Nursing and midwifery workforce expansion as a strategic lever to reduce maternal mortality: global evidence and policy implications from an ecological study

Background: 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. Methods: 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. Results: 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. Conclusions: 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.