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Midwifery and Quality Care

Article  in  Obstetrical and Gynecological Survey · January 2015

DOI: 10.1097/01.ogx.0000460706.27837.c4

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June, 2014 www.thelancet.com

Midwifery
An Executive Summary for The Lancet’s Series

“Midwifery is a vital solution to the challenges of

providing high-quality maternal and newborn care
for all women and newborn infants, in all countries”
 Executive Summary
Midwifery
Midwifery matters more than ever
The essential needs of childbearing women in all
countries, and of their babies and families, are the focus
of this thought-provoking series of international studies
on midwifery. Many of those needs are still not being
met, decades after they have been recognized. New
Gaby Jeffs
solutions are required.
The Series provides a framework for quality maternal
and newborn care (QMNC) that firmly places the needs
Key messages
• These findings support a system-level shift, from maternal and newborn care focused
on identification and treatment of pathology, to a system of skilled care for all, with
multidisciplinary teamwork and integration across hospital and community settings.
Midwifery is pivotal to this approach.
• Future planning for maternal and newborn care systems in low-income and middle-
income settings can benefit from using the evidence-based framework for quality
maternal and newborn care (QMNC) for workforce development and resource allocation.
• The views and experiences of women themselves, and of their families and
communities, are fundamental to the planning of health services in all countries.
• Midwifery is associated with more efficient use of resources and improved outcomes
when provided by midwives who are educated, trained, licensed, and regulated, and
midwives are only effective when integrated into the health system in the context of
effective teamwork and referral mechanisms and sufficient resources.
• Promoting the health of babies through midwifery means supporting, respecting, and
protecting the mother during the childbearing years through highest quality care;
strengthening the mother’s capabilities is essential to longer term survival and
wellbeing for the infant.
• Strengthening health systems, including building their workforce, makes the difference
between success or reversal in maternal and newborn health. Since 1990, the
21 countries most successful in reducing maternal mortality rates—by at least 2·5% a
year—have had substantial increases in facility-birthing, and many have done this by
deploying midwives.
• Effective coverage of reproductive, maternal, and newborn health (RMNH) care
requires three actions. These are: facilitating women’s use of midwifery services, doing
more to meet their needs and expectations, and improving the quality of care they
and their newborn infants receive.
• Although evidence from more settings is needed, evidence so far shows that
midwifery care provided by midwives is cost-effective, affordable, and sustainable.
The return on investment from the education and deployment of community-based
midwives is similar to the cost per death averted for vaccination.
• Quality improvements in RMNH care and increases in coverage are equally important
for achieving better health outcomes for women and newborn infants. Investment in
midwives, their work environment, education, regulation, and management can
improve the quality of care in all countries.
• Efforts to scale up QMNC should address systemic barriers to high-quality midwifery—
eg, lack of understanding of midwifery is and what it can do, the low status of women,
interprofessional rivalries, and unregulated commercialisation of childbirth.
2 www.thelancet.com
of women and their newborn infants at its centre. It is
based on a definition of midwifery that takes account
of skills, attitudes and behaviours rather than specific
professional roles. The findings of this Series support
a shift from fragmented maternal and newborn
care provision that is focussed on identification and
treatment of pathology to a whole-system approach
that provides skilled care for all. This will require
effective multidisciplinary teamwork and integration
across hospital and community. The evidence discussed
across the series indicates that midwifery is pivotal to
this approach.
The Series comprises four separate papers1–4
which have been developed collaboratively by
a multidisciplinary group, including academics,
researchers, advocates for women and children,
clinicians, and policy-makers. Together, the papers
address key issues on the contribution of midwifery, and
challenge much of the current thinking and attitudes
among health professionals, decision-makers, and the
public. They provide health professionals and decision-
makers with realistic, achievable, sustainable, and
evidence-based strategies. Central to these is midwifery
care for every woman and every newborn infant.
Midwifery is already widely acknowledged as making
a vital and cost-effective contribution to high-quality
maternal and newborn care in many countries. Despite
this, its potential social, economic and health benefits
are far from being realized on a global scale. This Series
strengthens the evidence base and demonstrates the
scale of the positive impact that can be achieved when
midwifery is implemented, especially in the context of
effective health systems.
The recommendations arising from this work can be
tailored to individual communities and countries at all
income levels. If implemented, these will be potentially
life-changing for mothers and babies, whether they are
the majority who are healthy, or the minority who need
additional care and services to avoid adverse outcomes.
The strategies put forward here will help to meet
the goal of universal health coverage and will be
fundamental to the UN post-2015 development agenda.
They will make an important contribution to the
effective actions for the Global Strategy for Women’s and
Children’s Health and the Every Newborn Action Plan.

The challenge
Every year there are an estimated 139 million births. An
estimated 289 000 women will die during pregnancy,
childbirth or soon after, 2·6 million will suffer stillbirths,
and 2·9 million infants will die in the first month of
life. Poor quality maternal and newborn care is a major
factor. Continued reductions in maternal and newborn
mortality require overall improvements in quality
throughout the continuum of care, as well as improved
emergency services.
Poor quality care is not just evident in a lack of
availability of services and care provision. While many
women and infants have inadequate access to any care,
there is global concern about the over-use of treatments
that were originally designed to manage complications,
with the consequence that many healthy women and
newborns in high-income, middle-income, and low-
income countries become exposed to the adverse effects
of unnecessary interventions used routinely, including
limited mobility in labour, episiotomy, and caesarean
section. Both underuse and overuse of interventions
contribute to acute and chronic clinical and psychological
morbidity for an estimated 20 million childbearing
women, with a lasting impact on mothers’ and infants’
physical and psychosocial health and well-being, on their
need to pay for ongoing health care costs, and on the
ability of their families to escape poverty. Poor quality
maternal and newborn care also has an economic impact
on communities and countries and hampers efforts to
tackle intergenerational inequalities in health.
The quality of care is not directly related to the
available resources in a health system. Despite their
relative wealth, some high-income countries, such as the
USA, rank lower on the health components of the 2013
Mothers Index than some far less wealthy ones, such as
Poland and Estonia. Although the level and type of risks
related to pregnancy, birth, postpartum and the early
weeks of life differ between countries and settings, the
need to implement effective, sustainable and affordable
improvements in the quality of care is common to all,
and midwifery is pivotal to this approach.
QMNC framework
As an essential pre-requisite to the Series, a framework
for quality maternal and newborn care was developed
from analyses of existing reviews of women’s views and
experiences, practices and interventions, and workforce,
www.thelancet.com 3
Executive Summary
Definition of midwifery
In some countries, the full scope of care that could be provided by qualified midwives is
limited by health system and cultural barriers, and there is some overlap in roles and
responsibilities between different health professionals. In many countries some aspects of
midwifery care are provided by obstetricians, family doctors, nurses, auxilliary midwives,
community health workers or traditional birth attendants, or by inadequately-trained
midwives, as well as by competent midwives educated to international standards, and by
nurse-midwives who are trained both as nurses and midwives. A definition of midwifery
as a package of care is needed to identify the important aspects of this care regardless of
care provider, and to provide a structure to support analysis of the reach and quality of
midwifery care.
Midwifery is defined in the series as: “Skilled, knowledgeable and compassionate care for
childbearing women, newborn infants and families across the continuum throughout
pre-pregnancy, pregnancy, birth, postpartum 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”.
The International Labour Organisation describes midwives as the primary (but not the
only) professional group to provide midwifery. The International Confederation of
Midwives defines a midwife as “…a person who has successfully completed a midwifery
education programme that is duly recognised in the country where it is located and that is
based on the International Confederation of Midwives’ Essential Competencies for Basic
Midwifery Practice and the framework of the ICM Global Standards for Midwifery
Education; who has acquired the requisite qualifications to be registered and/or legally
licensed to practice midwifery and use the title ‘midwife’; and who demonstrates
competency in the practice of midwifery”.
combined with the insight and experience of the series
authors. This framework describes the characteristics of
Save the Children Liberia/Jonathan Hyams
care that women, infants and families need from pre-
pregnancy, through pregnancy, to birth, postpartum
and the early weeks of life. The framework expands the
notion of quality of care from the technical dimensions
of what is done to include how, where, and by whom
this care is provided within any particular context. The
framework (figure 1) demonstrates the balance that is
required between skilled, supportive and preventive
care for all women and infants, regardless of education,
income, or health status; and the promotion of normal
reproductive processes, first-line management of
complications, and skilled emergency care; all within the
context of respectful care that is tailored to need and
that works to strengthen women’s capabilities. Crucially,
the framework shows the importance of linking care
and service provision across community and facilities,
through continuity of care and care provider, and places
midwifery into the mainstream of the wider health
system provision.
 Executive Summary

This evidence-based framework underpins all papers in
the Series and has been used to: assess evidence on what
women and infants need from maternal and newborn
services; define the range of practices included within
the scope of midwifery care; and identify components
of quality care that have to be strengthened in
country-level examples. The framework can also be
used to assess the quality of care, to plan workforce
development, resource allocation, or an education
curriculum, or to identify evidence gaps for future
research. It is intended to be relevant to any setting, and
to all who need, or provide, maternal and newborn care
and services. Inherent in this framework is the need for
interdisciplinary team work and collaboration.
What women need from maternal and newborn
services
The QMNC framework was used to review the evidence
on what women and newborn infants need from
maternal and newborn services. This review showed
that information and education were essential to
enable women to learn for themselves, to build on their
own strengths and to access services in a timely way.
The review showed that women needed services to be
provided in a respectful way by staff who engendered
trust and are empathic and kind, with care personalised
to their individual needs. Particularly, women wanted
health professionals who combined clinical with
interpersonal and cultural knowledge and skills.
Effectiveness of maternal and newborn care practices
The evidence examined in this Series suggests that
midwifery is uniquely placed to contribute to the QMNC
framework and to offer this combination of skills and
relationship-based care, appropriate to the context and
situation, and across the continuum.
Following on from the analysis of women’s views and
experiences, an analysis of 461 Cochrane systematic
reviews was undertaken to develop the framework
and inform the important components of quality care.
Through this process, 122 effective practices were
identified as relevant for all childbearing women and
infants. Of these, 72 effective practices were identified
Quality agenda for maternal and newborn care
Over the past decade, the primary care movement has fully
recognised the importance of person-centred and
people-centred care. Despite decades of protest by women’s
advocates, midwives and academics, the main focus of
developments in maternal and newborn health services has
until recent years tended to be on life-saving interventions and
increasing coverage of services. In that context, the quality
agenda for maternal and newborn health is only now slowly
starting to emerge. In high-income countries, the quality of
care debate has often focused on informed choice, without
addressing the other aspects of quality maternal and newborn
care. This has resulted in a focus being on relatively “quick fix”
technical solutions while ignoring the more difficult longer-
term task of building systems that include preventive and
supportive care that upholds the appropriate provider values
and attitudes required for delivering it.

For all childbearing women and infants For childbearing women and infants
with complications

Education Assessment Promotion of normal First-line Medical

Information Screening processes, prevention management obstetric
Practice categories Health promotion Care planning of complications of complications neonatal
services

Available, accessible, acceptable, good-quality services—adequate resources, competent workforce

Organisation of care
Continuity, services integrated across community and facilities

Respect, communication, community knowledge, and understanding

Values
Care tailored to women’s circumstances and needs

Optimising biological, psychological, social, and cultural processes; strengthening woman’s capabilities
Philosophy
Expectant management, using interventions only when indicated

Practitioners who combine clinical knowledge and skills with interpersonal and cultural competence
Care providers
Division of roles and responsibilities based on need, competencies, and resources

Figure 1: The framework for quality maternal and newborn care

Maternal and newborn health components of a health system needed by childbearing women and newborn infants (as re-drawn for Renfrew et al1).

4 www.thelancet.com

as being within the scope of midwifery and were further
analysed to identify the outcomes improved. It was found
that 56 outcomes could be improved by the combination
of practices that fall within the scope of midwifery. The
scale of the impact of these outcomes will vary across
settings and will depend on the organisation of services
and the skills and competencies of the workforce.
Further analysis found that 44 (61%) of the 72 effective
practices identified demonstrated the importance of
optimising normal processes of reproduction and early
life and of strengthening women’s capabilities to care for
themselves and their families.
Scope of practice of midwives
Educated, trained, licensed, and regulated midwives
can provide the full scope of midwifery as defined in
this Series. Multiple providers are active in providing
midwifery care, but with limited benefits where reliance
is solely on less skilled health-care workers. Care led by
midwives—educated, licensed, regulated, integrated
in the health system and working in interdisciplinary
teams—had a positive impact on maternal and perinatal
health across the multiple stages of the framework,
even when compared with care led by other health
professionals in combination with midwives. In the
high-income settings in which resource use has been
examined, there are indications that such midwife-led
care is a more cost-effective option than medically-led
care. When midwives work in collaboration as part of
multidisciplinary teams providing integrated care across
community and hospital settings, they can also provide
effective midwifery care for women and infants who
develop complications.
The projected impact of scaling up midwifery
The Series demonstrates the substantial health and well-
being benefits for women, mothers and their infants,
as well as families, when high-quality midwifery care is
delivered by midwives and others with midwifery skills.
The Lives Saved Tool (LiST) was used to model the
potential impact of the essential interventions for
reproductive, maternal, and newborn health (RMNH)
that are within the competencies of the midwife.
The modelling showed that scaling up midwifery could
help reduce mortality, even in resource constrained
environments. Midwifery could be implemented with
successful outcomes at any stage of a country’s transition
www.thelancet.com 5
Executive Summary
to lower maternal and newborn mortality rates. Universal
coverage of specific, essential interventions for RMNH
that are within the competencies of the midwife will lead
to reductions in maternal deaths, stillbirths, and newborn
deaths in 78 ‘Countdown’ countries classified according
to the human development index (HDI).
Gaby Jeffs
In low-resource settings the model predicts that,
compared with current baseline estimates and over
15 years, maternal and newborn mortality and stillbirths
could be reduced by between 27% and 82%. For
example, a recurrent 5-year increase of 10% coverage of
the interventions (including family planning) delivered
by midwives would lead to a 27% drop in maternal
mortality. A 25% increase from current baseline
estimates would lead to a 50% reduction of maternal
mortality, while 95% coverage would prevent 82% of
maternal deaths. The impact on reducing stillbirths and
newborn deaths would be similar.
The Series also estimated the value of incrementally
adding specialist care to midwifery on maternal, fetal
and neonatal lives saved. However, the impact of adding
specialist medical services to the midwifery package of
care was found to be far less than the impact observed
when only activities considered to be part of midwifery
(both maternal and child health and family planning)
were implemented.
Impact of midwifery on health, psychosocial, and resource use outcomes
The analyses showed that outcomes improved by midwifery care include reduced maternal
and newborn mortality, reduced stillbirth, reduced perineal trauma, reduced instrumental
birth, reduced intra-partum analgesia or anaesthesia, less severe blood loss, fewer preterm
births, fewer newborn infants with a low birth weight, and less hypothermia. The analyses
also found increased spontaneous onset of labour, greater numbers of unassisted vaginal
births, and increased rates of initiation and duration of breastfeeding. Increased referrals
for pregnancy complications, fewer admissions to neonatal intensive care units, and
shorter stays in neonatal units are examples of outcomes that indicate both improved care
and resource use. Importantly, women reported a higher rate of satisfaction with care in
general and with pain relief in labour in particular, and improved mother-baby interaction
was also identified.
Essential and effective interventions
The specific interventions examined were those identified in
the Essential Interventions, Commodities and Guidelines for
Reproductive, Maternal, Newborn and Child Health as being able
to be delivered as part of midwifery services, in particular, by
midwives educated to international standards and integrated
into the health system.
 Executive Summary
Scaling up midwifery in high-income countries is
likely to have more impact on morbidity than mortality,
given the very low rates of mortality in these settings.
Even though over-use of technical interventions is a
problem in countries at all income levels, the relative
negative contribution of over-use to under-use is
Gaby Jeffs
likely to be greater in high-income countries. Different
approaches therefore need to be developed to model
the impact of midwife-led care in countries with
different income levels.
Strengthening health systems and the
deployment of midwives in countries with high
maternal mortality
Learning from experience
The Series presents case studies from four countries
that sought to improve maternal and newborn survival
and health over the past three decades by investing
in midwives and strengthening other aspects of their
health systems. In Burkina Faso, Cambodia, Indonesia,
and Morocco, a combination of system changes and
staffing and service provision initiatives was used to
achieve sustained reductions in maternal and newborn
mortality. These four countries have opted, successfully,
for a rapid scale-up of their midwife workforce, and their
experience highlights two important issues.
Burkino Faso
Revitalisation and expansion of the service network (district model), accelerated after 2000
Investment in midwives
Removal of financial barriers
Action on quality of care
Cambodia
Establishment of a service network (district model) from 1995
Investment in midwives
Removal of financial barriers (not specific to maternal health)
Action on quality of care
Morocco
Expansion of the service network and technical platform: primary care from 1980s, hospitals during 1990s
Investment in midwives
Removal of financial barriers
Action on quality
Indonesia
of care
Surge of expansion of the service network: health centres from 1980s, hospitals 2000s
Investment in midwives, from late 1980s
Removal of financial barriers
Action on quality of care
1990s 2000s
Figure 2: Sequence of crucial interventions for health-system strengthening in support of quality and
maternal newborn health in Burkina Faso, Cambodia, Morocco, and Indonesia, from 1980s to present
6 www.thelancet.com
First, it suggests that a strategy for improving
maternal and newborn health cannot be reduced to
a choice of the professional category to be scaled up,
but critically depends on the design and investment in
the overall service delivery network. The deployment
of the workforce within this network is a question of
managing pace, cost and quality. Second, it confirms
that where systems are consistently strengthened over a
long period of time, investment in midwives is a realistic
and effective strategy to reduce maternal mortality,
including in resource-constrained contexts. Building
a network of facilities from scratch, as in Burkina Faso
and Cambodia, takes time. However, once it is in place,
deploying a workforce can proceed quite rapidly.
In three of these countries (Burkina Faso, Morocco,
and Cambodia), a substantial amount of time passed
between the expansion of infrastructure and the
deployment of a midwifery workforce. In Indonesia, the
new workforce was not just intended to staff facilities,
but also dedicated, village-level maternal health services
in parallel with the facilities. However, their productivity
was limited to the number of pregnant women in a
village and they operated as solo practitioners. This
suggests that most of the benefits in maternal mortality
reduction came from improved access to formal
facilities where more midwives were deployed (figure 2).
The quality challenge
In the four countries described above, concerns about
quality of care appeared late, well after the expansion
of networks and workforces, and the reduction of
financial barriers. More recently, all four countries
have become aware of the need to improve technical
standards, competencies, and equipment. Death-
miss and near-miss audits have also had an important
role in identifying areas that needed to be improved.
Health authorities in the four countries have also
shown willingness to improve access, while identifying
problems and obstacles over time. The design and
implementation of solutions may have suffered delays
and setbacks, but on the whole, there has been a
progressive sophistication in the management of the
maternal and child health programmes in all of the case
studies. This has created contexts in which substantial
increases in midwives were confirmed as a strategic
element in contributing to maternal and newborn
survival.

Policy implications for improving maternal and
newborn health through midwifery
The evidence outlined in this Series shows that
increasing coverage of services alone does not
guarantee high-quality care or a reduction in maternal
and newborn morbidity and mortality. Therefore,
policies should address improving coverage and quality
at the same time: both are equally important. This is
the concept of “effective coverage”—the proportion
of the population who have need of an intervention
and receive that intervention with sufficient quality
to be effective, and who benefit from it. This means
facilitating women’s use of midwifery services, doing
more to meet women’s needs and improving the quality
of care women and newborn infants receive.
Scaling up the contribution of midwives to the
expansion of available RMNH care is a strategic option
of considerable appeal among policy-makers today.
The effectiveness of midwives is evident in the country
experiences documented above and by the modelling
of the potential impact of technical interventions
that are within midwives’ scope of practice. It is likely
that the health and social impact of scaling up the
contribution of midwives would be further enhanced
through fuller attention to the other dimensions of
the QMNC framework: optimising normal processes
of reproduction, embedding mid­wifery into the wider
health system, continuity of care, and competent,
caring, trustworthy care providers.
Implementing the QMNC framework will be
challenging in those low-income and middle-income
countries where maternal and newborn mortality
remains high, service delivery networks are incompletely
developed, and human resources are wanting—see
example of Sub-Saharan Africa in panel. Additionally,
there can be inefficiencies in allocation of resources
when midwives and other health cadres are not enabled
to practice to their full competence.
To deliver high-quality care in all settings, health
professionals and policy-makers need to create an
environment where the 72 effective midwifery practices
identified in this Series can be implemented in line with
the woman-centred values and philosophy outlined in
the QMNC framework. This is likely to have important
economic effects, potentially reducing health spend,
and increasing the sustainability of maternity care
systems in the longer term.
www.thelancet.com 7
Executive Summary
Family planning as part of the midwifery package of care
Including family planning in the full package of midwifery care would prevent 50–75% of
maternal, fetal and neonatal deaths, with an additional effect of 10–20% reduction in all
deaths when linking to specialist care. Family planning alone could prevent 57% of all deaths,
because of reduced fertility and fewer pregnancies. In combination, the full package of
midwifery care with both family planning and maternal and neonatal health interventions
could avert a total of 83% of all maternal deaths, stillbirths and newborn deaths.
Midwives as the essential link in the continuum of care
Although the full spectrum of care up to and including specialist medical care averts the
most deaths, the midwife addresses the continuum of care from the community through
to complex clinical care whereas the medical specialist may not. Midwives are potentially
the facilitators—the essential link—to bring the woman into the health-care system at the
most effective and efficient time and level. Effective referral is often hampered by practical
considerations such as lack of finance, transport services and lack of services and access to
specialist medical care once in higher-level facilities. Again, this highlights the need for
midwifery, and midwives more specifically, to be situated as part of a team within a
functional and enabling health system that has a skilled health workforce with the
appropriate competencies, and is based in the community as well as in the hospital or
health facility. This is an important step in ensuring that women can have access to a
quality midwifery service that can use effective and appropriate maternal and newborn
health interventions and preventive health care strategies.
Expanding the midwifery workforce, investing in midwifery
Sub-Saharan Africa, where the annual number of pregnancies and births will continue to rise
in the foreseeable future, is of particular concern given the projected deficits in the health
workforce to meet increasing demand. Available data for 14 high maternal morbidity
countries in the region show that in 2009–10, the 71 243 midwives and nurse-midwives in
these countries attended an average of 42 births per year (3 million in total), resulting in a
coverage of 27%. Although these data show an increase in service provision, it is hardly
sufficient to keep up with predicted population growth. Improving effective coverage while
coping with this additional workload will not only require an accelerated expansion of the
number of full-time equivalent midwives, but substantial increases in their productivity.
At current levels of productivity, a doubling of the number of midwives by 2035 (requiring a
net increase of nearly 3% per year) would achieve a coverage of only 35·7%. A coverage of
75% in 2035 would require an increase of the stock to 299 661— a net growth per year of
nearly 6%. Without an expansion of the stock of midwives, productivity would have to
increase to an average of 175 births per midwife per year (the current WHO benchmark) to
achieve 75% coverage, which could exceed the available working time of a midwife for
health service activities, restrict the care provided to attendance in labour and birth and
compromise woman-centred, quality care.
Education of health care professionals and efficient
and effective regulation of practice are important
components of making that environment possible. It
is also important to create partnership and dialogue
UNFPA Zambia/Georgina Smith
between care providers and with care users and
communities. The QMNC framework provides evidence-
based guidance to help adjust education and regulation
to the needs of such a collaborative environment.
 Executive Summary

The Lancet Series on Midwifery
Executive Summary writing team
Mary J Renfrew,
Caroline S E Homer, Soo Downe,
Alison McFadden, Natalie Muir,
Thomson Prentice,
Petra ten Hoope-Bender
The Lancet Series on Midwifery
Executive Group Jim Campbell,
Luc deBernis, Soo Downe,
Helga Fogstadt,
Caroline S E Homer,
Holly Kennedy, Zoe Matthews,
Alison McFadden (Secretariat),
Mary J Renfrew (Chair),
Petra ten Hoope-Bender (Series
Coordinator)
Design and layout: The Lancet
Funding for this publication was
provided by The Bill & Melinda
Gates Foundation
(OPP1042500).
More information on what you
can do is available from:
Twitter: @midwiferyaction
Cover copyright © UNFPA Brazil/
Fernando Ribeiro
Conclusion
Midwifery’s contribution to the survival, health, and
wellbeing of childbearing women and newborn infants
is demonstrated in the analysis of systematic reviews,
case studies, and modelling of deaths averted that was
done for this Series. Midwifery is a vital solution to
the challenges of providing high-quality maternal and
newborn care for all women and newborn infants, in all
countries.
The Series is presented from the perspective of what
childbearing women need and want for themselves and
their newborn infants: to be healthy, safe, supported,
respected and to give birth to a healthy baby that can
thrive, after a positive and life-enhancing pregnancy
and birth experience, whatever complications they may
experience. This is also most likely to promote effective
attachment, and longer term survival and wellbeing for
the infant. Meeting these aspirations and needs is a critical
element in realising the right of all people to the highest
attainable standard of health. This Series identifies the
values, philosophy, and health-system functionality
required to deliver QMNC for all women and all infants.
The evidence from this Series shows that there is
unexploited potential for improving outcomes for
women and newborn infants through collaborative
practice of health-care professionals working along
the continuum of care. Educated, licenced and
supported midwives, including nurse midwives trained
to international standards in midwifery, possess the
competencies that span the RMNH continuum of
care, and are both a connector across and a driving
force behind that continuum. Although there are
resource constraints in many countries, there are
examples of governmental success in promoting the
implementation and expansion of midwifery even
where this has been hard to do. This will need a vision
for planning for optimum maternity care—shown here
to be a highly-effective strategy—and a willingness to
make it happen.
This is the most critical, wide-reaching examination
of midwifery to date, and it includes a broad range of
clinical, policy, and health system perspectives. The
findings should be considered carefully, and debated
widely. Practical testing of the evidence-based QMNC
framework proposed could identify the short-medium
and long-term outcomes—clinical, psycho-social, and
economic—in low-income, middle-income, and high-
income countries.

