Midwives' challenges and factors that motivate them to remain in their workplace in the Democratic Republic of Congo-an interview study

Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study

BACKGROUND

The midwife-led model of care is woman-centered and based on the premise that pregnancy and childbirth are normal life events, and the midwife plays a fundamental role in coordinating care for women and linking with other health care professionals as required. Worldwide, this model of care has made a great contribution to the reduction of maternal and child mortality. For example, the global under-5 mortality rate fell from 42 deaths per 1,000 live births in 2015 to 39 in 2018. The neonatal mortality rate fell from 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018. Even if this model of care has a pivotal role in the reduction of maternal and newborn mortality, in recent years it has faced many challenges.

OBJECTIVE

To explore facilitators and barriers to a midwife-led model of care at a public health institution in Dire Dawa, Eastern Ethiopia, in 2021.

METHODOLOGY

A qualitative approach was conducted at Dire Dawa public health institution from March 1-April 30, 2022. Data was collected using a semi-structured, in-depth interview tool guide, focused group discussions, and key informant interviews. A convenience sampling method was implemented to select study participants, and the data were analyzed thematically using computer-assisted qualitative data analysis software Atlas.ti7. The thematic analysis with an inductive approach goes through six steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up.

RESULT

Two major themes were driven from facilitators of the midwife-led model of care (professional pride and good team spirit), and seven major themes were driven from barriers to the midwife-led model of care (lack of professional development, shortage of resources, unfair risk or hazard payment, limited organizational power of midwives, feeling of demoralization absence of recognition from superiors, lack of work-related security).

CONCLUSION

The midwifery-led model of care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally. A multidisciplinary and collaborative effort is needed to solve those challenges.

Challenges and coping strategies for providing maternal health care services among health care professionals in rural health facilities in Wolaita Zone, Southern Ethiopia: a qualitative study

BACKGROUND

Many factors can decrease job productivity and cause physical and psychological complications for health care professionals providing maternal care. Information on challenges and coping strategies among healthcare professionals providing maternal healthcare services in rural communities is crucial. However, there needs to be more studies, especially qualitative research, to explore challenges and coping strategies for providing maternal health care services in Ethiopia among health care professionals, particularly in the Wolaita zone.

OBJECTIVE

To explore the challenges and coping strategies of professionals providing maternal health care in rural health facilities in Wolaita Zone, Southern Ethiopia, in 2023.

METHOD

A phenomenological qualitative study design was applied from May 20 to June 20, 2023. The study was conducted in rural areas of the Wolaita Zone, southern Ethiopia. Healthcare professionals from rural areas were selected using purposive sampling, and in-depth interviews were conducted. A qualitative thematic analysis was employed to analyze the data. Field notes were read, recordings were listened to, and each participant's interview was written word for word and analyzed using ATLAS.ti 7 software.

RESULT

Five main themes emerged from the data analysis. These themes included inadequate funding from the government, societal barriers to health and access to health care, professionals' personal life struggles, infrastructure related challenges and health system responsiveness, and coping strategies. Reporting to responsible bodies, teaching mothers about maternal health care services, and helping poor mothers from their pockets were listed among their coping strategies.

CONCLUSION

Healthcare professionals have a crucial role in supporting women in delivering babies safely. This study revealed that they are working under challenging conditions. So, if women's lives matter, then this situation requires a call to action.

Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study

OBJECTIVE

To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes.

DESIGN

A descriptive, multicentre cross-sectional survey.

SETTING

Maternity hospitals from the eastern, central and western regions of China.

PARTICIPANTS

Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires.

RESULTS

A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted β -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted β -0.171, 95% CI -0.190 to -0.056, p<0.001).

CONCLUSION

The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

A global overview of midwives' working conditions: A rapid review of literature on positive practice environment

BACKGROUND

In the United Kingdom (UK), a critical shortage of midwives puts pressure on the already overworked midwives working in maternity services. Considering the challenges that midwives in the UK face, this rapid review was conducted to inform a larger-scale initiative to improve the working conditions of midwives in an acute NHS Trust in the Midlands area of the UK.

OBJECTIVE

To describe midwives' perceptions and experiences of positive practice environments.

METHODS

A search strategy to identify literature about midwives' perceptions and experiences of positive practice environments was conducted in Medline, CINAHL Plus and Embase databases. Literature screening was conducted independently in two steps using an eligibility tool. The articles' quality assessment was conducted using the Mixed Method Appraisal Tool. Data were extracted using the Job Quality framework and managed using NVivo12.

RESULTS

Seventy articles were included in this review. Midwives' working conditions can be improved in all seven areas of the Job Quality framework. Most articles in the review reported the negative aspects of midwives' working environments, making it challenging for the team to define a positive practice environment for midwives. Despite this, authors discuss that a positive practice environment is at least sustained by ensuring midwives' ability to provide care; providing good employment conditions; developing respectful organisations; and increasing team resources, such as those that improve team resilience.

