This global cross-sectional study analyzed data from 266 “countries” and territories to evaluate the relationship between the nursing and midwifery workforce size (NMWS) and maternal mortality ratios (MMR). Drawing from five major United Nations and World Bank databases, the study offers robust and generalizable insights across diverse health systems and economic settings.
The study examined the association between the NMWS and MMR using scatterplots, bivariate and partial Pearson correlation coefficients, and multiple and stepwise linear regression models. Key confounding variables, including economic affluence measured by the gross domestic product (GDP) per capita adjusted for purchasing power parity, total fertility rate, and urbanization, were included to isolate the independent contribution of the NMWS to maternal health outcomes at the global and regional levels.
The NMWS accounted for 49.13 percent of the global variation in maternal mortality ratios, which indicates a strong inverse relationship. After adjusting for economic and demographic variables, the NMWS remained a significant independent predictor and explained 11.09 percent of the variance. A stepwise regression identified the NMWS as the second most influential predictor of maternal mortality after economic affluence and the fertility rate. The association was strongest in low- and middle-income countries, where workforce shortages and the maternal mortality rates are highest.
This study identifies the NMWS as a critical and measurable factor in reducing maternal mortality worldwide. This study's findings provide compelling evidence for a strategic investment in the nursing and midwifery workforce. Expanding this workforce is essential to improve the maternal health outcomes, especially in countries with limited resources, and should be prioritized in global maternal health and workforce planning strategies.
Citation: Wenpeng You. Nursing and midwifery workforce expansion as a strategic lever to reduce maternal mortality: Global evidence and policy implications from an ecological study[J]. AIMS Public Health, 2025, 12(2): 579-599. doi: 10.3934/publichealth.2025031
This global cross-sectional study analyzed data from 266 “countries” and territories to evaluate the relationship between the nursing and midwifery workforce size (NMWS) and maternal mortality ratios (MMR). Drawing from five major United Nations and World Bank databases, the study offers robust and generalizable insights across diverse health systems and economic settings.
The study examined the association between the NMWS and MMR using scatterplots, bivariate and partial Pearson correlation coefficients, and multiple and stepwise linear regression models. Key confounding variables, including economic affluence measured by the gross domestic product (GDP) per capita adjusted for purchasing power parity, total fertility rate, and urbanization, were included to isolate the independent contribution of the NMWS to maternal health outcomes at the global and regional levels.
The NMWS accounted for 49.13 percent of the global variation in maternal mortality ratios, which indicates a strong inverse relationship. After adjusting for economic and demographic variables, the NMWS remained a significant independent predictor and explained 11.09 percent of the variance. A stepwise regression identified the NMWS as the second most influential predictor of maternal mortality after economic affluence and the fertility rate. The association was strongest in low- and middle-income countries, where workforce shortages and the maternal mortality rates are highest.
This study identifies the NMWS as a critical and measurable factor in reducing maternal mortality worldwide. This study's findings provide compelling evidence for a strategic investment in the nursing and midwifery workforce. Expanding this workforce is essential to improve the maternal health outcomes, especially in countries with limited resources, and should be prioritized in global maternal health and workforce planning strategies.