Adding midwifery and midwives back into health systems

Case studies from Brazil, China, and India demonstrate the tendency of health systems in
rapid development to adopt a model relying on the routine use of medical interventions,
without the balance brought by midwifery.
India, China, and Brazil are ranked first, second and eighth worldwide in annual numbers
of births, and combined they account for 35% of all births globally. The case studies
presented in the Series suggest that a focus on facility-based and emergency care can
result in a reduction in maternal and perinatal mortality. However, without the balancing
effect of the full spectrum of midwifery care, this strategy has also resulted in rapidly-
growing rates of unnecessary and expensive interventions, such as caesarean sections,
and inequalities in the provision of care and outcomes.
China and Brazil have taken steps to reintroduce midwives in recent years, as a strategy to
reduce mortality, morbidity, and unnecessary intervention.
References
1 Renfrew MJ, McFadden A, Bastos MH, et al. Midwifery and quality
care: findings from a new evidence-informed framework for
maternal and newborn care. Lancet 2014; published online June 23.
http://dx.doi.org/10.1016/S0140-6736(14)60789-3.
2 Homer CSE, Friberg IK, Bastos Dias MA, et al. The projected effect of
scaling up midwifery. Lancet 2014; published online June 23. http://
dx.doi.org/10.1016/S0140-6736(14)60790-X.
3 Van Lerberghe W, Matthews Z, Achadi E, et al. Country experience
with strengthening of health systems and deployment of midwives
in countries with high maternal mortality. Lancet 2014; published
online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60919-3.
4 ten Hoope-Bender P, de Bernis L, Campbell J, et al. Improvement of
maternal and newborn health through midwifery. Lancet 2014;
published online June 23. http://dx.doi.org/10.1016/S0140-
6736(14)60930-2.

8 www.thelancet.com
 Series

Midwifery 1
Midwifery and quality care: findings from a new evidence-
informed framework for maternal and newborn care
Mary J Renfrew, Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung,
Deborah Rachel Audebert Delage Silva, Soo Downe, Holly Powell Kennedy, Address Malata, Felicia McCormick, Laura Wick, Eugene Declercq

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, Published Online
the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives June 23, 2014
http://dx.doi.org/10.1016/
and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the S0140-6736(14)60789-3
scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods
This is the first in a Series of four
approach including synthesis of findings from systematic reviews of women’s views and experiences, effective papers about midwifery
practices, and maternal and newborn care providers. The framework differentiates between what care is provided and Mother and Infant Research
how and by whom it is provided, and describes the care and services that childbearing women and newborn infants Unit, School of Nursing and
need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be Midwifery, College of
Medicine, Dentistry and
improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced
Nursing, University of Dundee,
stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public Dundee, UK
health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when (Prof M J Renfrew PhD,
provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift A McFadden PhD); Pan
American Health Organisation,
from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care
Brasilia, Brazil
for all. This change includes preventive and supportive care that works to strengthen women’s capabilities in the (M H Bastos PhD); Instituto de
context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, Cooperación Social Integrare,
and in which first-line management of complications and accessible emergency treatment are provided when needed. Barcelona, Spain
(J Campbell MPH); Division of
Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across
Social Statistics and
facility and community settings. Future planning for maternal and newborn care systems can benefit from using the Demography, Faculty of Social
quality framework in planning workforce development and resource allocation. and Human Sciences,
University of Southampton,
Introduction manage complications.13 Unnecessary inter­ ventions Southampton, UK
(A A Channon PhD); Midwifery
Every year there are an estimated 139 million births. 1
during pregnancy, birth, and the early weeks of life are Expert Committee of the
An estimated 289 000 women will die during pregnancy, escalating in high-income, middle-income, and some Maternal and Child Health
childbirth, or soon after;2 2·6 million will have low-income settings,14–16 risking iatrogenic harm to Association of China, Taiwan,
China (N F Cheung PhD); Parto
stillbirths,3 and 2·9 million infants will die in the first women and newborn infants,17,18 and the economic do Princípio–Mulheres em Rede
month of life.4 Poor quality maternal and newborn care costs of this overuse are substantial.19 pela Maternidade Ativa,
is a major factor for these deaths, and continued Although the degree and type of risk related to pregnancy, São Caetano do Sul, Brazil
reductions in maternal mortality needs overall birth, post partum, and the early weeks of life differ (D R A D Silva PhD); School of
Health, University of Central
improvements in quality throughout the continuum of between countries and settings, the need to implement Lancashire, Preston,
care and improved emergency services.5–7 Poor quality effective, sustainable, and affordable improvements in the Lancashire, UK
care does not just result in mortality; it contributes to quality of care is common to all. New knowledge is needed (Prof S Downe PhD); Yale School
acute and chronic clinical and psychological morbidity to eliminate avoidable maternal and newborn mortality and of Nursing, New Haven, CT,
USA (Prof H P Kennedy PhD);
for the estimated 20 million women who survive,8 with morbidity, and to inform decision making for universal Kamuzu College of Nursing
a lasting effect on mothers’ and infants’ physical and health care and the UN post-2015 development agenda,20 University of Malawi,
psychosocial health and wellbeing, on their need to pay the most effective actions for the Global Strategy for Lilongwe, Malawi
for ongoing health-care costs,9 and on the ability of Women’s and Children’s Health21, and the Every Newborn (Prof A Malata PhD);
Department of Health
their families to escape poverty.5 Poor maternal and Action Plan.22 Sciences, University of York,
newborn care have an economic effect on communities There is growing consensus among public health Heslington West, York, UK
and countries10 and hamper efforts to tackle inter­ professionals that midwifery care has an essential (F McCormick RM); Institute of
generational inequalities in health.11 Poor quality care is contribution to make to high-quality maternal and Community and Public Health,
Birzeit University, Birzeit,
not just about the available resources in a health newborn services.5,21,23–28 This consensus stems from Palestine (L Wick RM); and
system; some high-income countries (eg, the USA) evidence derived from randomised controlled trials in Community Health Sciences,
rank lower on the health components of the 2013 high-income settings,29 and from practical experience in Boston University School of
Public Health, Boston, MD,
Mothers Index12 than some far less wealthy ones (eg, low-income, middle-income, and high-income
USA (Prof E Declercq, PhD)
Poland, Estonia). Neither is poor quality care just about countries.5,23,28,30–37 Although other forms of care have
the absence of services. There is global concern about been shown to reduce maternal and newborn mortality38,
the overuse of interventions that were designed to these country-level experiences show that the

www.thelancet.com 9
 Series
Correspondence to: introduction of educated, trained, motivated, and
Prof Mary J Renfrew, Mother and respected licensed midwives, working effectively with
Infant Research Unit, School of
medical and public health colleagues, has been
Nursing and Midwifery, College
of Medicine, Dentistry and associated both with a rapid and sustained decrease in
Nursing, University of Dundee, maternal and newborn mortality, and with an
Dundee DD1 4HJ, UK improvement in quality of care.
m.renfrew@dundee.ac.uk
In these country examples and in common parlance the
term midwifery is used either to describe a collaborative
activity involving a range of care providers or to describe
the work of midwives, resulting in ambiguity.39 In this
first paper in a Series of four papers about midwifery, we
define the terms midwifery and midwife, specifying
which term the evidence presented relates to. We aimed
to test, comprehensively and systematically, the contri­
bution that midwifery—practised by midwives and
others—can make to the quality of care of women and
infants globally. Randomised trials can only be used to
examine some components of quality,40,41 so we have used
a multimethod approach to assess the key concepts of
quality in maternal and newborn care including safe,
effective, accessible, appropriate, affordable, equitable,
efficient, and woman-centred care.42
We devised and tested a framework for quality
maternal and newborn care in all settings, using the
Key messages
• There is growing consensus that midwifery has an important contribution to make to
high-quality maternal and newborn infant care. However, understanding of midwifery
is restricted by a failure to apply consistent definitions in implementation of
midwifery, resulting in a mixed workforce of professional and non-professional staff,
many of whom provide only some components of midwifery care.
• We agreed on a definition of midwifery and used a mixed-methods approach to
develop and test a framework for quality maternal and newborn care that describes
the characteristics of care that childbearing women, infants, and families need in all
countries.
• Analysis of 461 systematic reviews shows that 56 outcomes, including survival, health,
wellbeing of women and infants, and efficient use of resources can be improved by
practices that lie within the scope of midwifery.
• 62% of the 72 effective practices within the scope of midwifery show the importance of
optimisation of normal processes of reproduction and early life and strengthening of
women’s capabilities to care for themselves and their families.
• Findings of studies examining several providers active in provision of midwifery care
identified few benefits when reliance was solely on low-skilled health-care workers.
Midwifery was associated with improved efficient use of resources and outcomes
when provided by midwives who were educated, trained, licensed, and regulated, and
midwives were most effective when integrated into the health system in the context
of effective teamwork, referral mechanisms, and sufficient resources.
• Case studies from Brazil, China, and India show the tendency of health systems in
rapid development to adopt a model relying on the routine use of medical
interventions, without the balance brought by midwifery.
• These findings support a system-level shift, from fragmented maternal and newborn
care focused on identification and treatment of pathology, to skilled care for all, with
preventive and supportive care, and treatment of pathology when needed through
interdisciplinary teamwork and integration across facility and community settings.
Midwifery is pivotal to this approach.
10 www.thelancet.com
best available evidence for effective care practices and
for what women and newborn infants need, and we
used this evidence to assess the potential effect of
midwifery and the workforce groups best able to
provide midwifery care.
What is a midwife, and what is midwifery?
The definition of the midwife has been established by the
International Confederation of Midwives,43 as have the
competencies of the midwife44 (panel 1).
In some countries, the full scope of care that could be
provided by qualified midwives is limited by health-
system and cultural barriers,46–48 and some overlap
inevitably exists in roles and responsibilities between
different health professionals. In many countries, some
aspects of mid­wifery care are provided by obstetricians,
family doctors, nurses, auxilliary midwives, community
health workers, or traditional birth attendants, or by
unsupported or inadequately trained midwives, as well
as by competent midwives educated to international
standards (and by nurse-midwives who are trained both
as nurses and midwives).5,23,49 A definition of midwifery
as a package of care is needed to identify the important
aspects of this care and to provide a structure for our
examination of the quality of midwifery care.
In this Series, we define the practice of midwifery as the
“skilled, knowledgeable, and compassionate care for
childbearing women, newborn infants, and families across
the continuum throughout 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; respect for 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”.
Panel 1: International definition of the midwife
The International Labour Organisation (ILO) describes
midwives as the primary professional group to provide
midwifery.45 The International Confederation of Midwives
defines the work of midwives43 and core competencies and
standards for their education and practice.44
“A midwife is a person who has successfully completed a
midwifery education programme that is duly recognised in
the country where it is located and that is based on the
International Confederation of Midwives’ (ICM) Essential
Competencies for Basic Midwifery Practice and the
framework of the ICM Global Standards for Midwifery
Education; who has acquired the requisite qualifications to be
registered and/or legally licensed to practice midwifery and
use the title ‘midwife’; and who demonstrates competency in
the practice of midwifery.”
 Series

A framework for high-quality maternal and
newborn care: development and testing
We developed a framework for quality maternal and
newborn care to describe the characteristics of care that
women, newborn infants, and families need from pre-
pregnancy, during pregnancy and birth, and beyond.5
The framework identified both what a health system
needs to provide high-quality care and how it delivers its
functions and meets its goals within any particular
context.50 Essential components considered were effective
practices, the organisation of care, the philosophy and
values of the care providers working in the health system,
and the characteristics of care providers; these
components are interlinked.
Our multimethod approach (figure 1) used some of the
processes of conventional systematic review methods and
drew on advances in methods for interpretive
synthesis,51,–53 allowing us to incorporate a range of
relevant sources of evidence54 and synthesise the findings.
With the expert opinion of the 35 Series co-authors from
low-income, middle-income, and high-income settings,
we developed an outline frame­work that was refined in
view of analyses of the evidence from three systematic
reviews. We also drew on lessons learned from recent
developments in three large middle-income countries in
transition: Brazil, China, and India. The appendix shows
the number and type of sources of evidence that informed
each component of the framework for quality maternal
and newborn care, and figure 2 shows the final framework
for quality maternal and newborn care. The framework is
intended to be relevant to any setting, and to all who need,
or provide, maternal and newborn care and services.
Interdisciplinary teamwork and collaboration are
inherent in implementation of the framework.5,55
In this paper, we use the framework to structure
analyses of the evidence and to identify the scope of
midwifery practice. The second paper56 in the Series
used the framework to define the range of interventions
included in the scope of midwifery care. The third
paper38 used the framework to identify components of
quality care that need to be strengthened in country-level
examples. The framework can be used to assess the
quality of care; plan workforce development, resource
allocation, or an education curriculum; or identify
evidence gaps for future research. The framework can be
individualised to meet specific demands of population
demography and health; available resources; and the
political, social, and cultural context in which each
health system functions.
Assessment of components of quality maternal
and newborn care: review methods and findings
Review 1: women’s views and experiences of maternal
and newborn care
To assess evidence on what women and newborn infants See Online for appendix
need from maternal and newborn services, we did a
review of meta-syntheses of qualitative studies of
women’s views and experiences (review 1). The appendix

Expert opinion of
35 Series co-authors

Development of the framework for quality maternal and newborn care:

iterative process informed by and informing the Reviews

Education, Assessment, Promotion of First-line Management

Review 1: meta- Identification of elements information, screening, normal management of serious
syntheses of women’s of care that matter to and health and care processes, of complications
views and experiences women promotion planning prevention, complications
and
complications

Identification of and
assessment of the
evidence for the quality
of care that women and
babies need.
What is the contribution
that midwifery—practised
by midwives and others—
can make to the quality
of care of women and
infants globally?
Scope of midwifery
Organisation of care, values, philosophy, care providers
Review 2: systematic Identification of Step 1 Analysis: practices Step 2 Analysis:
reviews of practices in effective and ineffective mapped to components examined outcomes Findings—what women
maternal and newborn practices and of the framework improved by midwifery and infants need
care characteristics and
refining the framework
Mapping of international
Case studies of Brazil, competencies of midwives Conclusions
China, and India—lessons to framework
from health system
Review 3: systematic Identification of evidence Evidence restricted development without
reviews of workforce about midwives, family but shows value of midwives identified
groups providing physicians, obstetricians, midwives in context of
Findings—workforce
aspects of midwifery community, and interdisciplinary teams
care traditional health workers

Figure 1: Diagram of the multimethod approach used in this study

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 Series

For all childbearing women and infants For childbearing women and infants
with complications

Education Assessment Promotion of normal First-line Medical

Information Screening processes, prevention management obstetric
Practice categories Health promotion* Care planning† of complications‡ of complications§ neonatal
services¶

Available, accessible, acceptable, good-quality services—adequate resources, competent workforce

Organisation of care
Continuity, services integrated across community and facilities

Respect, communication, community knowledge, and understanding

Values
Care tailored to women’s circumstances and needs

Optimising biological, psychological, social, and cultural processes; strengthening woman’s capabilities
Philosophy
Expectant management, using interventions only when indicated

Practitioners who combine clinical knowledge and skills with interpersonal and cultural competence
Care providers
Division of roles and responsibilities based on need, competencies, and resources

Figure 2: The framework for quality maternal and newborn care: maternal and newborn health components of a health system needed by childbearing
women and newborn infants
*Examples of education, information, and health promotion include maternal nutrition, family planning, and breastfeeding promotion. †Examples of assessment,
screening, and care planning include planning for transfer to other services as needed, screening for sexually transmitted diseases, diabetes, HIV, pre-eclampsia,
mental health problems, and assessment of labour progress. ‡Examples of promoting normal processes and preventing complications include prevention of
mother-to-child transmission of HIV, encouraging mobility in labour, clinical, emotional, and psychosocial care during uncomplicated labour and birth, immediate
care of the newborn baby, skin-to-skin contact, and support for breastfeeding. §Examples of first-line management of complications include treatment of infections
in pregnancy, anti-D administration in pregnancy for rhesus-negative women, external cephalic version for breech presentation, and basic and emergency obstetric
and newborn baby care (WHO 2009 monitoring emergency care), such as management of pre-eclampsia, post-partum iron deficiency anaemia, and post-partum
haemorrhage. ¶Examples of management of serious complications include elective and emergency caesarean section, blood transfusion, care for women with
multiple births and medical complications such as HIV and diabetes, and services for preterm, small for gestational age, and sick neonates.

shows detailed methods and results from the 13 meta-
syntheses identified and the included studies and quality
assessment. Although data were predominantly from
high-income countries, 20 of the 229 studies were done
in low-income and middle-income countries.
In summary, women’s views and experiences reported in
these meta-syntheses showed the inter-relationship
between the different components of quality care
identified in figure 2. Women reported that information
and education were essential to allow them to learn for
themselves, that they needed to know and understand the
organisation of services so they could access them in a
timely way, that services needed to be provided in a
respectful way by staff who engendered trust and who were
not abusive or cruel, and that care should be personalised
to their individual needs, and offered by care providers
who were empathic and kind. Particularly, women wanted
health professionals who combined clinical knowledge
and skills with interpersonal and cultural competence.
These findings were of crucial importance in identification
of components of quality maternal and newborn care.
Review 2: effectiveness of maternal and newborn care
practices
Identification of practices
To identify high-quality, up-to-date evidence on
effective­
ness of specific practices in maternal and
newborn care, we used two sources: the 453 systematic
reviews contributed by the Cochrane Pregnancy and
Childbirth Group to the Cochrane Library57 and the
Partnership for Maternal, Newborn and Child Health
Review,58 which contributed an additional eight reviews
where evidence was derived from other Cochrane
groups (461 reviews analysed in total). As a final check
before publication, we examined Cochrane Pregnancy
and Childbirth Group reviews published between May
and December, 2013; see appendix for references to
20 new reviews and 15 updated reviews where the
conclusions had changed. One of these updated
reviews29 was of central importance to this work, and
we have included it in our analyses. The rigorous
methods used in Cochrane reviews are recognised
internationally as the highest standard in evidence-
based health care, hence further quality assessment
was not performed.
Figure 3 shows the process of identification and
classification of the included reviews. We scrutinised the
461 reviews to identify the effect on outcomes related to the
primary aim of each review. All the reviews related to the
practice categories (the top line of the framework); some
also related to some of the cross-cutting components of
organisation of care, values, philosophy, and care providers.
Appendix 1 summarises their distribution across frame­
work components.

12 www.thelancet.com
 Series

Cochrane reviews
453 reviews contributed by the Cochrane Pregnancy and Childbirth Group
8 reviews identified from The Partnership for Maternal, Newborn and Child
Health Review 201258 that were contributed by other Cochrane Groups

461 reviews
287 reviews excluded (evidence inconclusive
including absence of studies)
1 review excluded because it was an overview
of reviews that were included individually
173 reviews

123 reviews of 122 effective services 48 reviews of ineffective services

2 reviews of services that cause harm

73 reviews of 72 effective services
that map to the first 4 boxes
of services in the framework
(figure 1)—ie, within the scope
of midwifery
50 reviews of effective services that
map to fifth box of services in
the framework (figure 1)—ie,
medical, obstetric or paediatric
services
14 reviews of ineffective services
that map to first 4 boxes of
services in the framework
(figure 1)—ie, within the scope
of midwifery
34 reviews of ineffective
services and 2 reviews of
services that cause harm
that map to fifth box of
services in the framework
(figure 1)—ie, medical, obstetric,
or paediatric services

Figure 3: Flow diagram of numbers of studies and exclusions

Step 1 analysis: mapping the reviews to the framework for
quality maternal and newborn care
We classified the practice examined in each review as
effective or likely to be effective, likely to be ineffective or
harmful, or inconclusive regarding its effect (including an
absence of studies). We then mapped the 173 reviews that
had adequate evidence to assess effectiveness (ie, excluding
those when findings were inconclusive; figure 3) to the
relevant practice categories on the top line of the
framework. All figures and percentages refer to the
number of practices rather than the number of reviews.
Effective practices related to categories of the framework for
quality maternal and newborn care
The appendix shows the distribution across the practice
categories and panel 2 shows details of the specific
practices. 46 (38%)29,59–102,129 of the 122 effective practices
were relevant for all childbearing women and infants,
with 26 (21%)103–128,130,145 being first-line management for
women and infants with complications. 50 (41%) practices
required the input of a medical practitioner with advanced
skills in obstetrics, neonatology, or medicine, for serious
complications.
Step 2 analysis: examination of the effect of midwifery
We focused next on how midwifery fits within the
framework for quality maternal and newborn care and
what the evidence base tells us about its effect and its
contribution. We identified the first four practice categories
(education, information, health promotion; assessment,
screening care planning; promoting normal processes and
preventing complications; and first-line management of
complications) within the scope of midwifery using our
definition of midwifery. 72 (59%) of the 122 effective
practices identified in Step 1 were within this scope
(figure 3, and table for details of practices).
Outcomes shown to be improved by effective practices in the
scope of midwifery
These reviews of 72 effective practices in the scope of
midwifery were analysed further to identify the outcomes
improved. Caveats such as concern about the quality or
number of trials, or outcomes only shown to be beneficial
for subgroups of participants were noted. Two of these
reviews examined practices shown to be effective in
regard to their primary outcome, but when there was a
trade-off between benefits and harms, these have been
shown separately in table.
56 outcomes were improved by the combination of
practices that fall within the scope of midwifery (table).
These outcomes include reduced maternal and neonatal
mortality and fetal loss, reduced maternal and neonatal
morbidity including preterm birth, reduced use of
interventions, improved psychosocial outcomes, improved
public health outcomes, and improved organisational
outcomes. The scale of the effect of these outcomes varies
across settings and depends on the organisation of services
and the skills and competencies of the workforce.
Effective practices related to cross-cutting components of the
organisation of care and philosophy
We examined these 72 effective practices within the
scope of midwifery to assess whether they portrayed the
cross-cutting components of the framework. We were

