Experiences of a new cadre of midwives in Bangladesh: findings from a mixed method study

Midwifery education in Bangladesh: An in-depth analysis through a systematic review

BACKGROUND

While midwifery education in Bangladesh has expanded since its establishment in 2013, there is little information available about the quality of education. The aim of this project was to analyse the literature related to midwifery education in Bangladesh in reference to the Global Standards for Midwifery Education.

METHODS

A systematic review was conducted using PubMed, CINAHL, Web of Science and Scopus databases. A search using keywords was conducted in January 2024. Abstracts were screened against inclusion and exclusion criteria. Data was assessed using the Mixed Methods Appraisal Tool and grouped into the Global Standards for Midwifery Education for analytical purposes.

RESULTS

A total of 14 articles met the inclusion criteria and were included in the study. There was a combination of quantitative (n = 1), qualitative (n = 8) and mixed method studies (n = 5). Key themes included a lack of professional recognition, limited learning and economic resources and sociocultural barriers for students. The implementation of an accreditation tool, upskilling of educators and an improved comprehensive curriculum were found to have positive impacts. This review highlights the progress in midwifery education in Bangladesh in the last decade as there is advancement towards enhancing educator knowledge and programme quality assessment. Some challenges remain such as the limited autonomy and professional acknowledgement, inadequate educational resources, poor financial support, as well as social and cultural barriers.

CONCLUSION

Interventions designed to address these issues are needed to enhance midwifery education in Bangladesh, with a long-term view of contributing to improvements in maternal and neonatal health.

Strengthening midwifery in the South-East Asian region: A scoping review of midwifery-related research

Improving sexual, reproductive, maternal, newborn, and adolescent health outcomes necessitates greater commitment to, and investments in, midwifery. To identify future research priorities to advance and strengthen midwifery, we conducted a scoping review to synthesise and report areas of midwifery that have been explored in the previous 10 years in the 11 countries of the World Health Organization's South-East Asia region. Electronic peer-reviewed databases were searched for primary peer-reviewed research published in any language, published between January 2012 and December 2022 inclusive. A total of 7086 citations were screened against the review inclusion criteria. After screening and full text review, 195 sources were included. There were 94 quantitative (48.2%), 67 qualitative (34.4%) and 31 mixed methods (15.9%) studies. The majority were from Indonesia (n = 93, 47.7%), India (n = 41, 21.0%) and Bangladesh (n = 26, 13.3%). There were no sources identified from the Democratic People's Republic of Korea or the Maldives. We mapped the findings against six priority areas adapted from the 2021 State of the World's Midwifery Report and Regional Strategic Directions for Strengthening Midwifery in the South-East Asia region (2020-2024): practice or service delivery (n = 73, 37.4%), pre-service education (n = 60, 30.8%), in-service education or continuing professional development (n = 51, 26.2%), workforce management (n = 46, 23.6%), governance and regulation (n = 21, 10.8%) and leadership (n = 12, 6.2%). Most were published by authors with affiliations from the country where the research was conducted. The volume of published midwifery research reflects country-specific investment in developing a midwifery workforce, and the transition to midwifery-led care. There was variation between countries in how midwife was defined, education pathways, professional regulation, education accreditation, governance models and scope of practice. Further evaluation of the return on investment in midwifery education, regulation, deployment and retention to support strategic decision-making is recommended. Key elements of leadership requiring further exploration included career pathways, education and development needs and regulatory frameworks to support and embed effective midwifery leadership at all levels of health service governance.

An analysis of the global diversity of midwifery pre-service education pathways

BACKGROUND

The development of competent professional midwives is a pre-requisite for improving access to skilled attendance at birth and reducing maternal and neonatal mortality. Despite an understanding of the skills and competencies needed to provide high- quality care to women during pregnancy, birth and the post-natal period, there is a marked lack of conformity and standardisation in the approach between countries to the pre-service education of midwives. This paper describes the diversity of pre-service education pathways, qualifications, duration of education programmes and public and private sector provision globally, both within and between country income groups.

