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The year 2020 has been declared by the United Nations as the year of the nurse and midwife and stories of heroic and outstanding midwives and nurses are being highlighted throughout the year.

Yesterday, on 5 May, the world celebrated the International Day of the Midwife honoring the life-saving work of midwives everywhere.

The life of a midwife in Somalia is a 24/7 job combined with diverse emotions ranging from exhilaration to exhaustion. Some days a pregnancy ends with normal birth, and a healthy baby and the smile on the mother’s face make the midwife feel triumphant. When the mother and her family members express gratitude to her, she feels accomplished deep inside her. Some parents may even suggest naming the baby girl after the midwife hoping the new-born may borrow a little kindness and hard-work from their midwife. The midwife enthusiastically shares important information to the mother; she encourages early initiation of breastfeeding, the need to exclusively breastfeed in the first six months of the baby’s life, the importance of regular clinic attendance for growth monitoring and immunization. Similarly, the mother receives information related to birth spacing, postpartum clinic attendance, and adopting a healthier lifestyle. 

Other days are harder; the midwife finds herself in a situation where the woman is in severe distress and very few health professionals are around the midwife to lend her a helping hand. Occasionally, the necessary items needed to save the life of mother and baby may not be at hand. She immediately embarks on a series of interventions including opening the intravenous route, placing an infusion to prevent an imminent shock and informing the ambulance driver for a possible need of a referral to a hospital.

Sometimes the story ends with excitement and happiness while in other instances, it does not.  Many midwives work under harsh conditions because of security, absence of referral systems, competing with the traditional birth attendants. At times, no regular salaries are in place and the only motivation the midwives have is to help stop a lifelong tragedy to a family or families in her communities. 

Somalia has one of the worst health indicators in the world following decades of conflict complicated by natural disasters and disease outbreaks. The health system in Somalia is highly underfunded, relying mainly on user-fees and international donations.

Maternal Mortality Ratio (MMR) represents the risk of death associated with each pregnancy (obstetric risk) and is an essential indicator in the monitoring of the Sustainable Development Goals (SDGs).   The world has a global target of less than 70 maternal deaths per 100,000 live births and that all countries should have less than 140 maternal deaths per 100,000 live births by 2030 (Every Woman Every Child, 2015). In 2017 alone, 295,000 women died as a result of a pregnancy-related cause worldwide. More than 90 percent of the maternal deaths occurred in the developing countries, and sub-Saharan Africa accounted for almost 75 percent of the deaths (World Health Organization, 2019). With the right intervention at the right time, most of these deaths could have been avoided. According to the Somali Demographic Health survey (SHDS), the MMR in Somalia stands at 692 per 100,000 live births, a decline of 136 from 2017 estimates (Directorate of National Statistics, 2020).

Globally, hemorrhage, hypertensive disorders, and sepsis lead to more than 50 percent of maternal deaths, according to studies. In South Asia and sub-Saharan Africa, over 75 percent of pregnancy-related deaths and stillbirths are due to obstetric hemorrhage, pregnancy-inducted hypertensive disorders, and pregnancy-related infection. On the other hand, newborn deaths resulted mostly from foetal suffocation, severe infections, and preterm births. The most significant proportion of women die between the last three months of pregnancy and the first week of birth worldwide. Maternal deaths can be exceptionally high on the first two days after birth.(Ronsmans and Graham, 2006).

Similarly, 75 percent of newborns die within the first week of birth.  In Africa and Asia, a study found that 40 to 45 percent of maternal deaths, stillbirths, and neonatal deaths occurred during labour, childbirth, and 24 hours after birth. 

A responsive health system that ensures access to quality and timely emergency obstetric and neonatal care, coupled with access to family planning, is central to significant prevention of maternal and neonatal deaths. In Somalia, in 2016, only 35 percent of basic facilities offered all the Basic Emergency Obstetric and Neonatal Care while 37 percent provided full comprehensive obstetric and neonatal care services. According to the Somali Health and Demographic Survey (SHDS), only 32 percent of women delivered with the assistance of skilled birth attendants, a 23 percent increase from 2006 estimates. On the other hand, only 1 percent of women of reproductive age are currently using modern contraceptives, a figure that has not changed since 2006. There is a significant urban/rural/nomad disparity of the distribution of skilled health professionals as more than 85 percent are in the urban areas, according to a 2016 report by the Ministry of Health.

In the last two decades, the need for skilled birth attendants (SBA) at birth was promoted to reduce preventable maternal and perinatal deaths. 

Despite an increased proportion of women delivering with the assistance of SBA, in many developing countries, a proportional reduction of MMR was not observed. WHO, UNFPA, UNICEF and other partners revisited the definition of skilled birth attendance. In the new revision, the agencies emphasized the need to have an integrated team of maternal and neonatal health professionals, trained and accredited to national and international standards and working in an enabling environment.  The United Nations asserts that within an enabling environment, midwives who are trained and regulated to international standards can adequately offer 87percent essential care needed for women and new-born babies. In Somalia, there is a severe shortage of midwives which has resulted in avoidable maternal and newborn deaths.

In collaboration with the government, donors, and other relevant partners, UNFPA supported the development of a midwifery strategy, establishment/strengthening of midwifery schools, and strengthening of basic and comprehensive obstetric and neonatal care facilities. 

Since we are already in the last decade of the SDG era, Somalia needs to focus more than ever on the production of newly qualified midwives that are trained and regulated to the national and international standards. The midwifery and other health professional regulatory system strengthening must be prioritized. 

Having motivated midwives, who are educated and regulated to the national and international standards, equitably distributed and placed in facilities equipped with the necessary resources, is the best investment in time. Those midwives are able to promote birth spacing, help protect women and girls from harmful practices and avert maternal and neonatal morbidities and mortalities. 

During this COVID19 pandemic, midwives can safely provide a bulk of their antenatal and postnatal care services through media. All partners need to prioritize the personal protective equipment for midwives in this difficult time.

                                                                                                                                                                                                                        ------ Dr. Adam Haibeh Farah