Of the 146,000 midwives in the region, 30% (45,000) are categorized as midwifery professionals. Of the remainder, 4,000 are classed as midwife associate professionals, 57,000 as nurse-midwife professionals and 40,000 as nurse-midwife associate professionals. However, these aggregate figures mask the fact that many countries in the region have just one type of midwife in the workforce. High- and middle-income countries are more likely to have nurse-midwives in their workforces. In 10 countries, the midwifery workforce is composed entirely or almost entirely of professional midwives: Botswana, Burundi, Comoros, Eritrea, Ethiopia, Madagascar, Mozambique, Rwanda, South Africa and Uganda. In four countries (Eswatini, Kenya, Lesotho and Seychelles), the midwifery workforce consists entirely or almost entirely of professional nursemidwives. Zanzibar has a mix of midwives and nurse-midwives. Malawi, Mauritius, Tanzania (mainland) and Zimbabwe have a large number of associate professional nurse-midwives in the workforce. Similarly, DRC and Zambia rely very heavily on associate professional midwives. Associate professionals have a relatively narrow range of competencies and can therefore safely provide only some essential SRMNAH interventions.

Extent to which midwives in ESA countries adhere to the ICM definition of a midwife

Taking all of the above issues into account, we can assess the extent to which midwifery policy, education and regulation enables midwives in ESA countries to adhere to the ICM definition of a midwife. [25] Table 3.6 shows a number of indicators relating to three key aspects of the ICM definition: (1) a midwife has completed a highquality education programme, (2) a midwife is a “responsible, accountable professional”, and (3) a midwife works on her own responsibility across the full continuum of SRMNAH care. This analysis shows that, although some ESA countries do well on most indicators (most notably Ethiopia, Malawi and Zimbabwe), no country is rated positively on every indicator. Most of the gaps relate to the extent to which midwives are considered to be “responsible, accountable professionals”, but there are also major gaps in indicators of education quality, in particular the extent to which education curricula are aligned with ICM essential competencies.

The region’s first COVID-19 case was registered in March 2020, triggering national lockdowns and other stringent infection control measures in many countries. Most governments in the region responded quickly to control the spread of the virus, concerned that already fragile health systems would not be able to cope with increased demand. [62] However, these restrictions presented a major challenge to the work of midwives. In particular, lockdowns and ‘stay-athome’ orders, combined with fear of infection, discouraged or prevented women from seeking care. Efforts to contain disease outbreaks diverted resources (including human resources) away from the provision of other essential health services including SRMNAH care. [63] The arrival of COVID-19 in countries experiencing other health shocks (such as the Ebola and measles outbreaks in DRC) placed the health workforce under even more pressure, especially in locations experiencing violence and conflict. [64, 65] Emerging data indicate that COVID-19 will affect progress towards the SDGs unless there are significant efforts to mitigate its impact. 

Midwives provide many essential clinical SRMNAH interventions and can play a broader role in activities such as advancing SRMNAH care at the primary level and UHC, responding to violence against women, and addressing sexual and reproductive rights. [84] Their valued and respected role in the communities they serve positions them well to be agents of change in promoting women’s empowerment and behaviour change on family planning and also in addressing harmful social and gender norms and practices, such as female genital mutilation and child and early forced marriage. They can be a point of contact in the community for sexual and reproductive health services (see Box 4.1) and can support and promote self-care interventions such as self-monitoring of blood pressure during pregnancy. This chapter discusses the potential return on investment in midwives and provides examples of such investments from the ESA region.