without any access to care or experience too little
care too late while other women and newborns are experiencing too much intervention too soon (48). This over-medicalization of pregnancy and childbirth often results in unnecessary interventions including episiotomy and caesarean section. These interventions are life-saving when needed, but risky and costly when not (26, 49); women and newborns may be harmed by having an unnecessary caesarean section or episiotomy (48). Access to a facility does not in itself improve outcomes where the workforce lacks the competencies needed. Facilities can be a source of injury and pain. Neglect and abuse occur in low-, middle- and high-income countries (50–52). Cash incentives have helped more women to reach facilities to give birth, but this has not always measurably reduced maternal and newborn mortality (53). The lack of quality care has a negative impact on access by women, and can delay or prevent women seeking help (4, 54). The lack of welleducated midwives at facilities is contributing to poor quality care.
“High-quality health systems
could prevent … 1 million newborn deaths … and half of all maternal deaths each year.” Kruk et al. Lancet Global Health Commission (4).
“Although the degree and type
of risk 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.” Renfrew et al. Lancet Series on Midwifery (2).
A shortage of appropriately educated health
workers is a key factor. The State of the world’s midwifery report 2014 notes that of the 73 countries from which data were gathered, only four countries have the workforce capacity to provide the care needed by women in their reproductive years and newborns (5). There is increasing evidence to indicate that it is not only the shortage of health workers, but lack of education and skills among existing midwives, nurses and doctors, that remains a consistent barrier to improving maternal and newborn health. In a systematic mapping of barriers to the provision of quality care by midwifery personnel, the issue of poor midwifery education − often reduced to a matter of weeks − without qualified faculty and lacking in practical application, was identified as a major constraint (17). Additionally, many of the education programmes lacked crucial components of basic training, such as infection prevention and respectful care, leading to possibilities of links between poor education, poor clinical care, sepsis and mistreatment of women in facilities (17). It is clear that improved quality of care, as well as primary prevention, is needed to further accelerate improvement in maternal and newborn health. The education of midwives to international standards, with proven benefits to the outcomes for women and newborns, provides a vital solution.