If there’s anything about responding to an epidemic, it’s that speed matters, and so does investing in people closest to the problem, said Dr. Raj Panjabi, Assistant Professor of medicine at Harvard Medical School and CEO of Last Mile Health, in this week’s Friday Podcast. The latter, he said, is the root of resilience.
In addition to threatening immune systems, COVID-19 is a serious threat to the broader health system and to non-COVID-19 health care. Drawing on lessons from the Ebola outbreak, Panjabi said that the best system is an everyday system capable of surging in a crisis. Creating such a system would involve sufficiently funding community health workers before communities experience a state of emergency.
In the absence of existing and well-funded health systems, communities are left scrambling in a crisis and quality of care declines as a result. During the Ebola epidemic, the availability of skilled facility-based birth attendants across Liberia plummeted three-fold because health workers were becoming infected, Panjabi said. To complicate the issue further, health systems had poor infection control, and people were afraid to go to the hospital. Even in low-transmission areas, expectant mothers who believed they could get an infection from a health worker in a health center were about 50 percent less likely to go to the hospital for the birth, said Panjabi.
However, there were cases of strong community-based responses. South Africa, for instance, had about 27,000 HIV & TB community health workers who were retrained. They went on to screen more than 11 million people—about 20 percent of the population— and help detect COVID-19 at the community level in the first months of their pandemic, Panjabi said. South Africa managed to do this because it had been already investing in everyday health workers. And Liberia has improved its health systems since Ebola as well. One in two rural children with malaria are being tested and treated “by their neighbors, by community health workers,” said Panjabi.
These case studies illustrate why it is crucial that community health workers in Africa—most of whom are women from poor communities—should be viewed as invaluable employees rather than as informal volunteers. After all, investing in community health workers is not simply a health issue, said Panjabi. The COVID-19 pandemic has been a reminder that robust health systems can benefit both the economy and the security of nations, he said. Based on fiscal stimulus projections from the UN Economic Commission for Africa, Panjabi said that allocating just $2 to $4 billion of a $100 billion budget would help fund a potential pandemic health workforce that could not only help us deal with this current pandemic but help us become better prepared for the next one.
For every dollar invested in community health workers, there is ten dollars’ worth of economic return. That stimulus provides protection against the next outbreak and allows patients to lead longer, healthier, and more productive lives, said Panjabi. “But it’s also one of the fastest ways to create jobs for young people on the continent,” he said.
“Vaccine hesitancy is to be expected in a normal circumstance—it’s very different from being what we call ‘anti-vaccine,’” says Dr. Rahul Gupta, Senior Vice President and Chief Medical and Health Officer at March of Dimes, in this week’s Friday Podcast. He spoke at a recent Wilson Center event on ongoing efforts to develop and deliver a COVID-19 vaccine, co-sponsored by the University of Pittsburg, March of Dimes, and the Jonas Salk Legacy Foundation. "It is normal for average citizens and residents to be questioning the vaccine before they take it into their bodies. That's where the transparency of the manufacturing process, the regulatory process, and building trust in that system is so critical and important. It is not wrong, at all, to be hesitant. What is important is to demand that we have a safe and effective vaccine," said Gupta. “Leadership matters,” said Dr. Lisa Waddell, Chief Medical Officer of COVID-19 Emergency Response at the CDC Foundation. “If we have a consistency in messaging around the vaccine and everyone is actually sharing that message, then yes, it is going to build trust.” It is important to communicate early, often, and in different ways to ensure that people receive these messages, said Waddell. We also have to consider the role health inequities and racial injustices play toward vaccine hesitancy, particularly in African American and Latinx populations, and provide information on the COVID-19 vaccine and address concerns through trusted messengers, said Gupta. “It is good to ask questions and it is good and important to have trusted messengers in front of you who can answer the questions, who can relate, who can communicate,” said Dr. Paul Duprex, Director of the Center for Vaccine Research and Professor of Microbiology and Molecular Genetics at the University of Pittsburgh. “We have before us a national and a global teachable moment when it comes to vaccines,” said Dr. Ruth A. Karron, Director of the Center for Immunization Research and the Johns Hopkins Vaccine Initiative at the Johns Hopkins Bloomberg School of Public Health. While vaccines are regularly researched, developed, and deployed, the process is not often on center stage. This gives us an opportunity to really educate the public, said Karron. “And I think that if we do this right, we could not only increase confidence in COVID-19 vaccines, but increase confidence in all of the vaccines that we deploy.” “It's important to remember that we need to champion these products, we need to show what they have done in the past,” said Duprex. Polio, which ravaged the world’s youth for decades, has been “pushed to the edge of eradication by safe, efficacious vaccines,” he said. “I think we have to remember not to forget. Not to forget what these diseases did in the past and to actively collaborate, to work with each other, and to communicate well that vaccines work.”
