Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces

Health-care worker retention in post-conflict settings: a systematic literature review

Conflicts affect health-care systems not only during but also well beyond periods of violence and immediate crises by draining resources, destroying infrastructure and perpetrating human resource shortages. Improving health-care worker (HCW) retention is critical to limiting the strain placed on health systems already facing infrastructure and financial challenges. We reviewed the evidence on the retention of HCWs in fragile, conflict-affected and post-conflict settings and evaluated strategies and their likely success in improving retention and reducing attrition. We conducted a systematic review of studies, following PRISMA guidelines. Included studies (1) described a context that is post-conflict, conflict-affected or was transformed by war or a crisis; (2) examined the retention of HCWs; (3) were available in English, Spanish or French and (4) were published between 1 January 2000 and 25 April 2021. We identified 410 articles, of which 25 studies, representing 17 countries, met the inclusion criteria. Most of the studies (22 out of 25) used observational study designs and qualitative methods to conduct research. Three studies were literature reviews. This review observed four main themes: migration intention, return migration, work experiences and conditions of service and deployment policies. Using these themes, we identify a consolidated list of six push and pull factors contributing to HCW attrition in fragile, conflict-affected and post-conflict settings. The findings suggest that adopting policies that focus on improving financial incentives, providing professional development opportunities, establishing flexibility and identifying staff with strong community links may ameliorate workforce attrition.

Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments

INTRODUCTION

Women and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives.

METHODS

A structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020.

RESULTS

In total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning.

CONCLUSION

More efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings.

PROSPERO REGISTRATION NUMBER

CRD42021226323.

Identifying factors affecting dentists retention in deprived areas in Iran

BACKGROUND

One of the concerns of health managers in regard to improving the oral health of residents in deprived areas is to increase the tendency of dentists to stay in those areas. The purpose of this study was to explore factors affecting the intention of dentists to stay in deprived areas.

METHODS

The present qualitative study was carried out using semi-structured interviews. We interviewed 22 informants (4 oral health managers and 18 dentists) who were identified purposefully. Informants were asked what factors affecting retention in remote and deprived areas. Content analysis through the 7-step Colaizzi approach was used for data analysis.

RESULTS

Fifteen subthemes under five themes of individual factors, the development level of the region, social and cultural factors, financial issues, and managerial and organizational factors were identified as factors affecting tendency of dentist to stay and work in deprived areas.

CONCLUSION

According to the results of our study, health policymakers and managers should focus on culture and attitudes of the residents, Provision of financial incentives, structural problems and underdevelopment of the region, and high workload to increase the tendency of dentists to stay in remote and deprived areas.

"The midwife helped me ... otherwise I could have died": women's experience of professional midwifery services in rural Afghanistan - a qualitative study in the provinces Kunar and Laghman

Background

Afghanistan has one of the world’s highest maternal mortality ratios, with more than 60% of women having no access to a skilled birth attendant in some areas. The main challenges for childbearing Afghan women are access to skilled birth attendance, emergency obstetric care and reliable contraception. The NGO-based project Advancing Maternal and Newborn Health in Afghanistan has supported education of midwives since 2002, in accordance with the national plan for midwifery education.

The aim of this study is to explore women’s experiences of professional midwifery care in four villages in Afghanistan covered by the project, so as to reveal challenges and improve services in rural and conflict-affected areas of the country.

Methods

An exploratory case-study approach was adopted. Fourteen in-depth interviews and four focus-group discussions were conducted. A total of 39 women participated – 25 who had given birth during the last six months, 11 mothers-in-law and three community midwives in the provinces of Kunar and Laghman. Data generated by the interviews and observations was analysed using thematic content analysis.

Findings

Many of the women greatly valued the trained midwives’ life-saving experience, skills and care, and the latter were important reasons for choosing to give birth in a clinic. Women further appreciated midwives’ promotion of immediate skin-to-skin contact and breastfeeding. However, some women experienced rudeness, discrimination and negligence on the part of the midwives. Moreover, relatives’ disapproval, shame and problems with transport and security were important obstacles to women giving birth in the clinics.

