Midwifery: UNFPA's Investment in the Workforce

EXECUTIVE SUMMARY

Midwifery is the closest thing global maternal health has to a silver bullet: competent midwives, practising to their full scope, can address approximately 87% of all essential maternal and newborn health interventions, and the 2021 State of the World's Midwifery (SoWMy) report — UNFPA's flagship analysis co-produced with WHO and the International Confederation of Midwives — calculated that scaling up a competent global midwifery workforce could prevent 4.3 million deaths per year from maternal, newborn, and stillbirth causes. These are some of the most compelling numbers in global health, and they form the core of UNFPA's advocacy for midwifery investment.

The global gap is staggering. The SoWMy 2021 found that approximately 900,000 additional midwives are needed globally; the largest deficits are in sub-Saharan Africa and South Asia, precisely the regions carrying the highest maternal and newborn mortality burden. But the problem is not only about numbers. Midwifery education quality varies enormously, with many training programmes too short and too lacking in clinical hours to produce genuinely competent graduates. Regulatory frameworks in many countries are weak or absent, preventing midwives from practising to their full scope. And trained, deployed midwives frequently cannot function effectively without the enabling conditions — supplies, referral systems, security, management support — that health system strengthening requires.

UNFPA's midwifery programme works across the full pipeline from education through deployment: supporting curriculum development aligned with International Confederation of Midwives (ICM) global standards; strengthening midwifery education institutions; building regulatory frameworks; supporting workforce planning; and advocating for increased investment in midwifery as the central workforce strategy for maternal health. The evidence supporting this strategy is among UNFPA's strongest — well-designed, peer-reviewed, and based on robust methodology. Programme-level evaluations have found generally positive results in increasing the output of trained midwives, with the acknowledged weakest link being deployment and retention in underserved areas.

For funders, midwifery investment represents one of the best-evidenced pathways to reducing maternal and newborn mortality. The return on investment is calculable, the programme model is clear, and independent evaluations are generally positive. The constraint is government willingness to commit the recurrent budget expenditure needed to sustain a growing midwifery workforce — a political economy challenge that UNFPA's advocacy addresses but cannot control.

KEY FACTS

A competent midwifery workforce could address 87% of all essential interventions for mothers, newborns, and stillbirths — including 56 of the 59 highest-impact health interventions for this population (SoWMy 2021).
Scaling up to meet global midwifery workforce need would prevent an estimated 4.3 million deaths per year (maternal deaths, newborn deaths, and stillbirths combined) — SoWMy 2021 modelling.
Current global midwifery supply meets approximately 68% of need; the deficit of approximately 900,000 midwives is concentrated in sub-Saharan Africa, South Asia, and fragile states.
The global maternal mortality ratio is approximately 223 per 100,000 live births (WHO 2023 estimates); two-thirds of maternal deaths occur in sub-Saharan Africa.
Sub-Saharan Africa has approximately 10 midwives per 100,000 population; high-income countries average approximately 300 per 100,000 — a 30-fold disparity.
Countries with universal skilled birth attendance (SBA) have maternal mortality ratios consistently below 25 per 100,000 live births; countries with low SBA rates typically exceed 300 per 100,000.
Skilled birth attendance is the single strongest predictor of maternal mortality at country level — more predictive than income or health system expenditure (WHO analysis).
The SoWMy 2021 is based on primary data collection from 107 countries and secondary data from a further 87; it is the most comprehensive global midwifery workforce analysis ever conducted.
UNFPA co-publishes SoWMy reports with WHO and ICM; reports have been published in 2011 and 2021 (with a 2014 regional supplement). The 2021 report took four years to produce.
Midwifery education programmes vary from under 18 months to over 4 years globally; the ICM minimum standard for direct entry midwifery education is 3 years.
Approximately 60% of midwifery programmes assessed in SoWMy 2021 did not meet ICM minimum standards for clinical hours.
Brain drain is a significant midwifery workforce challenge: in some African countries, up to 40% of domestically trained midwives emigrate within five years of graduation (WHO data).
UNFPA has supported midwifery education reform in over 40 countries through the SoWMy implementation framework since 2021.
Violence against health workers — particularly women health workers including midwives — is a documented occupational safety issue in humanitarian and post-conflict settings that affects deployment and retention.
Approximately 2 million stillbirths per year are potentially preventable through skilled care during labour and delivery; competent midwifery care during labour is the primary preventive intervention (Lancet Ending Preventable Stillbirths series).
The cost of training one midwife to ICM-compliant standard is estimated at USD 3,000–8,000 depending on country context; the lifetime maternal and newborn health impact per trained, practising midwife is estimated at hundreds of thousands of dollars in economic value.