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 Series
Panel 2: Effective and ineffective practices presented by category of practice in the framework for quality maternal and newborn
care : in the scope of midwifery as defined in this paper
Effective practices for childbearing women and infants
Organisation of care (n=7)*
• Alternative vs conventional institutional settings for birth59
• Labour assessment programmes to delay admission to the
labour ward until labour is in the active phase60
• Exclusive breastfeeding for at least 6 months for optimal
health benefits61
• Community-based intervention packages for reducing
maternal and neonatal mortality and morbidity and
improving neonatal outcomes62
• Midwife-led continuity models vs other models of care for
childbearing women29
• Not reducing the schedule of antenatal visits in settings
where the number of visits is already low (eg, <5)63
• Lay health workers in primary and community health care for
maternal and child health and the management of infectious
diseases64
Education, information, health promotion, and public health
(n=11)*
• Insecticide-treated nets for prevention of malaria in pregnancy65
• Specific advice to increase dietary energy and protein intakes or
energy and protein supplementation in pregnancy66
• Interventions to promote smoking cessation in pregnancy67
• Health education and peer support to promote breastfeeding
initiation68
• Supplementation with folic acid for women ≤12 weeks pregnant
or pre-pregnant, for prevention of neural tube defects69
• Routine zinc supplementation for improving pregnancy and infant
outcomes70
• Daily universal oral supplementation with iron or iron and folic
acid during pregnancy for improvement of maternal health and
pregnancy outcomes71
• Intermittent oral supplementation with iron or iron and folic acid
or iron and vitamins and minerals during pregnancy for
improvement of maternal health and pregnancy outcomes72
• Calcium supplementation during pregnancy for preventing
hypertensive disorders and related problems73
• Mutiple micronutrient supplementation during pregnancy74
• Education for contraceptive use by women after childbirth75
Assessment, screening, and care planning (n=1)*
• Screening for and treatment of antenatal lower genital tract
infection for prevention of preterm delivery76
Promotion of normal processes and prevention of complications
(n=26)*
• Antiretroviral drugs for reducing the risk of mother-to-child
transmission of HIV infection77
• Drugs for prevention of malaria in pregnant women78
• Antiretroviral therapy for treatment of HIV infection in
antiretroviral therapy-eligible pregnant women79
• Antenatal digital perineal massage to prevent perineal trauma80
• Breast stimulation for cervical ripening or labour induction81
• Continuous labour support82
14 www.thelancet.com
• Upright positions in the first stage of labour83
• Relaxation techniques for pain relief in labour84
• Inhaled analgesia for pain relief in labour85
• Immersion in water in first and second stage labour86
• Perineal techniques in second stage labour87
• Restrictive episiotomy88
• Unclamping previously clamped and divided umbilical cord and
allowing blood from placenta to drain freely89
• Active management of third stage labour90
• Prophylactic ergometrine or oxytocin in third stage labour91
• Carbetocin to prevent post partum haemorrhage92
• Prophylactic oxytocin to prevent post partum haemorrhage93
• Prostaglandin (misoprostol) to prevent post partum
haemorrhage94
• Skin-to-skin mother-baby contact within 24 h of birth95
• Paracetamol (one dose) for early post-partum pain96
• Any type of approved analgesia for pains after vaginal birth97
• Analgesic rectal suppositories for the relief of pain from
perineal suturing98
• Support for breastfeeding mothers99
• Tetanus toxoid for pregnant women to prevent neonatal tetanus100
• Interventions to relieve constipation in pregnancy101
• Topical treatments for vaginal candidiasis in pregnancy102
First-line management of complications (n=25 interventions, in
26 reviews)†
• Antibiotics for gonorrhoea in pregnancy103
• Interventions for treating genital Chlamydia trachomatis
infection in pregnancy104
• Interventions for trichomoniasis in pregnancy105
• Antibiotics for treating bacterial vaginosis in pregnancy106
• Antibiotics for asymptomatic bacteriuria in pregnancy107
• Treatments for symptomatic urinary tract infections during
pregnancy108
• Anti-D administration in pregnancy for preventing rhesus
alloimmunisation109
• Interventions for preventing and treating pelvic and back pain in
pregnancy110
• Oral maternal hydration for increasing amniotic fluid volume in
oligohydramnios111
• External cephalic version for breech presentation at term112
• Antiplatelet agents (low-dose aspirin) for preventing pre-
eclampsia and its complications113
• Planned early birth vs expectant management for pre-labour
rupture of membranes at term114
• Pharmacological and mechanical interventions to induce
labour in outpatient settings115
• Massage, reflexology, and other manual methods for pain
management in labour116
• Acupuncture or acupressure for pain management in labour117
• Rapid vs stepwise negative pressure application for vacuum
extraction assisted vaginal delivery118
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(Continued from previous page)
• Continuous vs interrupted sutures for repair of episiotomy or
second degree tears119
• Anti-D administration after childbirth for preventing rhesus
allo-immunisation120
• Treatment for women with post-partum iron deficiency
anaemia121
• Antibiotic regimens for endometritis after delivery122
• Kangaroo mother care to reduce morbidity and mortality in low
birthweight infants123
• Preventive, non-pharmaceutical psychosocial or psychological
interventions for the prevention of post-partum depression124
• Fibreoptic phototherapy for neonatal jaundice125
• Emergency interventions:
• Magnesium sulphate for women with pre-eclampsia126
• Magnesium sulphate for eclampsia127,128
Effective practice for childbearing women and infants with a
trade-off between benefits and harms
Promotion of normal processes and prevention of complications
(n=26)*
• Prophylactic use of ergot alkaloids in third stage labour
(significant decrease in mean blood loss, post-partum
haemorrhage of at least 500 mL and use of therapeutic
uterotonics but adverse effects include elevated blood
pressure)129
First-line management of complications (n=25 interventions, in
26 reviews)†
• Membrane sweeping (digital separation of the membranes
from the lower uterine segment during vaginal examination)
for induction of labour (effective in reducing length of
pregnancy and number of pregnancies beyond 41 and
42 weeks but with adverse effects [pain, bleeding, irregular
contractions])130
able to assess three aspects of two components of the
framework; whether they offered continuity of care
(organisation), whether they strengthened women’s own
capabilities (philosophy), and whether they supported
the normal processes of pregnancy, birth, post partum,
breastfeeding and early life, and avoidance of unnecessary
interventions (philosophy).
Panel 2 and the appendix show findings from this stage
of the analyses. When the effective service supported
normal processes of reproduction and early life, the
intervention is shown in italics in panel 2 (44 [61%]
of 72 effective practices)29,59–66,68–78,80–84,86–89,95,99–101,109–114,116,117,120,121,122
within the scope of midwifery. Ten (14%)29,61,63,65–68,75,84,99 of
the 72 effective forms of care for all childbearing women
were intended to support women’s own capabilities with
information or advice that they could act on themselves
(appendix). Most of the effective practices (61 [85%])
related to only one phase of maternal and newborn
care, usually pregnancy or labour (appendix). Only
20 (28%)29,61,62,64,68,75,77,95–99,120–128 practices examined any aspect
www.thelancet.com Vol 383 15
Series
Ineffective practices for childbearing women and infants
Education, information, health promotion, and public health (n=11)*
• Vitamin A supplementation for post-partum women131
• Calcium supplementation (other than for prevention or
treatment of hypertension)132
Assessment, screening, and care planning (n=1)*
• Continuous cardiotocography as a form of electronic fetal
monitoring for fetal assessment during labour (associated with a
reduction in neonatal seizures, but no significant differences in
cerebral palsy, infant mortality or other standard measures of
neonatal wellbeing. However, cardiotocography was associated
with an increase in caesarean sections and instrumental vaginal
births).133
Promotion of normal processes and prevention of complications
(n=26)*
• Routine perineal shaving on admission in labour134
• Hands and knees posture in late pregnancy or labour for fetal
malposition (lateral or posterior)135
• Restricted pacifier use in breastfeeding term infants for increasing
duration of breastfeeding136
• Umbilical vein injection for the routine management of third stage
of labour137
• Enemas during labour138
• Amniotomy for shortening spontaneous labour139
• Timing of administration of prophylactic uterotonics (before
or after delivery of the placenta following vaginal birth)140
First-line management of complications (n=25 interventions, in
26 reviews)†
• Hospitalisation and bed rest for multiple pregnancy141
• Support during pregnancy for women at increased risk of low
birthweight babies142
• Umbilical vein injection for management of retained placenta143
• Vitamin supplementation for prevention of miscarriage144
of care after the birth for either mother or newborn
infant. Only midwife-led continuity models of care and
community-based packages of care applied across the
whole continuum.29,62 66 (92%) of the effective practices
related to care of either the woman or fetus, or both, with
five examining both the mother and newborn infant and
only one examining care of the infant.
Ineffective practices
Fourteen reviews131–143 identified practices within the
scope of midwifery that were ineffective (panel 2). Nine
(64%) of the ineffective practices133–139,141,143 identified
interventions that should not be used routinely (eg,
amniotomy in labour). These nine practices are shown
in italics in the ineffective practices section of panel 2,
and these findings support the approach of not routinely
interfering with the normal processes of reproduction
and early life (philosophy), bringing the total number of
reviews that support optimising normal processes to
53 (62% of the 86 total effective and ineffective practices).
 Series
Review 3: characteristics and effect of midwives and
other workforce groups providing some or all
components of midwifery care
To examine the characteristics and relative contribution
of midwives and other workforce groups providing
some or all components of midwifery care, we searched
For more on the Database of the Database of Abstracts of Reviews of Effectiveness
Abstracts of Reviews of (DARE) in 2012, updated in June, 2013, and checked
Effectiveness see http://www.
crd.york.ac.uk/CRDWeb/
again before publication in January, 2014, using the
terms: “midwife” or “midwifery” or “midwives” or
“skilled attendant*” or “birth attendant*” or “skilled
delivery attendant*” or “community health worker*”.
We identified seven high-quality reviews of randomised
controlled trials that examined the effectiveness of
interventions delivered by specific workforce cadres on
Maternal mortality reduced
Serious morbidity reduced
Fewer maternal infections including malaria and HIV
Less anaemia
Less pain
Reduced incidence of RhD alloimmunisation
Reduced risk of pre-eclampsia
Reduced risk of eclampsia
After eclampsia treatment: reduction in recurrence of
seizures; reduction in risk of pneumonia
Reduced post-partum haemorrhage
Reduced perineal trauma
Increased likelihood of spontaneous vaginal birth
Less augmentation of labour
Reduced pharmacological analgesic use (excluding regional Lauzon 2001,60 Hodnett 2012,82 Sandall 2013,29 Chou 2013,96 Hedayati 200398 (first 24 h after
analgesia or epidural) during pregnancy, childbirth, and in birth); Kettle 2012,119 Smith 2011117 (in one or possibly three trials, not well reported)
the postnatal period
Reduced use of regional analgesia or epidural
Fewer instrumental births
Fewer caesarean sections
Fewer episiotomies
Less perineal suturing
Less use of therapeutic uterotonics
Fewer blood transfusions
Less use of uterine massage
Fewer pregnancies beyond 41 weeks
Improved satisfaction with pain relief
Reduced anxiety during first stage of labour
Improved feeling of control during childbirth
Improved satisfaction with childbirth experience
Less likely to develop post-partum depression
16 www.thelancet.com
maternal or infant outcomes, or both. The pre-
publication search identified one updated review that
is of central importance to this question, and it has
been included here. 29 The appendix shows details of
included and excluded studies.
Midwifery care delivered by midwives and other professionals
We included two reviews with a total of 15 studies, all done
in high-income countries.29,146 Sandall and colleagues29
included 13 trials of 16 242 women. This Review compared
midwife-led continuity models of care, in which the
midwife is the woman’s lead professional during
pregnancy, labour, and birth (one or more consultations
with medical staff were often part of routine practice), with
obstetrician or family doctor-led care (midwives or nurses,
First author and year (caveats)
Duley 2010128
Hofmeyr 201073
Brocklehurst 2002,103 Dare 2006,114 Gulmezoglu 2011,105 Brocklehurst 2013,106
Siriwachirachai 2010,145 Smaill 2007,107 Gamble 200665 (in malaria endemic regions of Africa)
Pena-Rosas 2012,71 Gamble 2006,65 Garner 2006,78 Dodd 2004121
Smith 2011,84 Beckmann 200680 (in women who had previously given birth vaginally);
Chou 2013,96 Deussen 2011,97 Hedayati 200398 (in first 24 h after birth); Klomp 201285 (in labour,
side-effects noted); Kettle 2012,119 Pennick 2007110 (potential for bias in all but one study);
Smith 2011117 (caution about study quality); Smith 2012116 (caution about study quality)
Crowther 2013109, Crowther 1997120
Duley 2007113 (for women at high risk); Hofmeyr 201073 (effect was greatest for women with
low baseline calcium intake and women at high risk of pre-eclampsia)
Duley 2010126
Duley 2010,128 Duley 2010,127 Duley 2010127
Begley 2011,90 Kavanagh 2005,81 Tunçalp 2012,94 Cotter 2001,93 Liabsuetrakul 2007,129 McDonald 200491
Aasheim 2011,87 Carroli 2009,88 Beckmann 200680 (statistically significant for women without
previous vaginal birth only)
Hodnett 2012,59 Hodnett 2012,82 Sandall 201329
Hodnett 201259, Hodnett 201282
Lawrence 2009,83 Cluett 2009,86 Hodnett 2012,59 Hodnett 2012,82 Sandall 201329
Smith 2011,84 Hodnett 2012,59 Hodnett 2012,82 Sandall 2013,29 Smith 2011117
Hodnett 2012,82 Hofmeyr 2012112
Aasheim 2011,87 Carroli 2009,88 Beckmann 2006,80 Hodnett 2012,59 Sandall 201329
Carroli 200988
Liabsuetrakul 2007129 (trade-off: effects of the intervention [intramuscular or intravenous ergot
alkaloids] include increased blood pressure and pain after birth requiring analgesia)
Tunçalp 201294
Su 201292
Boulvain 2005130 (trade-off: adverse effects reported—pain, bleeding, irregular contractions.
Number needed to treat to avoid one formal induction, n=8)
Smith 201184 (caution about study quality); Smith 2011117
Smith 2012116 (reported in one study, concerns about quality)
Lauzon 200160
Cluett 200986 (reported in one study); Smith 2011,84 Hodnett 2012,59 Hodnett 201282
Dennis 2013124
(Table continues on next page)

(Continued from previous page)
Increased attendance by a known midwife during birth
Increased referrals for pregnancy complications
Shorter stays on labour ward
Increased breastfeeding rates—initiation
Increased breastfeeding rates—duration
Reduction in smoking in late pregnancy
Increased maternal post-partum weight loss
Increased birth spacing
Increased contraceptive use
Reduced preterm birth
Reduced low birthweight
Reduced small for gestational age babies
Fewer neural tube defects
Fewer babies with low 5 min Apgar scores
Increased average birthweight
Decreased number of admissions to neonatal
intensive care units
Reduced mother-to-child transmission of HIV
Reduced risk of infection
Reduced risk of hypothermia
Reduced serum bilirubin
Improved mother-baby interaction
Reduced crying
Breastfeeding initiation and duration improved
Increased immunisation uptake
Shorter hospital stay for babies
Fewer babies in SCBU more than 7 days
Based on analysis of included reviews (see methods) contributed to the Cochrane Library by the Cochrane Pregnancy and Childbirth Group and interventions in
The Partnership for Maternal, Newborn and Child Health Review 2012.58 RhD=rhesus antigen. SCBU=special care baby unit. *Denotes review of care provided by lay or
community health workers.
Table: Outcomes shown to be improved by midwifery, as defined in this paper
or both, provided intrapartum care and in-hospital post-
partum care under medical supervision), or shared models
of care. Khan-Neelofur and colleagues146 included three
randomised trials of 3075 women, one of which was also
included by Sandall and colleagues.29 This trial compared
shared midwife or general practitioner-managed care with
routine visits to obstetricians in one trial and backup from
obstetricians as needed in the other two trials with standard
shared care between obstetricians and midwives in two
trials and unspecified care in one trial.
Sandall and colleagues29 reported that women who had
midwife-led continuity models of care were less likely to
have regional analgesia, episiotomy, and instrumental
birth and were more likely to have no intrapartum
analgesia or anaesthesia, spontaneous vaginal birth,
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Series
First author and year (caveats)
Sandall 201329
Lassi 201062*
Lauzon 200160
Dyson 2005,68 Lassi 201062*
Moore 2012,95 Renfrew 2012,99* Lewin 2010,64 Conde-Agudelo 2011123
Lumley 200967
Kramer 201261 (in two studies from Honduras)
Kramer 201261
Lopez 201275 (caution about quality of evidence); Ota 201266 (only for balanced energy-protein
supplementation); Demicheli 2005,100* Lassi 2010,62 Garner 200678 (only among first-born or
second-born babies); Sturt 2010,79 Duley 2007,113 Conde-Agudelo 2011,123 Duley 2010,127
Sandall 201329 (before 24 weeks); Gamble 2006,65 Duley 2007113
Ota 201266 (for women given nutritional advice); Mori 2012,70 Sangkomkamhang 2008,76
Lumley 2009,67 Hofmeyr 2010,73 Duley 2007,113 Sandall 201329
Sangkomkamhang 2008,76 Lumley 2009,67 Smaill 2007,107 Gamble 200665 (not in women with
more than four previous pregnancies); Pena-Rosas 2012,71 Haider 201274
Ota 201266 (only for balanced energy protein supplementation; high protein supplementation
increased the risk); Duley 2007,113 Haider 201274
De-Regil 201069
Hodnett 2012,82 Duley 2010128
Ota 201266 (only for balanced energy-protein supplementation); Lumley 200967 (only in first and
second born infants); Garner 200678
Dare 2006114
Siegfried 2011,77 Sturt 201079
Conde-Agudelo 2011123
Conde-Agudelo 2011123
Mills 2001125
Moore 2012,95 Conde-Agudelo 2011123
Moore 201295
see above re breastfeeding outcomes for women
Lewin 201064*
Conde-Agudelo 2011123
Duley 2010,128 Duley 2010127
attendance at birth by a known midwife, and a longer
mean length of labour. No differences were noted between
groups for caesarean births. Women who were randomly
assigned to receive midwife-led continuity models of care
were less likely to have a preterm birth and fetal loss before
24 weeks’ gestation, although no differences between
groups were noted in fetal loss or neonatal death of at least
24 weeks nor in overall fetal or neonatal death. Most
included studies reported a higher rate of maternal
satisfaction in the midwifery-led continuity care model.
Khan-Neelofur and colleagues146 reported no difference in
clinical outcomes measured. However, women in the
shared midwife-general practitioner-managed clinics were
more satisfied with continuity of care than those in the
control group. Sandall and colleagues29 noted a trend
 Series
towards a cost-saving effect of midwife-led continuity
models of care compared with other models of care.
Components of midwifery care delivered by community and
traditional health workers
We identified five reviews with a total of 109 included
studies. Four reviews62,147–149 included studies in low-
income and middle-income countries, and one64 included
studies from low-income, middle-income, and high-
income countries. The focus of two reviews148,149 was
training for traditional birth attendants, whereas three
reviews62,64,147 focused on interventions delivered by other
community health workers with varying levels of training
and support: paid village or auxiliary health workers and
unpaid volunteers;147 lady health workers or visitors,
community or village health workers and facilitators;62
and lay health workers without professional or
paraprofessional training.64 Training and support generally
included practices and resources such as clean delivery
kits and resuscitation equipment, referral support, and
links with other health workers.
The findings of these reviews of community and
traditional health workers are very restricted in regard to
the contribution of midwifery to the quality of care. Not
only were the interventions heterogeneous but also most
studies were set in very low-income settings in which
women in the control group might have received no care,
or very basic care from less trained community workers.
None of the reviews compared one trained cadre with
another, or compared care offered by community and
traditional health workers with professional groups.
In all of the reviews and studies of workforce, the
mechanisms underpinning the effectiveness of the care
provided were briefly and inconsistently defined.
Scope of practice of midwives
We used the framework to map the scope of practice of
trained, licensed, and regulated midwives using
competencies of midwives as defined by the International
Confederation of Midwives44 (appendix). All the
competencies mapped to one or more components of the
framework, and all fell within the first four practice
categories, defined by us as the scope of midwifery,
showing that midwives meeting these standards practice
the full scope of midwifery. One competency, incorporating
collaborative working with colleagues, also mapped to
management of serious complications and workforce.
Case studies: health system development
without midwives
As a final step in our multimethod approach, we
examined three case studies from countries where care
by midwives has been absent from the health system.
These are described in panel 3.
India, China, and Brazil are ranked first, second, and
eighth worldwide in annual numbers of births, and
combined they account for 35% of all births globally.170
18 www.thelancet.com
We purposefully selected them to illustrate countries in
transition—they are the three countries with the most
rapid economic development since the late 20th century—
and where the contribution of midwives was either
absent or eliminated in the past.
Despite the diversity of these countries, and recognition
of the heterogeneity of circumstances within them, they
have common threads that illuminate the consequences
of economic development in settings in which midwives
have been marginalised or excluded from the health
system. The case studies suggest that a focus on facility
based and emergency care can result in a reduction in
maternal and perinatal mortality. However, without the
balancing effect of the full spectrum of midwifery care,
this strategy has also resulted in rapidly growing
numbers of unnecessary, expensive, and potentially
iatrogenic interventions and inequalities in the provision
of care and in outcomes. As the case studies show, the
prevalence of caesarean sections in Brazil and China is
among the highest in the world. India, despite its recent
economic development, has a high maternal mortality
rate with high inequalities related to poverty. High rates
of elective caesarean sections without medical indication
are associated with various poor perinatal outcomes,14,171,–175
and draw scarce resources from community based
primary care and prevention. A WHO study19 identified
3·2 million additional caesarean sections annually were
needed in low-income countries, whereas at the same
time, about 6·2 million unnecessary caesarean sections
were being done in middle-income and high-income
countries.
As the case studies show, both China and Brazil have
taken steps to reintroduce midwives in recent years, as a
strategy to reduce mortality, morbidity, and unnecessary
interventions.
Discussion
We used the analyses presented in this paper to develop a
new evidence-based framework that describes a system
for high-quality maternal and newborn care as a basis for
improvements in maternal and neonatal outcomes. Our
analyses began, not with the needs of professionals or
the health system, but with those described by pregnant
and postnatal women. Women’s perceptions of their
experiences are important in and of themselves,176 but if
systems do not meet their needs, women are less likely to
access services and might even reject them altogether.177
For women, good quality clinical care and improved
communication, education, information, and respect
from their providers are essential aspects of their care.
The combination of these factors is needed to keep them
and their newborn infants safe. Low quality services or
disrespectful care compromise the health and wellbeing
of women and children, and can stall global reduction in
maternal and newborn mortality and morbidity.178
We developed and tested the framework using a range of
sources of evidence. It incorporates the need to balance

Panel 3: Case studies
Brazil and China—reintroducing midwifery to countries in
economic transition
We chose these countries since they have shown the most rapid
economic development since the late 20th century and together
account for 35% of births globally. They have very large and
highly developed urban centres, remote rural populations, and
large disparities between the rich and the very poor. They have
high but falling rates of maternal mortality and some of the
highest rates of caesarean section in the world. In India and China,
progress in reduction of newborn deaths is slower than expected
for their stage of development.12
Brazil (52% caesarean section rate in 2010)150 and urban China
(54–64% caesarean section rate in 2008–2010)151,152 are two
contexts where rapid economic growth in recent years has been
accompanied by extraordinary increases in interventions, most
notably caesarean sections, with growing concerns in each
country over the medicalisation of birth and corresponding
potential links with an increased maternal or perinatal
mortality and morbidity. A 2010 study for WHO153 identified the
two countries as first and second in a global ranking of
unnecessary caesarean sections, China: 1 976 606 and Brazil
960 687, with a combined cost per year of over US$553 million.
This occurrence has been termed ”unnecesareans” in Brazil.154
In China, the increase in caesarean sections has been reported to
be a result of the national adoption and interpretation of WHO’s
safe motherhood policy and the Millennium Development Goals
(MDGs), resulting in the national policy for hospitalisation of all
births.155 In Brazil, the increases were despite a Ministry of Health
regulation in 2000 to reduce the increasing number of caesarean
sections;150 at least some contribution to this is driven by social
inequality and relates to women’s wish to have a caesarean
section to avoid substandard care in labour.156 Additionally, the
underlying trend is towards the increase of caesarean sections
without medical indications before labour. In China, caesarean
sections without medical indications in some hospitals have
grown from 5%157 in 1990 to 65·6% in 2010.158,159 China is
somewhat unique in that its one-child policy minimises the
likelihood of women having several caesarean sections and the
associated long-term placental problems. Similar to the situation
in China, Brazil’s data highlight a ten-fold increase in pre-labour
caesarean sections between 1990 and 2010.160
The current policy discourses within both countries have now
recognised that a continuation of present trends is neither
sustainable nor supportive of women’s needs. A midwife-led unit
established in China in 2008 has succeeded in great reductions in
caesarean sections and other forms of medical intervention.161–163
The success led to further programatic steps to reintroduce
midwifery by scaling up midwifery-led units in ten hospitals
across the country. China is also reinstating the role of the
midwife and striving to increase graduate numbers.164 In Brazil, a
policy initiative by the Ministry of Health launched in March 2011,
set up the Stork Network strategy, Rede Cegonha.150 The Network
has a set of measures to guarantee all Brazilians in the public
health system appropriate, safe, and humane care from
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Series
confirmation of pregnancy, through to the first 2 years of the
baby’s life, by building a network of primary care services for
women and children, including 280 midwifery-led birth centres.
The Ministry of Health has launched the National Residency
Program in Nursing and Midwifery, a federal government
initiative to encourage higher-education institutions to promote
the training of professionals with expertise in midwifery and
nursing to work in the public health system. The initiative aims to
enhance the role of midwifery and nursing to provide
comprehensive health care of women and children, from the
confirmation of pregnancy, to childbirth, post partum, and until
the second year of the child’s life.
Thus, two of the world’s most populous countries have had rapid
growth in caesarean sections without medical indications in the
past two decades, and then independently began steps to correct
an over-reliance on obstetric-led care through enhancement of
midwifery-led services. China and Brazil provide a cautionary case
study for those developing countries now modelling their
maternal and newborn care systems on those of the industrialised
countries that rely heavily on costly medical interventions to
improve maternal and infant outcomes in birth.
India
India is the leading example among a growing number of
countries where there is simultaneous overuse and underuse of
interventions. India has 27 million annual births, about one in
every five births worldwide. Although India has a relatively large
number of midwives, they are not consistently educated to
international standards, and they attend fewer than one in six
births,23 with doctors attending most births in urban areas and
one fourth in rural areas. The UNICEF 2009 Coverage Evaluation
Survey165 reported an Indian caesarean section rate of 15·1%,
almost within the WHO recommended range. However, that
overall rate masks enormous disparities within the country. Data
from an earlier DHS survey (2005–2006),166 which reported an
8·5% overall rate, showed mothers in the poorest rural areas had
a caesarean rate of 1·5%; and mothers in the wealthiest urban
areas had a caesarean rate of 32·1%. Regionally, almost a third of
mothers in Kerala (31%) gave birth by caesarean section
compared with 2·3% of mothers in Nagaland.167 The Coverage
Evaluation Survey165 noted a caesarean section rate of 34·6% in
private hospitals compared with 12·4% in government hospitals.
India has lost what was once a strong tradition of
midwifery-based practice168 and has been slow to reintroduce it.
Midwives have a restricted scope of practice and, over time,
experience the associated loss of skills.169 India is already showing
signs of following the model of China and Brazil, with high
caesarean rates in wealthy mothers in urban areas, leading to a
culture of non-medically indicated caesarean sections. As a
rapidly emerging economy, with an improving health
infrastructure and reliance on private obstetrical providers, India
has obvious parallels to Brazil and China. Whether India will also
follow a path of high levels of medical interventions followed by a
re-emphasis on midwifery remains to be seen.
 Series
community-based preventive and supportive services for
all childbearing women and newborn infants with the
elective and emergency services needed by those with
compli­ cations. Our findings are supported by recent
empirical data from a multicountry WHO study,6
suggesting that women need a health system that helps
them to stay healthy and care for their families and
provides a timely transition to elective and emergency care
for those who develop complications.179 The framework
differentiates between what care is provided, how it is
provided, and who should provide it, in all settings. As well
as offering a context for debate about the care and services
that childbearing women and infants need, the framework
might have other uses, such as structuring analyses of
health system provision, planning new services, or
develop­ing an education curriculum, and it can be tested,
debated, and further refined for different settings and
population groups. It could similarly be analysed using
appropriate evidence to describe the scope and effect of
obstetrics, family practice, nursing, skilled birth
attendance, and community and public health systems.
Specifically, our analyses suggest that midwifery has a
particular contribution to make to the quality care
identified in the framework in regard to education,
information and health promotion; assessment,
screening, and care planning; and promoting normal
processes and preventing complications in the context of
respectful care that is tailored to need and works to
strengthen women’s capabilities.
Analyses of systematic reviews of the maternal and
neonatal care workforce reported several providers active
in providing midwifery care, but few benefits when
reliance was solely on less skilled health-care workers.
Care led by midwives—educated, licensed, regulated,
integrated in the health system and working in
interdisciplinary teams—had a positive effect on maternal
and perinatal health across the many stages of the
framework, even when compared with care led by other
health professionals in combination with midwives. In
the high-income settings in which resource use has been
examined, there are indications that midwife-led care for
low-risk women and in the context of an interdisciplinary
team is a more cost-effective option than medically led
care.29,180 Empirical evidence in low-income and middle-
income settings is scarce, but analysis of the competencies
of the midwife in relation to our framework shows that
competent midwives offer comparative advantages in
providing continuity of care across the spectrum needed
by women and newborn infants regardless of setting.
When midwives work in collaboration as part of
interdisciplinary teams providing integrated care across
community and hospital settings, they also provide
effective midwifery care for women and infants who
develop complications.
In low-income and some middle-income settings where
there is a shortage of midwives and specialist and general
medical practitioners, there is a focus on ‘skilled birth
20 www.thelancet.com
attendants’,181 defined as accredited health professionals
educated and trained to proficiency in the skills needed to
manage uncomplicated pregnancies, childbirth, and the
immediate postnatal period, and in the identification,
management, and referral of complications in women
and newborn infants. The implementation of skilled birth
attendants over the past decade has contributed to the
overall decrease in maternal mortality.18 However, its
implementation in practice varies widely across countries,
and skilled birth attendants have uneven levels of
proficiency, restricted scope of practice, and varying levels
of training. They might not work across the continuum of
care or be trained to deal with unexpected complications,
all of which can result in harm.5,23,182–184
Findings from our case studies of countries in
economic transition show that care led mainly by
obstetricians without the balance midwives bring to the
health system might reduce mortality and morbidity, but
might also reduce quality and increase cost. Beyond the
effect on some women and infants of unnecessary
interventions, the economic costs of such systems of care
are likely to be unsustainable.19 For example, the cost of
unnecessary interventions in maternity care in the USA
has been estimated at around $18 billion annually.185 The
case studies also suggest a need for a whole-system
solution, rather than a focus on one component of
maternal and newborn care, such as the centralisation of
services in hospitals in the absence of well developed
community-based services. Implementation of midwifery
without adequate education, regulation, support, and
referral systems is likely to be ineffective, as Van
Leberghe and colleagues show in the example of
Indonesia in this Series.38
The sample size of trials and even meta-analyses in
maternal and newborn care are generally too small to
provide insights into mortality, especially maternal
mortality. To address this, Homer and colleagues, in this
Series,56 use modelling to estimate the effect of midwifery
on saving maternal, fetal, and neonatal lives. Our analyses
are not designed to identify the scale of the effect of
midwifery in different countries; this effect will depend
on the resources available, the organisation of services,
and the skills and competencies of the workforce.
However, we have shown that midwifery can have an
effect on specific practices that can save lives, such as the
early initiation and support of breastfeeding in the first
weeks of life. Continued breastfeeding has the potential
to save the lives of hundreds of thousands of infants and
to reduce health-care costs.16,186 Our Review has shown
that midwifery can reduce maternal anaemia and
infection, including malaria and HIV, and pre-eclampsia
and eclampsia. Midwifery therefore has an important
contribution to make to meeting international goals for
both maternal and newborn mortality and health.21,22,187
In common with studies of other complex
interventions,188 the absence of detail included in some of
the trials examined restricted our findings. The

