Barriers to developing midwifery as a primary health-care strategy: A Jordanian study

Job adjustment predictive factors of healthcare midwives in health system reform in Iran

BACKGROUND

Possessing sensitive and multiple responsibilities in the country's health system, particularly after the implementation of the health reform in Iran, midwives must be able to optimally perform their duties in their new job as healthcare providers. This study aimed to identify the factors that predict job adjustment for Iranian midwives working in healthcare.

METHODS

In this cross-sectional study, 310 midwives were recruited from 209 health centers in the Iranian province of West Azerbaijan using the census method and asked to complete research questionnaires. Data were collected using job adjustment, job satisfaction, and organizational commitment scales. SPSS version 25 was used to perform ANOVA and calculate multiple linear regression coefficients for data analysis. In addition, the AMOS software was employed for path analysis and the identification of predictive variables.

RESULTS

The mean age of the participants was 37.67 ± 7.1 years. Most participants (35.5%) were interested in their occupation as a midwife, and 27.1% were very interest. They had a moderate to strong tendency (76.1%) to remain in their new profession. In addition, 58.1% of participants experienced moderate job adjustment. For healthcare midwives, "desire to remain in the midwifery profession" and "organizational commitment" were significant predictors of job adjustment. "Desire to remain in the midwifery profession" directly affected midwives' job adjustment, while "interest in the new profession" had an indirect effect. Furthermore, "adequacy of income to expenses," "job satisfaction," and "organizational commitment" through the mediating role of "desire to remain in the profession" can, directly and indirectly, influence their job adjustment.

CONCLUSION

To better prepare midwives for their role as healthcare providers, organizational managers should focus their efforts and plan primarily on providing incentives to increase the longevity of staying in the profession of midwifery increase job adjustment, job satisfaction, and organizational commitment, thereby improving the quality-of-service delivery.

How midwives' perceptions of work empowerment have changed over time: A Swedish comparative study

OBJECTIVE

The aim of this paper was to compare current perceptions of empowerment in their work with results from a sample of midwives recruited 2012.

DESIGN

A comparative cross-sectional cohort study of national samples of midwives in Sweden from 2012 to 2022.

PARTICIPANTS

475 midwives recruited from the Swedish midwifery association in 2012 and 1782 through two midwifery unions in 2022.

METHODS

Data were collected using a questionnaire with background information and the revised version of the Perception of Empowerment Scale (PEMS). Mean scores and domains of the PEMS were compared between the years.

FINDINGS

Midwives' perceptions of empowerment changed over time, in both directions. Their perception of their skills and education, advocating for and empowering women as well as support from the team and manager increased over the years. Midwives in 2022 were less likely to perceive that they were involved in a midwifery-led practice, and the communication with managers was rated lower. Midwives sensed a lack of professional recognition from the medical profession and their contribution to the care of birthing women. Access to resources for birthing women was perceived lower in 2022 compared to 2012. Younger age, shorter work experience and working in labour wards or postnatal wards were associated with lower perceptions of empowerment.

CONCLUSIONS

Midwives need to have the authority and reality to practice midwife-led care, to receive control over their work. Good communication and recognition from the medical profession is essential to be empowered. This is important in order to maintain a healthy workforce.

Depression, anxiety, and stress symptoms among Jordanian midwives: A hospital-based study

OBJECTIVE

To investigate the prevalence of depression, anxiety, and stress symptoms in Jordanian midwives and identify associated factors.

DESIGN

Setting and participants: This descriptive, cross-sectional study was conducted with a sample of 321 registered midwives from 18 public hospitals in Jordan that provide antepartum, intrapartum, postpartum care, and family planning services. The survey included the Depression, Anxiety, and Stress Scale (DASS-21) and demographic and professional data forms.

FINDINGS

High rates of depression (76.2%); anxiety (85.3%) and stress (66.8%) symptoms were reported among midwives in Jordan. Midwives aged between 22 - 30 years reported more depression, anxiety, and stress symptoms than midwives in the other age groups. Married midwives had higher depression symptoms than single midwives. Midwives with < 10 years in practice had higher depression, anxiety, and stress symptoms compared to midwives with ≥ 10 years in practice. Midwives providing care for > 10 women per shift had higher anxiety and stress symptoms than midwives caring for five or less women per shift. Midwives who rotated between shifts had higher depression and stress symptoms than midwives who did not rotate.

