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The Fastest Route to Fewer Maternal Deaths: Scaling Midwife-led Continuity of Care [version 1; peer review: awaiting peer review]
Дата публикации: 05-08-2026 08:19:34
Background Maternal mortality has fallen by about 40% since 2000, but the progress has stalled. In 2023 roughly 260,000 women still died from causes tied to pregnancy and childbirth, one death about every two minutes, and the world remains far from the Sustainable Development Goal of fewer than 70 deaths per 100,000 live births by 2030. Almost all of these deaths can be prevented. They happen overwhelmingly where women cannot reach a skilled, trusted health worker who stays with them across pregnancy, birth and the weeks that follow. Policy and implications Midwife-led continuity of care (MLCC), where a known midwife or small team looks after a woman through pregnancy, birth and the postnatal period and refers her promptly when specialist care is needed, is recommended by the World Health Organization and backed by trial evidence: more spontaneous vaginal births, fewer unnecessary interventions, better experiences of care and lower costs. The problem is not the evidence. It is that midwifery remains underfunded, fragmented and only loosely stitched into most national health systems, with a global shortage of roughly 900,000 midwives. The real constraints on progress now sit in workforce, financing and regulation. Recommendations Four moves would change the trajectory: write MLCC into national strategies and the services that public funding pays for; invest in midwives by training, deploying, retaining and paying them properly; fix the referral systems and conditions that limit their scope of practice; and fund the disaggregated data needed to track who is still being left behind. Conclusions We already have what we need to prevent most maternal deaths. Reaching the 2030 target is less a technical problem than a political one: it means moving from scattered pilots to system-wide investment in continuity-based midwifery, then paying for it and holding someone accountable.
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Policy Brief
[version 1; peer review: awaiting peer review]
https://orcid.org/0000-0003-4906-1405
1,2https://orcid.org/0000-0003-4906-1405
1,21 University of North Texas College of Public Affairs and Community Service, Denton, Texas, USA
2 University of North Texas College of Public Affairs and Community Service, Denton, Texas, USA
Shyamkumar Sriram
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing
OPEN PEER REVIEW
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Abstract
Background
Maternal mortality has fallen by about 40% since 2000, but the progress has stalled. In 2023 roughly 260,000 women still died from causes tied to pregnancy and childbirth, one death about every two minutes, and the world remains far from the Sustainable Development Goal of fewer than 70 deaths per 100,000 live births by 2030. Almost all of these deaths can be prevented. They happen overwhelmingly where women cannot reach a skilled, trusted health worker who stays with them across pregnancy, birth and the weeks that follow.
Policy and implicationsMidwife-led continuity of care (MLCC), where a known midwife or small team looks after a woman through pregnancy, birth and the postnatal period and refers her promptly when specialist care is needed, is recommended by the World Health Organization and backed by trial evidence: more spontaneous vaginal births, fewer unnecessary interventions, better experiences of care and lower costs. The problem is not the evidence. It is that midwifery remains underfunded, fragmented and only loosely stitched into most national health systems, with a global shortage of roughly 900,000 midwives. The real constraints on progress now sit in workforce, financing and regulation.
RecommendationsFour moves would change the trajectory: write MLCC into national strategies and the services that public funding pays for; invest in midwives by training, deploying, retaining and paying them properly; fix the referral systems and conditions that limit their scope of practice; and fund the disaggregated data needed to track who is still being left behind.
ConclusionsWe already have what we need to prevent most maternal deaths. Reaching the 2030 target is less a technical problem than a political one: it means moving from scattered pilots to system-wide investment in continuity-based midwifery, then paying for it and holding someone accountable.
Keywords
maternal mortality; midwifery; midwife-led continuity of care; universal health coverage; health workforce; maternal health policy; Sustainable Development Goals; health systems strengthening
Corresponding author: Shyamkumar Sriram Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright: © 2026 Sriram S. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Sriram S. The Fastest Route to Fewer Maternal Deaths: Scaling Midwife-led Continuity of Care [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1300 (https://doi.org/10.12688/f1000research.184196.1) First published: 05 Aug 2026, 15:1300 (https://doi.org/10.12688/f1000research.184196.1) Latest published: 05 Aug 2026, 15:1300 (https://doi.org/10.12688/f1000research.184196.1)
Introduction
Few numbers tell you more about a health system than how many women it allows to die in pregnancy and childbirth. A maternal death is rarely a medical mystery. It is almost always a failure of access, quality or timing that someone could have prevented. The past two decades have brought real gains: the global maternal mortality ratio (MMR) dropped by around 40%, from roughly 328 deaths per 100,000 live births in 2000 to 197 in 2023.1 But the headline hides two harder truths. Progress has slowed, and the risk is extraordinarily concentrated.
