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Many women and newborns continue to be

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.