| [1] | Truth AU (2013) A universal truth: No health without a workforce. World health Organisation (WHO) report 1-104. [cited 2024 December 18]. Available from: https://cdn.who.int/media/docs/default-source/health-workforce/ghwn/ghwa/ghwa_auniversaltruthreport.pdf?sfvrsn=966aa7ab_7&download=true. |
| [2] | WHOMaternal mortality ratio (per 100 000 live births) (2024). [cited 2024 December 16]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/26?utm_source=chatgpt.com. |
| [3] | (2015) WHOTrends in maternal mortality: 1990–2015: Estimates from WHO, UNICEF, UNFPA, world bank group and the United Nations population division. World Health Organization. [cited 2024 December 19]. Available from: https://data.unicef.org/wp-content/uploads/2015/12/Trends-in-MMR-1990-2015_Full-report_243.pdf. |
| [4] |
Mzembe T, Chikwapulo V, Kamninga TM, et al. (2023) Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low-and middle-income countries: A review of systematic reviews. BMC Public Health 23: 1734. https://doi.org/10.1186/s12889-023-16558-y 
|
| [5] | WHOMaternal mortality (2019). [cited 2024 December 16]. Available from: https://iris.who.int/bitstream/handle/10665/329886/WHO-RHR-19.20-eng.pdf?sequence=1&utm_source=chatgpt.com. |
| [6] |
Bishai DM, Cohen R, Alfonso YN, et al. (2016) Factors contributing to maternal and child mortality reductions in 146 low-and middle-income countries between 1990 and 2010. PLoS One 11: e0144908. https://doi.org/10.1371/journal.pone.0144908
|
| [7] |
Campbell OMR, Amouzou A, Blumenberg C, et al. (2024) Learning from success: The main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes. BMJ Glob Health 9: e012126. https://doi.org/10.1136/bmjgh-2023-012126
|
| [8] |
Gillen P, Neill RD, Mallett J, et al. (2022) Wellbeing and coping of UK nurses, midwives and allied health professionals during COVID-19-a cross-sectional study. PLoS One 17: e0274036. https://doi.org/10.1371/journal.pone.0274036
|
| [9] |
Yasin YM, Alomari A, Al-Hamad A, et al. (2024) The impact of COVID-19 on nurses' job satisfaction: A systematic review and meta-analysis. Front Public Health 11: 1285101. https://doi.org/10.3389/fpubh.2023.1285101
|
| [10] |
Petrella AR, Hughes L, Fern LA, et al. (2021) Healthcare staff well-being and use of support services during COVID-19: A UK perspective. Gen Psychiatr 34: e100458. https://doi.org/10.1136/gpsych-2020-100458
|
| [11] |
Li LZ, Yang P, Singer SJ, et al. (2024) Nurse burnout and patient safety, satisfaction, and quality of care: A systematic review and meta-analysis. JAMA Netw Open 7: e2443059-e2443059. https://doi.org/10.1001/jamanetworkopen.2024.43059
|
| [12] |
Patrician PA, Bakerjian D, Billings R, et al. (2022) Nurse well-being: A concept analysis. Nurs Outlook 70: 639-650. https://doi.org/10.1016/j.outlook.2022.03.014
|
| [13] | WHOSDG Target 3.1 | Maternal mortality: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births (2024). [cited 2024 December 20]. Available from: https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/maternal-mortality?utm_source=chatgpt.com |
| [14] | Al-Worafi YM (2023) Healthcare workforce issues in developing countries: Public health and others. Handbook of Medical and Health Sciences in Developing Countries: Education, Practice, and Research . Cham: Springer International Publishing 1-25. https://doi.org/10.1007/978-3-030-74786-2_215-1 |
| [15] |
Fikre R, Gubbels J, Teklesilasie W, et al. (2023) Effectiveness of midwifery-led care on pregnancy outcomes in low-and middle-income countries: A systematic review and meta-analysis. BMC Pregnancy Childbirth 23: 386. https://doi.org/10.1186/s12884-023-05664-9
|
| [16] | (2014) WHOWHO recommendations on postnatal care of the mother and newborn. Official Website World Health Organization. [cited 2025 January 16]. Available from: https://www.who.int/publications/i/item/9789240045989 |
| [17] |
Boukhalfa C, Ouakhzan B, Masbah H, et al. (2024) Investing in midwifery for sustainable development goals in low-and middle-income countries: A cost-benefit analysis. Cost Eff Resour Alloc 22: 1. https://doi.org/10.1186/s12962-023-00507-y
