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 andimbalances in the distribution of health workers. With insufficient production,downsizing and caps on recruitment under structural adjustment and with frozensalaries and losses to the private sector, migration and HIV and AIDS, fillingthe supply gap will remain a major challenge for years to come.

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

In many countries the shortage is extremely acute, especiallyin sub-Saharan Africa. In Ethiopia, a total of only 1,936doctors are currently estimated to be working in a country that needs over 80percent more than that just for maternal health. In south and south-east Asiathere 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 therequired obstetricians and 27 percent of the required nurses/midwives are currentlyfully deployed in rural postings. Urgent action is therefore required tocorrect the geographical distribution, skills mix and working environment ofthe current maternal health workforce.

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

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

Means to address geographic gaps include:

• greaterattention to deployment procedures
• improvingincentives for nurses and doctors to serve in rural areas
• improvingworking conditions
• contracting with non-governmental organisations orself-employed doctors.

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

Progress in professionalising maternity care has been heldback by stagnation in many areas of the world. There is an urgent need forcountry specific comprehensive health plans with a clear understanding of thecurrent situation of maternal health workers, facilities, workforce needs andconstraints. Health workforce projections have shown that there is very littlebenefit in finding short-cut solutions. Tackling the problems of safemotherhood today requires scaling-up professional skilled care provided mainly infacilities. Reaching this goal requires strong political leadership and asustained commitment over time to tackle the severe crisis in human resourcesfor maternal health through efficient production, effective deployment,competent management of staff leaving the health sector, and appropriateutilisation of already existing resources.