characteristics of midwifery and of care offered to the
women in control groups were ill-defined and in­
consistent, which is likely to dilute the noted effect of
midwifery. Recognising these constraints, we used a
multimethod approach to maximise the strength and
transparency of our analyses.
There is substantial under-investment in research on
midwifery and specifically on midwives, and the research
has been dichotomised by development status. Studies of
care by midwives in low-income and middle-income
settings, integrated into the health system and working in
teams with medical staff and with properly trained support
staff, are an urgent priority. A focus on long-term psycho­
social outcomes and clinical outcomes is needed, in view
of improved understanding of the links between the
mental and physical health of the woman and the health
and development of her infant.189–193 Future research will
need resources of a scale that portrays the fundamental
importance of midwifery to the short-term, medium-term,
and long-term health and wellbeing of women and
children in all settings. The achievement of consensus on
research priorities will need partnerships between all
relevant stakeholders, including the active engagement of
service users and advocacy groups.
Conclusion
Despite progress in reducing the numbers of avoidable
deaths in pregnancy, birth, post partum, and the early
weeks of life, continued success in achievement of
internationally targeted reductions in these numbers and
meeting new challenges will need a substantial shift in
direction. Our analyses have informed the development of
a new framework for high-quality, cost-effective maternal
and newborn care that can be used for analysis and
planning of future services. With the use of this
framework, we have shown that midwifery has specific
contributions to make with regard to skilled supportive
and preventive care for all, promotion of normal re­
productive processes, first-line management of
complications, and skilled emergency care; all in the
context of respectful care that is tailored to need and works
to strengthen women’s capabilities, and is integrated
across facility and community settings. Midwifery was
associated with more efficient use of resources and
improved outcomes when provided by midwives who
were educated, trained, licensed, and regulated, and
midwives were most effective when integrated into the
health system in the context of effective teamwork and
referral mechanisms and with sufficient resources. There
are few benefits from relying on less-skilled health-care
workers. These findings support a system-level shift from
fragmented maternal and newborn care focused on
identification and treatment of pathology for the minority,
to skilled care for all. Midwifery is pivotal to this approach.
Future planning for maternal and newborn care systems
can benefit from incorporating the quality framework into
workforce development and resource allocation.
www.thelancet.com Vol 383 21
Series
Contributors
MJR devised the paper and wrote the first draft of the article, contributed
overall leadership to the project, and led revision of drafts. ED, AMcF
and AC contributed to the development of the paper and contributed to
the writing and revisions. AMcF led the work on the literature reviews.
ED, MHB, and NFC developed the case studies, and contributed to the
analysis, writing, and revisions. FM contributed to the literature reviews
and contributed to the writing and revisions. LW, AM, JC, HK and SD
contributed to the development of the paper, including analysis of the
literature reviews, writing, and revisions. DD contributed a service user
and advocacy perspective, and contributed to the writing and revisions.
All authors contributed to the development of the framework, helped to
interpret the findings, and undertook reviews and revisions of the paper.
Declaration of interests
We declare no competing interests.
Acknowledgments
The work on this paper was supported partly through a grant from the Bill
and Melinda Gates Foundation to the University of York and the
University of Dundee (grant number OPP1042500), and additional
support from the University of York and the University of Dundee. The
funding organisations had no role in the undertaking of the analysis and
synthesis of the findings of this report. The findings and conclusions in
this report are those of the authors and do not necessarily represent the
official position of their employers or the Bill and Melinda Gates
Foundation. Thomson Prentice was the technical editor for the Lancet
Series on Midwifery. Project support was provided by Natalie Muir, and
administrative support by Jenny Brown and Tracy Sparey. Julie Glanville
from the York Health Economics Consortium led the literature searches,
and the Midwives Information and Resource Service (MIDIRS) supported
the search work. Mari Tikkanen and her colleagues from M4ID produced
figure 2. Marcos Dias contributed to the analysis and classification of the
systematic reviews. Linda Orr and Jenna Breckenridge contributed to the
review of meta-syntheses. We thank the close readers and colleagues who
made helpful contributions: Olaya Astudillo, Agneta Bridges,
Mariam Claeson, Bernadette Daelmans, Frances Day-Stirk,
Declan Devane, France Donnay, Elizabeth Duff, Frances Ganges,
Atf Gherissi, Wendy Graham, Metin Gulmezoglu, Kathy Herschderfer,
Elizabeth Mason, Blerta Maliqi, Matthews Mathai, Zoe Mullan,
Frances McConville, Jennifer McNeil, Mary Newburn, Hermen Ormel,
Kerreen Reiger, Severin Ritter von Xylander, Arul Sabaratnam,
Kerri Schuiling, Kate Somers, Kate Teela, Joyce Thompson, and
Cathy Warwick. All co-authors of the Lancet Series on Midwifery
contributed to the concepts and commented on drafts of this paper.
Members of the Lancet Series on Midwifery Helicopter Group made
important additional contributions: Vincent Fauveau, Nester Moyo,
Susan Murray, and Veronica Walford. Other members of the Lancet Series
on Midwifery Executive Group made important contributions throughout
the writing of this paper: Luc de Bernis, Helga Fogstad,
Caroline S E Homer, Zoe Matthews, and Petra ten Hoope-Bender.
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 13tl2286
THELANCET-D-13-02286R2 Series
S0140-6736(14)60790-X
LWO
Embargo: June 23, 2014—00:01 (BST)
Version 1
This version saved: 13:41, 09-Jun-14

Midwifery 2
The projected effect of scaling up midwifery
Caroline S E Homer, Ingrid K Friberg, Marcos Augusto Bastos Dias, Petra ten Hoope-Bender, Jane Sandall, Anna Maria Speciale, Linda A Bartlett

We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified Published Online
into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the June 23, 2014
http://dx.doi.org/10.1016/
scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family S0140-6736(14)60790-X
planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were See Online/Comment/Review
all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal http://dx.doi.org/10.1016/PII
coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries This is the second in a Series of
with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could four papers about midwifery
prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning Faculty of Health, University
and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and of Technology Sydney, NSW,
Australia
neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being
(Prof C S E Homer PhD);
prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with Department of International
effective referral and transfer mechanisms to specialist care. Health, Johns Hopkins
Bloomberg School of Public

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 Inter­
ventions, including blood trans­ fusions 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, Health, Baltimore, MD, USA
(I K Friberg PhD, L A Bartlett MD);
knowledgeable, and compassionate care for childbearing Department of Obstetrics,
women, newborn infants and families across the Instituto Fernandes Figueira–
continuum from pre-pregnancy, pregnancy, birth, post FIOCRUZ, Rio de Janeiro, Brasil
(M A B Dias PhD); Instituto de
partum and the early weeks of life. Core characteristics Cooperación Social Integrare,
include optimising normal biological, psychological, Barcelona, Spain
social, and cultural processes of reproduction and early (P ten Hoope-Bender MBA);
life, timely prevention, and management of complications, Autonomous University of
Barcelona, Barcelona, Spain
consul­tation with and referral to other services, respecting (A M Speciale CNM); and
women’s individual circumstances and views, and Division of Women’s Health,
working in partnership with women to strengthen King’s College London,
women’s own capabilities to care for themselves and their Women’s Health Academic
Centre King’s Health Partners,
families”.1 St Thomas’ Hospital, London,
The effect of scaling-up midwifery and the associated UK (Prof J Sandall PhD)
interventions provided by midwifery services is not
presently known. We used the Lives Saved Tool (LiST)
Key messages
• Midwifery can deliver most effective maternal and newborn health interventions, and can
enable access to specialist and comprehensive emergency care when necessary.
• Universal coverage of these interventions will result in reductions in maternal deaths,
stillbirths, and neonatal deaths in 78 Countdown countries classified according to the HDI.
• 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.
• 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.
• 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.
• 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.

www.thelancet.com 1
 Series
Correspondence to:
Prof Caroline S E Homer, Faculty
of Health, University of
Technology Sydney, PO Box 123,
Broadway, NSW 2007, Australia
caroline.homer@uts.edu.au
For the Cochrane Library see
http://www.thecochranelibrary.
com/view/0/index.html
For the Countown to 2015
for maternal and child survival
see http://www.
countdown2015mnch.org
See Online for appendix
2 www.thelancet.com
to estimate deaths averted if midwifery was scaled-up 1 are insufficient midwives, other providers with mid­
in 78 countries classified by Human Development wifery skills can provide some or many of the effective
Index (HDI). interventions.1
Measurement of maternal and child health 5 Will an increase in coverage of midwifery avert
outcomes deaths?
An estimated 15–20 million women are affected every year Renfrew and colleagues1 have shown that midwifery is an
by substantial morbidity as a result of childbirth,5,6 affecting effective and probably cost-effective means to provide
not only the woman, but also her baby, other children, and reproductive, maternal, and newborn services. Therefore,
members of the broader community. To determine the full 10 we sought to establish the effect of scaling-up such services
effect of midwifery on women and newborn infants, on maternal and neonatal deaths. We aimed to estimate
biological (ie, morbidity and mortality), financial, social, the effect of midwifery, as defined in this Series,1 on
and psychological outcomes would need to be measured.1 maternal and newborn outcomes. The two objectives to
Poor maternal health contributes to economic hardship, achieve this aim were to estimate maternal, fetal, and
with potentially longer-term outcomes, including violence, 15 neonatal deaths averted using the Lives Saved Tool
stigmatisation, isolation, and divorce.5,7 Additionally, (LiST)29,30 under different scenarios of coverage of
mental health disorders in women have long-term midwifery from 2010 to 2025 in 78 low-income and middle-
implications for children,8,9 and the effects of maternal income countries, classified into three groups using the
depression might affect children’s lives as they grow up, in human development index (HDI); and to estimate the
the form of behavioural disorders, anxiety, depression, and 20 value of the incremental addition of specialist care to
impaired cognitive development.10–14 These morbidity midwifery on maternal, fetal, and neonatal lives saved.
outcomes are often not measured or available, and thus
difficult to account for at a population level.5,3 Indexes of The Lives Saved Tool
optimality have been proposed that count the frequency of LiST is one module in the Spectrum Policy Modeling
optimum rather than suboptimum events during 25 Software.31 Other Spectrum modules include HIV,
childbirth,15–20 although these are not widely used. Our demography, and family planning. LiST was selected as
analysis focuses on changes in maternal, fetal, and one tool that has the proven capacity to estimate the effect
neonatal mortality estimated by scaling-up midwifery and of discrete midwifery interventions, rather than a package
specialist care. of care as in the quality maternity framework, in The state
30 of the world’s midwifery 2014 report.32 In brief, the LiST
Coverage of maternal and newborn health model starts with a given population’s current health and
interventions mortality status, and coverage of health interventions. The
Regardless of the challenges associated with measurement, model then links those values to changes in coverage of
to improve outcomes, sufficient coverage of maternal and health interventions with the effectiveness estimates to
newborn interventions is required. The Countdown to 2015 35 calculate the number of lives saved through changes in
for maternal and child survival tracks progress towards coverage (appendix). We used the Spectrum version 4.51 of
achievement of Millennium Development Goals (MDGs) 4 LiST for all analyses.
and 5 in 75 high-burden countries21–26 and has shown that LiST was developed by the Child Health Epidemiology
the overall coverage of several components of midwifery is Reference Group for the 2003 Child Survival Series33 and
low, such as satisfaction of family planning needs (54%), 40 has since expanded to include interventions from the
four or more antenatal care visits (50%), skilled birth Lancet’s 2005 Neonatal Series,34 the 2008 Nutrition Series,35
attendance (54%), and early initiation of breastfeeding the 2011 Stillbirth Series,36 and the 2013 Child Nutrition
(47%). Midwifery is one means by which to deliver the Series37 It has been updated by two supplements of
effective maternal and newborn interventions as a package effectiveness information38–50 and also now includes effects
of care,1 which is likely to be more effective than individual 45 on maternal mortality,51 results of which were presented in
interventions alone.4,27 The Lancet Stillbirths Series.36 Full details of effectiveness
Renfrew and colleagues developed the framework for estimates and validation are available elsewhere.30,43,44,52,53
1
quality maternal and newborn care in this Series that LiST can only estimate cause-specific changes in
offers a mechanism for analysing the scope and mortality (maternal, fetal, and neonatal), calculated by
contribution of skilled birth attendants. Midwives are 50 combining the best available evidence of health
the core group that have the skills, knowledge, and intervention effectiveness with population-specific health
competencies to deliver the full scope of quality intervention coverage changes, mortality rates,29,43,48,54 and
midwifery care described in this framework if they are causes of death.21,48,55 Stillbirths are classified as either
regulated and educated to international standards, such antepartum or intrapartum,55 with interventions affecting
as the International Confederation of Midwives (ICM)’s 55 each type separately. LiST has only been used to estimate
Essential competencies for basic midwifery practice,28 which mortality effects in low-income and some middle-income
include family planning. However, in areas where there countries, and cannot calculate indirect effects or all-cause
 Series

effects that have no known biological mechanism. LiST is skilled attendant at birth. When we modelled this
1
limited to modelling effects on mortality and does not intervention at the level of an adequate CEmONC, we
model effects on experience of care; morbidity; other assumed it included caesarean sections and blood
potential benefits, such as wellbeing, empowerment, and transfusions. When we modelled skilled attendant at birth
self-reliance; morbidity; or intergenerational issues. As far 5 at the level of an adequate BEmONC, we excluded
as we are aware, there are no other methods that would caesarean sections, blood transfusions, or any interventions
allow for a similar quantitative analysis of non-mortality that would require these two CEmONC activities, but
effects. included other interventions that could be deemed to be
BEmONC (eg, clean birth and management of post-
Effective interventions and estimation of their 10 partum haemorrhage and post-partum sepsis). For this
baseline coverage analysis, we used all standard effect sizes available in LiST,
The effective maternal and newborn health interventions except in a few cases, in which no published effect sizes
were those identified in the Essential interventions, were available—eg, maternal sepsis case management. We
commodities and guidelines for reproductive, maternal, therefore estimated that 80% of all maternal sepsis deaths
newborn and child health,4 and in the study by Renfrew and 15 could be prevented with appropriate case management,
colleagues,1 as being able to be delivered as part of including parenteral antibiotics, based on a Delphi
midwifery services, particularly by midwives educated to analysis57 and additional historical data.58
international standards and who are integrated into the
health system. Specialist medical interventions were those Construction of the standard populations
requiring medical assistance such as blood transfusions or 20 We included 78 countries, incorporating all 58 countries in
caesarean sections (indicative of CEmONC).1 The state of the world’s midwifery 2014 report32 and
We obtained data for baseline coverage of maternal and extending to all additional Countdown 2015 countries.1
newborn health interventions from the most recent These 78 countries are high-burden, low-income and
Demographic and Health Surveys or Multiple Indicator middle-income countries, which account for 97% of For more on MICS see http://
Cluster Surveys (MICS). If no data were available for an 25 maternal and 94% of neonatal mortality.59,60 www.childinfo.org
indicator, we used the average for similar countries in We used the HDI61 to classify the countries. The HDI is a
terms of HDI. We identified assumptions or indicators composite statistic of life expectancy, education, and
used in the LiST model in The Lancet Neonatal Series,34 income indexes. We selected the HDI after examining
which are described in the LiST manual too.56 These several other databases that contained more women-
assumptions include the association between four or 30 focused indicators, including the Social Institutions and
more antenatal care visits and activities, such as access to Gender Index62 and the Gender Inequity Index.63 These
syphilis detection and treatment; between skilled databases did not contain complete data for our countries
attendance at birth, facility delivery, and access to of interest and we therefore excluded them. We also
emergency obstetric care and signal functions (including examined other possible social determinants, including
neonatal resuscitation); and between birth care and 35 women’s status, inequality, water and sanitation, and
hospital-based care for severe newborn infections34 proportion of urban population. These searches resulted
(table 1). For many indicators, no standard LiST proxy is in country groupings similar to those obtained using HDI.
available so we selected unique ones for this analysis, We used the HDI to categorise the 78 countries into
aiming for consistency with the standard proxies. three equal groups of 26 countries (table 2). We did this to
40 generate estimates of deaths averted within every group.
Active management of the third stage of labour Group A includes the lowest HDI countries, group B
Interventions includes low-to-moderate HDI countries and group C
We modelled the effect of increasing coverage of maternal includes moderate-to-high HDI countries. Within every
and newborn health interventions by calculating effect tertile (groups A, B, and C), we generated the average
sizes for every intervention and outcome linkage (see 45 mortality rates and ratios, health intervention coverage
appendix for a full list of estimates used). Whenever an values, HIV prevalence, contraceptive prevalence rate, and
individual effect size could be established, we separated total fertility rates. For a baseline for every group, we
the specific interventions from the larger package and applied the coverage of the effective interventions on a
used them separately in the model. For example, we hypothetical standardised baseline population of 1 million
estimated the individual effect sizes of interventions, such 50 people for the year 2010, using the UN population
as administration of magnesium sulphate for the projections for 201064 built into the modelling software
management of severe pre-eclampsia or eclampsia, active (appendix).
management the third stage of labour, and neonatal
resuscitation, from literature reviews of the evidence, and Modelling scale-up of interventions on the standardised
included them as individual effect sizes. When effect sizes 55 populations
were not known for individual interventions, we included Using the standardised baseline populations, we
them in the intervention of labour and birth care by a developed several scenarios between 2010 and 2025.

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The first scenario shows the numbers of deaths that are 1 rates, overriding the UN Population Division-projected
likely to be noted in 2025 with no change in coverage of secular trends in fertility and mortality (scenario 0;
the interventions and no change in present fertility table 3).

Before conception (family planning)
Contraceptive prevalence rate
Around the time of conception
Folic acid supplementation
Ectopic pregnancy case management
Safe abortion services
Post-abortion care
After conception (antenatal care)
Tetanus toxoid
IPTp
Multiple micronutrient supplementation
Calcium supplementation
Balanced energy supplementation
Syphilis detection and treatment if needed
Diabetes case management
Screening for and management of pre-eclampsia
with MgSO4
Case management of malaria in pregnancy
Screening and management of fetal growth
restriction
PMTCT
During labour and birth
Clean birth practices
Immediate assessment and stimulation
skilled birth attendant at birth
Neonatal resuscitation
Antenatal corticosteroids for preterm labour
Antibiotics for pPRoM
MgSO4 for eclampsia
Active management of the third stage of labour
Induction of post-term labour
Post-partum and newborn care
Thermal care and clean postnatal practices
Kangaroo mother care
Maternal sepsis case management
Breastfeeding promotion
Hospital-based care for severe newborn infections Proxy: facility delivery; formula: if facility delivery is >50%, 0·5×facility delivery; if facility delivery is
between 30% and 50%, 0·2 × facility delivery; if facility delivery is <30%, 0·1 × facility delivery
5
Indicator or proxy indicator and translation formula if no standard indicator is available
Percentage of women at risk of getting pregnant using any method of contraception
Proxy:* ANC4+; formula: 5%10 of women who have ANC4+ receive folic acid (ie, assumes that 5% of women
receiving four antenatal visits will receive folic acid supplementation)
Proxy: access to EmONC; formula: if facility delivery is >50%, 0·75 × facility delivery; if facility delivery is 30–
50%, 0·50 × facility delivery; if facility delivery is <30%, 0·10 × facility
Percentage of women getting an abortion who have a safe abortion (ie, medical or surgical)
Proxy: access to EmONC; formula:
15 if facility delivery is >50%, 0·75 × facility delivery; if facility delivery is
30–50%, 0·50 × facility delivery; if facility delivery is <30%, 0·10 × facility delivery
Protected by tetanus toxoid at birth
Percentage of pregnant women protected against malaria with two or more doses of sulfadoxine-
pyrimethamine (treatment options)
20
Percentage receiving iron-folate during pregnancy for ≥90 days
Proxy: ANC4+; formula: 5% of women who have ANC4+ receive calcium supplementation
Proxy: ANC 4+; formula: ANC4+ × the proportion of children aged 6–23 months appropriately fed
(included as effects on prematurity and neonatal death)
Proxy: ANC4+; formula if ANC4+ is >75, 0·70×ANC4+; if ANC is 40–75%, 0·5 × ANC4+; if ANC4+ is <40%,
0·2 × ANC4+ 25
Proxy: ANC 4+; formula: 5% of women who have ANC4+ have diabetes requiring and receiving
management
Proxy: ANC 4+; formula: 5% of women who have ANC4+ are screened for pre-eclampsia and managed
with MgSO4
Proxy: ANC 4+; formula: 5% of women who have ANC4+ are managed for malaria in pregnancy
30
Proxy: ANC 4+; formula: 5% women who have ANC4+ are screened and managed for fetal growth
restriction
Percentage of pregnant women who are HIV positive receiving option A
Formula: 50% skilled birth attendance at home; 60% essential care; 85% BEmONC; 95% CEmONC
35
Formula: 25% skilled birth attendance at home; 50% essential care; 80% BEmONC; 90% CEmONC
Formula: 100% of skilled birth attendance
Formula: 20% BEmONC; 70% CEmONC
Formula: 20% essential care; 85% BEmONC; 95% CEmONC
Formula: 20% essential care; 85% BEmONC; 95% CEmONC
40
Formula: 20% essential care; 85% BEmONC; 95% CEmONC
Formula: 20% essential care; 85% BEmONC; 95% CEmONC
Formula: 20% CEmONC
Proxy: 100% of a postnatal45visit within 48 h of birth
Proxy: facility delivery; formula 5% of facility delivery
Proxy: facility delivery; formula: if facility delivery is >50%, 0·5 × facility delivery; if facility delivery is
between 30– 50%, 0·2 × facility delivery; if facility delivery is <30%, 0·1 × facility delivery
Proxy: Percentage of newborn infants being breastfed exclusively, predominantly, partly, and not at all
50

ANC4+=four or more antenatal care visits. EmONC=emergency obstetrics and newborn care. IPTp=intermittent preventive treatment of malaria in pregnancy.
SP=sulfamethoxazole-pyradine. PMTCT=prevention of mother-to-child transmission of HIV. BEmONC=basic emergency obstetrics and newborn care. CEmONC=comprehensive
emergency obstetrics and newborn care. pPRoM=premature prelabour rupture of membranes. *In the absence of data, we used formulas to estimate the proportion of indicated
cases that receive management. For example, we estimated the proportion of ectopic pregnancy patients that obtain treatment with the assumption that when facility-based
deliveries are more than 50%, 75% of women who give birth in a facility who need the intervention
55 receive ectopic management or post abortion care if required.

