Unveiling the Impact of Conflict on Midwifery Education and Workforce Development: Insights from Research in Nigeria and Somalia

Amid crisis and conflict, young midwives display extraordinary resilience despite numerous challenges. As one Somali midwife described to the EQUAL research consortium, “There’s a chance that when you step out the door, you will hear a bomb go off close to you, or the roads will be closed, or there’s traffic jam, so you have to get off the bus and walk to make it to class. But you must look towards your goals. You need to be strong-willed and believe you can overcome this.”  This statement captures both the courage, and the difficulties faced by midwifery students and practitioners in conflict-affected areas.

Midwives play a critical role delivering essential care and when educated and regulated to international standards, they can meet up to 90% of the global need for essential SRMNAH interventions. Unfortunately, crisis-affected areas in sub-Saharan Africa face severe shortages of midwives, even though these dedicated professionals often continue to provide services during emergencies, when other healthcare providers may be unavailable.

Given that countries responding to crisis account for 58% of global maternal deaths, 37% of newborn deaths, and 36% of stillbirths, fostering the skills of midwives in these regions is crucial for improving health outcomes. 

Pursuing and sustaining a midwifery career in these contexts is challenging.  Although we know that the quality and accessibility of midwifery education and workforce support vary widely, evidence is limited, particularly regarding how insecurity affects the education and retention of these crucial frontline workers.

To address this gap and gain insights into the realities faced by midwives, EQUAL research consortium partners – Johns Hopkins Center for Humanitarian Health, the Institute of Human Virology, Nigeria (IHVN), and the Somali Research and Development Institute (SORDI) – are conducting research on midwifery education and early career midwives’ experiences in Yobe State, Nigeria, and Somalia. This research includes a rapid assessment of midwifery pre-service education and a multi-year cohort study tracking the experiences of midwifery students and recent graduates over time. We describe the research in this post.

The impact of insecurity on midwives’ practice and education

Insecurity disrupts midwives’ practice and undermines their education and training in both research contexts. In Yobe State, Nigeria, the Boko Haram insurgency has led to widespread displacement, the destruction of health facilities, and severe shortages of health workers (6 midwives per 10,000 people), contributing to alarmingly high maternal and newborn mortality rates. Similarly, in Somalia, internal conflict, political instability, armed groups, and the effects of climate change have displaced millions, devastated healthcare infrastructure, and contributed to a shortage of 20,000 midwives.

Metric	Nigeria	Somalia
Percentage of deliveries attended by skilled health personnel	51%	32%
Number of doctors, nurse, and midwives per 10,000 people	4 physicians + 15 nurses/midwives	4
Number of midwives per 10,000 people	6	0.4

Evaluating midwifery pre-service education programs in Somalia and Nigeria

The rapid assessment of midwifery pre-service education – conducted at seven schools in Somalia and two schools in Yobe State, Nigeria – evaluated how these education programs align with national and international standards and how ongoing conflict affects their effectiveness. Using the Midwifery Education Rapid Assessment Tool, supported by interviews and school tours, the assessment examined infrastructure, management, teaching, clinical practice, curriculum, and the impact of insecurity.

The findings highlight stark disparities in the quality of midwifery education between Somalia and Nigeria. The schools assessed in Nigeria met 77.3% to 81.8% of assessment standards compared to those in Somalia which met only 33.3 to 55.6%. While the schools visited in Somalia grapple with leadership and resource gaps, the programs in Nigeria, despite better alignment with standards, continue to struggle with staffing challenges.

Insights from the experiences of midwifery students and recent graduates in conflict zones

Building on these rapid assessment insights, EQUAL’s cohort study – through surveys, interviews, and focus group discussions – further explores the real-world experiences of midwifery students and recent graduates in the conflict affected areas of Somalia and Yobe State, Nigeria, examining how persistent conflict affects their education, career aspirations, and daily lives.

Though this research is ongoing, it has already provided valuable insights into the urgent need for targeted support and interventions. Key themes that have emerged from the research in Somalia and Nigeria, include:

• Motivations and aspirations: Midwives in both settings are driven by a commitment to saving lives, reducing preventable deaths, and improving health outcomes in their communities.

• Gender and social norms: Societal pressures often force young women to prioritize marriage over careers. A Mogadishu student noted, “Most of the time, we are told to get married. Huge pressure is put on us when we are not ready for it, and they believe that an educated girl will end up in the kitchen.” Despite these pressures, many women view midwifery as a path to challenge restrictive norms and achieve empowerment.

• Trust and professional status: Distrust of young midwives is common, with patients questioning their training and expertise and often preferring to work with older, traditional birth attendants (TBAs). In Somalia, skepticism about the necessity of professional midwifery persists. One student remarked that, “My mother said to me, I gave birth to all my children at home with the help of a TBA except one, and you are studying for four years to learn how to deliver a baby. That makes no sense.”

• Confidence and competence: Midwives feel confident managing uncomplicated cases but communicated the need for more clinical practice and hands-on training. Ongoing insecurity limits access to educational resources and practical experiences.

• Impact of insecurity: Conflict severely impacts access to education and professional practice. In Nigeria, midwives face targeted attacks and threats like kidnapping, with one participant saying, “There are times you will hear people running and when you ask, they tell you that the Boko Haram people said they are coming to that place, since you are already in your uniform, you have to look for what to change to, because if they identify you as a health worker, they will kidnap you, so you have to disguise as a villager, because even if you don’t run, you will be there not knowing what will happen and you are not safe. It’s between life and death.”

• Mental health and career progression: The stress and safety concerns associated with working and studying in conflict zones affect mental health and career progression, undermining overall well-being and job performance.

EQUAL’s research underscores the urgent need for targeted investments in midwifery education and workforce development. To strengthen the midwifery workforce and improve health outcomes, it is essential to enhance safety and protection measures, expand educational resources, and address gender and societal barriers.

As EQUAL continues to track the experiences of midwifery students and graduates, understanding the impact of conflict on midwives is critical. This knowledge is crucial for tailoring support and ultimately improving maternal and newborn health outcomes in the most affected regions.

To learn more about EQUAL’s research on midwifery and access detailed findings and recommendations from our studies, visit EQUALresearch.org. You can also follow @EQUAL_Research for updates.

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The following colleagues helped to contribute to this post and the research studies referenced: 

• Institute of Human Virology, Nigeria (IHVN): Emilia Iwu, Senior Technical Advisor; Sussan Israel-Isah, Research Study Coordinator; Rejoice Helma Abimiku, Senior Technical Advisor, Research Scientist; Charity Maina, Project Manager; Kazeem Olalekan Ayodeji, Data Analyst; George Odonye, Data Management Sub-unit Lead; Rifkatu Sunday, Senior Program Officer
• Somali Research and Development Institute (SORDI): Hawa Abdullahi, Researcher; Asia Mohamed, Senior Researcher
• Johns Hopkins Center for Humanitarian Health: Shatha Elnakib, Assistant Scientist; Emilie Grant, Research Associate; Hannah Tappis, Principal Technical Advisor 
• International Rescue Committee: Alicia Adler, Senior Research Uptake Advisor