Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

A gap analysis of midwifery competency, pre- and in-service education for reproductive, maternal, newborn, child and, adolescent health in Lao People's Democratic Republic

Background

Ensuring midwives deliver quality essential services requires systematic and timely updates to midwifery education based on constantly evolving global evidence and local needs. However, midwifery curricula are often not updated to incorporate new evidence, consistent with national standards. This study supported the Ministry of Health of Lao People's Democratic Republic to identify gaps in the midwifery competency framework and training packages.

Methods

Stakeholder consultations and a document review were conducted to define a core package of RMNCAH interventions and care tasks that midwives should provide based on the national Essential Health Service Package (EHSP). Nationally defined midwifery competencies, the higher diploma midwifery curriculum, and in-service training packages were mapped against required interventions and care tasks. Data were used to revise midwifery education standards.

Findings

Midwives were expected to provide 47 RMNCAH interventions based on the EHSP. At baseline, 7 (14.9%), 11 (23.4%) and 35 (74.5%) of the 47 interventions were included in the midwifery competency, higher diploma in midwifery curriculum, and in-service training materials, respectively. After revision, the midwifery competency framework included 42 of 47 interventions (89.4%). The data are currently being used to review and update the national midwifery pre-service diploma curriculum.

Interpretation

This analysis enabled the Ministry to identify RMNCAH content gaps in national midwifery education standards and align them with the EHSP. Regular use of a quantitative approach to review educational content is essential to ensure standards are consistent with changing evidence. The approach has potential application to other service areas, cadres, and countries.

Funding

Korea Foundation for International Healthcare (KOFIH) supported research operation.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia

INTRODUCTION

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken.

OBJECTIVE

The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers.

DESIGN

The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services.

FINDINGS

The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'.

DISCUSSION

All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals.

CONCLUSION

This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

Incidence and risk factors for umbilical cord prolapse in labor when amniotomy is used and with spontaneous rupture of membranes: A Swedish nationwide register study

INTRODUCTION

Umbilical cord prolapse (UCP) is a rare but severe obstetric complication in the presence of a rupture of the membranes. Although it is not possible to prevent a spontaneous rupture of the membranes (SROM), it is possible to prevent an amniotomy, which is a commonly used intervention in labor. This study aimed to explore the incidence and risk factors that are associated with UCP in labor when amniotomy is used vs SROM.

MATERIAL AND METHODS

A retrospective nationwide register study was conducted of all births in Sweden from January 2014 to June 2020 that were included in the Swedish Pregnancy Register (n = 717 336). The main outcome, UCP, was identified in the data by the International Classification of Diseases (ICD-10) diagnosis code O69.0. Multiple binary logistic regression analysis was used to identify the risk factors.

RESULTS

Amniotomy was performed in 230 699 (43.6%) of all pregnancies. A UCP occurred in 293 (0.13%) of these cases. SROM occurred in 298 192 (56.4%) of all cases, of which 352 (0.12%) were complicated by UCP. Risk factors that increased the odds of UCP for both amniotomy and SROM were: higher parity, non-cephalic presentation and an induction of labor. Greater gestational age reduced the odds of UCP. Risk factors associated with only amniotomy were previous cesarean section and the presence of polyhydramnios. Identified risk factors for UCP in labor with SROM were a higher maternal age and maternal origin outside of the EU.

CONCLUSIONS

UCP is a rare complication in Sweden. Beyond confirming the previously recognized risk factors, this study found induction of labor and previous cesarean section to be risk factors in labor when amniotomy is used.

The Climate Crisis and Breastfeeding: Opportunities for Resilience

The climate crisis is an emerging global challenge that poses potential risks to breastfeeding practices and outcomes. There are multifaceted effects of climate change affecting the breastfeeding dyad across environmental, societal, and human health dimensions. Breastfeeding support in the face of climate change will require solutions at the structural level-healthcare, community, and workplace settings-and at the mother-infant dyad level. Breastfeeding can additionally be an adaptive response to crisis situations and can mitigate some of the environmental challenges associated with climate change. Despite the undeniable significance of climate change on breastfeeding (and vice versa), our perspective as experts in the field is that this topic has not been systematically addressed. Although we highlight some of the challenges, potential solutions, and co-benefits of breastfeeding in the context of climate change, there are numerous issues that could be further explored and necessitate additional preparedness planning.

Advanced midwifery practice: A scoping review

PROBLEM

There is no international standard for advanced midwifery scope of practice.

BACKGROUND

Globally, there is variance in how scope of midwifery practice is determined and regulated, with no consensus on extended or advanced scope. This can lead to under-utilised staff potential, un-met consumer need, and loss of professional skill.

AIMS

The aim of this scoping review was to synthesise and map what is reported in the international literature on the advanced scope of midwifery practice.

METHODS

A systematic scoping review methodology was adopted utilising Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A full search was conducted of databases including MEDLINE, CINAHL, Scopus, Google. Publications from 2019 to August 2022 that met criteria were included. Reported skills were mapped to the International Confederation of Midwives (ICM) competencies of pre-conception, antenatal, labour and birth, postnatal plus globally identified areas for midwifery investment.

FINDINGS

28 articles met inclusion criteria. Reported skills included abortion care (n = 6), prescribing (n = 7), ultrasound (n = 2), advanced practice skills (n = 7), midwifery-led skills, primary health, post-graduate education, HIV/AIDS testing, advocacy, and acupressure (all n = 1).

DISCUSSION

This review presents a synopsis of publications describing what has been defined as advanced midwifery scope of practice in international contexts.

CONCLUSION

Establishing evidence of midwives working to the peak of professional scope is important to continue to develop professional capacity and support contemporary practice, regulation, governance, and policy while improving consumer access to equitable care. Findings aid service development, provision, and professional planning.

Investing in midwifery for sustainable development goals in low- and middle-income countries: a cost-benefit analysis

BACKGROUND

Maternal and neonatal mortality in low- and middle-income countries is frequently caused by inadequate management of obstetric and neonatal complications and a shortage of skilled health workers. The availability of these workers is essential for effective and high-quality healthcare. To meet the needs of sexual, reproductive, maternal, new-born, child, and adolescent health by 2030, more than one million health workers, including 900 000 midwives, are required globally. Despite this, uncertainty persists regarding the return on investment in the health workforce.

METHODS

The objective of this research was to determine the cost-benefit ratio of increasing investment in midwifery in Morocco from 2021 to 2030. A comparative analysis was conducted between scenarios "with" and "without" the additional investment. The costs and benefits were estimated using relevant data from national and international sources.

RESULTS

Following the International Confederation of Midwives' recommendations, it is advised that Morocco recruit 760 midwives annually to achieve 95% of universal health coverage. This increase in midwifery could result in saving 120 593 lives by 2030, including reducing maternal deaths by 3 201, stillbirths by 48 399, and neonatal deaths by 68 993. The estimated economic benefit of investing in midwives was US$ 10 152 287 749, while the total cost was US$ 638 288 820. Consequently, the cost-benefit ratio was calculated as 15.91, indicating that investing in midwifery would provide 16 times more benefits than costs.

CONCLUSION

Increasing investment in midwifery appears to be an efficient strategy for achieving comprehensive maternal and child health coverage in low- and middle-income countries.

Putting co-creation into practice: lessons learned from developing a midwife-led quality improvement intervention

BACKGROUND

Integrating evidence-based midwifery practices improves healthcare quality for women and newborns, but an evidence-to-practice gap exists. Co-created quality improvement initiatives led by midwives could bridge this gap, prevent resource waste and ensure intervention relevance. However, how to co-create a midwife-led quality improvement intervention has not been scientifically explored.

OBJECTIVE

The objective of this study is to describe the co-creation process and explore the needs and determinants of a midwife-led quality improvement targeting evidence-based midwifery practices.

METHODS

A qualitative deductive approach using the Consolidated Framework for Advancing Implementation Science was employed. An analysis matrix based on the framework was developed, and the data were coded according to categories. Data were gathered from interviews, focus group discussions, observations and workshops. New mothers and birth companions (n = 19) were included through convenience sampling. Midwives (n = 26), professional association representatives, educators, policymakers, managers, and doctors (n = 7) were purposely sampled.