Table 1: Health indicators modelled and proxies used for estimating baseline coverage of health interventions

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The remaining scenarios estimated the effect of 1

different increases in coverage. The first estimated a
modest increase for each of the health interventions
(scenario 1). We defined modest as a relative 10%
increase above baseline coverage rates for every 5
intervention for every 5-year period between 2010 and
2025. The next scenario was a substantial scale-up
(scenario 2), which we defined as a relative 25% increase
above the baseline coverage rate for each intervention
for every 5-year period between 2010 and 2025. In the 10 high HDI
third scenario, we postulated universal coverage to be
95% of all interventions by the year 2025 (scenario 3;
appendix).
Countries included*
Group A: Afghanistan, Benin, Burkina Faso, Burundi, Central African Republic, Chad, Comoros, CÔte
low HDI† d’Ivoire, Democratic Republic of the Congo, Djibouti, Eritrea, Ethiopia, Gambia, Guinea,
Guinea-Bissau, Liberia, Malawi, Mali, Mozambique, Niger, Rwanda, Sierra Leone, Somalia‡,
Sudan§, Zambia, Zimbabwe
Group B: Angola, Bangladesh, Bhutan, Cambodia, Cameroon, Congo (Brazzaville), Haiti, Kenya, Laos,
low-to- Lesotho, Madagascar, Mauritania, Myanmar, Nepal, Nigeria, Pakistan, Papua New Guinea, Sao
moderate Tome and Principe, Senegal, Solomon Islands, Swaziland, Tanzania, Timor-Leste, Togo,
HDI Uganda, Yemen
Group C: Azerbaijan, Bolivia, Botswana, Brazil, China, Equatorial Guinea, Egypt, Gabon, Ghana,
Guatemala, Guyana, India, Indonesia, Iraq, Kyrgyzstan, North Korea¶, Mexico, Morocco,
Nicaragua, Peru, Philippines, South Africa, Tajikistan, Turkmenistan, Uzbekistan, Vietnam
HDI=human development index. *78 countries included in Countdown 2015 and The State of the World’s Midwifery
2014 Report. †The terminology of low, low-moderate, and moderate-high reflects the human development index
31

To highlight the risks of a deteriorating system (ie, category. ‡Somalia was moved from its other country category into low HDI. §Sudan was included before disaggregation
population growth, but no additional resources, access, 15 into South Sudan and Sudan. ¶North Korea was moved from its other country category into moderate-high HDI.
or staffing), we included a negative scenario, which Table 2: Countries included in the three standardised populations (per 1 million population) based on
estimated the deaths averted with a 2% decrease below HDI category
baseline coverage of the interventions over every 5-year
period between 2010 and 2025 (scenario 4). We analysed Description Percentage change
all four scenarios in three ways. The first analysis 20
0 No change from current No change in current coverage rates
included all maternal and child health interventions,
1 Modest scale-up in coverage 10% increase in each of 3 5-year periods
along with family planning (scaled-up contraceptive
2 Substantial scale-up in coverage 25% increase in each of 3 5-year periods
prevalence rates), whereas the second only included the
maternal and child health interventions, with no change 3 Universal coverage of all interventions 95% coverage of each intervention

in contraceptive prevalence rate . The third analysis only 25 4 Attrition back from current status 2% reduction in each of 3 5-year periods
looked at the changes in family planning through Table 3: Scenarios used in modelling the impact of midwifery
scaling-up contraceptive prevalence rate (data not shown
for all analyses).
Quality of care cannot be modelled as a direct input smallest in group C (table 4). In the lowest levels (group
into LiST. However, LiST was designed to assume that as 30 A), the very basic facility delivery care is increased, with a
coverage of delivery care services increases, there will be minimal increase in emergency care. At the highest level
a corresponding increase in quality.34 This means that the (group C), basic care is available to all people, so the scale-
model assumes that as coverage increases, services up results in substantial quality improvement. We noted
become more complete, moving from minimum access similar results relative to the mortality rates and ratios
to skilled delivery care provision, and then through 35 (appendix). This is because quality, in terms of availability
BEmONC to CEmONC, a full package of care including of CEMONC versus BEMONC, increases at a greater rate
referral to specialist care. In the model, quality increases at higher levels of coverage.
substantially faster when institutional delivery is greater A substantial increase in coverage every 5 years
than 95% than when it is between 50% and 95%. (scenario 2) resulted in a similar pattern, with the greatest
Similarly, quality increases faster between 30% and 50% 40 reductions in numbers of maternal deaths, neonatal
than between 0% and 30%. deaths, and stillbirths in 2025 being noted in group A
countries (table 4). However, the greatest percentage
Deaths averted under different increased reduction of maternal deaths was found in the group B
coverage scenarios countries, at 75·4% (table 4, figure 1).
A modest increase in coverage of midwifery, including 45 In group A countries, stillbirths decreased by 26·3%
family planning, by 10% every 5 years (scenario 1) could from no change in coverage (scenario 0) to a modest
result in a 27·4% reduction in maternal deaths in the increase in coverage (scenario 1). In scenario 2, with
group A countries, a 35·9% reduction in the group B substantial increase in coverage, stillbirths reduced by
countries, and a 62·7% reduction in the group C countries 49·7%, whereas with universal (95%) coverage (scenario
(table 4). Given the lower number of maternal deaths in 50 3), there was a 75·9% reduction. By contrast with this
the group C countries than in the other groups, a reduction was scenario 4 (attrition), where stillbirths had a marginal
in the absolute number of maternal deaths resulted in a increase. We noted similar substantial reductions in
larger proportional effect in group C than in group A neonatal deaths (table 4). The analyses in figure 1
countries. Similar reductions were seen for stillbirths and included family planning as an integral part of midwifery
neonatal deaths. Using our standardised population sizes, 55 as a package of care because family planning utilisation
the reduction in absolute numbers of deaths was largest reduces fertility, which reduces the number of women at
in the group A countries, smaller in group B, and the risk of maternal death and stillbirth or neonatal death.

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1
Scenario 0: no change Scenario 1: modest scale-up* Scenario 2: substantial Scenario 3: universal Scenario 4: attrition§
(deaths [n]) scale-up† coverage‡
Deaths (n) Reduction (%) Deaths (n) Reduction (%) Deaths (n) Reduction (%) Deaths (n) Reduction (%)
Group A: low HDI¶ 5
Maternal deaths 300 200 27·4% 150 49·7% 50 81·5% 300 –2·3%
Stillbirths 1850 1350 26·3% 900 49·7% 450 75·9% 1900 –2·4%
Neonatal deaths 2000 1450 26·8% 950 52·6% 200 90·3% 2100 –4·0%
Group B: low-to-moderate
HDI||
10
Maternal deaths 150 100 35·9% 40 75·4% 30 77·5% 150 –5·5%
Stillbirths 1200 800 32·1% 400 67·2% 350 69·4% 1300 –4·1%
Neonatal deaths 1300 850 34·9% 350 73·9% 150 87·9% 1400 –5·8%
Group C: moderate-to-high
HDI**
15
Maternal deaths 50†† 20 62·7% 15 68·0% 15 69·8% 50 –11·1%
Stillbirths 800 400 50·1% 400 51·0% 400 52·9% 900 –9·9%
Neonatal deaths 550 250 52·5% 200 63·6% 100 77·4% 600 –12·7%

See appendix for mortality rates and ratios. HDI=human development index. *10% increase in coverage every 5 years (2010–25). †25% increase in coverage every 5 years (2010–25). ‡95% coverage by 2025.
§2% decrease in coverage every 5 years (2010–25). ¶56 000 births. ||46 500 births. **29 000 births. ††All numbers were rounded
20 to portray the precision of model assumptions. The percentage reduction
calculations were done on unrounded numbers of deaths; see appendix for raw data.

Table 4: Reductions of maternal, fetal, and neonatal deaths by 2025 in four scale-up scenarios of midwifery care and three HDI categories, per 1 million people

maternal deaths are averted by midwifery care. Similarly,

20
25 at all HDI levels, 23·8–31·0% of stillbirths can be
averted with midwifery care. Alternatively, more than
Change in maternal, fetal, and neonatal mortality (%)

0 half of neonatal deaths can be prevented through

midwifery care. If family planning was included as part
of midwifery, 44·7–80·6% of maternal, fetal, and
–20
30 neonatal deaths would be prevented (figure 2A). In
particular, in Group C countries, family planning alone
–40 could avert 57·2% of all deaths because of reduced
fertility and fewer pregnancies. In combination, the full
–60
package of midwifery care with both family planning
35 and maternal and newborn health interventions could
avert a total of 83·3% of all maternal deaths, stillbirths,
–80
Group A: low HDI and neonatal deaths (appendix).
Group B: low–moderate HDI

–100
Group C: moderate–high HDI
Estimation of the additive value of specialist care
Modest* (scenario 1) The second aim of this study was to estimate the value of
Substantial† (scenario 2) Universal‡ (scenario 3) Attrition§ (scenario 4) 40
adding specialist (obstetrician) care to midwifery on
Figure 1: Total percentage changes in maternal, neonatal, and fetal mortality, by level of HDI, under maternal, fetal, and neonatal lives saved. To do this, we
4 different intervention scenarios, per 1 million population.
HDI=human development index. *10% increase in coverage every 5 years (2010–25). †25% increase in coverage included all activities that could reasonably be delivered
every 5 years (2010–25). ‡95% coverage by 2025. §2% decrease in coverage every 5 years (2010–25). by a midwife to be midwifery care,28 covering activities
45 ranging from community-based to BEmONC-level care;
To assess the effect that midwifery has on maternal, these are included in the first four boxes in the framework
fetal, and newborn outcomes, we assessed the reduction for quality maternal and newborn care1 in this Series.
in the number of deaths caused by the maternal and We included additional interventions deemed to be
newborn health interventions separately from the CEmONC or that require medical care as specialist care.
increase in family planning use. With universal coverage 50 These activities included safe abortion services, ectopic
of maternal and newborn health interventions only, pregnancy case management, diabetes case management,
excluding family planning, for group A countries, 60·9% labour and delivery at the CEmONC level (including
of all maternal, fetal, and neonatal deaths could be caesarean section and blood transfusion), antenatal
prevented (appendix). corticosteroids for preterm labour, induction of labour
We did an additional analysis to examine the reduction 55 for  post-term pregnancies, and hospital-based case
with universal coverage (scenario 4), but excluding management of severe newborn infection. We deemed
family planning. In the three HDI groups, 29·9% of antenatal corticosteroids for preterm labour and induction

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of labour to be part of specialist care as they required 1 A

obstetric and newborn service provision. This analysis 2100 Specialist clinical care
allowed us to examine the effect of midwifery as a package Midwifery care
Remaining deaths
of care, with the cumulative effect of linking to specialist 1750
medical care. 5

Deaths averted or remaining

We noted an additional effect on deaths averted when 1400
specialist care is included in the model for scenario 3
(universal coverage). However, this effect is far less 1050
pronounced than that of midwifery care (both maternal
and child health, and family planning), regardless of the 10 700
inclusion of family planning (figure 2).
350
Interpretation
Even modest increases in coverage can save lives
0
Even at the lowest level of scale-up, of 10% per 5 years 15
relative to baseline, we noted a noticeable reduction in
the number of maternal and neonatal deaths, with the B
2100
greatest absolute reduction in the low-HDI countries.
The largest percentage reduction was seen in the
1750
moderate-to-high HDI category, possibly because the 20
overall coverage was already high (75% of institutional
Deaths averted or remaining

births), so quality was most likely to be affected. 1400

Analyses and reports in the past two decades 25,26,65

have
highlighted the need to scale-up coverage of maternal 1050

and newborn interventions. In many countries, this has 25

not occurred because of a range of political, social, 700
cultural, and resource constraints.1 The challenge
facing health policy makers and planners is how to 350
scale up high-quality midwifery services while
addressing the complexity of the underlying issues.66 30 0
Group A Group B Group C Group A Group B Group C Group A Group B Group C
For the most part, scaling up is a political decision that Maternal Stillbirths Neonatal
includes the allocation of resources, along with the buy- Type of death and country
in of professional groups and the views and demands
or needs of the population,66 with countries trying to Figure 2: Number of maternal, fetal, and neonatal deaths averted by midwifery care and specialist care of
deaths that would have occurred in 2025 with no scale-up, per 1 million population
make decisions that provide the best outcomes for the 35 (A) Including family planning. (B) Excluding family planning. *Deaths that would not necessarily be averted by the
lowest cost. achieved coverage of the specific interventions in the model.
We recognise that our best-case scenario (universal
coverage by 2025) assumes that efficacious, quality Contribution of family planning
interventions are effectively delivered within a Midwifery includes community-based interventions such
functional health system by a team of fully-competent 40 as family planning. In a combined model of care that
midwifery and specialist medical staff linking from included maternal and newborn infant interventions,
community to primary, secondary, and tertiary services. and family planning, family planning has the most
In view of the current worldwide challenges associated substantial effect on deaths averted because of a
with competencies and quality of care, and the reduction in the number of pregnancies that are of
insufficient attention to life-saving functions in many 45 potential risk for mother, foetus, and newborn infant.
midwifery curricula, this is probably an overestimation The importance of family planning in preventing deaths
of the effect. The best-case scenario will be challenging has been well articulated.70 The Series on family planning
for many countries to achieve; nonetheless, it shows in The Lancet71,72 again emphasised the importance of a
the possible effects if political will and substantial focus on family planning to improve the health of
planning and resources were in place. Some countries 50 communities. It has been estimated that increasing
have managed to show important improvements in contraceptive use in developing countries has reduced
maternal mortality with substantial scale-up of access the number of maternal deaths by 40% over the past 20
to effective interventions.67,68 For example, Eritrea, years because of a reduction in the number of unintended
Bangladesh, and Egypt are low-resource countries that pregnancies.71,73
are deemed on track to reaching the MDGs with a 55 The full scope of midwifery includes family planning,
greater than 5·5% reduction in maternal mortality rates highlighting the substantial contribution that midwives
every year since 1990.69 can make to averting deaths through enabling access to

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family planning. Another modelling analysis74 using 1 of standardised methods and the implementation of
Spectrum in two small island nations in the South Pacific strategies to collect and collate data need to occur.
showed that meeting family planning needs would Measurement strategies for mortality and morbidity
substantially reduce the number of unintended should be suited to the needs and resources of the
pregnancies, high-risk births, and maternal and infant 5 particular country, and must strengthen the country’s
deaths. Furthermore, preventing unintended pregnancies technical capacity to generate and use credible estimates
would have substantial economic benefits for the health too.77,78 Measurement of broader maternal and newborn
and education sectors.72 outcomes will provide more detailed evidence about
In practice, scaling up of maternal and newborn quality of services, which can then be tied to the
interventions, and family planning, as part of midwifery 10 measurement of accountability and action for scaling up
as a package of care has to occur in parallel, since both midwifery to improve maternal and newborn services,
are dependent on a functional workforce and health and to ensuring that services are designed to better meet
service. Family planning is an integral part of midwifery28 the needs of women.65,79
and so midwifery could be a means to gain access to Outcomes in high-income countries, where quality of
family planning. Countries that have increased family 15 care and other health outcomes might have a different
planning coverage have shown reductions in maternal priority than additional deaths averted, need to be
mortality.75 For example, the total fertility rate in examined differently. Nonetheless, quality of care and the
Bangladesh has fallen from 6·3 to 2·7 between 1975 and experiences of women are important in settings of high,
2007; the contraceptive prevalence rate increased from middle, and low incomes, and are likely to influence
8% to 56% between 1975 and 2007, and the maternal 20 health-seeking behaviours and outcomes. The panel
mortality ratio has decreased from 800 in 1990 to 240 explains the contribution that midwife-led care and units
in 2010.76 in high-income countries have on improving outcomes,
including positive outcomes such as breastfeeding and
Effect of specialist care women’s views and experiences. In high-income countries,
In our second analysis, we estimated the lives saved based 25 inappropriately used interventions—eg, unnecessary
on an incremental increase from midwifery alone to caesarean section or induction of labour, are also likely to
midwifery with specialist medical care. Regardless of the contribute to morbidity and mortality.1 Different
inclusion of family planning, the effect of specialist approaches need to be developed to model the effect of too
medical services is less pronounced than the initial effect many interventions compared with too few, and the effect
noted from activities deemed to be part of midwifery as a 30 of midwife-led care in countries with different income
package of care. In our analysis, we found the incremental levels.3,86–88
benefit of specialist medical care to be most substantial on
maternal mortality, where up to 20% of maternal deaths Ensuring midwives can be the providers of care
are able to be prevented by activities that require We used this modelling to examine the contribution of
CEmONC. We recognise that, just like medical and 35 midwifery interventions rather than midwives
surgical care, midwifery must be situated within a themselves as providers of health care. The midwife, as a
functional health system with an effective referral system, health-care worker, can efficiently and effectively deliver
including communications and transportation equipment, the package of intervention as highlighted by Renfrew
and readily-accessible, equipped, and staffed health and colleagues.1 Although the full spectrum of care up to
facilities that can provide specialist medical care.1 We also 40 and including specialist medical care averts the most
assumed in this analysis that specialist medical skills are deaths, the midwife addresses the continuum of care
available in a functional health system. In countries that from the community through to complex clinical care,89
do not have sufficient obstetricians and gynaecologists, whereas the medical specialist might not. Midwives can
the ability to provide specialist medical care will be potentially bring the woman into the health-care system
restricted and the potential benefits therefore less. 45 at the most effective and efficient time and level. Effective
referral is often hampered by practical considerations,
Investing in improved outcome measurement for such as poor finance and transport services, and access to
the future specialist medical care once in higher-level facilities.
We used maternal, fetal, and neonatal mortality as the Again, this highlights the need for midwifery, specifically
primary outcomes of our analysis because they are the 50 midwives, to be part of a team within a functional and
most readily available. Most clinical outcomes in enabling health system that has a skilled health workforce
maternal and newborn infant health take a negative with the appropriate competencies and is based in the
rather than positive perspective, such as the measurement community and hospital or health facility. This is an
of death or disability. Future analyses should focus on important step towards ensuring that women can have
broader outcomes, particularly morbidity, mental health, 55 access to a quality midwifery service that can provide the
and quality of life, as these can also be affected by maternal and newborn health interventions, and
midwifery.1 Substantial investments in the development preventive health-care strategies.

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Limitations 1 processes of pregnancy, childbirth, and the early weeks

LiST provides a user-friendly method to quantify the after birth.1 In future, it will be important to go beyond
effect that can be achieved by scaling up different the interventions that often focus on mortality and
maternal and newborn interventions.48,36,41 It has also include these elements of broader quality of care in
been used to guide strategic planning at a country- 5 such analyses.
specific level.90 The method was originally developed for We used the HDI to categorise 78 countries into three
child health in what became the Lancet’s Child Survival groups. HDI is not the only measure that could have been
Series33 and has since been expanded to model the effect used. We did examine other indexes and did not find
of scaling up in newborn infant,34 fetal, and maternal substantial differences in the classification of individual
health.36 LiST, however, has limitations. It can only 10 countries, hence we used the HDI.
model mortality effects in low-income and some middle-
income countries, and cannot examine broader, more
sociological effects, such as empowerment or quality of Panel: Improving quality and safety in maternity care: the contribution of
life. Although it was initially designed to measure midwife-led care and units in high-income countries
community-based effects on child survival, it has now 15 This Panel considers how the organisation of care providers, models of care, and
been expanded to model maternal mortality and birthplace setting contribute to high-quality and safe care for mothers and their newborn
stillbirths, and some facility-based interventions. It was infants in high-income countries.
not designed to model the effect of intervention overuse, The philosophy behind midwife-led continuity models is “normality, continuity of care
as might be seen in some high-income countries.91–93 and being cared for by a known, trusted midwife during labour. The emphasis is on the
This method is also reliant on the data available for those 20 natural ability of women to experience birth with minimum intervention”.3 Midwife-led
countries, which is particularly important since the continuity of care can be provided in small teams or as a caseload model, and occurs within
countries that can be modelled are those with the poorest a multidisciplinary network of consultation and referral with other care providers.
quality and quantity of data, especially in terms of causes Midwife-led continuity of care is associated with substantial benefits for mothers and their
of maternal mortality. LiST is based on the estimation of newborn infants, and has no identified adverse effects compared with shared or medically-
mortality outcomes that includes only the interventions 25 led care in high-income countries according to one systematic review.3 The authors of a
with known effect size differences. This characteristic second systematic review80 concluded that midwife-led services might offer a cost-
means that interventions for which little research has effective alternative to the prevailing maternity care model. More recently, an Australian
been done to generate the data on effect size differences randomised controlled trial81 reported that caseload midwifery is associated with cost
cannot be included, with the wide range of other non- savings in women of all risks, with similar clinical outcomes.
mortality outcomes also unable to be included. Proxy 30
Midwife-led birth settings include midwife-led units sited alongside obstetric units and
indicators and interventions might have large variations
freestanding midwife units. Midwife-led units that are based in or next to hospitals
and further research is needed to quantify these
compared with conventional hospital labour wards produce an increased likelihood of
indicators.
spontaneous vaginal birth and decreased likelihood of oxytocin augmentation, assisted
Because of the emphasis of biomedical interventions,
vaginal birth, caesarean birth, and episiotomy, with no difference in infant outcomes.82
LiST does not take into account the effect of broader 35
social determinants of health. Victora48 has argued that With regard to freestanding midwife units, there is less evidence.83 A prospective study of
most of the effect of broad social determinants on child freestanding midwife unit care in Denmark84 found important benefits, such as higher
mortality will be mediated by interventions included in levels of satisfaction, decreased maternal morbidity, decreased use of birth interventions,
LiST, such as improved water and sanitation, better including caesarean sections, and increased likelihood of spontaneous vaginal birth
antenatal, labour and birth care, improved nutrition, and 40 compared with labour ward care. There were no differences in perinatal morbidity in
greater access to high-quality case management of infants of low-risk mothers.85
diseases, such as pneumonia, diarrhoea, and malaria. In The Birthplace in England Study86 assessed outcomes by intended place of birth for
the future, tools that are more sensitive to midwifery as a women at low risk. For low-risk women, the overall incidence of adverse perinatal
package of care need to be developed to enable the outcomes was low in all birth settings. For multiparous low-risk women, no differences
measurement of increase in the coverage of 45 were noted in adverse perinatal outcomes between settings. However, the risk of an
interventions, quality of care, and the broader aspects of adverse perinatal outcome was higher for women having their first baby who planned to
care, including the interpersonal elements, which are give birth at home compared with in an obstetric unit, although the overall level of risk
part of midwifery. was low. The intrapartum transfer rate for women having their first baby was high
Another limitation of LiST is that quality cannot be (36–45%), which might explain the adverse outcome rate. The costs were lower for births
included as a separate and specific indicator. We based 50 planned at home, in a freestanding unit, or alongside a midwife unit than for planned
our analysis on the assumption that, as coverage of birth in obstetric units.87
delivery care increases, so does quality. This statement Overall, in high-income settings, both the model of care and place of birth are important
might not be correct in all situations. The other influences on a range of health and clinical outcomes for mothers and newborn infants,
elements that cannot presently be modelled include and have economic implications for the health system. Systems need to be in place to
respect for and understanding of the individual needs 55 allow safe and timely transfer to obstetric care and skills without financial, professional,
of the mother, child, and family, and a commitment to and organisational barriers.
active promotion of normal biopsychosocial cultural

www.thelancet.com 9
 Series

We found it difficult to decide which interventions were 1 Howard Friedman, Cathy Warwick, Frances Day-Stirk, Fabienne Richard,
deemed part of midwifery or specialist medical care. We Jerker Liljestrand, Elizabeth Mason, Fran McConville, Blerta Maliqi,
Matthews Mathai, Metin Gülmezoglu, Veronica Walford, Hermen Ormel,
recognise that some interventions, such as safe abortion Kate Teela, France Donnay, and Mariam Claeson. All coauthors of the
services, could be considered part of midwifery as a Lancet Series on Midwifery commented on drafts of this manuscript.
package of care because of an increasing proportion of 5 Eugene Declercq and Vincent Fauveau, other members of the Lancet
manual vacuum aspirations being safely done by mid- Series on Midwifery Helicopter Group, also made important
contributions, along with Mary Renfrew, Luc de Bernis, Zoë Matthews,
level providers, including midwives and nurses,94 at a Helga Fogstad, and Alison McFadden, other members of the Lancet Series
primary care facility level. Another intervention that was on Midwifery Executive Group, who made important contributions
95

classified as specialist care was antenatal corticosteroids. throughout the writing of this report.
The classification of the interventions was a consensus 10 References
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 Series

