Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study

Background: Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios. Methods: For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world’s maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. Findings: We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly concentrated in the group B countries, which currently account for a large proportion of the world’s population and have high mortality rates compared with group C. Interpretation: Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. Funding: New Venture Fund. For this modelling study, we used the Lives Saved Tool (LiST), part of the Spectrum software suite, to model the country-specific effect of changes in health intervention coverage on mortality. This approach uses the best available estimates of baseline health status, population size, and linear assumptions of intervention effectiveness on specific causes of death. We used LiST to model the effects on mortality and nutrition that could be attained by scaling up the interventions that can be provided specifically by midwives. We used Spectrum, version 5.8, for all analyses. All LiST default assumptions were used unless otherwise stated, including 2017 maternal mortality ratio estimates,10 2018 neonatal mortality rate estimates,11 and 2015 stillbirth rate estimates.12 LiST only includes health interventions that directly affect mortality (maternal, neonatal, child, or stillbirth) or nutritional status. LiST excludes interventions without proven effect on mortality and those that improve other outcomes, such as routine monitoring with a partograph, counselling on birth preparedness, and screening for post-partum depression.1 For an intervention to be included in our modelling study, it had to be available within LiST or Spectrum, deliverable in its entirety by a midwife according to ICM global standards (hereafter referred to as midwife-delivered interventions), and listed as an essential intervention within the ICM essential midwifery competencies8 or the Global Strategy for Women’s, Children’s, and Adolescents’ Health.1 This selection was done by listing the LiST interventions and then mapping the ICM competencies to them. Any areas of uncertainty were resolved by discussion among the study team. The modelled interventions and their baseline coverage values are listed in the appendix (p 1). We should note that the full scope of practice of a midwife is broader than this: midwives play important roles as part of teams doing other life-saving interventions, such as caesarean sections, assisted deliveries, and blood transfusions. Changes to LiST defaults were made for one intervention: antenatal corticosteroids. The same default coverage was assumed as for uterotonics and the previous default effectiveness13 was used. Although antenatal corticosteroids for preterm labour is a standard LiST intervention, coverage and effectiveness currently default to 0, due to updates to WHO guidelines regarding this intervention. However, antenatal corticosteroids are a midwife-delivered intervention, and this analysis assumed that midwives are practising in a strong and supportive health system. Our analysis used four scenarios to show the effects of altering the coverage of midwife-delivered interventions by a modest amount, a substantial amount, and by the amount needed to reach universal coverage of these interventions (table 1). The fourth scenario used was an attrition scenario, which indicates the effect of either a small decline in the training, education, and deployment of midwives, or no increase in these to match population growth. These are the same scenarios used in the 2014 Lancet Series on Midwifery. Scenarios used to model the impact of midwives on maternal and neonatal deaths and stillbirths, 2020–35 Baseline coverage rates are presented in the appendix (pp 3–7) and coverage rates achieved under each scenario are also presented in the appendix (pp 8–48). The analysis included the 81 Countdown to 2030 countries plus the seven Countdown to 2015 countries that are not Countdown to 2030 countries (Brazil, China, Egypt, Mexico, Peru, São Tomé and Príncipe, and Vietnam). Collectively, these 88 countries accounted for 98% of the world’s maternal deaths in 2017,10 96% of the world’s neonatal deaths in 2018,11 and 95% of the world’s stillbirths in 2015.12 We used the 2018 Human Development Index (HDI)14 to classify the countries in three equal-sized groups (appendix p 2). Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. We created individual LiST baseline projections for each of the 88 countries from 2020 to 2035 (appendix pp 3–7). On the basis of these individual country projections, we calculated results for each group of countries by aggregating the individual country estimates. These baseline results were compared with the various scenarios of how coverage of midwife-delivered interventions might change between 2020 and 2035 (table 1). The funder of the study had no role in study design, data analysis, data interpretation, or writing of this paper. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.