Anfa Abdirahman Ahmed, 23, from Lower Shabelle, is a qualified midwife, but she is unemployed. “I don’t have a job because I wasn’t willing to take up the one I was offered in a hardship area far from home. I was deployed to a health centre almost 100 kilometers from here. I fear for my safety as the area is insecure and faces terror attacks,” says Ms. Ahmed.
She also says she was more discouraged to take up her post after hearing of frequent salary delays from some of her friends who work in hardship areas. “Where will I get money for bus fare to travel to and from work if salaries delay and there is a security problem? I would rather look for some private work, though low paying, but not go so far away from my home,” Ms. Ahmed says.
Over two decades of instability and the chronic crisis situation in Somalia have had a negative impact on access to healthcare and professional development, including reproductive health services and midwifery. The country remains one of the most complex emergencies globally, as it still experiences protracted conflict in addition to natural disasters such as recurrent drought, floods, cyclones and most recently, a massive locust infestation.
“The fragile and weak health system, in addition to access constraints due to security concerns, contribute to the poor reproductive and maternal health outcomes especially among the most vulnerable populations., says UNFPA Somalia midwifery specialist Ms. Hawa Abdullahi Elmi.
Somalia has one of the highest maternal mortality rate in the world, although it has reduced from 732 in 2015 to 692 per 100,000 live births in 2020. Despite the progress, the maternal mortality ratio is still one of the highest globally. Access to skilled birth attendance and facility-based deliveries has decreased from 36 percent in 2011 to 32 percent in 2020.
“A strong component of reducing maternal mortality is by ensuring skilled birth attendants at every birth. In Somalia, midwives are one of the most important components of reducing maternal mortality,” said Ms. Elmi, adding: “there is a severe shortage of midwives in Somalia, with a gap of over 20,000 midwives, with increasing needs as the population grows; through high fertility rates.”
According to the midwifery specialist, a weakened health infrastructure, high illiteracy levels, shortage of skilled health workforce, inadequate health personnel training institutions, and inadequate investment in public health have stalled a sound health system.
A deployment policy for nurses and midwives in Somalia was developed in 2019. It emphasizes the transparent selection and recruitment process and equitable distribution of workforce along rural and urban and hard-to-reach areas balance and the urgent need to compensate the health workers adequately. The policy is yet to be implemented.
Ms. Fatima Mohamed Abdalla, fondly known as Mama Fatima, an official of the Somali Midwifery Association who has also served as a midwife for over 30 years, wants to see the policy in motion. “This policy should be able to enable the young midwives to be willing to take up jobs in hard-to-reach areas and provide much-needed maternal and neonatal services to people.”
She said she endured as she has worked in many places around, including hard-to-reach areas, to save the lives of my fellow Somali women who cannot easily access quality reproductive health. “Many end up dying needlessly,” she laments.
“Challenges such as poverty, walking long distances to reach the nearest health facility where there are no buses, no good roads and no ambulances for effective referral of cases to the hospital are some of the issues contributing to the high maternal mortality in Somalia. The deployment policy should be able to enable young midwives to make a difference,” said Ms. Abdalla.
Ms. Elmi, the UNFPA Midwifery Specialist, underscores the importance of commitments by midwifery stakeholders to support the employment, deployment, retention and motivation of midwives to serve the mothers and children of Somalia effectively.
Elmi says, “We can only improve the health of women and their children by having the midwives work across the country, particularly in the hard-to-reach areas where access to skilled birth attendant is difficult, and the maternal mortality rate is very high, therefore investing in Midwifery deployment is very crucial”.
UNFPA is committed to supporting Somalia to increase the skilled birth attendants at every birth. The evidence shows that it is one of the most cost-effective interventions in reducing maternal and neonatal mortality. In pursuance of this belief, UNFPA has been providing significant technical and financial assistance to Somalia since 2010 towards the professional development of the health workforce, especially in midwifery through professional training, practice leadership, governance and work employment.
The needs of the maternal health workforce include the criterion for all health professionals to be trained in an approved training institution and licensed to practice by their respective regulatory agency, regardless of whether or not they are employed in a public or private facility. There is a significant disparity in health workforce training, employment, deployment and distribution across the country. This is primarily influenced by the number and quality of training institutions, health facilities, type and capacity of employers, compensation packages and prospects for career development.
Most health care employers, midwifery training institutions and maternal health facilities are concentrated in the cities, which negatively impacts rural and hard-to-reach populations.
The number of health professionals across all cadres is also far below the global standards recommended by the World Health Organisation (WHO) and the Sustainable Development Goals (SDGs) index.
Somalia has an unmet gap of 20,000 midwives. Further, about half of the trained midwives are not employed by the Ministry of Health due to budgetary limitations and instead work for non-governmental organizations (NGOs) and private employers whose schemes of service are not well-coordinated and as such, not sustainable. Consequently, women in the hard-to-reach areas of the country remain without access to skilled birth attendants.
UNFPA supports midwifery training schools to produce well qualified and competent workers to offset the shortfalls in the midwifery workforce. In line with this, UNFPA continues to lobby for resources to be set aside in the public sector for employing and deploying qualified midwives, especially to underserved areas.
UNFPA intends to continue supporting the health system in Somalia so that, in due course, the country will have quality maternal and reproductive health.
