First Forum on Midwifery in the Community

First Report from Hammamet Forum

Evidence shows that the health and well-being of mothers and their babies have improved in several countries,such as Costa Rica, Egypt, Malaysia, South Africa, Sri Lanka, Thailand and Tunisia, because of their investment in midwives’ and others’ training through national midwifery programme development. "Midwives form the bridge between communities and facilities. They transcend the levels of care within health systems, and are essential to the continuum of care during the childbearing cycle," said Kathy Herschderfer, the Secretary-General of the ICM.

Access to skilled care during pregnancy and childbirth is a woman’s basic human right. Investment in the training and supporting of midwives is urgently needed worldwide. An estimated 334,000 more midwives are required to reduce maternal and newborn death and disability, according to the 2005 WHO World Health Report. "A strong midwifery profession is key to achieving safer childbirth, and all pregnant women should have access to a midwife," said UNFPA Executive Director Thoraya Ahmed Obaid.

The organisers

The 1st International Forum on ‘Midwifery in the Community’ was organised by the International Confederation of Midwives (ICM), the United Nations Population Fund (UNFPA) and the World Health Organization (WHO), with the support of the Swedish International Development Agency (Sida), the Government of Luxembourg, the global research initiative IMMPACT, Family Care International (FCI), Averting Maternal Death and Disability (AMDD) and the Partnership for Maternal Newborn and Child Health (PMNCH).

The Forum brought together multi-disciplinary experts from 22 low- and middle-income countries in four regions of the world (Africa, Asia, Latin America and the Caribbean, and the Middle East) to consider how midwifery care in the community can be scaled-up. The organisers of the Forum recognise that efforts to date under the umbrella of the Safe Motherhood Initiative have always prioritised the need for skilled care at birth. However, the issue of strengthening quality midwifery care in the community has not received due attention, as compared to the focus on expandng – or ‘scaling up’ - emergency obstetric and neonatal care (EmONC). Yet without skilled midwifery providers working closely with women and their families, the knowledge of when and how to access such care, even the willingness to do so, is limited.

The background

The international community’s involvement in the scaling-up of the work of midwives and others with midwifery skills took a different dimension and pace with the publication of the World Health Report 2006 on ‘ Working together for Health’. The recognition of the magnitude of human resource shortages, coupled with the Lancet Series on Maternal Survival published later in 2006, triggered debate about the most effective strategies for reaching MDG5. As a result, attention is currently focused on how best to invest in the human resource dimension. It is recognised that there is an urgent need to review the characteristics of the current programmes for scaling up human resources for safe motherhood and to assess their potential effectiveness, before other countries embark on costly initiatives.

Delegates at the Forum brought together over 100 multi-disciplinary experts from 22 low- and middle-income countries in four regions of the world (Africa, Asia, Latin America and the Caribbean, and the Middle East) The overall objective of the Forum was to collate knowledge and experiences for developing policy and programme guidance for low-income countries wishing to strengthen their community midwifery workforce to save the lives of mothers and newborns. The specific objectives were:

  • to share lessons learnt in countries about strengthening community midwifery as a part of MMR reduction
  • to develop a framework for assessing midwifery capacity
  • to highlight issues requiring policy and programmatic action,
  • to develop a consensus on best-practice options for rapid scale-up on educating midwives and others with midwifery skills
  • to share experiences on developing a plan of action at country and regional levels to strengthen midwifery professional associations.

The themes

The Forum was inaugurated by Professor Mohamed Bechir Helayem, Director of the Tunisian National Centre for Training of Health Personnel, on behalf of the Tunisian Minister of Public Health. Technical sessions and country presentations fell under six main themes concurrent with current evidence seen as crucial for scaling up human resources for safe maternal and newborn care. The six themes were:

  • ‘Getting on to the political radar screen’
  • Ensuring that the poor and hard-to-reach have midwifery care
  • Education
  • Supervision
  • Enabling factors
  • Monitoring and evaluation.


Following the country presentations, participants then worked for two days in multi-country groups to consider recommendations for scaling up midwifery in the community in three typical, but different, case scenarios: a large low-income country, with high maternal mortality, low proportion of births by skilled birth attendants; a medium-sized low-income country with rapid urbanisation and maldistribution of skilled birth attendants; and a small country with a collapsed or close to nonexisting infrastructure. In closing, the participants of this 5-day Forum, the first of its kind, concluded that there were a number of issues that must be addressed in any country scenario for scaling-up midwifery in the community. These fall under six major headings:

  • Policy, legal framework and national standards and guidelines on midwifery
  • Ensuring equitable access to midwifery care
  • Competency-based education and training, including competency-based curricula, competent midwife teachers, capacity building of training institutions and parallel action for short and long-term Human Resources strategies 
  • Supportive and capacity-building supervision
  • Providing an enabling environment for midwives working in the community, including need for professional collaboration, equipment and supplies, housing, personal security, etc
  • Better evidence gathering, mainly through strong monitoring and evaluation.