CONCLUSIONS

Rates of depression, anxiety, and stress symptoms reported by Jordanian midwives were higher than rates reported by midwives in other countries. The high rates of distress highlight the urgent need for national strategies to support the emotional wellbeing and retention of midwives within Jordanian settings.

A systematic integrative literature review of the factors influencing the professionalization of midwifery in the last decade (2009-2019)

BACKGROUND

The professionalization of midwifery is not only important for midwives themselves, but for women and society in general since professionalism is associated with high-quality services and moral and ethical standards.

AIM

This systematic integrative literature review seeks to investigate the factors that have affected the professionalization of midwifery in the last decade (2009-2019).

METHODS

Systematic searches were conducted in EBSCO, PubMed, ScienceDirect, SAGE and the Web of Science Core Collection. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). The findings were synthesised through a thematic analysis. The PRISMA statement was used to guide the reporting.

FINDINGS

Analysis of the 20 studies included detected two main themes: professionalization barriers and professionalization opportunities. The first theme includes issues concerning power imbalance, social recognition, conflicting perspectives on childbirth, professional autonomy, work characteristics, midwifery associations, and regulation. The second theme includes opportunity issues related to woman-centred care, expansion of professional competency, interprofessional collaboration, and education.

KEY CONCLUSIONS

Over the last decade, the midwifery profession has faced several barriers that seem to be historically entrenched in the professionalization of midwifery, yet changes in the professionalization process are visible in the shift towards elements of the 'new professionalism' that is rising to the surface during this process.

IMPLICATIONS FOR PRACTICE

The findings suggest the socialisation process of midwifery candidates must focus on raising their self-awareness, self-esteem and confidence in their professional role; woman-centred care needs to be further promoted and implemented; and interprofessional collaboration should be addressed in educational programmes for all health professionals.

Midwifery in Middle Eastern and North African countries: A scoping review

BACKGROUND

While midwives are positioned as critical providers for improving sexual, reproductive, maternal and newborn health outcomes in the Middle East and North African (MENA) countries, the standards of midwifery have not been explored systematically in this region.

AIM

The purpose of this scoping review was to provide an overview of existing literature on midwifery practice, education, and regulation in MENA countries in the context of ICM standards.

METHODS

A search was conducted inclusive of English and Persian written studies published between 2000 and 2019 in CINAHL plus; Ovid MEDLINE; PubMed; Scopus; and grey literature. Title and abstract and full-text review were performed in Covidence, and data extraction and synthesis performed using NVivo 12.

RESULTS

The initial search identified 7,994 articles. Overall, 139 studies were included in the review. Although, the primary concept of most included studies was "midwifery practice", "midwifery regulation" was addressed in limited way. Approximately 90% were from Middle Eastern countries. Forty-two per cent of studies used cross-sectional designs, and most originated from Iran, Jordan, and Palestine. Diversity was found in midwifery education, practice and regulation across the MENA countries. Midwives from different nations had uneven levels of proficiency, scope of practice, and education. Midwifery curricula were aligned with ICM competencies in some countries. Most countries had midwifery associations and were members of ICM. Some countries had regulations recognising midwifery as an autonomous profession.

CONCLUSION

Midwifery practice, education and regulation in MENA countries were not always comparable with ICM standards, although some progress was evident.

From hopelessness to some hope: A qualitative interpretive research project to improve birthing experiences in Jordan

BACKGROUND

Many women living in Middle Eastern countries report negative, dehumanising experiences of childbirth. Finding effective ways of changing maternity care to improve women's experience is needed but is challenging.

AIM

This paper explores the potential strategies to improve birthing experiences of women in Jordan and identifies the facilitators and obstacles to change.

METHOD

A qualitative interpretive research design underpinned by a feminist approach was used. Seventeen community women, 14 midwives and midwifery leaders were engaged in workshops and face-to-face semi-structured interviews. Data were transcribed verbatim and thematic analysis undertaken.

RESULTS

An overarching theme "From hopelessness to some hope" emerged from data analysis and comprised of two themes: 'It's hopeless-there are so many obstacles'; and 'Finding some hope for the way forward'. The community women were unhappy with the current maternity services but accepted the situation. Midwives offered explanations for the way women are treated, including that women have no voice. For these participants, the obstacles seemed almost insurmountable; however, there was some hope expressed about potential for small changes to occur.

