International Day of the Midwife - Q&A with Sulekha Rashid Ali, Federal MoH Somalia
Midwives are an essential part of the global health workforce responsible for providing lifesaving maternal and newborn care and in some cases other reproductive health services including providing family planning and detecting and treating sexually transmitted infections.
Evidence shows that “when midwives are educated to international standards, and midwifery includes the provision of family planning, it could avert more than 80% of all maternal deaths, stillbirths and neonatal deaths.” Furthermore, evidence shows midwives can meet “nearly 90% of the need for essential sexual reproductive maternal and newborn health (SRMNHA) services.”
Despite the case for investment, UNFPA’s 2021 State of World’s Midwifery reported a global shortage of 900,000 midwives. This gap is apparent in Somalia – a country considered one of the world's most fragile states after decades of conflict, insecurity, and natural disasters have resulted in a weak health system with more than five million people in need of humanitarian assistance. Today, Somalia has among the world’s highest rates of maternal and newborn mortality making the need for trained midwives essential.
In recognition of International Day of the Midwife – May 5, 2022 – EQUAL had the honor of speaking with Sulekha Rashid Ali, head of the National Midwifery schools of Mogadishu, Baidoa, Kismayo, Galgaduud midwifery school and the midwifery focal person at the Federal Ministry of Health (FMoH). Today, Sulekha is responsible for all midwifery related programs including coordinating activities that aim to strengthen the country’s midwifery education and profession. As part of this special Q&A, Sulekha helped EQUAL better understand the realities of being a midwife in Somalia and the efforts being made to strengthen the country’s essential health workforce.
1. It has been said that midwifery is the cornerstone of quality reproductive, maternal, newborn, and child health care. What role do midwives play in providing care in Somalia and what are some of the challenges they face?
In Somalia, midwives are frontline reproductive health care providers working in both urban and rural settings. Midwives play a critical role in emergency preparedness and response by delivering lifesaving sexual and reproductive health (SRH) services throughout crises including gender-based violence services and family planning. Midwives in Somalia face many challenges that hinder their work including socio-economic barriers, weak midwifery regulation, limited leadership, and rigid gender norms – particularly problematic since midwifery is considered a female profession. Social and religious pressures create additional challenges – for example when midwives champion zero tolerance for female genital mutilation (FGM) they face a lot of pushback. Many of these challenges require advocacy to promote and improve the midwifery profession, yet advocacy skills are lacking.
2. The State of the World’s Midwifery 2021 report sounded the alarm that the world urgently needs 1.1 million more essential health workers to deliver sexual, reproductive, maternal, newborn and adolescent health care, and 80% of these missing essential health workers are midwives. What strategies are being used to help fill this gap and expand the future generation of midwives in Somalia?
UNFPA has reported that Somalia needs an additional 20,000 midwives to meet existing needs. The Somali midwifery strategy and Human Resources for Health (HRH) strategic policy highlight possible ways that these gaps can be addressed. With the support of UNFPA, there are now 14 midwifery schools across the country that provide quality midwifery education in line with global midwifery education standards.
3. Education is just the first step in preparing midwives for the lifesaving work they will provide. What type of investments should also be made to support the employment, deployment, retention, and motivation of midwives in Somalia – including those deployed to hardship posts?
I strongly believe that no woman should die while giving birth and that this can be achieved through quality midwifery education and practice. Unfortunately, Somalia’s health system is donor dependent and we are struggling to employ midwives based on resource availability and needs. This includes issues absorbing trained midwives into the health system and effectively deploying them to hard-to-reach areas.
We are already in the last decade of the Sustainable Development Goals (SDGs). Now more than ever, Somalia needs to prioritize strengthening the midwifery professional regulatory system to ensure we can develop more qualified midwives that are trained and regulated to national and international standards.
I believe having motivated midwives, who are educated and regulated to the highest standards and then equitably distributed to facilities equipped with the necessary resources, is the best investment. Those midwives will then be able to promote birth spacing, help protect women and girls from harmful practices, and ultimately avert maternal and neonatal morbidities and mortalities.
4. Establishing a supportive environment to help midwives deliver high-quality, respectful care is critical to reducing preventable maternal and newborn deaths. What actions are stakeholders in Somalia taking to help facilitate this?
The Ministry of Health took the lead by developing a midwives posting and retention policy to support midwives in accessing a supportive working environment both in the private and public sectors. Unfortunately, this policy is not yet being implemented due to funding gaps and because the COVID-19 pandemic caused many delays in seeing such documents prioritized and implemented.
Fortunately, in collaboration with the government, donors, and other relevant partners, UNFPA supported the development of a midwifery strategy, established/strengthened midwifery schools, and strengthened basic and comprehensive obstetric and neonatal care facilities.
5. The work of midwives has always been essential. How has their work been impacted during the pandemic now? Are there any lessons we can learn from this experience to ensure midwives are sufficiently prepared to respond to future crises – including outbreaks, conflict, and implications of climate change?
My colleague from UNFPA explained it well in a post published on Relief web. She said “COVID-19 is harming an already-challenging health system. The situation has been exacerbated due to restrictions on movement, lack of security in some areas but also increasingly conservative gender norms, harmful cultural practices such as female genital mutilation and early marriage and lack of access to SRH including family planning.” The post further notes challenges related to inadequate availability of personal protective equipment (PPE) which increased fear among many midwives in performing their duties, and additional stress on midwives as they not only work long shifts but also manage concerns over the health and wellbeing of their own families. It is also worth reiterating how the pandemic “challenged pre-service training institutions in Somalia and brought challenges on employment opportunities for midwives.”
6. On International Day of the Midwife in 2020, a global call to action was published including a recommendation to ensure midwives are engaged in policy, decision-making, planning and response to the crisis. What actions are being taken in Somalia to take to heed this call?
There is an ongoing effort to support Somali midwives’ association leaders to advocate for and engage midwives in policy, decision- making, planning, and response to crises. Specifically, there is a collaborative effort being led by the Ministry of Health in partnership with UNFPA and the Canadian association of midwives to strengthen midwifery advocacy and leadership skills so they are better prepared to engage in these processes
7. Gender inequality is often an unacknowledged driver of the global shortage of midwives. Women account for 93% of midwives yet in many places girls don’t have equal access to education ultimately resulting in gaps in maternal health services where they are needed most. Does this reflect your experiences with the midwifery workforce in Somalia? Overall, how can we work to strengthen and support the female- dominated workforce while simultaneous addressing the underlying gender issues that impact the policies and practices surrounding midwifery?
Here in Somalia, the midwifery workforce is 100% represented by female professionals. Like all other women, Somali midwives encounter a range of gender-driven challenges when performing their work. To address this, we need more investments made to engage midwives in leadership positions across the health system. This can be done by strengthening midwifery regulation, enhancing midwives’ advocacy and leadership capacities, and supporting workforce development and retention practices. We also need to help midwives to engage with the communities where they work so people understand the essential role they play in providing lifesaving maternal and newborn health care.
8. On International Day of the Midwife, what your main call to action to decision makers on how we can better support midwives?
More than ever, Somalia needs to invest in midwives to help save lives. This includes investing in midwifery leadership and helping midwives to have a more supportive and enabling work environment.
NOTE: Through EQUAL, SORDI will conduct a study to gain deeper understanding and actionable insights into issues influencing midwives’ ability to deliver quality MNH services in conflict-affected contexts. This includes assessing the quality of midwifery pre-service education in Banaadir and Galgaduud regions, generating evidence on factors affecting early career midwives' workforce participation and retention, and documenting early career midwives' experiences working in conflict-affected areas.