An innovative UN Population Fund (UNFPA) report launched on Monday,The State of the World's Midwifery, focuses much needed attention on service providers, and will help to achieve millennium development goals (MDGs) 4 and 5.
Malawi has an insufficient number of midwives, so staff work long hours and have few breaks. Photograph: White Ribbon Alliance /Maternal Mortality Campaign
A recent paper on maternal health staff in a district referral hospital in Malawi concluded that burnout appears to be common among those providing antenatal, delivery and postnatal health services. Of the 101 participants, nearly three-quarters (72%) reported emotional exhaustion, more than one-third (43%) reported de-personalisation and three-quarters (74%) experienced reduced personal accomplishment.
Malawi has one of the worst maternal mortality rates in the world; from 2005 to 2009, for every 100,000 live births, 1,140 mothers died. By comparison, in the UK on average 8.2 mothers die per 100,000 live births. Malawi's health service is chronically under-staffed – the World Health Organisation recommends that each country has a minimum of one physician for every 5,000 people; Malawi has one for every 62,000.
Through its own work in Malawi, Women and Children First (UK) (WCF) has observed that maternal and newborn health staff are overworked and underpaid. There are insufficient midwives, so staff work long hours and have few breaks. In addition, they deal with death after death of mothers and babies – a highly emotional experience. Hospital staff report they suffer stress and fatigue from such a relentless workload, which has increased over the last two to three years since government policy began to push for all women to give birth in health facilities, although the supply of hospital beds, drugs and staff has not kept pace. As a result, quality of care is compromised and, at times, delay in providing skilled care ends in needless fatalities.
Is it any wonder, then, that medical staff in resource-poor settings frequently suffer burnout? A psychological term for the negative response to chronic job-related emotional stress, burnout is on the rise and poses a serious threat to achieving the MDGs aimed at reducing maternal and newborn mortality. Burnout occurs when people give too much of their time, energy, and effort to a job over a long period of time, without adequate time to recover physically or emotionally.
Though maternal health has improved in Malawi over the last few years, the positive trend will reverse if staff continue to be placed under unremitting physical and emotional stress.
Quality midwifery is a well-documented component of success in saving the lives of women and newborns; it also promotes health in general and spurs development. If midwives are looked after, it follows that their patients' health will improve.
Sadly, Malawi is not a unique case. Dissatisfaction with pay and working conditions, migration, and deaths from Aids-related illnesses has meant that, globally, the number of skilled healthcare providers has not significantly increased over the last 30 years. It is even declining in some countries. The WHO reports a 350,000 shortage of midwives.
For MDGs 4 and 5 to be achieved, there needs to be a significant increase in midwifery staff across the developing world. This involves governments, NGOs and health workers understanding and addressing the working conditions of current staff.
The UNFPA report addresses these issues. It provides an insight into the state of midwifery in 58 countries across the world. The report examines the number and distribution of health professionals involved in the delivery of midwifery services; explores emerging issues related to education, regulation, professional associations, policies and external aid; analyses global issues regarding health personnel with midwifery skills, and the constraints and challenges that they face in their lives and work; and calls for more investment in scaling up midwifery services.
The UNFPA and Unicef have long produced annual reports on the state of the world's children and the state of the world's population, but service providers have not previously been a focus. This is the first time that such intensive attention has been paid to midwives, and it will be a vital tool for governments and NGOs when it comes to improving maternal and neonatal health.
Though the report is no silver bullet, it will take us a step closer towards achieving MDGs 4 and 5. Governments should take note of the contents and use it to formulate policy. Stakeholders should use it to make demands on their governments, and international development workers should use it to highlight the unacceptable disparity in health provision across the world.