Rwanda’s midwifery profession has expanded from a non-existent structured workforce after the 1994 Genocide against the Tutsi to more than 2,400 midwives today, according to André Gitembagara, President of the Rwanda Nurses and Midwives Union (RNMU). ALSO READ: Why Rwanda needs to train 5,000 new midwives in four years “After the genocide, there was no midwifery profession in the country, but today we count more than 2,400 midwives. We have also moved from diploma training to bachelor’s and master’s degrees, improving both the quality of care and professional competence,” he said. He noted that midwives now form the main workforce in maternity units at district and referral hospitals, where they account for the majority of staff, alongside a small number of nurses. Dr Menelas Nkeshimana, Head of the Health Workforce Department at the Ministry of Health, partly attributes this progress to the 4x4 Reform, a strategy that was introduced in 2023 with the aim of quadrupling the number of healthcare professionals. Before the introduction of the 4x4 Reform, there was a significant shortage of training and Rwanda was graduating only about 72 midwifery students each year. That number could not meet the country’s needs. Dr Nkeshimana said that Rwanda has increased the number of schools training midwives since 2023, recruited more tutors, expanded simulation laboratories for practical learning, and introduced one harmonised curriculum for all institutions. “The curriculum, published by the Higher Education Council after national consultations, was designed around Rwanda’s needs while drawing on international standards from the International Confederation of Midwives. The number of students joining midwifery each year has now risen from 72 to 1,050,” he said. Rising demand for midwives As the world marks the International Day of the Midwife on May 5 under the theme “One Million More Midwives,” the International Confederation of Midwives (ICM) is drawing attention to the global shortage of midwives and calling for greater investment, advocacy, and government commitment to sexual, reproductive, maternal, and newborn health. Gitembagara observed that staffing at health centres remain inadequate, with most facilities operating with just one to three midwives despite serving a population of about 15,000 people, placing heavy pressure on maternity services, he added. He said that the shortage has pushed workloads far above normal limits, with some midwives and nurses working more than 60 hours a week, above the 40-hour legal limit, without compensation for the extra hours. “The pressure is influencing deployment decisions among young graduates, many of whom avoid rural postings due to workload and staffing conditions. Salaries have remained unchanged since 2016, with a nurse at health centre level earning about Rwf 200,000 a month,” he noted. “Young graduates who expect access to smartphones and better IT infrastructure are often deployed to very remote areas, while transport costs in rural areas add further strain, with motorcycle fares from main roads to health centres reaching about Rwf 5,000 in some areas,” he added. Gitembagara said increased investment is needed in the recruitment and retention of midwives and nurses, including a dedicated budget for hiring and keeping them in the system. He noted that while more health workers are being trained, funding gaps for employment and retention continue to strain the workforce. Dr Nkeshimana, explained that midwives are responsible for supporting mothers throughout pregnancy, labour and delivery, but their numbers are too low compared to the growing demand for care. He said Rwanda has more than five million people of reproductive age, while health facilities register about 300,000 births each year, creating a heavy workload for a small number of trained midwives. “When the continuum of care is not done well, that is how we continue to record maternal mortality and neonatal mortality,” he said, adding that although the country has made progress in reducing maternal deaths, the country still loses mothers and newborns during childbirth. Dr Nkeshimana highlighted that Rwanda recorded more than 1,000 maternal deaths per 100,000 live births about two decades ago. That figure has since dropped, but deaths are still reported in health facilities. “Every day, women go to hospitals and health centres to give birth, and some do not make it. In some cases, both the mother and the newborn die.” He said the shortage of midwives has left those in service overwhelmed, indicating that clinical standards recommend one midwife per woman in labour before delivery and two midwives during the pushing stage in a normal delivery. “However, in many health facilities, a single midwife may be responsible for up to 20 women in labour at the same time. They move from one mother to another, responding where the need is greatest, but it becomes impossible to give each woman the attention she needs,” he explained. The official said that from 2027, Rwanda is expected to graduate more than 1,000 midwives every year, a change he believes will ease shortages in hospitals and health centres over time. He added that training more midwives is only part of the answer, noting that the Ministry of Health, working with professional associations and councils, is also promoting career guidance so students understand what midwifery involves before choosing it as a profession. “We want people who are committed to the work, who understand the profession and want to grow in it, and building a strong profession also requires unity, mentorship, research and collaboration, which help attract and retain people in midwifery,” he said.
