Inequity between the need for and availability of SRMNAH workers is also evident between WHO regions (see Additional file 1: Table S3 for a list of countries in each region). SoWMy 2021 shows that Africa and South-East Asia account for half of the world’s need for SRMNAH worker time, but just 20% of the world’s midwives, nurses and doctors. By contrast, Europe and the Americas account for 20% of the need but 50% of the supply.
Although Africa has the lowest density of SRMNAH workers overall, relative to the overall size of the workforce this region has the highest proportion of professional midwives, and nearly 40% of the available SRMNAH worker time is from midwives. Africa stands out as having the most severe SRMNAH worker shortage in the world: it accounts for over half of the global shortage, the workforce can meet no more than half of the need, and in reality it almost certainly meets much less than half. These challenges, coupled with rapid population growth in many African countries, mean that the situation is predicted to improve only slightly by 2030 unless there is significant additional investment.
Midwives in Africa tend to have a broader scope of practice than those in other regions: they are generally authorized to perform all seven BEmONC signal functions and provide all modern methods of contraception. Africa also has a high proportion of countries with midwife leaders in the national MoH: it is second only to the Americas on this indicator. About half of responding countries in this region offer postgraduate study in midwifery. On the other hand, many African countries rely on midwife educators who are not themselves midwives to teach pre-service education programmes, indicating a shortage of suitably qualified midwives to teach the next generation. Fewer than half of African countries report that their midwives must provide evidence of continuing professional development (CPD), which calls into question whether the skills of the midwifery workforce are routinely kept up-to-date.
The Americas is the region with the lowest midwife density and the highest nurse density: indicating that this region relies very heavily on nurses as providers of SRMNAH interventions. Fewer than half of responding countries in this region offer a postgraduate qualification in midwifery. Despite this, most responding countries report that midwifery is recognised as a separate profession, that it has a separately regulatory system, that there is a professional association specifically for midwives and that there are midwife leaders in the national MoH.
The Eastern Mediterranean region has the second lowest SRMNAH worker density after Africa and accounts for almost 20% of the global midwife shortage. Its SRMNAH workforce can meet no more than 70% of the need (and like Africa, probably meets much less than this). In contrast to Africa, however, current trends suggest that the situation will be much improved by 2030. Most of the midwives in the Eastern Mediterranean region are professionals, but most of its nurses are associate professionals. Relative to the number of midwives and nurses, the region has a lot of doctors in its SRMNAH workforce, indicating a medicalized SRMNAH care system in many countries in the region.
The Eastern Mediterranean region is one of only two regions, where the vast majority of midwife educators are themselves midwives (the other being Europe). However, fewer than half of countries in this region offer a postgraduate qualification in midwifery, fewer than half have a separate regulation system for midwives and only half require midwives to provide evidence of CPD to continue practising. Some countries in the region restrict the midwife’s scope of practice, e.g., fewer than half of countries authorize midwives to conduct manual placenta removal and manual vacuum aspiration.
The overall density of SRMNAH workers in Europe is similar to the Americas, but midwife density is 2.5 times higher in Europe than in the Americas, and nearly all of Europe’s midwives are professionals rather than associate professionals. As noted above, most European countries use midwives to educate midwives, and it is the only region in which the majority of countries offer a postgraduate qualification in midwifery. Similarly, nearly all countries have a separate regulatory system for midwives and an association specifically for midwives. On the other hand, very few countries in this region have a midwife leader in the national MoH and the scope of practise of midwives is often restricted, e.g., very few countries permit midwives to perform vacuum extraction and manual vacuum aspiration, and midwives do not tend to be authorized to provide modern contraceptives.
A large proportion of the SRMNAH workers in South-East Asia are midwives, but nearly all of this region’s midwives are associate professionals rather than professionals and, therefore, can provide a smaller number of essential SRMNAH interventions. About half of responding countries in this region offer a postgraduate qualification in midwifery. The scope of practise of midwives is broader than in all other regions except Africa. However, only about half of the reporting countries in this region have legislation recognizing midwifery as distinct from nursing, only about two-thirds have a separate regulatory system for midwives, and fewer than one in three have a midwife leader in the national MoH.
The Western Pacific region has a relatively high midwife density, second only to South-East Asia, and nearly all of its midwives are professionals. However, in this region, less than 10% of the available SRMNAH worker time comes from midwives, because there is an even higher density of nurses and doctors. Nearly all responding countries in this region have a separate regulatory system for midwives and a professional association specifically for midwives, and the scope of practice of a midwife tends to be broad (the main exception being that fewer than half of countries in this region authorize midwives to perform manual vacuum aspiration). However, fewer than half of countries offer a postgraduate qualification in midwifery, fewer than half have midwife leaders in the national MoH, and fewer than half require periodic evidence of CPD.