|
| [18] |
Martin B, Kaminski-Ozturk N, O'Hara C, et al. (2023) Examining the impact of the COVID-19 pandemic on burnout and stress among US nurses. J Nurs Regul 14: 4-12. https://doi.org/10.1016/S2155-8256(23)00063-7
|
| [19] |
Mattison C, Bourret K, Hebert E, et al. (2021) Health systems factors impacting the integration of midwifery: An evidence-informed framework on strengthening midwifery associations. BMJ Global Health 6: e004850. https://doi.org/10.1136/bmjgh-2020-004850
|
| [20] |
Marufu TC, Collins A, Vargas L, et al. (2021) Factors influencing retention among hospital nurses: Systematic review. Br J Nurs 30: 302-308. https://doi.org/10.12968/bjon.2021.30.5.302
|
| [21] |
Hungerford C, Jackson D, Cleary M (2025) Quiet quitting, resenteeism and other forms of disengagement: What are the answers for nurses?. J Adv Nurs 81: 2855-2857. https://doi.org/10.1111/jan.16574
|
| [22] |
Renfrew MJ, McFadden A, Bastos MH, et al. (2014) Midwifery and quality care: Findings from a new evidence-informed framework for maternal and newborn care. Lancet 384: 1129-1145. https://doi.org/10.1016/S0140-6736(14)60789-3
|
| [23] | World Bank GroupWorld development indicators (Public) (2022). [cited 2025 January 26]. Available from: https://databank.worldbank.org/home.aspx |
| [24] | World Bank GroupNurses and midwives (per 1,000 people) (2022). [cited 2025 January 26]. Available from: https://data.worldbank.org/indicator/SH.MED.NUMW.P3 |
| [25] |
You W, Donnelly F (2023) Although in shortage, nursing workforce is still a significant contributor to life expectancy at birth. Public Health Nurs 40: 229-242. https://doi.org/10.1111/phn.13158
|
| [26] |
You W, Cusack L, Donnelly F (2023) A global comparison of nursing and midwifery's and medical efficacy in preventing COVID-19 deaths 2019–2022. Int Nurs Rev 70: 552-559. https://doi.org/10.1111/inr.12887
|
| [27] |
Cha S, Jin Y (2020) Have inequalities in all-cause and cause-specific child mortality between countries declined across the world?. Int J Equity Health 19: 1-13. https://doi.org/10.1186/s12939-019-1102-3
|
| [28] |
Ruel MT, Alderman H (2013) Nutrition-sensitive interventions and programmes: How can they help to accelerate progress in improving maternal and child nutrition?. Lancet 382: 536-551. https://doi.org/10.1016/S0140-6736(13)60843-0
|
| [29] |
Swift R (2011) The relationship between health and GDP in OECD countries in the very long run. Health Econ 20: 306-322. https://doi.org/10.1002/hec.1590
|
| [30] |
Norris M, Klabbers G, Pembe AB, et al. (2022) A growing disadvantage of being born in an urban area? Analysing urban–rural disparities in neonatal mortality in 21 African countries with a focus on Tanzania. BMJ Glob Health 7: e007544. https://doi.org/10.1136/bmjgh-2021-007544
|
| [31] |
Kimani-Murage EW, Fotso JC, Egondi T, et al. (2014) Trends in childhood mortality in Kenya: The urban advantage has seemingly been wiped out. Health Place 29: 95-103. https://doi.org/10.1016/j.healthplace.2014.06.003
|
| [32] |
Bradshaw CJA, Perry C, Judge MA, et al. (2023) Lower infant mortality, higher household size, and more access to contraception reduce fertility in low-and middle-income nations. PLoS One 18: e0280260. https://doi.org/10.1371/journal.pone.0280260
|
| [33] |
Saha UR, van Soest A (2013) Contraceptive use, birth spacing, and child survival in Matlab, Bangladesh. Stud Fam Plann 44: 45-66. https://doi.org/10.1111/j.1728-4465.2013.00343.x
|
| [34] | World Bank GroupFertility rate, total (births per woman) (2017). [cited 2025 January 26]. Available from: https://data.worldbank.org/indicator/SP.DYN.TFRT.IN |
| [35] |
O'brien RM (2007) A caution regarding rules of thumb for variance inflation factors. Qual Quant 41: 673-690. https://doi.org/10.1007/s11135-006-9018-6
|
| [36] |
You W (2025) Birth rate as a determinant of dementia incidence: A comprehensive global analysis. Am J Alzheimers Dis Other Demen 40: 15333175241287677. https://doi.org/10.1177/15333175241287677