Globally, Indigenous women experience worse maternal health outcomes than non-Indigenous women. In the United States, the risk of maternal death is twice as high for Native women than for white women, while in Australia the risk is four and a half times higher. This week’s edition of Friday Podcasts highlights remarks from a recent Wilson Center event with the United Nations Population Fund (UNFPA) and the International Confederation of Midwives about Indigenous midwifery.
“The decline of Indigenous midwifery really happened through the outlawing and the denigration of Indigenous midwifery, and was an attack on our Indigenous knowledge systems, our ways of being, our ceremonies and our practices,” said Claire Dion Fletcher, an Indigenous Potawatomi-Lenape Registered Midwife and co-chair of the National Aboriginal Council of Midwives. “The control of Indigenous women through the, at times, violent control of our reproduction was and continues to be a tool of colonization.”
“In the 19th century with the medicalization of birth, there was a decline of midwifery in Canada, almost to the point of non-existence,” said Fletcher. Yet Indigenous women still wanted to have traditional births according to their customs and knowledge. “The Inuit women in Nunavik wanted Inuit midwives,” she said. “They wanted to give birth in their communities with their families surrounded by their knowledge and their teachings.” To this day, the resulting community-driven Inuit midwifery program has some of the “best health outcomes in the world,” said Fletcher.
Similarly, colonization played a key role in the decline of Indigenous midwifery in New Zealand, said Nicole Pihema, Māori Registered Midwife and President of the New Zealand College of Midwives. In New Zealand in 1840, British colonizers and Māori leaders signed a document intended to ensure that the British would not interfere in Māori life, said Pihema. But instead, the colonial government continued to interfere in Māori life by passing harmful legislation including the Tohunga Suppression Act of 1907, which led to the desecration of Māori midwifery practices. However, there is a resurgence within Māori midwifery to try to rediscover traditional practices, said Pihema. This resurgence requires a commitment to normalizing inclusive language, “because you can teach cultural competency all you want, but you're never [going to] get it unless you know the language,” she said.
“In Mexico, midwifery has existed even before we were colonized by the Europeans,” said Ofelia Pérez Ruiz (through a translator), an Indigenous Registered Midwife and spokesperson for the Chiapas Nich Ixim Movement of Traditional Midwives. “And traditional midwifery in Mexico has been here despite criminalization and going through exclusion policies,” she said. In Mexico, Indigenous midwives are not included in conversations about maternal health. “They [doctors and health institutions] don't take us into account as part of the maternal and neonatal care,” said Pérez Ruiz. “We want to have a relationship with health institutions, but based on respect. We wanted to work along and hand in hand with the doctors using those skills and knowledge of all of us as a team … so that indigenous women will receive a timely care and respectful care during their pregnancy, birth, and after birth.”
“Unintended pregnancy and abortion are reproductive health experiences shared by tens of millions of people around the world, irrespective of personal status or circumstance. What differs though are the obstacles,” said Dr. Zara Ahmed, Associate Director of Federal Issues at the Guttmacher Institute in this week’s Friday Podcast. Research from the Guttmacher Institute on sexual and reproductive health (SRH) found that in 2018, there were 121 million unintended pregnancies globally, and of those, 61 percent ended in abortion. About half of these abortions were in unsafe conditions and led to approximately 23,000 preventable pregnancy related deaths, said Ahmed.
