Why all this fuss about midwives?

Community Midwifery Education Program. Photo: Aga Khan Foundation: Sandra Calligaro. Flickr CC.

Community Midwifery Education Program. Photo: Aga Khan Foundation: Sandra Calligaro. Flickr CC.

The reason why Sweden is making such a noise is two-fold. The main reason of course, is that midwives play a crucial role in saving the lives of mothers and infants, but the other reason we are pushing it so strongly is that Sweden has an interesting history when it comes to midwifery.

The enormous gap in maternal mortality between high- and low-income countries is a disgrace and, of course, also a reflection of gross inequity and structural gender inequality, and a violation of the right to health. Midwives are key to reducing maternal mortality.

First the obvious. Today there is a consensus on the important role of midwives in saving lives during pregnancy and childbirth, and this consensus is clearly illustrated by the fact that the Millennium Development Goal on maternal health has skilled care in childbirth as one of the indicators. Of course, midwives need to be part of a health system in which women have access to all levels of care, but midwives have a key role to play. This consensus has, however, not always been there. I would like to point to two major shifts in recent decades that have contributed to placing midwives at the centre of maternity care.

The first shift is the recognition that it takes skill to treat complications during pregnancy and childbirth. It has long been debated whether traditional birth attendants (TBAs, women with no formal training assisting deliveries) could, with short additional training, manage complications during pregnancy and childbirth. We now know that this does not work. TBAs can be very useful, but they do not have enough skills to lower maternal mortality, even with short additional training.

The second shift is regarding the risk approach. Previously, it was thought that it was possible to identify women with a high risk of complications through prenatal care, and offer those women delivery care at institutions with skilled midwives and high-level obstetric care. We now see that this is not an appropriate strategy. Most complications cannot be predicted. We therefore have to give skilled care to every woman in order to be able to handle severe complications.

The consequence of these shifts is that we now know that skilled care for all pregnancies is what we have to achieve.

So let me come back to the second reason why Sweden is taking this initiative. I see three aspects of this point: our history, our current situation, and our policy.

History first: an advanced civil registration system made it possible for Dr Ulf Högberg to demonstrate in his research how the maternal mortality in Sweden fell over the last 150 years and how that was related to the spread of midwives in Sweden. This research has been critical to the present consensus on the importance of midwifery skills. In 2011, the Swedish Association of Midwives celebrated the 300-year anniversary of the first midwife trained in this profession.

So what about the current situation? Today in Sweden we have a system in which midwives are responsible for care in normal pregnancies and childbirth. Medical doctors come in when complications occur. This means that a woman can go through an entire pregnancy without seeing a doctor. With this system we have one of the lowest maternal mortality ratios in the world. And this major role of midwives in the Swedish health system adds weight to our advocating for midwives, since we see that midwives are the first choice for the handling of normal pregnancies, not because they are cheaper to employ than medical doctors, but because they are the best option. Sweden walks the walk.

In addition to contributing to maternity care, in Sweden midwives play an important role in supplying reproductive health services, in particular to adolescents.

Finally, from a policy perspective the emphasis on the importance of midwives is a demonstration of Sweden’s focus on gender equality and sexual and reproductive health and rights.

Anders Molin,
Sida’s Lead Policy Expert on Health