RESULTS

The co-creation process of the midwife-led Quality Improvement intervention took place in four stages. Firstly, core elements of the intervention were established, featuring a group of midwife champions leading a quality improvement initiative using a train-the-trainers approach. Secondly, the intervention needs, context and determinants were explored, which showed knowledge and skills gaps, a lack of shared goals among staff, and limited resources. However, there was clear relevance, compatibility, and mission alignment for a midwife-led quality improvement at all levels. Thirdly, during co-creation workshops with new mothers and companions, the consensus was to prioritise improved intrapartum support, while workshops with midwives identified enhancing the use of birth positions and perineal protection as key focus areas for the forthcoming Quality Improvement intervention. Lastly, the findings guided intervention strategies, including peer-assisted learning, using existing structures, developing educational material, and building stakeholder relationships.

CONCLUSIONS

This study provides a practical example of a co-creation process for a midwife-led quality improvement intervention, which can be relevant in different maternity care settings.

Quality midwifery care during the COVID-19 pandemic in Bangladesh: A focus group study with midwives, nurses, and midwifery educators

INTRODUCTION

Bangladesh has made remarkable strides in the development of the midwifery profession. However, the COVID-19 pandemic has had profound effects on healthcare systems worldwide, including those related to reproductive, perinatal, and maternal health. Given the recent advancements in the midwifery field in Bangladesh, it is crucial to examine the pandemic's impact on existing barriers and the capacity of midwifery professionals to deliver high-quality care. The aim of this study is to describe the possibility of midwives being able to provide quality midwifery care in Bangladesh during the COVID-19 pandemic.

METHODS

To gather insights, data were collected from July to October 2020 via four qualitative focus group discussions online; 23 actively practicing midwives, nurses specializing in midwifery care, and midwifery educators, participated. The data analysis employed reflexive thematic analysis.

RESULTS

The COVID-19 crisis posed significant threats to women's safety and health, with lockdowns exacerbating gender inequalities in society. Midwives faced added challenges due to their relatively low professional status and increased workloads. Insufficient policy implementation further compromised midwives' safety. Fear of contracting the virus and working during their free time also raised concerns about the quality of care provided. Nevertheless, the pandemic provided opportunities for midwives to demonstrate their ability to deliver independent midwifery care in Bangladesh.

CONCLUSIONS

The pandemic underscored the importance of creating respectful and dignified working conditions for midwives. It revealed that professional midwives can work independently when provided with the necessary space and a supportive work environment. This opens the door for the implementation of a midwifery-led care model. Further research is recommended to investigate the medical safety and efficacy of independent midwifery care in the context of Bangladesh.

Experience and perceptions of healthcare providers on clinical management and care of near-miss infants: a qualitative content analysis

INTRODUCTION

Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia.

METHODS

Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis.

RESULTS

The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant.

CONCLUSION

Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

Maternal anaemia care in Kano state, Nigeria: an exploratory qualitative study of experiences of uptake and provision

Background

Maternal anaemia (anaemia in pregnancy, childbirth, and the postpartum period) remains a persistent challenge, particularly in Kano State, Nigeria, which has the highest prevalence of maternal anaemia globally, at 72%.

Methods

We conducted a qualitative study in Murtala Muhammad Specialist Hospital in Kano State, Nigeria. We aimed to identify factors constraining uptake and provision of maternal anaemia care, exploring perspectives across different stakeholders. We carried out 10 key informant interviews with policymakers and hospital managers, 28 in-depth interviews with healthcare providers and pregnant women using antenatal services and four focus group discussions with pregnant women's husbands and mothers-in-law. Data were analysed thematically.

Results

Issues with provision include a lack of provider training and guidelines specific to maternal anaemia and blood transfusion, insufficient staff to meet increasing demand, and inadequate resources. Issues with uptake include the inability to afford informal user fees, distrust in health services and the blood transfusion process, and a lack of understanding of the causes, consequences, and treatment for anaemia, resulting in poor uptake of care and adherence to treatment.

Conclusions

This study recommends the implementation of standardized guidelines and training sessions to better support healthcare providers in offering quality services and increasing funding allocated to supporting maternal anaemia care. Education initiatives for service users and the public are also recommended to build public trust in health services and to improve understanding of maternal anaemia.

"I was able to take it back": Seeking VBAC after experiencing dehumanizing maternity care in a primary cesarean

In this article, we present findings from a qualitative narrative analysis that examined the pregnancy, primary cesarean, and subsequent birth experiences of women in the United States. Using a maximal variation sampling strategy, we recruited participants via social media and networking to participate in semistructured interviews. Twenty-five women from diverse backgrounds and geographic locations across the U.S. participated, eight self-identified as racialized and seventeen as non-Hispanic, White. Data were analyzed iteratively using Clandinin and Connelly's approach to Narrative Inquiry. Across their narratives, participants described their experiences of maternity care that were either generally negative (dehumanizing care) or positive (humanized care). They further described how their experiences of dehumanizing or humanized care impacted their decision-making for subsequent births, mental health, relationships with the healthcare system, early parenting birth satisfaction, and family planning. Findings suggest that regardless of ultimate mode of birth, what was most important to women was how they are treated by their maternity care team. We suggest practice changes that may improve the experience of maternity care for primary cesarean and subsequent births, especially among those made marginal by systems of oppression.

Measuring midwives' perceptions of their practice climate across racial-ethnic identities: An invariance analysis of the Midwifery Practice Climate Scale

Diversification of the midwifery workforce is key to addressing disparities in maternal health in the United States. Midwives who feel supported in their practice environments report less burnout and turnover; therefore, creating positive practice environments for midwives of color is an essential component of growing and retaining midwives of color in the workforce. The Midwifery Practice Climate Scale (MPCS) is a 10-item instrument developed through multiphase empirical analysis to measure midwives' practice environments, yet the MPCS had not been independently tested with midwives of color. We conducted invariance analyses to test whether latent means can be compared between midwives of color and non-Hispanic White samples. A step-up approach applied a series of increasingly stringent constraints to model estimations with multiple group confirmatory factor analyses with two pooled samples. A configural model was estimated as the basis of multiple group comparisons where all parameters were allowed to freely vary. Metric invariance was estimated by constraining item factor loadings to be equal. Scalar invariance was estimated by constraining intercepts of indicators to be equal. Each model was compared to the baseline model. The findings supported scalar invariance of MPCS across midwives of color and non-Hispanic White midwives, indicating that the MPCS is measuring the same intended construct across groups, and that differences in scores between these two groups reflect true group differences and are not related to measurement error. Additionally, in this sample, there was no statistically significant difference in perceptions of the practice environments across midwives of color and non-Hispanic White midwives (p > 0.05).

Facilitators influencing midwives to leadership positions in policy, education and practice: A systematic integrative literature review

The development of midwives as leaders is a crucial step towards achieving equality in sexual, reproductive, maternal, and neonatal health, Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). However, many midwives work only to implement policies made by others rather than being drivers of policy changes. Little is known and researched about why midwives are not involved in decision and policymaking related to sexual, reproductive, maternal, and neonatal health. Hence, with a focus on midwifery leadership within the global community and the limited opportunities for women to hold leadership positions, this research explores the facilitators influencing midwives' opportunities to become leaders in policy development, education and practice. Inspired by Whittemore and Knafl, this integrative literature review was conducted after twenty-two relevant articles were identified through a search of the following databases: PubMed, CINAHL, and Scopus. Inductive content analysis was applied to analyze data. The result indicates that for midwives to become influential leaders, they must be active in strategic planning at the highest level. This inevitably effects how far midwives can act as agents for change, even if they possess the knowledge and skills for a leadership position. Policies and regulations influence how midwives' status in society is acknowledged and recognized. A clearly articulated educational pathway will enable their professional growth and expertise, making them knowledgeable and skillful as leaders. Enabling midwives to step into leadership positions at government level requires reforms which include midwives in decision-making. Excluding midwives from decision-making processes is detrimental to the goal of achieving universal health coverage. The first step is to provide midwives with a protected title, enabling them to work autonomously in an enabling environment with normal pregnancy and birth to achieve the SDG 2030 goals.

