“Belly woman” is the name for a pregnant woman in Sierra Leone. There is a song that the midwives sing with the words, “we won’t let the belly woman die.” Sadly, the maternal mortality rate in Sierra Leone is known as one of the highest in the world, so they know first hand the importance of those words. Sierra Leone is a country in western Africa with a maternal mortality rate of 701 maternal deaths for every 100,00 live births as documented by the World Health Organization in 2019. In the U.S., the current maternal mortality rate is 22 per 100,000 — vastly different from Sierra Leone, yet also the highest among industrialized nations.
I have cared for pregnant women and their families in Homer for over 30 years and I came to Sierra Leone in July to work with an organization called Seed Global Health as a midwife educator. We are partners with the Sierra Leone government with the mission of increasing the health care workforce of midwives to strengthen access to high quality care with the goal of decreasing maternal and neonatal mortality. The ongoing work that Seed partners have done in the towns of Bo and Mekeni has demonstrated a positive impact and has decreased the maternal mortality rate and improved health outcomes for pregnant women and their newborns.
My colleague, Priscilla, a midwife from Malawi with a Ph.D. in Maternal and Child Health, and I are tasked with opening a new midwifery school in the city of Kenema, as well as starting a midwifery preceptorship and mentoring program at Kenema Government Hospital. I have some personal history of working in Africa, and I am familiar with the slow pace, the scarce resources, the reliance on government bodies for policies, the corruption, and the poor working conditions. In Sierra Leone this is compounded by a country that underwent a horrific 11-year civil war from 1991-2002, followed 12 years later by the ravages of a two-year Ebola crisis. The people here are resilient and generous; in fact, I was shocked to learn that over 50% of people who work at the hospital do so as volunteers, waiting for a spot for a paid position from their government.
The 2021 State of the World’s Midwifery Report published by the International Confederation of Midwives, the WHO, and the United Nations Population Fund reveals that the world urgently needs 1.1 million more essential health workers to deliver sexual, reproductive, maternal, newborn and adolescent care — and that 80% of these missing essential workers are midwives. Presently in Sierra Leone, maternal deaths count for 36% of all deaths among women aged 15-49. Women die from obstetric hemorrhage, hypertension and preeclampsia, obstructed labor and sepsis; all preventable diseases.
The current workforce statistic finds Sierra Leone with fewer than 1,800 working midwives in a country with a population of 8.6 million. According to WHO, Sierra Leone needs 3,000 midwives to serve its population. Doctors you ask? OBGYNs you ask? I have been told there are fewer than 15 in the country, and all reside in the capital of Freetown. Quite simply, it takes much longer to train as a doctor and many end up working in the capital city or leaving the country altogether for higher paying jobs. Sierra Leone, similar to many other developing countries is truly, where there is no doctor, and midwives, nurses, and traditional birth attendants have been the front line providers for the vast majority of maternity and neonatal care.
According the American College of Nurse Midwives and multiple recent studies, midwifery in the U.S. is also under-utilized and underfunded. A 2018 analysis of the integration of midwives in the U.S. health system found that increasing access to midwives can improve equity, as well as maternal and neonatal outcomes. Currently, there are approximately 14,000 midwives in the U.S. including those not in clinical practice, with approximately four midwives employed for every 1,000 live births. According to the WHO worldwide recommendations, at least 22,000 midwives are needed here in the U.S. to meet the goal of at minimum six midwives per 1,000 live births. And even at that rate, we would have a smaller midwifery workforce than other high-income countries with better outcomes than our own.
A report release by the Commonwealth Fund in June 2024 reveals that the maternal mortality rate in the U.S. has increased in recent years and it is higher than any other high income nation. In the U.S. in 2022, maternal mortality was 22 out of every 100,000 live births, and for Black women that number has risen to 45 per 100,000. Two out of three maternal deaths occur up to 42 days after birth, highlighting the importance of postpartum care which only some state Medicaid programs and private insurers cover (Denali Kidcare is an exception and new legislation was passed just this year to cover the postpartum mother for up to a year after giving birth).
The organization of Economic Co-Operation and Development, known as the gold standard that tracks health care metrics across 38 high income countries, revealed that out of 14 high income countries, 10 had a maternal mortality rate of less than 10 per 100,000 and in 2022 Norway’s maternal mortality rate was 0. This report also revealed that access to midwives was an important factor in countries with the lowest maternal mortality rate. Again, this was high income countries.
In the U.S., Canada and South Korea, OBGYNs outnumber midwives, but in the majority of high income nations, midwives are more prevalent. The U.S. and Canada face a shortage of both midwives and OBGYNs — almost 7 million people in the U.S. live in areas without hospital or birth centers offering obstetric care, or any obstetric providers, and this shortage is expected to get worse. Close to home, we can see the communities of Seward and Cordova as examples, as well as the communities across Kachemak Bay that are asked to stay here in Homer during the last month of their pregnancy until they deliver. Additionally, the United States is the only high income nation without a federally mandated paid parental leave policy and universal health care. Only 13 states and D.C. have paid family and medical leave laws; these policies have been shown to improve health outcomes for pregnant people.
Fortunately, the women and families of the southern Kenai Peninsula have solid access to excellent midwifery care within an integrated system that includes OBGYNs. Birthing families here in Homer have had access to a long-standing midwifery service for over 40 years through Homer Medical Center/SPH and the West Wing. Additionally, out-of-hospital birth options provided by certified professional midwives allow people to choose their place of birth — home or birth center, within a network that involves a coordinated transfer into the hospital for care as needed.
National midwifery week is Oct. 6-12. Let us all join together and celebrate midwives and the important work we do — in Homer and in the world. The word “midwife” is a German word and simply means, “With Woman.” Go celebrate your midwife today!
Dana Whittaker, CNM, APRN has cared for pregnant women and their families for over 30 years and has lived in Homer since 1986. She recently retired form South Peninsula Hospital to spend a year working in Sierra Leone.
