05 May 2020

International Day of the Midwife: Q&A with Anneka Knutsson

“Once a midwife, always a midwife,” says Anneka Knutsson, chief of the sexual and reproductive health branch at the United Nations Population Fund. Anneka, who grew up in Ethiopia, became a teacher in midwifery before earning her doctorate in health care pedagogics. She was a midwife advisor for UNFPA in Bangladesh and worked at the Swedish International Development Agency for a decade.

For the International Day of the Midwife, Every Woman Every Child caught up with Anneka to learn about the roles of midwives, how their jobs have changed during the COVID-19 crisis, and the best ways to protect them during this pandemic. This interview has been lightly edited for clarity.

For those who might not know, how does one become a midwife? 

Midwifery is a profession and as such it has a standardised educational program. In the best of worlds, that curriculum is a three-year direct entry BSc program that in some countries can also include a master’s and PhD degree. 

The core of midwifery care is really about accompanying women through processes related to her sexual and reproductive life; through pregnancy and childbirth, but also through her whole life course from puberty to menopause. The education is both theoretical and practical and the practical part cannot be underestimated. The midwifery science and the midwifery practice is very much in how you use your senses as tools and is embodied in your hands, your ears, your eyes, your mind and critical thinking. 

In the program I went through, I had to deliver 50 babies independently and care for 100 women in labour. This is not the case in all countries. Sometimes, unfortunately, the regulation is such that [midwives] are not allowed to be part of a real delivery until education is finalized. That is why it is so important that we support evidence-based education programs and ensure that graduate midwives are competent and skilled.

What types of work does a midwife do? 

Midwives are often seen as working mainly with pregnancy and childbirth. This is true and essential, as midwives with the right education and skills can save lives by  handling some of the complications that are direct causes of maternal deaths—hemorrhage, infection, sepsis and a condition called preeclampsia. 

The midwife’s scope of practice is also much broader. A midwife can work with adolescents. She can work as a contraceptive counselor. She can work with counseling and supporting women through menopause. She can work with cervical cancer and morbidities. Midwives help with preventing unintended pregnancies, unsafe abortions, informing and educating people around their sexual and reproductive life and health and wellbeing. 

On a bigger scale, midwives are women who are well-connected in their communities. They have the women’s trust so when the midwife has established a relationship, it’s more likely that the woman will seek clinical services when it’s time for her to deliver. They empower women and make them feel respected and trusted. If there is no respectful care, women will find out very quickly and they may avoid going to the clinic. 

Usually, what we say is that midwives can provide 87 per cent of all the interventions that a woman needs for her sexual and reproductive health and well-being—but that can only happen if the midwife is well-educated according to the international standard, her practise is regulated, and she has the support and enabling environment she needs. And the WHO estimates that there will be a shortage of nine million nurses and midwives by 2030

 How is COVID-19 impacting pregnancy and birth and the work of midwives? 

One of the big risks with COVID-19 is that women fear going to the clinic. They do not know whether it’s safe, so we will see a spike, I think, in going back to traditional birth attendants and delivering on their own at home, because they’re really scared of contracting COVID-19 in the clinic. Women may also not have the ability to go to the clinic and may be stopped heavy-handedly by law enforcement if they try and this violates the physical distancing or curfew rules.

Overmedicalization is something we struggled with before COVID—doctors promoting Caesarean sections when it’s not medically necessary. When midwives are leading, we don’t see this as much. But what we’ve seen in relation to COVID is that some countries have wanted to speed up delivery for the woman and what we know is that if you induce a woman who is not [ready], that will create more complications. If you want to speed up something that nature wants to do at its own pace, you may end up with more severe complications than in letting nature do its part. 

What are some other changes to midwifery and birth during this pandemic? 

First of all, midwives are many times not even considered for receiving protective garments. That is one thing that UNFPA is working very hard to get. If midwives don’t have protective garments, women will not seek the care, and we have a vicious cycle of complications and deaths. 

The pandemic is also influencing the psychosocial wellbeing of parents and midwives and raising the stress levels. My son and his partner just had their first child and, in a country where partner participation has been central, suddenly he was only allowed to be there four hours after the delivery and then he had to go home. In other places partners are not allowed at all or babies and mothers may be separated due to misinterpretation of guidelines.  

One of the suggestions in the call to action released today is to include midwives in policy, decision-making, planning and response to the crisis. Concretely, what does that look like? 

Every hospital and every clinic has a structure for making decisions, putting out guidelines for how the hospital should function and how the maternity ward should function. Midwives need to be in those committees. They need to be asked. It’s really about asking for advice about what they think would be the best solution, because otherwise we may end up with a situation where the midwives cannot work or they cannot provide the care that they are requested to provide. 

So I think it may sound very high-level, but it can be done at the local level, the regional level, and also at the high policy level in different ways. It is important for it to be done at all levels. 

I also think it’s important to remember that midwives are usually women working with women, and they also experience the same structural discrimination as their clients. That makes it harder for them to have their voices heard, harder for them to be part of these policy decision-making structures. They themselves are exposed to sexual harassment, they often have responsibility for their own children. They may be exposed to gender-based violence at home. 

Another interesting suggestion in the call to action was to avoid redeployment of midwives in other spheres, such as to care for COVID patients, unless otherwise unavoidable. Why? 

If a midwife is also a nurse, they can more easily be moved around to other specialities. But the midwife is trained to do midwifery and not nursing. If she is redeployed, it has a big effect on her own professional capacity, her own safety—but most of all, the safety of the women that need her in maternal health care. We need to maintain services to ensure that we don’t get another pandemic in the pandemic and are not going back on the results we have achieved in terms of decreasing maternal and newborn deaths. 

Please visit the International Confederation of Midwives’ COVID-19 resource page for more information.