We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with effective referral and transfer mechanisms to specialist care.
Introduction
Midwifery is one effective means to promote the health and wellbeing of women of childbearing age and their newborn infants and families, with a potentially rapid and sustained effect on population health outcomes1 through the provision of maternal and newborn interventions. The interventions known to be effective in improving health outcomes, such as antenatal corticosteroids for women in preterm labour2 and midwife-led care,3 have been detailed in the Cochrane Library and the Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health.4 This last review4 identified 56 essential interventions that, when implemented in packages relevant to local settings, were most likely to save lives, especially in low-income and middle-income populations. As part of this Lancet Series about Midwifery, Mary Renfrew and colleagues1 re-examined the effective interventions that have been shown to improve maternity-related outcomes for women and newborn infants, and showed that midwifery, as delivered by midwives and others with midwifery skills, can deliver most effective maternal and newborn health interventions, including the elements (also known as signal functions) for basic emergency obstetrics and neonatal Care (BEmONC; ie, assisted delivery, removal of retained products, manual removal of the placenta, administration of oxytocic drugs, antibiotics, and anticonvulsants, and neonatal resuscitation).1 Interventions, including blood transfusions or caesarean section capacity (indicative of comprehensive EmONC [CEmONC]), are classified as specialist (ie, that require the input of a medical practitioner with advanced skills in obstetrics and advanced medical equipment and medicines). Renfrew and colleagues'1 definition of midwifery is used in this and all other articles in this Series.
The practice of midwifery is defined as “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, post partum and the early weeks of life. Core characteristics include optimising normal biological, psychological, social, and cultural processes of reproduction and early life, timely prevention, and management of complications, consultation with and referral to other services, respecting women's individual circumstances and views, and working in partnership with women to strengthen women's own capabilities to care for themselves and their families”.1
The effect of scaling-up midwifery and the associated interventions provided by midwifery services is not presently known. We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled-up in 78 countries classified by Human Development Index (HDI).
Key messages
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Midwifery can deliver most effective maternal and newborn health interventions, and can enable access to specialist and comprehensive emergency care when necessary.
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Universal coverage of these interventions will result in reductions in maternal deaths, stillbirths, and neonatal deaths in 78 countries classified according to the HDI.
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In countries in the lower HDI tertile, maternal mortality would decrease by 27% with a modest (10%) increase in coverage of the interventions delivered by midwifery, including family planning, over a 15-year period (2% per year on present baseline estimates), by 50% with a substantial coverage increase (25%), and by 82% with universal coverage (95%). We noted similar reductions on stillbirths and neonatal deaths.
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Family planning alone also contributed to substantially decreasing deaths, since fewer women are exposed to the risk of maternal death. The full scope of midwifery practice should include family planning.
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In addition to the estimation of mortality, morbidity, quality of life, and wellbeing should also be measured to provide more detailed evidence on the full effect of midwifery.
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At all HDI levels, about 30% of maternal deaths could be averted by midwifery, with an additional 30% averted with the addition of specialist medical care.
HDI=human development index.
Section snippets
Measurement of maternal and child health outcomes
An estimated 15–20 million women are affected every year by substantial morbidity as a result of childbirth,5, 6 affecting not only the woman, but also her baby, other children, and members of the broader community. To determine the full effect of midwifery on women and newborn infants, biological (ie, morbidity and mortality), financial, social, and psychological outcomes would need to be measured.1 Poor maternal health contributes to economic hardship, with potentially longer-term outcomes,
Coverage of maternal and newborn health interventions
Regardless of the challenges associated with measurement, to improve outcomes, sufficient coverage of maternal and newborn interventions is required. The Countdown to 2015 for maternal and child survival tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5 in 75 high-burden countries21, 22, 23, 24, 25, 26 and has shown that the overall coverage of several components of midwifery is low, such as satisfaction of family planning needs (54%), four or more antenatal
Will an increase in coverage of midwifery avert deaths?
Renfrew and colleagues1 have shown that midwifery is an effective and probably cost-effective means to provide reproductive, maternal, and newborn services. Therefore, we sought to establish the effect of scaling-up such services on maternal and neonatal deaths. We aimed to estimate the effect of midwifery, as defined in this Series,1 on maternal and newborn outcomes. The two objectives to achieve this aim were to estimate maternal, fetal, and neonatal deaths averted using the Lives Saved Tool
The Lives Saved Tool
LiST is one module in the Spectrum Policy Modeling Software.31 Other Spectrum modules include HIV, demography, and family planning. LiST was selected as one tool that has the proven capacity to estimate the effect of discrete midwifery interventions, rather than a package of care as in the quality maternity framework, in The State of the World's Midwifery 2014 Report.32 In brief, the LiST model starts with a given population's current health and mortality status, and coverage of health
Effective interventions and estimation of their baseline coverage
The effective maternal and newborn health interventions were those identified in the Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health,4 and in the study by Renfrew and colleagues,1 as being able to be delivered as part of midwifery services, particularly by midwives educated to international standards and who are integrated into the health system. Specialist medical interventions were those requiring medical assistance such as blood
Deaths averted under different increased coverage scenarios
A modest increase in coverage of midwifery, including family planning, by 10% every 5 years (scenario 1) could result in a 27·4% reduction in maternal deaths in the group A countries, a 35·9% reduction in the group B countries, and a 62·7% reduction in the group C countries (table 4). Given the lower number of maternal deaths in the group C countries than in the other groups, a reduction in the absolute number of maternal deaths resulted in a larger proportional effect in group C than in group
Estimation of the additive value of specialist care
The second aim of this study was to estimate the value of adding specialist (obstetrician) care to midwifery on maternal, fetal, and neonatal lives saved. To do this, we included all activities that could reasonably be delivered by a midwife to be midwifery care,28 covering activities ranging from community-based to BEmONC-level care; these are included in the first four boxes in the framework for quality maternal and newborn care1 in this Series.
We included additional interventions deemed to
Even modest increases in coverage can save lives
Even at the lowest level of scale-up, of 10% per 5 years relative to baseline, we noted a noticeable reduction in the number of maternal and neonatal deaths, with the greatest absolute reduction in the low-HDI countries. The largest percentage reduction was seen in the moderate-to-high HDI category, possibly because the overall coverage was already high (75% of institutional births), so quality was most likely to be affected.
Analyses and reports in the past two decades25, 26, 65 have
Conclusions
We have described the range of potential benefits that full and comprehensive scale-up of midwifery can bring to communities and families worldwide, regardless of their present level of development. Although it is clear that these benefits can be very important, further critical assessment and research is required to establish how health systems and community services can be best improved and strengthened in order for midwifery to be available and accessible to all.
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