2.

7 Midwives educated to
international standards save
resources
The midwifery model of care has a significant
impact on cost reductions arising from higher rates
of spontaneous vaginal birth, less postpartum
haemorrhage, fewer admissions to neonatal units,
and increased breastfeeding rates (Box 8) (6–8, 41).
This has been shown using a range of research
designs including randomized controlled trial,
cross-sectional study, modelling and observational
study for women of all risk profiles.
Because of the lifelong impact of healthy pregnancy
and birth, family planning, breastfeeding, good
mental health, uptake of vaccinations and other
interventions, the long-term economic gains
resulting from midwives educated to international
standards are even greater than the specific
savings from improved short-term clinical
outcomes and reduced costs of interventions (2).
The escalating rates of caesarean sections and
other unnecessary interventions globally (26, 42),
often driven by commercial forces that result in
health service resources being spent on facilities
and equipment rather than on the personnel who
can prevent complications, can be counterbalanced
by midwifery (39, 43).
The International Federation of Gynaecology and
Obstetrics (FIGO) position paper: How to stop the
caesarean section epidemic (2018) highlights that
to overcome perverse incentives to increase
unnecessary interventions, the fees for physicians
for undertaking caesarean section and attending
vaginal birth should be the same, using a mean
fee (44). This should also happen in private
practice settings.
The FIGO position paper also notes: “Money that
will become available from lowering CS [caesarean
section] costs should be invested in resources,
better preparation for labour and delivery and
better care, adequate pain relief, practical skills
training for doctors and midwives, and
reintroduction of vaginal instrumental deliveries to
reduce the need for CS in the second stage of
labour” (44).
2.8 Why more needs to be done
2.8.1 “Poor quality of care is now a
bigger barrier to reducing mortality than
insufficient access to care.”
Kruk et al. Lancet Global Health Commission (4).
Steady progress was made in reducing
maternal deaths during the millennium
development goal period, with a global
reduction in the MMR from 385/100 000 live
births in 1990 (534 000 maternal deaths per
year) to an MMR of 216/100 000 live births
(303 000 maternal deaths) in 2015 (45).
There was a rapid decline in the under-five
mortality rate which dropped from 92 deaths
per 1000 live births in 1990 to 41 deaths per
1000 live births in 2016, but proportionately a
slower rate of decline in newborn deaths.
Almost 50% of deaths in the under-fives now
occur among newborns (45). The globalnewborn mortality rate declined by 41%
between 2000 and 2018, from 31 deaths per
1000 live births to 18 deaths per 1000 live
births (2.5 million deaths per year) in 2018 (46).
These early gains in maternal and newborn
mortality reduction in LMICs can largely be
attributed to primary prevention measures, for
example access to family planning, iron
supplementation and insecticide-treated nets
(described as Stage 2 in the obstetric transition)
(3). However, the major causes of maternal
deaths continue to be haemorrhage, eclampsia
and sepsis; and in newborns, deaths from
preterm birth, asphyxia and sepsis. Preventing
these deaths will require more complex
measures, including quality midwifery education
and care. Poor quality of care is now the most
significant barrier to further reductions in
mortality and morbidity, contributing to 61% of
neonatal deaths and half of deaths from
maternal diseases according to the Lancet
Global Health Commission (Fig. 6) (47).