Expanding midwifery care in the United States: Implications for clinical outcomes and cost

BACKGROUND

This study compared clinical and financial outcomes for low-risk birthing people between those attended by midwives and those attended by obstetricians during hospital births.

METHODS

We conducted a retrospective cohort analysis of births from January 1, 2016 to December 31, 2020 at hospitals participating in a perinatal quality improvement collaborative, Obstetrical Care Outcomes Assessment Program (OB COAP), in the Northwest region of the United States and estimated risk ratios using a multivariate regression approach with a modified Poisson binomial for mode of delivery, labor interventions, and newborn outcomes comparing midwife-led to obstetrician-led care. Using publicly available data on average costs of vaginal and cesarean births, we then extrapolated the cost differences in care between midwives and obstetricians.

RESULTS

Births in the midwife group were less likely to be associated with induction (17.6% vs. 20.3% RR 0.74; 95% CI 0.70-0.78), epidural use (58.9% vs. 76.3% RR 0.78; 95% CI 0.77-0.80), and episiotomy (2.2% vs. 3.4% RR 0.68; 95% CI 0.58-0.81). Cesarean birth was also lower in the midwifery group (7.8% vs. 12.3% RR 0.68, 95% CI 0.62-0.73), without a corresponding increase in risk in adverse neonatal outcomes. We estimated that expanding midwifery care to 100% of low-risk births across the United States could save as much as $340 million per year.

CONCLUSIONS

Midwifery care is associated with a lower risk of cesarean birth and other interventions versus care provided by obstetricians and is therefore likely lower-cost.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali

BACKGROUND

Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali.

METHODS

This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents.

RESULTS

The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective.

CONCLUSION

The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

What influences women's experiences of childbirth in Flanders? - A quantitative cross-sectional analysis of the Babies Born Better survey

OBJECTIVE

Labour and birth experiences are of great importance since these can have positive, but also negative effects on women's health and wellbeing. This is the first study, which investigated the factors that influence women's experiences of childbirth in Flanders, Belgium.

DESIGN

A cross-sectional quantitative analysis was used to examine primary data obtained by the Babies Born Better project. Data collection took place via an online survey from April 2018 until August 2018 in Flanders.

PARTICIPANTS

1414 women that gave birth across all birth settings between 2013 and 2018, who speak Flemish/Dutch were included. Participants were self-selected by filling out the Babies Born Better survey in 2018.

FINDINGS

The majority of the Flemish women included in this study reported a positive labour and birth experience. Analysis of the demographic variables showed that women who were single or not co-habiting reported a worse experience of labour and birth (P = 0.012). All obstetric factors included showed significant differences (P<0.01). Lastly, women were more likely to report a better experience when birth took place at home or in a midwifery unit and when the main care provider was a midwife (P<0.01). When controlled for significant variables from the univariate analysis, an impact on the birth experience was only found with the obstetric factors. A preterm (OR 0.544, 95%CI 0.362-0.817) and post term birth (OR 0.664, 95% CI 0.462-0.953) were found to reduce the chance of a good experience compared to a birth at term. In case of complications during pregnancy, women were less likely to report having had a good experience (OR 0.632, 95% CI 0.470 - 0.849). Medical interventions such as induction- (OR 0.346, 95% CI 0.241 - 0.497) and augmentation of labour (OR 0.318, 95% CI 0.218-0.463), an instrumental birth (OR 0.318, 95% CI 0.218-0.463) or a planned- (OR 0.349, 95% CI 0.205-0.596) or emergency caesarean section (OR 0.190, 95% CI 0.109-0.329) reduced the chances of women reporting to have had a good experience with care around labour and birth.

KEY CONCLUSIONS

The majority of women included in this study reported a good experience of care during labour and at birth. Certain obstetric factors such as having a straightforward pregnancy without complications, a physiological onset of labour at term without the need for augmentation and to give birth vaginally (without instrument) have shown a positive impact on women's reported birth experiences.

IMPLICATIONS FOR PRACTICE

Women's involvement in decision-making, especially when medical interventions are wanted or needed can improve positive birth experiences. More research is needed on how to support women and empower them, even more so in case of complications to ensure a sense of control and achievement.

How should a video-call service for early labour be provided? A qualitative study of midwives' perspectives in the United Kingdom and Italy

PROBLEM

Women in early labour are typically encouraged to delay admission to the maternity unit, but they may find this challenging without appropriate professional support.

BACKGROUND

Prior to the pandemic, research conducted with midwives and women showed positivity towards using video-technology for early labour, with concerns raised about privacy.

AIM

To explore midwives' perspectives on potential use of video-calls during early labour METHODS: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained prior to commencing the study and ethical processes were followed. Seven virtual focus groups were conducted with 36 participants, 17 midwives working in the UK and 19 midwives working in Italy. Line-by-line thematic analysis was performed and themes agreed by the research team.

FINDINGS

The findings include three main themes: 1) who, where, when and how: key aspects to consider for an effective video-call service in early labour; 2) video-call content and expected contribution; 3) potential barriers to address.

DISCUSSION

Midwives responded positively to the concept of video-calling in early labour and provided detailed suggestions on how an ideal video-call service for early labour should be provided to maximise effectiveness, safety and quality of care.

CONCLUSION

Guidance, support and training should be provided to midwives and healthcare professionals, with dedicated resources for an early labour video-call service that is accessible, acceptable, safe, individualised and respectful for mothers and families. Further research should systematically explore clinical, psychosocial and service feasibility and acceptability.

Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women

OBJECTIVE

To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs.

DESIGN

A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis.

SETTING

The study was conducted in Sweden.

PARTICIPANTS

Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth.

FINDINGS

The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information.

KEY CONCLUSIONS

Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns.

IMPLICATIONS FOR PRACTICE

The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

Midwifery education in Pacific Island countries: A discussion paper

BACKGROUND

The aim for 95% maternal health care coverage and zero-unmet need for family planning in Pacific Island countries by 2030 could be achieved by strengthening the midwifery workforce. To enable health services to provide accessible, locally acceptable, and high-quality care, the midwifery workforce must be regulated and educated to global standards and supported to practice in enabling environments. In 2019, around 64,000 live births occurred in Pacific Island countries, yet information regarding the state the midwifery workforce and midwifery education is limited.

AIM

Using data from recent reports and country case studies, this paper provides an overview of the current midwifery education situation in Pacific Island countries and discusses strategic directions for strengthening quality midwifery education and therefore quality midwifery care provision in Pacific Island countries.

DISCUSSION

Six Pacific Island countries have midwifery curricula, all post-nursing programs, although few offer midwifery education programs on a regular annual basis. Current programs do not meet ICM Global Standards for Midwifery Education. Critical areas for strengthening include making underpinning philosophical frameworks, the vision for midwifery education, and program intended learning outcomes explicit in curricula documents and ensuring integration of these in program implementation. Fortunately, five of six midwifery education programs are under processes of renewal and strengthening against global, regional, and national standards.

CONCLUSION

Strengthening the midwifery workforce in the Pacific to meet maternal and newborn health targets can be achieved through supporting the existing midwifery education programs to meet global standards. Strengthened midwifery education programs in Pacific Island countries offer an opportunity to meet each country's maternal and newborn health targets.

Achieving international consensus on the concept of woman-centred care: A Delphi study

PROBLEM

There is no internationally-informed understanding of how midwives perceive woman-centred care and use it in practice.

BACKGROUND

Woman-centred care is integral to the role of the midwife and to determining standards of practice. Few empirical studies have explored the meaning of woman-centred care, and those that have are limited to country specific research.

AIM

To gain an in-depth understanding and consensus on the concept of woman-centred care from an international perspective.

METHODS

A three round Delphi study was conducted, with surveys distributed online to a group of international expert midwives to draw consensus on the topic of woman-centred care.

