History of Midwifery: The role of advocacy in midwifery

3 November 2022

Advocacy is innate to midwifery. Since the earliest days of the profession midwives have witnessed and experienced the challenges faced by women at birth beyond and have communicated those challenges to community leaders. The history of midwifery is therefore inextricably linked with movements to expand women’s rights and bodily autonomy, and as we celebrate ICM’s centennial anniversary, it’s important to reflect on the role of advocacy in shaping our profession and advancing human rights.

To do this, we spoke with Angela Nguku — graduate midwife, founder of White Ribbon Alliance Kenya, Deputy Chief Executive Officer of White Ribbon Alliance and a passionate maternal, newborn and adolescent health thought leader and champion whose career spans over 17 years of dedicated work towards ending preventable maternal and newborn deaths globally. By walking us through her career, Angela highlights the changes she’s witnessed in how midwives practice and acquire advocacy skills and how these skills are becoming increasingly essential for young and up-and-coming midwives.

For Angela, the role of advocacy in midwifery is personal.

“When I started out my midwifery career, I was really excited to go out and work with mothers and deliver babies,” says Angela. “I thought the systems were going to support me to do my job well.”

In 2006,  Angela was fresh from a midwifery internship and decided to leave Kenya for South Sudan to gain international work experience. South Sudan had just emerged from a brutal civil war that had extracted a terrible toll in the form of preventable maternal and newborn deaths.

“My hands were tied because first off, the system was fully dysfunctional, but mothers were still delivering babies and they needed midwives to support them, says Angela. “There weren’t even basic supplies like gloves or blood…in fact, there were no trained midwives, only traditional birth attendants.”

Angela had the skills and competencies to support the women seeking her care, but she lacked the system support to be able to adequately deliver this care. In other words, what we now refer to as the enabling environment for midwives — one that supports the infrastructure, profession, and system-level integration needed for midwives to effectively practice their full scope of work — was missing, and as a result women and newborns were dying from preventable causes.

While there was no clear or easy solution to the challenges Angela confronted in South Sudan, she realised that one area she could advance was midwifery education. With support from her then organization and funding from UNFPA, Angela spearheaded work on the country’s first midwifery education curriculum and went on to start the first-ever Community Midwifery School in Maridi, South Sudan. Despite this accomplishment, she recognised that real, systemic change would only be possible if more midwives had the tools and skills to advocate for their needs, and the needs of the women in their care.

“There was so much disconnect between midwifery skill sets and competencies and the functional health system. [Decision makers and community members] didn’t understand that midwives without a functional health system – they simply can’t practice,” says Angela. “At some point I said ‘no’, we cannot continue with business as usual. Midwives need to speak up about their issues and what they are going through, but better still, the world needs to know that mothers and newborns are dying, and these deaths are preventable.”

This realisation catalysed Angela’s advocacy career, and her work training and supporting midwives to tell their stories as a way of effecting systemic change. And while Angela says she has witnessed an increase in the number of midwives involved in advocacy work in Kenya and elsewhere, she notes there are barriers to midwives participating in policy reform.

“A lot of midwives want to speak up, but the patriarchal systems don’t allow it – there are hierarchies in place, and midwives are reprimanded if they try and change the status quo,” says Angela.

Moving forward, Angela hopes that advocacy skills become integrated into midwifery curricula, allowing midwives to understand their potential as change-makers and women’s rights advocates.

“Advocacy is an afterthought in many spaces,” says Angela. “As midwives, we are constantly told that we are patient-advocates, but if you are not given the skills to be able to do that, it’s impossible… in the same way we connect midwifery educators, we need to create spaces to connect midwife advocates so that they can share ideas and collaborate towards like-minded objectives.”

To support advocacy skills-building, Angela coined what she calls ‘the four Ps of midwifery advocacy:

“Number one, you have to have the Passion to seek change and you can’t stop. Two, you must Persist, because the journey can be disheartening… [Three], you have to Persevere.” The fourth ‘P’ is ‘Pay’ which Angela says represents the need to have a clearly defined understanding of what success looks like. 

Angela herself has experienced plenty of success in her own career, having played an integral role in shaping and exemplifying midwifery advocacy. She was involved in adapting the SMART advocacy programme for midwives, building the Midwives’ Voices, Midwives Demands survey, and throughout her career, she has represented midwives in global, regional and local forums, contributing to the way leaders, decision makers and community members understand midwives and midwifery.

So, what should we take away from Angela about midwifery advocacy and the historical and inextricable link between midwives and social movements? As long as women and newborns are dying from preventable deaths, and as long as women are fighting for their rights to control their own bodies and dictate their futures, midwives like Angela will keep championing their demands.

Here’s to the next 100 years of midwifery advocacy.

To learn more about ICM’s advocacy resources – click here.

To learn more about how the White Ribbon Alliance supports and develops advocates, click here.