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Advocating for midwives in low-to-middle income countries in the COVID-19 pandemic

Published:August 17, 2021DOI:https://doi.org/10.1016/j.wombi.2021.08.006
      Throughout history, epidemics have exacerbated inequalities, and health care workers, including midwives, have faced immediate threats to their health and well-being but still work to protect maternal and newborn health. While this is not the first pandemic, the impact of the coronavirus disease 19 (COVID-19) pandemic has been unprecedented. At the time of writing (August 2021), the COVID-19 pandemic continues to place an unyielding burden on healthcare systems across the globe [
      • World Health Organization
      ,
      • Eagen‐Torkko M.
      • Altman M.R.
      • Kantrowitz‐Gordon I.
      • Gavin A.
      • Mohammed S.
      Moral distress, trauma, and uncertainty for midwives practicing during a pandemic.
      , ]. Worldwide, the contagiousness of this virus has meant the number of cases has exceeded the workforce, resources and equipment that are available. Clinical practice settings, many of which already faced midwife shortages, had to change and adapt rapidly in response to the shifting needs. At first, there was uncertainty about the transmission of the virus, and a lack of effective or available treatments, meaning there was immense fear and uncertainty. The evidence has since been gathered in support of the airborne route of transmission, and more is known about the virus, including the existence of new, even more transmissible variants such as the Delta variant which can impact the rate of infection. We know so much more than we did in early 2020 yet the world still faces huge challenges especially in the provision of usual maternal and newborn health.
      When a virus, such as the one that causes COVID-19, is circulating widely in a population, it has a chance to mutate and spread. The World Health Organization (WHO) has recommended public health measures such as handwashing, physical distancing, wearing a mask and getting vaccinated as soon as one becomes available. However, low-to-middle-income countries (LMICs) have faced shortages in vaccine supply and 92 of these countries, including Indonesia, are reliant on financial aid to achieve a vaccination rate of 20% of their population through the COVAX initiative [
      • World Health Organization
      ]. The WHO has stressed the importance of fair and equitable distribution of vaccines to help stop the pandemic and rebuild societies [
      • World Health Organization
      ]. Health care workers are a top priority for vaccination according to the WHOs Strategic Advisory Group [
      • World Health Organization
      ]. As the pandemic continues, many countries report personal protective equipment (PPE) shortages, meaning that midwives are placed at risk in the work environment [
      • Halberg N.
      • Jensen P.S.
      • Larsen T.S.
      We are not heroes—the flipside of the hero narrative amidst the COVID19‐pandemic: a Danish hospital ethnography.
      ,
      • Panda S.
      • O’Malley D.
      • Barry P.
      • Vallejo N.
      • Smith V.
      Women’s views and experiences of maternity care during COVID-19 in Ireland: a qualitative descriptive study.
      ,
      • Renfrew M.J.
      • Cheyne H.
      • Craig J.
      • et al.
      Sustaining quality midwifery care in a pandemic and beyond.
      ,
      • Semaan A.
      • Audet C.
      • Huysmans E.
      • et al.
      Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic.
      ]. In many countries, midwives have been infected with COVID-19 and have subsequently died.
      Health care workers, including midwives, have rights and professional boundaries. However, the hero narrative has been driven by the media. This narrative places the onus on the individual efforts of the heroic health care workers rather than on the responsibilities of society, and the systems and policymakers who need to adequately resource health care [
      • Halberg N.
      • Jensen P.S.
      • Larsen T.S.
      We are not heroes—the flipside of the hero narrative amidst the COVID19‐pandemic: a Danish hospital ethnography.
      ,
      • Semaan A.
      • Audet C.
      • Huysmans E.
      • et al.
      Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic.
      ]. The stories and realities of health workers in the mainstream and social media coverage show that midwives are committed to providing midwifery care amid the lack of PPE and often in unsafe working environments. Midwives have experienced burnout, stress, ongoing trauma and post-traumatic stress disorder (PTSD) which has the potential for long term consequences []. Some midwives may be more susceptible to infection due to personal characteristics or underlying health conditions and will have specific support needs in the workplace. While there has been a plethora of research in the past year, little has been published on the impact of COVID-19 on midwives in LMICs [
      • Shorey S.
      • Valerie C.
      Lessons from past epidemics and pandemics and a way forward for pregnant women, midwives and nurses during COVID-19 and beyond: a meta-synthesis.
      ]. Therefore, more research is required to acknowledge and learn from their experiences.
      Amidst the second wave of COVID-19, the State of the World’s Midwifery Report (SoWMy) 2021 was published, revealing an up-to-date global needs-based shortage of over one million dedicated sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) equivalent workers to achieve Universal Health Care and the Sustainable Development Goals [
      • UNFPA, International Confederation of Midwives, World Health Organization
      The State of World’s Midwifery 2021.
