Implementation guidance

on transitioning to midwifery
models of care
Implementation guidance
on transitioning to midwifery
models of care
 Contents
Implementation guidance on transitioning to midwifery models of care

ISBN 978-92-4-011019-9 (electronic version)

ISBN 978-92-4-011020-5 (print version)
Contents v
© World Health Organization 2025 Acknowledgements vi
1. Introduction 1
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC
1.1 What is the purpose 7
BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/).
1.2 Who are the expected users? 8
1.3 Exploring midwifery models of care of the implementation guidance 9
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is
appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific
1.3.1 Continuity of midwife care models 13
organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under
1.3.2 Community-based midwifery models of care 15
the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along 1.3.3 Birth centres 17
with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the 1.3.4 Private midwifery models of care 19
content or accuracy of this translation. The original English edition shall be the binding and authentic edition.” 1.3.5 Midwifery models of care in humanitarian and crisis settings 21
1.4 A flexible approach for transitioning to midwifery models of care 23
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World 2. Essential pillars for the transition to midwifery models of care 27
Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). 2.1 Foster and secure political commitment and funding 31
2.2 Establish or strengthen governance 32
Suggested citation. Implementation guidance on transitioning to midwifery models of care. Geneva: World Health Organization; 2025. 2.3 Build partnerships 33
Licence: CC BY-NC-SA 3.0 IGO. 2.4 Ensure sustainability for the transition to midwifery models of care 35
3. Strategic planning process 37
Cataloguing-in-Publication (CIP) data. CIP data are available at https://iris.who.int/.
Step 1 Conduct a situation analysis 41
Step 2 Design a strategic plan 43
Sales, rights and licensing. To purchase WHO publications, see https://www.who.int/publications/book-orders. To submit requests for
Step 3 Develop an operational plan with a monitoring and evaluation framework 44
commercial use and queries on rights and licensing, see https://www.who.int/copyright.
Step 4 Develop a financial plan and allocate resources 45
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is
4. Transition areas for midwifery models of care 47
your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk 4.1 Women and community engagement 49
of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. 4.2 Service delivery for maternal and newborn care 53
4.3 Interprofessional collaboration 61
General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of 4.4 Midwifery leadership and research 65
any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or 4.5 Policy and regulatory environment 69
concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which 4.6 Education and continuous professional development 73
there may not yet be full agreement. 4.7 Health workforce strategies 77
4.8 Supportive health system environment 81
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO 5. Transition framework assessment tool 85
in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
6. Transition stories 107
distinguished by initial capital letters.
6.1 Transitioning to midwifery models of care in the absence of midwives: a story 111
from Bangladesh
All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published
6.2 Continuity of midwife care for survivors of sexual violence: a transition story 119
material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of
from the Democratic Republic of the Congo
the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
6.3 From political commitment to large-scale change: transition to continuity of 125
Design and layout by Sonder Design Collective midwife care in England
6.4 Introducing a continuity of midwife care model in Northern Ethiopia 131
6.5 Transitioning to continuity of midwife care in a conflict-affected setting: story 135
from the West Bank
References 141
Annex I 147
IV
Acknowledgements
External reviewers
WHO is grateful to the external reviewers who provided comprehensive review of the various areas covered: Jane Frances Acam (Ministry of
Health, Uganda); Anna af Ugglas (ICM, Kingdom of the Netherlands); Farah Babey (Ministry of Health and Medical Education, Islamic
Republic of Iran); Sarah Bar-Zeev (Burnet Institute*, Australia); Ndeye Bigue Ba Mbodji (Association nationale des sages-femmes d’Etat du
Sénégal, Senegal); Hélène Carrere (Collectif inter-associatif autour de la naissance, France); Maria Helena daSilva Bastos (Rede Feminista de
The World Health Organization (WHO) gratefully acknowledges the many individuals who contributed to this guidance document.
Ginecologistas e Obstetras, Brazil); Alison Eddy (New Zealand College of Midwives, New Zealand); Ubah Farah Ahmed (Somali Pediatric
Association, Somalia); Inderjeet Kaur (Fernandez Hospital, India); Debrah Lewis (Mamatoto Resource & Birth Centre, Trinidad and Tobago);
Leadership and coordination Alison McFadden (University of Dundee, United Kingdom); Paula Medway (Department for Health and Wellbeing, Government of South
This document was prepared under the overall strategic leadership of Anshu Banerjee (Director, WHO Department of Maternal, Newborn,
Australia, Australia); Berit Mortensen (Oslo Metropolitan University, Norway); Goma Devi Niraula (Midwifery Society of Nepal, Nepal); Jovita
Child and Adolescent Health and Ageing [MCA]) and Allisyn Moran (Unit Head, Maternal Health Unit, WHO MCA). Justine Le Lez (Consultant,
Ortiz Contreras (University of Chile, Chile); Loveday Penn-Kekana (London School of Hygiene & Tropical Medicine, United Kingdom); Lucia
WHO MCA) and Ulrika Rehnström Loi (Technical Officer, Midwifery, WHO MCA) were responsible for the technical leadership, coordination
Rocca-Ihenacho (City St George’s, University of London, United Kingdom), Yoko Shimpuku (Hiroshima University, Japan); Suzanne Stalls
and production of the document.
(MOMENTUM Country and Global Leadership, United States, in 2023 and 2024).

The Strategic and Technical Advisory Group of Experts for Maternal, Newborn, Child and Adolescent Health and Nutrition (STAGE)
Global advisers from UNFPA and UNICEF also for their technical contributions to the review: Chisato Masuda and Duncan Shikuku (UNFPA
Midwifery Working Group
headquarters, United States) and Shaimaa Ibrahim and Gagan Gupta (UNICEF headquarters).
WHO thanks the members of the STAGE Midwifery Working Group for their technical guidance through regular meetings between
November 2022 and January 2025 and input to the review: the two co-chairs, Sally Pairman (International Confederation of Midwives [ICM],
WHO contributors and reviewers
Kingdom of the Netherlands) and Jane Sandall (King’s College London, United Kingdom of Great Britain and Northern Ireland); Koki
The following staff from WHO for the technical guidance and review: contributors from WHO headquarters in Geneva, Switzerland: Agya
Agarwal (MOMENTUM Country and Global Leadership, the United States of America), Narendra Kumar Arora (The INCLEN Trust
Mahat and Carey McCarthy (WHO Health Workforce Department), John Fogarty and Blerta Maliqi (WHO Integrated Health Services
International, India), Oliva Bazirete (University of Rwanda, Rwanda), Marina Boykova (Council of International Neonatal Nurses, United
Department), Uzma Syed (WHO MCA) and Tova Tampe (WHO’s Special Programme on Primary Health Care). Contributors from WHO offices:
States), Gary Darmstadt (Stanford University School of Medicine, United States), Jacqueline Dunkley-Bent (ICM, Kingdom of the
Dalia Abujahel and Itimad Almadhoun (WHO office for West Bank and Gaza), Adeniyi Aderoba (WHO Regional Office for Africa, Republic of
Netherlands), Abby Kra-Friedman (International Council of Nurses, Switzerland), Asheber Gaym (United Nations Children’s Fund [UNICEF]
Congo), Mohammed Afifi (WHO Regional Office for the Eastern Mediterranean, Egypt), Moe Ando (WHO office, Lao People’s Democratic
Regional Office for South Asia, Nepal), Atf Gherissi (international midwife educator and researcher, Tunisia), Caroline Homer (STAGE Chair,
Republic), Ana Baraldi (WHO country office, Brazil), Leontien Becker (WHO office, Nepal), Clara Fischer (WHO office, Liberia), Bremen de
Burnet Institute, Australia), Deepika Cecil Khakha (Ministry of Health and Family Welfare, Government of India, India), Zuzana Krišková
Mucio (WHO Regional Office for the Americas/Pan American Health Organization, United States), Silvia Gatscher (WHO office, Romania),
(Women’s Circles, Slovakia), Geeta Lal (United Nations Population Fund [UNFPA] headquarters, United States), Deborah Money
Minhyung Hwang (WHO office, Bangladesh), Margrieta Langins (WHO Regional Office for Europe), Bernadette Mbu Nkolomonyi (WHO office,
(International Federation of Gynecology and Obstetrics [FIGO], United Kingdom), Geraldine Nyaku (Independent researcher, Zimbabwe),
Democratic Republic of the Congo), Robert Mulunda Kanke (WHO office, Democratic Republic of the Congo), Md Nuruzzaman (WHO office,
Naveen Thacker (International Pediatric Association, United States), Patricia Titulaer (Laerdal Global Health, Norway), and Dilys Walker
Bangladesh), Georgiana-Victoria Schiere (WHO office, Romania), Ai Tanimizu (WHO Regional Office for South-East Asia, India), Ellen Thom
(University of California San Francisco, United States).
and Qudsia Uzma (WHO country office, Pakistan).

The STAGE Midwifery Core Group

WHO Strategic and Technical Advisory Group of Experts for Maternal, Newborn, Child and Adolescent Health and Nutrition endorsed the
WHO acknowledges the STAGE Midwifery Core Group members for their technical guidance to the development and review of the
implementation guidance, in May 2025.
implementation guidance through regular meetings between August 2024 and January 2025: Sally Pairman and Jane Sandall, Ferdousi
Begum; Geeta Chibber (public health consultant, India); Jennifer Dohrn (Columbia University School of Nursing, United States); Fatoumata
Financial contributions
Ngayta Diop (UNFPA, Senegal); Jama Egal (Somaliland Nursing and Midwifery Association, Somalia); Atf Gherissi; Solomon Hailemeskel
WHO acknowledges financial support received from the Gates Foundation and MSD for Mothers.
Beshah (Debre Berhan University, Ethiopia); Pandora Hardtman (Jhpiego, United States, in 2024); Dewan Md Emdadul Hoque (UNICEF,
Bangladesh); Zuzana Krišková; Michelle Sadler (Observatory of Obstetric Violence, Chile) and Daphne Shamambo (Ministry of Health,
Zambia).

Transition stories
WHO expresses appreciation to the following individuals and organizations for the development and review of the transition stories:
Association Marocaine des Sages-femmes (Morocco); Rowsan Ara (UNFPA, Bangladesh); Rabeya Basri (Government of Bangladesh,
Bangladesh); Farida Begum (UNFPA, Bangladesh); Ferdousi Begum (Obstetrical and Gynaecological Society Bangladesh, [OGSB],
Bangladesh); Marie Berg (The Evangelical University in Africa, Democratic Republic of Congo); Makundane Marthe Byamungu (Panzi Referral
Hospital, Democratic Republic of the Congo); Susan Díaz Díaz (Hospital Eloísa Díaz de La Florida, Chile); Jacqueline Dunkley-Bent; Alison
Eddy; Víctor Flores Carrasco (Hospital Eloísa Díaz de La Florida, Chile); Atf Gherissi; Solomon Hailemeskel Beshah; Abu Sayed Hasan
(UNFPA, Bangladesh), Maria Hogenäs (Art of Life and Birth, Sweden); Dewan Md Emdadul Hoque; Joy Kemp (UNFPA, Bangladesh); Anneka
Knutsson (independent sexual and reproductive health and rights consultant, Sweden); Gonzalo Leiva Rojas (Hospital Eloísa Díaz de La
Florida, Chile); Helena Lindgren (Karolinska Institutet, Sweden); Camila López Echavarri (Hospital Eloísa Díaz de La Florida, Chile); Berit
Mortensen (Oslo Metropolitan University, Norway); Sarah Namyalo (Uganda Private Midwives Association, Uganda); Fatoumata Ngayta
Diop; Jovita Ortiz Contreras (University of Chile, Chile); Sally Pairman; Pronita Raha (UNFPA, Bangladesh); Jane Sandall, and Michelle
Sadler and Esubalew Tesfahun (University of Gondar, Ethiopia). * During the work, this contributor’s institutional affiliation changed from UNFPA initially
to the Burnet Institute

vi vii
Wording used A newborn is weighed by a midwife
during a home visit in the postnatal
period in Pakistan. © ICM

in this document

In this implementation guidance, when referring to pregnancy, childbirth and

the postnatal period, the term “women” is also intended to include adolescent
girls. The terms “women” and “mothers” are intended to be inclusive of all
those who self-identify as women and/or who give birth. While the majority
of people who are pregnant or can give birth are cisgender women (who were
born and identify as female), this guidance is also inclusive of the experiences
of transgender men and other gender-diverse individuals who have the
reproductive capacity to give birth.