Key messages

Having considered all the presentations and lessons learnt from countries working to strengthen provisions of midwifery services in or close to the community the participants of the 1st International Forum of Midwifery in the Community concluded that:

  • It is a right of all pregnant women to have access to skilled care before during and after childbirth. Care should be provided as close as possible to where women live 
  • Countries with high MMR should focus on scaling up skilled attendance with providers possessing the full range of midwifery core competencies (as defined by the ICM Essential Competencies for Basic Midwifery Care) - skills alone are not sufficient. Efforts must be driven by evidence from regular monitoring and evaluation
  • Birth attendants without full midwifery competencies must be supervised and trained by a competent midwife 
  • Midwifery is different from obstetric and/or maternity nursing and should be respected for its discrete and unique body of knowledge 
  • All midwives, including those working in the community, must function in an enabling environment, including supportive legal and policy framework, as well as having back-up from a supportive fully-functioning EmONC facility, adequate housing, provision for children’s education and personal security and be part of the overall maternity care team 
  • Teachers and supervisors of midwifery must be competent and experienced in midwifery, as well as educational and training technologies 
  • Men should be actively encouraged to engage more in culturally appropriate solutions to ensure access to skilled midwifery care in the community.


Further it was felt that there is an urgent need to bring to the attention of the wider community globally and their own countries, the issue of lack of access to midwifery care, particularly at the community level. With this in mind a Call to Action was made to all stakeholders, for urgent and intensified attention to scaling up midwifery in the community, addressing a number of priority areas: policies to ensure equitable access to midwifery care, strengthening regulatory systems for deployment and retention, investing in competency-based education and training, peer support and supportive supervision, provision of an enabling environment that includes ensuring basic safety of staff and their families. Permanent monitoring and periodic evaluation should drive all efforts.

The way forward

The following framework will be applied for developing the guidance document from this Forum. After a brief introductory session outlining the problems and issues, the guidance will be structured around the main recommendations that emanated from the groupwork:

  • advocacy for getting supportive policies and the necessary legal framework
  • ensuring competency-based education and training
  • provision of supportive supervision
  • providing an enabling environment
  • monitoring and evaluation
  • stewardship and funding 
  • Widespread dissemination of the final report and the guidance document to be produced. 
  • WHO to use the findings to convene a technical meeting to review the evidence and develop specific recommendations 
  • UNFPA and ICM, with other partners, to hold regional workshops to assist with operationalising the guidance
  • A plan to be developed for intensified advocacy and dissemination of the Call to Action, focusing on the need for urgent and concerted action in countries with high MMR and calling on them to include, as an urgent priority, greater investment in midwifery in the community.


Karen Odberg Pettersson, Della Sherratt and Nester T Moyo report on the 1st International Forum on Midwifery in the Community, held in Hammamet, Tunisia, 11–15 December 2006 (Article in International Midwifery, Volume 20 – Number 1 March 2007 9)

References and bibliography

De Bernis L, Sherratt DR, AbouZhar C, Van Lerberghe W.

Skilled attendants for pregnancy and childbirth. Br Med Bull 2003; 68; 39-57.

Högberg, U. Maternal mortality in Sweden. Doctoral Thesis, Umeå University, Umeå., Sweden, 1985

Koblinsky M, Matthews Z, Hussein J et al. Going to scale with professional skilled care. Lancet 2006; 368: 1377-86.

Campbell OMR, Graham WJ et al. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006; 368: 1284-99.

Padmanathan I, Liljestrand J et al. Investing in Maternal Health in Malaysia and Sri Lanka. World Bank 2003.

Pettersson KO, Christensson K, Gomes de Freitas EF, Johansson E. Adaptation of healthcare seeking behaviour during childbirth.

Focus group discussions with women living in the suburban areas of Luanda, Angola. Health Care for Women International 2004; 25.

Segovia I. The midwife and her functions by level of care. Int J. Gynecol Obstet 1998; 63, Suppl 1: S61-S66.

Stanton C, Blanch A, Croft T, Choi Y. Skilled care at birth in the developing world; progress to date and strategies for expanding coverage. J Biosoc Sci 2006; March; 1-12.

WHO, UNICEF Antenatal care in developing countries, promises achievements and missed opportunities: an analysis of trends, levels and differentials, 1990-2001. WHO Geneva 2003.

WHO. Critical Role of Skilled Attendants. A Joint Statement by WHO ICM FIGO. WHO, Geneva, 2004.

WHO. World Health Report 2005 Make every mother and child count. WHO, Geneva 2005.

WHO. World Health Report 2006, Working Together for Health. WHO, Geneva, 2006.

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