FINDINGS

A panel of 59 expert midwives representing 22 countries participated. Fifty-nine statements about woman-centred care, of which 63% of statements reached the 75% a priori agreement level, were developed and categorised under four emergent themes: defining characteristics of woman-centred care (n = 17), the role of the midwife in woman-centred care (n = 19), woman-centred care and systems of care (n = 18), woman-centred care in education and research (n = 5).

DISCUSSION

Participants agreed that woman-centred care should be provided by any health care professional in any health care setting. Systems of maternity care should provide holistic care tailored for the individual woman rather than subject her to routine practices and policies. Although continuity of care is important to midwifery practice, it was not reported as a core characteristic of woman-centred care.

CONCLUSION

This is the first study to investigate the concept of woman-centred care as it is experienced globally by midwives. The findings of this study will be used to contribute to the development of an internationally informed evidence-based definition of woman-centred care.

Early labour experience questionnaire: Translation and cultural adaptation into German

PROBLEM

Evidence on early labour care suggests that women's needs are not adequately met.

BACKGROUND

Women's perceptions of early labour management impact on their overall birth experience. Valid measurement tools are needed for evaluation and improvement of early labour care.

AIM

Translation and cultural adaptation of the Early Labour Experience Questionnaire for use in a German context.

METHODS

Translation and adaptation followed internationally recognised guidelines. The process comprised for- and backward translation, an expert panel review using a three-round modified Delphi process and cognitive interviews with representatives of the target group using paraphrasing and retrospective probing. The interviews were conducted online, video-recorded and transcribed. Based on the results of the interviews the pilot version of the questionnaire was compiled.

FINDINGS

Nine experts, including a representative of the target group, participated in the Delphi process. Twelve cognitive interviews were conducted. Most of the translation and adaptation issues needing clarification related to differences in the organisation of maternity care, the term early labour and the translation of the single word expressions for women's affective state in early labour. Few problems emerged during cognitive interviews and related to conceptual understanding, reference points, instructions, and response categories. The pilot version of the German Early Labour Experience Questionnaire (G-ELEQ) comprises a total of 25 items.

CONCLUSION

With the G-ELEQ a tool for measuring women's early labour experience in the German context with good face and content validity is available. Psychometric testing is now needed to assess the instrument's validity and reliability.

Comparison of maternal outcomes in caring by Doula, trained lay companion and routine midwifery care

INTRODUCTION

The aim of this study was to compare maternal and neonatal outcomes in the care provided by Doula, trained lay companion, and routine midwifery care in the labor and obstetric units. In this study, only results related to maternal outcomes were presented.

METHOD

This is a quasi-experimental study, which was conducted on 150 women with low-risk pregnancies who had been selected for vaginal birth at private clinics and public hospitals of Arak, Iran. Participants were divided into three groups, two intervention groups, doula and trained lay companion, and one control group, midwife's routine care. The intervention groups, in addition to receiving routine care from the labor and maternity units, also received support and training by doula or a trained lay companion, but 50 the control group received only routine midwifery care. In the control group and the trained companion, the samples were taken from 10 clinics of different parts of the city by random sampling method using the SIB center system. Then, among selected numbers, we randomly selected samples for each group. But in Doula group, because of limited number of samples, convenience sampling was used and all women enrolled in doula care were included in the study until the number reached 50. In each group, outcomes such as the duration of active phase and second stage of labor, as well as the severity of pain, anxiety and maternal satisfaction with birth were measured and compared with other groups. Data were collected by a researcher-made checklist, the Spielberger's State-Trait Anxiety Inventory (STAI), the Pain Visual Assessment Scale (VAS), and the Hollins Martin's Birth Satisfaction Scale-Revised (BSS-R). Data were analyzed by SPSS-22 statistical software using Kruskal Wallis, Chi-Square, ANOVA and Fisher's exact tests.

FINDINGS

Based on the results, the mean duration of active phase between three groups was 234.68 ± 118.74, 256.66 ± 108.75 and 279 ± 94.37 min, respectively (p = 0.022). Also, the mean duration of second stage in three groups was 10 ± 5.61, 10.35 ± 5.1 and 22.30 ± 75.57 min, respectively (p < 0.001). The difference between mean pain scores in the first, second, third, fourth and fifth hours was not statistically significant. The average difference in anxiety score in the two stages of labor was higher in the lay companion group, and this difference was statistically significant (p < 0.001); however, the level of satisfaction in doula group was higher compared to the lay companion and control groups (p < 0.00 1).

CONCLUSION

According to present study, doula care has a greater effect on reducing the duration of labor than other care models. Based on the study, there was no statistically significant difference between the three groups in terms of variables such as the severity of labor pain. However, the level of anxiety of pregnant mothers in the group supported by lay companion was lower than the other two groups, which indicates the positive effect of mothers' training on increasing maternal comfort and satisfaction. It is suggested that further research investigate the severity of labor pain in groups supported by different care models and also we recommend the use of lay companion' support during childbearing of mothers who could not afford doula.

TRAIL REGISTRATION

This article has been registered in Iran's Clinical Trial Center with the code: IRCT20230620058548N1. 2023/08/29.

Health System Strengthening Through Professional Midwives in Bangladesh: Best Practices, Challenges, and Successes

In 2008, a cadre of professional midwives was introduced in Bangladesh. Since then, 120 midwifery educational programs have been established. There are 2,556 midwives serving at 667 government health facilities, and there are more midwives working in nongovernmental organizations and the private sector. This case study documents the process of establishing a midwifery profession with distinct midwifery expertise in Bangladesh and aims to guide other low- and middle-income countries in best practices and challenges. We describe the national administrative groundwork for the profession's launch, roll-out of an education program aligned with the International Confederation of Midwives, national deployment, enabling environments in deployment, and the professional association. Bangladesh's professional midwives' roles in humanitarian response and the COVID-19 pandemic are also discussed. The first and final authors were closely involved in supporting the government's establishment of the profession, and their direct experience is drawn upon to contextualize the topics. In addition, the authors conducted a desk review of documents that supported the profession's integration into the health system and documented its results. Both routine program data and existing research studies were reviewed. Outcomes show that midwives are deployed to 95% of government subdistrict hospitals. About 50% of these hospitals are fully staffed with 4 midwives, and within the hospitals, midwives are in charge of 90% of the maternity wards and attend 75%-85% of the births. Since the midwives' deployment, significant quality improvement for most World Health Organization indicators has been found, along with increases in service utilization. The experience of establishing a new midwifery profession in Bangladesh shows that it is possible for a lower middle-income country to introduce a globally standard midwifery profession, distinct from nursing, to improve quality sexual, reproductive, maternal, newborn, and adolescent health services in both humanitarian and development settings.

Mapping factors that may influence attrition and retention of midwives: a scoping review protocol

INTRODUCTION

An appropriately staffed midwifery workforce is essential for the provision of safe and high-quality maternity care. However, there is a global and national shortage of midwives. Understaffed maternity services are frequently identified as contributing to unsafe care provision and adverse outcomes for mothers and babies. While there is a need to recruit midwives through pre-registration midwifery programmes, this has significant resource implications, and is counteracted to a large extent by the high number of midwives leaving the workforce. It is increasingly recognised that there is a critical need to attend to retention in midwifery in order to develop and maintain safe staffing levels. The objective of this review is to collate and map factors that have been found to influence attrition and retention in midwifery.

METHODS AND ANALYSIS

Joanna Briggs Institute guidance for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will be used to guide the review process and reporting of the review. CINAHL, MEDLINE, PsycINFO and Scopus databases will be searched for relevant literature from date of inception to 21 July 2023. Research from high-income countries that explores factors that influence leaving intentions for midwives will be included. Literature from low-income and middle-income countries, and studies where nursing and midwifery data cannot be disaggregated will be excluded. Two reviewers will screen 20% of retrieved citations in duplicate, the first author will screen the remaining results. Data will be extracted using a preformed data extraction tool by the first author. Findings will be presented in narrative, tabular and graphical formats.

ETHICS AND DISSEMINATION

The review will collate data from existing research, therefore ethics approval is not required. Findings will be published in journals, presented at conferences and will be translated into infographics and other formats for online dissemination.