“A major finding of our research is about the legal status of abortion,” said Ahmed. “This is important. Abortion rates are the same where abortion is broadly legal and where it's restricted - exactly the same.” Guttmacher research shows that in settings where abortion is restricted, the proportion of unintended pregnancies that end in abortion increased nearly 40 percent over the last 30 years.
“There are persistent inequities in meeting needs for contraceptive services,” said Ahmed. Today, 923 million women want to avoid a pregnancy and among these women, about one in four, or 218 million, have an unmet need for modern contraceptive methods. Unmet need for modern contraception is higher in low-income countries and for adolescents than it is in high- income countries and for older women. In order to meet this global need for family planning, the United States must restore funding for UNFPA and increase funding for global family planning and reproductive health programs, said Ahmed.
The COVID-19 pandemic has threatened access to SRH services worldwide. A decline of 10 percent in access to SRH services, said Ahmed, would lead to “an additional 49 million women with an unmet need for modern contraception, an additional 15 million unintended pregnancies, an additional 28,000 maternal deaths, an additional 168,000 newborn deaths, and an additional 3 million unsafe abortions, as well as an additional 1,000 maternal deaths due to unsafe abortion.”
“In the middle of a global pandemic, the Trump administration is trying to make it harder for people to get the [SRH] care they want and need. A few weeks ago, the administration announced that it's proposing to expand the dangerous and harmful Global Gag Rule even further than it already has,” said Ahmed. The Global Gag Rule (GGR) is a policy that “prevents foreign NGOs that receive U.S. funds through grants and cooperative agreements from using their own non-U.S. funding to provide abortion services, information, counseling, referrals, or advocacy,” she said. Guttmacher research in Uganda shows that the GGR led to a “reduction in the number of community health workers, engaged in family planning work.”
“People are complex and they live multifaceted lives with changing [SRH] needs,” said Ahmed. The global community must invest in the full range of SRH services to meet these needs. “Doing so is a smart investment, but it's also the right thing to do.”
“I believe that we're experiencing a national reckoning and in this unique moment, I definitely see an opportunity for Congress, but also for our local governments to enact policies that begin to address our country's greatest ills,” said Representative Alma Adams (D-NC-12) at a recent Wilson Center event on women, race, and COVID-19 in the United States. “COVID-19 has revealed what the Black community and communities of color have known for a long time—health outcomes are further compounded by systemic and structural racism. COVID-19 has exposed what women have known for a long time—gender inequality exists, it threatens economic empowerment, and it increases vulnerabilities.”
“The pandemic has shown us in the starkest terms how wide the gaps are in health outcomes between Black and White America and between men and women,” said Rep. Adams. Black women, regardless of their educational level or socioeconomic status, are nearly four times more likely to die from preventable pregnancy-related complications than women of other races. “The United States has the highest maternal mortality rate among affluent countries because of the disproportionate death rate of Black mothers,” she said. “Black maternal health in the coronavirus era is truly a crisis within a crisis.”
“The pandemic has completely wiped out the historic job gains women have made over the past decade,” said Rep. Adams. Before COVID-19, women made up the majority of the U.S. workforce. They are highly represented in the sectors most impacted by the pandemic. Women are the majority of essential workers, and non-white women are more likely to be doing essential jobs than anybody else, said Rep. Adams. “The work that they do has often been underpaid, undervalued, and an unseen labor force that keeps the country running.”
While there has been a positive reduction in women’s unemployment since the pandemic’s onset, most of those impacted are mothers. 41 percent of mothers, and close to 80 percent of Black mothers are the breadwinners for their families, yet continue to face wage inequality. “They're doing the providing, yet they're not getting the income,” she said. “We deserve equal pay for equal work. You know working hard is not enough if you don't make enough.”