The terminology of health professions is aligned with the current (2008)

edition of the International Standard Classification of Occupations (ISCO-08),
a publication of the International Labour Organization1. In this document,
“midwives” refers to both midwives and nurse-midwives, provided that the
nature of the work performed by nurse-midwives aligns with the midwifery
tasks specified and listed in ISCO-08. Midwives can be of any gender.

viii ix
01
Introduction
Implementation guidance on transitioning to midwifery models of care Introduction
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Enjoying the highest attainable standards of health To improve maternal and newborn health and well-being outcomes and achieve universal health coverage, the
World Health Organization (WHO) supports the transition to midwifery models of care; a way to optimize service

is a fundamental human right. Despite progress in delivery to better meet the needs of women and newborns before, during and after pregnancy and childbirth (8).
In these models, quality care is coordinated by midwives who make autonomous decisions across their full scope

recent decades, maternal and neonatal mortality, of practice, as part of interdisciplinary teams. When complications arise, midwives collaborate seamlessly with
obstetricians, paediatricians and other specialists, through effective consultation and timely referral systems,

morbidity and stillbirths remain high globally (1–5). jointly ensuring continuous, personalized care to women and newborns.

Many women and newborns experience A single health system can accommodate multiple models for maternal and newborn care, each adapted to
different needs and contexts. Expanding service delivery through midwifery models of care represents a
mistreatment and overmedicalization throughout cost-effective, evidence-based and human rights-driven strategy that saves lives and enhances the health and
well-being of women and newborns worldwide. This approach ensures the provision of quality maternal and
antenatal, intrapartum and postnatal care, which newborn care before, during and after pregnancy, while addressing critical maternal and newborn health and
equity challenges (8). The best results are achieved when care is provided by the same midwife or team of
can severely affect their health and well-being and midwives during pregnancy, birth and the postnatal period (continuity of midwife care).

hinder progress towards achieving universal health In 2024, WHO published a global position paper presenting the definition, guiding principles and case for

coverage (6,7). transitioning to midwifery models of care (8). Figure 1 summarizes the key information from this position paper.

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Midwifery models of care

Fig 1. Key concepts related to midwifery models of care. Source: WHO, 2024 (8)

Midwifery models of care provide women and newborns with care from
an autonomous midwife, working as part of a team, throughout pregnancy,
childbirth and the postnatal period.

Woman- and
newborn-centred care

Provided by autonomous
midwives within teams

Why choose midwifery models of care? A trusting woman-midwife

relationship and partnership
To save lives Supporting healthy and
physiological processes
To increase vaginal birth rates
To reduce assisted vaginal births and caesarean
section rates
To improve women’s experience of care Quality and holistic care,
based on evidence
To reduce health inequities and reach universal health
Provided before and during
coverage pregnancy, childbirth
and the postnatal period
To improve cost-effectiveness

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1.1 What is the purpose 1.2 Who are the expected users?
of the implementation
guidance?

This guidance is designed to support government officials within the Ministry of Health—particularly those
involved in maternal and newborn health, human resources for health, primary health care and broader health
systems. The successful transition and sustainability of midwifery models of care depend on strong leadership
and ownership from the Ministry of Health (9–11).

Under the Ministry of Health's leadership, a broad range of stakeholders should be involved in transitioning
to these models, and they too can benefit from this guidance. These stakeholders include:

This document provides strategic and practical End-users and women’s and community groups

guidance to countries transitioning to midwifery Health care policymakers and government leaders in maternal and newborn health,

models of care. human resources for health, and health systems

Representatives from other relevant ministries

(e.g., Finance, Education, Planning, and Women’s Affairs)
Aligned with global health priorities and the Sustainable Development Goals (SDGs), this document provides
strategic and practical guidance to countries transitioning to midwifery models of care. It equips policymakers
Implementing partners, international health organizations and nongovernmental organizations
and health care leaders with evidence-based practices and a transition framework assessment tool to optimize
services and resource use. By emphasizing interdisciplinary collaboration and coordination, the guidance outlines
actionable steps for integrating and strengthening midwifery care within national and subnational health Health care administrators, managers, midwives and other health workers

systems.
Professional associations, regulatory authorities, educational and training institutions
Recognizing that countries are at different stages of transition, this flexible guidance is designed to adapt to each
country’s specific needs—whether are newly committed to adopting midwifery models of care or are already Researchers, academics, advocacy groups and media and communication professionals
scaling up established midwifery services.

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1.3 Exploring midwifery models

Table 1. Core service delivery elements of each midwifery model of care

of care
Care recipients Women and newborns
There is no single, standardized description of midwifery models of care, as each country tailors its approach to
meet its unique needs. This customization results in a diverse range of models worldwide (12).
Package of midwifery services Reproductive, maternal and newborn care
Designing a model of care involves defining key service delivery elements (13). For a model to be considered a services
midwifery model of care, it is essential that professional midwives serve as the main care providers for women
and newborns across the continuum of maternal and newborn health services. These services include
pre-pregnancy, antenatal, intrapartum and postnatal care (8). Midwives provide care autonomously within their
Continuum of care Pre-pregnancy, pregnancy, labour and childbirth
scope of practice while collaborating within interdisciplinary teams. This collaboration is supported by and/or the postnatal period
established referral systems and mechanisms for interprofessional collaboration across health workers and
service delivery platforms to ensure continuity of care in the event of complications (8). The midwifery approach
Main care providers Midwives providing and coordinating care
to care is grounded in the core philosophy and principles of the profession, providing person-centred, respectful
and evidence-based care, and encouraging a strong partnership and relationship between the midwife and the Making their own decisions within their scope
woman (8). of practice

Table 1 presents the core service delivery elements of midwifery models of care. While these are foundational,
they can be expanded to suit the unique needs and context of each country. For example, the service package Approach to care Based on the midwifery philosophy of care (14)
might be expanded within midwives’ scope to include sexual and reproductive health services, extending the - Person-centered
continuum of care beyond the postnatal period and potentially broadening the target population to include - Relationship and partnership between
adolescent girls and boys.
midwives and women
Countries also have the flexibility to select service delivery platforms that best meet local needs.
- Optimization of physiological, biological,
These platforms can be: psychological, social and cultural processes
- Use of interventions only when indicated.

Community-based settings

Hospital-based settings

Public and private sectors, including public–private partnerships

Facilities in resource-limited environments, or humanitarian and crisis settings (8)

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Midwifery models of care are flexible and can be integrated or merged to suit varying contexts. For instance, a
midwife might provide continuity of care within a community-based birth centre during a humanitarian
crisis. As each country has specific needs, midwifery models of care should be tailored accordingly. In
decentralized systems, this approach can also be applied at the subnational level.

To assist countries in designing their tailored models, this document provides examples of adaptable
configurations, including:

Continuity of midwife care models

Birth centres

Community-based models

Private practice models

Models for humanitarian and crisis settings

These examples are not meant to represent definitive best practices but to serve as adaptable options to inspire
context-specific solutions.

A pregnant woman and her husband are shown exercises to facilitate birth by a midwife in Portugal. © WHO/Carlo Bruno Santos

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1.3.1 Continuity of midwife

care models %$/"0

Continuity of midwife care in New Zealand

Continuity of midwife care models are defined as approaches in which a
known and trusted midwife—or a small team of midwives—acts as the In New Zealand, pregnant women choose a Lead Maternity Carer, often a midwife, who
primary caregiver for women and their babies throughout the entire coordinates all aspects of their maternity care, including antenatal, intrapartum and postnatal
continuum of care, from the antenatal period through labour and childbirth care for up to six weeks. This model centres on women, supporting informed decision-making
about their care.
to the postnatal phase (8).
Lead Maternity Carer midwives are available 24/7, often working in small group practices to
This model provides consistent care and emotional support during pregnancy, provide continuous care. A fully publicly funded network of midwife-led facilities provides
intrapartum and postnatal care services at all levels of care. This approach addresses clinical and
labour, childbirth and the weeks that follow. It fosters ongoing personal
sociocultural needs and improves access for priority groups such as Māori, Pasifika, socially
connections, effective care management and seamless information sharing, disadvantaged women and women with disabilities.
resulting in more personalized and integrated care (8). WHO recommends
these models in settings with well-functioning midwifery programmes Lead Maternity Carer midwives have access agreements with hospitals and collaborate with
hospital staff to ensure person-centred, integrated and seamless care, including access to
(15–17). Box 1 provides an example of continuity of midwife care in New specialized care through referral and consultation. National referral guidelines and electronic
Zealand. records support and facilitate interdisciplinary collaboration. The success of this system
highlights the importance of strong partnerships, comprehensive training and effective
collaboration among health care providers.

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1.3.2 Community-based midwifery

models of care %$/"1

Itinerant midwives strategy in Senegal:

Community-based midwifery models of care provide essential services
a community-based midwifery model
directly to local communities, ensuring that quality, culturally sensitive of care
and personalized care is accessible where people live. As a core component
of primary health care, this approach is essential for achieving universal
health coverage by adapting services to local needs and preferences (13). In Senegal, the itinerant midwife (sage-femme itinérante in French) conducts regular visits to
It is particularly beneficial in rural, remote and underserved areas where health posts, community sites and local gathering places to ensure comprehensive, integrated,
community-based maternal, newborn, child and adolescent health services. This care spans from
access to health care facilities is limited. These models use various service antenatal care, intrapartum care, and essential newborn care; to immunization, integrated
delivery platforms—such as mobile health units and community health management of childhood illnesses, nutrition counselling, family planning and health education.
centres—to bring midwifery care closer to the population effectively. The itinerant midwife also manages medication and supplies, oversees data collection and use,
and trains and supervises community health workers. Women and communities are central to
Box 2 provides an example of a community-based midwifery model of care
the success of the itinerant midwife strategy. They actively participate in planning and evaluating
in Senegal. itinerant services, support itinerant midwife mobility and help secure suitable housing when
needed. Communities also engage in outreach and promotion to raise awareness and encourage
the use of itinerant midwife services.

Through close collaboration with local actors, the intinerant midwife strengthens community
health systems, expands access to quality care and creates an environment that supports positive
maternal and child health outcomes.

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1.3.3 Birth centres

%$/"2

Implementation of midwife-led birth

Birth centres2 are dedicated spaces where women and newborns at low risk
centres: a policy brief by ICM (22)
of complications receive quality care provided and coordinated by midwives
(18–22). While these centres always provide intrapartum care, they sometimes
The ICM released a policy brief on implementing birth centres, presenting the Pathway to
offer additional services, such as antenatal, postnatal and sexual and
Change—which outlines the processes and mechanisms required to scale up birth centres—and
reproductive health services, provided through a continuity of midiwife care detailing a series of actions to ensure their successful implementation. This policy brief was
model (19,22). based on evidence from a descriptive case study of four birth centres in Bangladesh, Pakistan,
South Africa and Uganda, providing valuable insights into these service delivery platforms (9).
Birth centres are part of the health system and can either be:

Freestanding birth centres – located outside of the hospital setting with the option to refer women
and newborns to a higher-level facility in case of complications (18–20,22,23).

Alongside birth centres – located within a hospital setting, physically connected to the hospital for easy
access to additional resources in case of complications (18–20,22,23).