Conclusions

Local recruitment and professional education of midwives as promoted by Afghan authorities and applied in the project seem successful in promoting utilisation and satisfaction with maternal and neonatal health services in rural Afghanistan. Nevertheless, the quality of the services is still lacking, with some women complaining of disrespectful care. There seems to be a need to focus more on communication issues during the education of midwives. An increased focus on in-service training and factors promoting quality care and respectful communication is necessary and should be prioritised.

Factors associated with midwives' job satisfaction and intention to stay in the profession: An integrative review

AIMS AND OBJECTIVES

To conduct an integrative review of the factors associated with why midwives stay in midwifery.

BACKGROUND

Midwifery retention and attrition are globally acknowledged as an issue. However, little is known as to why midwives stay in midwifery as the focus has previously focussed on why they leave.

DESIGN

A structured six-step integrative review approach was used, and this involved the development of a search strategy, study selection and critical appraisal, data abstraction and synthesis, interpretation of findings and recommendations for future practice.

METHODS

The review was conducted using the databases MEDLINE, CINAHL and PsychInfo. Included studies were in the English language with an unlimited publication date.

RESULTS

Six studies were included in this review: one qualitative, two quantitative and three using mixed methods. Seven themes emerged from synthesisation of the data reported for the six included studies that together help answer the question of why midwives stay in midwifery.

CONCLUSION

This integrative review has highlighted some important factors that assist in answering the question why midwives stay in midwifery. However, it has also highlighted the need for quality data that reflects the range of contexts in which midwifery is practised.

RELEVANCE TO CLINICAL PRACTICE

There is an abundance of literature focussing on why midwives leave the profession; however, the gap exists in the reasons why midwives stay. If we can uncover this important detail, then changes within the profession can begin to be implemented, addressing the shortage of midwives issue that has been seen globally for a large number of years.

Scaling up newborn care in Afghanistan: opportunities and challenges for the health sector

Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation's weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015-20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative.

Current and future availability of and need for human resources for sexual, reproductive, maternal and newborn health in 41 countries in Sub-Saharan Africa

BACKGROUND

The WHO African region, covering the majority of Sub-Saharan Africa, faces the highest rates of maternal and neonatal mortality in the world. This study uses data from the State of the World's Midwifery 2014 survey to cast a spotlight on the WHO African region, highlight the specific characteristics of its sexual, reproductive, maternal and newborn health (SRMNH) workforce and describe and compare countries' different trajectories in terms of meeting the population need for services.

METHODS

Using data from 41 African countries, this study used a mathematical model to estimate potential met need for SRMNH services, defined as "the percentage of a universal SRMNH package that could potentially be obtained by women and newborns given the composition, competencies and available working time of the SRMNH workforce." The model defined the 46 key interventions included in this universal SRMNH package and allocated them to the available health worker time and skill set in each country to estimate the potential met need.

RESULTS

Based on the current and projected potential met need in the future, the countries were grouped into three categories: (1) 'making or maintaining progress' (expected to meet more, or the same level, of the need in the future than currently): 14 countries including Ghana, Senegal and South Africa, (2) 'at risk' (currently performing relatively well but expected to deteriorate due to the health workforce not keeping pace with population growth): 6 countries including Gabon, Rwanda and Zambia, and (3) 'low performing' (not performing well and not expected to improve): 21 countries including Burkina Faso, Eritrea and Sierra Leone.

CONCLUSION

The three groups face different challenges, and policy solutions to increasing met need should be tailored to the specific context of the country. National health workforce accounts should be strengthened so that workforce planning can be evidence-informed.