“We are finding that from the offset of the COVID-19 pandemic there has been an increase in gender-based violence around the world. For every three months of lockdown, there will be an additional 15 million cases of gender-based violence,” said Sarah Barnes, Project Director of the Maternal Health Initiative and Women and Gender Advisor at the Wilson Center.
“As a survivor myself of domestic violence, I know firsthand how important it is that we keep working to pass and strengthen legislation to improve services for survivors like the Violence Against Women Act,” said Rep. Adams. “I see a tremendous opportunity for Congress and our society, as well, to pursue transformational structural change because the system isn't working for so many people, especially women and minorities, and it really is time to try to do something else.”
“NCDs have raised the risk of and the severity of the COVID-19 infection,” says Dr. Belén Garijo, Executive Board Member and CEO of Healthcare at Merck KGaA Darmstadt, Germany, in this week’s Friday Podcast. Women living with NCDs like cardiovascular disease, hypertension, cancer, mental health disorders, multiple sclerosis, and diabetes, have an increased risk of severe complications and death from COVID-19. “When you take a look at the mortality rate for one million inhabitants, you see a lot of diversity, and what has been consistent amongst all the countries is the association between severity of the infection and underlying diseases,” says Garijo.
“We know that this pandemic is affecting women in a number of ways that are very harsh compared to men,” says Dr. Felicia Knaul, an international health economist and founder of Tómatelo a Pecho. Since the onset of the COVID-19 pandemic, women have experienced “more unemployment, more lack of access to jobs in all but the health sector, more issues of caregiving and less ability to earn income, more exposure to domestic violence.”
“In the U.S., women accounted for up to 55 percent of the 20.5 million jobs that have been lost in April. In February, the unemployment rate for adult women was 3.1 [percent], in April this has gone up to 15 percent. In the same period, the unemployment rate for adult men was of 3.6 percent. And in April, this rate, 13 percent,” says Garijo. “The risk that we're facing is that we will see the gains of decades—which were not enough, but were still gains—in gender equality being eroded if we're not careful,” says Knaul.
“This pandemic has really changed the way we are looking at our research focus,” says Garijo. “I can tell you that we have, right now, almost completely focused our efforts in finding solutions for pandemics. I am hoping that we will never forget this, and that our pandemic preparedness will stay strong for the future in any and every continent. As an industry, we can never do that alone. We need to collaborate with others. We need to collaborate with governments. We need to collaborate with academic institutions, with healthcare professionals, with patient associations.”
“You cannot have strong health systems if you don't include women, not least which, because they are the majority of providers today.” says Knaul. “We've been working on some ideas around how to strengthen health systems in the face of COVID-19 and the first and key lesson is that this cannot be done without a gender transformative response.” A gender transformative response requires the inclusion of all genders, “otherwise we would never be strong enough, not only to respond to the COVID-19 onslaught, but what we're talking about today, which is the incredible onslaught of NCDs that face low- and middle-income populations and countries, as well as, high-income countries.”
“I am absolutely sure that you are aware of the articles highlighting that countries that have performed better against COVID-19 are led by women. I have to say that I don't believe this is by chance,” says Garijo. “Female leaders promote the more inclusive leadership model and they are willing to listen. They are willing to listen to diverse opinions and voices. They don't believe they know it all.”
This podcast is part of the Maternal Health Initiative’s CODE BLUE series, developed in partnership with EMD Serono, a business of Merck KGaA, Darmstadt, Germany.
COVID-19 has wreaked havoc the world over, and recent data shows that the hardest hit will be the world’s women and girls and populations impacted by racism and discrimination. This week’s Friday Podcast highlights remarks from a recent Wilson Center event sponsored by EMD Serono, the biopharmaceutical business of Merck KGaA, Darmstadt, Germany in the United States and Canada, on the impact of COVID-19 on race and gender inequities.