The successful implementation of birth centres depends on delivering quality midwifery care that is recognized
and valued by the community. This is supported by strong referral systems and seamless coordination between
health care providers and facilities (19,22,24). When more complex care or specialized interventions are needed,
midwives consult with and refer women and newborns to specialist practitioners—such as obstetricians,
paediatricians or other experts—ensuring that interdisciplinary teams work collaboratively to provide the best
possible care. Box 3 provides information on a policy brief released by ICM on birth centres.

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1.3.4 Private midwifery models

of care %$/"3

Private maternity homes in Uganda:

Midwifery care can also be provided by a privately practising midwife, either
continuity of maternal and newborn care
individually or as part of a private health care organization. To ensure that all provided by private midwives
women and newborns receive quality, equitable and financially sustainable
care, these private models should be fully integrated into national and
subnational health systems through a robust policy and regulatory In Uganda, private maternity homes provide continuity and person-centred antenatal,
framework, including financing mechanisms preventing financial hardships. intrapartum and postnatal care to women and newborns, often delivered by the same one or two
midwives. Women enter the model with an antenatal visit and continue with monthly visits,
Box 4 provides an example of a private midwifery model of care in Uganda. aiming for eight throughout pregnancy. They receive intrapartum care during labour and
childbirth, followed by a structured postnatal care system based on the “4–6 model,” which
includes follow-ups at six hours, six days, six weeks and six months postpartum, along with
immediate access to family planning services.

In private maternity homes, midwives work closely with other health workers, including doctors
and nurses, ensuring a collaborative approach to care, particularly for referrals or managing
complications. Financing for private maternity services varies by location, with urban centres
generally more expensive than rural ones. To ease financial burdens, many centres offer flexible
payment options, allowing women to pay in instalments throughout pregnancy.

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1.3.5 Midwifery models of care

in humanitarian and crisis settings %$/"4

Mobile midwifery model of care during

Midwifery models of care can be adapted to resource-constrained
floods in Pakistan
environments, providing essential maternal and newborn interventions in
humanitarian and crisis settings. These settings include refugee or internally
In June 2022, devastating floods in Pakistan displaced over 33 million people, severely disrupting
displaced persons camps, armed conflict and natural disasters (8). Box 5
health services and leaving pregnant women highly vulnerable with limited access to essential
provides an example of a midwifery model of care in Pakistan during floods. health services, compounded by unsafe shelters lacking privacy, hygiene and basic resources.

In response, a mobile midwifery model was implemented to provide timely, life-saving support to
women and newborns despite the challenging terrain and disrupted infrastructure. The model
ensured an early response to the health care needs of pregnant women and newborns in
flood-affected districts. Equipped with essential supplies and trained in emergency obstetric and
neonatal care, mobile teams of midwives traveled by boat, vehicle or on foot to reach affected
areas, providing antenatal visits, quality labour and childbirth care, and postnatal care, with
referrals for more complex emergencies.

This model prioritized flexibility, cultural sensitivity and strong collaboration with local
authorities, community leaders and other humanitarian actors. By integrating health education
and counselling on topics such as breastfeeding, newborn care and early detection of
complications, the mobile midwifery teams supported women and families to make informed
health decisions during the crisis, strengthening community trust, resilience and capacity,
ultimately contributing to more equitable and sustainable maternal and newborn health services
even after the emergency had subsided.

21 22
Implementation guidance on transitioning to midwifery models of care Introduction
!""#$"%&'(")$")&%*+"$,"'$-)+-).

1.4 A flexible approach Transitioning to midwifery models of care

is a dynamic, non-linear and context-specific
for transitioning to process that requires a structured yet
midwifery models of care adaptable approach.
This guidance outlines eight areas that must be addressed to achieve
a sustainable transition to midwifery models of care. Each area is divided into
Engagement of women five phases of transition. All transition areas are essential, and progress in one
and communities
often drives—or depends on—progress in others.

Service delivery
for maternal and
Interprofessional newborn care
collaboration

Midwifery
leadership

Policy and regulatory

environment

Education, continuous
professional development
and research
Health workforce
strategies

Midwifery models of care

Supportive health
system environment

23 24
Implementation guidance on transitioning to midwifery models of care Introduction
!""#$"%&'(")$")&%*+"$,"'$-)+-).

The transition process proposed in this guidance involves initiating and sustaining change through essential
pillars, as outlined in Chapter 2. It is anchored in the development of strategic and operational plans, structured
into a four-step process to support priority setting, described in Chapter 3. To guide this process, a transition
framework assessment tool is provided to help countries estimate their current phase of transition in each area.
Recommended actions for advancing each transition area—such as women and community engagement or
interprofessional collaboration—are presented in Chapter 4 and can be incorporated into countries’ operational
plans, based on evolving needs.

Tailored solutions aligned with each country’s unique health system, policies and cultural context are essential.

and external factors, such as political instability or changes in national and subnational priorities (10). Rather than
prescribing a rigid process, this document offers a flexible, adaptable approach that can respond to changing
circumstances and emerging challenges.

Annex I presents the development process of this implementation guidance. The essential pillars and transition
areas presented in this guidance were identified through a literature review and further refined through expert
consultations. While they provide a strong foundation, further research is needed—particularly on the transition
to continuity of midwifery care models to determine optimal service delivery designs and strategies for
sustainable national scale-up. This includes economic analyses of relative costs and benefits. The economic
analysis of relative costs and benefits is particularly important to build a compelling investment case for midwifery
models of care, including improved maternal and neonatal health outcomes, social and economic advantages
and efficient use of healthcare resources.

Women receive counselling from a midwife about breastfeeding, nutrition and handwashing at the Noor-e-Khuda
Clinic in Mazar-e-Sharif, Afghanistan. © UNICEF Afghanistan

25 26
51
Essential pillars
for the transition
to midwifery
models of care
Implementation guidance on transitioning to midwifery models of care Essential pillars for the transition to midwifery models of care
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This chapter presents the essential pillars for

initiating and sustaining the transition
to midwifery models of care. These pillars are
not intended to be followed in a strict sequence;
rather, they are typically pursued concurrently.
Sustained, adaptive efforts are essential to maintain
these pillars, achieve lasting impact, strengthen
health system resilience and improve maternal and
newborn health outcomes.

A woman receives antenatal care from a midwife at the Pala Island village health post, in South Sulawesi,
Indonesia. © WHO / Harrison Thane

29 30
Implementation guidance on transitioning to midwifery models of care Essential pillars for the transition to midwifery models of care
!""#$"%&'(")$")&%*+"$,"'$-)+-).

2.1 Foster and secure political 2.2 Establish or strengthen

commitment and funding governance

Political commitment is essential for creating an Establishing or strengthening governance fosters political commitment and national and/or subnational
consensus, ensures strategic alignment and efficient use of resources for the transition to midwifery models

enabling environment for change and mobilizing of care, and facilitates stakeholders’ engagement in the process (10,11,29,30). This involves creating or reinforcing
two key structures:

the necessary resources for a successful transition

to midwifery models of care (10,25–27). National Technical and Strategic Advisory Midwifery Working Group: this group guides strategic direction
and oversight of the transition to midwifery models of care.

When policymakers prioritize midwifery models of care, they drive systemic reforms, secure funding for workforce Project management team: this team supports the operationalization of the strategic plan.
development and implement supportive policies that improve both maternal and neonatal health outcomes. This
commitment not only legitimizes these models but also fosters the collaboration needed for sustainable,
long-term improvements in maternity services. Engaging decision-makers by demonstrating how the transition Additionally, countries may opt to establish a temporary national midwifery task force to address specific,
aligns with subnational, national and global health goals helps secure political support. The return of investment time-sensitive issues, such as policy development or urgent midwifery challenges. Depending on the country
from midwifery models of care can serve as a strong advocacy tool. Ongoing advocacy and leadership across context, strengthening or creating regional midwifery working groups can also provide valuable support.
all levels are critical for sustaining political momentum and ensuring that midwifery models of care remain a
priority at both national and subnational levels (10,26,28) In some settings, the midwifery working group may function as a subgroup within national technical advisory
groups on maternal and newborn health, human resources for health or primary health care. If the national
midwifery working group operates independently, strong communication and collaboration with these technical
While transitioning to midwifery models of care requires initial investments, their medium- and long-term
advisory groups—where they exist—are highly recommended.
cost-effectiveness optimizes subnational and national resource use, resulting in significant cost savings and
reduced health expenditures (8). To ensure the transition is both effective and sustainable, securing dedicated
These structures can also be established or strengthened at the subnational level.
funding from diverse sources—through earmarked budgets and the integration of midwifery financing into.
broader health strategies, like universal health coverage—is essential to cover operational costs (10,25,26)

31 32
Implementation guidance on transitioning to midwifery models of care Essential pillars for the transition to midwifery models of care
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2.3 Build partnerships

Leading advocacy for midwifery professional
recognition and safe practice in Morocco

The Association Marocaine des sages-femmes (Moroccan Association of Midwives) led a

successful advocacy campaign to establish midwives’ professional identity, scope of practice and
competencies, culminating in the passage of Law No. 44-13 in 2016—a significant milestone for
the profession. The Association Marocaine des sages-femmes developed policy briefs and

Interest groups play a significant role in the awareness campaigns, with support from many stakeholders, including the Association
Nationale des Sages-Femmes au Maroc (National association of midwives in Morocco), leveraging

integration of midwifery models of care within scientific evidence to highlight the critical role of midwives in reducing maternal mortality in
Morocco over the past 30 years. Their efforts resulted in the 2016 law, which, for the first time,
health systems, either supporting or opposing the formally defined the identity and scope of midwifery practice in the country. This structured
approach involved extensive advocacy and stakeholder engagement—including with
transition to these models (11). parliamentarians, ambassadors, media, United Nations agencies, feminist associations and
health authorities—and demonstrated the power of an evidence-based approach, persistence,
collaboration and solidarity. It also underscored the importance of building midwives’ capacity
for effective advocacy.
To foster acceptance and improve coordination across sectors, it is essential to build strategic partnerships and
engage key stakeholders—such as women, community members, obstetricians, paediatricians, nurses, midwives
and policymakers—early in the process (10,11,27,30). Their continued involvement is crucial for a successful and
sustainable transition, with professional associations also playing an important role.

(10,26,27). Continuous advocacy is essential to improving understanding of midwifery models of care and the role
of midwives through clear, evidence-based communication, cross-sector discussions, joint workshops and
learning events (10,26,28). Additionally, influential leaders acting as advocacy champions, along with a strong
media strategy—including press releases, journalist engagement and social media coverage—can further bolster
these efforts. Box 6 presents an example of successful advocacy for midwifery professional recognition in Morocco.

33 34
Implementation guidance on transitioning to midwifery models of care Essential pillars for the transition to midwifery models of care
!""#$"%&'(")$")&%*+"$,"'$-)+-).

2.4 Ensure sustainability

of the transition to midwifery
models of care

Sustainability is crucial for realizing the full

potential of midwifery models of care. With strong
political, financial and operational support,
countries can establish midwifery models of care
that consistently provide quality, accessible care to
women and newborns (10,11,26,27).

