How midwives are delivering universal health coverage

Over-medicalisation of pregnancy and childbirth has escalated in recent decades. A new approach that puts midwives at the centre of healthcare delivery is set to improve outcomes for mothers and babies. 

A midwife gives a baby back to the mother. Photo: International Confederation of Midwives

The World Health Organization (WHO) recognises that care from midwives is essential to achieving universal health coverage (UHC)—particularly in low- and middle-income countries (LMICs) where health systems often face significant challenges, such as workforce shortages and high maternal and newborn death rates.  

Indeed, according to a new global position paper from the WHO released in October 2024, midwives—with the support of interdisciplinary teams in what they call midwifery models of care—could meet up to 90% of the worldwide need for essential sexual, reproductive, maternal, newborn, child, and adolescent health interventions throughout the life course.  

But in many nations—some high-income as well as many LMICs—over-medicalisation of pregnancy, childbirth, and the neonatal and postpartum periods has escalated in recent decades. The WHO says this has led to “poor quality of care and unfavourable outcomes for women and newborns…posing a barrier to achieving universal health coverage.”

Setting new standards for midwifery-led care 

One organisation’s chief aim is to encourage and expand the move to midwifery models of care globally. The International Confederation of Midwives (ICM), which has 136 member associations from around the world, is the only global professional organisation that defines the standards for midwifery education and regulation. 

Evidence says that maternal and newborn mortality rates and postpartum care can be improved by moving towards a model of care where midwives, trained to the ICM standards, are the main care providers for women and newborns. “This would mean increasing the number of midwives globally and improving the quality of their training in many settings,” says Sandra Oyarzo Torres, president of ICM. “It would also free up specialist obstetricians to work with women and newborns with complex needs.” 

“If we want to improve outcomes, it’s absolutely necessary that midwives and midwifery become a profession that is integrated into the education and health system of every country.”

The implementation of midwifery models of care is patchy for various complex reasons that depend on context and setting. In some cases, colonial powers eliminated midwifery with the introduction of male-supervised obstetrics; in other cases, the health system was simply developed using the male-dominated obstetric model as its foundation.  

“Women have a right to choose what happens to their bodies, and the types of care they get. Midwives help them to achieve this but unfortunately midwifery has been marginalised in many countries,” Oyarzo Torres says.  

With so many countries facing similar challenges, ICM decided to work with its large membership and create unified, global standards. “This way, we were giving midwives’ associations, regulators, educators, and policymakers tools they could use, created by midwifery experts and voted on by all ICM members,” Oyarzo Torres says.  

As such, in 2024, ICM updated its Essential Competencies for Midwifery Practice, which represent a minimum set of knowledge, skills, and professional behaviours a midwife should have upon graduating from an accredited midwifery programme. The length of these programmes varies globally, from three to four years, and as long as six years.  

“If we want to improve outcomes, it’s absolutely necessary that midwives and midwifery become a profession that is integrated into the education and health system of every country, and where midwives are educated and regulated according to ICM standards,” Oyarzo Torres emphasises. 

Using midwives improves outcomes for mothers and babies  

When doctors are unnecessarily involved in pregnancy and childbirth, it can lead to a host of avoidable interventions—such as induction of birth, delivery by forceps or vacuum aspiration, and caesarian (C)-sections.  

“Now we have a huge body of literature that supports midwifery models of care, showing how this model can improve health, improve outcomes and wellbeing for both mother and baby, and reduce C-section rates.” 

One of the key aims of midwifery models of care—in which midwives are the main care providers for women and newborns, starting from pre-pregnancy and continuing all the way through the postnatal period—is to use interventions only when indicated. 

According to the WHO, a rate of 10–15% of women giving birth by C-section is considered ‘normal’; yet in many places, rates exceed 50% or even higher. Many countries globally have C-section rates above 50%, and in some areas, like Latin America and the Middle East, they reach as high as 80% and over. 

This means that more women are having more C-sections, making every next pregnancy and birth more complex, with a higher chance of complications—and at significant cost to families and health systems. There is more and more evidence showing that medically unnecessary C-sections lead to a rise in adverse outcomes for women and newborns, and for this reason, it is important to balance the risks and benefits holistically. 

A midwife checks on her pregnant client during an antenatal visit at a clinic in Kampala, Uganda. Photo: International Confederation of Midwives

The science of midwifery has been in existence for millennia but, as Oyarzo Torres explains, “the body of scientific evidence as we know it has really grown in the last 30 years. Now we have a huge body of literature that supports midwifery models of care, showing how this model can improve health, improve outcomes and wellbeing for both mother and baby, and reduce C-section rates.”  