      ]. The most significant shortage is of midwives and the wider sexual, reproductive, maternal, newborn, child and adolescent workforce. The health workforce is on average 70% women [
      • UNFPA, International Confederation of Midwives, World Health Organization
      The State of World’s Midwifery 2021.
      ]. Midwives are likely to be women who also experience substantial gendered disparities in remuneration rates, career pathways and decision-making power. The SoWMy 2021 Report estimates that the world’s SRMNAH workforce could meet 75% of the world’s need for essential SRMNAH care. However, in LMICs, the lowest in African and Eastern Mediterranean WHO regions, the workforce could meet only 41% [
      • UNFPA, International Confederation of Midwives, World Health Organization
      The State of World’s Midwifery 2021.
      ]. Much evidence of the SoWMy 2021 was gathered before the pandemic; inevitably, the COVID-19 pandemic has now exacerbated the shortages in the midwifery workforce.
      Earlier on in the pandemic, the vulnerability of health workers, especially midwives, was highlighted as maternal and newborn care cannot be postponed [
      • O’Connell M.
      • Crowther S.
      • Ravaldi C.
      • Homer C.
      Midwives in a pandemic: a call for solidarity and compassion.
      ]. Recognising this, the Pandemic Preparedness and Response at the United Nations recently listened to nurses, midwives, and community health workers who took on additional risks to save lives [
      • The Independent Panel for Pandemic Preparedness and Response
      ]. Approximately 17,000 health workers are estimated to have died globally to date. Data from Indonesia in August 2021 confirms that 1808 Indonesian health workers, including 640 doctors, 594 nurses, and 331 midwives have died due to COVID-19 [
      • LaporCovid19
      Terima Kasih Pahlawan Kesehatan Indonesia.
      ]. These figures are likely to be an underestimate due to discrepancies in data and lack of testing for COVID-19 in LMICs. The loss of these essential workers who contributed to the Indonesian health system and the health facilities left a feeling of powerlessness or defeat. The deaths of Indonesian health care workers due to COVID-19 highlights the critical needs for appropriate PPE, vaccination and more profound forms of support.
      It is hard to predict the end of the COVID-19 pandemic. After 18 months, while more is known, and we are better equipped, uncertainty remains. Vaccines are effective and protect individuals from hospitalisation and death, and PPE like masks protect against transmission. Yet, in LMICs, a lack of equity of access to vaccines and basic PPE is ongoing. All governments have not only a moral duty to keep the health workforce safe, but urgently need to implement policies that protect and consider the value of their lives. The tragic deaths of health workers, including midwives, show that they were not protected during the COVID-19 crisis and many were failed by governments through a lack of preparation or contingency for a pandemic. Global solidarity and compassion with midwives worldwide is needed to prioritise the welfare of this vital workforce and ensure equitable access for all. Midwives around the world need to remain vigilant, promote dignity at work and support each other, aiming to maintain a safe working environment through the recommended public health measures, as well as provide evidence-based information about vaccination.
      While high-income countries compete to vaccinate their whole population, in LMICs, the demand for vaccines far exceeds supply, and many frontline workers have yet to be vaccinated. This may be considered ethically unacceptable and insufficient during the pandemic. Beyond pain, we have seen the utter intensity of health workers, including midwives, who continue to die from COVID-19 during a trend in vaccine uptake in high-income countries. At this point, there is a huge need for effective, context-specific vaccination campaigns and the scaling up of vaccination programs to protect all health workers and communities. It is critical to keep vaccine and health equity for health workers at the core of complex solutions, primarily in LMICs. All health workers, including midwives, have human rights for public health safety and the right to a safe work environment. Global resilience and commitment towards vaccine equity across the world is needed. It is also important to recognise midwives who keep showing up to work, risking their lives and health due to COVID-19 to offer respectful and compassionate midwifery care at their health care facilities and in the community.
      Midwives and midwifery care matters more than ever as childbearing continues just as before the COVID-19 crisis [
      • O’Connell M.
      • Crowther S.
      • Ravaldi C.
      • Homer C.
      Midwives in a pandemic: a call for solidarity and compassion.
      ]. We pay tribute to all health care workers, including midwives, who have died due to COVID-19. The grief and loss in so many countries and communities is palpable and those lives that have been lost cannot be replaced. Together, as a global community of midwives, we must advocate and work towards equity for all midwives – equity of access to vaccines, PPE, mental health support and safe working conditions. As the UN Secretary General has said “In an interconnected world, none of us is safe until all of us are safe” [
      • United Nations
      None of Us Is Safe Untill We All Are, Says UN Chief at EU Push to End COVID-19 Pandemic.
      ]. We could not agree more.

      Funding

      None declared.

      Ethical approval

      Not required.

      Conflict of interest

      None declared.

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