To preserve and enhance these benefits in the long term, and to achieve lasting impact, a comprehensive strategy
is needed. This strategy should maintain political commitment, sustain ongoing advocacy and leadership,
integrate midwifery models into national and/or subnational health systems, secure long-term funding and
remain adaptable to evolving needs (10,25,26).
A woman receives antenatal care at Nonsavang Healthcare Center, Champasak, Lao People's Democratic Republic
(2023). © WHO/Enric Catala

35 36
52
Strategic planning
process
Implementation guidance on transitioning to midwifery models of care Strategic planning process
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The transition to midwifery models of care requires a structured strategic

planning process that includes:

Situation analysis
Assessing current conditions

Strategic plan
Identifying national and/or subnational priorities

Operational plan and monitoring and evaluation

framework
Outlining actionable steps

Financial planning and resource allocation

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39 40
Implementation guidance on transitioning to midwifery models of care Strategic planning process
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"*#+&,
Identify women’s and communities’ values, needs and preferences
for maternal and newborn care.
Conduct a situation analysis
Review the policy, regulatory and financial environment supporting
or hindering the transition.
A thorough situation analysis provides a clear understanding of the current
landscape and identifies specific areas requiring improvement. The following
list of suggested areas for situation analysis can be adapted depending Examine existing service delivery and models of maternal and
on the needs of your country. newborn care.

Assess interprofessional collaboration among health workers in maternal

Assess the current state of maternal and newborn health, key quality and newborn care.
indicators and service coverage.

Conduct workforce planning and forecasting for midwifery models

Evaluate governance structures, political commitment and midwifery of care.
leadership.

Review midwifery education programmes, including opportunities

Conduct a strengths, weaknesses, opportunities and threats analysis for continuous professional development.
to identify barriers and enablers for the transition.

Assess health system infrastructure and capacity for transitioning

Perform stakeholder analysis and community mapping. to midwifery care.

41 42
Implementation guidance on transitioning to midwifery models of care Strategic planning process
!""#$"%&'(")$")&%*+"$,"'$-)+-).

"*#+&- "*#+&.

Design a strategic plan Develop an operational

plan with a monitoring
and evaluation framework
Identify priorities: determine the key national and/or subnational
priorities for transitioning to midwifery models of care and develop a
comprehensive strategic plan for their effective implementation (27).
Chapter 5 introduces a transition framework assessment tool to assist
countries in estimating their current phase of transition across various Develop a tailored operational plan that aligns with the local context
areas and in identifying areas of progress. and available resources. Chapter 4 of this document outlines specific
actions for each transition area that can be incorporated into the plan.
Include a dedicated section that details how women, communities and
stakeholders will be engaged specifying points of contact,
Ensure alignment: integrate these national and/or subnational priorities communication methods, transition areas, channels and frequency.
and objectives with the needs of the target users, ensuring alignment
with existing subnational, national and international programmes,
policies and strategies.
Incorporate a robust monitoring and evaluation framework to assess
the effectiveness of the implemented strategies (27).

Develop a regular review cycle to track progress, ensure accountability,

address challenges and adapt to changing needs (27).

43 44
Implementation guidance on transitioning to midwifery models of care Strategic planning process
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"*#+&/

Develop a financial plan

and allocate resources

Secure financial support including identifying and securing the

necessary financial resources from government budgets, international
donors and private sector partnerships. Explore various funding
mechanisms, including grants, loans and public–private partnerships.

Conduct budgeting and cost analysis including estimating the costs

associated with workforce training, recruitment, infrastructure
development or adaptation, service delivery platforms and other
operational needs (27). Develop a comprehensive, costed national
and/or subnational implementation plan for midwifery models of care,
ensuring that budgets cover ongoing operational costs and
contingencies.

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Three women and their newborns receive postnatal education at the National Centre for Maternal and Child
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Health, in Bayangol District, Ulaanbaatar, Mongolia, during the COVID-19 pandemic in 2021. © WHO/Khasar
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45 46
53
Transition areas
for midwifery
models of care
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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4.1 Women and community A fundamental principle of midwifery models

of care is the trusting relationship and partnership
engagement between midwives and women (8). By empowering
and involving women and their communities
in the transition to midwifery models of care —
and fostering demand for quality midwifery care —
the transition can be successful, even
in humanitarian and fragile settings (10,35–37).

This approach ensures that the models are responsive to the diverse needs,
beliefs and practices of women and communities, ultimately improving health
outcomes, strengthening primary health care, increasing community
acceptance of midwifery models of care, enhancing midwives' job satisfaction
and retention and reducing costs (9,10,35,38–40).

It is important to include representatives from vulnerable communities and

marginalized groups to ensure their perspectives are fully integrated into the
process and that no one is left behind. Box 7 provides an example of women
and community engagement for midwifery models of care in La Florida, Chile.

49 50
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
%$/"X

Improving community awareness about midwifery

Enhancing community engagement for models of care
midwifery models of care at Dra. Eloísa Develop tailored communication materials about midwifery models of care addressing literacy
levels and cultural contexts, based on evidence.
Díaz Hospital, La Florida, Chile Promote positive stories by using storytelling to share the experiences of women and newborns
receiving care during pregnancy, childbirth and the postnatal period in a midwifery model of
care.
Organize awareness-raising activities, such as community forums, media campaigns or
Dra. Eloísa Díaz Hospital in La Florida, Chile, handles approximately 2500 births annually. outreach sessions. Engage women and community leaders, advocates and influencers to
The hospital-based midwifery model emphasizes respectful, person-centred care, supporting amplify messaging.
women and their families to actively participate in the childbirth process. Since 2023, the hospital Empower communities to advocate for midwifery models of care at local, subnational and
is has adopted the “Open Hospital” strategy, aimed at fostering community engagement by national levels.
encouraging citizen participation in decision-making and providing clear, accessible information
about services, resources and policies to women, their partners, families and the broader
community.
Fostering engagement with women and communities
The open hospital strategy includes a public information access representative and committees
Define and implement participatory approaches to actively engage women and community
focused on public information and innovation, promoting community co-creation and enhancing
members, including monitoring and evaluation mechanisms.
health care access for all. Strong community connections are cultivated through guided
Integrate participatory practices within the health system to ensure sustainable participation of
maternity ward tours with midwives and the collaborative development of birth plans, allowing
women and communities in the transition process.
women and their families to share their preferences and expectations for childbirth. Direct
Integrate women and communities into governance structures.
communication between the health care team and the community is further enhanced through
Establish social accountability and feedback mechanisms, enabling continuous feedback on
an Instagram account managed by midwives, which has gained nearly 10 000 followers.
midwifery models of care.
Collaborate on projects and mobilization initiatives to support the transition to midwifery
The model has achieved the highest rate of normal births in Chile's national public health
models of care.
network and is nationally recognized for its positive community impact. It has significantly
improved birth experiences, fostered evidence-based practices and received outstanding
feedback from the community.

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51 52
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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4.2 Service delivery for

maternal and newborn care

A sustainable transition to midwifery models of care

requires comprehensive organizational changes and
ongoing adaptation across the health system,
including a thorough service delivery design and
implementation approach of the model !""#$%#$&#$'(I

Effective models of care are dynamic, continuously evolving through

performance monitoring and responding to changing population needs,
health priorities and local contexts. This approach ensures that every
individual receives timely and appropriate care delivered by the right team
in the right setting (12).

53 54
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
Preparing for the design phase
Gather evidence from global and local best practices.
Arrange for interdisciplinary visits to pilot sites or locations where midwifery models of care
been successfully implemented.

Designing tailored models

Agree on the approach, care recipients, service package, delivery platforms, care providers, care
pathways – including referral systems, interprofessional collaboration mechanisms and
financing mechanisms. Table 2 provides important considerations for each of these elements.

Implementing the new or updated midwifery

models of care
Pilot in selected facilities and or regions, including capacity building for health workers on the
model and approach to care.
Assess, document and share lessons learned.
Refine the model and prepare for scale-up.

A pregnant woman undergoes an ultrasound scan performed by a midwife using portable ultrasound
technology at Ntimaru Sub-County Level 4 Hospital in Kehancha, Migori County, Kenya. © UNFPA Kenya

55 56
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
!""#$"%&'(")$")&%*+"$,"'$-)+-).

Table 2. Important considerations when designing a midwifery model of care

Approach to care Ensure that the approach integrates the key elements of quality health care: people-centred, Delivering quality health services: a global
effective, safe, timely, equitable, integrated and efficient (40). imperative for universal health coverage.
Define the model’s guiding principles
Align the approach with the midwifery philosophy of care. WHO, 2018 (40)
and core values to ensure the provision Whenever possible, prioritize continuity of midwife care provided by the same midwife or small team Standards for improving quality of maternal
of quality care. of midwives throughout the continuum of care. and newborn care in health facilities.
Ensure that these values, along with a common vision and shared goals, are understood and WHO, 2016 (44)
embraced by key stakeholders. Transitioning to midwifery models of care:
global position paper. WHO, 2024 (8)
Continuity and coordination of care: a practice
brief to support implementation of the WHO
Framework on integrated people-centred
health services. WHO, 2018 (45)

Care recipients Aim to achieve universal health coverage and equity for all women and newborns, regardless of Innov8 approach for reviewing national health
geographic location, ethnicity, religion, education level, employment status, income level, disability, programmes to leave no one behind: technical
Identify the target populations and
sexual orientation, age or cultural background. handbook. WHO, 2016 (46)
intended beneficiaries of the model. Ensure that the model prioritizes underserved and high-risk populations and actively works to reduce WHO AccessMod 5 tool. Supporting Universal
disparities. Health Coverage by modelling physical
accessibility to health care. WHO, 2023 (47)

Midwifery service package Develop a comprehensive midwifery service package that spans pre-pregnancy, antenatal, WHO universal health coverage Service
intrapartum and postnatal care. Planning, Delivery & Implementation (SPDI)
Determine the range of health services
Ensure the package aligns with midwives' scope of practice and includes all key service Platform. WHO (48)
to be provided by midwives within the categories—such as promotion of self-care, prevention, health education and counselling for women
model. and newborns, diagnostics and treatment.
Emphasize continuity of health service delivery across the entire continuum of care.

57 58
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Table 2. Important considerations when designing a midwifery model of care

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Service delivery platforms Ensure that services are available closer to where women and communities live. WHO AccessMod 5 tool. Supporting Universal
Adapt service delivery platforms to accommodate resource-limited or crisis settings, as needed. Health Coverage by modelling physical
Define the appropriate settings for care
Strengthen linkages between traditional birth attendants, community-level health workers and accessibility to health care. WHO, 2023 (47)
provision, such as community-based facility-based providers to support seamless care transitions across the continuum.
services, hospitals or birth centres.

Care pathways and providers Identify the entry point to the model of care for women and newborns. Networks of care for maternal and newborn
For models based on continuity of midwife care model, define a manageable caseload per midwife or health: implementation guidance.
Establish clear pathways that promote
small group of midwives (i.e. the number of women per year for whom each midwife will serve as the WHO, 2024 (49)
continuity of care across health main care provider). Develop a care pathway for complications that includes clear referral and
providers and levels of the health escalation protocols, and fosters interprofessional collaboration across health care providers and
system, including in cases of service platforms. This approach should support continuity of care, while maintaining the

complications. relationship between women, newborns and their midwives. This includes developing referral,
escalation and communication protocols.
Define the roles and responsibilities of all health workers involved in the model, ensuring these are
reflected in official job descriptions to support effective collaboration.

Financing mechanisms Ensure health financing for universal access to essential midwifery services by exploring public WHO Health Financing Progress Matrix.
funding, insurance schemes and cost reduction strategies. WHO (50)
Secure sustainable financing
mechanisms, including financial
protection and payment systems, to
promote equity in care.

59 60
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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4.3 Interprofessional
collaboration

In midwifery models of care, midwives work

autonomously within their scope of practice while
collaborating with obstetricians, paediatricians,
nurses and other health professionals. Trust-based,
respectful and non-hierarchical interprofessional
collaboration is essential for a successful transition
to midwifery models of care and for ensuring
quality care (26,27,35,39,51–54).

