Relationship between midwifery density and midwifery regulatory environments in International Confederation of Midwives member countries

BackgroundMidwives are a cost-effective solution for reducing preventable maternal death, but barriers to their recruitment, training, deployment, and retention exist. Improved midwifery regulation is proposed to address these challenges through activities related to education and qualification, licensure, registration/re-licensure, and scope and conduct of practice. However, no quantitative analysis of the associations between midwifery regulation and workforce density in low- and middle-income countries has been conducted, limiting actionable insights for policymakers. The objective of this study was to evaluate the relationship between midwifery regulatory environments and midwifery workforce densities (midwives per 10,000 population) in International Confederation of Midwives member countries. MethodsThe study used secondary data from the 2019 Global Midwives Associations Map Survey to perform a cross-sectional analysis of 103 International Confederation of Midwives member countries. To operationalize the strength of a countrys midwifery regulatory environment, we used a previously developed Midwifery Regulatory Environment Index. We conducted multivariable linear regression analysis to evaluate the relationship between this index and country-level midwifery density, available from the National Health Workforce Accounts. ResultsMidwifery regulatory environments are significantly associated with midwifery workforce densities across countries. For every 1-point increase in the Midwifery Regulatory Environment Index (indicating activities in at least one additional regulatory domain), midwifery density increased by 0.66 midwives per 10,000 population (p = 0.011). This effect decreased to 0.41 midwives per 10,000 population yet remained significant even after controlling for country level income, per capita health spending, income inequality, and human development index (p = 0.04). ConclusionStronger regulatory environments are associated with higher densities of midwives, even when controlling for potential confounding factors such as country-level income and health spending. This relationship suggests that policymakers should invest in midwifery regulation to improve maternal health outcomes.