Midwifery 3
Country experience with strengthening of health systems
and deployment of midwives in countries with high
maternal mortality
Wim Van Lerberghe, Zoe Matthews, Endang Achadi, Chiara Ancona, James Campbell, Amos Channon, Luc de Bernis, Vincent De Brouwere,
Vincent Fauveau, Helga Fogstad, Marge Koblinsky, Jerker Liljestrand, Abdelhay Mechbal, Susan F Murray, Tung Rathavay, Helen Rehr,
Fabienne Richard, Petra ten Hoope-Bender, Sabera Turkmani

Published Online This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-
June 23, 2014 income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve
http://dx.doi.org/10.1016/
S0140-6736(14)60919-3
maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions
deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education
This is the third in a Series of
four papers about midwifery of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by:
Center for Family Welfare, expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of
Faculty of Public Health midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and
University of Indonesia, Depok, respectful woman-centred care have received little or no attention.
West Java, Indonesia
(E Achadi DrPH); Brussels,
Belgium (C Ancona MD); Introduction Guinea, Peru, Rwanda, Senegal, Sierra Leone, Somalia,
Instituto de Cooperación Social To argue that strengthening health systems makes the South Sudan, Sudan, Tanzania, Togo, Uganda, Yemen,
Integrare, Barcelona, Spain difference between successes and reversals in maternal Zambia, and Zimbabwe). 21 of these 48 countries reduced
(J Campbell MPH,
and newborn health has become a cliché.1–14 This consensus this maternal mortality ratio by at least 2∙5% per year
P ten Hoope-Bender MBA);
Department of Social Statistics contrasts with the paucity of empirical documentation of between 1990 and 2000, and again between 2000 and
and Demography, University of the long-term efforts to adapt and strengthen health 2010,15 a median drop in maternal mortality ratio of 63%
Southampton, Southampton, systems in support of maternal and newborn health. over 20 years (appendix p 15).16−26 These 21 countries are all
UK (A R Channon PhD); UN
Population Fund, Geneva,
Of the low-income and middle-income countries with either on track or making good progress towards
Switzerland (L de Bernis MD); currently more than 5 million inhabitants, 48 had a Millennium Development Goal 5;15 in many of the other
Holistic Santé, Montpellier, maternal mortality ratio of 200 per 100 000 livebirths or countries the hoped for 75% drop in maternal mortality15 is
France (V Fauveau PhD); Woman more in 1990 (Afghanistan, Angola, Bangladesh, Benin, unlikely to have occurred before 2015.
& Child Health Research Centre,
Institute of Tropical Medicine,
Bolivia, Burkina Faso, Burundi, Cambodia, Cameroon, These 21 countries made substantial efforts to enhance
Antwerp, Belgium Chad, Côte d’Ivoire, Democratic Republic of the Congo, uptake of health services. Where data were available, they
(Prof V De Brouwere, PhD); Norad Dominican Republic, Eritrea, Ethiopia, Ghana, Guatemala, showed substantial increases in facility birthing (figure 1A).
Oslo, Norway (H Fogstad MHA); Guinea, Haiti, Honduras, India, Indonesia, Kenya, Lao, This increase in facility birthing contrasts with the slower
US Agency for International
Development, Washington DC,
Madagascar, Malawi, Mali, Morocco, Mozambique, or no progress made by 17 countries without a sustained or
USA (M Koblinsky PhD); Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New rapid reduction in maternal mortality ratio, for which
sequential data on facility birthing were available
(figure 1B). Five of those countries made slow but steady
Key messages gains in facility birthing (Haiti, Honduras, Mali, Senegal,
• Effective coverage in the countries reviewed has crucially depended on the investment and Uganda). Three experienced drops in mortality from a
in the overall service delivery network and facility birthing. The expansion of the high baseline, with little progress in facility-birthing (Chad,
service network has kickstarted a virtuous cycle of uptake of care by mothers, Nigeria, and Niger). Finally, the remaining nine countries
deployment of midwives to both meet and generate increased demand, pressure to made little or no progress or had a reversal in either
lift financial barriers and further uptake of maternal care. maternal mortality ratio or facility birthing.
• Attention for quality of care in the countries reviewed has taken off only when uptake The evolution of the proportion of births attended by a
of care had already substantially increased. Until very recent years they have given midwife, auxiliary midwife, or nurse-midwife was
little or no attention to what midwives and doctors can do to curb overmedicalisation documented in 15 of the 21 countries with sustained
and promote respectful woman-centred care. improvement in maternal mortality ratio: in four
• The deployment of midwives in the countries reviewed has been the result of (Bangladesh, Bolivia, India, and Pakistan), although
managerial choices to accelerate and operationalise universal access to care. professional care at birth has increased, the proportion of
Endorsement in the national political arena came only later in the process, once births attended by a midwife, auxiliary midwife, or nurse-
appreciation by the population of the successful deployment of midwives became midwife has decreased in favour of those attended by
apparent and civil society more vocal and assertive. medical doctors. In Burkina Faso, Cambodia, Indonesia,
Malawi, Morocco, and Nepal, and to a lesser extent in

38 www.thelancet.com
 Series

Bangladesh and Eritrea, this proportion has increased Extrapolation from individual country experience is Lund University, Sweden
(figure 2). hazardous and complicated by the paucity, poor precision, (J Liljestrand PhD); Evidence for
Action, University of
As a complement to the other papers28,29 in this Series and, at times, contradictions in the data for some years in Southampton, Southampton
about midwifery, this paper documents the constellation of the period of interest. This issue is compounded by the UK (Prof Z Matthews PhD);
health-system efforts in support of maternal and newborn leaps of faith required to link decades of health system Rabat, Morocco
health in four of these 21 countries: Burkina Faso, initiatives plausibly to outcomes. Even an in-depth review (A Mechbal MPH); International
Development Institute, King’s
Cambodia, Indonesia, and Morocco. These four countries of sources and documentation inevitably leaves gaps in the College London, London, UK
have shown sustained and substantial reduction of reconstitution of the sequence of events. (S F Murray PhD ); Evidence for
maternal and newborn mortality while deploying midwives Data on the decline of maternal mortality—crucial for Action, London, UK
as a core constituent of their strategy (appendix p 1−14). assessing outcomes—have to be interpreted with some (H Rehr MSc); Institute of
Tropical Medicine, Antwerp,
These countries have shown gains in facility birthing in caution. We have used the 2013 WHO/UNFPA/UNICEF/ Belgium (F Richard PhD);
every wealth asset quintile (figure 3A) and the proportion World Bank estimations for decadal change.27 These are National Reproductive Health
of births attended by a midwife, auxiliary midwife, or modelled from censuses and surveys, adjusted for under- Program, Phnom Penh,
Cambodia (T Rathavay MPH);
nurse midwife has increased in the four lowest quintiles reporting and misclassification, and finally combined with
Afghan Midwives Association,
(Cambodia, Indonesia, and Morocco) or in all five quintiles best-estimate-envelopes of birth and death totals from
(Burkina Faso; figure 3B).
A Countries with a sustained and rapid reduction in maternal mortality ratio over two decades
Methods and data limitations 1600 Bangladesh 1994–2010
Bolivia 1994–2008
Maternal mortality ratio (deaths per 100 000 livebirths)

Burkina Faso, Cambodia, Indonesia, and Morocco were Burkina Faso 1993–2010
1400
selected as countries for three reasons: they have shown Cambodia 2000–2010
Eritrea 1995–2002
two decades of reduction of maternal and neonatal 1200 Ethiopia 2000–11
mortality (appendix pp 15−17); they have started up or Ghana 1993–2008
accelerated investment in cadres of midwives; and 1000 India 1993–2005
Indonesia 1991–2012
accounts by expert witnesses and documented evidence Malawi 1992–2010
800
permit a credible reconstruction of the pathways of the Morocco 1992–2011
Mozambique 1997–2011
efforts in health systems strengthening in support of 600 Nepal 1996–2011
maternal health services over the past 20–25 years. The Pakistan 1990–2012
appendix (p 15) summarises how data availability has Peru 1992–2012
400
Rwanda 1992–2010
constrained the selection of countries for in-depth study.
We triangulated interviews with key informants and expert 200

witnesses with documentation obtained through a

0
structured literature search across a range of electronic
databases, complemented by documentation obtained B Countries without a sustained and rapid reduction in maternal mortality ratio over two decades
through the country-specific key informants and ministry 1600 Cameroon 1991–2011
of health sources. Chad 1996–2004
Maternal mortality ratio (deaths per 100 000 livebirths)

1400 Côte d’Ivoire 1994–2011

For every country, we identified specific interventions in Dominican Republic
health system strengthening relevant to the deployment of 1991–2007
1200 Haiti 1994–2012
midwives and maternal health and iteratively validated Honduras 1996–2005
them through the literature review and interviews with key 1000 Kenya 1993–2008
informants. We collated and assessed available information Madagascar 1992–2009
Mali 1995–2006
on progress with maternal and newborn outcomes against 800 Niger 1992–2006
the aspirational quality maternal and newborn health Nigeria 1990–2008
600 Senegal 1992–2010
framework.1 Interviews with the expert-informants related Tanzania 1991–2010
outcomes to efforts in health system strengthening in 400
Uganda 1995–2011
three linked layers. First, we mapped efforts to enhance Yemen 1992–1997
Zambia 1992–2007
the effectiveness of coverage and examined plausible links 200 Zimbabwe 1994–2010
with outcomes. Second, we identified the efforts to
enhance coverage through improved access and uptake of 0
0 10 20 30 40 50 60 70 80 90 100
services. Third, we examined the initiatives to improve Births in facilities (%)
steering or governance and resource allocation (focusing
Figure 1: Change in maternal mortality ratio and proportion of facility births since the 1990s
on availability of information and research, evidence of (A) Countries with a sustained and rapid reduction of maternal mortality ratio over two decades. This graph
priority setting, and budgeting) as to their contribution to shows 16 countries with data; time series data were not available for five other countries (Lao, Myanmar, Papua
improved access and effective coverage, with specific New Guinea, South Sudan, and Sudan) with a sustained reduction of maternal mortality ratio over two decades.
attention for the role of domestic political leadership and (B) Countries without a sustained and rapid reduction of maternal mortality ratio over two decades. This graph
shows 17 countries with data; time series data were not available for ten other countries (Benin, Guatemala,
the sensitivity of external aid to the maternal and newborn Guinea, Sierra Leone, Tanzania, Togo, Uganda, Yemen, Zambia, Zimbabwe) with a non-rapid sustained reduction
health agenda. We gave particular attention to ascertaining in maternal mortality ratio over two decades. Source of data for health facility births: DHS surveys. Data for
the time sequence of these efforts and initiatives. reduction in maternal mortality ratio: WHO, UNICEF, UNFPA, World Bank 2014.27

www.thelancet.com 39
 Series

100 Bangladesh 1993–2010

effectiveness, and quality of services provided.31–33 For all
Bolivia 1994–2008 the standardisation of the DHS surveys, “facility birthing”
90 Burkina Faso 1993–2010 covers very different realities, from a midwife’s home in an
Cambodia 2000–2010
isolated village to well equipped specialised hospitals. By
Births with midwives, auxillary midwives,

80 Eritrea 1995–2002

70
Ghana 1993–2008 contrast with antenatal care, metrics of quality of birthing
India 1993–2005
care or access to referral care are not readily available in
or nurse-midwives (%)

Indonesia 1991–2012
60 Malawi 1992–2010 ways that allow for comparison across countries or across
Morocco 1992–2011 time. Metrics to assess trends over time in compassionate
50 Mozambique 1997–2011
Nepal 1996–2011 and respectful care do not currently exist. Policy and
40
Pakistan 1990–2012 systems interventions are rarely systematically docu­
Peru 1992–2012
30
Rwanda 1992–2010 mented, and few key informants can claim objectivity and
20 continuity of memory for the whole period. Past events
might be rationalised selectively, underestimating
10
serendipity. Inference about the relative contribution of
0 specific health system efforts is thus tentative at best and
0 10 20 30 40 50 60 70 80 90 100
requires careful triangulation.
Births in facilities (%)

Figure 2: Trend in facility birthing and proportion attended by midwives after 1990 in countries with a rapid
and sustained reduction of maternal mortality ratio over two decades
Source of data for health facility births: DHS surveys. Data for reduction in maternal mortality ratio: WHO, UNICEF,
UNFPA, World Bank 2014.27 This graph shows 15 countries with data; time series data were not available for
six other countries (Ethiopia, Lao, Myanmar, Papua New Guinea, South Sudan, and Sudan) with a rapid and
sustained reduction of maternal mortality ratio over two decades.
Jhpiego, Kabul, Afghanistan WHO/UN databases. They are in line with modelled
(S Turkmani MPH); and WHO estimates published in 2012,15 but diverge substantially
Regional Office for Europe,
Athens, Greece
from other recently published modeled estimates.30
(Prof W Van Lerberghe PhD) Although systematic modelling might provide for more
Correspondence to: robust estimates of aggregate trends and inter-country
Prof Wim Van Lerberghe, WHO comparison, the analysis of individual trajectories over a
Regional Office for Europe, timespan can be problematic. For example, Cambodia’s
Athens 11521 , Greece
wvl@euro.who.int
spectacular acceleration in the decline of maternal
mortality ratio after 2005 shown by the direct survey data is
See Online for appendix
smoothed out in the modelled estimates. In Indonesia,
recent measurements are above the smoothed modelled
trend estimates, whereas in Morocco a large recent
multiround survey has generated robust measurements
that are lower than the modelled estimates.
Where some data for the evolution of neonatal mortality
are available, the story is usually incomplete for stillbirths.
Information about morbidity is anecdotal at best, as is
information about unsafe abortion, an important cause of
maternal mortality. The social outcomes to which better
maternal and newborn health care is expected to contribute
(social integration, gender equity, women’s autonomy and
participation) are poorly documented and difficult to
attribute to programme performance, as are the contextual
elements that influence health decision making and
uptake of care: the capabilities of women in a modernising
society to make use of the opportunities offered by
improved transport, mobile phones, audio-visual
information, and education.
Reconstruction of trends in programme output is equally
precarious. What is “skilled attendance” and even what is
understood by the categories of “nurse-midwife” or
“auxiliary midwife” used in the Demographic and Health
Survey (DHS) questionnaires varies from one country to
the other and over time—and so does the range,
Commonalities and lessons
Creation of a virtuous cycle of access, uptake, and
effective coverage
Despite these limitations it has been possible to reconstitute
how countries deployed a collection of partly connected
initiatives and measures to adapt to and improve on a
changing environment, where strategies emerged and self-
organised over time, rather than as imple­mentations of a
predefined comprehensive plan. The appendix maps the
multiple measures that have contributed to making
coverage more effective, access and uptake more universal,
and steering and resource mobilisation more purposeful.
Rather than relying on a magic bullet, each of the four case-
study countries has intervened at various levels in the
health-care system, innovating or adapting policies,
procedures and approaches as obstacles were encountered.
The appendix maps measures of health system
strengthening taken over the past 25 years to improve
maternal and newborn care in each of the case-study
countries. Individual country narratives, which for reasons
of editorial space policy has been put in the appendix
(pp 1–14),16–26,34–105 provide further documentation, evidence,
and details about the interlinkages between the various
measures, their time sequence and their relevance to the
outcomes that were obtained (figure 4 and 5).
A common pattern emerges from the various inter­
ventions for health-system strengthening detailed in
figure 4 and in the appendix (pp 1–14). Four sequential lines
of action have jointly contributed to improved maternal and
newborn health outcomes: (1) extension of a close-to-client
network of health facilities, resulting in improved access to
and uptake of facility birthing and hospital care for
complications; (2) scale-up of the workforce providing
professional birthing care to respond to the growing
demand; (3) reduction of financial barriers to access to
further enhance uptake of care; and (4) attempts to improve
quality of care. Figure 6 shows the sequence of those
system-wide efforts along an approximate timeline—with
somewhat arbitrary starting dates given the gradual build-
up of such interventions over years.

40 www.thelancet.com
 Series

In all four countries, enhanced close-to-client access to
facility birthing has been the foundation of improved
effective coverage. Increased facility birthing in the case-
study countries was part of a wider trend in low-income
and middle-income countries in the 1990s.106 It resulted
from a combination of increased supply and increased
uptake of services, the latter facilitated by modernisation,
rising incomes, better roads and transport, improved
communication, urbanisation, and more readiness to use
services.107 The slower pace of this trend in sub-Saharan
Africa can at least partly be explained by the difficulty of
scaling up supply at a speed commensurate with the
ongoing annual growth of the number of births, as is well
illustrated by the case of Burkina Faso (pp 5–6).
The extension of the network of health facilities, and its
subsequent increase in workforce has characterised all
four case-study countries from an early stage. In Morocco
the extension of the network of health facilities started in
the 1980s—first with extension of primary care centres,
and in the 1990s with major, albeit not maternal health-
specific investments in hospitals. In Indonesia the
expansion of the (less systematically structured and
unequally distributed) network of public and private
facilities started well before the 1990s. In Burkina Faso, the
extension dates back to the beginning of the 1990s and
and Nepal, or earlier Chile, have opted for the training and
deployment of large cohorts of midwives to meet the
workload. They did so by scaling up existing efforts, and
multiplying new initiatives of pre-service education. The
scale-up seems to have been mainly a managerial response
to the challenge of service delivery consequent on
expansion of the health infrastructure rather than an
ideological preference for midwives over medical doctors.
Speed and cost considerations have been the determining
factor106 (appendix pp 3, 6).
After densification of the service network and scaling up
the workforce, all countries have been confronted with the
need to address the financial barriers that continued to
constrain access. Cambodia stands out as a country where
concerns for financial accessibility, albeit not specific to
maternal health, preceded the scaling up of the production
and deployment of midwives (figure 5). In the other
countries, such efforts came at a later stage. The actual
techniques adopted have ranged from equity funds,
A Gains in facility birthing
100 Burkina Faso 2010
Cambodia 2010
Indonesia 2012
Morocco 2011
80 Burkina Faso 1993
Cambodia 2000
Births in a health facility (%)

accelerated after 2000. In Cambodia, a district system was Indonesia 1991

Morocco 1992
built from scratch from 1993–95 onwards. The investment 60
in these networks of health facilities was not specific to
maternal and newborn health but rather resulted from a
generic desire to expand access to health care. 40

Building a network of facilities from scratch, as in

Burkina Faso and Cambodia, takes time. Once it is in
20
place, deploying a workforce can proceed quite rapidly.
Nevertheless, there has been a substantial lag between the
expansion of infrastructure and the deployment of 0
midwives in Burkina Faso, Cambodia, and Morocco.
Indonesia stands out as a country where that new B Gains in proportion of births mainly attended by midwives,
auxillary midwives, and nurse-midwives
workforce was not just intended to staff expanded service 100 Burkina Faso 2011
infrastructure, but also designed to lead to the ex-novo Cambodia 2010
creation of dedicated, village-level delivery points for Indonesia 2012
Morocco 2003
maternal health services in parallel to the expansion of 80 Burkina Faso 1993
infrastructure. However, the low productivity of the Cambodia 2000
Births in a health facility (%)

Indonesia 1991
Indonesian village midwives operating as a solo Morocco 1992
practitioner suggests that most of the benefits were reaped 60

through improved access to formal facilities—to which a

large proportion of the midwives were deployed.
40
Women are quick to seize the opportunities of a denser
service network, particularly when transport and
communications further facilitate physical accessibility. In 20
many countries, the expanded network has kick-started a
virtuous cycle of increased supply, expanded access,
increased uptake and demand, and scaling up of the 0
Poorest Second Middle Fourth Richest
midwife cadre. In countries such as Egypt or India, a large Wealth asset quintile
supply of doctors has been able to meet the increasing
Figure 3: Gains in facility birthing and proportion of births primarily attended by midwives, auxiliary
demand, in line with social pressure and professional
midwives, or nurse-midwives by wealth asset quintiles in the case study countries
lobbying. By contrast, health authorities in the countries (A) Facility birthing. (B) Proportion of births primarily attended by midwives, auxiliary midwives, or nurse-
documented in this paper, as well as Afghanistan, Malawi, midwives. Source of data: Demographic and health surveys; Enquêtes Nationales Population Nutrition Santé.

www.thelancet.com 41
 Series

A Morocco

Outcomes
More equitable Better maternal Improved social
maternal and newborn and newborn inclusion, gender equity,
outcomes outcomes participation

2010: standardisation of care. Effective coverage End 2000s: procedures for transfer and
Mother- and Effective and safe Hospital backup and management of complications formalised.
baby-centred care interventions and skills parsimonious referral

Mid 1990s: midwifery schools reopened. 1980–90s: scaling up of investment in

2002: competency based curriculum. basic health and hospital infrastructure.
End 2000s: posts created and accelerated 1990s: EmOC equipment; hospital
deployment to expanding network of autonomy.
facilities. Access and uptake
Midwives: supply, deployment, Removal of barriers to Close-to-client facilities,
remuneration, retention access equipped and supplied Late 1980s: long-term investment in
infrastructure.
End 1990s: budgets for midwife posts.
2008: delivery care free in public facilities.
End 2000s: major budget earmarks for
maternal health.

Steering and resource mobilisation

Unmet Obstetric Needs survey 1980s; Strategic information Recognition as priority Translation into budget 1987: Nairobi meeting.
5 yearly population surveys; near-miss and intelligence allocation and regulation 1990s: pressure from donor agencies;
research programme; EmONC survey. lobbying by MOH officials.
2000s: media pressure.

Commitment of political leadership Aid sensitive to MNH priorities

2008: Minister of Health makes maternal 1990s: maternal health becomes priority
health top priority. for donors and partners.

B Burkina Faso

Outcomes
More equitable Better maternal Improved social
maternal and newborn and newborn inclusion, gender equity,
outcomes outcomes participation

2001: first national guidelines. Effective coverage 2006: referral standardised.

Mother- and Effective and safe Hospital backup and Ambulance service organised.
baby-centred care interventions and skills parsimonious referral
1980s: auxiliary midwives.
1997: professional union.
2001–10: midwife workforce tripled; 2002: antenatal is free of charge.
career paths defined. 2006: government partially reimburses
household expenditures for normal
Access and uptake deliveries, complications and C sections.
Midwives: supply, deployment, Removal of barriers to Close-to-client facilities,
Sequential DHS surveys.
remuneration, retention access equipped and supplied
Unmet Obsteric Needs survey 1990s;
2006 Census; 2005 ‘Reduce’ study;
2003–12: 804 facilities upgraded, bringing
maternal death and near miss audits.
the total to 1054.

1998: maternal health targets. Steering and resource mobilisation

2006: broad professional and political Strategic information Recognition as priority Translation into budget 2000s: public investment in infrastructure.
consensus on priority and 10-year MNH and intelligence allocation and regulation 2006: dedicated public funding for
acceleration plan. childbirth costs.
2008: regulatory body for midwives.

Explicit political support since early 2000s. Commitment of political leadership Aid sensitive to MNH priorities
Needs assessment led by Parliament
in 2006. Seed funding by WHO/UNICEF/UNFPA.

Figure 4: Health systems strengthening measures aimed at improving maternal and newborn health in Morocco and Burkina Faso since the late 1980s
(A) Morocco. (B) Burkina Faso. Document analysis and expert witness interviews made it possible to identify health-system strengthening measures that can plausibly be linked to improved outcomes.
We mapped these measures according to their contribution to steering and resource mobilisation, improving access and uptake of care, and effective coverage—taking into account key dimensions of
quality. This figure only represents a small portion of the analysis that is available in the appendix, which shows a detailed narrative for every case (summarising the available evidence and detailing the
inter-linkages between the various measures, their time sequence and their relevance to the outcomes). This information was put in the appendix (pp 1–14) for editorial reasons of space policy.
EmONC=emergency obstetric and newborn care. MNH=maternal and newborn health. MOH=ministry of health.

42 www.thelancet.com
 Series

A Indonesia

Outcomes
More equitable Better maternal Improved social
maternal and newborn and newborn inclusion, gender equity,
outcomes outcomes participation

Late 2000s: in-service training programme Effective coverage 2011: health centres and hospitals
by MOH & midwifery association; Mother- and Effective and safe Hospital backup and brought under joint funding and
accreditation; quality circles; maternal baby-centred care interventions and skills parsimonious referral management.
death audits.

2005: health insurance safety net for the

poor. Special arrangements for remote
Massive “village midwife” programme: populations.
pre-service training and deployment of Access and uptake
midwives, both to health facilities and as
Midwives: supply, deployment, Removal of barriers to Close-to-client facilities,
private practice at village level. By 1997: 20 000 village maternity clinics
remuneration, retention access equipped and supplied
established.

Pay per delivery financial incentives for

public sector midwives. Market prices for Late 1980s: recognised as a priority in
private midwives. legal frameworks.
Steering and resource mobilisation
Strategic information Recognition as priority Translation into budget
and intelligence allocation and regulation
Regular DHS; multiple studies and surveys
since 1980s; confidential enquiries. 1989 onwards: increased earmarking for
maternal health, with particular focus on
midwives.
Commitment of political leadership Aid sensitive to MNH priorities
High priority for leaders within health
sector since mid 1980s. 1990s: development partner priority.