METHODS

We present data from 107 countries based on survey responses from an International Confederation of Midwives (ICM) member association survey conducted in 2020, which included questions on direct entry and post-nursing midwifery education programmes.

FINDINGS

Our findings confirm that there is complexity in midwifery education in many countries, which is concentrated in low -and middle-income countries (LMICS). On average, LMICs have a greater number of education pathways and shorter duration of education programmes. They are less likely to attain the ICM-recommended minimum duration of 36 months for direct entry. Low- and lower-middle income countries also rely more heavily on the private sector for provision of midwifery education.

CONCLUSION

More evidence is needed on the most effective midwifery education programmes in order to enable countries to focus resources where they can be best utilised. A greater understanding is needed of the impact of diversity of education programmes on health systems and the midwifery workforce.

Responding to Humanitarian Crises: Midwifery Care in Bangladesh

Sexual and reproductive health and rights (SRHR) is often a neglected topic of intervention in humanitarian crises despite its wide-ranging impact on women and girls' well-being. Increasing frequency of climate-induced natural disasters calls for an urgent need to identify innovative practices for sustainable and effective humanitarian preparedness and response to ensure SRHR of affected populations. One such innovation is the empowerment of midwives in disaster response program planning and implementation. This article describes how midwives deployed to rural primary health centers provided quality SRHR services, particularly for labor and birth assistance and initial management of perinatal emergencies and referral in the aftermath of the 2022 flooding in northern and northeastern Bangladesh. Supportive supervision from physicians, adequate health care logistics and supplies, and administrative support from local health authorities created an enabling environment for the midwives. Community engagement through volunteers helped build rapport with residents and allowed patients to navigate health services. Deploying midwives as a response to climate-induced natural disaster was successful in establishing quality SRHR services. Future recommendations include systematically deploying midwives in health centers closest to the communities in locations vulnerable to climate change as part of routine health service delivery. This innovative approach clearly demonstrated that utilization of midwives during and after natural disasters could build community and health system resilience to climate change.

The commitment to a midwifery centre care model in Bangladesh: An interview study with midwives, educators and students

BACKGROUND

Midwifery-led care is a key factor in reducing maternal and new-born mortality globally. In Bangladesh, only a third of births are attended by professionals and almost 70% of births occur outside healthcare facilities. Midwifery is a relatively new profession in Bangladesh and a midwifery centre care model has only recently been introduced. This study aims to explore the willingness within the healthcare system to support a greater role for midwifery centres in maternity services.

METHODS

Data were collected through individual semi-structured interviews with 55 midwives, midwifery educators and final year midwifery students. Two of the midwifery educators were principals of nursing institutes involved in the government's midwifery leadership and considered as experts in the midwifery care system. The data was analysed using qualitative content analysis. The transcribed interviews comprised 150 pages. The study received ethical approval from the Directorate General of Nursing and Midwifery in Bangladesh.

RESULTS

One main category emerged from the study: "The foundations of a midwifery centre care model need to be strengthened for the sustainable implementation of midwifery centres in Bangladesh to continue". Five additional categories were identified: 1) The midwifery centre care model is inaccessible for communities, 2) Striving for acceptable standards of care within a midwifery centre care model is not a priority 3) Respectful, woman-centred care is weak, 4) Community engagement with the midwifery centre care model is insufficient, and 5) The midwifery centre care model is not integrated into the healthcare system. These categories were supported by the identification of 11 sub-categories.

CONCLUSION

The willingness to commit to a midwifery centre care model is not yet in place in Bangladesh. Advocacy, information, and education about the benefits of normal birth assisted by professional midwives is needed at all levels of Bangladeshi society.

