Shortages and shortcomings: the maternal health workforce crisis

Providing maternal care requires a viable and effective health workforce. In many countries, and certainly in all countries where maternal mortality is high, the size, skills and infrastructure of the workforce is inadequate.

The most visible features are the staggering shortages and imbalances in the distribution of health workers. With insufficient production, downsizing and caps on recruitment under structural adjustment and with frozen salaries and losses to the private sector, migration and HIV and AIDS, filling the supply gap will remain a major challenge for years to come.

With the world’s 136 million births every year an estimated 152,000 doctors and 759,000 midwives or nurses (according to WHO 2005 benchmarks) are needed to provide adequate pregnancy, delivery and postnatal care for both mothers and babies. More than 80 percent of these workers are needed in the 75 countries that rank highest in the world in terms of both rates and gross numbers of maternal deaths.

In many countries the shortage is extremely acute, especially in sub-Saharan Africa. In Ethiopia, a total of only 1,936 doctors are currently estimated to be working in a country that needs over 80 percent more than that just for maternal health. In south and south-east Asia there are also shortages, but primarily the issue is one of poor distribution. In India, for example, a national assessment found that only six percent of the required obstetricians and 27 percent of the required nurses/midwives are currently fully deployed in rural postings. Urgent action is therefore required to correct the geographical distribution, skills mix and working environment of the current maternal health workforce.

In many countries salary levels are unfair and insufficient to provide for daily living costs, let alone to meet the expectations of health professionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers service delivery as health workers practice simultaneously in the public and private sectors to make ends meet, leading to a drain on the public sector, conflicts of interest between health workers and their patients, and sometimes outright financial exploitation of women and their families.

Apart from taking urgent corrective action on salaries and conditions, strategic decisions must be made in three areas: training, deployment and retention of health workers. This is not impossible. Results from simulations show that, in Bangladesh, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40 percent by 2015. Such an approach creates the possibility of scaling-up maternal services as much as 10 times more quickly than would be the case with deploying solo dedicated or even multipurpose health workers for home deliveries.

Means to address geographic gaps include:

• greater attention to deployment procedures
• improving incentives for nurses and doctors to serve in rural areas
• improving working conditions
• contracting with non-governmental organisations or self-employed doctors.

However, evidence to guide some of these strategies is currently patchy and will require further development. Delegation of responsibility to lower level cadres along with additional training have also been used effectively to fill some surgical skills’ gaps in Mozambique and Malawi.

Progress in professionalising maternity care has been held back by stagnation in many areas of the world. There is an urgent need for country specific comprehensive health plans with a clear understanding of the current situation of maternal health workers, facilities, workforce needs and constraints. Health workforce projections have shown that there is very little benefit in finding short-cut solutions. Tackling the problems of safe motherhood today requires scaling-up professional skilled care provided mainly in facilities. Reaching this goal requires strong political leadership and a sustained commitment over time to tackle the severe crisis in human resources for maternal health through efficient production, effective deployment, competent management of staff leaving the health sector, and appropriate utilisation of already existing resources.

Source(s):
'Going to Scale with Professional Skilled Care', The Lancet Maternal Survival Series 3 368(9544), pages 1377-1386, by Marge Koblinsky, Zoë Matthews, Julia Hussein, Dileep Mavalankar, Malay K. Mridha, Iqbal Anwar, Endang Achadi, Sam Adjei, P. Padmanabhan, Bruno Marchand, Vincent De Brouwere and Wim van Lerberghe, 2006

id21 Research Highlight: 2 August 2007

Further Information:
Malay Kanti Mridha and Marge Koblinsky
Public Health Sciences Division
ICDDR,B
GPO Box 128
Dhaka 1000
Bangladesh

Tel: +880 988 1762
Fax: +880 2 882 6050
Contact the contributor: margek@icddrb.org

Public Health Services Division, ICCDR,B, Bangladesh

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'Improving the health of mothers and babies: breaking the health system constraint', id21 insights health 11, August 2007 >

'Editorial: Improving the health of mothers and babies'

''Too much care' threatens maternal health'

'Achieving universal coverage of maternal health care'

'The impact of maternal health on poverty'

'Generating political priority to reduce maternal mortality'

'A forgotten priority: maternal health service infrastructure'