Video by Joel Bobeck/Jhpiego


Breathing Room:
A Midwife’s Role
Expands with Education

By Maryalice Yakutchik

Three decades, two civil wars and one Ebola epidemic ago, Lucy Barh delivered a baby, the first of thousands to come.

“I still have my delivery notepad from 1986, with the name of the patient I helped,” the Liberian midwife says, recalling how she rubbed Mary Johnson’s back during an excruciating labor. “I was so afraid to see a baby coming.”

At some point, Barh thought, “I can do this.”

A senior midwife had been there guiding her, Barh says, “She encouraged me to turn the head… to do this, to do that. I was in training, so followed her instruction.”

Importantly, Barh learned from real midwives during real births about how to practice real midwifery—which, at its most basic, is defined as “being with women,” explains Dutch midwife Petra ten Hoope-Bender, who coordinated a seminal midwifery series in The Lancet after having helped draft the first State of the World’s Midwifery report in 2011.

Midwives like Barh allow the natural processes of labor and birth to take their course, all the while remaining watchful—aware that things can and sometimes do go wrong—and knowing why, when and how to intervene or to refer, ten Hoope-Bender says.

It’s crucially important for midwives to work within a fully functional health system that stands ready to respond effectively to the referrals they make.Petra ten Hoope-Bender

Jhpiego has worked for decades to ensure that midwives throughout the developing world obtain all the skills they need to make birth as worry-free as possible, and if complications arise, to respond quickly and with best practices. In just the last four years, from 2012 to 2016, Jhpiego’s support translated into skilled midwives having attended 8.6 million births. Notably, maternal deaths due to pregnancy or childbirth have dropped since 1990 by 40 percent, from half a million to 289,000, with much of the decline attributed to skilled birth attendants. A longtime partner with the International Confederation of Midwives (ICM), Jhpiego shares its vision that every childbearing mother and her newborn have access to a midwife’s care, and, therefore, a better chance to survive and thrive.


Mementos of a Midwife’s Life: Lucy Barh reflects on 30 years with the help of her very first delivery notepad and photos snapped during training, practice and graduation. Photos by Liz Eddy. Archival materials courtesy of Lucy Barh.

Two midwives

As ambassador for the Zimbabwe Confederation of Midwives, Clara Methie (right) knows the importance of a midwife mentor and a strong professional association. Methie looks to senior Jhpiego midwife Fishiwe Chiyaka for guidance. The pair recorded a series of conversations on mentorship, motivation, memories, maternity care and the future.

Listen to the Full Conversation

While attending Johnson during labor, Barh had a first glimpse into a core tenet of midwifery—that is, giving space to a normal life event, one that didn’t necessarily need to be turned into a medical procedure. She witnessed a healthy baby girl finally emerge, gulping air. The trainee then sailed through the remaining half of a two-year midwifery course, acquiring and practicing the many clinical skills she needed for professional competency—which means she can provide 87 percent of the 46 essential interventions needed by pregnant and laboring women and their newborns.

Delivering babies, Barh would learn, was only part of her job. In Liberia and elsewhere, midwives provide antenatal care and family planning services, as well as write prescriptions and make referrals when necessary—doing virtually everything related to maternity care except for surgery.

If that first birth left a lasting impression on Barh, so did her first graduation. For 30 years, she described the day she earned her midwifery diploma as “the best” of her life.

But no longer.

At the age of 57, the career midwife had an even better best day. In June 2016, she stood proudly among the first cohort of Liberian midwives to graduate college with a bachelor of science degree.

Midwifery - An International Journal


Here’s a handful of notable Jhpiego peer-reviewed journal articles related to midwifery

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Midwives who are educated and regulated to international standards can provide 87 percent of the essential care needed for women and newborns. Photo by Karen Kasmauski/Jhpiego.

A midwife doing a delivery training exercise

A New Learning Approach Builds Competencies, Confidence

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Newly empowered by more education, Barh now is envisioning a day that could be the best of the best.

“I work in the clinic,” she says, “but there is a need to educate more midwives. There is a shortage of midwives in Liberia. If I’m given the privilege, I would like to be a midwife educator.”

To achieve that goal, Barh’s set her sights on a master’s degree in midwifery.

More degrees and letters behind her name means more respect and money for her, of course. But Barh sees the personal status bump only as a means to a much greater end, one that is global: more mothers and newborns surviving birth and then thriving.

She’s all too aware that in her country, the maternal mortality ratio—at 1,072 per 100,000 live births—is one of the highest in the world. Barh has seen “a lot” of women die in childbirth, she says.

“A lot,” she repeats.

She’s convinced that more education in midwifery would help her to tackle that issue.

“I absolutely agree with Lucy,” says Nester T. Moyo, senior midwifery advisor for ICM, which is based at The Hague in the Netherlands. “To be midwives at the bedside, we need to have an education that is sound and well-regulated; one that gives us the competencies that allow us to practice safely—not necessarily higher degrees.