Implementing a new birthing room design: a qualitative study with a care provider perspective

BACKGROUND

Research shows that interventions to protect the sensitive physiological process of birth by improving the birthing room design may positively affect perinatal outcomes. It is, however, crucial to understand the mechanisms and contextual elements that influence the outcomes of such complex interventions. Hence, we aimed to explore care providers' experiences of the implementation of a new hospital birthing room designed to be more supportive of women's birth physiology.

METHODS

This qualitative study reports on the implementation of the new birthing room, which was evaluated in the Room4Birth randomised controlled trial in Sweden. Individual interviews were undertaken with care providers, including assistant nurses, midwives, obstetricians, and managers (n = 21). A content analysis of interview data was conducted and mapped into the three domains of the Normalisation Process Theory coding manual: implementation context, mechanism, and outcome.

RESULTS

The implementation of the new room challenged the prevailing biomedical paradigm within the labour ward context and raised the care providers' awareness about the complex interplay between birth physiology and the environment. This awareness had the potential to encourage care providers to be more emotionally present, rather than to focus on monitoring practices. The new room also evoked a sense of insecurity due to its unfamiliar design, which acted as a barrier to integrating the room as a well-functioning part of everyday care practice.

CONCLUSION

Our findings highlight the disparity that existed between what care providers considered valuable for women during childbirth and their own requirements from the built environment based on their professional responsibilities. This identified disparity emphasises the importance of hospital birthing rooms (i) supporting women's emotions and birth physiology and (ii) being standardised to meet care providers' requirements for a functional work environment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03948815, 14/05/2019.

Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review

Background and Objectives: Respectful maternity care promotes practices that acknowledge women's preferences and women and newborns' needs. It is an individual-centered strategy founded on ethical and human rights principles. The objective of this systematic review is to identify the impact of income on maternal care and respectful maternity care in low- and middle-income countries. Materials and Methods: Data were searched from Google Scholar, PubMed, Web of Science, NCBI, CINAHL, National Library of Medicine, ResearchGate, MEDLINE, EMBASE database, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Maternity and Infant Care database. This review followed PRISMA guidelines. The initial search for publications comparing low- and middle-income countries with respectful maternity care yielded 6000 papers, from which 700 were selected. The review articles were further analyzed to ensure they were pertinent to the comparative impact of income on maternal care. A total of 24 articles were included, with preference given to those published from 2010 to 2023 during the last fourteen years. Results: Considering this study's findings, respectful maternity care is a crucial component of high-quality care and human rights. It can be estimated that there is a direct association between income and maternity care in LMICs, and maternity care is substandard compared to high-income countries. Moreover, it is determined that the evidence for medical tools that can enhance respectful maternity care is sparse. Conclusions: This review highlights the significance of improving maternal care experiences, emphasizing the importance of promoting respectful practices and addressing disparities in low- and middle-income countries.

Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review

BACKGROUND

There is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems.

METHODS

An integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis.

RESULTS

Fifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers.

CONCLUSIONS

Effectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization.

TRIAL REGISTRATION

The protocol is registered in PROSPERO (CRD42022367657).

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

Woman-centered care and associated factors among midwives working in urban health centers and public and private hospitals in Tabriz, Iran: a cross-sectional study

BACKGROUND

Woman-centered care (WCC) is the cornerstone of the midwifery profession. However, no study has been conducted on WCC provided by Iranian midwives and its associated factors. Thus, this study aimed to determine WCC and factors associated with midwives' WCC for midwives working in urban health centers and public and private hospitals in Tabriz, Iran.

METHODS

This cross-sectional study was the first part (i.e., the quantitative phase) of a sequential explanatory mixed-method study conducted on 575 midwives working in urban health centers and public and private hospitals in Tabriz-Iran from November 2022 to January 2023. The required data was collected by distributing a socio-demographic and job characteristics questionnaire and woman-centered care scale-midwife self-report (WCCS-MSR). To determine the factors associated with WCC, an independent t-test or one-way analysis of variance (ANOVA) was used in bivariate analysis, and a general linear model (GLM) was employed in multivariate analysis to control possible confounding variables.

RESULTS

The statistical population consisted of 575 midwives, with a response rate of 88.2%. According to the GLM, the total mean WCCS-MSR score of single [β (95% CI) 23.02 (7.94 to 38.10)] and married [β (95% CI) 21.28 (6.83 to 35.72)] midwives was significantly higher than that of divorced midwives after adjusting their demographic and job characteristics. Also, the total mean WCCS-MSR score of midwives with sufficient income was significantly higher than those with insufficient income [β (95% CI) 8.94 (0.12 to 17.77). In addition, the total mean WCCS-MSR score of midwives with < 5 years of work experience [β (95% CI) - 7.87 (- 14.79 to - 0.94)], and midwives with official-experimental employment status [β (95% CI) - 17.99 (- 30.95 to - 5.02)], was significantly lower than those with more than 5 years of work experience and contractual employment status.

CONCLUSIONS

The findings indicate that marital status, level of income, years of practice, and employment status were significantly related to WCC provided by midwives. Focusing only on the midwifery community is insufficient to ensure the improved quality of WCC. However, arrangements should be made at three levels, including policy-makers, managers, and health care provider (midwives).

A postpartum intervention for vaccination promotion by midwives using motivational interviews reduces mothers' vaccine hesitancy, south-eastern France, 2021 to 2022: a randomised controlled trial

BackgroundDespite childhood vaccine mandates imposed in 2018 in France, parental vaccine hesitancy (VH) remains frequent. Interventions in Quebec, Canada, applying motivational interviewing (MI) techniques have successfully reduced parents' VH for childhood immunisations.AimTo determine whether MI intervention for mothers in maternity wards in the days after birth in France could significantly reduce VH, increase intentions to vaccinate (VI) their child at 2 months and reduce VH social inequalities.MethodsWe conducted a parallel-arm multicentre randomised controlled trial from November 2021 to April 2022 to compare impacts of MI performed by MI-trained midwives (intervention) vs a vaccination leaflet (control). We included 733 mothers from two maternity hospitals in south-eastern France, randomly assigned either arm. The validated Parents Attitudes about Childhood Vaccines questionnaire was used before and after MI or leaflet to assess mothers' VH (13 items, 0-100 score) and VI (1 item, 1-10 score). Difference-in-difference (D-I-D) models were used to estimate net impact of MI vs leaflet for the entire sample and stratified by VH and education level.ResultsMotivational interview intervention reduced mothers' VH score by 33% (p < 0.0001) and increased VI by 8% (p < 0.0001); the effect was largest for the highest initial VH levels. D-I-D analyses estimated net VH decrease at 5.8/100 points (p = 0.007) and net VI increase at 0.6/10 points (p = 0.005). Net VH decrease was highest for high initial VH levels and low education levels.ConclusionsOur results show positive effects of MI intervention, and means of its implementation should be investigated in France.

Midwife Educators' perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh

INTRODUCTION

Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

METHOD

Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data.

RESULTS

The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement.

CONCLUSION

There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

Assessment of the relevance of midwifery competencies in academic education in Germany from the midwives' perspective: A structural analysis of cross-sectional survey data

INTRODUCTION

The acquisition of academic competencies is one of the main outcomes of the academization of midwifery education. To analyze midwives' views on the key academic competencies of the recently reformed midwifery education in Germany, an existing assessment instrument was adapted to the German context of care and psychometrically analyzed. Furthermore, it was investigated whether the relevance assessments of academic and non-academic midwives differ from each other.

METHODS

The study design was cross-sectional. A total of 193 (prospective) midwives answered the items on the assessed relevance of midwifery competencies in academic education (59 items); 3 items were added (referring to evidence-based practice and digital literacy). Construct validity was tested using exploratory factor analysis. Item and reliability analysis as well as unpaired t-tests were performed.

RESULTS

Considering insufficient item-construct associations (20 items), a single factorial solution best fits the data (eigenvalue: 18.36; explained variance: 29.60%). Internal reliability was demonstrated to be very good with Cronbach's α=0.954. The assessed relevance of academic midwifery competencies from academic and non-academic midwives did not differ significantly from each other for students and trainee midwives (t=0.18; df=6.66; p=0.86), and for for midwives educated at vocational school and university (t= -0.035; df=106; p=0.97).