|
| [37] | WHONewborns: Improving survival and well-being (2020). [cited 2025 January 22]. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality |
| [38] | United Nations Statistics DivisionComposition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings (2013). [cited 2025 January 27]. Available from: http://unstats.un.org |
| [39] | WHOWHO regional offices (2018). [cited 2025 January 26]. Available from: http://www.who.int |
| [40] | ACDMember countries of Asia cooperation dialogue (2024). [cited 2025 January 26]. Available from: http://www.acddialogue.com |
| [41] | APECMember economies-Asia-pacific economic cooperation (2024). [cited 2025 January 27]. Available from: http://www.apec.org |
| [42] | World Bank GroupArab world | Data (2024). [cited 2025 January 26]. Available from: http://data.worldbank.org/region/ARB |
| [43] | European Free Trade AssociationWhat is the European economic Area? (2022). [cited 2025 January 26]. Available from: http://www.efta.int/eea |
| [44] | The United Nations Educational Scientific and Cultural OrganizationUNESCO regions-Latin America and the Caribbean (2022). [cited 2025 January 26]. Available from: http://www.unesco.org |
| [45] | OECDList of OECD member countries (2024). [cited 2025 January 28]. Available from: http://www.oecd.org |
| [46] | SADCSouthern African development community: Member states (2023). [cited 2025 January 30]. Available from: http://www.sadc.int |
| [47] | European UnionEUROPA - Countries (2023). [cited 2025 January 26]. Available from: http://europa.eu |
| [48] |
Nove A, Boyce M, Neal S, et al. (2024) Increasing the number of midwives is necessary but not sufficient: Using global data to support the case for investment in both midwife availability and the enabling work environment in low-and middle-income countries. Hum Resour Health 22: 54. https://doi.org/10.1186/s12960-024-00925-w
|
| [49] |
ten Hoope-Bender P, de Bernis L, Campbell J, et al. (2014) Improvement of maternal and newborn health through midwifery. Lancet 384: 1226-1235. https://doi.org/10.1016/S0140-6736(14)60930-2
|
| [50] |
Manandhar DS, Osrin D, Shrestha BP, et al. (2004) Effect of a participatory intervention with women's groups on birth outcomes in Nepal: Cluster-randomised controlled trial. Lancet 364: 970-979. https://doi.org/10.1016/S0140-6736(04)17021-9
|
| [51] |
Prost A, Colbourn T, Seward N, et al. (2013) Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: A systematic review and meta-analysis. Lancet 381: 1736-1746. https://doi.org/10.1016/S0140-6736(13)60685-6
|
| [52] | (2014) WHOWHO recommendation on community mobilization through facilitated participatory learning and action cycles with womens groups for maternal and newborn health. World Health Organization. [cited 2025 January 27]. Available from: https://www.who.int/publications/i/item/9789241507271 |
| [53] |
Downe S, Finlayson K, Oladapo OT, et al. (2018) What matters to women during childbirth: A systematic qualitative review. PLoS One 13: e0194906. https://doi.org/10.1371/journal.pone.0194906
|
| [54] |
Pandey MS, Miller CM, Harris EN, et al. (2016) Activation of ERK and NF-κB during HARE-mediated heparin uptake require only one of the four endocytic motifs. PLoS One 11: e0154124. https://doi.org/10.1371/journal.pone.0154124
|
| [55] |
Blanchard AK, Prost A, Houweling TAJ (2019) Houweling, Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: A mixed-methods systematic review. BMJ Glob Health 4: e001308. https://doi.org/10.1136/bmjgh-2018-001308
|
| [56] | (2009) NPC, ICF MacroNigeria demographic and health survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro. [cited 2025 January 13]. Available from: https://www.dhsprogram.com/pubs/pdf/FR222/FR222.pdf. |
| [57] |
Perry M, Becerra F, Kavanagh J, et al. (2014) Community-based interventions for improving maternal health and for reducing maternal health inequalities in high-income countries: A systematic map of research. Global Health 10: 63. https://doi.org/10.1186/s12992-014-0063-y