In 2023 about 260,000 women died from maternal causes, one roughly every two minutes. Nearly 70% of those deaths were in sub-Saharan Africa and another 17% in Central and Southern Asia.1 The pace of decline tells its own story. Since 2015 the MMR has been falling by only about 2% a year, when reaching the SDG 3.1 target of fewer than 70 deaths per 100,000 live births by 2030 would now demand close to 15% a year.1,2 Most high-burden countries will not get there on the path they are on.
That gap frames the question this brief tries to answer. The conditions that kill women, mainly hemorrhage, hypertensive disorders, sepsis and unsafe abortion, are largely treatable with interventions we have had for decades. So why does progress keep stalling, and which model of care offers the most dependable way to speed it up? The argument here is that midwife-led continuity of care (MLCC), properly funded and built into the wider system, is the most practical lever a government has. The aim is to turn a settled body of evidence into choices a health ministry can actually make.
This is not the first call to invest in midwifery. The International Confederation of Midwives set out the policy conditions for scaling midwife-led care in 2021,3 and a growing body of reviews has since confirmed its benefits across low- and middle-income settings.4 What this brief adds is more recent evidence and a narrower argument: it reads the case for midwife-led continuity of care against the 2025 maternal mortality estimates, treats it as the highest-leverage choice available to governments rather than one option among several, and sets out recommendations sequenced from national strategy through to implementation.
Policy outcomes and implications
The problem is delivery, not discovery
The interventions that save mothers’ lives are neither exotic nor expensive: antenatal monitoring, a skilled attendant at birth, prompt treatment of hemorrhage and pre-eclampsia, a safe caesarean when one is needed, and proper postnatal follow-up. What fails is delivery, meaning getting every woman to a skilled, trusted professional who can spot trouble early and move her to emergency care without delay. That is exactly what a strong midwifery workforce does, and exactly where many systems are thinnest.
What the evidence shows about midwife-led continuity of care
Under MLCC, a named midwife or a small team carries primary responsibility for a woman across the antenatal, intrapartum and postnatal periods, working inside a multidisciplinary system and handing over to obstetric or specialist colleagues when complications appear. The largest synthesis we have, a Cochrane review of 17 randomized trials and more than 18,000 women, found that compared with other models this approach led to more spontaneous vaginal births, less use of interventions such as epidurals and episiotomy, a lower risk of fetal loss before 24 weeks, better experiences of care, and savings during pregnancy and birth.5 The WHO recommends it wherever functioning midwifery programs exist.6
Two qualifications matter. Most of the trial evidence comes from high-income countries, so the model has to be adapted to lower-resource systems rather than copied wholesale, with particular attention to whether referral actually works. And the reviews are explicit that women with serious medical or obstetric complications need integrated specialist care, not midwifery care on its own.5 MLCC works best as the spine of a maternity system, not as a replacement for emergency obstetric and newborn services.
The binding constraint: workforce, financing and integration
The obstacle is no longer the evidence. It is chronic under-investment. The world is short roughly 900,000 midwives, and the gap is widest exactly where maternal mortality is highest.7 Even where midwives are in post, they are often boxed in by narrow scopes of practice, weak regulation, irregular pay, difficult conditions, missing supplies and referral chains that break under pressure. Antenatal, delivery and postnatal services are frequently run as separate, uncoordinated encounters, so the continuity that makes the model work never materializes.
The cost of this is measurable. Modelling for the State of the World’s Midwifery found that fully resourcing midwife-delivered care by 2035 could avert around two-thirds of maternal deaths, newborn deaths and stillbirths, yet the money rarely follows the evidence.8 Maternal care is also fragile in the face of wider shocks. Conflict, climate disruption and austerity all eat away at the continuity women depend on, which is why fragile and conflict-affected settings carry such a disproportionate share of the burden. Treating midwifery as core infrastructure rather than an optional extra is the precondition for moving faster.
Methods of analysis
This brief draws on three bodies of work: the latest internationally comparable maternal mortality estimates from the UN Maternal Mortality Estimation Inter-Agency Group (WHO, UNICEF, UNFPA, the World Bank Group and UNDESA/Population Division)1; systematic-review and guideline evidence on midwife-led continuity of care5,6; and modelling and workforce evidence on midwifery investment.7,8
Actionable recommendations
The recommendations below run from strategy to implementation. They are meant to be adapted to national circumstances and read as a set, since each one leans on the others.