B Cambodia

Outcomes
More equitable Better maternal Improved social
maternal and newborn and newborn inclusion, gender equity,
outcomes outcomes participation

Mid 2000s: generalised quarterly inservice Effective coverage Mid 1990s: referral system instituted
training and co-ordination workshops at Mother- and Effective and safe Hospital backup and with district health care system; C-section
district level. Introduction of routine active baby-centred care interventions and skills parsimonious referral capacity part of roll-out of districts.
management of third stage of labour and
MgSO4. Offer of legal abortion.
End 1990s onwards: vouchers, equity
fund exemptions, and other mechanisms.
2005 onwards: training stepped up;
deployment of midwives to most health Access and uptake
units 2005. Midwives: supply, deployment, Removal of barriers to Close-to-client facilities, Mid 1990s onwards: rollout of district
2009: pre-service curriculum review. remuneration, retention access equipped and supplied network of health centres and hospitals.

From mid-1990s: donor investment and

Four supplementary income streams to increased government expenditure on
top up midwife income beyond salaries, health (no explicit earmarking for
including “live-birth incentives”. Steering and resource mobilisation maternal health).
Strategic information Recognition as priority Translation into budget
and intelligence allocation and regulation
Mid 1990s onwards: numerous surveys Mid 1990s: within district development
and studies. plans; explicit priority for partner-
supported NGOs & CSOs.
Commitment of political leadership Aid sensitive to MNH priorities
2005: explicit commitment Minister of
Health to midwife-based strategies. Mid 1990s onwards: donor agency priority.

Figure 5: Health systems strengthening measures aimed at improving maternal and newborn health in Indonesia and Cambodia since the late 1980s
(A) Indonesia. (B) Cambodia. Document analysis and expert witness interviews made it possible to identify health-system strengthening measures that can plausibly be linked to improved outcomes.
We mapped these measures according to their contribution to steering and resource mobilisation, improving access and uptake of care, and effective coverage—taking into account key dimensions of
quality. This figure only represents a small portion of the analysis that is available in the appendix, which shows a detailed narrative for every case (summarising the available evidence and detailing the
inter-linkages between the various measures, their time sequence and their relevance to the outcomes). This information was put in the appendix (pp 1–14) for editorial reasons of space policy.
MOH=ministry of health. DHS=demographic and health survey. MNH=maternal and newborn health. NGO=non-governmental organisation. CSO=civil society organisation.

www.thelancet.com 43
 Series
Burkino Faso
Revitalisation and expansion of the service network (district model), accelerated after 2000
Investment in midwives
Removal of financial barriers
Action on quality of care
Cambodia
Establishment of a service network (district model) from 1995
Investment in midwives
Removal of financial barriers (not specific to maternal health)
Action on quality of care
Morocco
Expansion of the service network and technical platform: primary care from 1980s, hospitals during 1990s
Investment in midwives
Removal of financial barriers
Action on quality
of care
Indonesia
Surge of expansion of the service network: health centres from 1980s, hospitals 2000s
Investment in midwives, from late 1980s
Removal of financial barriers
Action on quality of care
1990s 2000s
Figure 6: Sequence of crucial interventions for health-system strengthening in support of quality maternal
and newborn health in Burkina Faso, Cambodia, Morocco, and Indonesia, 1980s to present
exemptions, insurance mechanisms, government re­
imburse­ment, vouchers, and conditional cash transfers,
to, in some instances, a return to free health services
(appendix pp 3, 7). Mainly targeted at covering the medical
costs for both childbirth and referral, initiatives to cover
transport costs have appeared since the 2000s. Cambodia
has made explicit attempts to overcome the ubiquitous
informal payments to government officials. In the other
countries, how the complex equilibrium of financial
incentives to public sector staff performance has played
out is less clear.
The quality challenge
As of the mid 2000s, these efforts had radically enhanced
access and uptake of maternal health care, with midwives
taking up a large share of the workload. Concerns about
quality of care—about effective coverage as opposed to
mere uptake of care—appeared late, well after the countries
had started expanding networks and workforces, and
reducing financial barriers. Some attention to improve
technical standards, competencies, and equipment, has
been noted, and death audits and near-miss audits have
had an important role in highlighting quality issues108,109
(appendix pp 2, 9, 10, 14).Nevertheless, in the countries
studied, the quality maternal and newborn health
framework1 is far from being translated into the practice of
midwives and medical personnel. Awareness among
managers of maternal and newborn health programmes
of the various dimensions of quality is just beginning.
All observers agree that much remains to be done, not
just in terms of technical quality but also in terms of
44 www.thelancet.com
coordination of care and referral between peripheral units
and hospitals. The organisation of referrals continues to be
a sore point, particularly in situations in which the overall
coordination of the care network is wanting, such as in
Indonesia (appendix p 10).
Women and families themselves are, however, becoming
smarter at overcoming the deficiencies in system
integration and coordination, by taking advantage of
improved knowledge, communication, and transport to
procure access to specialised services when problems
occur. The surprisingly low maternal mortality ratio
among home births in Morocco and the selective uptake
care for complicated cases in public hospitals in Indonesia
confirm this trend (appendix pp 1, 8).
Health authorities in the four countries, governmental
and other, have shown willingness to maintain continuity
of the efforts to improve access, while identifying problems
and obstacles as time went by. The design and imple­
mentation of solutions might have had delays and setbacks,
but on the whole, we have noted a progressive
sophistication in the management of the maternal health
programmes. This sophistication has created contexts in
which substantial increases in midwives were confirmed
as a strategic element in the contribution to maternal and
newborn survival.
Surveys on the size of the challenge and the progress
towards addressing the remaining needs have had a real
role in all countries (appendix pp 3, 7, 15). In the 1980s and
1990s, information was used for putting maternal health
on the policy agenda and keeping it there. Development
partners and agencies had a key role in doing so. Later,
there seems to have been a shift towards more detailed
analytical work that highlights problems with access and
performance. All countries can currently avail themselves
of much improved—if still patchy—information that
combines regular population surveys with improved
routine information systems and specific instruments
such as maternal death and near-miss audits.
Policy implications
The experience of the four countries suggests that a
strategy for improving maternal and newborn health
cannot be reduced to a choice of professional category to
be scaled up, but crucially depends on the design and
investment in the overall network of service delivery: the
way it provides a compromise between proximity and
technical resources and creates space for uptake of facility
birthing. The deployment of the workforce within this
network is a question of managing speed, cost and quality.
The four countries documented here have opted for a
rapid scale-up of a midwife workforce. Over the next
decade the absolute number of births primarily assisted by
midwives or auxiliary midwives will increase in all four
countries. In sub-Saharan Africa, where contrary to much
of the rest of the world the number of pregnancies is set to
increase year on year, current trends suggest the workload
taken on by midwives will expand considerably (figure 7).

The growth of the workforce will need to accelerate to keep
up with this increase. Only if the economic growth of the
past decade continues, will Africa be able to afford the
workforce expansion required to accelerate coverage and
make it more effective.
Both the professional categories of doctors and midwives
constitute such an important interface between health
services and the population that a dedicated effort to
improve quality of care is justified—without the time lag
experienced in the past decades between improvement of
accessibility and improvement of quality. Managing quality
also means addressing two remaining blind-spots.
First, policy makers are only beginning to take the quality
dimension of respectful woman-centred care to heart.
Things might begin to change: person-centredness and
people-centredness is a rapidly growing concern for
primary care managers across the world; academic
research, the press, and the judiciary system are drawing
attention to long existing issues specific to maternal and
newborn health.22,110,111 In the rare instances in which these
issues were recognised, they have often been dismissed as
something that pre-service education would address
perfectly adequately. None of the four countries has
designed and implemented a systematic approach on a
large scale. This absence of systemic approach is worrying,
since quality, along with access, is at the core of legitimate
expectations and the rights of mothers and their families.
The second blind-spot is that of overmedicalisation. The
most obvious is the epidemic of caesarean sections. This
epidemic is clearly linked to the ability and willingness to
pay, particularly among the richer. The shift from midwife-
assisted to doctor-assisted birthing, which is already visible
for the higher income groups in Cambodia and Indonesia,
is likely to accelerate the trend. The role midwives can have
in mitigating the excessive reliance on birthing by
caesarean section is unclear, in contexts in which financial
incentives are combined with biased risk-perception,
supply-induced demand, and the social sense of what is
“modern”. Other types of overmedicalisation and iatro­
genesis (abuse of anaesthetics, induction drugs, labour
augmentation, antibiotics, and others) are poorly docu­
mented in the case-study countries, as in most low-income
settings. All categories of professionals (doctors, midwives
and auxiliary midwives) seem to contribute. The relative
role of various professional categories (particularly of
doctors versus midwives, auxiliaries, nurse-midwives), of
facility ownership (public, private-for-profit, private not-for-
profit), and of the interaction between quality standards,
working environment and financial consi­ derations
remains a largely unexplored area. There is clearly a need
for better documentation and intervention research on
mitigating of overmedicalisation, specifically of intra­
partum care, in midwife-led facilities and in hospital
environments.
The four case-study countries currently have high-level
political commitment to improvement of maternal and
newborn health and to the expansion of the cadre of
www.thelancet.com 45
Series
100 Lay or no-one
Traditional birth attendants
90 Doctor
Midwife, nurse, auxilliary, or other skilled
80
70
Births per year (millions)
60
50
40
30
20
10
0
1990–97 1998–2004 2005–11 2012–18
Years
Figure 7: Projected births attended by midwives, auxiliary midwives, and
nurse-midwives; by doctors; by traditional birth attendants; and by lay
persons or not attended, in 14 sub-Saharan countries
midwives. With the exception of Indonesia, this
phenomenon is relatively recent. In the three other
countries the political commitment in the early 1990s was
first to a general expansion of the health-care network,
with limited visibility of specific commitment to an agenda
for maternal newborn and child health and no specific
strategy of investment in midwives. Nevertheless, staff
from ministries of health and non-governmental
organisations in Morocco, Burkina Faso, and Cambodia
used the generic drive towards universal access as the
vehicle to promote the maternal health agenda. They opted
for investment in midwives as matter of expediency in
scaling up of the supply of services, and resulted in rapid
increase of uptake and coverage.
The absence of political support in these early phases
was compensated to some extent by the support of the
international community. Later, during the 2000s, the
investment in midwives gained political traction:
politicians endorsed it publicly and actively, as the maternal
health agenda gained visibility and increased access to
midwives proved effective and popular (appendix
pp 3, 4, 7, 14). This political support gives impetus and
continuity to current efforts: failure to provide adequate
maternal care is becoming a political liability as civil society
becomes more critical and vocal. Civil society’s increased
ascertiveness exposes both politicians and health
authorities to the risk of a backlash if no satisfactory
response is given to the quality issues that affect birthing
care. The expectations of the increasingly well informed
public are rising: access, without crippling financial
barriers, to health-care providers (midwives and doctors)
who provide effective, safe, respectful, and compassionate
care. The credibility and legitimacy of health authorities,
also in low-income and middle-income countries, depends
on their will and ability to respond to these expectations,
and to do so without the delays that have occurred too
often in recent years.
 Series
Contributors
WVL redesigned the analysis after the first review, provided the health
systems framework for the case studies, and wrote the final version of the
paper and the case studies. ZM devised the first version of the paper and
assisted WVL with the reformulated paper after review. EA participated in
the development of the case studies and overall writing and revisions.
CA participated in revision discussions and in structuring and finalising
the second version. HB was involved in creating a case study that was
subsequently dropped and contributed with discussions and comments.
JC participated in the initial development meetings, provided comments
throughout the process, and collaborated in managing the reference
database. AC provided the equity survey data analysis and the projection of
births for African countries. LdB participated in the initial development
meetings, contributed to the case studies, and provided comments
throughout writing and revisions. VDB contributed to the reconstruction
and interpretation of the sequence of health systems interventions in
Burkina Faso and Morocco and in the identification of relevant grey and
published documentation. VF participated in the initial development
meetings, contributed to the Cambodia and Morocco case studies, and
provided comments throughout the process. HF assisted with initial
conceptualisations of the paper, writing of the first version, and discussion
of the governance and quality of care issues for the final version.
MK participated in the initial development meetings, contributed to the
Indonesia case study, and to the design and writing of the final version.
JL developed the case studies and contributed to the overall writing and
revisions. AM contributed to the overall design of the second version of the
paper, identification of the relevant publications, grey literature, and
documentation for the Morocco case study. SM participated in the initial
development meetings, provided comments throughout the process of
drafting and revision, and developed a case study that was subsequently
dropped. HR contributed to the paper development, and helped to produce
data for some tables and figures. FR helped develop the Burkina Faso case
study and commented on the overall revisions. TR helped develop the case
studies and commented on the overall revisions. PtH participated in
restructuring the paper after the first submission and finalising the paper.
ST was involved in creating case studies that were subsequently dropped
and commented on the overall revisions.
Declaration of interests
We declare no competing interests.
Acknowledgments
The work on this paper was supported partly through a grant from the Bill
& Melinda Gates Foundation (OPP1042500) and additional support from
ICS Integrare, the University of York, and the University of Dundee.
Julie Glanville from the York Health Economics Consortium contributed
to the literature searches, and the Midwives Information and Resource
Service (MIDIRS) supported the search work. PtH-B’s work was supported
by the Instituto de Cooperación Social Integrare. The funding
organisations had no role in the undertaking of the analysis and synthesis
of the findings of this report. The findings and conclusions in this report
are those of the authors and do not necessarily represent the official
position of their employers. Jenny Brown and Tracy Sparey provided
administrative support, and Natalie Muir provided project support. We
thank the close readers and colleagues who made helpful contributions:
Hamid Ashwal, Hilda Bonilla, Mickey Chopra, Bernadette Daelmans;
Frances Day-Stirk, Eugene Declerc, France Donnay, Soo Downe;
Elizabeth Goodburn, Wendy Graham, Isaline Greindl, Caroline Homer,
Louise Hulton, Peter Johnson, Fran McConville, Blerta Maliqi, Liz Mason,
Matthews Mathai, Remo Meloni, Nester Moyo; Mary Renfrew,
Arul Sabaratum, Kate Somers, Kate Teela, and Veronica Walford.
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MIDWIFERY_REVIEW_2006.pdf (accessed Dec 6, 2013).
103 Liljestrand J, Moore J, Tholandi M. Active management of the third
stage of labor and eclampsia management as critical components of
skilled care during birth in Cambodia. Int J Gynaecol Obstet 2010;
111: 188–89.
104 Eng S, Rathavy T, Krasovec K, Liljestrand J. Quality of maternal and
newborn health care in Cambodian hospitals in 2011, 2012 and 2013.
University Research Corporation, Phnom Penh. In press, 2014.
105 Bulatao A, Ross J, Ketsana. C. Ratings of maternal and
neonatal health programs across developing countries.
Cambodia’s ranking (Reproductive and Child Health Alliance Studies:
Number 12). Phnom Penh, Cambodia, 2001.
106 Koblinsky M, Matthews Z, Hussein J, et al. Going to scale with
professional skilled care. Lancet 2006; 368: 1377–86.
107 Koblinsky M. Reducing maternal mortality: learning from Bolivia,
China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe.
Washington DC, USA: The World Bank, 2003.
108 Muffler N, El Hassane Trabelssi M, De Brouwere V. Scaling up
clinical audits of obstetric cases in Morocco. Trop Med Int Heal 2007;
12: 1248–57.
109 Soura Y, Lankoande J, Siho N, Ouedraogo C, Zigani C, Richard F.
Rapport de mission atelier regional sur les audits des deces maternels
et des cas de morbidites maternelles et neonatales graves. Ouidah,
Burkina Faso, 2005.
110 Bowser D, Hill K. Exploring evidence for disrespect and abuse
in facility-based childbirth report of a landscape analysis.
Washington DC, USA: USAID, 2010.
111 Jaffré Y, Olivier de Sardan J. Une médecine inhospitalière: les difficiles
relations entre soignants et soignés dans cinq capitales d’Afrique de
l’Ouest [Inhospitable medicine: difficult relations between carers and
cared for in five West African capital cities]. Paris, Karlhala, 2003.
 Series

Midwifery 4
Improvement of maternal and newborn health through
midwifery
Petra ten Hoope-Bender, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S E Homer, Holly Powell Kennedy,
Zoe Matthews, Alison McFadden, Mary J Renfrew, Wim Van Lerberghe

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for Published Online
quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice June 23, 2014
http://dx.doi.org/10.1016/
of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible S0140-6736(14)60930-2
in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and
This is the fourth in a Series of
newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, four papers about midwifery
alongside necessary increases in universal coverage. In this report, we propose three priority research areas and Instituto de Cooperación Social
outline how national investment in midwives and in their work environment, education, regulation, and management Integrare, Barcelona, Spain
can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international (P ten Hoope-Bender MBA,
J Campbell MPH); UN
goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.
Population Fund, Geneva,
Switzerland (L de Bernis MD);
Introduction to make services for maternal and newborn health School of Health, University of
This is the final paper in a Series in which we provide available and ensure that they are used and of high Central Lancashire, Preston, UK
(Prof S Downe PhD); Holistic
evidence (analyses of systematic reviews, case studies, quality. We highlight research priorities to generate
Santé, Montpellier, France
analysis, and modelling of deaths averted) for the better evidence and suggest practical steps for all (V Fauveau PhD); Norwegian
contribution of midwifery to the survival, health, and countries to move towards people-centred9 and woman- Agency for Development
wellbeing of childbearing women and newborn infants. centred10 care, which includes the baby, the family, the Cooperation, Oslo, Norway
(H Fogstad MHA); Faculty of
We present the Series from the perspective of what partner, and others identified by the woman. In the final Health, University of
childbearing women need and want for themselves and part of the article, we discuss how achievement of Technology, Sydney, NSW,
their newborn infants—to be healthy, safe, supported, universal, effective coverage of high-quality maternal and Australia
respected, and to give birth to a healthy baby that can newborn care is of central importance to primary health (Prof C S E Homer PhD); Yale
School of Nursing, New Haven,
thrive. To meet these needs is a crucial element in care and the broader agenda for global health. CT, USA (Prof H P Kennedy PhD);
realisation of the right for all people to have the highest Recognising the diversity of care providers across University of Southampton,
attainable standard of health. In the Series, we discuss the countries, the contributors of the other reports in this Southampton, UK
values, philosophy, and health system functionality Series6–8 examine both midwifery and the people who (Z Matthews PhD); Mother and
Infant Research Unit, School of
needed to deliver high-quality maternal and newborn provide that care (midwives and others). This Nursing and Midwifery, College
care. The evidence shows that increases in crude consideration has allowed an examination of the evidence of Medicine, Dentistry and
population coverage of services alone do not guarantee base that distinguishes between what care is needed, Nursing, University of Dundee,
high-quality care or a reduction in maternal and newborn how it is provided, and who should provide it, and Dundee, UK (A McFadden PhD,
Prof M J Renfrew PhD); and
morbidity and mortality. Therefore, policies should thereby it can offer essential information to educators, WHO Regional Office for
address improvements in coverage and quality at the regulators, health system planners, and decision makers Europe, Copenhagen, Denmark
same time—both are equally important. This balance is (panel 1). (Prof W Van Lerberghe PhD)
the concept of effective coverage1–4 (the proportion of the The article by Van Lerberghe and colleagues6 provides a Correspondence to:
population who have need of an intervention and receive review of four countries’ efforts (Burkina Faso, Cambodia, Petra ten Hoope-Bender,
Instituto de Cooperación Social
that intervention with sufficient quality to be effective, Indonesia, and Morocco) over the past three decades to Integrare, Barcelona 08007,
and benefit from it4,5). Women’s use of midwifery services improve maternal and newborn survival and health Spain
should be supported, more should be done to meet through investment in midwives and strengthening of petra.tenhoope@integrare.es
women’s needs, and improvements should be made in other aspects of their health systems. In all these
the quality of care received by women and newborn countries, a combination of system changes and
infants. Progress in all three areas is needed to obtain a initiatives were used to achieve sustained reductions in
comprehensive health gain.5 maternal and newborn mortality. The article shows a
In this paper, after briefly summarising the other three recurrent sequence of events, beginning with the
papers in the Series,6–8 we discuss the lessons learned expansion of networks of health facilities, then the
from efforts to improve the coverage and quality of scaling up of education and deployment of midwives and
maternal and newborn care and then identify actions reductions in financial barriers, and, finally,
that are necessary, urgent, and feasible to improve the improvements in quality of care. In every case, access
health and wellbeing of women, newborn infants, and issues (expansion of networks and workforces; reductions
children. Proactive and substantial changes are needed in financial barriers) were addressed well before concerns

www.thelancet.com 49
 Series
Key messages
• Provision of accessible quality midwifery services that are
responsive to women’s needs and wants should be part of
the design of health-care service delivery and should inform
policies related to the composition, development, and
distribution of the health workforce in all countries
• Efforts to scale-up quality maternal and newborn care should
include effective measures to identify and tackle systemic
barriers to high-quality midwifery—eg, the low status of
women, interprofessional rivalries, poor understanding of
midwifery care and what it can do, and unregulated private
sector maternal and newborn health care
• To recognise and enable the important contribution of
midwifery to improve health in both mothers and newborn
infants is important for national, regional, and global health
programmes, initiatives, and institutions
• Midwifery can lead to positive health outcomes, especially
in settings in which midwifery services are valued and
respected, community-based, and integrated effectively
into a functioning health system
• Expansion of equitable coverage and improvements in the
quality of midwifery care will be challenging for many
countries, especially those in which the number of births per
year is projected to rise
• Women and communities should be included in decision
making to improve midwifery services
• Midwifery care can be cost effective, affordable, and
sustainable; national governments should invest in
deploying midwives and national health plans should have
a strategy to scale-up midwifery
• More investment is needed (by countries and development
partners) in relevant research and routine collection of data
for quality maternal and newborn care and on the
reproductive, maternal, and newborn health workforce
• The coverage and quality of midwifery care should be
monitered regularly and be used to hold stakeholders,
including providers and programme managers, accountable
about quality of care were noted by health system
developers. Government responses to quality of care
included improvements in technical standards,
competencies, and equipment, and carrying out
systematic death and near-miss audits. The experience of
the four countries confirms that, when systems are
consistently strengthened over a long period of time,
investment in midwives is a realistic and effective
strategy to reduce maternal mortality, including in
resource-constrained contexts. However, the time lag
between expansion of coverage and improvement in
quality, and these improvements being limited to
technical dimensions and essential interventions, is
concerning. In these selected countries, and in many
others, a substantial gap exists between the attributes of
quality care and the realities on the ground. Indeed, in
some countries, decision makers are only now starting to
50 www.thelancet.com
Panel 1: Definitions used for midwifery and midwives
In this Series, we define the practice of midwifery as: “skilled,
knowledgeable and compassionate care for childbearing
women, newborn infants and families across the continuum
throughout 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.”
The International Labour Organisation11 describes midwives
as the primary professional group to provide midwifery.
The International Confederation of Midwives12,13 defines the
midwife, as well as core competencies and standards for
education and practice as: “A midwife is a person who has
successfully completed a midwifery education programme
that is duly recognised in the country where it is located and
that is based on the International Confederation of Midwives’
(ICM) Essential Competencies for Basic Midwifery Practice
and the framework of the ICM Global Standards for Midwifery
Education; who has acquired the requisite qualifications to be
registered and/or legally licensed to practise midwifery and
use the title midwife; and who demonstrates competency in
the practice of midwifery”.
We define reproductive, maternal, and newborn care as the care
provided to girls, women, and newborn infants during
pre-pregnancy, pregnancy, and birth, the post-partum period,
and the postnatal period, and through to the early weeks of life.
become aware of the multiple dimensions of quality—
ie, the technical (competencies, equipment), the inter-
personal (respectful, responsive, inclusive care), and the
organisational (facilities, referral mechanisms).
Using analyses of what women and infants need, and
recognising that the midwifery care that women and
newborn infants need can be provided by a diverse
workforce composed of midwives and others, Renfrew
and colleagues7 define the key aspects of quality maternal
and newborn care. These features include: provision of
preventive and supportive care and effective treatment
for problems when they arise; respect for women and
newborn infants and being responsive to their needs,
including those for safety, privacy, and dignity; use of
interventions only when they are indicated; and
strengthening of the capabilities of women to care for
themselves and their infants. The contributors propose
an evidence-based framework for quality maternal and
newborn care, which expands the notion of quality of
care from the conventional technical dimensions of what
is done, to include how, where, and by whom this care is
provided. The framework shows a balance between
preventive and supportive care, in addition to elective
 Series

and emergency care, and allows for continuity of both
the care and the caregiver from community to facility
settings. The report proposes a shift from a system that
focuses on identification and treatment of disease and
disorders to a system of skilled care for all (figure 1).
The report by Homer and colleagues8 uses the Lives
Saved Tool14 to model the potential effect of scaling up
essential interventions for reproductive, maternal, and
newborn health15 that are within the competencies of the
midwife.13 Findings show that scaling up midwifery
could help reduce adverse health outcomes, even in
resource-constrained environments, and could be
implemented with successful outcomes at any stage of a
country’s transition to lower maternal and newborn
mortality rates. Policy makers can use this paper as a
guide to strengthen the efficiency and effectiveness of
their services for reproductive, maternal, and newborn
health and to measure how they affect outcomes.
The scope of midwifery practice combines both
technical interventions and family planning, providing a
substantial return on investment that is enhanced
further by appropriate and timely referral to specialist
care. In low-resource settings, as an example, the model
predicts that, compared with present baseline estimates,
and over 15 years, a 10% increase in coverage (every
5 years) of interventions (including family planning)
given by midwives would lead to a 27% drop in maternal
mortality. A 25% increase from available baseline
estimates would lead to a 50% reduction of maternal
mortality, and 95% coverage would prevent 82% of
maternal deaths. The effect on reductions of stillbirths
and newborn infant deaths would be similarly great. In
Malawi (which has a population of slightly less than
15 million people and a maternal mortality ratio of 460
per 100 000 livebirths16) a 10% increase in coverage every
5 years would reduce maternal deaths from 4500 per year
in 2010 to 1200 per year in 2025, fetal deaths would
decrease from 27 500 to 7200, and newborn infant deaths
would fall from 30 000 to 8000. A list of modelled deaths
averted for the 78 countries is available in the online
appendix for the paper by Homer and colleagues.8
In their paper, they suggest that there is unexploited
potential to improve outcomes for women and newborn
infants through collaborative practice17 of health-care
professionals working along the continuum of care,
provided that there are accessible health services,
provisions for communication and transportation, and
no financial barriers.
Towards effective coverage of maternal and
newborn health care
In many countries, multiple health-care professionals,
such as doctors, midwives and nurses, are engaged in
services for reproductive, maternal, and newborn health,
and supported by auxiliary health staff, and community
health workers. To ensure continuity and quality of care,
their varied competencies and expertise should be brought
together into an interprofessional practice-ready team.
Health-care professionals working together with local
providers can increase the reach of the health system, thus
combining coverage with quality of care. Midwives,
provided they are well educated and supported, possess
the competencies across the reproductive, maternal and
newborn health continuum and are both a connector
across and a driving force behind that continuum.18,19
Scaling up the contribution of midwives to the expansion
of available reproductive, maternal, and newborn health
care is a strategic option of great appeal for policy makers.