BACKGROUND AND CONTEXT

The Midwifery Case: Why Midwives Are Central to Maternal Health

The argument for midwifery as the primary maternal and newborn health workforce investment rests on several convergent lines of evidence:

Breadth of function: A competent midwife is trained to provide the full essential package of maternal and newborn care: comprehensive antenatal care across the pregnancy; physiologically normal labour and birth management; immediate newborn care and resuscitation; postnatal care for mother and infant; family planning counselling and method provision; identification and referral of complications; and basic management of common obstetric emergencies pending transfer. This breadth means that a single midwife in a community can deliver what would otherwise require a team of differently specialised health workers — making midwifery uniquely cost-effective in low-resource settings.

Cost-effectiveness at system level: Multiple economic analyses have demonstrated that the midwifery workforce investment has among the highest returns per dollar of any health workforce investment. The SoWMy 2021 modelling explicitly compared scenarios with and without midwifery scale-up; the modelled cost-per-death-averted from full midwifery workforce scale-up compares favourably with almost any other health intervention.

Alignment with rights-based care: Beyond technical competence, the ICM model of midwifery practice emphasises woman-centred, respectful care — a rights-based approach to birth that addresses the "disrespect and abuse" in childbirth documented across multiple countries as a major deterrent to facility-based delivery. A workforce trained in midwifery philosophy, not only obstetric procedures, is better positioned to deliver care that women and families actually choose and return to.

Global Maternal Mortality: The Remaining Burden

Despite dramatic progress over two decades — global maternal mortality declined by approximately 34% between 2000 and 2020 — the remaining burden is enormous and inequitably distributed. Sub-Saharan Africa accounts for approximately 70% of all maternal deaths globally; South Asia for approximately 17%. Within countries, rural populations, the poorest quintile, and women in conflict-affected settings die at dramatically higher rates than urban, affluent, and peaceful populations.

The causes of maternal death that midwifery can address are well-established: haemorrhage (the leading cause, approximately 27%), hypertensive disorders (eclampsia, pre-eclampsia), sepsis, obstructed labour, and complications of unsafe abortion. Each of these causes is preventable or manageable with skilled midwifery care — this is the basis for the 87% figure in SoWMy 2021.

What midwifery cannot address is the referral back end — severe cases requiring caesarean section, blood transfusion, and intensive care. A functional midwifery system therefore requires functional referral systems. Midwifery investment without health system investment in surgical capacity and emergency transport produces a programme that can prevent death in most cases but loses avoidable deaths in the most severe complications. This systems-level dependency is an important constraint on interpreting midwifery impact modelling.

Historical Development of UNFPA's Midwifery Role

UNFPA's engagement with midwifery as a specific programmatic focus developed from its broader maternal health mandate. The publication of the first Lancet series on midwifery (2014) — which synthesised evidence on midwifery's potential impact and the barriers to realising it — was a significant academic landmark that aligned with UNFPA's programme investments. The UNFPA-WHO-ICM partnership for the SoWMy reports formalised UNFPA's position as the lead UN system agency for midwifery workforce data and advocacy.

The ICM's global competency standards (first published in 2002, revised in 2019) provide the normative framework for midwifery education and practice that UNFPA's programme investments are designed to achieve. The alignment of the SoWMy evidence framework, ICM standards, and UNFPA programme investments represents a well-integrated multilateral approach to midwifery development.