CONCLUSIONS

Midwives' working conditions are universally challenging. Failure to address the situation will compromise recruitment and retention, increasing the shortage of midwives. Provision of safe and respectful care appears to be directly linked to midwives' safe and respectful working conditions.

Midwives' Voices on Early Initiation of Antenatal Care Following a Positive Gravindex Test: A Qualitative Study

Background

Early Antenatal Care (ANC) initiation is aimed at improving maternal and perinatal health outcomes through the identification of complications and determining the level of care needed. This study aimed to determine the voices of midwives on the provision of early initiation of ANC following positive gravindex.

Materials and Methods

The phenomenology approach underpinned the study. The participants included midwives providing ANC at health facilities under Tshino-Mutsha local area in May-December 2020. Nonprobability, purposive sampling was used to select four clinics and to sample 20 midwives. Semistructured face-to-face, in-depth interviews were conducted using an interview guide. Data saturation was reached at Participant 15; however, the researcher continued until Participant 20. Trustworthiness was ensured and ethical principles were adhered to. Data analysis was done using Tesch's open coding approach.

Results

Two themes and seven subthemes emerged, as challenges related to the provision of midwifery practice and to pregnant women. The seven subthemes were the shortage of resources, poor support of midwives, poor adherence to the available protocol for the provision of ANC, blaming of midwives by management and community, late ANC booking by pregnant women, denial of pregnancy by young women ignorance leading to a general resistance to ANC instructions, hence late booking.

Conclusions

It was concluded that shortage of human and material resources hindered the initiation of early ANC to detect, prevent, and manage the existing and potential causes of maternal and newborn mortality and morbidity.

Contextual factors influencing implementation of a university-based midwifery education programme in Central Africa: A qualitative study

AIM

To investigate contextual factors and their influence on implementing a 90-credit midwifery education programme for nurses at a university in the eastern DRC.

BACKGROUND

To improve maternal and neonatal health, there is a government policy in the Democratic Republic of Congo (DRC) to educate midwives at a higher education level according to international norms. This study investigates contextual factors and their influence on the implementation of a midwifery education programme which is based on national curriculum and has a profile of person-centred care, simulation-based learning pedagogy and information and communication technology.

METHOD

A qualitative study was conducted with data collected through semi-structured interviews with 22 participants who were directly or indirectly involved in establishing the midwifery education programme. Transcribed interviews were analysed using content analysis.

RESULTS

The factors influencing the implementation of the new midwifery education programme comprise facilitating and hindering factors. Facilitating factors were: (i) awareness that midwives educated at a higher education level can deliver higher-quality health care, (ii) women are motivated to seek care from well-educated midwives, (iii) the planned programme is attractive and (iv) the university has a stable academic administration and established collaborations. Hindering factors were: (i) Students' lack of prerequisites for study; (ii) objections to educating midwives at a higher education level; (iii) inadequate teaching resources; and (iv) inadequate working conditions for midwives.

CONCLUSION

The facilitating factors strengthen the belief that it is possible to implement this midwifery education programme, while the hindering factors need to be addressed to run the programme successfully. The findings can guide higher education institutions starting similar midwifery education programmes in the DRC and elsewhere, although it is crucial to conduct a context study in those specific contexts.

Professional Self-Esteem of Turkish Midwifery Students: A Mixed-Methods Approach

Professional self-esteem (PSE) is the individual's judgment of worthiness formed regarding the self-attributions related to the individual's profession. A well-developed PSE is important for midwives to be successful in their profession, have a strong sense of belonging, and see the profession as important and valuable. This study aims to determine the perception of PSE among midwifery students, explain how their perceptions are formed, and reveal how they perceive the midwifery profession and how the components that make up this perception determine their PSE. Students' average PSE score was analyzed, and the study was conducted using an explanatory sequential, which is a mixed-method approach, to interpret the results of the questionnaire and comparative analysis in more detail through direct interviews with university midwifery program students in western Turkey. Quantitative data were collected using the Individual Data Collection Form and the Professional Self-Esteem Scale. One-way analysis variance and independent sample t-tests were used to analyze the quantitative data. The students with the highest and lowest scale scores from each class level were interviewed using a Semi-Structured Interview Form. Thematic analysis was applied to analyze the qualitative data. The mean PSES score was 117.51 ± 17.60. The t-test analysis result shows that there was a significant difference between the PSES score and choosing the midwifery department willingly, believing that they could perform the midwifery profession before and after starting the midwifery education (p < 0.05). Three main themes were obtained: the meaning of being a midwife, deciding to become a midwife, and the difficulties of being a midwife. It can be said that the main force behind the students' belief that the difficulties of the midwifery profession can be overcome is their strong love for the midwifery profession and their internalization of its importance.