CONCLUSIONS

This study highlights the value of women and midwives sharing experiences and listening to the stories of women. Listening to women's birth stories may also be an important element of undergraduate and continuing education in Jordan. Small changes, such as promoting women's dignity by ensuring they are covered during birth are possible, but real change needs to be generated at a professional and societal level.

Teaching Midwifery Module to Male Undergraduate Nursing Students: Case Report in Jordan

This case report presented our experience of teaching male student nurses a midwifery course. The aim was to present the teaching experience of midwifery module to male undergraduate nursing students at the School of Nursing at The Hashemite University. In teaching a midwifery course, an educational approach has been adopted, focusing on a more holistic perspective of the problem in its own contextual nursing environment. Using Problem Based Learning (PBL) as a model of education instead of the traditional way of teaching played a major role in overcoming the challenges of involving male students in midwifery module education in Jordanian conservative culture.

Job satisfaction, work environment and intent to stay of Jordanian midwives

AIM

The aims of this study were to (1) assess the levels of Jordanian midwives' job satisfaction, intention to stay and work environment; (2) examine the relationship between work environment and intention to stay, and the level of job satisfaction among midwives working in Jordanian hospitals and maternal and child health centres and (3) to investigate the associations between job satisfaction and selected demographic variables among Jordanian midwives.

BACKGROUND

The shortage, turnover and retention of midwives are global problems and Jordan is one of the countries thathas a shortage of midwifery workforce. Job satisfaction is well studied among nurses worldwide; however, there are inadequate studies that have assessed the job satisfaction among midwives including Jordan.

METHODS

A descriptive, correlational design survey was used and a sample of 413 midwives were recruited from 14 different hospital settings (12 governmental and 2 teaching hospitals) and 8 health centres.

RESULTS

The levels of job satisfaction of Jordanian midwives were neither satisfied nor unsatisfied. The overall mean intent to stay at work was between neutral to agree in general. A positive significant correlation was found between job satisfaction, work environment and intent to stay. The work environment was neither a favourable nor an unfavourable. CONCLUSION AND IMPLICATIONS FOR NURSING, HEALTH AND EDUCATION POLICY: Jordanian midwives have neutral job satisfaction and work environment. Managerial plans and interventions are needed to improve midwives' job satisfaction and to create a favourable work environment which might reflect positively on their work and performance and improve their retention. Policymakers and mangers should enhance midwives' job satisfaction through external reward via salary, vacation and benefits packages. Engaging in research activities, publication and more collaboration with academic staff may improve midwives' professional development. Midwives should take more active roles in hospital affairs and receive more support by their management in Jordan.

Personal, professional and workplace factors associated with burnout in Jordanian midwives: A national study

OBJECTIVE

To investigate the prevalence of burnout and explore associated socio-demographic and work-related factors among Jordanian midwives.

DESIGN

A cross-sectional survey design. The survey tool included the Copenhagen Burnout Inventory (CBI) and socio-demographic and work-related data forms.

SETTING

All government-funded hospitals in Jordan (18 hospitals) that provide antenatal, labour and birth, or postnatal care for women.

PARTICIPANTS

A sample of 321 midwives participated.

DATA ANALYSIS

Frequencies, means, and standard deviations were calculated as appropriate on the demographic variables and scale scores. The CBI was assessed for internal consistency using Cronbach's alpha. Multiple regression analyses using backward elimination were undertaken to determine associations between variables and CBI subscales. An alpha level of 0.05 was used for all statistical tests.

