Sector in Focus: Midwives – Care and Worker’s Rights for the Caregiver

by Angela Nguku, Founder and Executive Director of the White Ribbon Alliance Kenya (WRA Kenya)

Midwives stand with women at every stage of life – providing comprehensive reproductive health, counseling, support services and more. Midwives, too, play the role of advocates of women’s rights since they are exposed to the inequities and inequalities facing women in their day-to-day work and are best placed to voice their clients’ needs to those in power. They are also the most important frontline health worker during the critical period of labor, delivery and post-delivery for a mother, her newborn, and their family.

Data shows that achieving universal coverage of midwife-delivered interventions by 2035 could avert 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths – ultimately saving 4.3 million lives per year. But midwives need a conducive work environment and supportive healthcare team to ensure that the care for women and birthing persons is optimally delivered.

However, these conditions are not always met, especially in low- and middle-income countries, due to the acute human resource shortages for health workforces, limited investment in the profession, and an overburdened health system.  For example, the World Health Organization (WHO) recommends that 1 midwife is available per 175 people, but in Malawi there is 1 midwife per 5,058 people – or a national gap of 20,217 midwives – to provide services to the total population.[1] These shortages mean that working midwives experience high workloads and high exhaustion as they are pressured to care for increasing numbers of women, with less and less time available to do so. This affects midwives’ ability to provide quality services and affects their own right to decent working conditions.

Malawian nurses and midwives advocating for their rights within the healthcare system to be respected, protected and fulfilled during the COVID-19 crisis. (Credit: Newton Kalua, White Ribbon Alliance Malawi.)

Midwives have long faced enormous challenges ranging from poor working conditions, limited resources to deliver needed care, social isolation from their families, and a lack of security and fear of violence – especially for those working in humanitarian settings. In a global World Health Organization report documenting the voices and experiences of 2,470 midwifery personnel in 93 countries, 37% of midwives experienced harassment at work including “verbal bullying and, at times, physical and sexual abuse.”[2] Further, their voices were often dismissed or disregarded – with 36% of respondents noting a lack of respect by senior medical staff[3]. In Kenya, for instance, midwives are dismissed within the health system’s decision-making hierarchy which denies the midwife a recognized place to make life-saving decisions with her client and can delay action at health facilities and lead to fatal results.

Despite their life-affirming role in providing care for women, midwives— a predominantly female workforce— also face persistent and gendered struggles in their economic rights, such as pay inequity, lack of recognition and autonomy in their roles, and a lack of clear career pathway. Midwives are among the least paid healthcare cadre within the health ecosystem of most low- and middle-income countries. Midwives report salaries so low that they sometimes must take up second or third jobs to survive, adding to their exhaustion and pressure.[4] Lack of a career pathway or professional recognition of their roles compounds this pay inequity challenge by preventing them from attaining formally recognized training, accessing positions with higher pay, and having a voice in health system leadership to raise the profile of their work.

The Covid-19 pandemic has exacerbated these pre-existing challenges. With the rise in unintended pregnancies and a decline in accessible, facility-based care during Covid-19, so too there is a rise in demand for midwifery services. Additionally, midwives are not prioritized for personal protective equipment (PPE) and are omitted from vaccine priority lists in countries where they are not considered formal health professionals. Yet, midwives cannot cease work, just as women’s sexual and reproductive health needs do not cease during pandemics.

These challenges call for social, economic, and health system changes and investments, as well as a shift in the legal and regulatory enabling environment dictating their working conditions. Governments must consider policies and legal instruments, such as the International Labour Organization’s (ILO) Convention 190 (C190), to address the gender-based violence and harassment facing midwives in their world of work.

Midwives around the world work in both the formal and informal economy. Even in the formal economy, there is a global trend in temporal/informal recruitment of midwives which offers the employer an opportunity to bypass the employment laws of countries. For example, some midwives might be recruited on a ‘part-time’ basis or for short-term six-month contracts – despite midwifery being a uniquely 365/24/7 type of profession – so that their employers and the government does not have to provide them with full pay or basic benefits.

Despite critical shortages of midwives in hospitals, midwives are not offered formal employment or recruited for these roles, sidelining them in unstable and underpaid informal work arrangements. Ensuring legal and social protection that is gender-responsive and which recognizes the unique burdens facing midwives will enable the investments that midwives self-identify as critical for their right to safe and decent work.

Midwives must be encouraged and supported in using ILO C190 for mobilization against harassment at work. If ignored, the disproportionate impact of Covid-19 on workers in the informal economy, especially women, risks deepening the discrimination, violence and harassment often faced by midwives, both as workers and personally, in violation of their human rights.

Midwives have an opportunity to join global and country-based movements with care economy workers and women’s rights activists to call on their governments to ratify and implement ILO C190 as a rallying cry to end gender-based harassment and discrimination in their world of work, and indeed in the broader world of work and caregiving. As the International Year of the Nurse and Midwife extends into 2021 in recognition of the dedication and sacrifice of millions of nurses and midwives during the pandemic, we must take advantage of the visibility of our work to join forces with allies, like the Global 16 Days Campaign, to ensure this recognition of our work is followed by recognition of our rights.

[1] White Ribbon Alliance. 2017. A Count of Bedside Midwives in Malawi. Lilongwe: White Ribbon Alliance Malawi.

[2] Midwives Voices, Midwives Realities: Findings from a global consultation on providing quality midwifery care (ISBN 978 92 4 151611 2). (2016). Retrieved;jsessionid=ED011CD050B74F1A4A5F8FAD31DB924A?sequence=1

[3] Midwives Voices, Midwives Realities: Findings from a global consultation on providing quality midwifery care

[4] Midwives Voices, Midwives Realities: Findings from a global consultation on providing quality midwifery care

Angela Nguku, BscN, MN, MAPPM, is the Founder and Executive Director of the White Ribbon Alliance Kenya (WRA Kenya), a people-led movement for reproductive, maternal and newborn health and rights. A graduate midwife and an accomplished thought leader, Angela’s’ career spans over 16 years of dedicated work towards ending preventable maternal and newborn deaths globally and amplifying the voices of marginalized and vulnerable populations in Kenya, throughout Africa, and around the world. A passionate maternal, newborn and adolescent health champion, Angela advocates for the accountability for the health of mothers, newborns, adolescents and frontline health workers mainly nurses and midwives.