61 62
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
Building relationships and enhancing collaboration
Foster and leverage positive relationships among midwives, doctors, nurses and other health
workers, promoting collaboration based on equality, trust and mutual respect.
Establish shared values, as well as a common vision and goals, across professional groups.
Enhance health workers’ understanding of midwives’ roles, responsibilities and the principles and
benefits of midwifery models of care.
Reduce hierarchical structures and promote shared decision-making. This enables midwives to
fully exercise their autonomy within their scope of practice, and supports equitable, collaborative
care.
Foster psychological safety by challenging and addressing cultures of blame and shame.
Build and strengthen alliances between professional associations of midwives, obstetricians,
paediatricians, nurses and other health workers through jointly organized initiatives and events.
Ensure the inclusion of midwives in interprofessional committees and working groups, such as
maternal and perinatal death surveillance and response committees.

Fostering interdisciplinary communication

Develop and strengthen communication and coordination mechanisms among health workers,
including in emergency settings.
Promote regular interdisciplinary meetings to review cases, address challenges and reinforce
teamwork.
Establish and maintain networks of care that connect facilities and health workers across all levels
of the health system.
Implement effective systems for conflict resolution among health workers to support collaboration
and professional respect.

Enhancing joint education and orientation

Engage midwives, obstetricians, paediatricians, nurses and other relevant health workers in joint
education and orientation, both pre-service and in-service.

!"#$!%&'#"(!')#"& A surgical mobile interdisciplinary team pictured after a successful caesarean section performed during a
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63 64
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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4.4 Midwifery leadership

and research

Strong midwifery leadership at every

level—educational, regulatory, political, research,
clinical and operational as well as robust research,
is critical to support the transition to midwifery
models of care and to ensure that the needs of
women and newborns are effectively represented
and addressed (10,11,28,55,56).

This approach not only elevates the quality of care but also accelerates the
adoption of evidence-based practices (10, 28, 57). Strong midwifery
associations must be actively engaged in policy dialogue and
decision-making.

65 66
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
Ensuring midwifery representation in decision-making Building strong professional associations
Establish and strengthen senior leadership positions to support the governance and management Strengthen midwifery professional associations to engage effectively with allied associations in
of midwives, ensuring their active contribution to health policy, as outlined in the WHO Global delivering quality, respectful care.
Strategic Direction for Nursing and Midwifery (SDNM) 2021–2025 policy priority (55). Depending on Ensure that associations in fragile contexts are equipped to represent midwives during crises.
the national context, subnational positions may also be required.
Engage midwives in policy decisions, midwifery models of care planning, implementation and
monitoring and evaluation at all levels—subnational, national, regional and global.
Fostering research
Encourage and promote research coordinated or led by midwives.
Strengthening leadership capacities of midwives Establish partnerships with research institutions to support and advance evidence-based
practices.
Invest in strengthening midwives' leadership capacity, as outlined in the WHO SDNM policy
priority (55).
Strengthen the capacity for midwives to lead and advocate, ensuring involvement in health policy
decision-making and planning (56).
Identify and support midwifery champions within communities and health systems.
Encourage midwifery leaders to join health committees, advisory groups, or task forces.
Develop awards and recognition mechanisms to highlight midwifery leaders' contributions,
providing role models for early-career midwives.
Create leadership programmes for young midwives to prepare them for roles in subnational,
national and global health dialogues.

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67 68
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4.5 Policy and regulatory

environment

Creating a supportive policy and regulatory

environment is crucial for providing quality care
to women and newborns (11,24,26,27,37,56,59).
This entails recognizing midwives as autonomous
practitioners and enabling them to operate within
their full scope of practice (10,11,26,27).

69 70
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
Establishing and strengthening a supportive policy
environment
Ensure that subnational and national policies, strategies, plans and budgets support the
sustainable implementation of midwifery models of care.
Develop laws and policies to recognize midwives as autonomous health practitioners, allowing
them to fully exercise their scope of practice.
Design and implement midwifery policies that contribute to progress toward Every Woman Every
Newborn Everywhere targets, universal health coverage and Sustainable Development Goals,
particularly in maternal, newborn and reproductive health, gender equality and equitable
quality education.

Establishing and strengthening a supportive

regulatory environment
The specific actions to strengthen midwifery regulation depend on the context and the risks to patient
safety. Where applicable, consider an umbrella law for all health practitioners and a multi-practitioner
regulatory agency to ensure consistency while addressing specific risk profiles.
Licensing schemes include:

Tailored entry-to-practice requirements with minimum standards for midwifery education and
practice.
Mechanisms to assess and assure continuing competence.
Accreditation of midwifery education institutions and licensing of graduates based on clear
standards.
Recognition of international midwifery qualifications based on competence and comparability.
A code of conduct and ethics for professional practice.
Protocols for addressing professional misconduct and resolving grievances
Regulated scope of practice determined by education, skills and competence, supported by
governance and clinical oversight (59).

A woman is supported during labour by her companions of choice and a midwife at Casa Angela birth centre,
São Paulo, Brazil, in 2023. © ICM

71 72
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4.6 Education and continuous

professional development

Adequate midwifery education and sustained

investment in continuing professional development
support the delivery of quality care.

This, in turn, strengthens midwives' professional identity, competence and

confidence, while enhancing their autonomy across their scope of practice
(10,11,26,27,37,48,51,55,56). As outlined in the WHO SDNM 2021–2025, midwife
graduates should meet or exceed health system needs and possess the
needed knowledge, competencies and attitudes to address national health
priorities (50). Box 8 provides information on the WHO, UNICEF, UNFPA and
ICM seven-step action plan to strengthen the quality of midwifery education.

73 74
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Recommended actions
%$/"Y

Developing and strengthening standards and curricula

Align midwifery education with optimized roles within health and academic systems as outlined in Seven-step action plan to strengthen
the WHO SDNM policy priority (50).
Create and implement competency-based education programmes that incorporate effective
quality midwifery education
learning design, adhere to quality standards and meet population health needs, as outlined in the
WHO SDNM policy priority (50).
Develop and implement flexible and validated national education and continuous professional
WHO, UNFPA, UNICEF and ICM developed a seven-step action plan to strengthen quality
development programmes to keep midwives updated with evolving evidence-based practices.
midwifery education. This action plan provides a framework to develop and strengthen
midwifery education through intersectoral collaboration and engagement from multiple
stakeholders and the community (61).
Strengthening faculty and educating students
Ensure faculty are competent in effective pedagogical methods and technologies and possess
clinical expertise, as outlined in the WHO SDNM policy priority (50).
Prepare and strengthen educational institutions, practice settings and clinical mentors.
Utilize innovative learning methods alongside traditional theory and clinical practice.
Enhance student well-being and retention with financial support, scholarships, mentorship
programmes, peer support groups and well-being services.

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75 76
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4.7 Health workforce strategies

Adequate workforce planning, improved working

conditions and targeted retention strategies
are essential to ensure equitable and accessible
midwifery models of care for all women
and newborns (10,11,24,26,27,37,55,56).

These measures help build a resilient and responsive health workforce

capable of addressing the diverse needs of maternal and newborn care. The
WHO SDNM 2021–2025 recommends that countries increase the availability of
midwives by sustainably creating midwifery positions, recruiting and retaining
midwives, and ethically managing international mobility and migration (55).

77 78
Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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Recommended actions
Conducting workforce planning Developing attraction and retention strategies
Conduct midwifery workforce planning and forecasting using a health labour market lens, as Evaluate national pay scales in relation to living wages and commit to establishing a fair,
outlined in the WHO SDNM policy priority (55), determined by the midwifery models of care the gender-neutral remuneration system for all midwives, including those in the private sector,
country will adopt. adequate to the levels of responsibility
Attract, recruit and retain midwives in the locations with greatest needs, as outlined in the WHO Consider incentives and supportive social policies to attract individuals to the midwifery
SDNM policy priority (55). workforce.
Explore how the transition to midwifery models of care can impact access, quality, recruitment Establish benefits for midwives working in emergency and humanitarian settings, such as
and retention. overtime and hazard pay where needed, benefit from comprehensive occupational health and
Map health care facility needs to identify service gaps and determine staffing requirements for safety measures, specific training in emergency preparedness and response, diagnosis and mental
midwifery models of care implementation. health support and services.
Develop or update workforce strategic and investment plans using insights from data and analysis. Establish clear career pathways and continuous professional development programmes for
Maintain a national registry of qualified midwives to support workforce planning, deployment and midwives to encourage professional growth and advancement, including management,
ongoing professional development. leadership, education and research. Acknowledge the educational advancements of midwives by
aligning their roles and responsibilities with appropriate remuneration.
Implement policies and establish practices that promote work–life balance by ensuring
manageable workloads and adequate staffing levels.
Develop mentoring and management, including support for early career midwives.
Developing recruitment and deployment strategies
Optimize the domestic production of midwives to meet or surpass health system demand, as
outlined in the WHO SDNM policy priority (55).
Sufficient job opportunities to support health service delivery for maternal and newborn health
care, as outlined in the WHO SDNM policy priority (55).
Implement the WHO Global Code of Practice on the International Recruitment of Health Personnel
(the “Code”), as outlined in the WHO SDNM policy priority (55).
Increase and secure job opportunities to ensure unemployed midwives are employed in the health
sector, addressing critical gaps in supply and distribution.
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Implementation guidance on transitioning to midwifery models of care Transition areas for midwifery models of care
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4.8 Supportive health system

environment

A supportive health systems environment

is essential for a successful transition to midwifery
models of care, ensuring women and newborns
receive quality midwifery care (26,27,37,54–56).

This includes ensuring that midwives, doctors, nurses and other health
workers have access to safe and supportive gender-responsive working
conditions, in an environment with adequate infrastructure and commodities
(24,35,46). This also involves midwives being enabled to autonomously
provide care within their full scope of practice, free from interference caused
by institutional hierarchical structures or unequal power dynamics in
management (10,26,54,71). Effective teamwork and interprofessional
collaboration are addressed in the relevant section.

81 82
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'0123304505&6178249
Fostering adaptive workplace practices and policies
Enable midwives to fully contribute to service delivery as outlined in the WHO SDNM policy
priority, including enforcing policies that protect their autonomy within their defined scope of
practice (55).
Create a gender-responsive environment free from discrimination, violence and harassment.
Enforce zero tolerance for verbal, physical, and sexual harassment and promote workplace
violence prevention through conflict management training.

Developing or improving infrastructure and facilities

Establish workplace policies that provide essential resources such as water, sanitation, electricity,
supplies, commodities and safe infrastructure, including accommodation and transport.
Ensure that appropriate health care facilities are available, including referral systems and
transportation, and evaluate the need for new or tailored facilities.
Identify the essential medical supplies and equipment needed.
Ensure a supply allocation and distribution plan is determined for each scenario or location.

Promoting the use of innovation and technology

Expand workers’ access to innovation, tools, and technology to enable them to maximize their
performance, well-being, motivation and job satisfaction, including in the context of performance
management, service delivery and advanced practice.
Assess the need for electronic health records, data management systems and other digital tools to
support maternal and neonatal outcomes monitoring and evaluation.

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A mother being supported by a midwife on how to breastfeed her newborn baby at Raja Isteri Pengiran Anak
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Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam, in 2016. © WHO Yoshi Shimizu

83 84
54
Transition
framework
assessment tool
Implementation guidance on transitioning to midwifery models of care Transition framework assessment tool
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A transition framework assessment tool, presented For each transition area, it is recommended to follow these steps:

in Table 3, was developed to help countries Review. Examine the findings from the situation analysis using
estimate their current phase of transition across the transition areas outlined in the Transition Framework
Assessment Tool.
transition areas such as women and community
engagement, service delivery and interprofessional Compare. Assess the country’s situation by comparing it to the
collaboration. By identifying their phase, countries descriptions provided for each phase in the tool.

can better understand their progress, identify Select. Identify the phase that best reflects the country’s situation
national and/or subnational priorities and for each transition area and circle the corresponding box. Since each
box covers multiple elements, the country may be at different levels
determine necessary actions for strengthening for different aspects. In such cases, it is recommended to select the
health systems and midwifery models of care. lowest applicable phase.