WHAT UNFPA DOES: PROGRAMME DETAIL

Pre-Service Midwifery Education

Curriculum development and review: UNFPA supports national midwifery education programmes to develop or revise curricula aligned with ICM global competency standards. The 2019 ICM Essential Competencies for Midwifery Practice define the knowledge, skills, and professional behaviours that all midwives should demonstrate at entry to practice. Curriculum alignment involves: competency mapping (identifying gaps between existing curricula and ICM standards); curriculum revision with national midwifery educators and professional bodies; piloting of revised curricula in selected schools; and monitoring of competency achievement.

Clinical training hours and simulation: A persistent weakness identified in SoWMy 2021 is that many midwifery programmes have insufficient clinical training hours and inadequate clinical learning environments. UNFPA addresses this through: supporting access to adequate clinical practicum placements (sufficient women delivering in programme hospitals); introducing simulation-based learning (obstetric mannequins, task trainers) for competencies that are rare or high-risk; and strengthening supervision of clinical learning.

Faculty development: A trained midwifery faculty is the prerequisite for a quality midwifery education programme. UNFPA invests in faculty upgrading — supporting midwifery educators to gain advanced qualifications, access training in midwifery education methodologies, and build research capacity. In countries where midwifery faculty are nurse-educators without midwifery specialisation, UNFPA advocates for faculty qualification standards.

Programme accreditation: UNFPA supports development and strengthening of national midwifery programme accreditation systems — independent review mechanisms that assess whether education programmes meet national and international standards. Without accreditation, programme quality is not externally verified and may deteriorate without accountability.

Physical infrastructure: In some country contexts, UNFPA has supported construction or rehabilitation of midwifery education facilities — classrooms, simulation laboratories, student dormitories. This infrastructure investment is typically done in partnership with national governments, with UNFPA contributing the capital investment and the government committing to recurrent operating costs.

Regulatory Framework Support

Scope of practice legislation: UNFPA advocates for and supports national legislation that clearly defines midwifery's scope of practice — the range of interventions midwives are legally authorised to perform. In many countries, scope of practice is either undefined or more restrictive than midwifery competence justifies, preventing midwives from providing services they are trained to provide (such as oxytocin administration for postpartum haemorrhage prevention or insertion of IUDs). Scope expansion requires legislative and regulatory reform, medical profession engagement, and professional association advocacy — all components of UNFPA's regulatory support work.

Licensing and registration systems: UNFPA supports development of functioning midwifery licensing systems — requiring that all practising midwives hold a valid licence issued by a regulatory body, with requirements for competency demonstration and periodic renewal. In countries where licensing systems exist but are not functional (licences issued without competency assessment, no enforcement of unlicensed practice), UNFPA supports system strengthening.

Nursing-midwifery distinction: A persistent issue in workforce policy is the conflation of nurses and midwives — the assumption that trained nurses can substitute for trained midwives without additional specialised training. UNFPA advocates, with ICM, for the recognition of midwifery as a distinct regulated profession from nursing, while supporting nurse-midwife conversion programmes in countries where nurses are the available workforce.

Workforce Planning and Data

Costed midwifery workforce plans: SoWMy 2021's primary recommendation to governments was to develop and implement costed midwifery workforce plans — analyses of current midwifery workforce numbers, distribution, and quality against projected need, with costed strategies to close the gap over a ten-year horizon. UNFPA supports governments to develop these plans, using SoWMy methodology adapted to country context. Plans should cover: pre-service training scale-up requirements; regulatory reform timelines; deployment incentive mechanisms; and recurrent budget projections.

Health Management Information Systems (HMIS): Workforce planning requires data — how many trained midwives are in the system, where are they deployed, are they practising to their scope? In many countries, HMIS does not capture midwifery-specific data reliably. UNFPA supports HMIS improvement to capture midwifery workforce data as part of broader health information system strengthening.

Deployment and Retention

This is the programmatic weakest link — extensively documented in IEO evaluations and in SoWMy 2021, and inadequately addressed by current programme investments. The problem: even countries that successfully train midwives see those midwives concentrated in urban hospitals and not deployed to the rural, remote, and peri-urban communities where most preventable maternal deaths occur.

