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The third global State of the World's Midwifery report (SoWMy 2021) provides an updated evidence base on the sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workforce. For the first time, SoWMy includes high-income countries (HICs) as well as low- and middle-income countries. This paper describes the similarities and differences between regions and income groups, and discusses the policy implications of these variations. SoWMy 2021 estimates a global shortage of 900,000 midwives, which is particularly acute in low-income countries (LICs) and in Africa. The shortage is projected to improve only slightly by 2030 unless additional investments are made. The evidence suggests that these investments would yield important returns, including: more positive birth experiences, improved health outcomes, and inclusive and equitable economic growth. Most HICs have sufficient SRMNAH workers to meet the need for essential interventions, and their education and regulatory environments tend to be strong. Upper-middle-income countries also tend to have strong policy environments. LICs and lower-middle-income countries tend to have a broader scope of practice for midwives, and many also have midwives in leadership positions within national government. Key regional variations include: major midwife shortages in Africa and South-East Asia but more promising signs of growth in South-East Asia than in Africa; a strong focus in Africa on professional midwives (rather than associate professionals: the norm in many South-East Asian countries); heavy reliance on medical doctors rather than midwives in the Americas and Eastern Mediterranean regions and parts of the Western Pacific; and a strong educational and regulatory environment in Europe but a lack of midwife leaders at national level. SoWMy 2021 provides stakeholders with the latest data and information to inform their efforts to build back better and fairer after COVID-19. This paper provides a number of policy responses to SoWMy 2021 that are tailored to different contexts, and suggests a variety of issues to consider in these contexts. These suggestions are supported by the inclusion of all countries in the report, because it is clear which countries have strong SRMNAH workforces and enabling environments and can be viewed as exemplars within regions and income groups.

Background: Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). Most stillbirths are preventable. To develop strategies and take effective actions to end preventable stillbirths, a good understanding of the cause of death and its contributing factors is necessary. There is, however, a paucity of data from most LMIC settings. This study aimed to determine the cause of stillbirth in LMIC using three methods of assessment, and to assess quality of care delivered to mothers who had stillbirth. Methods: The study involved 1,563 stillbirths which occurred in 12 selected secondary and tertiary hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. The cause of death was determined by: (1) consensus of healthcare providers (HCPs) through stillbirth review; (2) expert review of cases and; (3) computer algorithms. Cause of death was classified using the classification according to Relevant Condition at Death (ReCoDe) and the International Classification of Diseases for Perinatal Mortality (ICD-PM). Quality of antenatal and intrapartum care and health system factors were reviewed using a set of criteria. Results: A total of 1,329 cases were reviewed, of which 1,267 (95.3%) stillbirths met the inclusion criteria. By country, the stillbirth rate ranged from 20.3 (Malawi) to 118.1 (Sierra Leone) per 1,000 births. The distribution of the major causes of stillbirth differed by method of assessment: asphyxia (18.5% – 37.4%), placental disorders (8.4% – 15.1%), hypertensive disorders in the mother (5.1% – 13.6%), infection (4.3% – 9.0%), cord problems (3.3% – 6.5%), and ruptured uterus due to obstructed labour (2.6% – 6.1%). Information was insufficient to assign cause of stillbirth in 17.9% - 26.0% of cases. Significant agreement was observed between cause of stillbirth assigned by the expert panel and by HCP (k=0.69; p