FINDINGS

Over three-quarters of midwives reported personal (78.1%), work-related (82.2%), and client-related (71.3%) burnout (scored >50 on CBI). Compared to midwives aged between 21 - 30 years, those between 31 - 40 years of age scored on average a 11.75 (95% CI = 7.05 - 16.45) points lower personal burnout score. Married midwives had on average a 6.44 (95% CI = 1.57 - 11.31) points higher personal burnout score compared to single midwives. Midwives with ≥ 10 years' experience had on average a 4.29 (95% CI = 1.93 - 6.64), 5.27 (95% CI = 3.17 - 7.36), and 7.31 (95% CI = 4.84 - 9.78) points lower personal, work-related, and client-related burnout scores respectively compared to midwives with < 10 years' experience.Compared to midwives providing care for 1 - 5 women per shift, those providing care for > 10 women per shift reported 9.98 (95% CI = 6.06 - 13.90) and 5.35 (95% CI = 0.71 - 9.99) points higher work-related and client-related burnout scores respectively. Midwives who rotated between shifts had on average a 5.87 (95% CI = 1.27 - 10.48) and 11.2 (95% CI = 5.78 - 16.66) points higher work-related and client-related burnout scores respectively than those who did not rotate.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The high prevalence of burnout identifies the urgent need for a national plan to address midwives' psychological health in Jordan. Midwives should be appropriately trained to recognize the signs and symptoms of burnout in a timely way, and for support services to be offered. The government could consider implementing continuity of midwifery care models, reducing the administrative burden on midwives, and empowering them to work to their full scope of practice.

"Resumption of Sexuality and Health Education in Postpartum Period: From Jordanian Health Care Professionals' Perspectives"

Objective: to explore Jordanian health care professionals' perspectives about sexual education after giving birth. Methods: a descriptive qualitative approach was used to address the study aim. A purposive sampling method was used to recruit seven midwives, 13 nurses and two obstetricians from three Primary Health Centres. The inclusion criteria were: midwives, nurses or obstetricians with at least two years' experience and currently working at a maternity health centre. Focus group discussions were used to collect data. A manual Thematic Content Analysis Tool was used to analyse the data. Results: five major themes emerged. Silence; resumption of sexuality after giving birth/area of conflict; men's authority in resumption of sexuality; the importance of sexual education (what, when and whom) and suggestions for sexual education approaches. Conclusions: Healthcare professionals were hesitant to open sexuality topic with the women during antenatal and postnatal visits due to cultural limitations and lack of knowledge. Therefore, in a time of global migration, the healthcare professionals have the need to understand cultural differences in attitude towards health care issues involving sexuality.

Exploring woman -Nurse interaction in a Jordanian antenatal clinic: A qualitative study

BACKGROUND

Effective woman-nurse interaction is critical in providing quality nursing care and would improve the health outcomes and the level of women's satisfaction with health and nursing services.

AIM

To explore how Jordanian nurses and pregnant women perceive their interaction during antenatal visits.

METHODS

A descriptive qualitative study was conducted using a purposive sample of twelve pregnant women and twelve nurses. Data were collected through four focus group discussions organized at an antenatal clinic of a large hospital in Jordan. The data were analyzed using Giorgi's four stages of data analysis.

FINDINGS

Approaches to interaction; barriers to interaction; quality of interaction were the main themes emerged from the data. Nurses and pregnant women also provided suggestions for strengthening the womannurse interaction during antenatal visits.

CONCLUSION

The different aspects of interaction described by the participants of this study may raise awareness and appreciation of the important roles health care providers can play in promoting the health outcomes of pregnant women when effective interaction is built and strengthened. Relevant policies and guidelines on improving appointment systems, and continuing education on communication skills and health education would be needed. More attention is required to adopt appropriate antenatal clinical guidelines and protocols to meet women's needs in Jordan.

The role and scope of practice of midwives in humanitarian settings: a systematic review and content analysis

BACKGROUND

Midwives have an essential role to play in preparing for and providing sexual and reproductive health (SRH) services in humanitarian settings due to their unique knowledge and skills, position as frontline providers and geographic and social proximity to the communities they serve. There are considerable gaps in the international guidance that defines the scope of practice of midwives in crises, particularly for the mitigation and preparedness, and recovery phases. We undertook a systematic review to provide further clarification of this scope of practice and insights to optimise midwifery performance. The review aimed to determine what SRH services midwives are involved in delivering across the emergency management cycle in humanitarian contexts, and how they are working with other professionals to deliver health care.

METHODS

Four electronic databases and the websites of 33 organisations were searched between January and March 2017. Papers were eligible for inclusion if they were published in English between 2007 and 2017 and reported primary research pertaining to the role of midwives in delivering and performing any component of sexual and/or reproductive health in humanitarian settings. Content analysis was used to map the study findings to the Minimum Initial Service Package (MISP) for SRH across the three phases of the disaster management cycle and identify how midwives work with other members of the health care team.

