Over the last five years, countries around the world have begun to undertake new initiatives to improve maternal health outcomes through strengthening midwifery care. The 2011 and 2014 State of Midwifery in the World reports, the 2014 and 2016 Lancet series on midwifery and maternal health, and the World Health Organization's 2016 Midwives' Voices, Midwives' Realities, have taken us a long way in recognizing a cadre that has been too long overlooked. The International Confederation of Midwives and its member associations have helped position midwifery as an essential part of reproductive and sexual health services.
We have evidence that midwifery is associated with more efficient use of resources and improved health outcomes, especially in settings where health teams work together and referral systems are robust. The Lancet's case studies on India, Brazil, and China show how promoting facility-based and emergency care can help reduce maternal and perinatal mortality. However, if it is not accompanied by the integral care that midwifery offers, it can also have unintended negative effects. These include an increase in unnecessary, expensive, and potentially harmful interventions, and greater inequality in access to care.
This is where Mexico comes in. While much of the global work has moved forward, an impressive groundswell has taken shape here in response to these issues that has yet to gain recognition by the global community. Now is a good time to call it to attention.
In 2014 MacArthur bolstered its nearly 30 years of support for reproductive and sexual health in Mexico by launching an initiative to strengthen professional midwifery. In Mexico, some 23,000 traditional midwives provide care to less than 3 percent of the nearly 2.4 million births annually. And while there are 16,000 obstetric nurses, most don't have the full range of midwifery skills. As a donor with historic ties to the women's rights and health movements, MacArthur, together with many of its reproductive health grantees, took on the challenge of sparking a paradigm shift toward the woman-centered, respectful care that characterizes the midwifery model. This begins with generating recognition of midwifery as a legitimate and necessary element of maternal and reproductive health care.
Since 2015, the Foundation has supported efforts to promote quality midwifery care through professional training programs, to better integrate midwifery into Mexico's health system, to demonstrate the legitimacy of midwifery, and to establish a regulatory framework that is supportive of midwifery.
MacArthur's initiative is now at the halfway point of its three-year duration, and there are signs of advance, though still much work to be done.
This undertaking requires diverse voices and mobilization at many levels simultaneously. Grassroots organizations in states like Guerrero and Chiapas are working with traditional and professional midwives to generate conditions that will enable professionalization that respects Mexico's great traditions, and that responds to the cultural needs and desires of indigenous women who often lack access to or have reason to mistrust public health services.
Higher up the chain, a handful of state health ministries has developed plans for opening midwifery schools and deploying graduates. The federal Ministry of Health and the United Nations Population Fund are working with states that have taken steps toward the midwifery model of care. With support from their state health ministers, new experiences of midwifery services are blossoming. A competition was launched in coordination with the PanAmerican Health Organization/World Health Organization for states to strengthen local initiatives that incorporate professional midwives. Collective state-level work can bolster and encourage a bolder national position on midwifery.
MacArthur's initiative is now at the halfway point of its three-year duration, and there are signs of advance, though still much work to be done. In 2018, MacArthur will compare the field with its 2015 baseline that documented quantitative indicators - such as the number and quality of training programs and students, or the creation of formal midwifery certification - and qualitative indicators such as health authorities' understanding of and support for professional midwifery, or whether and how different cadres of midwives are advancing toward a clearer vision for their role in health services.
All of this is happening in a country that is suffering tremendous difficulties, from budget cuts to a crisis in human rights violations, violence, corruption, and impunity. This context not only affects health services, it also has negative repercussions on the relationships between civil society and government. It impacts the ability of health officials and providers to challenge the status quo by backing a new model of care that defies the longstanding balance of power between men and women within the health system. While Mexico's problems will differ from those of other countries, despite tremendous challenges, individuals in the right places are moving the needle toward more respectful, better quality health care for women. Bringing these individuals together in a purposeful movement can help strengthen their resolve and increase their likelihood of success. Mexico is already seeing signs of this.
The Foundation shares aspirations with the reproductive health and justice community, and practitioners for building momentum around midwifery to improve the right to health and the quality of care for women.
A version of this post was published on the Maternal Health Task Force blog.