“Mortality of men [due to COVID-19] is higher but let me just emphasize that women play an outsized role in responding not only to COVID-19, but in many of the pandemics,” said Katja Iversen, President and CEO of Women Deliver. “The default health worker is now female,” said Dr. Roopa Dhatt, Founder and Executive Director of Women in Global Health. “Women make up majority of the workforce, but they remain clustered in the lower status, lower paid jobs, mainly the frontline. They also occupy most of invisible lower status jobs as well, so we need to factor in that they're subject to more sexual harassment and violence as a result and are not part of the decision-making table.”
“In the midst of this pandemic, bad policies and structural barriers may contribute to millions of people losing access to essential sexual and reproductive health (SRH) services,” said Zara Ahmed, Associate Director for Federal Issues at Guttmacher Institute. To minimize the negative impacts of COVID-19 on SRH services, Ahmed recommends defining and promoting SRH as essential; strengthening supply chains to make SRH medicines more accessible; making contraception available without a prescription; adopting innovative care models of care; and addressing the unique needs of vulnerable and marginalized populations.
UNFPA projections show that for every three months of lockdown, there will be an additional 15 million cases of gender-based violence. “In terms of gender-based violence, we're seeing an increase, and this is because of isolation, locked down, restricted movements, tensions in the households from financial and economic stresses,” said Leyla Sharafi, Senior Gender Advisor of UNFPA. Further marginalized groups like women with disabilities, indigenous women, and women and girls living in humanitarian settings have a heightened risk of experiencing violence, said Sharafi.
COVID-19 also exacerbates racial inequities. “So, we have three main root causes [of inequities] and those are racism, classism, and gender oppression,” said Dr. Joia Crear-Perry, Founder and President of the National Birth Equity Collaborative. “We do know that black women in the United States, despite income or education, are still more likely to die in childbirth than their white counterparts, so that's really where you see the overarching how those inequities and those beliefs around hierarchy can come together in one space and cause people to die,” said Dr. Crear-Perry.
Health care providers are at the center of addressing inequities in the healthcare system, said Dr. Neel Shah, Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and a practicing OB-GYN in Boston. “One of the challenges that I'm seeing right now is that the biology of this disease and the sociology of this disease really interact, and the people that are historically experts in the biology aren't fully attending to the sociology and honestly, vice-versa,” said Dr. Shah. “Currently we have to isolate people who are both symptomatic and asymptomatic which is effectively everyone. And isolating everyone takes all of the existing inequities in our society and it throws them into a pressure cooker.”
The year 2020 has been designated as the Year of the Nurse and the Midwife by the World Health Organization. In April 2020, the World Health Organization (WHO), International Council of Nurses, and Nursing Now, published the first-ever State of the World’s Nursing Report. This week’s Friday Podcast highlights remarks from a recent Wilson Center event on the report’s findings and recommendations.
One of the most exciting things about the report is the evidence on the nursing profession. The data gives nurses the opportunity to find their voices, said Barbara Stilwell, Executive Director of the Nursing Now Campaign. Instead of saying they need more nurses because they feel short of staff, they can present data to decision-makers to show that more nurses are needed on a ward. “You can put it in a graph like Florence Nightingale did and you can take it and show it and make your case for being given more resources,” said Stilwell. “And that’s exactly what’s happening now where we see nurses advocating for more resources to help them deal with the pandemic.”
While report findings show that approximately 90 percent of the world’s 28 million nurses are female, they still operate at a disadvantage compared to their male colleagues when it comes to pay equity, hiring, education, and workplace violence and harassment. “The same systems and structures of marginalization or oppression that we see in society such as sexism, racism, patriarchy, we also see these reflected in health systems,” said Rosemary Morgan, Assistant Scientist for the Bloomberg School of Public Health and School of Nursing at Johns Hopkins University.
