them feel safer by decreasing the possibility of contracting an infection or being coaxed into a Caesarean.

Still, the American College of Obstetricians and Gynecologists argues that home births are unsafe and does not support them.

“It’s important to remember that home births don’t always go well, so as physicians, we have an obligation to provide families with information about risks, benefits, limitations and advantages,” said Richard N. Waldman, the group’s president.

Insurance companies have decided to follow ACOG’s advice by refusing to reimburse clients for at-home births. Londino says she doesn’t understand the logic from a financial perspective.

“Hospital births, without intervention or complication, cost roughly 9,500 dollars, which an insurance company is willing to pay,” she says. “Yet an at-home birth performed by a midwife, whose invoice includes regular pre-natal visits, all necessary tools and delivery, is only 3,500 dollars – which is refused reimbursement.”

Retired hospital midwife Ellen Cohen, who wrote a book about the effectiveness of pre-natal care in order to deliver safe babies without modern technology, says bearing a child is a vulnerable time in women’s lives where they try to do the best for themselves and their newborns.

“If one looks at childbirth as a pathological incident as opposed to something natural, then they will use a machine to help them feel safe – even something like the electrical fetal [heartbeat] monitoring,” Cohen added.

This method is not for everyone though, Pinheiro cautioned. “If you feel safer in a hospital then do that, but there should not be an assumption that hospitals are safer than home. One responds better when they are in their own environment. For me, it was a remarkable experience.”

There are 135 million live births every year, with only 11 million benefitting from quality care. Credit: Photo stock

By Joan Erakit
UNITED NATIONS, May 8 2013 (IPS)

The story goes like this: a young mother lies quietly in a dimly lit room having just given birth to her baby. For the next seven days she watches over the child with caution, nursing and swaddling it patiently. Fearful that the infant will not survive past a few days, she refuses to give it a name.

Unfortunately, this scenario remains the reality for many women across the globe. There are 135 million live births every year, with only 11 million benefitting from quality care – a divide not only between rich and poor but also between life and death.“We’re not going to solve all these issues without involving and engaging men.” -- CEO of Save the Children Carolyn Miles

On Tuesday, Save the Children launched their annual report State of The World’s Mothers 2013: Surviving the First Day. The report emphasises the need for quality care around pregnancy, delivery and postnatal care.

“The first hours and days of a baby’s life are especially critical,” it says. “About three-quarters of all newborn deaths (over 2 million) take place within one week of births. Thirty-six percent of newborn deaths (1 million) occur on the day a child is born.”

Sometimes it is as simple as not having access to an educated midwife or community nurse. Other times it’s as complicated as having to wait for a husband’s approval in order to go to the hospital to deliver the baby.

Then there are the infections that newborns are prone to when they come into this world, and also the health of the mother during and after pregnancy.

Empowered mothers

“An empowered and educated mother is the best thing for a child,” President and CEO of Save the Children Carolyn Miles said as the report was launched at the United Nations.

The report cites three major causes of newborn mortality: severe infections, pre-term birth and complications during childbirth.

At the heart of the problem is the fact that millions of women lack access to a physician or healthcare facility.

“As we start to do more for newborns, the quality of care is also really critical, because we want babies not just to survive, but to survive without disability,” said Professor Joy Lawn, director of the MARCH Centre at the London School of Hygiene and Tropical Medicine.

This means making maternal and child health a priority for government officials and community leaders. It means having conversations with husbands and fathers about the need to have a birthing plan.

“We’re not going to solve all these issues without involving and engaging men,” Miles told IPS.

“We have got to work in communities to actually engage husbands, make them part of the plan. A woman develops a plan to get to the hospital to be able to deliver; engage her husband in that plan. Make sure he’s expected to be part of the plan and has put away a little money if there’s a transportation need. He’s actually part of that.”

Growing midwifery

Losing a baby during childbirth has become commonplace in the developing world. It is understood that childbirth is a terribly difficult thing with sometimes devastating results, but still a natural order.

“There is this sense of, ‘this is just what happens’. Babies die, babies are born too early, and they’ll die. Mothers don’t name their children for seven days because so many will die,” Miles told IPS. “So it’s changing that idea that every mother and every child deserves to live through birth.”

According to the report, 800 women die during pregnancy or childbirth and 8,000 newborn babies die during their first month of life. It all seems to boil down to two essential factors: education and access.

Those few midwives or birth attendants who are available – especially in rural areas – usually lack adeqate training in prenatal and postnatal care. What little education on the topic they have, they’ve learned along the way from previous childbirths, some not so successful.

Public health advocates say these providers need proper training and tools to carry out basic tasks like cleaning the umbilical cord after childbirth and teaching new mothers about infection.

This leads to access, another issue preventing pregnant women from receiving the best care during such a critical time. Rural areas are hard to reach, community workers are not paid enough to allow travel, and resources are scant.