Summarize. Provide a summary of the results. A summary table

This framework was developed through a literature review and expert consultation. While it has not yet been pilot
tested in any country, this implementation guidance presents it as a flexible and adaptable tool that can be
could be used to describe the identified phase and its associated
tailored to fit different national contexts and specific needs. Further research is recommended to enhance its colour for each transition area.
effectiveness and refine its application.

Example: In country X, for the transition area “women and community engagement”, there is clear understanding
of midwifery models of care (phase IV). However, there is no formal women and community representation in
advocacy, governance or decision-making processes (phase II). Phase II will be circled as the final assessment,
and the summary table will be completed accordingly, reflecting this phase and its corresponding colour.

Transition area Women and community engagement

Phase Phase II - Initial transition

Associated colour

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Women and community

engagement
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

There is little to no awareness There is limited but growing There is growing awareness and There is a clear understanding A comprehensive and widespread
of midwifery models of care. awareness of midwifery models understanding of midwifery models of midwifery models of care. understanding of midwifery models
of care. of care. of care is established.

Women and communities have Formal engagement mechanisms

limited or no involvement Initial efforts are underway Structured engagement and formal have been established to ensure Ongoing and inclusive engagement
in the transition to midwifery to involve women and communities participatory approaches involving structured participation of women with women and community
models of care. in the transition to midwifery women and communities are and communities in the transition of representatives – including those
models of care. underway in the transition to midwifery models of care, with from vulnerable settings – is fully
midwifery models of care; however, feedback systems in place. integrated into the transition
accountability and feedback process.
Women and communities are mechanisms remain limited.
minimally represented in advocacy, Women and communities are not yet
governance and decision-making formally represented of women and Advocacy, governance,
process related to this transition. communities in advocacy, decision-making and continuous Participatory approaches are
governance or decision-making Representation of women and improvement processes include established, ensuring active
processes related to this transition. communities in advocacy, voices from vulnerable communities involvement in advocacy,
governance or decision-making and marginalized groups. governance, decision-making and
processes is emerging, but continuous improvement processes.
vulnerable communities and
marginalized groups are not
systematically involved.

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Service delivery

^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

There are no midwifery models of Discussions are emerging on the The design of the midwifery model The midwifery model of care has The midwifery model of care has
care in place. design of a context-specific of care has been finalized, been scaled up nationally, ensuring been fully integrated into the
midwifery model of care, including incorporating a comprehensive access to quality midwifery care for national health system, ensuring
the definition of the midwifery package of services provided by all women and newborns. quality and equitable continuity of
service package and care pathways, midwives and clearly defined care midwife care for all women and
to establish a strong conceptual pathways to ensure continuity of newborns.
foundation. care across health platforms.
Discussions are emerging on
adapting the model to a continuity
of midwifery care model where it Monitoring and evaluation
Initial preparations for pilot Pilot implementation has been does not exist yet. frameworks, along with continuous
implementation are under way. launched in select regions and/or quality improvement mechanisms,
facilities, with initial monitoring and are in place.
evaluation frameworks being
established.

Discussions are emerging on the

development of a strategy scale up.

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Interprofessional
collaboration
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Collaboration among midwives, Early collaboration and Collaboration has been Midwives demonstrate autonomy in Collaboration is fully embedded
obstetricians, paediatricians, nurses relationship-building efforts are strengthened through structured decision-making within their scope across the health system,
and other health workers remains taking place through informal joint interdisciplinary initiatives. of practice, while maintaining characterized by equal partnerships,
limited or minimal. initiatives among midwives, doctors, interprofessional collaboration. continuous interprofessional
nurses and other health workers. education, formal networks of care
and effective conflict resolution
Shared decision-making is mechanisms.
Decision-making remains increasing; however, the process They maintain clear, respectful and
hierarchical, with midwives Initial steps are being taken towards remains largely hierarchical, with consistent communication with
operating under the supervision more equitable decision-making. midwives continuing to work under other health professionals to ensure
of medical doctors, including However, midwives largely continue the supervision of medical doctors, coordinated care and positive health A culture of trust and shared
obstetricians. to operate under the supervision of including obstetricians. outcomes. leadership is maintained,
medical doctors including underpinned by an ongoing
obstetricians, who often retain commitment to continuous quality
authority over clinical decisions, improvement.
including those within the midwifery
scope of practice.

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Midwifery leadership
and research
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Midwifery leadership is absent or Informal leadership among Midwifery leadership positions are Senior midwifery leadership Midwifery leadership drives
minimal. midwives is beginning to emerge. increasing. positions are fully integrated within continuous improvement across
health and education governance policy, education, research and
structures. practice.

There is no organizational structure Initial steps are under way to There is expanded midwifery
for midwifery within the Ministry of establish midwifery representation representation in formal governance
Health. within the Ministry of Health. and decision-making processes, A Chief Midwife or equivalent Midwifery representation in
although midwives' contributions position exists within the Ministry of governance and decision-making
are not always fully considered. Health. processes within the Ministry of
Health is strong and formalized, with
Midwifery representation in Midwives are starting to participate midwives’ voices actively
governance and decision-making in governance and decision-making considered.
processes is lacking or minimal. processes. A professional midwifery association Midwives are represented in
has been established, with a basic governance and decision-making
governance framework and clearly processes, and their contributions
defined objectives. are actively considered. Supported by a sustainable funding
No professional midwifery Discussions on establishing a model, the professional midwifery
association exists. professional midwifery association association plays a pivotal role in
are emerging, although efforts advocacy and contributes to
remain unstructured. An increasing number of midwives The professional midwifery national decision-making processes.
are engaging in research activities; association functions as a formal
Midwives are not engaged in however, they continue to lack and established entity, advocating
research activities. leadership roles in research, and for and representing midwives in
Some midwives are beginning to there are no formal midwifery national decision-making processes. Midwives are leading and
engage in research activities, but research initiatives or dedicated coordinating research activities,
they are not leading research, and funding. supported by dedicated funding and
institutional support for institutional mechanisms.
midwifery-led research initiatives is Midwives are leading and
limited or absent. coordinating research activities,
although funding for midwifery
remains limited.

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Policy and regulatory

environment
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Formal strategies or policies that Discussions on incorporating Draft policies and strategies specific Enacted policies enable midwives to Comprehensive and
acknowledge midwives and midwifery models of care into to midwifery care define the roles practise as autonomous well-established national strategies
midwifery care as absent or national health strategies are under and responsibilities of midwives. professionals, with authority to and policies fully acknowledge and
minimal. way, with initial drafts of legal make decisions within their defined support midwifery models of care.
frameworks in development. scope of practice.

The midwifery regulatory system has

No regulatory system or licensing expanded to include a defined scope A robust midwifery regulatory
scheme for midwifery is in place. Emerging licensing schemes include of practice, accreditation Regulatory processes are system and licensing scheme are
documented minimum education mechanisms for midwifery implemented at the national level, fully integrated into the national
and practice standards, although education programmes, and a with documented evidence of health system, with established
these are inconsistently applied. formal code of conduct and ethics, regular review and standardized monitoring and evaluation
Workplace policies and institutional officially endorsed by a regulatory practices in official guidelines. processes in place.
constraints limit midwives from authority.
practising to the full extent of their
nationally recognized qualifications Preliminary efforts are being made
and education. to revise workplace policies and Midwifery models of care are Workplace policies and institutional
reduce institutional constraints. Workplace policies have been included in national health frameworks fully support midwives
revised to enable midwives to strategies. to practise to the full extent of their
practise to the full extent of their nationally recognized qualifications
qualifications and education. and education.

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Education and continuous

professional development
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Formal midwifery education A competency-based midwifery The midwifery curriculum has been Competency-based midwifery Competency-based midwifery
programmes are either absent or curriculum of at least three years is revised based on pilot feedback and education and continuing education and continuing
severely limited. being piloted in select educational formally adopted by educational professional development professional development
institutions, with feedback institutions nationwide to align with programmes are standardized and programmes are fully aligned with
mechanisms in place to support evolving population needs. implemented nationwide. national health strategies and legal
curriculum refinement. frameworks, supported by
Discussions are emerging on the dedicated budget allocations and
development of a robust monitoring and evaluation
competency-based midwifery Continuing professional Comprehensive continuing systems.
curriculum with a minimum Preliminary frameworks for development programmes have professional development
duration of three years. continuing professional been expanded and standardized to opportunities enable midwives to
development programmes have ensure the consistent delivery of continuously update and enhance
been developed, focusing on quality professional development their competencies. Ongoing evaluation and continuous
essential skills, attitudes and opportunities for midwives. improvement processes are
Continuing professional knowledge updates for practising established for both the midwifery
development programmes are not in midwives. education curriculum and
place. continuing professional
development programmes.

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Health workforce
strategies
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Coordinated workforce planning for Emerging workforce planning and The first data-driven workforce plan The comprehensive workforce plan The workforce plan and forecast are
midwifery models of care is either forecasting efforts include initial and forecast have been established, and forecast have been fully continuously updated and refined
absent or minimal. mapping of service gaps and facility addressing service gaps, facility implemented, providing a clear based on data and feedback to
needs. needs and future workforce roadmap to address service gaps, ensure alignment with evolving
requirements. facility needs and future workforce healthcare needs and priorities.
requirements.
Data on workforce needs are limited.
Steps have been initiated to gather
and compile workforce data from Preliminary reviews of existing Workforce data systems are fully
multiple sources, including surveys, workforce data have been Workforce data are thoroughly integrated across all relevant
There is no national registry of institutional records, and national conducted. reviewed using advanced analytics platforms, enabling real-time data
midwives. databases. to identify trends, competency gaps access and more precise workforce
and opportunities for optimization. management.

Development of a national registry

Targeted recruitment and retention Preliminary discussions are under for midwives is under way to ensure
initiatives are lacking. way to establish a national registry accurate tracking and management The national registry for midwives is The national registry of midwives is
of midwives. of midwifery professionals. operational, offering accurate and fully operational and continuously
up-to-date information on midwifery updated, including features for
professionals to support workforce professional development,
planning and management. managing certification renewals and
Early discussion are taking place on Strategic discussions on innovative generating workforce analytics.
recruitment and retention recruitment and retention
strategies. approaches have been initiated,
focusing on competitive Recruitment and retention strategies
compensation, flexible work have been implemented, resulting in Recruitment and retention
arrangements, and employee improved compensation packages, programmes are well established
engagement programmes to attract flexible work arrangements and and continuously improved,
and retain midwives. enhanced employee engagement incorporating best practices and
programmes that effectively attract feedback to maintain a stable,
and retain midwives. satisfied and highly skilled
midwifery workforce.

101 102
Implementation guidance on transitioning to midwifery models of care Transition framework assessment tool
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)8G?9"2I")78=A;6;>="Q78S9T>7H"8AA9AAS9=6"6>>?"

Health system
environment
^L&.+"[ ^L&.+"[[ ^L&.+"[[[ ^L&.+"[d ^L&.+"d

Foundational health system Efforts have been initiated to Infrastructure and resources to Key components of a supportive The health system environment is
elements to support midwifery establish foundational infrastructure support midwifery models of care, health system have been expanded. fully supportive of midwifery models
models of care are either absent or and resources to support midwifery including essential utilities such as of care, with well-equipped,
minimal. models of care, including the water and electricity, are being functional infrastructure and
provision of essential supplies and strengthened. An increasing number universally implemented safe and
equipment to health facilities. of facilities are now adequately Facilities across all levels of care are secure working conditions.
equipped with essential supplies consistently equipped with essential
Essential equipment and supplies and equipment. resources.
required to provide midwifery
services are lacking. Initial steps are being taken to Policies and governance
improve working environments, mechanisms foster a sustainable
with a focus on meeting basic safety, Safe and secure working conditions Safe, secure and enabling working and supportive environment for
security and hygiene standards. are progressively prioritized. conditions are established as health workers.
Referral systems are either While progress remains limited, This includes: standard practice, supported by
unavailable or inadequate, these efforts represent the - Workplace safety: policies and measures that promote
hindering the effective transfer of beginning of meaningful enhancements to workplace staff well-being and job satisfaction.
women and newborns. improvements. safety protocols and practices.
- Protection Measures:
implementation of measures to
protect health workers from
Midwives and other health workers harassment or violence,
face unsafe and unstable working promoting a safe and supportive
conditions. work environment.