Documented failure modes:

Rural deployment stipends exist on paper but are not paid reliably, destroying the financial incentive.
Housing for rural midwives is promised but not built or maintained.
Career progression is slower for midwives who take rural postings, creating a systematic incentive against rural practice.
Security concerns (violence against women, particularly in post-conflict settings) make rural postings untenable for midwives without adequate security infrastructure.
"Ghost worker" phenomena — midwives officially posted to rural facilities who are actually working in cities — are documented in multiple countries and inflate apparent rural staffing levels.

UNFPA's response: UNFPA has invested in retention incentive policy development and advocacy, but implementation is a government responsibility that UNFPA can support only indirectly. The gap between policy design and implementation is the central failure mode in UNFPA's midwifery deployment work.

Advocacy and the SoWMy Reports

The State of the World's Midwifery reports are UNFPA's primary advocacy instrument for midwifery investment. The SoWMy 2021 generated significant international media coverage and was used to brief health ministers, finance ministers, and donors in multiple countries. UNFPA's midwifery advocacy work includes:

Direct engagement with heads of state, finance ministers, and health ministers to make the economic case for midwifery investment.
Engagement with the Global Financing Facility (GFF) and international financial institutions to incorporate midwifery workforce investment into health system financing frameworks.
Supporting ICM's engagement with international nursing and medical professional bodies to secure professional recognition of midwifery's distinct role.

THE EVIDENCE BASE

SoWMy 2021 Modelling: Methodology and Reliability

The 4.3 million deaths preventable per year figure is the centrepiece of midwifery advocacy and deserves scrutiny. The modelling was conducted using the Lives Saved Tool (LiST) — a WHO-endorsed software model that calculates intervention impact based on intervention coverage, effect size (from meta-analyses), and cause-specific mortality rates. The approach:

Defined the package of interventions deliverable by a competent midwife (87% of essential interventions for maternal, newborn, and stillbirth outcomes).
Estimated current coverage of each intervention globally and by country.
Applied published effect sizes (from Cochrane reviews, systematic meta-analyses) to estimate deaths preventable if each intervention achieved universal coverage.
Summed preventable deaths across interventions, accounting for overlapping effects.

Strengths of the methodology: The LiST model is transparent, peer-reviewed, and widely used in global health planning. The effect sizes for individual interventions (skilled birth attendance, active management of third stage of labour, magnesium sulphate for eclampsia, etc.) come from rigorous systematic reviews. The SoWMy 2021 papers were published in The Lancet Global Health and peer-reviewed.

Limitations of the methodology: The 4.3 million figure assumes that scale-up achieves universal coverage of all interventions — an assumption of full implementation fidelity. In practice, coverage gaps, quality gaps, and systems failures mean that midwifery scale-up would achieve a fraction of theoretical impact. The figure is best understood as the ceiling of what a fully functional, universally accessible midwifery workforce could achieve — not a prediction of what current programme investment will produce. Citing the 4.3 million figure without these caveats, as is common in UNFPA advocacy materials, overstates the expected impact of incremental investment.

Evidence for Individual Midwifery Interventions

The evidence base for specific midwifery interventions is strong and well-established:

Skilled birth attendance: The Lancet series on maternal survival (2006) identified skilled birth attendance as the intervention with the greatest potential to reduce maternal mortality. Countries that have achieved >90% skilled birth attendance have dramatically lower maternal mortality than countries with <50%. The association is robust, consistent, and biologically plausible. Methodological caveat: observational data; randomised assignment of skilled birth attendance is not possible, so the evidence is inferential from cross-country comparisons and time-series analyses.

Active management of third stage of labour (AMTSL): Prevention of postpartum haemorrhage — the leading cause of maternal death — through oxytocin administration at delivery is supported by strong RCT evidence (Cochrane review, multiple trials). AMTSL is within the scope of competent midwifery practice and is the single most cost-effective maternal mortality intervention available.

Magnesium sulphate for eclampsia: Supported by very strong RCT evidence (Magpie Trial, 33 countries, 10,141 women). Prevents convulsions and maternal death from eclampsia. Within midwifery scope in most regulatory frameworks; a flagship example of why scope of practice matters.

Kangaroo mother care for preterm/low-birth-weight neonates: Supported by strong RCT evidence (WHO-coordinated multicountry trials). Delivered by midwives and mothers together; highly cost-effective in resource-limited settings.

