Video by Joel Bobeck/Jhpiego


The ultimate goal of professional associations is to foster a dynamic, collaborative, fit-for-purpose, practice-ready team of health care professionals who are responsive to the needs of women and children.

—The State of the World’s Midwifery 2014

Resuscitating a
Professional Association

By Maryalice Yakutchik

A squalling baby, a smiling mother: This is joy for Lucy Barh.

This is why she has worked hard to remedy the fact that her profession—preoccupied as it is with women’s survival—was a dead end for many midwives during the three decades she has practiced in Liberia.

Here’s the situation as Barh saw it: There weren’t enough midwives in her country, which meant long days and nights only grew longer. Meanwhile, working conditions and issues of salary and respect remained challenging.

She feared that if midwives lacked opportunities and options, the maternal mortality ratio plaguing Liberia—1,072 per 100,000 live births—would remain abysmally high.

Surely more smart, young Monrovians would follow her down the path of delivering babies, counseling women on family planning and providing critical obstetric care if that path was more expansive. The key, Barh recognized, was organizing a professional association to give voice to the concerns of midwives working in village clinics, health centers and city hospitals.

A longtime partner of the International Confederation of Midwives (ICM), which represents more than 400,000 midwives globally, Jhpiego values association as one of midwifery’s three interdependent pillars, along with education and regulation. While an educated, skilled midwife can offer lifesaving care to an individual pregnant woman before, during and after birth, an association can strengthen care for millions of women by advocating for the providers at the center of maternal and newborn care as well as for key decisions and policies affecting midwifery services.

Two midwives
Mentorship Fosters
Quality Care

Listen to the Full Conversation

The United States Agency for International Development’s Maternal and Child Health Integrated Program (MCHIP) supports the HoHoe Midwifery Training School in Hohoe, Ghana. The students get practical experience at the local municipal hospital as well as attend lectures and watch reenactments of women in labor. Photo by Karen Kasmauski/MCHIP.


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

As Jhpiego’s President and CEO Leslie Mancuso has often urged midwives and nurses: “If you don’t have a seat at the table, bring your own chair.”

Associations help bring chairs to the table. Strong associations can do the heavy lifting, which is a real benefit for members feeling frustrated, overwhelmed or alone—those most in need of having a seat, and having a say.

The largest global online survey of midwives to date, Midwives’ Voices, Midwives’ Realities, reveals that many of the 2,470 midwives from 93 countries who participated self-describe as “exhausted” in answer to the question “How would you say you feel on a daily basis in your job?”

Barh can relate.

She worked in Monrovia throughout the Ebola epidemic, even as it decimated the ranks of health care providers in her country. But that was hardly the first—or longest—crisis Barh faced as a midwife.

Awful as Ebola was, it happened years after the BBC had featured Barh in its series, “Toughest Place to Be a…”, a worldwide look at difficult jobs. During Liberia’s civil wars, Barh didn’t flee the country as hospitals were shuttered; instead, she chose to care for mothers and babies in her home. Tough as she was, Barh spoke candidly to the BBC about her beloved profession: “There is no career path, and even after many years you have no chance of promotion or salary increase, so many midwives are leaving.”

If you don’t have a seat at the table, bring your own chair.Leslie Mancuso

A midwife attends a woman carrying twins, one in the breech position, during a difficult labor at the birthing center at the King Fahad IBN Abdul-Azeez Women and Children Hospital in Gusau, Nigeria. Photo by Karen Kasmauski/Jhpiego.


166 million: the number of pregnancies worldwide per year.

Barh knew then that saving lives meant reviving her profession.

“Lucy’s experience is not uncommon,” says ICM President Frances Day-Stirk. “In many countries, midwifery isn’t seen as attractive for all of the reasons that are now in the public domain as evidence,” she adds, citing The State of the World’s Midwifery 2014, a report by the United Nations Population Fund, ICM, World Health Organization and others, with critical contributions from Jhpiego.

The report focuses on 73 low- and middle-income countries (Liberia among them) where more than 92 percent of the world’s maternal and newborn deaths occur. It reveals that many midwives share the perception that the “profession is loved, but the lack of career plans tends to discourage people.”

That’s why, as soon as Liberia’s civil conflicts ceased, Barh busied herself breathing new life into a professional association for Liberian midwives. Originally established in 1958, it had disbanded for more than a decade during wartime.

“In Liberia, I consider the midwives as the pathway to a healthy nation. I have been putting all my strength, all my energy just to get this profession to where it is today. Through the help of God, we have brought the Liberian Midwives Association (LMA) to where it is now, with 100 active midwife members.”

I consider the midwives as the pathway to a healthy nation.Lucy Barh

Others have had her back along the way, Barh says, crediting the United States Agency for International Development and Jhpiego with providing critical support and guidance to nurture, strengthen and sustain the association.

Notably, Jhpiego has worked with the World Health Organization, Liberia’s ministry of health and others to expand the role of midwives in childbirth, developing a policy that would permit midwives with appropriate, additional training to perform cesarean sections. “This task-shifting would ensure the availability of more skilled health care providers to manage potentially life-threatening complications at birth,” says Marion Subah, a nurse-midwife and native of Liberia.

A midwife doing a delivery training exercise

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Junior midwife Jamila Sani Shariff, 24, just a few months qualified, holds a newborn girl at the birthing center at the King Fahad IBN Abdul-Azeez Women and Children Hospital in Gusau, Nigeria. Photo by Karen Kasmauski/Jhpiego.

A group of midwives

The new generation of midwife in Pakistan.

Subah oversaw Jhpiego’s role in the Ministry of Health and Social Welfare/Rebuilding Basic Health Services project, funded by the United States Agency for International Development. Through this project, training institutions, professional associations, regulatory bodies and others worked to strengthen the role of the midwife by developing a competency-based curriculum, preparing teachers and preceptors to implement that curriculum, and improving skills lab and clinical sites.

“These activities, along with midwifery strengthening according to ICM standards, led to the initiation of a bachelor’s degree program in midwifery that put Lucy and others on a career path toward leadership and management,” Subah says.

Along with many of the 130 midwives’ associations worldwide, the LMA is intent on grooming leaders who will inform decisions that empower midwives to be more responsive to women’s and children’s needs.

“Their role in quality improvement could be strengthened if they were enabled to contribute to policy discussions and key decisions affecting midwifery services,” according to The State of the World’s Midwifery 2014.

Quality care in Liberia is contingent upon women going to health facilities in time to deliver safely, says Barh, who served from 2012 to 2016 as president of the LMA. Midwives in her country have a major role to play in educating women about home versus facility births, she insists. Not satisfied with simply promoting good practice, the LMA seeks to guide policy.

“ICM is strengthening associations so they can take these issues on, build the arguments and hold governments responsible,” says Nester T. Moyo, senior midwifery advisor for ICM. “The messages need to come from midwives.”

The messages need to come from midwives.Nester T. Moyo

For all who may be listening, Barh’s message is clear: “We need more midwives. I want others to get into this profession!”


73 African, Asian and Latin American countries represented in The State of the World’s Midwifery 2014 report account for 96% of global maternal deaths, 91% of stillbirths and 93% of newborn deaths, but have only 42% of the world’s doctors, midwives and nurses.

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