While the vast majority of the nursing workforce are women, men hold most nursing leadership positions. “We must have a gender transformative leadership development program for women in the nursing workforce,” said Leslie Mancuso, CEO and President of Jhpiego. She called for nurses to have equal standing and a level playing field in pay and practice. Nurses, she said, should be treated equally regardless of gender, degree, or wages. One way to ensure that female nurses are adequately represented in nursing leadership is to invest in nursing.
The report highlights that we spend 25 percent of the healthcare education budget globally on nurses and midwives who make up 59 percent of the workforce. But that large a shortage may not be acceptable, given what it means for people’s work-life balance, stress, pressure, burnout as well, said Howard Catton, the Chief Executive Officer of International Council of Nurses.
WHO is working on investments in the health workforce to address the 6 million shortfall in nurses. The solution involves not only investment for education and training to increase the supply of nurses, but also creating decent, well-paid jobs with good working conditions, said Michelle McIsaac, Economist at WHO and Co-chair of the Global Health Workforce Network Gender Equity Hub.
While the data are impressive, so are the gaps in reporting, said Jennifer Breads the Gender Technical Advisor at Jhpiego, particularly around entry-level salaries, educational investments, labor market flows, and gender wage gaps.
The COVID-19 pandemic has illuminated the importance of nurses globally. Now more than ever, special attention needs to be focused on nursing. “Nurses remain the heroes we have in tough times that we are in today and they need our support,” said Emily Katarikawe, Country Director of Jhpiego Uganda.
“What are the underlying drivers of risk that created the conditions for Covid-19 to emerge, and how do we better address them?” said Lauren Herzer Risi, Project Director for the Environmental Change and Security Program, in this week’s Friday Podcast, recorded during a recent Wilson Center Ground Truth Briefing on the Covid-19 pandemic. This question framed the discussion, which explored the intersection of the environment, public health, and national security. Although the global pandemic came as a shock to many, the novel coronavirus was not a surprise to epidemiologists and experts who had been sounding the alarm for decades. There have been clear signals of the risks we face from animal-to-human virus transmission, including Ebola, SARS, and other regional epidemics, said Risi. These zoonotic diseases, especially now, are creating concerns about food safety, wildlife conservation, and public health. But the risks don’t just come from wet markets and our increasingly connected world.
Drivers of the Outbreak
Rapid urbanization and population growth created a ticking time bomb, as we have increasingly intruded into natural habitats. The loss and fragmentation of wildlife ecosystems has brought humans into closer contact with animals than ever before. While the exact origins of coronavirus have yet to be confirmed, we know that this amplified opportunity for virus transmission is a major factor. “An estimated 70 percent of new human infectious disease outbreaks come from pathogens that originated in animals,” said Sharon Guynup, Global Fellow at the Wilson Center and a National Geographic Explorer.
We are constantly expanding our interaction with animals and nature. “We need to be very, very clear that this is a human-made problem, a humanity-made problem,” said Dr. Ellen Carlin, Assistant Research Professor at the Center for Global Health Science and Security and Director of the Graduate Program in Global Infectious Disease at Georgetown University. “It’s really all of us collectively making decisions about the way that we live.” Human behavior puts pressure on natural ecosystems through land use and development, mass urbanization, agricultural intensification, extractive industries, and the growing global demand for commodities. Climate change further exacerbates the environmental degradation. Overall this trend is accelerating the emergence of zoonotic diseases in human populations.
Another aspect of this close contact between humans and animals is the prevalence of illegal wildlife trade and consumption. Some have called for bans in China, but wildlife trade and wet markets aren’t unique to China, and a solution will require global efforts, said Guynup. It will also be crucial to uphold and enforce the bans put into place, as China’s actions will have a ripple effect on the policies of neighboring consumer and hub countries. For progress to be made, she said, countries must develop multi-pronged approaches, including strengthening policies and enforcement at national levels, raising public awareness, promoting community involvement, and changing consumer behavior. While Covid-19 is much bigger than just a wildlife trade issue, it is a critical piece of the puzzle, said Guynup.