Evidence on UNFPA's Programme Investments Specifically

Country programme evaluations (IEO): IEO evaluations that have assessed UNFPA's midwifery programme contributions have generally found:

Output achievement: training institutions supported, number of midwives trained, curricula revised — these outputs are typically achieved when UNFPA provides adequate financial and technical support.
Outcome limitations: whether trained midwives are deployed to underserved areas, maintaining competence in practice, and producing improved birth outcomes — the evidence at country level is mixed and often not measured in routine monitoring.
The specific IEO evaluation of UNFPA's maternal health and midwifery work in Ethiopia (2019) found that UNFPA's midwifery education investments contributed to a significant increase in trained midwife output, but found limited evidence that the deployment and retention components had been adequately implemented.

Lancet series on midwifery (2014): A landmark academic analysis of the potential and barriers of midwifery investment. Published peer-reviewed analysis established the case for midwifery as the central strategy for maternal and newborn health. UNFPA co-authored sections; the series shaped international consensus.

Evidence Quality Assessment (GRADE-Style)

Skilled birth attendance reducing maternal mortality: Strong evidence (consistent, large-magnitude, plausible mechanism; observational design limitation acknowledged).
AMTSL (oxytocin) preventing postpartum haemorrhage: Very strong evidence (multiple large RCTs; Cochrane review; globally endorsed).
Magnesium sulphate preventing eclampsia deaths: Very strong evidence (Magpie Trial and supporting RCTs).
UNFPA's education investments increasing trained midwife output: Moderate evidence (country evaluations consistently positive on output; outcome measurement limited).
UNFPA's deployment/retention investments improving rural midwifery coverage: Weak evidence (acknowledged programme weakness; limited evaluation data).
Midwifery workforce scale-up preventing 4.3 million deaths annually: Theoretical upper bound with strong methodological foundation; actual impact of incremental investment is uncertain and almost certainly lower.

IMPLEMENTATION REALITIES

The Education-Deployment Gap

The most fundamental implementation challenge in global midwifery programming is the gap between training and deployment. Countries graduate midwives who are then not deployed where they are needed. This is not a simple logistical problem; it is a political economy problem:

Trained midwives prefer urban postings for multiple reasons: better infrastructure, professional development opportunities, secondary schooling for children, security, and in many countries, access to private practice that supplements public sector salaries. Rural and remote postings are less attractive and are not compensated sufficiently to overcome the preference differential.

Governments commit to rural deployment incentive policies (salary supplements, housing allowances, preferential promotion for rural service) but frequently cannot or do not fund these at the committed levels. Implementation of deployment incentive programmes is among the most poorly documented aspects of midwifery programme monitoring.

The result: in countries where UNFPA has invested heavily in midwifery education, the number of midwives working in rural health facilities has often not increased proportionately to training output. The trained midwives are in the system; they are not in the right place.

Brain Drain and the International Migration Dynamic

An additional challenge is brain drain: midwives trained in low-income countries migrating to high-income countries where salaries are dramatically higher. This is a particularly acute issue in sub-Saharan Africa, where several countries (Ghana, Nigeria, Zimbabwe, Zambia) have historically lost significant proportions of their trained health workforce to migration to the United Kingdom, Canada, and Australia.

WHO's health workforce migration ethical guidelines discourage active recruitment from countries with critical health workforce shortages, and receiving-country governments have made commitments to reduce exploitative recruitment practices. But the economic incentives for both individual midwives and receiving-country employers are powerful, and bilateral ethical recruitment agreements are imperfectly enforced.

UNFPA's midwifery investment is partly vulnerable to this dynamic: countries where UNFPA has invested most heavily in education quality may produce graduates who are most attractive for international recruitment. Programme design has not fully addressed this tension.

Humanitarian Setting Midwifery: The Most Extreme Context

In humanitarian settings — active conflict, acute displacement, post-disaster contexts — the midwifery gap is most acute and the constraints most severe. Women in humanitarian settings deliver without skilled attendance at dramatically higher rates than in stable contexts; facilities are destroyed, midwives are displaced, supplies are unavailable, and referral chains are broken.