RESULTS

Fourteen studies from ten countries were included. Twelve studies were undertaken in conflict settings, and two were conducted in the context of the aftermath of natural disasters. We found a paucity of evidence from the research literature that examines the activities and roles undertaken by midwives across the disaster management cycle. This lack of evidence was more apparent during the mitigation and preparedness, and recovery phases than the response phase of the disaster management cycle.

CONCLUSION

Research-informed guidelines and strategies are required to better align the scope of practice of midwives with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP, to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle.

Challenges to midwives' scope of practice in providing women's birthing care in an Australian hospital setting: A grounded theory study

OBJECTIVE

To identify and explore processes midwives use to exercise their scope of practice whilst caring for women during normal birth.

METHODS

Strauss and Corbin's (1998) grounded theory approach was used. Data were collected from 17 midwife participants using participant observation of women's labour and birth care followed by semi-structured interviews.

RESULTS

The core category of promoting normal birthing: aspiring to develop a midwife-led scope of practice conceptualises midwives working to develop their scope of practice to promote and facilitate normal birthing for women. Two interrelated categories, promoting and maintaining healthy birthing and optimising scope of practice further explicate how midwives provide woman-centred care within their scope of practice.

CONCLUSIONS

The theoretical framework generates conceptual knowledge of how midwives aspire to promote healthy, safe and responsive birthing care for women in their scope of practice in a hospital setting. Findings provide greater insights into the competing perspectives of birthing care challenging midwives' capacity to provide woman-centred care, influencing the degree to which midwives are able to exercise their scope of practice in promoting normal birth.

Effect of midwife-led care on birth outcomes of primiparas

BACKGROUND

The high caesarean section rate is a prominent public health problem in China.

AIM

This study aimed to determine the effects of midwife-led care during labour on birth outcomes for healthy primiparas.

DESIGN

Randomized controlled trial.

SETTING

The Obstetrics Department of Fujian Provincial Maternity and Child Health Hospital.

METHODS

A total of 666 primiparas in labour were randomly divided into an intervention and control group (333 in each group). The intervention group received a midwife-led model of care during labour.

RESULTS

Data from 648 cases (331 intervention group and 317 control group) were analysed. The intervention group was less likely to experience caesarean section, postpartum haemorrhage, opiate analgesia, vaginal examinations, neonatal asphyxia, and neonatal hospitalization and was more likely to experience shorter length of labour and vaginal birth than the control group (all, P < 0.05). No differences were found in the number of artificial rupture of membranes and oxytocin use (P > 0.05).

CONCLUSIONS

Midwife-led care can reduce the caesarean section rate, promote normal birth, improve birth outcomes, and promote maternal and child health.

[Construction of a common vision of nurses and midwives training in Democratic Republic of the Congo.]

OBJECTIVE

To present the activities that facilitate the development of a public policy by public health and higher and university education ministry stakeholders - based on a common vision of nurses and midwives training in Democratic Republic of the Congo (DRC).

METHODS

An operational research using different methods applied by experts called ?policy brokers? according to a framework covering the advocacy mechanisms (Advocacy Coalition Framework) designed to promote the development of a public policy. The population comprised 2 types of common interest groups (coalitions), derived from 3 systems (sociocultural-legal, educational, professional), involved in the choice of the ?secondary AND higher? or ?secondary OR higher? training profile for the concerned professionals. The methods comprised: workshops (discussion, training, restitution, validation, negotiation, scientific, reflection group meetings), training activities (programme development, training of nursing and midwives trainers-supervisors) and a variety of media coverage and marketing activities.

RESULTS

The nurses and midwives profiles required in the DRC have been established. The levels required for their training have been validated and defined by a common vision of the two ministries concerned. A formal consultation framework was set up to launch the required reform for the review of these two professional's profiles.

CONCLUSION

The public policy experts' activities based on the advocacy framework are complex, lengthy and time-consuming. In DRC, a Ministerial decree is currently being finalized to address the creation of a formal consultation framework concerning the training and utilisation of human health resources.

Assessment of Barriers for Midwives to Achieve Professional Management Positions from Midwives' Point of View

BACKGROUND

Despite the effects of midwives on the health of family and community through promotion of maternal and child health indicators, they are not in the position of professional decision making. Therefore, this study was aimed to determine the barriers to achieve professional management positions by midwives.