CONCLUSIONS

The adapted assessment tool can be used with minor modifications to reliably and validly measure the assessed relevance of academic competence from the midwives' perspective. Combined with data on the assessments of medical practitioners and laypersons, the assessment provides a substantial data basis for the development of a competence profile for academic midwifery education in Germany.

Describing the transition from late pregnancy into early labour - A prospective cohort study

OBJECTIVE

The time between self-assessed first symptoms and clinical confirmation of labour onset is marked by uncertainty, particularly for primiparas. Accordingly, primiparas often seek professional care to confirm their perceptions of labour onset. This paper describes the transition into early labour among primiparas considering their level of certainty in labour onset and their perception of labour onset symptoms prior to birth.

METHODS

A prospective exploratory cohort study was conducted in Germany between July 2020 - March 2021 among a convenience sample of 69 primiparas. Respondents recorded in a non-validated questionnaire their perceptions of nine symptoms and degree of certainty about labour onset every day from 37 weeks gestation. Descriptive analysis included certainty in labour onset and dedicated symptoms in relation to days before birth.

RESULTS

The participants (n=69) reported a little certainty of labour onset up to 32 days before birth and most of them became certain up to four days before birth. Associated symptoms were regular and irregular pain, symptoms of vaginal loss and emotional symptoms. Gastrointestinal symptoms and nausea were not indicated by a majority. Uncertainty of labour onset, however, was indicated up until the day of birth.

CONCLUSION

Although interpretation is based on a small sample size, primiparas are able to self-diagnose labour onset and report connected symptoms up to four days before birth. We suggest calling this time between self-diagnosis of labour onset and confirmed labour onset based on clinical parameters the transition into early labour.

Freebirth, the only option for women who do not fit into common practice- A Swedish national interview study

OBJECTIVE

To explore women's experience of freebirth, as giving birth without the presence of a skilled healthcare professional such as a midwife.

METHODS

Online semi-structured interviews with nine multiparous women in Sweden. A qualitative experiential approach, as described by Burnard, was followed for data analysis.

RESULTS

The five main categories explored were: (i) previous negative experiences of hospital care as a reason for freebirth; (ii) receiving support for the decision of freebirth was crucial; (iii) longing for individual midwifery-assisted home-birthing support; (iv) to give birth in peace and in self-control, in the safe home environment; and (v) helpful support during labor and birth was appreciated.

CONCLUSIONS

The women in the study had a powerful and positive experience of freebirth, but individual midwifery birthing support was also requested. Easily available and respectful midwifery support should be offered to all childbearing women.

Predictors of childbirth experience: Prospective observational study in eastern Spain

BACKGROUND

In recent years, birth experience has been highlighted by national and international organisations as a relevant value in measuring maternal health care quality. According to a standardised tool, we aimed to assess which clinical indicators had the most significant influence on the birth experience.

METHODS

This prospective observational study was carried out in fourteen hospitals in eastern Spain. 749 women consented to the collection of birth variables at discharge, and subsequently, at 1-4 months, data were collected on the birth experience as measured by the Spanish version of the Childbirth Experience Questionnaire. Next, a linear regression analysis was performed to determine which clinical birth indicators greatly influence the birth experience measure.

RESULT

The study sample (n = 749) was predominantly Spanish and primipara, with 19.5% vaginal births. The predictors that emerged in the linear regression model were to have a birth companion (B = 0.250, p = 0.028), drink fluids during labour (B = 0.249, p < 0.001), have early skin-to-skin contact (B = 0.213, p < 0.001) and being transferred to a specialised room for the second stage of labour (B = 0.098, p = 0.016). The episiotomy (B = -0.100, p < 0.015) and having an operative birth (B = -0.128, p < 0.008) showed a negative influence.

CONCLUSION

Our study supports that intrapartum interventions recommended according to clinical practice guidelines positively influence the mother's birth experience. Episiotomy and operative birth should not be used routinely as they negatively influence the birth experience.

Systematic review of women's experiences of planning home birth in consultation with maternity care providers in middle to high-income countries

AIM

To synthesise findings from published studies, which reported on women's experiences of planning a home birth in consultation with maternity care providers.

DESIGN

Systematic Review DATA SOURCES: We searched seven bibliographic databases, (Ovid Medline, Embase, PsycInfo, CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library), from January 2015 to 29th April 2022.

REVIEW METHODS

Primary studies were included if they investigated women's experiences of planning a home birth with maternity care providers, in upper-middle and high-income countries and written in English language. Studies were analysed using thematic synthesis. GRADE-CERQual was used to assess the quality, coherence, adequacy and relevance of data. The protocol is registered on PROSPERO registration ID: CRD 42018095042 (updated 28th September 2020) and published.

RESULTS

1274 articles were retrieved, and 410 duplicates removed. Following screening and quality appraisal, 20 eligible studies (19 qualitative and 1 survey) involving 2,145 women were included.

KEY CONCLUSIONS

Women's prior traumatic experience of hospital birth and a preference for physiological birth motivated their assertive decision to have a planned home birth despite criticisms and stigmatisation from their social circle and some maternity care providers. Midwives' competence and support enhanced women's confidence and positive experiences of planning a home birth.

IMPLICATIONS FOR PRACTICE

This review highlights the stigma that some women feel and the importance of support from health professionals, particularly midwives when planning a home birth. We recommend accessible evidence-based information for women and their families to support women's decision-making for planned home birth. The findings from this review can be used to inform woman-centred planned home birth services, particularly in the UK, (although evidence is drawn from papers in eight other countries, so findings are relevant elsewhere), which will impact positively on the experiences of women who are planning home birth.

Student midwives' perspectives of women's sexual and reproductive health literacy in Turkey

OBJECTIVE

This study focused on the issues surrounding health literacy in the context of women's sexual and reproductive health (SRH), the significance and availability of information for midwives and women; and the socio-cultural influences and barriers related to women's level of health literacy.

METHODS

A cross sectional on-line survey was distributed to 280 student midwives in their 2nd 3rd and 4th year of a midwifery programme. This paper focuses on the responses from 138 students which were analysed using descriptive and non-parametric tests.

RESULTS

Student midwives indicated their level of agreement regarding women's ability to access, understand, and appraise information they received verbally and in written form about the six main SRH topics (namely contraception, STIs, abortion, Pap tests and cervical cancer, and fertility and pregnancy), from their midwife but agreement was much lower regarding women's access to SRH information from peers and their families. False beliefs were ranked as the most common barrier to accessing information and services. Students ranked being a refugee, being from a rural area, being educated to a primary school level or not formally educated, as having the greatest negative impact on women's health literacy.

CONCLUSIONS

Findings from this study indicate the role that the sociocultural background of Islamic culture plays in the disparities in sexual and reproductive health literacy (SRHL) for women from the perspective of student midwives. Our findings indicate the need for future research to focus on women as participants to gain their first-hand experiences of SRHL.

Exploring women's experiences, views and understanding of vaginal examinations during intrapartum care: A meta-ethnographic synthesis

OBJECTIVE

To conduct a systematic review exploring women's experiences, views and understanding of any vaginal examinations during intrapartum care, in any care setting and by any healthcare professional. Intrapartum vaginal examination is deemed both an essential assessment tool and routine intervention during labour. It is an intervention that can cause significant distress, embarrassment, and pain for women, as well as reinforce outdated gender roles. In view of its widespread and frequently reported excessive use, it is important to understand women's views on vaginal examination to inform further research and current practice.

DESIGN

A systematic search and meta-ethnography synthesis informed by Noblit and Hare (1988) and the eMERGe guidance (France et al. 2019) was undertaken. Nine electronic databases were searched systematically using predefined search terms in August 2021, and again in March 2023. Studies meeting the following criteria: English language, qualitative and mixed-method studies, published from 2000 onwards, and relevant to the topic, were eligible for quality appraisal and inclusion.