UNFPA's Minimum Initial Service Package (MISP) for reproductive health in emergencies addresses the acute phase, including through deployment of reproductive health kits (RH Kit) containing supplies for clean delivery and basic obstetric emergency management. But MISP delivery does not substitute for a functioning midwifery workforce — it is designed for the emergency period only.

Rebuilding midwifery capacity in post-conflict and protracted humanitarian contexts is among the most challenging aspects of UNFPA's programme portfolio. In South Sudan, Somalia, and parts of the Sahel, programme continuity is routinely disrupted by security incidents; training investment is lost when trained staff are displaced; and the enabling environment for midwifery practice (facilities, supplies, security) is absent.

COVID-19 Disruption and Recovery

The COVID-19 pandemic directly disrupted midwifery education programmes globally: clinical placements were suspended when hospitals diverted to COVID response; simulation-based learning was disrupted; and some midwifery education institutions were temporarily closed. The pandemic's clinical education gap — typically six to twelve months of reduced or suspended clinical training — has left a cohort of midwifery graduates with below-standard clinical experience.

Recovery of midwifery education programmes has required accelerated clinical catch-up placements, intensified simulation-based training, and extended supervised practice periods for graduates from pandemic-era cohorts. UNFPA has prioritised this recovery as a specific programme focus in its 2021–2025 implementation planning.

FUNDING, SCALE AND RESOURCES

UNFPA's Midwifery Investment

UNFPA's midwifery programme expenditure is distributed across country programmes and is not reported as a single global budget line. Estimates from UNFPA Annual Results Reports and country programme documents suggest total global investment in midwifery-specific activities of approximately USD 40–60 million per year — making it one of UNFPA's larger sectoral investments within maternal health.

The Global Funding Gap

SoWMy 2021 estimated the annual additional investment needed to close the global midwifery workforce gap (training, deploying, and retaining 900,000 additional midwives) at approximately USD 4.5 billion per year in additional health system expenditure — the vast majority of which would need to come from domestic government health budgets rather than from international donors. External development assistance, including UNFPA's investments, represents a small fraction of what would be needed for full-scale implementation.

This context is essential for interpreting UNFPA's midwifery investment: UNFPA's approximately USD 40–60 million per year is critically important for norm-setting, education system strengthening, and catalysing government investment — but it cannot substitute for the much larger domestic budget commitments that sustainable midwifery workforce development requires.

Cost-Effectiveness Data

The cost per death averted through midwifery investment has been modelled in several settings. A Lancet Global Health analysis (2017) estimated the cost-per-life-year-saved for an expanded, competent midwifery workforce at well under USD 1,000 in most low-income settings — making it one of the most cost-effective health investments globally by standard global health metrics (typically, interventions under USD 2,000–3,000 per life-year saved in low-income countries are considered cost-effective).

These figures are based on modelling assumptions and should be treated as indicative. But the general finding — that midwifery investment is highly cost-effective — is well-supported and has been influential in donor engagement.

KEY DEBATES AND CONTESTED QUESTIONS

1. Direct-Entry Midwifery Versus Nurse-Midwifery

A persistent debate in workforce policy is whether countries should develop direct-entry midwifery programmes (three-year specialist midwifery training from secondary school) or nurse-midwifery programmes (training nurses to acquire midwifery competencies). ICM and UNFPA formally support both pathways, provided graduates achieve equivalent competencies. In practice:

Nurse-midwifery programmes are more common in many countries because nursing infrastructure exists; starting direct-entry midwifery from scratch requires significant investment.
Direct-entry midwives often have stronger midwifery competencies (their entire training is midwifery-focused) but weaker general nursing competencies.
The choice has resource and policy implications that vary by country context.

2. Is Education Investment Enough Without Enabling Conditions?

A methodological debate in the midwifery literature concerns whether midwifery workforce investments can produce mortality impact without concurrent investment in the enabling conditions: medical supplies, functional referral systems, facility infrastructure, and management support. Some analyses suggest that health workers trained to identify complications will produce worse outcomes if they cannot treat those complications or transfer patients in time — because identifying a complication without acting on it may delay traditional community responses without providing modern clinical benefit.

