Opinion: What we learned from the 50,000 Happy Birthdays project

Improving maternal and newborn health remains at the heart of many of the issues we face as a global health community, and here in Ethiopia, Rwanda, and Tanzania, this issue is especially relevant.

Maternal deaths in our region accounted for approximately two-thirds of the global maternal deaths in 2017, and a child in sub-Saharan Africa is 10 times more likely to die in their first month compared to a child born in the global north. The majority of maternal deaths due to difficulties during pregnancy and giving birth could be prevented according to the latest “State of World’s Midwifery” report.

Between 2018 and 2020, the 50,000 Happy Birthdays project aimed to save the lives of thousands of mothers and newborns in Ethiopia, Rwanda, and Tanzania. Throughout this project, we have seen how competent midwives can help reverse preventable mortality rates.

In our three countries, more than 18,500 midwives and other health care providers have been trained to improve management of birth asphyxia, newborn prematurity, post-partum hemorrhage, and eclampsia. Across the project implementation sites, internal project data indicated a 26% reduction in stillbirth rates in Ethiopia, a 57% reduction in newborn deaths in Rwanda, and a 33% reduction in maternal deaths in Tanzania.

We have come together as midwives and project managers to draw on our experiences and outline ways in which maternal and newborn health care can be strengthened in our respective countries as COVID-19 continues to further compromise efforts to improve maternal and newborn health.

Provide frequent, simulated training to student midwives

The 50,000 Happy Birthdays project addressed both preservice and in-service health providers, aligning the knowledge and skills of students with experienced clinicians, ultimately decreasing the disparity between theory and practice.

Through the project, life-like maternal and newborn mannequins were provided to universities and colleges, allowing students to practice and feel confident performing simulated obstetric emergency skills prior to entering a health facility and caring for patients.

We saw that students who were trained during this project had confidence to resuscitate a newborn, call for help to manage bleeding after birth, and could identify signs of life-threatening complications. These findings showed that parallel training of midwifery students and practicing midwives improves communication and collaboration between health care providers and improves quality of care for women and newborns.

In 2019, Rukia Ramadhani Shaban, a midwife of seven years from Tanzania’s Pwani Region, attended a 50,000 Happy Birthdays training where she learned core midwifery skills. Recently, she was able to put her training to use during a delivery where a mother was experiencing rapid blood loss. Rukia recognized the symptoms of a postpartum hemorrhage and administered a dose of oxytocin, helping the mother to deliver the placenta and ultimately saving her life.

Increase the competencies of in-service midwives

Midwives are integral to the childbirth continuum — they support women and their communities with prenatal and newborn care, breastfeeding, family planning, and screening for HIV, among many other responsibilities.

There is a global shortage of midwives which may contribute to high death rates of mothers and babies across the continent, and the death rates of birthing women and newborns may be on the rise as a result of diverted attention from maternal health sectors to the management of COVID-19.

Through the 50,000 Happy Birthdays project, we’ve managed to increase the number of competent in-service midwives significantly in all three regions. In Ethiopia alone, the project has trained 12,000 midwives and other health care professionals to effectively manage the most frequent complications that arise during birth. But much more needs to be done to ensure young people in underresourced countries and around the world are pursuing a career in midwifery.

Bring greater awareness and autonomy to the profession of midwifery

Around the world, we see midwifery continually conflated with nursing, and our three countries are no exception. The necessity and value of each profession is undisputed. However, in conflating the two, we risk negatively impacting midwives, women, and newborns. Nurses sometimes end up representing midwives in policy- and decision-making conversations pertaining to maternal and newborn health. Nurses typically focus on the treatment of the sick and injured, whereas midwives see pregnancy and birth as normal life events that usually don’t require medical intervention.

Rwandan facilitators of the 50,000 Happy Birthdays regularly worked with women and communities who were unaware of the differences between nurses and midwives. As a result, they lacked adequate or correct information about how birthing experiences can be improved with the care provided by a well-trained midwife. An unintended but positive outcome of this project was the opportunity to correct these common misconceptions.

Perhaps more significantly, we see firsthand that the limited availability of competent midwives is a significant impediment to achieving Sustainable Development Goal 3.

To increase the number and status of midwives, advocacy is essential, not only through highlighting the achievements of initiatives such as the 50,000 Happy Birthdays project but also through the strengthening of midwives' associations, positioning these organizations to collaborate with ministries of health and inform policies that impact mothers and newborns.

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