Improving the Quality of Maternity Care through the Introduction of Professional Midwives and Mentoring in Selected Sub-District Hospitals in Bangladesh: A Mixed Method Study Protocol

Introduction: Bangladesh introduced professional midwives in 2018 to address gaps in sexual and reproductive health services, focusing on improved maternity care. Facility mentoring has been introduced in selected facilities within the government to enable midwives as they move into their new roles. Objectives: To describe a protocol (1) to determine if introducing international standard midwives in rural sub-district hospitals in Bangladesh, both with and without facility mentoring, improve the availability and quality of maternal and newborn health care compared to the facility without midwives; and (2) to explore the experiences of the midwives, and the maternity staff and managers that they joined, following their introduction. Methods: This will be a mixed-methods study to examine differences between selected hospitals grouped into three categories: without midwives (only nurses), with midwives, and both with midwives and mentorship. Hospital selection will be based on choosing those with the highest birth caseload. The quantitative component will consist of facility observations and clinical data extraction to assess their (hospital and midwives) readiness (birth preparedness and complication readiness) and clinical care to explore whether facilities with newly introduced midwives have improved availability and quality of care. We will use facility assessment tools to extract clinical data. In addition, we will use a structured open-ended interview guideline to conduct focus groups and in-depth interviews to understand the perceptions, attitudes, and experiences among maternity staff (e.g., nurses and paramedics) and health managers (e.g., facility manager, residential medical officer, consultants), as well as the midwives themselves toward the newly introduced midwives and the quality of care. We plan to use a fixed effect logistic regression to compare the relationship between variables in the three hospital types for each observed data point. For analyzing qualitative data, we will adopt content analysis and use NVivo to identify themes related to perceptions, attitudes, and experiences. Expected results: The introduction of professional midwives may improve the quality of maternal health care in rural settings. The addition of a mentoring program can support midwives in transitioning into their new roles and introduce improved care quality.

Birth anthropometry predicts neonatal and infant mortality in rural Bangladesh: a focus on circumferential measurements

BACKGROUND

Low birth weight predicts risk of infant death. However, several birth measurements may be equally predictive, for which cutoffs and associated risks are less explored.

OBJECTIVES

We assessed and optimized population cutoffs of birth length, weight, and midupper arm circumference (MUAC), head circumference (HC), and chest circumference (CC) for predicting neonatal (≤28 d) and infant (≤365 d) mortality in northwest Bangladesh.

METHODS

Among 28,026 singletons born in an antenatal micronutrient supplement trial, 21,174 received anthropometry ≤72 h after birth, among whom 583 died in infancy. Optimization for predicting mortality for each measurement was guided by the Youden Index (sensitivity + specificity - 1). Relative risk ratios (RRRs) and positive predictive values (PPVs) were calculated across cutoff ranges for individual and any pair of measurements.

RESULTS

Optimal cutoffs, harmonized to 100-g or 0.5-cm readings, for neonatal and infant mortality were 44.5 cm for length, 2200 g for weight, 9.0 cm for MUAC, 31.0 cm for HC, and 28.5 cm for CC, below which all predicted mortality. However, a CC <28.5 cm, alone and combined with HC <31.0 cm, yielded the highest RRR [9.68 (95% CI: 7.84, 11.94) and 15.74 (95% CI: 12.54, 19.75), respectively] and PPV (11.3% and 10.7%) for neonatal mortality and highest RRR [6.02 (95% CI: 5.15, 7.02) and 9.19 (95% CI: 7.72, 10.95)] and PPV (16.3% and 14.5%) for infant mortality. Pairs of measurements revealed a higher RRR for neonatal and infant mortality than individual measurements of any one pair, although the ranges of PPV remained comparable.

CONCLUSIONS

In Bangladesh, multiple birth measurements alone or in combination, particularly chest circumference, predict neonatal and infant mortality.

Adopting workload-based staffing norms at public sector health facilities in Bangladesh: evidence from two districts

BACKGROUND

Bangladesh's Health system is characterized by severe shortage and unequitable distribution of the formally trained health workforce. In this context, government of Bangladesh uses fixed staffing norms for its health facilities. These norms do not always reflect the actual requirement in reality. This study was conducted in public sector health facilities in two selected districts to assess the existing staffing norms with the purpose of adopting better norms and a more efficient utilization of the existing workforce.