Dr Solomon Hailemeskel, president of the Ethiopian Midwives Association, agrees, explaining that the shorter training period for midwives compared to doctors and obstetricians results in more cost-effective healthcare. “The training for midwifery is shorter [than for physicians] so we can deploy them quickly and they will promote more natural childbirth,” says Hailemeskel, whose association is working under the umbrella of the ICM.  

Another very important argument for the use of midwifery models of care is that they “improve maternal satisfaction and enable women to make informed health decisions,” Hailemeskel says, noting that recent studies he conducted in hospitals in Addis Ababa revealed an 87% improvement in satisfaction in the group of women who received midwifery models of care, compared to conventional care.  

“We can have midwives in urban areas, rural areas, and in even in the most difficult-to-reach areas of our country,” Hailemeskel says. “Implementation of midwifery models of care will promote and encourage use of primary healthcare and therefore, we can increase access to UHC very easily.”  

Gearing up to provide midwifery-led care 

Another country that is working to implement to the midwifery-centred practice advocated by ICM is Uganda. 

“We now have more than 100 training centres across the country, where previously there were very few,” says Sarah Namyalo, president of the Uganda Private Midwives Association, which is also working under the umbrella of the ICM.  

“With better training, we now have many facilities led by midwives alone. We provide enhanced antenatal care, and outcomes during birth and postpartum have also improved.”  

She acknowledges that the country has a high maternal mortality ratio—estimated in 2016 at around 336 mothers per 100,000 who die in or around childbirth. However, Namyalo highlights that that figure has now decreased to 189 per 100,000, according to statistics from 2022.     

This is largely due to a reduction in fatal postpartum haemorrhage (bleeding), which is one of the leading causes of maternal mortality in Uganda. “We have had postpartum haemorrhage campaigns this year, led by the Ministry of Health, to raise awareness on the prevention, causes, and management, including timely referrals,” Namyalo says, explaining that the campaigns targeted both midwives and women in the community.  

Lobbying to implement midwifery models of care 

Although there is a realm of published clinical trials supporting midwifery models of care, Hailemeskel conducted two large trials in hospitals in North Shoa zone in Ethiopia’s Amhara state to provide some local data for his country. The results were published in the journal Women and Birth in July and November 2022.  

Women in the midwifery model of care group always saw one of a group of midwives during the course of their pregnancy and afterwards, whereas the control group received standard care, which often involved a different healthcare provider and included physicians. 

The results of the trials are impressive. Of significance, Hailemeskel says, the midwifery models of care “reduced the rate of preterm birth by 61%”. 

A woman takes her baby for immunisation at a clinic in Kampala, Uganda. Photo: International Confederation of Midwives

Among the women who were receiving midwifery models of care, 87% had a spontaneous vaginal delivery, compared with 70% in the control group. The women in the midwifery models of care group also required fewer interventions—vacuum-assisted deliveries were reduced by 58% and episiotomies by 74%—and admissions to the neonatal unit were reduced by 50%. The C-section rate was reduced by 52% in the midwifery model of care group compared to the control group.  

In addition, 89% of women in the midwifery model of care group were breastfeeding within one hour of birth, compared with 61% in the control group. The condition of the newborn babies was significantly higher immediately after birth. And 97% of women who were in the midwifery model of care group received continuity of care from their midwives during and after labour, compared to 25% in the control group. 

Off the back of these findings, Hailemeskel is now negotiating with the Ministry of Health in his country. “I hope the Ministry of Health will approve and launch the protocol nationwide within a very short period of time. We are in the final stages,” he says.  

Transitioning to new ways of working 

Oyarzo Torres acknowledges that there is a long way to go but notes that many countries around the world are working extremely hard, often under difficult geopolitical circumstances, to try to transition to midwifery models of care. 

“Many of ICM’s midwives’ associations are working closely with governments and women’s groups to ensure midwifery models of care become the norm. From Pakistan to Yemen and Ukraine, South Africa to Guatemala, many moving pieces are coming together to make this model a reality for the wellbeing of women and newborns,” Oyarzo Torres says.  

She says transitioning to midwifery models of care is “essential for UHC” and that a multidisciplinary approach is “key to good outcomes”.  

“If we want to make UHC a reality, midwives are absolutely key. But midwives need to work in health systems that enable their practice and encourage multidisciplinary collaboration. Midwives are primary health workers—they need to be able to escalate care when necessary, and include colleagues such as obstetricians, gynaecologists, and neonatal doctors.”