Rwanda has undergone a remarkable journey in tackling its high maternal mortality rate over the past decade. From an alarming 1071 maternal deaths per 100,000 live births in 2010, the country has accelerated its rate of reduction in the MMR, reaching 210 deaths per 100,000 live births in 2015. In recent years, the decline has been slower, with the MMR standing at 203 per 100,000 live births in 2020 - a decline of only 7 data points over 5 years.
With Rwanda currently operating at a ratio of 1 skilled health professional per 1000 population - below the WHO recommended minimum of 4 per 1000 - the Government of Rwanda introduced a comprehensive plan designed to strengthen the nation's health system. Known as the "4x4 Strategy", the initiative aims to quadruple the health-care workforce over four years, while implementing significant enhancements to health-care infrastructure and processes.
Dr. Menelas Nkeshimana, the Head of the Department of Health Workforce Development at the Ministry of Health, highlighted the urgency of the situation, emphasizing the need to address the current shortage of health professionals. Examining the burden of work and quality of care, particularly in maternal and child care, Dr. Nkeshimana underscored the stark reality of having around 2000 midwives registered for a population of 13 million.
"Specialist gynaecologists and obstetricians, essential for maternal health, are also in short supply, with only 115 registered professionals. To achieve our vision of reducing maternal deaths below 50 per 100,000 live births by 2050, we face the challenge of not only increasing the workforce but also strategically distributing these professionals across the country," he said. At the current trajectory, the MMR is likely to decrease only to 156 deaths per 100,000 live births by 2050, underscoring the urgency of the mission.
In response, UNFPA in Rwanda has committed to supporting the 4x4 Strategy, with a specific focus on midwifery as a crucial step to combatting maternal and child mortality rates.
Prioritizing midwives
In 2023, through a partnership with the Ministry of Health, UNFPA Rwanda provided 50 students with midwifery scholarships. The aspiring midwives started their studies at the Ruli Higher Institute for Health in November 2023.
Alleluia Betty is one of the students who benefitted from the scholarship. She expressed her gratitude for obtaining the scholarship, recognizing it as a crucial opportunity to contribute to addressing challenges like maternal and child deaths. Her joy stemmed from the prospect of actively participating in initiatives that help alleviate these critical issues.
"I wanted to pursue midwifery so that I can help save the lives of those mothers and babies who are in need. Some people discouraged me from choosing this faculty due to perceived risks that come with it, but I am ready to overcome the challenges by prioritizing my passion for the course and focusing my genuine interest in saving lives," said Ms. Betty.
A tangible multiplying effect
In the past few years, UNFPA has supported midwives with Master's and PhD scholarships, to strengthen the profession and build a faculty able to become the intellectual foundation of the country's first-of-its-kind Master's-level programme for midwifery. This was done with the University of Rwanda in 2023 and the scholarship support for higher education still continues. Furthermore, UNFPA, in partnership with Laerdal Global Health, has contributed over 450 birthing simulators and simulation lab equipment allocated to universities and institutes with established midwifery programs. Elevating the educational experience, the UNFPA and Laerdal Global Health has taken a step further by instituting a Simulation Facilitation Program called SimBegin. This program involves training faculty from 11 institutes.
Highlighting UNFPA's Rwanda commitment to support the Ministry of Health in its vision in the area of midwifery, UNFPA Rwanda Deputy Representative, Dr. Renata Tallarico emphasizes that the scholarship and equipment not only symbolizes tangible support but also represents a commitment to practical, hands-on learning that prepares students for the realities of their future profession. "We want to empower midwives, ensure the quality of education, a standardized national curriculum, and give any other support needed to ensure that no mother dies while giving birth." emphasizes Dr. Tallarico.
As part of the support to the 4x4 strategy, the need to emphasize the quality of education became evident. Thus, the Ministry of Health in collaboration with UNFPA embarked on a journey to develop a national standardized midwifery curriculum aligned to national and international standards.
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Reflecting on the role of partnerships in achieving the 4x4 reform goals, Dr. Nkeshimana commended UNFPA's contribution in facilitating the enrollment of more midwives in education. "During our engagement, coinciding with the 4x4 reform announcement in July 2023, conversations with UNFPA were seamless. It served as a wake-up call, with their expressed willingness to collaborate in enrolling more midwives in education. At that time, our baseline data revealed midwifery schools were operating at only 20% capacity, despite having the necessary infrastructure, validated curriculum, and faculty. The challenge was the lack of students to fill the remaining 80% of seats." Says Dr. Menelas.
Through initiatives like the government's 4x4 Strategy and collaborations with educational institutions and stakeholders, significant strides have been made in bolstering midwifery education and enhancing the quality of care. UNFPA's partnership with the Government of Rwanda to elevate this field will continue to focus on strengthening competency-based midwifery training; developing strong regulatory mechanisms to ensure quality services; and advocating for increased investments in midwifery services.