National Security Risks
The cascading impacts of the pandemic on human health, national economies, and society has elevated the coronavirus as not just a public health crisis, but a national security threat as well. There is currently a disconnect between environmental threats and security paradigms, said Rod Schoonover, founder and CEO of Ecological Futures Group. “Unfortunately, U.S. national security is outdated and needs to be recalibrated, I think, to reflect the threats that the country faces,” he said. Topics like climate change, land use, and biodiversity need to be core national security concerns instead of add-ons to geopolitical goals, said Schoonover, who was Director of Environment and Natural Resources for the National Intelligence Council. Security dialogues need to involve experts such as epidemiologists, ecologists, and climate scientists in order to establish a climate-smart, ecologically informed pandemic preparedness policy. “If you understand the deep connectedness of the planet,” he said, “you understand that the very support system of humanity is in jeopardy.”
Solutions for Covid-19
How to solve the current pandemic is a priority, but developing long-term plans for how we can better prepare for next pandemic is also important. “Given the deep interconnectedness of our world, this coronavirus will not be the last outbreak,” said Guynup. Among the many scientific and global health initiatives looking to develop solutions, the Global Virome Project is working to discover unknown zoonotic viral threats and stop future pandemics before outbreaks occur. The Coalition for Epidemic Preparedness is coordinating the development of vaccines against coronavirus and emerging infectious diseases. Although there is no binding global legal agreement on wildlife crime, the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), is scaling up enforcement efforts and incorporating the consideration of health risks.
We need to tackle the drivers of the pandemic to ultimately achieve prevention, said Dr. Carlin. A shift of epic proportions will be needed to reduce environmental and ecosystem harm. We have a choice to ignore recommendations and continue on with business as usual, or we can recognize our vulnerability to these emerging viral threats, Guynup said. “Our well-being is inextricably linked with that of the planet’s web of life,” she said. “In fact, one could argue that the state of the world can be measured by the state of the wild.”
What is inherent in the word “universal,” is that it is for all women, said Anneka Knutsson, Chief of the Sexual and Reproductive Health Branch at the United Nations Population Fund (UNFPA), at a recent Wilson Center event on the importance of midwives in achieving universal health coverage.
To achieve the ambitious sustainable development goal of universal health coverage, one challenge is to make sure that the women most marginalized aren’t left behind. Elena Ateva, Advocacy Manager at White Ribbon Alliance, said that in order to best support women, we need to ask them what they really need and want. And what women want differs from woman to woman depending on her beliefs, customs, gender identity, sexuality, etc. “We cannot determine policies for somebody else. We need people to be part of those processes,” said Ateva.
Midwives can play an important role in representing the needs of a community and reaching women traditional health facilities have often excluded. But, we have to be careful when thinking midwives, alone, are the answer, said Franka Cadée, President of the International Confederation of Midwives. “Midwives are part of a system.” Cadée said that while people are happy to have midwives working with patients, midwives need to also be at the decision-making table, at the ministry, and working with politicians. In the United Kingdom, a midwife serves as a medical officer to advise the Minister of Health on midwifery. To have a midwife in this high-level position allows midwives the opportunity to represent the communities they serve, as well as support the midwifery profession.
One way to elevate the status of midwifery and enact concrete change is through midwifery education. Since the early 1990’s, Sweden has created 13 midwifery education programs that go beyond clinical skills. Marie Klingberg-Allvin, Midwife and Professor in Global Sexual and Reproductive Health at Dalarna University said it is important to have strong academic environments which include research. Understanding and contributing to research gives midwives the ability to reflect, to read new science, to be part of developing new standard guidelines in the clinic, and to be vocal and take lead for their own profession, she said.
Globally, women make up the vast majority of midwives and gender discrimination plays a role in the limited number of midwives in decision-making positions. To close the gender gap, Klingberg-Allvin said, “you need to have gender-intentional governments to start with” and you also need to have a government that gives status to sexual reproductive health and rights. Cadée said, “Midwives don’t need to be empowered; midwives are very, very powerful. Midwives simply need to be listened to.”