“But to contribute to policy, then we need a little more. The advantages of a higher education have to do with gaining credibility with policymakers. With enhancing assertiveness and critical thinking, and broadening our horizon; with opening our eyes to the meanings of the things we are seeing on a daily basis.”

The advantages of a higher education have to do with gaining credibility with policymakers. . . with opening our eyes to the meanings of the things we are seeing on a daily basis.” Nester T. Moyo


Investing in midwifery education, with deployment to community-based services, could yield a 16-fold return on investment in terms of lives saved and costs of caesarean sections avoided, and is a “best buy” in primary health care.

—The State of the World’s Midwifery 2014

Photo by Karen Kasmauski/Jhpiego.

A midwife with a mother and her newborn baby

Midwifery knows no gender in Burkina Faso

Barh has skills to spare and wisdom to share. Thirty years spent bedside with an average of seven laboring women per week informs her perspective. So, too, does the fact that she’s a Jhpiego alumna, having participated in a number of technical and capacity-building trainings over the years, including emergency obstetric and newborn care, and malaria in pregnancy.

As a global leader in maternal and newborn health, Jhpiego has introduced policies and guidelines with the aim of helping midwives like Barh learn more, practice better and do their jobs safely and efficiently. Entrusted by the United States Agency for International Development (USAID) to implement its flagship maternal and child health program, Jhpiego was invited by the Liberian government to reposition family planning, using midwives, in the wake of civil war. Jhpiego and partners worked with Liberia’s ministry of health to develop and initiate a family planning course, a reproductive health policy and, notably, a roadmap for the reduction of maternal mortality.

Barh’s own roadmap intersects with that of her country precisely at the point of maternal deaths. This is why she’s charting her next educational step—one that would set her on a path toward making an impact on future midwives and lawmakers.

“Midwives should take the lead in reducing maternal mortality… in providing quality care to mothers and newborn babies,” Lucy says. More women would survive if her profession’s vanguards appropriately asserted themselves in terms of guiding policies and informing decisions related to maternal and perinatal care, she says.

Midwives should take the lead in reducing maternal mortality… in providing quality care to mothers and newborn babies.Lucy Barh

The State of the World’s Midwifery 2014 report, which examines the global midwifery landscape across 73 low- and middle-income countries, echoes Barh’s refrain. In it, Jhpiego and other contributors call for “urgent investment in high-quality midwifery to save millions of lives every year.”

Liberia is among those African, Asian and Latin American countries that collectively account for 96 percent of global maternal deaths, 91 percent of stillbirths and 93 percent of newborn deaths. Meanwhile, these countries have only 42 percent of the world’s doctors, midwives and nurses.


99 percent of all maternal deaths occur in developing countries.

—World Health Organization

Elizabeth Mpunga, a midwife who has undergone basic emergency obstetric and neonatal care (BEmONC) takes blood from an expectant mother to conduct routine syphilis and HIV screening in the Health Centre in Rtamba, Tanzania.

Only four of the 73 countries included in The State of the World’s Midwifery 2014 have a midwifery workforce able to universally deliver the 46 essential interventions for sexual, reproductive, maternal and newborn health recommended by the Partnership for Maternal, Newborn and Child Health.

Efforts to professionalize midwifery by investing in recruitment and continuing education could help bridge that gap and prevent some two-thirds of maternal and newborn deaths, The State of the World’s Midwifery 2014 report concludes. It begins in schools with educational programs that have evidence-based curricula, competent instructors and preceptors, qualified management and adequate infrastructure, including skills labs, supplies and books, as well as strengthened clinical sites that reflect current best practices. These are all focus areas for Jhpiego, which has worked to prevent needless deaths of women and their families for nearly 45 years in more than 150 countries.

“We really need midwives now more than ever before,” Barh says, adding, “We are indeed grateful to Jhpiego and USAID for all the support.”

“Not supporting people like her is not an option,” Moyo says, referring to Barh. “She has powerful internal motivation, strong insights and a conviction that ‘I can do this!’”

Two midwives and two babies

Midwives in Myanmar deliver!

The Pillars of Midwifery

“With regard to the pillars of education, regulation and association, they are equal. Regulation is of primary importance as it sets the standards for midwifery education and practice. Associations are important—that’s what ICM’s mission is about: strengthening or helping to develop midwifery associations in countries where they don’t exist. Education is great, but there’s no point educating people who then are unable to practice of their scope of practice, because there’s no regulation. That’s why I start with regulation first.” – ICM President Frances Day-Stirk



Midwifery education must be actively managed to ensure that the future workforce is highly competent and qualified to meet the needs of populations.



Regulation is a set of criteria and processes arising from the legislation that identifies who is a midwife and who may use the title of midwife. Regulation also describes the scope of midwifery practice.



Strong organizations of member midwives provide professional support, contribute to national policy development and support relationships with other health care professions.

Photo by Liz Eddy