MATERIALS AND METHODS

This study was a descriptive and cross-sectional study. The members of board commission of midwifery and reproductive health, the academic members of midwifery department and midwives working at the adjutancy of health and treatment were selected from eight Iranian universities of medical sciences. Data was collected through demographic characteristics questionnaire, a researcher-made questionnaire about administrative barriers, and management skills. Validity and reliability of this tool was confirmed through content validity and Cronbach's alpha coefficient, and the results were analyzed using inferential statistics (analysis of variance and Kruskal-Wallis test).

RESULTS

The results of this study showed that the barriers for midwives to achieve professional management positions in order of preference were organizational barriers (71.4%), cultural barriers (42.4%), and individual barriers (30.8%).

CONCLUSIONS

Based on the findings of this research, organizational barriers are the most important obstacle to achieve professional management positions. Therefore, the role of the authorities is emphasized to eliminate organizational barriers and provide more resources to reduce this problem.

Midwifery empowerment: National surveys of midwives from Australia, New Zealand and Sweden

BACKGROUND

the predicted midwifery workforce shortages in several countries have serious implications for the care of women during pregnancy, birth and post partum. There are a number of factors known to contribute to midwifery shortages and work attrition. However, midwives assessment of their own professional identity and role (sense of empowerment) are perhaps among the most important. There are few international workforce comparisons.

AIM

to compare midwives' sense of empowerment across Australia, New Zealand and Sweden using the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised).

METHOD

a self-administered survey package was distributed to midwives through professional colleges and networks in each country. The surveys asked about personal, professional and employment details and included the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). Descriptive statistics for the sample and PEMS were generated separately for the three countries. A series of analysis of variance with posthoc tests (Tukey's HSD) were conducted to compare scale scores across countries. Effect size statistics (partial eta squared) were also calculated.

RESULTS

completed surveys were received from 2585 midwives (Australia 1037; New Zealand 1073 and Sweden 475). Respondents were predominantly female (98%), aged 50-59 years and had significant work experience as a midwife (+20 years). Statistically significant differences were recorded comparing scores on all four PEMS subscales across countries. Moderate effects were found on Professional Recognition, Skills and Resources and Autonomy/Empowerment comparisons. All pairwise comparisons between countries reached statistical significance (p<.001) except between Australia and New Zealand on the Manager Support subscale. Sweden recorded the highest score on three subscales except Skills and Resources which was the lowest score of the three countries. New Zealand midwives scored significantly better than both their Swedish and Australian counterparts in terms of these essential criteria.

DISCUSSION/CONCLUSIONS

midwives in New Zealand and Sweden had a strong professional identity or sense of empowerment compared to their Australian counterparts. This is likely the result of working in more autonomous ways within a health system that is primary health care focused and a culture that constructs childbirth as a normal but significant life event. If midwifery is to reach its full potential globally then developing midwives sense of autonomy and subsequently their empowerment must be seen as a critical element to recruitment and retention that requires attention and strengthening.

What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective

BACKGROUND

Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider's perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care.

METHODS AND FINDINGS

A systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care.

CONCLUSIONS

Significant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

Midwives’ Experiences, Education, and Support Needs Regarding Basic Newborn Resuscitation in Jordan

Newborns who are compromised at birth require rapid attention to stabilize their respiration attempts. Lack of knowledge regarding basic newborn resuscitation is a contributing factor to poor newborn health outcomes and increased mortality. The purpose of this study was to explore Jordanian midwives’ experiences, education, and support needs to competently perform basic newborn resuscitation. Qualitative descriptive methodology was used to analyze a convenience sample of 20 midwives. A thematic approach was used to analyze the data. Participants discussed their experiences of basic newborn resuscitation including knowledge, skills, and barriers and suggested solutions to improve practice. Four themes were revealed: lack of knowledge and skills in newborn resuscitation, organizational constraints, inadequate teamwork, and educational needs. The midwives perceived that their ability to perform newborn resuscitation was hindered by lack of knowledge and skills in newborn resuscitation, organizational constraints (such as lack of equipment), and poor co-ordination and communication among team members.