A Qualitative Inquiry Into the Challenges of Medical Education for Retention of General Practitioners in Rural and Underserved Areas of Iran

OBJECTIVES

General practitioners (GPs) retention in rural and underserved areas highly effects on accessibility of healthcare facilities across the country. Education seems to be a critical factor that affects GPs retention. Thus, the present study aimed at inquiry into medical education challenges that limit their retention in rural and underserved areas.

METHODS

A qualitative approach was applied for the aim of this study. Data were gathered via 28 semi-structured interviews with experts at different levels of Iran's health system as well as GPs who retained and refused to retain working in rural settings. Interviews mainly were performed face-to-face and in some cases via telephone during 2015 and then coded and analyzed using content analysis approach.

RESULTS

Iran's medical education is faced with several challenges that were categorized in four main themes including student selection, medical students' perception about their field of study, education setting and approach, curriculum of medical education. According to experts this challenges could results in making GP graduates disinterested for practicing in rural and underserved areas.

CONCLUSIONS

Challenges that were found could have negative effects on retention. Modification in student's perception about rural practice could be done via changing education setting and approach and curriculum. These modifications could improve GPs retention in rural and underserved areas.

Community midwifery initiatives in fragile and conflict-affected countries: a scoping review of approaches from recruitment to retention

BACKGROUND

Birth assisted by skilled health workers is one of the most effective interventions for reducing maternal and neonatal mortality. Fragile and conflict-affected states and situations (FCAS), with one-third of global maternal deaths, face significant challenges in achieving skilled care at birth, particularly in health workforce development. The importance of community-level midwifery services to improve skilled care is internationally recognized, but the literature on FCAS is limited. This review aimed to examine community midwifery (CMW) approaches, from recruitment to retention, in FCAS.

METHODS

This scoping review design adapted Arksey and O'Malley's six-stage framework. Data collection included systematic searching of seven databases, purposive hand-searching of reference lists and web sites, and stakeholder engagement for additional information. Potential sources were screened against inclusion and exclusion criteria. Included sources were appraised for methodological quality using the McGill University Mixed Methods Appraisal Tool. Data were analysed thematically, using deductive (i.e. cadre definition, recruitment, education, deployment and retention) and inductive coding (i.e. capacity, gender and insecurity).

RESULTS

Twenty-three sources were included, of 2729 identified, discussing community midwifery programmes in six FCAS (i.e. eight for Sudan, six for Afghanistan, three each for Mali and Yemen, two for South Sudan and one for Somalia). Source quality was relatively poor, and cadre definitions were context dependent. Major enablers for effective CMW programmes were community linkages and acceptance, while barriers included inappropriate recruitment, non-standardized education, weak supportive environment, political insecurity and violence.

CONCLUSIONS

While community engagement and acceptance were crucial, CMW programmes were weakened by inappropriate recruitment and training, lack of support and general insecurity. Further research and implementation evidence is needed to aid policy-makers, donors and implementing agencies in developing and implementing effective CMW programmes in FCAS.

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.

Scaling up high-impact interventions: how is it done?

Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale-up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high-impact interventions: the Helping Babies Breathe initiative; pre-service midwifery education in Afghanistan; and advanced distribution of misoprostol for self-administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well-established; the intervention is as simple and cost-effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives.

Job satisfaction and retention of midwives in rural Nigeria

BACKGROUND

Nigeria is one of the 57 countries with a critical shortage of human resources for health, especially in remote rural areas and in northern states. The National Midwifery Service Scheme (MSS) is one approach introduced by the Government of Nigeria to address the health workforce shortage in rural areas. Since 2009, unemployed, retired and newly graduated midwives are deployed to primary health care (PHC) facilities in rural areas of Nigeria. These midwives form the mainstay of the health system at the primary health care level especially as it relates to the provision of skilled attendance at birth. This study followed up and explored the job satisfaction and retention of the MSS midwives in three Northern states of Nigeria.