1. Make MLCC explicit national policy. Write midwife-led continuity of care into national maternal and newborn health strategies and into the package of services that public financing actually covers, so that continuity becomes an entitlement rather than something that depends on the next donor project. Attach coverage targets to it, and name who is responsible for delivering them.
2. Invest in the midwifery workforce. Expand pre-service education and accredit it to international competency standards, create funded and permanent posts, and hold on to the people you train through fair pay, safe conditions and a real career path. Put the greatest effort into rural, remote and underserved areas, where the burden is heaviest and the workforce thinnest.
3. Let midwives practice to their full scope. Reform the regulations and protocols that stop midwives from delivering the full evidence-based package of care, and fix the surrounding system: dependable supplies, working referral transport, and round-the-clock access to emergency obstetric and newborn care, so that continuity does not snap at the moment a woman needs it most.
4. Fund data systems built around equity. Pay for the unglamorous infrastructure: civil registration, maternal death surveillance and response, and reporting broken down by region, wealth and other equity dimensions. Without it, progress is invisible, inequities stay hidden, and money flows to the wrong places.
5. Protect maternal services during shocks. Treat maternity care as essential and non-deferrable in budgets, emergency planning and humanitarian response, so that continuity survives conflict, climate disruption and fiscal squeezes instead of being among the first things cut.
These recommendations come with limits worth stating plainly. The strongest evidence for MLCC comes from higher-income settings, and how well it works elsewhere depends heavily on the referral and emergency-care infrastructure around it. They are necessary but not sufficient on their own, since they assume parallel investment in facilities, commodities and specialist services. And they need political commitment and predictable money that outlast electoral and donor cycles.
Conclusions/Discussion
The world is not failing to save mothers for lack of knowledge. The interventions are known, the model of care is evidence-based, and the major international bodies already back it. What is missing is the decision, sustained and paid for, to fund midwife-led continuity of care at scale and to build the emergency and specialist services that make it safe.
The work now is to move past the pilot stage. MLCC has been shown to work often enough; the task is system-wide implementation, carried by national strategies, real workforce investment, regulatory reform and financing someone is accountable for. The payoff runs wider than maternal mortality alone, because a trusted, accessible maternity workforce is part of the foundation of primary health care and universal health coverage.
Some questions remain genuinely open and deserve more research: how to adapt MLCC most cost-effectively to low-resource and fragile settings, which financing models actually keep midwives in their jobs, and how to design referral systems that hold continuity together while still getting women to emergency care fast. None of this is out of reach. The maternal survival gap can be closed within a generation, but only if policy finally catches up with what the evidence has been saying for years.
Data and software availability
Underlying data
No primary data are associated with this article. This policy brief is an analysis of previously published, publicly available estimates and systematic-review evidence, all of which are cited in the References section.
Extended data
No extended data are associated with this article.
Software and code
No software or code was generated for this article.
Reporting and source datasets referenced in this brief are openly available from their original publishers.
References
- 1. World Health Organization, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division: Trends in maternal mortality 2000 to 2023. Geneva: World Health Organization; 2025. 978-92-4-010847-9. Reference Source
- 2. United Nations General Assembly: Transforming our world: the 2030 Agenda for Sustainable Development. Resolution A/RES/70/1. New York: United Nations; 2015. Reference Source
- 3. International Confederation of Midwives: Building the enabling environment for midwives: a policy brief. The Hague: International Confederation of Midwives; 2021. Reference Source
- 4. Adnani QES, Nurfitriyani E, Merida Y, et al.: Ninety-one years of midwifery continuity of care in low and middle-income countries: a scoping review. BMC Health Serv. Res. 2025; 25(1): 463. Publisher Full Text
- 5. Sandall J, Fernandez Turienzo C, Devane D, et al.: Midwife continuity of care models versus other models of care for childbearing women. Cochrane Database Syst. Rev. 2024; 4: CD004667. PubMed Abstract | Publisher Full Text | Free Full Text
- 6. World Health Organization: WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016. 978–92–4-154991-2. Reference Source
- 7. United Nations Population Fund, International Confederation of Midwives, World Health Organization: The State of the World’s Midwifery 2021. New York: UNFPA; 2021. Reference Source
- 8. Nove A, Friberg IK, de Bernis L , et al.: Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Glob. Health. 2021; 9(1): e24–e32. PubMed Abstract | Publisher Full Text | Free Full Text
The author(s) declared that no grants were involved in supporting this work.
© 2026 Sriram S. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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