FINDINGS

Six studies met the inclusion criteria. Three from Turkey, one from Palestine, one from Hong Kong and one from New Zealand. One disconfirming study was identified. Following both a reciprocal and refutational synthesis, four 3rd order constructs were formed, titled: Suffering the examination, Challenging the power dynamic, Cervical-centric labour culture embedded in societal expectations, and Context of care. Finally, a line of argument was arrived at, which brought together and summarised the 3rd order constructs.

KEY CONCLUSIONS AND IMPLICATIONS OF PRACTICE

The dominant biomedical discourse of vaginal examination and cervical dilatation as central to the birthing process does not align with midwifery philosophy or women's embodied experience. Women experience examinations as painful and distressing but tolerate them as they view them as necessary and unavoidable. Factors such as context of care setting, environment, privacy, midwifery care, particularly in a continuity of carer model, have considerable positive affect on women's experience of examinations. Further research into women's experiences of vaginal examination in different care models as well as research into less invasive intrapartum assessment tools that promote physiological processes is urgently required.

Midwives' and women's experiences with respectful maternity care around the globe: A meta-synthesis

BACKGROUND

All women have the right to the highest attainable standards of health, including the right to respectful maternity care (RMC). A qualitative body of knowledge describing midwives' and women's experiences of the value and importance of RMC exists. However, no qualitative synthesis exists about midwives' and women's views of respectful care.

AIM

This review aims to present a qualitative synthesis of global perceptions and experiences of midwives and women regarding RMC.

METHODS

A systematic search was conducted in October 2021 and updated in March 2023 on Science Direct, EBSCO host, PubMed, Nexus and ProQuest databases. The synthesis included qualitative studies published between 2010 and 2023. Qualified midwives and pregnant and postnatal women were the samples of the review. The studies' screening and selection for inclusion in the review are presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart, and the quality of the included studies was appraised using the Critical Appraisal Screening Programme (CASP) tool. Thematic analysis was conducted.

FINDINGS

Fifteen studies met the review inclusion criteria involving 266 women and 147 midwives. Five themes were identified from the data: commitment to women's rights; excellence in midwifery knowledge and skills; a facilitative built environment; optimising the interpersonal dimension; and the development of women's resourcefulness and resilience.

CONCLUSION

Maternity care is collaborative, and midwives and women are partners in the process. Midwives play a significant role in promoting women's rights, fostering interpersonal working and client relationships, and addressing women's rights and needs.

"Midwives are heroes of the country": qualitative evaluation of a midwifery education program in South Sudan

Background

Countries affected by armed conflict have higher maternal mortality than stable settings. South Sudan has one of the highest maternal mortality ratios in the world, with an estimated 789 maternal deaths per 100,000 live births. Long-term socio-political instability has contributed to significant challenges in its health system. To reduce maternal and newborn morbidity and mortality, South Sudan must increase the number of skilled midwives.

Methods

A cross-sectional mixed methods study was conducted in 2022 to assess the midwifery education program at three schools receiving support from International Medical Corps in South Sudan, including in-depth interviews with 15 midwifery school graduates currently working as midwives, their supervisors, 16 school faculty (in dyads), and two Ministry of Health officials; and nine focus group discussions with women clients of graduate midwives.

Results

Participants identified strengths of the schools, including being well equipped with trained and competent teaching staff, competency-based curriculum, including practical training which prepared graduate midwives to apply their skills in practice. Weaknesses of the program included its dependence on donor funding, inadequate mentorship and number of tutors, and insufficient practice for some services due to low client load at clinical sites. Additionally, participants identified challenges affecting midwives' ability to provide good quality care, including lack of equipment and supplies, low client load, low salaries, and insecurity due to conflict. Nevertheless, women in the community appreciated the immense work that midwives do. Midwives were respected by the community at large, and graduates expressed pride and satisfaction in their job, as well as the positive impact they have had in providing critical services to communities.

Discussion

Overall, the quality of the midwifery education program appears to be strong, however gaps in the program and the provision of quality care remain. The findings highlight the need to ensure sustained funding for midwifery education, as well as health system strengthening to ensure midwives can practice their skills. Continued investment in midwifery education and training is critical to reduce high maternal mortality and morbidity in South Sudan.

Key factors associated with quality of postnatal care: a pooled analysis of 23 countries

Background

Progress in reducing maternal and neonatal mortality, particularly in low-income and middle-income countries (LMICs) and regions, is insufficient to achieve the Sustainable Developmental Goals by 2030. High-quality postnatal care (PNC) for mothers and neonates is crucial for mothers and babies, yet it remains the most neglected intervention on the continuum of maternal and child care. We aimed to estimate the associations between observable factors and high-quality maternal and neonatal PNC in pooled and country-specific analyses.

Methods

In this cross-sectional study, we used the most recent (2015-2022) Demographic and Health Surveys from 23 countries across Africa (n = 14), Southeast Asia (n = 3), Eastern Mediterranean (n = 2), Europe (n = 2), Americas (n = 1), and Western Pacific (n = 1). Women who, within the last 5 years, were aged 15-49 years at their last live birth that had delivered a singleton child were included. We identified eleven PNC behaviours recommended by the World Health Organization (WHO) to measure PNC quality, and applied thresholds to create binary outcomes for quality maternal and neonatal PNC. 15 factors were included in our analysis to assess their association with high-quality PNC for mothers and neonates in a series of single-adjusted and mutually adjusted logistic regression models, both in pooled and country-specific analysis. We also conducted two sets of subgroup analyses for place of residence and maternal age at last birth, and two sets of supplementary analyses to test the robustness of the results.

Findings

Among 172,526 women and their most recent child, 41.42% (40.93-41.91) received quality maternal PNC while 42.34% (41.86-42.83) received quality neonatal PNC. In the pooled analysis, we found that the factors showing the strongest associations with quality maternal PNC were delivery by skilled birth attendants (SBAs) (OR: 4.92; 95% CI: 4.32-5.59), four or more antenatal care (ANC) visits (OR: 1.69, 1.58-1.81), and institutional delivery (OR: 1.61; 1.46-1.78). Consistent results were found for all factors of quality newborn care (e.g., delivery by SBA: OR, 4.25; 3.75-4.81; four or more ANC visits: OR, 1.83; 1.70-1.96) except institutional delivery. The association between these leading factors and PNC quality were broadly consistent across countries. Subgroup analyses and sensitivity analyses showed generally consistent results.

Interpretation

Our study demonstrated that institutional delivery and frequent ANC visits had the strongest positive associations with quality PNC for both mothers and neonates. Our findings highlight that improvements to the quality of maternal and neonatal PNC in the LMICs we assessed are urgently needed to achieve ambitious maternal, newborn, and child health goals.

Funding

China National Natural Science Foundation.

Care provided by midwives and the unmet needs of pregnant and postpartum women: A qualitative study of Japanese mothers

Objectives

We aimed to clarify the content of care provided by midwives working in hospitals and clinics in Japan and the unmet needs in midwifery care from mothers' perspectives.

Design

This study employed a qualitative approach through semi-structured interviews.

Setting

Fifteen Japanese women, whose youngest singleton children were aged 12-18 months, were asked to recall their experiences with midwives, from pregnancy through the first postpartum year. Verbatim records were analyzed using thematic analysis.

Results

Seven themes regarding the care provided by midwives were generated: confirmation of physical condition, maintenance and promotion of perinatal physiological process, support for better preparation for childbirth, assistance in labour and childbirth, support for a new life with a baby at home, support for the family, and care for comfort and confidence as a mother. Unmet needs were identified in all themes, except for 'confirmation of physical condition' and 'support for the family'. Ten subthemes, under the five themes of unmet needs, were integrated into three categories: midwives' responses to potential concerns, lack of continuity of care, and lack of personalised care.

Key conclusions and implications for practice

Midwives in hospitals and clinics in Japan mainly provided care from pregnancy to one-month postpartum, in line with global core competencies. However, they could respond more effectively to the potential concerns of women, and provide continuous, personalised care more sufficiently. Improving working environments for midwives and collaborating with postpartum public health services are key to addressing these unmet needs of women, leading to women-centred care.

