Why midwives alone are not enough

Talking to midwives from across Ethiopia and Kenya about the challenges and triumphs of being a clinician, the conversation often turned to where to go next (Box 1). Although there have been considerable steps taken over the recent decades to reduce maternal, neonatal and child mortality and morbidity (Alkema et al, 2016), there is still some way to go. Across eastern Africa, many programmes of risk and harm reduction have centred on the training of healthcare professionals, both increasing the skills of those already practising and introducing new positions, such as the community health extension workers (Say et al, 2014). There are proven benefits to such approaches, with research demonstrating a general raised awareness of common health problems, vaccinations, and the importance of public health education (regarding, for example, access to clean water, improved hygiene practices, and adherence to medicine schedules) in the prevention of certain disease outbreaks (Perry et al, 2014). In addition, research has also shown a decreased burden on larger medical facilities, with basic treatment outsourced to community-based health posts (Perry et al, 2014). These are commendable improvements that work. But in the realm of maternal health, the problems run deeper (Say et al, 2014). As midwives have said:

Case study

Southern Nations, Nationalities, and People's Region, Ethiopia

Asku has just given birth to her fourth baby. The baby, a girl, is well. The labour and birth went smoothly. Her family are relieved, relaxed, and praying their thanks. Her midwife, Tsega, is not. She has been quietly waiting for the delivery of the placenta for some time now. It comes, finally, with the expected gush of blood. A gush of blood that doesn't stop. Tsega watches, and still it doesn't stop. Tsega has a vial of oxytocin in the vaccine freezer box, but only one. She is wondering whether to use it now, or wait a little longer. Perhaps the bleeding will arrest with other steps, and she can save the oxytocin.

Tsega travelled to a training course not so long ago on obstetric emergencies. In her mind, she has already rehearsed the management of postpartum haemorrhage, and now she puts it into practice. She massages Asku's uterus, checks that her bladder is empty, assesses for vaginal tearing, rechecks the placenta again to assure completeness, and encourages the baby to the breast. But the bleeding doesn't stop. In her mind, this is no longer postpartum haemorrhage; this is a massive obstetric haemorrhage, and still the bleeding doesn't stop.

Tsega decides to use the oxytocin. She starts an intravenous line in each of Asku's hands, using two of the three bags of fluid she has, but still the bleeding doesn't stop. Asku's uterus simply isn't contracting, and Tsega can't control the bleeding. She is fully aware that Asku needs a transfer, but it has been raining all week, and the roads are inaccessible. The electricity is down, so she hasn't been able to charge her phone, and the ambulance is stationed 80 km away at the nearest hospital. The ending to the story is inevitable: an obstetric emergency, an uncontrollable bleed, and midwife who knows what needs to be done, but can't do it.

While there is no question that having a skilled birth attendant, particularly a midwife, available to attend births goes far in reducing maternal morbidity and mortality, especially in areas with higher levels of obstetric complications (Amouzou et al, 2014), this alone is not enough. Midwives with the training to recognise a rapidly deteriorating situation are then left with one question: what next? Without robust referral systems, adequate transport and roads, and hospitals that are properly equipped and prepared to receive obstetric and neonatal emergent cases, what is the benefit in having detected the problem at all? It is a cruelty to the midwives to train them to recognise a problem, and then leave them alone with the consequences of being unable to alleviate it.

For midwives working in rural areas, especially in countries affected by a rainy season for several months of the year, the isolation, inaccessibility, and remoteness of their posts leaves them in an impossible position. In many obstetric emergencies—from placental abruption to postnatal haemorrhage—time is of the essence. Once a problem has been identified, action needs to be taken. Properly trained midwives are skilled, competent, and knowledgeable practitioners; but they have also chosen a profession that involves significant emotional investment in the health and wellbeing of the women and babies in their care. It is not possible to be a midwife without being emotionally affected by the sheer magnitude of the role you have, to ensure the safe introduction of new life into the world, during one of the most dangerous times in a woman's life.

These two factors in combination leave midwives more vulnerable than other health professionals. In an emergent case, where the life of the mother, the baby, or both, is in jeopardy, it is the midwife's role to act to change the situation. This is where the problem starts: if a midwife is in a village where the roads have turned to rivers in the rainy season; or where just three ambulances serve a population of several hundred thousand people and an area of almost one million kilometres squared; or where the nearest referral hospital (which may or may not have the equipment and medication to receive cases) is more than 6 hours away—what then? How is the midwife, who is more than aware of the devastating likely outcomes of emergency situations under such circumstances, supposed to react? How are they to face a woman—who knows and trusts her midwife—and tell her that everything will be okay, when they know that is unlikely to be the case? The psychological impact of such a situation cannot be understood by anyone, except those who have also been there. For a midwife to hold the hand of a woman and watch her die, knowing that under different circumstances, saving her life would not be so difficult, is an impossible task. In such moments, all the training in the world cannot negate the insurmountable challenges of no way to travel, and nowhere to go.

If the rates of maternal morbidity and mortality are to be reduced further, midwives are not enough. Midwives are the gateway, but alone, they cannot always save lives. To make healthcare safe and accessible, there needs to be road engineers, construction workers, ambulance drivers, medical suppliers, the electricians and plumbers, and a multitude of other professionals. This relies on adequate all-weather roads, enough available transport, and hospitals with consistent access to equipment that are able to adequately manage cases received.

The difficulty comes in where to start. Building an all-weather road is often prohibitively expensive, and a referral hospital even more so. In contrast, training a midwife is relatively affordable, with ‘photo opportunity’ results: a student in an academic gown graduating from college, a village health survey able to tick another box, a certificate hung on the wall of a mud hut. These midwives are then left alone to deal with the consequences of wider global health inequalities, with poorly nourished and poorly educated women accessing their care and no options left when things go wrong. It is therefore a great sadness, and asks too much of midwives who, under such circumstances, have no answer to the question of ‘what next?’