Submission ID 131276
| Issue/Objective | The dominant framework positions community health workers, including midwives, as delivery endpoints - the final link in a chain designed elsewhere. This framing underutilises their potential and leaves health systems brittle when crises hit. Drawing on Pakistan's decade-long investment in midwifery education, regulation, and deployment across stable and humanitarian contexts, this paper examines what enables midwives to function as connective tissue between communities and health systems - with direct implications for gender equity, local leadership, and crisis resilience. |
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| Methodology/Approach | Evidence draws from five complementary sources spanning 2014-2025: qualitative research on structural barriers facing community midwives in Pakistan; development and national accreditation of Pakistan's first direct-entry BSc Midwifery curriculum (UNFPA, with ICM oversight); EmONC Health Facility Assessments across 22 UHC priority districts; emergency obstetric care assessment in five flood-affected districts of Sindh; and participatory action research on SRH service gaps for GBV survivors in humanitarian settings, alongside integration of the Minimum Initial Service Package into public health training programmes. |
| Results | Midwives operating within enabling conditions - defined by regulatory recognition, task-sharing protocols, and institutional support - demonstrate impact beyond clinical delivery: sustaining care-seeking, navigating household gender barriers, and maintaining SRH continuity when facility-based systems collapse. Where enabling conditions are absent, the same cadre is constrained to narrow roles with high attrition. Crisis-setting evidence from Sindh and conflict-affected areas shows that midwives with crisis-specific protocols maintain service continuity where other cadres withdraw. Curriculum development confirmed that regulatory investment, not training volume, is the primary determinant of whether midwifery workforce spending translates into population-level outcomes. |
| Discussion/Conclusion | Pakistan's experience offers a replicable model: regulatory frameworks, crisis-responsive protocols, and community integration must be co-designed rather than sequenced. The paper argues for reframing midwifery from a last-mile delivery mechanism to a form of community-anchored system architecture - with corresponding shifts in how it is financed, regulated, and deployed. As a predominantly female, community-embedded cadre, midwifery represents an underutilised vehicle for gender equity in health leadership. Scaling this model has direct implications for how LMICs structure primary health care investment and humanitarian health system preparedness. |
| Presenters and Affiliations | Mariyam Sarfraz Health Services Academy Mariyam Sarfraz Health Services Academy Maida Umer Health Services Academy Aashifa Yaqoob Health Services Academy Irfan Ahmed Health Services Academy |