METHODS

To carry out this assessment, WHO's Workload Indicators of Staffing Need (WISN) method was applied. Selection of the two districts out of 64 and a total of 24 health facilities were made in consultation with the formally established steering committee of the Ministry of Health. Health facilities, which were performing well in serving the patients during 2016-2017, were selected. This assessment examined staffing requirement of 20 staff categories.

RESULTS

Based on the computer-generated WISN results, most of the staff categories were found to have a workload pressure of Very High (seven out of 20 staff categories), followed by Extremely High (five staff categories). Two staff categories had high, three had moderately high, two normal, and one low workload. Nurses were found to be predominantly occupied with support activities (50-60% of working time), instead of actual nursing care. Regarding vacancy, if all the vacant posts were filled, understandably, the workload would reduce, but not yet sufficient to meet the existing staff requirements such as consultants, general physicians and nurses at the district and sub-district/upazila-based hospitals.

CONCLUSION

The existing staffing norms fall short of the WISN staffing requirement. The results provide evidence to prompt a revisit of the staffing policies and adopt workload-based norms. This can be supplemented by reviewing the scope of practice of the staff categories in their respective health facilities. In the short term, government might consider redistributing existing workforce as per workload. In the long term, revision of staffing norms is needed to provide quality health services for all.

An Uninformed Decision-Making Process for Cesarean Section: A Qualitative Exploratory Study among the Slum Residents of Dhaka City, Bangladesh

The decision-making process and the information flow from physicians to patients regarding deliveries through cesarean section (C-section) has not been adequately explored in Bangladeshi context. Here, we aimed to explore the extent of information received by mothers and their family members and their involvement in the decision-making process. We conducted a qualitative exploratory study in four urban slums of Dhaka city among purposively selected mothers (n = 7), who had a cesarean birth within one-year preceding data collection, and their family members (n = 12). In most cases, physicians were the primary decision-makers for C-sections. At the household level, pregnant women were excluded from some crucial steps of the decision-making process and information asymmetry was prevalent. All interviewed pregnant women attended at least one antenatal care visit; however, they neither received detailed information regarding C-sections nor attended any counseling session regarding decisions around delivery type. In some cases, pregnant women and their family members did not ask health care providers for detailed information about C-sections. Most seemed to perceive C-sections as risk-free procedures. Future research could explore the best ways to provide C-section-related information to pregnant women during the antenatal period and develop interventions to promote shared decision-making for C-sections in urban Bangladeshi slums.

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.

Facilitators of and barriers to providing high-quality midwifery education in South-East Asia-An integrative review

BACKGROUND

With a diversity in midwifery education across the South-East Asia region, and with the knowledge about the lifesaving competency of the midwife profession, this study's aim is to describe facilitators of and barriers to providing high-quality midwifery education in South-East Asia.

METHODS

Inspired by Whittemore and Knafl, we conducted a systematic integrative literature review including the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results. The literature searches were conducted in October 2020 in the databases CINAHL, PubMed, and Scopus. A deductive data analysis based on global standards was performed.

RESULTS

The search identified 1257 articles, 34 of which were included. Countries in South-East Asia did not fully comply with the ICM global standards. Midwifery education was not separated from that of nursing, and educators lacked formal qualifications in midwifery. Curriculum implementation in the clinical area was a key barrier to achieving learning outcomes. Higher academic education for midwifery educators and mentorship programs facilitated the pedagogic and assessment process, focusing on the abilities of critical thinking, reflection, and decision-making.

CONCLUSIONS

Countries in South-East Asia still have a long way to go before they can provide high-quality midwifery education. The identified facilitators can lead to a difference in students' academic achievement and confidence in their clinical work. Coordinated actions will enable the progress in achieving competent midwives matching national health priorities. The findings highlight a need for more research on midwifery education in both theory and practice across the region.