Midwives Can Reduce the Number of Preventable Deaths From Pre-Eclampsia: Research from Kenya and Nigeria

Amy Dempsey, Population Council

Sunday, May 5 is International Day of the Midwife, a global advocacy day dedicated to raising awareness of the importance of these defenders of women’s rights. To raise awareness, please read and share the International Confederation of Midwives’ social media toolkit.

The World Health Organization (WHO) defines “midwifery” as the “care of women during pregnancy, labour, and the postpartum period, as well as care of the newborn. It includes measures aimed at preventing health problems in pregnancy, the detection of abnormal conditions, the procurement of medical assistance when necessary, and the execution of emergency measures in the absence of medical help.”

The Ending Eclampsia project believes midwives are essential to reducing preventable maternal health and newborn deaths, specifically those related to pre-eclampsia/eclampsia (PE/E).

As awareness of the high maternal mortality rate – especially among black women and other women of color –  in the United States increases, so to do the calls-to-action that aim to get the maternal health community to address the problem. One – perhaps obvious – course of action is better collaboration, partnership and communication between and among health care providers. Last year, the American College of Nurse-Midwives (ACNM) and the American College of Obstetricians and Gynecologists (ACOG) released their Joint Statement on the Practice Relations between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives, which says:

"ACOG and ACNM believe health care is most effective when it occurs in a system that facilitates communication across care settings and among clinicians. Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed independent clinicians who collaborate depending on the needs of their patients."

These American agencies are not the first to advocate for midwife-led continuity of care during pregnancy or strengthening the capacity of midwives so they can provide better care to pregnant women, nor are these efforts limited to high-resource settings.

In a retrospective study conducted by the USAID-funded Ending Eclampsia project in Kenya, researchers aimed to understand the factors that impact women’s maternal health care seeking behaviors, and specifically looked at the barriers women face when trying to access services related to PE/E. In the preliminary analysis of this study, researchers found that 83% of all maternal deaths within the study period had a late diagnosis of PE (unpublished). The authors speculated that these deaths could have been averted or reduced with adequate availability of skilled providers, especially midwives in the early stages of the pregnancy continuum.

Related research in Nigeria revealed providers – the majority were community health extension workers and community health workers, but also included 63 midwives – could better detect severe pre-eclampsia after receiving training on emergency obstetric and neonatal care (EmONC); measuring for, and managing, high blood pressure; and follow-up of women throughout their pregnancies and into the postnatal period.

These results are promising, and make a case for investing resources into training midwives in Nigeria, where there also are not enough midwives at primary health care centers to serve their communities. But we know there are several contributors to maternal mortality, and access to providers is only one of them. Poor management of risk factors – hypertension, obesity, diabetes, among others – early in a woman’s pregnancy, as well as insufficient number of the high cost of services, medicines, and transportation, and household-level barriers are all players here. However, a health systems approach that focuses on increasing the number skilled providers at every tier of a health system would enhance pregnant women’s ability to access and receive high-quality care when and where they need it.

Midwives are improving maternal health outcomes in South Sudan, where the government increased the number of trained midwives in the country from fewer than 10 in 2012 to more than 700 midwives today.  

Read more about Ending Eclampsia’s work with midwives in Nigeria.