Deploying midwives in poorest nations could avert millions of maternal and newborn deaths

June 25, 2014

A modest increase in the number of skilled midwives in the world's poorest nations could save the lives of a substantial number of women and their babies, according to new analyses by researchers from the Johns Hopkins Bloomberg School of Public Health.

Maternal mortality is a leading cause of death for women in many developing countries and public health efforts to avert it have only made headway in a few countries. Elsewhere, progress has either never started or has stalled in recent years. Poor nations also have troubling rates of infant and fetal deaths. Midwives can play a crucial role in preventing the deaths of millions of women and children around the world who die during and around the time of pregnancy, the researchers reported June 23 in The Lancet.

"Even deploying a relatively small number of midwives around each country could have a profound impact on saving maternal, fetal and newborn lives," says study leader Linda Bartlett, MD, MHSc, a faculty member in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. "Our study shows that maternal mortality can be prevented, even in the most difficult of places."

In their analysis, researchers found that a 10 percent increase in midwife coverage every five years through 2025 could avert more than a quarter of maternal, fetal and infant deaths in the world's 26 neediest countries such as Ethiopia and Somalia.

The estimates were done using the Lives Saved Tool (LiST), a computer-based tool developed by Johns Hopkins Bloomberg School of Public Health researchers that allows users to set up and run multiple scenarios to look at the estimated impact of different maternal, child and neonatal interventions for countries, states or districts. For this analysis, the tool compared the effectiveness of several different alternatives including increasing the number of midwives by varying degrees, increasing the number of obstetricians, and a combination of the two.

In a separate study of the 58 poorest countries, reported last week in the journal PLOS One, Bartlett and her team used the LiST tool to estimate that 7 million maternal, fetal and newborn deaths will occur in those nations between 2012 and 2015. If a country's midwife access were to increase to cover 60 percent of the population by 2015, 34 percent of deaths could be prevented, saving the lives of nearly 2.3 million mothers and babies.

Bartlett says maternal mortality is the public health indicator with the greatest disparity between developed and developing countries. "With a very functional medical system," she says, "maternal deaths become extremely rare events."

The 58 countries studied account for about 91 percent of maternal deaths worldwide.

The researchers say boosting coverage of midwives who provide family planning as well as pregnancy care to 60 percent of women would cost roughly $2,200 per death averted as compared to $4,400 for a similar increase in obstetricians. Midwives are cheaper to train and can handle interventions needed during uncomplicated deliveries, while obstetricians are needed when surgical interventions such as cesarean sections are necessary, Bartlett says. Midwives can administer antibiotics for infections and medications to stimulate or strengthen labor, remove the placenta from a patient having a hemorrhage as well as handle many other complications that may occur in the mother or her baby.

While adding more obstetricians would save additional lives, they cost more to deploy and can only use their surgical skills in a sterile hospital setting, something that is often unavailable in many rural settings. When both midwives and obstetricians who provide family planning are available, even more lives can be saved, Bartlett says: 83 percent of all maternal, fetal and newborn deaths could be prevented with universal (95 percent) coverage.

While the cost of such interventions isn't small - an estimated $5.5 billion if access to midwives increases to 60 percent coverage - Bartlett says that governments and aid agencies are already spending large sums of money on programs to address these issues. "We have identified a cost-effective way to spend the money," she says.
"The projected effect of scaling up midwifery" was written by Caroline Homer; Ingrid Friberg; Marcos Augusto Bastos Dias; Petra ten Hoope-Bender; Jane Sandall; Anna Maria Speciale; and Linda Bartlett and appeared in the June 23, 2014 online edition of the Lancet. (Subscription required. Media copies available from media contacts.)

"The Impact and Cost of Scaling up Midwifery and Obstetrics in 58 Low- and Middle-Income Countries" was written by Linda Bartlett; Eva Weissman; Rehana Gubin; Rachel Patton-Molitors; and Ingrid K. Friberg and appeared in the June 18 edition of PLOS One.

The study was supported by a USAID grant to JHPIEGO's MCHIP program (GHSA00080000200).

Johns Hopkins University Bloomberg School of Public Health

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