|
| [58] |
McNeill J, Lynn F, Alderdice F (2012) Public health interventions in midwifery: A systematic review of systematic reviews. BMC Public Health 12: 1-23. https://doi.org/10.1186/1471-2458-12-955
|
| [59] |
You W, Donnelly F (2024) A greater nurse and midwife density protects against infant mortality globally. J Pediatr Nurs 77: e158-e166. https://doi.org/10.1016/j.pedn.2024.04.004
|
| [60] | WHOInvesting in midwife-led interventions could save 4.3 million lives per year, new study finds (2020). [cited 12 January 2025]. Available from: https://www.who.int/news/item/03-12-2020-investing-in-midwife-led-interventions-could-save-4.3-million-lives-per-year-new-study-finds?utm_source=chatgpt.com |
| [61] |
Nove A, Friberg IK, de Bernis L, et al. (2021) Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: A Lives Saved Tool modelling study. Lancet Glob Health 9: e24-e32. https://doi.org/10.1016/S2214-109X(20)30397-1
|
| [62] | WHOMaternal mortality in 2030 (2024). [cited 11 January 2025]. Available from: https://srhr.org/mmr2030/?year=2015?mmr=219?arr=6.1 |
| [63] | WHOStandards for improving quality of maternal and newborn care in health facilities (2016). [cited 20 January 2025]. Available from: https://www.who.int/publications/i/item/9789241511216 |
| [64] |
Cantor AG, Jungbauer RM, Skelly AC, et al. (2024) Respectful maternity care: A systematic review. Ann Intern Med 177: 50-64. https://doi.org/10.7326/M23-2676
|
| [65] |
Tilden EL, Jungbauer R, Hart EL, et al. (2025) One hundred years of seeking respectful maternity care: History and evolution. Birth 52: 129-137. https://doi.org/10.1111/birt.12876
|
| [66] | WHOHealth workforce- Nursing and midwifery (2025). [cited 10 January 2025]. Available from: https://www.emro.who.int/health-workforce/nursing/index.html?utm_source=chatgpt.com |
| [67] | (2019) ICMEssential competencies for midwifery practice. International Confederation of Midwives . Netherlands: ICM The Hague. https://internationalmidwives.org/resources/essential-competencies-for-midwifery-practice/ |
| [68] |
Ashinze P (2024) New certificate verification guidelines for Nigerian nurses. Lancet 403: 1138. https://doi.org/10.1016/S0140-6736(24)00370-2
|
| [69] |
Singh K, Osei-Akoto I, Otchere F, et al. (2015) Ghana's national health insurance scheme and maternal and child health: A mixed methods study. BMC Health Serv Res 15: 108. https://doi.org/10.1186/s12913-015-0762-y
|
| [70] |
Reddy B, Thomas S, Karachiwala B, et al. (2022) A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care. PLoS Glob Public Health 2: e0001134. https://doi.org/10.1371/journal.pgph.0001134
|
| [71] | Poku CA, Mensah E, Kyei J, et al. (2023) Nursing workforce retention in rural Ghana: The predictive role of satisfaction, rural fit, and resilience. J Nurs Manag 2023: 9396817. https://doi.org/10.1155/2023/9396817 |
| [72] |
Dahlen HG, Drandic D, Shah N, et al. (2022) Supporting midwifery is the answer to the wicked problems in maternity care. Lancet Glob Health 10: e951-e952. https://doi.org/10.1016/S2214-109X(22)00183-8
|
| [73] |
Carvajal B, Hancock A, Lewney K, et al. (2024) A global overview of midwives' working conditions: A rapid review of literature on positive practice environment. Women Birth 37: 15-50. https://doi.org/10.1016/j.wombi.2023.08.007
|
| [74] |
Thumm EB, Smith D, Giano Z (2024) Evaluating the roles of workload and practice climate in workforce retention across the midwifery career lifespan: A latent profile analysis of early-, mid-, and late-career US midwives. Women Birth 37: 101833. https://doi.org/10.1016/j.wombi.2024.101833
|
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Wenpeng You. Nursing and midwifery workforce expansion as a strategic lever to reduce maternal mortality: Global evidence and policy implications from an ecological study[J]. AIMS Public Health, 2025, 12(2): 579-599. doi: 10.3934/publichealth.2025031
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