This study, “Empowering Women in Pakistan by Empowering Midwives”, is a part of PBC’s series on the services sector. The primary goal of this study is to evaluate the critical role and the potential of the midwifery workforce in Pakistan to significantly improve maternal and newborn health outcomes, thus strengthening the national healthcare system. The study identies specific challenges related to the education, regulation, and professional acceptance of midwives and which currently hinder their optimal contribution, both domestically and potentially in global markets. The objective of this study is to suggest strategies to elevate the technical skillsets of Pakistani midwives, enhance their professional standing, and ensure optimal quality of care delivery nationwide.
Global Importance of Midwives
The global Maternal Mortality Rate (MMR) fell from 391 to 197 per 100,000 live births (1990–2023), while the Neonatal Mortality Rate (NMR) dropped from 36.7 to 17.3 per 1,000. Studies show that midwives can prevent over 80% of maternal and neonatal deaths, with every $1 invested returning $16 in economic and social gains. Despite this, the world faces a shortage of about 980,000 midwives.
Key Global Statistics on Midwives as per 2025
Source: Midwives’ Data Hub (2025)
Midwifery in Pakistan
Pakistan has one of the highest NMRs globally (37.6) and an Infant Mortality Rate (IMR) of 50.1. Midwife density remains critically low at 0.7 per 10,000 population (2.2 when including CMWs, LHVs, and midwifery-trained nurses). Heavy reliance on legacy cadres, weak regulation, delayed International Confederation of Midwives (ICM) alignment, and limited clinical authority constrain the profession. Provincial disparities persist—Punjab shows MMR progress but remains a major contributor to NMR, while Balochistan faces stagnation. A rapidly widening shortage (3,100 in 2021 to 81,900 in 2024) reflects chronic underinvestment and weak workforce planning.
2023 Global Health Standings in Maternal and Child Health & Pakistan’s Position
| Maternal Mortality Rate |
Neonatal Mortality Rate |
Infant Mortality Rate |
| Rank |
Country |
MMR |
Rank |
Country |
NMR |
Rank |
Country |
IMR |
| 1st |
Nigeria |
993 |
1st |
South Sudan |
40.2 |
1st |
South Sudan |
72.6 |
| 2nd |
Chad |
748 |
2nd |
Pakistan |
37.6 |
2nd |
Somalia, Fed. Rep. |
67.8 |
| 3rd |
Central African Republic |
692 |
3rd |
Somalia |
34.9 |
3rd |
Niger |
67.4 |
| 4th |
South Sudan |
692 |
4th |
Afghanistan |
34.3 |
4th |
Guinea |
61.5 |
| 5th |
Liberia |
628 |
5th |
Niger |
33.8 |
5th |
Central African Republic |
60.4 |
| 50th |
Pakistan |
155 |
6th |
Nigeria |
33.7 |
14th |
Pakistan |
50.1 |
| Source: Unicef (2025 b) and the World Bank (2025) |
Pakistan ranks among the highest-burden countries: 50th for MMR (155), 2nd for NMR (37.6), and 14th for IMR (50.1). These rankings highlight the urgent need to expand access to skilled midwifery care.
Major Findings
- High Prevalence of Missed Antenatal Care (ANC) Visits
Many women miss ANC due to financial and decision-making barriers, reinforcing the need for accessible, community-based midwifery care.
- A Doctor-Centric and Costly System
Dependence on physicians limits rural reach and undermines primary midwife-led models.
- Medicalization and Status-Driven Choices
Urban families prefer doctor-led births for social status, reducing trust in midwives even for normal pregnancies.
- Rising C-Sections & Lower Physiological Birth Rates
High elective C-section rates reflect systemic medicalization and weakened demand for safe midwife-led birth.
- Historical Nurse-Midwife Model Inefficiencies
Dual training have produced nursing professionals who seldom practice midwifery, leading to skill dilution and resource wastage.
- Cadre Overlap & Community Confusion
Blurred roles between CMWs, LHVs, and FWWs reduce clarity and weaken service delivery.
- Educational Misalignment with Global Standards
Outdated curricula, weak assessments, and limited faculty reduce clinical competence and global mobility.
- Career Stagnation & Low Motivation
Poor career progression, corruption in licensing , and inadequate pay tend to push midwives out of the profession.
- Marginalization and Mislabelling
Midwives face disrespect and are often equated with dais, undermining professional identity.
- Weak Regulation & Lack of Representation
PNMC reforms remain incomplete; midwives lack leadership presence and regulatory autonomy.
- Suspended Prescription Rights
Without authority to administer essential drugs, midwives’ ability to manage emergencies is compromised.
- Legal Grey Areas in Clinical Practice
Midwives frequently perform emergency tasks without legal protection or resources.
- Severe Shortages & Burnout
High workloads and insufficient staffing compromise care quality.
- Governance and Leadership Gaps
Nursing-dominated systems exclude midwives from decision-making and institutional leadership.
- Sanctioned Post & Title Disparities
Midwifery posts remain disproportionately low within health facilities.
- Leadership Instability
Lack of succession planning results in recurring leadership gaps.
- Abolished Community Midwives (CMW) Stipends
Withdrawal of stipends has left thousands of CMWs without employment or community practice support.
- Balochistan Midwifery Crisis
Licensing gaps, absence of posts, and weak deployment systems prevent effective service delivery.
- Donor Dependency & Exclusion from Policy
Donor-funded programs overshadow structural government reforms, often sidelining midwives.
- Weak MAP Institutional Capacity
MAP lacks permanent staff and stable funding to act as a national professional body.
- Fragmented NGO Efforts
Uncoordinated NGO projects create duplication and unsustainable initiatives.
- Male Engagement & Three Delays
Men’s influence on household decisions affects ANC attendance and emergency referrals.
Recommendations
Educational & Faculty Advancement
- Standardize 2-year associate and 4-year BSM programs to replace fragmented cadres.
- Launch master’s programs to build faculty and leadership capacity.
- Ensure training institutions partner with high-volume maternity facilities.
- Modernize curricula, textbooks, and assessments to reflect global competency standards.
- Recruit and strengthen specialist midwifery faculty through structured development programs.
Governance & Leadership Reform
- Create independent midwifery directorates for equal authority and budgeting.
- Implement structured mentorship and succession planning.
- Integrate donor efforts into government systems and strengthen midwifery data registries.
- Provide stable funding to MAP to function as a national voice for midwives.
- Improve donor accountability and alignment with midwifery priorities.
Regulatory & Legal Empowerment
- Immediately restore prescription rights by finalizing SOPs.
- Provide legal protection for midwives performing recognized BEmONC functions.
- Introduce emergency licensing measures for Balochistan.
- Ensure dedicated midwife seats in PNMC leadership.
Operational Sustainability & Professional Growth
- Convert donor-funded skills labs into permanent government facilities.
- Create clear, transparent career pathways and ensure appropriate deployment.
- Conduct national campaigns to differentiate midwives from dais and build public trust.
- Offer financial and safety incentives for midwives in remote regions.
- Strengthen monitoring systems to ensure adherence to training and quality standards.
- Expand male engagement programs to reduce the Three Delays.
The PBC is a private sector not-for-profit advocacy platform set-up in 2005 by 14 (now 100+) of Pakistan’s largest businesses. PBC’s research-based advocacy supports measures which improve Pakistani industry’s regional and global competitiveness. More information about the PBC, its members, objectives and activities can be found on its website: www.pbc.org.pk
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