UNFPA's position is that midwifery education investment must be accompanied by health system strengthening investment — this is explicitly stated in SoWMy and in programme documentation. The challenge is that UNFPA's programme investments often cannot control the enabling condition investments, which are typically government or World Bank-funded.

3. How to Address the Deployment-Retention Problem

The most contested implementation question in midwifery programming is how to get trained midwives to rural and remote communities and keep them there. There is no proven model. Options debated in the literature include:

Financial incentives only: Salary supplements for rural postings. Evidence suggests these have moderate, time-limited effectiveness.
Mandatory rural service: Requiring graduates to complete a period of rural service as a licence requirement. Evidence from some countries (Cuba, China) is positive; in others, mandatory service has driven informal avoidance strategies.
Community health worker integration: Training community members as skilled birth attendants with abbreviated midwifery training, deployed where trained midwives will not go. Contested — abbreviated training produces lower competency than full training; WHO guidelines are cautious about this approach.
Systems redesign: Rather than deploying midwives to rural communities, building a hub-and-spoke system where community health workers identify and refer, and midwives are based at referral hubs with transport connectivity. Potentially the most sustainable model but requires significant health system investment.

IMPLICATIONS BY AUDIENCE

For Frontline Staff and Practitioners

Clinical competency is the foundation of midwifery impact. If you are a midwifery educator or clinical supervisor: the ICM Essential Competencies for Midwifery Practice (2019) is the standard reference for what every midwife should know and be able to do at graduation. Map your curriculum and clinical training programme against these competencies — not as a compliance exercise, but as a genuine quality assessment. Identify and address gaps in clinical exposure, particularly for management of the second stage of labour, immediate newborn resuscitation, and haemorrhage management.

For practising midwives: if your scope of practice is more restricted than your competence (e.g., you are competent to insert an IUD or administer oxytocin but are legally or institutionally prohibited from doing so), document this and escalate through your professional association. Scope restriction is a system failure that costs lives, and midwifery professional associations need evidence of the scope gap to advocate effectively.

For managers of midwifery teams: zero tolerance for disrespect and abuse in childbirth. Disrespect and abuse by health workers during childbirth — documented across multiple countries — is both a rights violation and a deterrent to facility delivery. It undermines the entire midwifery investment. Team supervisors have primary responsibility for establishing and maintaining the culture of respectful care.

For Programme Managers and Decision-Makers

The SoWMy 2021 country report for your programme country (where available) provides the most specific analysis of national midwifery workforce size, distribution, education quality, and regulatory framework. Use it as the evidence baseline for country programme design — it identifies the specific bottlenecks to address and the priority investments.

Resist the temptation to report training output as the primary measure of programme success. Training output is the necessary first step. What donors, governments, and the public ultimately care about is whether maternal and newborn mortality is declining. Build your results framework to measure: the proportion of trained midwives who are deployed to underserved areas; the proportion of facilities with at least one qualified midwife on duty at all times; the proportion of births attended by a competent health worker; and where feasible, facility-level maternal and newborn mortality rates.

For Donors and Board Directors

Midwifery is among the best-evidenced investments in UNFPA's portfolio. The case is clear, the methodology is peer-reviewed, and the return on investment is calculable and compelling. Investment should be framed as a multi-year commitment — midwifery education quality improvement and workforce development is a seven-to-ten year investment horizon, not a three-year project cycle.

The key constraint on impact is not UNFPA's programme quality — it is government commitment to the recurrent budget expenditure needed to fund, deploy, and retain trained midwives. Donors should use programme discussions, G7/G20 health commitments, and bilateral government engagement to push governments to commit domestic resources to midwifery workforce funding. UNFPA's catalytic investment is best understood as a mechanism to build the case, demonstrate the model, and leverage domestic government investment — not to substitute for it.

The unresolved deployment and retention problem is where the most additional rigorous evidence and programme innovation is needed. Donors interested in reducing maternal mortality should prioritise funding for implementation research on deployment models — especially in fragile state contexts where the workforce challenge is most acute.

