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Tackling gender power relations is key to ensuring the safety and wellbeing of health workers and the ability to deliver quality care, say Asha George and colleagues

Purpose To highlight ongoing and emergent roles of nurses and midwives in advancing the United Nations 17 Sustainable Development Goals by 2030 at the intersection of social and economic inequity, the climate crisis, interprofessional partnership building, and the rising status and visibility of the professions worldwide. Design Discussion paper. Methods Literature review. Findings Realizing the Sustainable Development Goals will require all nurses and midwives to leverage their roles and responsibility as advocates, leaders, clinicians, scholars, and full partners with multidisciplinary actors and sectors across health systems. Conclusions Making measurable progress toward the Sustainable Development Goals is critical to human survival, as well as the survival of the planet. Nurses and midwives play an integral part of this agenda at local and global levels. Clinical Relevance Nurses and midwives can integrate the targets of the Sustainable Development Goals into their everyday clinical work in various contexts and settings. With increased attention to social justice, environmental health, and partnership building, they can achieve exemplary clinical outcomes directly while contributing to the United Nations 2030 Agenda on a global scale and raising the profile of their professions.

Background In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce. Methods The State of the World’s Midwifery report 2014 used a broad definition of midwifery (“the health services and health workforce needed to support and care for women and newborns”) and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework. Results Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation. Conclusions The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued.

The State of the World’s Midwifery Report 2014: A universal pathway, a women’s right to health (SoWMy2014) was published in June 2014 and joins the ranks of a number of publications which contribute to the growing body of evidence about a global midwifery workforce that can improve maternal and child health. This editorial provides an overview of these publications that have been supported by global movements in the area of sexual, reproductive, maternal, and newborn and child health over the last four years. Background information is given on the methodology and data collection of SoWMy2014, the main findings cover the area of the availability, accessibility, acceptability and quality of midwifery services and a 2 page country brief shows the SRMNH data and workforce projections for each of the 73 “Countdown countries” that participated. SoWMy 2014 report shows that midwives can provide 87% of the needed essential care for women and newborns, when educated and trained to international standards. Midwives however, are most effective when they work within a functional health system and enabling environment. Also, a supportive team of auxiliaries, physicians and specialists is essential in order to ensure coverage of SRMNH services to women and newborns across the whole continuum of care, from pre-pregnancy through to pregnancy, childbirth and the post-natal period and from household to hospital. Based on these findings, the report puts forward a vision of Midwifery2030, a pathway for women’s health and for midwifery policy and planning through the end of 2030. It promotes women-centered and midwife-led care to achieve the goal of universal health coverage for all women.

Caesarean sections can be a lifesaving procedure for mother and baby, but rates beyond 10% of live births are not associated with reductions in maternal and newborn mortality. Caesarean section rates at national level vary between around 2% in Chad, Burkina Faso, Ethiopia or Madagascar and above 50% in Brazil, Dominican Republic or Egypt. The trend towards overuse of caesarean sections is a major concern globally, given the risks to the mother and her child associated with unnecessary caesarean birth. These risks include avoidable maternal complications such as infections, haemorrhage, complications related to use of anaesthesia or blood transfusion, and infant morbidity, for example, respiratory problems, asthma and obesity in children. Caesarean sections can also lead to added complications for the mother in subsequent pregnancies, including uterine rupture, placental implantation problems and need for hysterectomy. High rates of caesarean sections are also associated with substantial health-care costs, which can pose a considerable burden on health systems. Multiple factors are driving increases in caesarean section rates. Clinical reasons for growing rates include increases in the incidence of maternal obesity, multiple pregnancies and a higher maternal age at birth. These factors alone are unlikely to explain the extent of the rise in caesarean section rates or the substantial variations among health-care providers, hospitals and regions. Studies have shown associations between caesarean section rates and non-clinical factors such as differences in health provider practices, fear of malpractice litigation and organizational, economic, social and cultural factors. A growing proportion of caesarean sections globally are not medically indicated and could have been avoided. To address the rising rates worldwide and prevent the harm to women and newborns resulting from overuse of this procedure, in 2018 the World Health Organization (WHO) published new recommendations on non-clinical interventions to reduce unnecessary caesarean sections. In this guideline, non-clinical interventions are defined as those interventions that are applied outside of the routine clinical interactions between a provider and pregnant woman. The interventions may target women (for instance, birth preparation classes), health-care providers (clinical practice guidelines) or health organizations (different payment systems for caesarean sections). The recommendations, are grouped according to the target of interventions and address major determinants of caesarean section rates. The recommendations are intended to inform the development of national and subnational policies and protocols to reduce unnecessary caesarean births in high-, middle- and low-income countries. The new recommendations should be integrated and implemented with other related WHO guidelines, such as WHO recommendations on antenatal and intrapartum care for a positive childbirth experience.