METHODS

this was a descriptive study. Data were collected using a mixed method approach which included a job satisfaction survey, focus group discussions (FGDs) and exit interviews to explore job satisfaction and retention factors. All 119 MSS midwives deployed by the National Primary Health Care Development Agency between 2010 and 2012 to the 51 Partnership for Reviving Routine Immunisation- Maternal and Child Health (PRRINN-MNCH) programme targeted PHC facilities were included in the study.

RESULTS

MSS midwives were very satisfied with from the feeling of caring for women and children in the community (4.56), with the chance to help and care for others (Mean 4.50), the feeling of worthwhile accomplishment from doing the job (Mean 4.44) and the degree of respect and fair treatment they received from more senior staff and/or supervisor (Mean 4.39). MSS midwives were least satisfied with the lack of existence of a (established) career ladder (Mean 2.5), availability of promotional opportunities within the scheme (Mean 2.66), safety of accommodation (Mean 3.18), and with 'the degree to which they were fairly paid for what they contribute to the health facility' (Mean 3.41). When asked about future career plans, 38% (n=33) of the MSS midwives planned to leave the scheme within two years, of which 16 (18%) wanted to leave within one year. However, 39% of the midwives (n=34) indicated that they would be happy to continue working even after the scheme has ended. Of these 34 participants, 18 would like to continue working in the same facility where they are now whereas the remaining 16 would like to continue working in the north but not in the facility where they are working currently. Eight themes on job satisfaction and retention emerged from the FGDs conducted with current midwives, whereas six themes emerged from the exit interviews from midwives who have left the scheme.

CONCLUSION

the MSS programme is a short-term solution to increase SBA coverage in rural Nigeria. MSS midwives were dissatisfied with the short term contract, lack of career structure, irregular payment, poor working condition, inadequate supervision and poor accommodation being offered by the programme, which all contribute to poor retention of MSS midwives. IMPLICATIONS FOR POLICY AND PRACTICE: midwives׳ job satisfaction and retention are critical to improving the health of mothers and their newborn. Poor job satisfaction and retention therefore requires improvements in financial and non-financial incentives, health systems, supportive supervision, ensuring job security and a career structure for midwives working in rural health facilities. Initiating effective strategies to motivate and increase the retention of rural health workers is important for Nigeria to achieve the Millennium/Sustainable Development Goals.

Human resource management in post-conflict health systems: review of research and knowledge gaps

In post-conflict settings, severe disruption to health systems invariably leaves populations at high risk of disease and in greater need of health provision than more stable resource-poor countries. The health workforce is often a direct victim of conflict. Effective human resource management (HRM) strategies and policies are critical to addressing the systemic effects of conflict on the health workforce such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of human resource data. This paper reviews published literatures across three functional areas of HRM in post-conflict settings: workforce supply, workforce distribution, and workforce performance. We searched published literatures for articles published in English between 2003 and 2013. The search used context-specific keywords (e.g. post-conflict, reconstruction) in combination with topic-related keywords based on an analytical framework containing the three functional areas of HRM (supply, distribution, and performance) and several corresponding HRM topic areas under these. In addition, the framework includes a number of cross-cutting topics such as leadership and governance, finance, and gender. The literature is growing but still limited. Many publications have focused on health workforce supply issues, including pre-service education and training, pay, and recruitment. Less is known about workforce distribution, especially governance and administrative systems for deployment and incentive policies to redress geographical workforce imbalances. Apart from in-service training, workforce performance is particularly under-researched in the areas of performance-based incentives, management and supervision, work organisation and job design, and performance appraisal. Research is largely on HRM in the early post-conflict period and has relied on secondary data. More primary research is needed across the areas of workforce supply, workforce distribution, and workforce performance. However, this should apply a longer-term focus throughout the different post-conflict phases, while paying attention to key cross-cutting themes such as leadership and governance, gender equity, and task shifting. The research gaps identified should enable future studies to examine how HRM could be used to meet both short and long term objectives for rebuilding health workforces and thereby contribute to achieving more equitable and sustainable health systems outcomes after conflict.

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.