A case study evaluation of an intervention aiming to strengthen the midwifery professional role in Morocco: anticipated barriers to reaching outcomes

BACKGROUND

In order to reduce the high maternal mortality ratio, Morocco is strongly committed to strengthen its midwifery professional role. This study aimed to identify barriers that could potentially hinder an action plan to strengthen the midwifery professional role from achieving desired outcomes. We used a conceptual framework, which is derived from Hatem-Asmar's (1997) framework on the interaction of educational, professional, and sociocultural systems in which a professional role evolves and from Damschroder et al's (2009) framework for the implementation analysis.

METHODS

This paper builds on a qualitative case study on the factors affecting the action plan's implementation process that also revealed rich data about anticipated barriers to reaching outcomes. Data were collected through training sessions, field observations, documents, focus groups (n=20), and semistructured interviews (n=11) with stakeholders pertaining to the three systems under study. Content analysis was used to identify themes related to barriers.

RESULTS

Seven barriers that may compromise the achievement of desired results were found. They relate to the legal framework, social representations, and media support in the sociocultural system and the practice environment, networks and communication mechanisms, and characteristics related to the role and the readiness in the professional system.

CONCLUSION

Disregarding sociocultural and professional system level, barriers may impede efforts to strengthen the midwife's role and to provide qualified midwives who can improve the quality of maternal care. Making changes in the educational system cannot be thought of as an isolated process. Its success is closely tied with multiple contextual factors pertaining to the two other systems. Activities recommended to address these barriers may have great potential to build a competent midwifery workforce that contributes to positive maternal and neonatal health outcomes.

Quality of care in primary health care settings in the Eastern Mediterranean region: a systematic review of the literature

PURPOSE

This systematic review aims at offering a comprehensive synthesis of studies addressing quality of care in the primary healthcare (PHC) sector of the Eastern Mediterranean Region (EMR).

DATA SOURCES

A systematic search was conducted using Medline, Embase and Global Health Library (IMEMR) electronic databases to identify studies related to quality in PHC between years 2000 and 2012.

STUDY SELECTION/DATA EXTRACTION

One hundred and fifty-nine (159) studies fulfilled the eligibility criteria. Each paper was independently reviewed by two reviewers, and the following information was extracted/calculated: dimension of care investigated (structure, processes and outcomes), focus, disease groups, study design, sample size, unit of analysis, response rate, country, setting (public or private) and level of rigor (LOR) score.

RESULTS OF DATA SYNTHESIS

Most of the studies were descriptive/cross-sectional in nature with a relatively modest LOR score. Assessment of quality of care revealed that the process dimension of quality, specifically clinical practice and patient-provider relationship, is an area of major concern. However, interventions targeting enhanced quality in PHC in the EMR countries had favorable and effective outcomes in terms of clinical practice.

CONCLUSION

These findings highlight gaps in evidence on quality in PHC in the EMR; such evidence is key for decision-making. Researchers and policy-makers should address these gaps to generate contextualized information and knowledge that ensures relevance and targeted high-impact interventions.

Improvement of maternal and newborn health through midwifery

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

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

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Development and Validation of Women's Satisfaction With Hospital-Based Intrapartum Care Scale in Jordan

BACKGROUND

Measuring satisfaction with care during labor is an important way to improve maternity services for women. This study was undertaken to develop an instrument to measure women's satisfaction with intrapartum hospital-based care.

METHOD

A multidimensional instrument was initially developed, using three core aspects identified from the literature. An expert panel was convened to further modify the instrument. Finally, a total of 300 low-risk women who gave birth in the past 2 months were asked to complete the instrument to assess validity and reliability.

FINDINGS

The 14-item instrument was found to have content and construct validity as well as a high level of reliability (α = .88).

CONCLUSIONS

This new instrument is a valid and reliable measure of satisfaction with intrapartum care in a Jordanian setting. The instrument can provide valuable information on the quality of services and on future planning for maternity services.

A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

OBJECTIVE

to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

DESIGN

systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

SETTING

midwifery services in any setting in low-, middle-, and high-income countries.

PARTICIPANTS

midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

INTERVENTIONS

task shifting to and from midwives.

FINDINGS

thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

KEY CONCLUSIONS

this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

IMPLICATIONS FOR PRACTICE

evidence from the review fed into the World Health Organisation's 'Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting' guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.