“Part of the solution is to train more community midwives and health workers,” says Catherin Ojo, a chief nursing officer at Ahmadu Bello University Teaching Hospital in Zaria, Nigeria.

“Midwives in Guatemala attend to women during pregnancy, the birth and the post-partum period. They give the women warmth and support, because they speak the same language and belong to the same culture,” said Silvia Xinico with the Network of Organisations of Indigenous Women for Reproductive Health.

Xinico, a member of the Cakchiquel indigenous community, told IPS that the midwives “are treated as part of the family; they give people advice about how to solve their difficulties.” They are also called on when there is a health problem in the community.

Most indigenous women in Guatemala use the services of midwives. Credit:Danilo Valladares/IPS

The important role played by local midwives is reflected in the official statistics, which show that nearly half of all births in this Central American country are attended by midwives.

The 2008-2009 National Maternal-Infant Health Survey reported that 48 percent of pregnancies in the country were attended in the homes of the expectant mother or the midwife. But in departments (provinces) where most of the population is indigenous, the proportion reached almost 80 percent.

The survey also indicated that 43 percent of births took place in public hospitals and clinics, and just under eight percent in private health facilities.

The Health Ministry reported that midwives attended 45.7 percent of the 115,997 births registered in the country from January to October 2011.

The National Survey on Living Conditions carried out last year reported that 54 percent of Guatemala’s 14 million people live in poverty and 13 percent in extreme poverty.

The worst poverty and lack of public services, healthcare and education are concentrated in indigenous provinces. (According to official statistics, 40 percent of Guatemala’s population of 14 million is indigenous, although native organisations put the proportion at over 60 percent.)

Despite the important role they play in providing healthcare, Guatemala’s traditional midwives are sometimes denigrated. “Because they are indigenous, they are discriminated against and treated with scorn by staff in the public health services” to which they turn when patients with complications must be transferred to the hospital, Xinico said.

“The doctors don’t let us go in the hospital, they only let the patient in, which makes us feel bad,” said Regina Patzán, a native midwife from San Juan Comalapa in the central department of Chimaltenango.

This happens even though many of the expectant mothers do not speak Spanish, only their native language, she told IPS.

Patzán, who has been a midwife for 16 years, says her skills are a gift from God.

“When I was just a little girl I wanted to know how babies came into the world. My great-grandmothers and my grandparents would get angry when I asked them,” she said, adding that she was even whipped a couple of times for asking about “adult things.”

But she was determined to know. “I wanted to receive the children when they were born,” she said. So she got involved in a non-governmental organisation, and was trained as a midwife, seeing her dream come true.

“When women come with complications, we immediately send them to the hospital. We are also visited by 14- or 15-year-old girls who come in with a stomach ache and we explain that it’s menstruation,” she said.

Her hunger for knowledge remains intact. “We would like to learn how to detect haemorrhaging when we are in the village and how we can help the women,” she said.

María Clara Mux, 55, another midwife from Chimaltenango, inherited her craft from her grandmother. “The first birth I attended was my daughter-in-law’s, because I had seen how my grandmother did it. Thank God everything went well. My grandson is now 13 years old,” she told IPS.

She strongly emphasises the need for family planning. “Now there are many planning methods to use. It’s not like before, when families had 16 kids. Things are difficult and we have to pay for school, clothing and food,” she said.

Mux is now receiving training at the local health centre and continues to help pregnant women and attend births, although she does so in precarious conditions.

“We need equipment – gloves, scissors and a syringe. The Health Ministry gave us some, but they eventually wear out. We also need a lantern, because some people don’t even have electricity and we can’t see a thing.”

The absence of health services in the most remote parts of the country means midwives play a key role in preventing maternal deaths.

Aracely Tórtola with the Asociación Pro Bienestar de la Familia de Guatemala – the Guatemalan association of family welfare, a local NGO – said the midwives “play a very important role in society, helping to curb maternal mortality, because many women are in areas where there are no hospitals.”

“These women also face economic and cultural hurdles to gaining access to hospitals,” the expert said.

Tórtola said midwives should receive training and education in the rights of women, family planning methods, prevention of sexually transmitted diseases, prevention of risks, and breastfeeding.

“If the midwife provides good advice and information, if she tells women that they have a right to family planning, if she takes them to the hospital when the pregnancy is at risk, she is helping bring down the maternal mortality rate,” she said.

The latest available statistics, from the national survey on maternal mortality published in December 2011, indicate that the maternal mortality rate fell from 153 deaths per 100,000 live births in 2000 to 139 deaths in 2007.

But the ratio is three times higher among indigenous women, the Observatory on Sexual and Reproductive Health reports.

Leonor Calderón, the delegate of the United Nations Population Fund (UNFPA) in Guatemala, commented to IPS that women play a fundamental role in society because of their contribution to maternal health. She said the state should recognise their skills and knowledge.

Calderón described traditional midwives as “agents of development” because of the social role they play in attending births, reducing maternal mortality and encouraging family planning.