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 of the maternal health workforce crisis 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 acute, especially in sub-Saharan Africa. In Ethiopia, a total of only 1,936 doctors are 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.

Recruitment and retention

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, leading to a drain on the public sector, conflicts of interest between health workers and their patients, and sometimes 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 varied 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.

Malay Kanti Mridha and Marge Koblinsky
Public Health Sciences Division, ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh
T +880 988 1762
F +880 2 882 6050
margek@icddrb.org

See also

African Health Workforce Observatory: Health Workforce Information
www.afro.who.int/hrh-observatory/hwinformation

World Health Report 2006: Working Together for Health
www.who.int/whr/2006/en/index.html

'Going to Scale with Professional Skilled Care', The Lancet Maternal Survival Series 3 368(9544), pages 1377-1386, by Marge Koblinsky, Zo‘ Matthews et al, 2006
www.thelancet.com/journals/lancet/article/PIIS0140673606693823/fulltext

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