For all childbearing women and infants For childbearing women and infants
with complications

Education Assessment Promotion of normal First-line Medical

Information Screening processes, prevention management obstetric
Practice categories Health promotion Care planning of complications of complications neonatal
services

Available, accessible, acceptable, good-quality services—adequate resources, competent workforce

Organisation of care
Continuity, services integrated across community and facilities

Respect, communication, community knowledge, and understanding

Values
Care tailored to women’s circumstances and needs

Optimising biological, psychological, social, and cultural processes; strengthening woman’s capabilities
Philosophy
Expectant management, using interventions only when indicated

Practitioners who combine clinical knowledge and skills with interpersonal and cultural competence
Care providers
Division of roles and responsibilities based on need, competencies, and resources

Figure 1: The framework for quality maternal and newborn care: maternal and newborn health components of a health system needed by childbearing
women and newborn infants
Used from Renfrew and colleagues,7 the first report in this Series.

www.thelancet.com 51
 Series
The effectiveness of midwives is evident in the countries
documented in this Series6 and by modelling of the
potential effect of technical interventions that are in
midwives’ scope of practice.8 The health and social effect
of scaling up the contribution of midwives would be
enhanced further through fuller attention to the other
dimensions of the framework for quality maternal and
newborn care—ie, optimisation of normal processes of
reproduction and early life; continuity of care; and
competent, caring, and trustworthy care providers.
However, the challenges for implementation of the
framework for quality maternal and newborn care are
substantial in low-income and middle-income countries
with high maternal and newborn mortality, incomplete
service delivery networks, and insufficient human
resources. Additionally, inefficiencies can occur when
midwives and other health cadres are not given the
chance to practise to their full competence. Sub-Saharan
Africa, where the number of pregnancies and births per
year will continue to rise,20,21 is of particular concern, in
view of the projected deficits in the health workforce to
meet increasing demand.22–24 According to the medium
scenario in UN Population Projections,20 the number of
births will grow from 11 million in 2010 to 16·8 million
in 2035. The extent of the challenge is shown by the 14
sub-Saharan countries with high maternal mortality that
have available trend data on the midwife-share of
assistance at childbirth. In 2009–10, 71 243 midwives and
nurse-midwives in these countries attended an average
of 42 births per year (3 million in total), resulting in a
coverage of 27%.19 Although this figure is nearly 1 million
more than the 2·1 million births attended by midwives
in the early 1990s in sub-Saharan Africa,25 this increase
in service provision is not sufficient to keep up with the
demographic growth. Improvements in effective
coverage while midwives work with this additional
workload will not only need an accelerated expansion of
the number of full-time equivalent midwives (the
workforce stock), but will also need substantial increases
in their productivity. No golden standard exists to
measure health workforce productivity and determine
staffing requirements,26 but for the purpose of the
challenge, we use the number of births per year attended
by a midwife (figure 2).
At present levels of productivity, a doubling of the
number of midwives by 2035 (a net increase of nearly 3%
per year) would achieve only 36% coverage. Coverage of
75% of births in 2035 would require an increase of stock
to 299 661 full-time midwives—a net growth of nearly 6%
per year. Without an expansion in the number of
midwives, productivity would have to increase to an
average attendance of 175 births per midwife per year
(the current WHO benchmark27) to achieve 75% coverage,
which could exceed the available working time of a
midwife for health service activities,28 restrict the care
provided to attendance in labour and birth, and
compromise woman-centred quality care.
52 www.thelancet.com
In the report State of the World’s Midwifery 201429 new
calculations based on data from many countries make it
possible to refine staffing requirements in relation to
women’s needs for the continuum of maternal and
newborn care.
Investment in education alone will not suffice and will
have to be combined with investment in regulation,
effective human resource management, and the service
delivery environment in which future midwives will
work, so that they will not only be able to cope with the
increased workload, but will also ensure quality clinical
and psychosocial care. More evidence is needed to inform
effective ways of scaling up the midwifery workforce:
education, regulation, in-service training, career
progression, deployment, and retention and increasing
of the quality, relevance, and productivity of midwives
across public, private, and not-for-profit sectors. Three
priority research areas are of interest.
First, better evidence is needed about labour mobility—
the recruitment, posting, and transfer of staff to remote
and underserved areas; how to measure and improve
staff deployment and retention; and how to ensure that
the net increase in the number of midwives matches
increases in demand in rural and urban areas. New
thinking on posting and transfer is emerging30 and
WHO31 guidelines are available for recruitment and
retention of health workers in rural and remote areas.
New technologies allow for the identification of
subnational geographical differences in the supply of
and demand for maternal and newborn health services;
information that is essential to identify and address
inequities in access to these services.32–34 Disaggregated,
locally driven data are also important to inform
appropriate strategies for labour mobility and effective
coverage.
Second, a better appreciation of productivity is needed.
Assessment, understanding of, and improvements in
productivity is an area of increased interest that is partly
based on health labour market studies22,35,36 and new
initiatives for results-based or performance-based
financing but is also associated with discrepancies
between health-care providers’ knowledge, behaviours,
and skills (competence); what they personally can or
cannot do (capacity); and what they ultimately do
(performance).37 A deeper understanding is needed of
the productivity of the midwifery workforce, maternity
units, and the models of practice, such as midwifery led
care38 and collaboration with traditional birth attendants
and community health workers that can drive gains in
efficiency in low-income and middle-income countries.
However, any work in this area must be careful not to
lose sight of the essential need to prioritise delivery of
quality of care over simple economics.
The 2005 WHO benchmark of attendance of 175 births
per midwife per year27 is a frequently used productivity
benchmark for workforce planning and projections.
However, this figure, which is well above the current

average of 42 in sub-Saharan Africa, needs to be refined
to allow for greater sensitivity in subnational settings and
contexts so that future guidance can propose a range of
estimates that meet women’s needs throughout pre-
pregnancy, pregnancy, birth, and post-partum and
postnatal care, in remote, rural, peri-urban, and urban
areas. Also needed is a set of effective implementation
strategies that both enhance productivity and are
compatible with the framework for quality maternal and
newborn care for health services provided by teams in
facilities and close to the community.
Third, rising demand in a tight labour market is likely
to accelerate the commercialisation of childbirth. The
rapid growth of private sector for-profit maternity
services, insufficient regulatory mechanisms, and
informal fee-for-service payments39 are examples of
policies and practices that lead to overmedicalisation. To
address the social and economic mechanisms underlying
the commercialisation of childbirth has not been at the
top of the agenda for maternal and newborn health
research, policy, and practice development over the past
three decades. The development of adequate strategies to
manage increasing commercialisation needs a better
understanding for emerging trends and feasible options
that will mitigate the adverse effects of commercialisation
and tackle the resulting inequalities.
Improvement of the quality of maternal and
newborn health care
Over the past decade, the primary health-care movement
has fully recognised the importance of people-centred
care,39 whereas within maternal and newborn health, the
main focus has been on life-saving interventions and
increases in coverage. This difference has led to the
quality agenda for maternal and newborn health only
now starting to emerge. Attention to quality of care has
been shown in documentation about the sometimes
difficult relationship between care providers and
women,40,41 which can result in disrespect, abuse, and
abandonment of care. But these situations are often
symptoms of deeper health system problems,42 rather
than simple measures of poor quality, and their
documentation has not led to coherent political strategies
to address these issues. In high-income countries, quality
of care often focuses on informed choice without
addressing the other aspects of the framework for quality
maternal and newborn care, resulting in a focus on
relatively quick-fix technical solutions while little
attention is paid to the more difficult longer-term
building of systems that include preventive care and that
uphold the appropriate provider values and attitudes
needed to deliver it.
Even in situations in which the health system provides
adequate and appropriate facilities, workforce,
equipment, and drugs, high-quality reproductive,
maternal, and newborn health care might still not be
good enough. Research done in facilities with at least
www.thelancet.com 53
Series
175
150
To maintain 2009 coverage
100
42
Births per midwife per year
175
150
To rise to 50% coverage
100
42
175
150
100
To rise to 75% coverage
42
0 50 000 100 000 150 000 200 000 250 000 300 000
Number of midwives
Figure 2: Projected number of midwives needed to achieve specified coverage levels by 2035 in
14 sub-Saharan countries made under various assumptions of midwifery productivity
The countries included are Benin, CÔte d̓Ivoire, Ghana, Kenya, Madagascar, Malawi, Mali, Namibia, Niger,
Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Midwifery productivity is identified as births attended
per midwife per year.19 At present, there are an average of 42 births per midwife per year in sub-Saharan Africa.
1000 births per year across Africa, Asia, Latin America,
and the Middle East noted that a high coverage of
essential interventions alone did not reduce maternal
mortality.43 Maternal mortality was only reduced in
facilities that combined essential interventions with
comprehensive emergency care and made overall
improvements in the quality of maternal health care. The
contributors concluded that, in facilities in which the
workforce and enabling environment were present,
mortality remained high when interventions were
delayed or poorly implemented or when they did not
form part of a continuum of care.
To deliver high-quality care, health professionals and
policy makers need to create an environment in which
the 72 effective midwifery interventions identified in this
Series7 can be implemented consistently with the woman-
centred values and philosophy outlined in the framework
for quality maternal and newborn care,7 43 (60%)
of 72 interventions show a need to optimise the normal
processes of reproduction and early life to avoid
complications and to strengthen women’s capability to
take care of themselves and their families. This change is
likely to have important economic effects, potentially
reducing health spending, and increasing the
sustainability of maternity care systems in the longer
term. Education of health-care professionals and efficient
regulation of practice are important components to make
that environment possible, but it is also important to
create partnership and dialogue between care providers
and with care users and communities. The framework
for quality maternal and newborn care provides evidence-
based guidance to help to adjust education and regulation
to the needs of such a collaborative environment.
All countries face challenges in provision and
measurement of quality maternal and newborn health
care. The medicalisation of childbirth44 is increasing in
most countries. In lower-income countries, pregnancy
 Series
and childbirth are slowly moving from a normal life
event to a medicalised intervention. As in many high-
income countries, care is also becoming more
medicalised, resulting in similar shortcomings in quality.
Experience from some high-income and middle-income
countries, as discussed in other papers in this Series,7
shows the importance of using a framework such as the
framework for quality maternal and newborn care to
strengthen the quality of services and service providers
and to ensure that all aspects of quality care are monitored
and addressed.
In low-income and middle-income countries, there are
signs of increasing user expectations for high-quality,
safe care during pregnancy and childbirth. Individual
Panel 2: Pragmatic actions to improve the coverage and quality of maternal and
newborn care through midwifery.
• Regularly discuss and refocus the package of care and the quality (technical capacities,
interpersonal relationship capacities, and ability of health systems to create the
enabling environment) that reproductive, maternal, and neonatal health teams
provide using the framework for quality maternal and newborn care.
• Involve women, families, and communities in the design and delivery of quality
maternal and newborn care.
• Ensure that education covers all the elements of the framework for quality maternal
and newborn care and is taught to all providers of reproductive, maternal, and
neonatal health care. Ensure that there is a balance between theory and practice so
that midwives can be fully functional in all contexts as soon as they graduate. Ensure
effective interdisciplinary education at all stages (pre-service and in-service), which is
likely to result in a stronger integrated team for quality maternal and newborn care,
decrease professional silos, and improve collaboration along the continuum of care.
• Use the framework for quality maternal and newborn care and its evidence base to
identify, analyse, and solve problems in service provision and to strengthen regulation
and legal frameworks used across reproductive, maternal, and neonatal health teams
that promote and support collaborative practice and accountability.
• Undertake regular midwifery workforce assessments and reorganise the health system
so as to ensure available, accessible, acceptable, and good-quality maternal and
neonatal health services.
• Make the necessary health system and regulatory changes for midwives to work to
their full capacity and to carry out all the basic emergency obstetric and newborn care
functions as close to women as possible without compromising the quality of care.
Those functions include prescription authority for essential medicines.
• Ensure that midwives have effective back-up when needed and that they are part of a
collaborative team of health-care professionals to provide the continuum of care
along the reproductive life cycle and from home to hospital. Midwife-led units that
work closely with communities and community health workers are an effective
mechanism to bring health systems closer to people.
• Secure a fully enabled environment, including functioning facilities and equipment,
effective communication, and transportation for women and newborn infants in
need, in addition to an efficient recruitment and retention of staff, an appropriate
living wage, supportive supervision, and professional and career development
opportunities.
• Test and develop the effectiveness of reproductive, maternal, and newborn health
services with use of indicators such as rates of intrapartum stillbirth, early neonatal
mortality, and maternal death surveillance and response mechanisms to monitor the
quality of care and to guide and measure progress.
54 www.thelancet.com
and community drivers (eg, local opinion about facility
birthing, experience at facilities by other members of the
community, absence of equipment and drugs, and a bad
reputation for interpersonal relations) are strong
influences on people’s decisions about choice of birthing
facility, with patients bypassing nearby facilities in favour
of those with a better reputation further away. A recent
study showed that the quality of care in bypassed clinics
was indeed worse.45 This finding led to suggestions that it
would be more efficient to invest in making birthing
services available at a level at which quality care can be
provided, rather than to provide care unconditionally at
community level.46
Countries across a wide geographical and income
range have reduced maternal and newborn mortality by
offering more effective services. Several countries have
tackled the entrenched financial and health system
barriers to midwifery services and attempted to solve
fragmentation of the scope of midwifery among different
cadres, but most countries are still contending with
ineffective policy environments for quality maternal and
newborn care, the low status of women,47–49 and the
domination of midwifery by medicine.50,51 Countries are
showing a trend towards increased service provision by
doctors, which, in some countries, has led to a significant
reduction in the number of practising midwives51 and
increased medicalisation of pregnancy and childbirth.
Professional education is core to increases in the
quality and coverage of quality maternal and newborn
care.52 WHO guidelines53 on transformative education
targeted to low-income and middle-income countries,
emphasise that both pre-service and in-service health
professional education must increase the quantity,
quality, and relevance of future providers for them to
meet the needs and expectations for population health.
New ideas and avenues need to be explored to produce a
workforce that is fit for purpose24 and regulated to enable
their full scope of practice to contribute to the effective
delivery of quality maternal and newborn care.
What midwifery can contribute to effective
coverage and woman-centred agendas
Midwives, when working to the framework for quality
maternal and newborn care and within an enabled
environment, have the potential to bring care close to
women and communities and tailor it to their social
and cultural needs. As this Series shows, midwives can
optimise the normal processes of reproduction and the
early years of life, and still ensure the identification and
management of complications before they become life
threatening and to refer women when necessary.
Results from the reviews of systematic reviews done in
this Series7 show that midwifery, as defined in this
Series, can result in a decrease in maternal and
newborn mortality, stillbirths, perineal trauma,
instrumental births, intrapartum analgesia and
anaesthesia, severe blood loss, preterm births, newborn

infants with a low birthweight, admissions to neonatal
intensive care units, and hypothermia. The analyses
also reported that midwifery can result in increases in
spontaneous onset of labour, numbers of unassisted
vaginal births, and incidence and prevalence of
breastfeeding. Importantly, women reported a higher
rate of satisfaction with care in general, particularly
with pain relief. Panel 2 presents some essential actions
in the areas of education, regulation and team
development that can be initiated immediately to
increase women’s access to midwifery services and
quality maternal and newborn care.
Evidence has been established for the potential gains
for quality care being given closer to women and
communities.54 New approaches to identify students from
rural locations will enable this goal, and it will be key for
students from the community to be retained in that
community.55,56 Evans57 reviewed the community-based
midwifery diploma programme in Bangladesh and
showed that a hub-and-spoke model of midwifery
education reduced the cost per midwifery student per
year to a third of the cost of traditional education models.
The return on investment predicted from the deployment
of additional midwives in rural communities in which
maternal and newborn health needs are greatest includes
increases in the number of lives saved, decreases in
morbidity, and reductions in the number of caesarean
sections. The assessment identifies the return on
investment from the education and deployment of
community-based midwives as similar to the cost per
death averted by vaccination—known in public health as
one of the most cost-effective ways to save lives.58
Target year Actions or targets
Stillbirths (2011) 2020
Preventing early pregnancy and poor ··
reproductive outcomes among
adolescents in developing countries
(2011)
Global Plan Towards the Elimination of 2015
New HIV Infections Among Children by
2015 and Keeping Their Mothers Alive
(2011)
Family Planning 2020 (2012) 2020
A Promise Renewed (2012) 2035
Ending Preventable Maternal Mortality 2030
(2013)
Every Newborn Action Plan (2014) 2035
Framework of Actions for the follow-up ··
to the Programme of Action of the
International Conference on Population
and Development Beyond 2014 (2014)
Table: Guidelines and global actions and targets in reproductive, maternal, newborn, child, and adolescent health59–66
www.thelancet.com 55
Series
High-quality maternal and newborn care:
a global health priority
People-centred care that recognises people’s legitimate
right to and expectations for equitable, high-quality, safe,
and respectful care should be a global health priority and
be put at the heart of the movement to improve maternal
and newborn care. Midwifery is a vital solution to the
challenges of providing high-quality maternal and
newborn care for all women and newborn infants, in all
countries. Improvements in availability, accessibility,
acceptability, and quality of midwifery services, within a
functioning health system that is responsive to women’s
needs and requirements, is crucial not only to accelerate
efforts to attain the Millennium Development Goals
(MDGs) by 2015, but also to the development of the
post-2015 agenda’s goals and targets, in which emphasis
on reduction in maternal and newborn morbidity should
be even stronger than it has been in the past.
Available guidelines and global initiatives for
stillbirths,59 family planning,60 maternal,61 newborn,62
child,63 and adolescent64 health, HIV/AIDS,65 and non-
communicable diseases66 are opportunities to promote
the widespread adoption of the framework for quality
maternal and newborn care proposed in this Series. This
approach to midwifery is an effective solution to enable
the achievement of these ambitious targets. Countries
urgently need to put policies in place that allow for its
implementation (table).
The health workforce has long been recognised as
crucial to improvements in health outcomes.67,68 The
2013 report A Universal Truth: No Health Without a
Workforce24 re-emphasised this notion. Unfortunately,
For countries with a stillbirth rate of more than five per 1000 births, reduce stillbirth rates by at least
50% from 2008 rates; for countries with a stillbirth rate of less than five per 1000 births, eliminate
all preventable stillbirths and close equity gaps
To improve adolescent morbidity and mortality by reducing the chances of early pregnancy and its
resulting poor health outcomes:
Reduce pregnancy before age 20 years
Increase use of contraception by adolescents at risk of unintended pregnancy
Reduce unsafe abortion in adolescents
Increase use of skilled antenatal, childbirth, and postnatal care in adolescents
Estimated number of new HIV infections in children reduced by at least 85% in each of the 22 priority
countries; estimated number of HIV-associated pregnancy-related deaths reduced by 50%
To make available affordable lifesaving contraceptive information, services, and supplies to an
additional 120 million women and girls in the world’s poorest countries by 2020
All countries to lower child mortality rates to 20 or fewer deaths per 1000 livebirths by 2035
Proposal at consultation: to reduce maternal mortality ratios to less than 70 deaths per 100 000
livebirths by 2030
Proposal at consultation: to reduce neonatal deaths to less than 10 deaths per 1000 livebirths and
to reduce stillbirths to less than 10 per 1000 total births, by 2035, with interim targets for 2030
States should remove legal, regulatory, and policy barriers to sexual and reproductive health services
for adolescents, and ensure information and access to contraceptive technologies, prevention,
diagnosis, and treatment for sexually transmitted infections and HIV, including the human
papilloma virus vaccine, and referrals to other health concerns such as mental health problems
 Series
progress made in the midwifery workforce has not been
sufficient in the almost 30 years of the Safe Motherhood
and Making Pregnancy Safer initiatives to enable the
attainment of MDG 4 and MDG 5 in all countries by
2015. Horton69 argues that the lack of a skilled health
workforce is failing women badly, and that this failure is
now the biggest obstacle to improvements in women’s
and children’s health. The independent Expert Review
Group on Information and Accountability for Women’s
and Children’s Health70 calls for quality of care to be a
route to equity and dignity for women and children and
to make health-care professionals that serve women and
children with measureable effect count. Langer and
colleagues,71 in A Manifesto for Maternal Health Post 2015,
call for “universal access…to properly trained health
individuals, especially midwives and those providing
midwifery services”. The global consultation for the
Every Newborn Action Plan62 includes several calls to
strengthen the role of the midwife.
The Lancet Commission on investing in health72 shows
that the return on investment in health is large, and that,
with the technical and financial capacities available
worldwide, it is possible to lower mortality rates to the
levels of the best performing middle-income countries by
2035. This grand convergence can be achieved through a
focus on infections; reproductive, maternal, newborn,
and child health; and non-communicable diseases with
targeted approaches not only in low-income countries,
but also in lower-income and rural subpopulations of
middle-income countries. Similarly, WHO, World Bank,73
and WHO Consultative Group on Equity and Universal
Health Coverage74 identify reproductive, maternal,
newborn, and child health; non-communicable diseases;
and injuries as areas that will support the achievement
and measurement of progress towards universal health
coverage. Each of these forward-looking perspectives
focuses on equity and improvements in the effective
coverage of reproductive, maternal, and newborn health
services, especially in the crucial period around
pregnancy, childbirth, and the early weeks of life.75 These
are further justifications that investment in midwifery is
an effective solution to attain MDG 4 and MDG 5 and the
new global targets, provide a basis for primary health
care and universal health coverage, achieve the grand
convergence in global health by 2035, and deliver on
women’s rights to sexual and reproductive health.66
Conclusion
As the 2015 target date for the MDGs draws near, and
attention turns to the post-2015 sustainable development
agenda,76–79 this Series comes at an opportune moment to
support the move towards universal coverage of high-
quality maternal and newborn care. As shown by the
estimates of lives saved through increases in coverage of
the midwifery package of care8 and the experiences of a
few exemplary low-income and middle-income countries
that have invested in midwives,6 use of the framework for
56 www.thelancet.com
quality maternal and newborn care is a means to good
health and improved social outcomes for women, men,
and children.
The momentum is tangible. Reproductive, maternal,
and newborn health are global health priorities.
Economic growth in Africa and southeast Asia creates
opportunities for change, which could make greater the
return on investment in quality maternal and newborn
health care. However, many of the commitments that
have been made to Every Woman Every Child by
countries and development partners still only relate to
provision of medical interventions for life-threatening
complications. But essential medical interventions only
cover a fraction of the needs of women and their
families and miss the opportunity to prevent the
occurrence of such life-threatening situations. The
midwifery package of support and care is an efficient
and effective way to optimise normal reproductive
processes, improve health and psychosocial outcomes,
and strengthen the capabilities of women and their
communities in all countries.
The high-quality maternal and newborn care described
in this Series should be at the heart of all subnational,
national, regional, and global efforts to improve women’s
and children’s health and wellbeing, and it needs a core
position within the post 2015 agenda. The knowledge
and methods are available to achieve quality maternal
and newborn care. Political will and commitment are
increasing, women’s and families’ voices are growing
louder, and economic growth and education for girls are
on the rise. The opportunity to transform health,
education, and social systems and to make maternal,
newborn, and child health a reality for all, is here.
Contributors
PtH-B prepared the first draft. All co-authors, except WVL and VF,
contributed sections to that draft and reviewed the paper. PtH-B, WVL,
and JC further developed the second draft. All co-authors contributed to
the further development, revision, and finalisation of the paper. All
authors approved the final version.
Declaration of interests
We declare no competing interests.
Acknowledgments
The work on this paper was supported partly through a grant from the
Bill & Melinda Gates Foundation (grant number OPP1042500). The
findings and conclusions in this report are those of the authors and do
not necessarily represent the official position of their employers or the
Bill & Melinda Gates Foundation. MJR’s work was supported by the
University of Dundee. PtH-B’s work was supported by the Instituto de
Cooperación Social Integrare. Maria Guerra Arias managed and checked
all the references. Thomson Prentice edited sections of the first draft.
Joanne McManus edited the second draft. Administrative support was
provided by Jenny Brown and Tracy Sparey, and Natalie Muir provided
project support. We thank all series co-authors, close readers, and the
reviewers from ICM, FIGO, WHO, and the Bill & Melinda Gates
Foundation for their contributions and support.
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