For Researchers

The midwifery research agenda has five priority areas that current evidence does not adequately address:

Deployment and retention intervention trials: What interventions (incentive packages, mandatory service, hub-and-spoke models) effectively deploy and retain trained midwives in underserved areas? The evidence base is primarily observational; controlled evaluations of specific retention interventions would substantially improve policy.
Education quality and competency achievement: What features of midwifery education programmes predict competency at graduation? Are there minimum training hour requirements that reliably produce competent graduates? How does simulation-based learning compare to clinical placement in skill acquisition? These are education science questions with direct policy relevance.
Respectful maternity care at scale: The evidence that disrespect and abuse deters facility delivery is robust. The evidence on how to change provider behaviour at scale — training, supervision, accountability systems, accreditation — is much weaker.
Midwifery-led care in low-resource settings: Most evidence on midwifery-led care (versus physician-led or shared care models) comes from high-income countries. Evidence on optimal care models in low-resource, high-burden settings — where both midwives and physicians are scarce — is thin.
Cost-effectiveness of training models: Direct-entry versus nurse-midwifery, different programme durations, simulation versus clinical hours — comparative cost-effectiveness of different education approaches has not been rigorously assessed.

CURRENT STATUS AND FUTURE DIRECTIONS

Midwifery investment is a central priority in UNFPA's 2022–2025 Strategic Plan, and SoWMy 2021 provides the most detailed and well-resourced evidence platform UNFPA has developed in any sector. Implementation of SoWMy recommendations — governments developing costed midwifery workforce plans — is proceeding in approximately 20 priority countries with UNFPA support.

The post-COVID recovery of midwifery education programmes is ongoing. UNFPA has identified specific cohorts of graduates with COVID-era clinical education gaps and is working with national education systems to address these through accelerated clinical catch-up programmes.

The broader context is one of increasing global recognition of midwifery's importance, catalysed partly by SoWMy 2021. The WHO-UNFPA-ICM partnership is well-positioned to maintain advocacy momentum. The political economy challenge — generating sufficient domestic government budget commitment to sustain a growing midwifery workforce — is the central constraint on translating advocacy into mortality reduction.

SOURCES

State of the World's Midwifery 2021 (UNFPA/WHO/ICM): The primary reference for all global midwifery workforce data. Covers 194 countries, based on primary data from 107 countries. Includes country profiles, modelled impact estimates, and costed recommendations. The 2021 companion papers in The Lancet Global Health provide peer-reviewed methodology documentation.

Homer CSE et al. (2014): "Midwifery." The Lancet. Landmark series establishing the evidence case for midwifery investment. Four papers covering global context, competence and effectiveness, workforce development, and scaling up. The foundational academic reference for UNFPA's midwifery advocacy.

ICM (2019): Essential Competencies for Midwifery Practice. The normative standard for midwifery competency globally. Used as the benchmark for curriculum alignment in UNFPA's midwifery education investments.

WHO (2020): WHO Global Strategic Directions for Nursing and Midwifery 2021–2025. WHO's framework for midwifery workforce development; aligns with SoWMy recommendations and provides global normative direction.

Magpie Trial Collaborative Group (2002): "Do Women with Pre-Eclampsia, and Their Babies, Benefit from Magnesium Sulphate?" The Lancet. The definitive RCT evidence for magnesium sulphate in eclampsia prevention. Strong evidence for a core midwifery intervention.

Sutton A et al. (2021): State of the World's Midwifery: Lancet Global Health companion papers. Peer-reviewed methodology documentation for the 4.3 million deaths estimate and the 87% interventions figure.

UNFPA IEO: Multiple country evaluation reports including midwifery components. Available at unfpa.org/evaluation. The Ethiopia evaluation (2019) is a particularly detailed assessment of education investment outcomes and deployment gaps.

Bohren MA et al. (2015): "Mistreatment of Women During Childbirth in Health Facilities Globally." PLOS Medicine. The first systematic review documenting disrespect and abuse during childbirth; essential for understanding the respectful care agenda.

WHO (2018): WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience. Clinical guideline synthesising evidence for all aspects of intrapartum care; a core reference for midwifery clinical standard-setting.