Exploring health care professionals' experiences and knowledge of woman-centred care in a university hospital

Inspired by the six quality-of-care goals developed by the Institute of Medicine, woman-centred care (WCC) as model of care is used in maternity services as it gives an emphasis on the woman as an individual and not her status as a patient. Bringing stronger attention to women's needs and values, is proven to have clear benefits for perinatal outcomes, but fails to be known or recognised by healthcare professionals' (HCPs) and implemented. Using a mixed-methods approach, this study aimed to explore HCPs definitions of WCC and identify the degree of agreement and knowledge regarding perinatal indicators when a WCC model of care is implemented. The quantitative part was carried using a self-administered questionnaire with perinatal indicators identified from the literature. Semi-structured interviews were realized using a purposive sample of 15 HCPs and an interview grid inspired by Leap's WCC model. The study was conducted in the maternity of a university hospital in French-speaking part of Switzerland. Out of 318 HCPs working with mothers and their newborns, 51% had already heard of WCC without being familiar with Leap's model. The HCPs were aware of the positive perinatal care outcomes when WCC was implemented: women's satisfaction (99.2%), health promotion (97.6%), HCP's job satisfaction (93.2%) and positive feelings about their work (85.6%), which were strongly emphasised in the interviews. The respondents reported institutional difficulties in implementing the model such as administrative overload and lack of time. The positive outcomes of WCC on spontaneous deliveries and improved neonatal adaptation were known by most HCPs (63.4% and 59.9%, respectively). However, fewer than half of the HCPs highlighted the model's positive effects on analgesia and episiotomies or its financial benefits. Knowledge of quality-of-care outcomes (i.e women's satisfaction, positive impact on practice…) was prevalent among most of HCPs. Without adhering to a common definition and without a specific model for consensus, most providers have integrated some aspects of WCC into their practice. However, specific perinatal indicators remain largely unknown, which may hinder the implementation of WCC.

Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda

Evidence-based quality care is essential for reducing sub-Saharan Africa's high burden of maternal and newborn mortality and morbidity. Provision of quality care results from interaction between several components of the health system including competent midwifery care providers and the working environment. We assessed midwifery care providers' ability to provide quality intrapartum and newborn care and selected aspects of the working environment as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) project in Benin, Malawi, Tanzania, and Uganda. We used a self-administered questionnaire to assess provider knowledge and their working environment and skills drills simulations to assess skills and behaviours. All midwifery care providers including doctors providing midwifery care in the maternity units were invited to take part in the knowledge assessment and one third of the midwifery care providers who took part in the knowledge assessment were randomly selected and invited to take part in the skills and behaviour simulation assessment. Descriptive statistics of interest were calculated. A total of 302 participants took part in the knowledge assessment and 113 skills drills simulations were conducted. The assessments revealed knowledge gaps in frequency of fetal heart rate monitoring and timing of umbilical cord clamping. Over half of the participants scored poorly on aspects related to routine admission tasks, clinical history-taking and rapid and initial assessment of the newborn, while higher scores were achieved in active management of the third stage of labour. The assessment also identified a lack of involvement of women in clinical decision-making. Inadequate competency level of the midwifery care providers may be due to gaps in pre-service training but possibly related to the structural and operational facility characteristics including continuing professional development. Investment and action on these findings are needed when developing and designing pre-service and in-service training. Trial registration: PACTR202006793783148-June 17th, 2020.

Determinants of neonatal, infant and under-five mortalities: evidence from a developing country, Bangladesh

We investigated the macroeconomic determinants of neonatal, infant, and under-five mortalities in Bangladesh for the period 1991-2018 and discuss implications of the United Nations' Sustainable Development Goal 3 (SDG 3) and Millennium Development Goal 4 (MDG 4) for developing countries. We used annual time series data and the econometric techniques of Fully Modified Ordinary Least Squares (FMOLS) and Dynamic Ordinary Least Squares (DOLS) regressions for analysis. Determinants most effective in combating neonatal, infant, and under-five mortalities include variables such as 'protecting newborns against tetanus', 'increasing healthcare expenditure', and 'making sure births are attended by skilled healthcare staff'. Employing more healthcare workers and assuring more and improved healthcare provisions can further reduce the neonatal, infant, and under-five mortalities. Developing countries with similar macroeconomic profiles can achieve similar SDG 3 and MDG 4 outcomes by emulating the policies and strategies Bangladesh applied to reducing child mortalities over the last three decades.

Validating midwifery professionals' scope of practice and competency: A multi-country study comparing national data to international standards

BACKGROUND

There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition.

METHODS AND FINDINGS

We compared midwives' scope of practice in Argentina, Ghana, and India to the ILO Tasks and ICM Essential Competencies for Midwifery Practice. We compared midwives self-reported skills/behaviors with the ICM Competencies. Univariate and bivariate analysis was conducted to describe the association between midwives' skills and selected characteristics. National scopes of practice matched two ILO tasks in Argentina, four in India, and all in Ghana. National standards partially reflected ICM skills in Categories 2, 3, and 4 (pre-pregnancy and antenatal care; care during labor and birth; and ongoing care of women and newborns, respectively) in Argentina (range 11% to 67%), mostly in India (range 74% to 100%) and completely in Ghana (100% match). 1,266 midwives surveyed reported considerable variation in competency for skills and behaviors across ICM Category 2, 3, and 4. Most midwives reported matching skills and behaviors around labor and childbirth (Category 2). Higher proportions of midwives reported gaining basic skills through in-service training and on-job-experience than in pre-service training.

CONCLUSION

Estimating the density of midwives needed for an adequate midwifery workforce capable of providing effective population coverage is predicated on a valid numerator. A reliable and valid count of midwives to meet population needs assumes that each midwife counted has the authority to exercise the same behaviors and reflects the ability to perform them with comparable competency. Our results demonstrate variation in midwifery scopes of practice and self-reported competencies in comparison to global standards that pose a threat to the reliability and validity of the numerator in measures of midwife density, and suggest the potential for expanded authorization and improved education and training to meet global reference standards for midwifery practice has not been fully realized. Although the universally recognized standard, this study demonstrates that the complex, composite descriptions of skills and behaviors in the ICM competencies make them difficult to use as benchmark measures with any precision, as they are not defined or structured to serve as valid measures for assessing workforce competency. A simplified, content-validated measurement system is needed to facilitate evaluation of the competency of the midwifery workforce.

Exploring networks of care in implementing midwife-led birthing centres in low- and middle-income countries: A scoping review

The evidence for the benefits of midwifery has grown over the past two decades and midwife-led birthing centres have been established in many countries. Midwife-led care can only make a sustained and large-scale contribution to improved maternal and newborn health outcomes if it is an integral part of the health care system but there are challenges to the establishment and operation of midwife-led birthing centres. A network of care (NOC) is a way of understanding the connections within a catchment area or region to ensure that service provision is effective and efficient. This review aims to evaluate whether a NOC framework-in light of the literature about midwife-led birthing centres-can be used to map the challenges, barriers and enablers with a focus on low-to-middle income countries. We searched nine academic databases and located 40 relevant studies published between January 2012 and February 2022. Information about the enablers and challenges to midwife-led birthing centres was mapped and analysed against a NOC framework. The analysis was based on the four domains of the NOC: 1) agreement and enabling environment, 2) operational standards, 3) quality, efficiency, and responsibility, 4) learning and adaptation, which together are thought to reflect the characteristics of an effective NOC.Of the 40 studies, half (n = 20) were from Brazil and South Africa. The others covered an additional 10 countries. The analysis showed that midwife-led birthing centres can provide high-quality care when the following NOC elements are in place: a positive policy environment, purposeful arrangements which ensure services are responsive to users' needs, an effective referral system to enable collaboration across different levels of health service and a competent workforce committed to a midwifery philosophy of care. Challenges to an effective NOC include lack of supportive policies, leadership, inter-facility and interprofessional collaboration and insufficient financing. The NOC framework can be a useful approach to identify the key areas of collaboration required for effective consultation and referral, to address the specific local needs of women and their families and identify areas for improvement in health services. The NOC framework could be used in the design and implementation of new midwife-led birthing centres.