Midwives are vital to the health and protection of women in childbirth. In 2017, an estimated 295,000 women worldwide died from causes related to pregnancy or childbirth—the vast majority of them in low-income and lower-middle-income countries. Most of these deaths were preventable. Throughout this health emergency, we must ensure that midwife-led care is maintained as far as possible.

As it stands, midwives in all regions are facing acute shortages of personal protective equipment (PPE) and other infection-control supplies, including hand sanitiser, which means they must face painful and traumatic decisions. Should they risk their own families’ health in order to care for women in childbirth? How should they provide assistance without PPE, given that they are unable to maintain a safe distance from the women in their care? Is it better to provide normal care anyway, even at the risk of infecting their patients?

There also is mounting evidence that the over-medicalisation of childbirth has increased during the pandemic. The World Health Organisation recommends that caesarean sections be performed only when medically justified, but there is growing concern from health-care professionals and the wider global health community about the number of unnecessary and inappropriate procedures. This troubling pattern suggests a weakening of women’s right to make informed decisions regarding childbirth and their overall health.

Where women are given the space to decide, they are increasingly choosing to give birth at home with the support of a midwife, or in a midwife-led unit, rather than in a hospital. This shift reflects not only fear of Covid-19, but also many women’s realisation that they can opt for more decentralised services that cater to their needs. In the case of low-risk pregnancies, national governments should support this decision.

But decentralising childbirth poses its own challenges. In particular, we must provide adequate resources to support it, and respect and recognise the work carried out in homes to ensure the safety of pregnant women. Increased pandemic-related concerns regarding pregnancy have made the midwife’s role in providing antenatal care even more important. In many cases, however, home services are unrecognised and unpaid, and continue even during PPE shortages, putting both midwives and patients at risk.

Many have been shocked by our health-care systems’ lack of basic resources and inadequate capacity in the face of a global pandemic. But such shortcomings should come as no surprise. Health-care staff are overworked and underpaid, have inadequate training opportunities, and are subject to restrictive policies. For example, midwives often are not recognised as frontline health-care workers.

These problems are still more acute in midwifery, which, even before the pandemic, had long struggled to gain recognition as an autonomous profession—and to secure access to the funding, resources, and training that goes with it. And now the failure to invest in maternal health services, and to pay women fairly for their contributions to the health sector, has weakened the global response to Covid-19 and put women at greater risk of infection, especially in lower-middle-income countries.

To keep midwives safe and enable them to provide women-centred care, governments, international donor agencies, and philanthropic organisations must make funding for maternal health services a high priority. That includes supporting community-based care, which is crucial at a time when facility-based services are declining. Without such assistance, midwives will struggle to reach the most vulnerable.

The international community must support the female health workforce and allocate funds directly to organisations that represent midwives as front-line maternal health-care providers. We must trust women at the centre of health-service delivery to use funding as they see fit, and to invest in the protection and resources they need to ensure the continued safety of our communities.

—Project Syndicate