How to tackle Africa’s chronic shortage of midwives: ‘Many feel invisible’

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Basa Christine Samson, from South Sudan, decided that to help end the string of maternal deaths she had witnessed among her friends and family, she needed to become a midwife.

“There was a lot of maternal death in the community I live in,” she tells The Independent. After training in midwifery, Basa worked in hospitals, in the community, and now in a healthcare facility run by the International Rescue Committee humanitarian organisation.

Although she finds the work rewarding – “once you see the mother and baby are alive and well, you are very joyful,” she says – the challenges are endless.

“You're looking at your patient, and you know you can't provide her with the correct equipment,” she said. “Because of the funding shortages, we have faced challenges with supplies. There are insufficient medical supplies and medications. We don't have catheters; we don't have sterile gloves. Sometimes the lights go out when there is no fuel, and we work in darkness and use torches.”

These challenges, and many more, help to explain why there is a shortage of midwives throughout Africa.

EQUAL, a multi-country research consortium generating evidence on effective approaches to deliver life-saving maternal and newborn health care in countries affected by conflict, recently found that there is a global midwife shortage up to 980,000, and that Africa needing half of those. The continent is home to 19 per cent of the world’s women of reproductive age but carries 46 per cent of the global midwife shortage.

“The 2025 State of the World's Midwifery Report for East and Southern Africa reported an increase from 2.5 to 3.2 midwives per 10,000 population, but this remains well below the global average of 4.4per 10,000,” Shatha Elnakib, an assistant research professor at Johns Hopkins Bloomberg School of Public Health, tells The Independent. “We really need to accelerate progress; the gains are too modest and fragile.”

Elnakib says too few midwives in Africa are being trained due to insufficient training capacity, that the ones who are trained are finding it difficult to get jobs, and once jobs are found, “low salaries, burnout, unsafe working conditions, limited professional support, and insecurity push many midwives out of the workforce.”

In conflict-zones throughout Africa – including South Sudan, parts of the eastern Democratic Republic of Congo, Sudan, Mali, and Burkina Faso – the picture for midwives, and in turn for mothers and babies, is even more bleak. “Conflict zones sit at the extreme end of a shortage that's already severe continent-wide,” Dr Caroline Tatua, Regional Health Lead at International Rescue Committee, says.

“Insecurity is a big challenge,” Viola Kiden, a midwife working in conflict-torn South Sudan for the past three years tells The Independent. “Sometimes the mothers don't come early enough because movement at night is difficult, and by the time they arrive they have complications or are in an advanced stage and we have to try to manage and save them.”

It’s not only mothers and their babies midwives have to safely manage in the middle of conflict zones; midwives in these areas are desperately trying to keep themselves safe as well.

“Picture this,” Dr Tatua says, describing a typical day for a midwife in a conflict zone. “The roads are too dangerous or too damaged, so there is no ‘send her to hospital’ option. The power cuts out mid-delivery. There is no oxygen, and no medication to stop severe bleeding after birth. Patients don’t arrive until they’re in danger and experiencing life-threatening complications, so the midwife is doing emergencies, not just routine births. She’s working completely alone, with no colleague to consult mid-crisis or debrief with if a mother or a baby doesn’t survive.”

Working conditions are grim – but there are more systemic reasons fewer and fewer midwives are working in conflict zones.

Healthcare facilities have been attacked and/or destroyed, leaving midwives without safe workplaces. Midwives have reported they have been specifically targeted by militants as a military strategy (sometimes being kidnapped). Along with thousands of others fleeing, midwives themselves are displaced from conflict zones, unable to continue working in their home countries. Insecurity blocks deployment of midwives, with governments and NGO’s unable to safely deploy staff in active conflict areas. International funding cuts have depleted resources in war-torn countries, disrupting midwifery training, salaries, and essential commodity and equipment supply chains.

But it isn’t conflict that creates the midwifery gap. “It detonates an existing one,” says Dr Tatua.

And the gap is leaving midwives in conflict zones “overwhelmed, isolated, and under supported,” Dr Tatua continues. “Those are the words that come up again and again when you talk to midwives working in conflict-affected areas. And underneath the exhaustion, there's real frustration. Midwives are highly skilled providers. But many feel invisible — sidelined by policy, without the formal recognition their clinical judgment actually deserves.”

Something has to be done to train and retain midwives, Elnakib of Johns Hopkins University, says, otherwise, “midwives will continue leaving the profession, or choose not to work in conflict-affected areas; the workforce will shrink, and women and babies will continue to die from preventable causes.”

To train, deploy, and retain midwives, Elnakib says, governments need to strengthen employment pathways, improve deployment systems, and provide financial and security incentives for working in conflict-affected areas.

“Midwives need better salaries, hazard pay, security escorts, safe accommodation, better lighting and fencing around facilities, improved working conditions, and systematic mental health support rather than ad hoc or one-off interventions,” she adds.

Dr Tatua agrees, suggesting that “without adequate security and safe access, nothing else matters,” and that local governments, NGOs and local communities can work to ensure this for midwives and patients.

She also says that community-based service modalities such as mobile clinics and outreach teams “make a difference” when it comes to care because they bring midwives to displaced populations instead of expecting people to make it to a facility that “may have been bombed or too dangerous to reach.”

Enos Walela, a nurse midwife working in one of these mobile units in the Kakuma Refugee Camp in Kenya, tells The Independent that the greatest present need is for well-stocked supplies. “There was a time we were out of drugs for postpartum haemorrhage for almost a week,” he said. “We need adequate staffing and we need to make sure we have enough resources, especially supplies and emergency obstetric and newborn care medicines.”

There are two arguments for why the midwifery shortage in Africa, particularly in conflict-torn areas, matters to people in the UK, according to Elnakib.

“The moral argument is simple: mothers and babies should not die when their deaths are preventable, and we all have a duty to stop these unpreventable deaths,” she says. “The practical argument, which I feel is superfluous frankly because the moral one should be sufficient, is that healthy populations are essential for economic growth, stability, and development. Our health systems are increasingly interconnected, and investing in Africa's health workforce ultimately benefits us all.”