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Once the tool has been applied and the summary table completed with the
Monitor progress over time. Apply the tool periodically to track
phase assigned to each transition area, the following steps are recommended
progress and support adjustments to strategic planning.
to analyze and make strategic use of the results.

Utilize results in broader reporting and advocacy. The results can

Identify national priorities. Review the transition areas at the lowest inform national reports, operational plans, advocacy initiatives and
phase, as these indicate the most delayed components of the reporting to international partners.
transition process. Prioritizing these areas for short- and
medium-term interventions can help accelerate progress effectively.
Communicate results effectively. Develop a concise summary or
visual representation using colour coding to share findings with
Compare across areas. Look for inconsistencies or gaps between authorities, technical teams and community organizations. This
related transition areas. For example, standardized and enforced enhances transparency, fosters ownership and promotes
competency-based midwifery education and continuing multisectoral engagement.
professional development may be at Phase IV, while awareness
among women and communities about midwifery models of care
remains at Phase I. Such discrepancies may indicate bottlenecks or
critical areas for improvement.

Define strategic actions and integrate them into the operational

plan. Based on the assessment results, define specific actions to
advance each transition to the next phase. Include these actions in
the operational plan. Detailed suggested actions for each transition
area can be found in Chapter 4.

105 106
5N
Transition
stories
Implementation guidance on transitioning to midwifery models of care Transition stories
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This chapter presents transition stories from five

different settings and scopes of transition. These
stories are not meant to represent definitive best
practices but to serve as adaptable options to
inspire context-specific solutions.

A pregnant woman receives antenatal care at Barangay Health Station in a fishing village in Malita, Davao
Occidental, the Philippines. © WHO / Yoshi Shimizu

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Bangladesh Transition process

Essential pillars
6.1 Transitioning to midwifery
models of care in the absence
of midwives: a story from
Bangladesh

Location Scope
Bangladesh (nationwide) National transition

Strong political commitment from the Government and leadership

)2470:7 from the Ministry of Health and Family Welfare, along with close
collaboration between government ministries and departments.
Bangladesh had made significant progress in improving maternal and
newborn health outcomes. However, challenges persisted, particularly in rural
areas where skilled health personnel remain scarce and home births were still
common. Robust partnerships were established with key stakeholders –
including UNFPA, WHO, UNICEF, international donors, local NGOs,
In 2008, to improve maternal and newborn health outcomes, the Government the Obstetric and Gynaecological Society of Bangladesh, and other
of Bangladesh—supported by UNFPA, WHO, UNICEF and other partners – professional associations and community leaders – to provide support
began transitioning to a midwifery model of care. At that time, there were no and advocacy.
professional midwives in the country, making this a groundbreaking initiative.

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Bangladesh
Transition process
Process by transition area Education and continuing professional development
-;,;<-;,- Development of a national midwifery curriculum.
-;,, Launch of an advanced six-month education programme for
nurse-midwives.
Introduction of a three-year diploma programme in midwifery.
Policy and regulatory environment -;,.
Midwifery schools equipped with skills laboratories and necessary
-;;? Development of strategic direction to support the introduction infrastructure.
of professional midwives, with an interim focus on the effective -;,= Launch of a blended master’s programme in sexual and reproductive
utilization of nurse-midwives. health and rights for midwifery faculty.
-;,/ Publication of the National Strategic Directions for the Midwives in -;,> Initiation of accreditation processes for midwifery education
Bangladesh. programmes.
-;,= Upgrade of the Directorate of Nursing Services and the Bangladesh -;-; Development of a draft continuous professional development
Nursing Council to include midwifery. programme linked to re-licensing.
Development of a regulatory framework and licensing scheme, -;-- Introduction of a post-basic bachelor's degree in midwifery.
defining midwives’ scope of practice. -;-. Implementation of a quality assurance programme for midwifery
-;,A Development of a standard operating procedure for midwifery education.
practice, revised in 2022 to include the administration of essential
-;-= Launch of a two-year in-service master’s programme in midwifery.
medicines by midwives.
Deployment of national guidelines for midwives.
-;-, Development of a Costed National Action Plan for Midwifery
(2021-2025) and Deployment Guidelines for Midwives. Workforce strategies

-;,/ Creation of 3000 midwifery posts, prioritizing underserved regions.

-;,? Deployment of 1149 midwives in public health facilities
Supportive health system environment -;-, Deployment of an additional 1407 midwives in public health
facilities.
-;,=&< Provision of essential supplies and logistics to health facilities to support -;--<-;-/& Creation of 7000 new posts for midwives in the public sector.
BC09047 midwifery services. -;-@ Development of a structured career pathway for midwives.

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Bangladesh
Transition process
Process by transition area Interprofessional collaboration
98410&-;;= Advocacy and support from the Obstetrical and Gynaecological Society
of Bangladesh.
98410&-;,= Joint advocacy, orientation and training on midwives’ roles and
Midwifery leadership and research responsibilities for health service managers and other health workers.
Formal definition of midwives’ roles and responsibilities within health
-;,; Establishment of the Bangladesh Midwifery Society. facilities.
98410&-;,A Capacity-building of the Bangladesh Midwifery Society. -;,A Launch of facility-based mentorship by medical doctors to support
-;,? Launch of the Young Midwife Leaders development programme to midwifery implementation.
empower midwives through leadership training, coaching and -;,? Continued advocacy and orientation at district level to support
mentorship. implementation of the updated midwives’ scope of practice.
-;-; Establishment of a dedicated midwifery unit within the Directorate
General of Nursing and Midwifery, Ministry of Health.
Women and community engagement

National and local awareness-raising campaigns on the benefits of

Service delivery midwifery models of care, conducted through community outreach,
mass media and observance of the International Day of the Midwife.
98410&-;,= Implementation of the midwifery model in public health facilities.
Ongoing engagement with local communities and leaders to increase
Midwives provide a comprehensive range of sexual and reproductive
demand for midwifery services and promote facility-based childbirth.
health and rights services—including maternal care, normal deliveries,
family planning and gender-based violence response—while coordinating
maternal and newborn care within their scope of practice. They also
collaborate with other health professionals during emergencies. In
facilities where midwives are deployed, they manage approximately 89%
of deliveries.
-;,? Integration of midwifery service data into the District Health Information
System.

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Lessons learned

Transitioning to midwifery models of care is a long-term process that

requires sustained political commitment and continuous engagement
with communities and stakeholders.

Adequate recognition and institutional support for midwives are

essential to enable them to provide quality care and thrive within the
health care system.

Engagement of the private sector is critical to expanding access to sexual

and reproductive health and rights services through midwifery care.

Job creation should be promptly followed by deployment of midwives

into the workforce.

The deployment of midwives must be accompanied by the creation of a

supportive environment for midwifery practice.

Despite limited resources and high workloads, strong teamwork, ongoing

mentorship and strategic collaboration can help overcome barriers and enhance
the quality of care.
A woman holding a newborn with the support of a midwife in Bangladesh. © ICM

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Democratic Republic of the Congo Transition process

Essential pillars
6.2 Continuity of midwife care
for survivors of sexual violence:
a transition story from
the Democratic Republic
of the Congo
Location Scope
Bukavu, Democratic Republic Implementation at Panzi General
of the Congo Referral Hospital

Model of care Care recipients Establishment of a project management team, including a designated
Continuity of midwife care Pregnant women and survivors
project lead.
throughout pregnancy, childbirth of sexual violence
and the postnatal period

Regular team coordination through structured meetings and

)2470:7 collaboration.

Recognizing the distinct physical and psychological challenges of survivors of

sexual violence, Panzi General Referral Hospital in the Democratic Republic of
the Congo developed a holistic and integrated model of care. This approach External funding support from organizations such as Médecins du
addressed the full continuum of care—from pregnancy, childbirth and the Monde, UNFPA and Panzi Foundation USA.
postnatal period, through to one year in the postnatal period.

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Democratic Republic of the Congo

Transition process
Process by transition area Women and community engagement
Service delivery: design of the model A Mentor Mothers network has been established and continues to
provide peer support and weekly antenatal classes featuring shared
The service delivery model is person-centred, integrated and
experiences.
grounded in continuity of midwifery care. It is supported by a strong
Women were given the opportunity and continue to actively
interprofessional team approach that empowers pregnant girls and
develop their own support plans.
women as active agents in their care journey.
Each woman is paired with a dedicated midwife who provides
antenatal, intrapartum (when feasible), early postnatal care, and,
where possible, follow-up home visits for up to one year. Midwifery leadership and research
The midwife is supported by an interdisciplinary team of
obstetricians, paediatricians, psychologists and social workers for A responsible chief for the labour and maternity ward was assigned.
integrated, holistic care. A dedicated pool of project-affiliated midwives was appointed.

Interprofessional collaboration Supportive health system environment

Organizing regular interdisciplinary team meetings to ensure An individual birthing room was created to offer a calm and
coordinated, trauma-sensitive care. supportive atmosphere.
Providing joint interprofessional training on the care model for all
staff.
Creating safe group reflection spaces for the interprofessional team.
Education and continuous professional development

Capacity-building activities were organized and tailored to

Policy and regulatory environment midwives’ needs and perceived challenges.

Facility policies and protocols were revised to align with the model’s
approach.

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Lessons learned

This model of care demonstrates that, even in low-income, conflict-affected

settings with high rates of sexual violence, pregnancy and childbirth can
become empowering and positive experiences for women. Strengthening
midwives' professional autonomy, competencies, interprofessional
collaboration and working conditions benefits both women and their
newborns, while also enhancing midwives’ satisfaction and clinical
performance.

A pregnant woman receives holistic support from a midwife during labour at Panzi Referral Hospital in the
Democratic Republic of the Congo. © UNFPA Democratic Republic of the Congo/Lisa Thanner

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England Transition process

Essential pillars
6.3 From political commitment
to large-scale change:
transition to continuity of
midwife care in England
Political commitment from the Secretary of State for Health and Social
Care to reduce neonatal mortality and morbidity.
Location Scope
England, United Kingdom Across England
(United Kingdom)
Governance and leadership through an expert panel, including
representatives of women.
Model of care Care recipients
Continuity of midwife care All pregnant women
throughout pregnancy, childbirth
and the postnatal period
Incremental funding allocated to support the transition.

)2470:7
Appointment of the first Chief Midwifery Officer, instrumental in
In 2015, England (United Kingdom) initiated a review of maternity services to setting the vision and direction for maternity care.
assess maternity care provision and explore new models of care to better meet
the needs of women and newborns. Informed by evidence and a broad
consultation process with women and communities, the Better Births Review
report (2016) recommended continuity of midwife care to create safer, more Appointment of regional leads across England (United Kingdom) to
personalized and equitable services. This shift required large-scale support the transition process.
transformation, driven by key factors outlined below (73).

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England
Transition process
Process by transition area Service delivery: model design (2016)
-;,= The service model is defined as person-centred and personalized,
based on women’s needs and decisions. It is integrated, delivered
Policy and regulatory environment
with continuity and provided close to where women lived.
-;-, Guidance for planning, implementation and monitoring of Continuity of care entails women receiving antenatal, intrapartum
continuity of midwifery care was developed and published (69). and postnatal care from the same midwife, supported by a team of
Continuity of midwife care for women from Black, Asian and midwives (typically in groups of eight or fewer), with an annual
minority ethnic communities and from the most deprived groups caseload of approximately 36 women.
was included as a clinical focus area in the National Healthcare Each team maintains links with an obstetrician to ensure timely
Inequalities Improvement Programme. referral for specialized care.
-;-. A three-year delivery plan for maternity and neonatal services was
developed.
Education and continuous professional development

E-learning modules and a board game on continuity of midwife

Women and community engagement -;,?
care were created by the Royal College of Midwives.
Women and communities are engaged through regional drop-in
-;,> The continuity of midwife care model was incorporated into
events, service visits, a maternity review email inbox, focus groups, midwifery education programmes.
listening events and an online consultation.
An annual assessment of women’s experience of care is conducted
through the Care Quality Commission maternity survey (75). Health workforce strategies
-;-, Workforce planning was conducted, and tools were developed to
Interprofessional collaboration determine the number of midwives required for sustainable service
delivery.
-;-/ A training programme on continuity of midwife care was developed
by the National Health Service England.

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Outcomes

Compared with women who received no continuity of care, those receiving

continuity of midwifery care reported a better experience of care, with the most
significant improvements reported by women receiving continuity throughout
the antenatal, intrapartum and postnatal periods (75).

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Ethiopia Transition process

6.4 Introducing a continuityof
midwife care model in Northern
Ethiopia

Location Scope
North Shoah Zone, Amhara Four primary hospitals
National Regional State, Ethiopia

Model of care Care recipients

Continuity of midwife care through Pregnant women at low risk Strong leadership from the Ministry of Health and
pregnancy, childbirth and the of complications
immediate postnatal period the Ethiopian Midwives Association was crucial.
Sustained advocacy and partnerships were established through policy
dialogues involving the Ministry of Health, regional health bureaus, facility
leaders, project team members and the Ethiopian Midwives Association.
These efforts guided the model design and implementation planning.
)2470:7 Following these discussions, midwives were organized into teams of four to
eight and trained on the care model and its philosophy. Each midwife
Between August 2019 and September 2020, four hospitals in Ethiopia piloted a provided comprehensive care across the continuum to a caseload of 37
continuity of midwife care model. Instead of seeing different providers at each women. If the primary midwife was not available, another midwife from the
visit, pregnant women were supported by the same midwife—or a small team stepped in. In cases of complications, obstetricians and other health
team—throughout pregnancy, childbirth and the early days after birth. workers provided support.

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Outcomes Next steps

Based on these outcomes, the Ethiopian Ministry of Health, with support from
In the continuity of midwifery care model, 97% of women already knew
the Ethiopian Midwives Association, developed implementation guidance for
the midwife supporting them during intrapartum care (76).
the national rollout of the model. Plans to scale up the pilot implementation in
24 woredas (districts) are under consideration.
Women reported higher satisfaction with antenatal, intrapartum and
postnatal care. Utilization of health services improved, with an increase
in antenatal care and postnatal care coverage (76,77).

Vaginal deliveries and breastfeeding within one hour of birth significantly

increased (76).

Unnecessary interventions were reduced, including a 51% decrease in

emergency caesarean sections, a 57% decrease in vacuum births, a 73%
decrease in episiotomy rates and a 47% decrease in induction of labour
(76).

Neonatal outcomes improved, with a 61% reduction in preterm birth

rates, a 59% reduction in low 5-minute Apgar scores (<7) and a 50%
reduction in neonatal intensive care admissions (76).

Midwives working in the continuity model reported higher job

satisfaction.

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West Bank Transition process

Essential pillars
6.5 Transitioning to continuity
of midwife care in a
conflict-affected setting:
story from the West Bank
Location Scope
West Bank, occupied Palestinian Across the West Bank (oPt)
territory (oPt)

A working group and project management team were established to

Model of care Care recipients adapt the continuity of midwifery care model to the local context and
Continuity of midwife care Underserved women in a oversee its implementation.
throughout pregnancy and the resource-constrained,
postnatal period conflict-affected setting

Stakeholders, including the Ministry of Health, Palestinian Red

)2470:7 Crescent Society, community representatives, hospital
representatives. and donors were engaged in planning, budgeting and
The model was introduced through a pilot collaboration between the operational processes.
Palestine Committee of Norway, the Palestinian Red Crescent Society and the
Palestinian Ministry of Health. It aimed to address challenges faced by
pregnant women in rural areas of the West Bank, particularly restricted access
to hospitals. Implementation began in 2013 in two areas and, by 2016, had Initial funding was provided by Norway, followed by financial support
expanded to six public regional hospitals and 37 rural villages, in collaboration from the Ministry of Health.
with the Norwegian Aid Committee (78).

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West Bank
Transition process
Process by transition area Health workforce strategies
Bachelor-level midwives replaced less formally trained auxiliary
Service delivery: model design midwives, supported by scholarships for professional licensing as
autonomous practitioners.
Midwives managed caseloads in village clinics to build continuous,
Hospital midwife staffing levels were increased.
trusted relationships, with flexible adaptations to respond to local
needs.
Weekly visits by midwives from nearby public hospitals ensured
comprehensive antenatal, postnatal and follow-up care. Specialist Supportive health system environment
referrals were made as needed while maintaining continuity of
midwife care. Midwives received driving lessons and licenses, and designated,
marked cars were provided to ensure their safe transportation to
rural clinics and homes.

Women and community engagement

Women and community representatives were engaged in planning,
Midwifery leadership and research
budgeting and implementation processes.
Regional midwives coordinated services and supervised head
midwives and nurse supervisors, adapting schedules to meet local
Interprofessional collaboration needs.

Smartphones were used to facilitate communication and

coordination between the community and interprofessional teams.
Monthly team seminars were held to address challenges and update
clinical practices.
Capacity-building efforts included a two-day seminar to train
midwives, nurses and doctors on the principles and practice of
continuity of midwifery care.

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Outcomes

A 20% reduction in unplanned caesarean section rates, a 21% reduction

in preterm birth rates and a 28% reduction in postnatal anaemia rates
were observed (79).

A significant increase in exclusive breastfeeding rates within six months

after birth was reported (80).

Women reported high satisfaction with care throughout the continuum

(80).

Utilization of health services improved (81).

Activities were temporarily halted in April 2020 due to COVID-19 and political
challenges.
A woman holds her newborn in a hospital in the West Bank, occupied Palestinian territory. © ICM

139 140
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Annex I. Role of the WHO STAGE midwifery secretariat
The WHO Secretariat, led by the Department of Maternal, Newborn, Child and Adolescent

Development process Health and Ageing (MCA), was supported by various WHO departments, including the
Office of the Chief Nurse, the Health Workforce Department and the Department of

of the implementation Integrated Health Services. Its responsibilities included ensuring alignment with WHO
policies, coordinating with STAGE members, providing technical and administrative

guidance
support and overseeing the writing, production and publication of the guidance.

Structure and responsibilities of external groups

Three distinct groups were convened to contribute to the guidance development process.
Group members were selected with consideration of geographical and field of expertise
balance while ensuring midwifery representation as recommended by STAGE.

The Working Group

Purpose: provide overall direction for guidance development, steer the
This guidance was developed by the World Health Organization (WHO) after the development process and ensure expertise across relevant disciplines.
Strategic and Technical Advisory Group of Experts (STAGE) for Maternal, Composition: co-chaired by Sally Pairman (ICM) and Jane Sandall (STAGE member),
Newborn, Child, and Adolescent Health and Nutrition recommended in May the group included 20 experts in midwifery, health systems, policy and
2022 that WHO develop implementation guidance with a multidisciplinary implementation science, including STAGE members, professional associations
working group, to support countries in transitioning to midwifery models of representatives, women’s groups representatives and UN partners.
care requiring professional midwives.

Following this recommendation, a STAGE midwifery working group was The core group
established in November 2022. The working group identified the need for a Purpose: offer technical expertise, detailed feedback and case study identification
global position paper to define midwifery models of care, outline their guiding while supporting the drafting of guidance.
principles and provide rationale for transitioning to these models. The position Composition: included two representatives from women's groups experienced in
paper, developed with contributions from over 90 individuals and organizations community engagement and 10 professionals from academia, professional
and endorsed by STAGE, was published by WHO in October 2024. This associations, governments and programme management, each with at least seven
publication laid the groundwork for subsequent guidance development. years of relevant experience.

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The expert group Chief Midwives, Directors of Midwifery Services or equivalent from the Ministry of
Health and Medica Education of the Islamic Republic of Iran, the Ministry of Health
Purpose:
Uganda, and Ministry of Health of Zambia.
Composition: included two representatives from women's groups experienced in
January 2025: virtual consultation organized by the Chief Nurse and Chief Midwives
community engagement and 10 professionals from academia, professional
or equivalent from the Ministry of Health and Family Welfare of India, the Ministry of
associations, governments and programme management, each with at least seven
Health and Medical Education of the Islamic Republic of Iran, the Ministry of Health
years of relevant experience.
Uganda and Ministry of Health of Zambia.

Technical experts guidance from the Core Group, Working Group, and STAGE
Development process members through:
Identification of enablers, barriers and transition process to midwifery models of care.
To develop the document's outline and content, and the transition framework Weekly core group technical meetings between August and December 2024 to
assessment tool, the Secretariat identified enablers, barriers, process and required discuss the content, including the recommended actions by transition area and the
actions for transitioning to midwifery models of care through: transition framework assessment tool.
Three Working Group meetings for additional inputs between September 2024 and
A review of published articles, grey literature, national reports and key publications January 2025. The Gorking group also regularly met between November 2022 and
from WHO, the United Nations Population Fund (UNFPA), the United Nations July 2024 to develop the WHO global position paper on transitioning to midwifery
Children's Fund (UNICEF), Jhpiego and the International Confederation of Midwives models of care. Technical expertise provided during this process was also considered
(ICM) on midwifery, health workforce, primary health care and health systems. when relevant to the guidance.

Insights from national policy dialogues on the transition to midwifery models of care Technical guidance and recommendations from STAGE members:
supported by the WHO Regional Office for South-East Asia in December 2023 in Presentations by WHO secretariat and technical discussions with STAGE members
Bangladesh, Indonesia and Nepal which helped identify key milestones in the and partners took place at the 6th STAGE meeting in November 2022, 7th STAGE
transition of each of these countries. meeting in May 2023, 8th meeting in November 2023 and at the 10th meeting in

Country consultations
Guidance development
July 2024: regional technical meeting on the operationalization of Every Newborn
Action Plan and the Ending Preventable Maternal Mortality in Lusaka, Zambia.
September 2024: UNFPA pre-conference ahead of the ICM Regional Congress Africa
feedback, the document was finalized for validation by STAGE.
and Eastern Mediterranean in Kigali, Rwanda.
September 2024: discussion at the ICM regional congress in Kigali, Rwanda with

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Transition stories and examples identification
Transition stories and country examples are not intended to represent definitive best
practices. Rather, they offer adaptable options that may inspire context-specific
solutions. These examples have been identified through a literature review and
consultations with partners and members of various groups, based on the following
criteria:

Documented transitions to midwifery models of care, including detailed descriptions

of implementation processes and measured outcomes, where available.
Representation of diverse midwifery models of care (e.g. continuity of midwife care,
birth centres).
Geographic diversity, with examples from both high-income countries and low- and
middle-income countries.
Variation in implementation scope (e.g. facility level, national level)

Identification of useful resources

Useful resources were identified, screened and selected by the WHO Secretariat in
collaboration with relevant departments and units. Only WHO resources were included.

151 152
World Health Organization

Department of Maternal, Newborn, Child

and Adolescent Health and Ageing

20 Avenue Appia
1211 Geneva 27
Switzerland

Email: [email protected]
Website:
www.who.int/teams/maternal-newborn-child
-adolescent-health-and-ageing

www.who.int