Using process-oriented groups reflections with health care providers to improve childbirth care in the Democratic Republic of Congo - An implementation study

OBJECTIVE

The ability to systematically reflect on care during labour and birth needs to be developed among health care providers. This study investigates the experiences of health care providers who have participated in process-oriented group reflections. The activity of group reflections was one of the three pillars of a training intervention seeking to implement evidence-based care routines during labour and birth that could contribute to reduced mortality and improved maternal and newborn health in the Democratic Republic of Congo (DRC).

METHODS

Using a qualitative approach, we interviewed 131 health care providers, in focus groups (n = 19) and individually (n = 2). Analysis of transcribed interviews was conducted using qualitative content analysis according to Elo and Kyngäs.

RESULTS

Group reflections added essential knowledge to the other components of the three-pillar training intervention. Through sharing and analysing care situations health care providers got increased self-awareness, tools to achieve structured and safe care routines, and to practice teamworking.

CONCLUSION

Using a structured model of process-oriented group reflection for health care providers on care during labour and birth proved to be a vital aspect of the training intervention, as it added knowledge to the skills gained through theoretical and simulation-based education. The three-pillar training intervention improved care routines that supported healthy births and management of complications. We recommend that structured and secure group reflections be included in similar training activities in the DRC and elsewhere, and assessed in further studies.

A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Midwifery Now: Narratives about Motivations for Career Choice

The objective of this study was to analyse nursing students’ motivation to choose the midwifery career. This is a cross-sectional study with a qualitatively driven mixed-methods approach. The settings are three higher education institutions located in Portugal. The study was conducted between September 2019 and November 2021, with the participation of 74 midwifery master’s students, through convenience sampling. The data were collected through the LimeSurvey software and were subsequently analysed in the SPSS and IRaMuTeQ software programs. The emerging thematic areas were as follows: (1) building a professional identity and (2) knowledge construction. From these two thematic areas, six classes emerged that revealed commitment to the profession. It is in Class 6 that the ancestral essence of the profession lies, revealing the meanings of competence and care perpetuation linked to gender. Midwifery is a first-line profession, and the career choice reflects a commitment to support the mother/newborn dyad in view of the inevitability of human care for the preservation of the species. Midwives with a Socratic inspiration are the model for the profession. Given the development of professional identity, it can be interesting to have an educational curriculum where human values are reinforced. A woman-centred birth environment and birth territory are elementary for midwifery education.

Contextual factors influencing a training intervention aimed at improved maternal and newborn healthcare in a health zone of the Democratic Republic of Congo

Background

Maternal and neonatal mortality and morbidity in the Democratic Republic of Congo (DRC) are among the highest worldwide. As part of a quality improvement programme in a health zone in the DRC aimed at contributing to reduced maternal and neonatal mortality and morbidity, a three-pillar training intervention around childbirth was developed and implemented in collaboration between Swedish and Congolese researchers and healthcare professionals. The aim of this study is to explore contextual factors influencing this intervention.

Methods

A qualitative research design was used, with data collected through focus group discussions (n = 7) with healthcare professionals involved in the intervention before and at the end (n = 9). Transcribed discussions were inductively analysed using content analysis.

Results

Three generic categories describe the contextual factors influencing the intervention: i) Incentives motivated participants’ efforts to begin a training programme; ii) Involving the local health authorities was important; and (iii) Having physical space, electricity, and equipment in place was crucial.

Conclusions

This study and similar ones highlight that incentives of various types are crucial contextual factors that influence training interventions, and have to be considered already in the planning of such interventions. One such factor is expectations of monetary incentives. To meet this in a small research project like ours would require a reduction of the scale and thus limit the implementation of new evidence-based knowledge into practice aimed at reducing maternal mortality and morbidity.

Self-concept Factor Influencing Antenatal Provider Selection: A Qualitative Study from Indonesian Midwives

Background: The different philosophies of care between midwives and obstetricians influence maternal health services. Midwives deliver a holistic physiological approach, while obstetricians implement a medical approach and a technocratic model. Different perspectives in interpreting professional philosophies may impact the choices of antenatal providers for midwives, themselves. This study aims to determine the self-concept of Indonesian midwives in interpreting professional philosophy regarding the decision-making of the antenatal provider during pregnancies. Materials and Methods: A qualitative descriptive with a phenomenological approach was carried out. It used a purposive sampling method. This study involves 15 midwives who are still active in providing services in private midwifery practices, primary health centers, and hospitals that had experienced pregnancy. The variable was the perspective of midwives in choosing ANC providers considering the self-concept. Data obtained by in-depth interview technique for 60-90 minutes duration and is analyzed using thematic analysis techniques. Results: As the results, the selection of ANC providers has been shaped by the self-concept factor. Most perspectives are influenced by (1) knowledge of the physiological and high-risk of pregnancy concept (2) previous experiences in pregnancy/ childbirth/ after birth (3) role in families when addressing reproductive health decisions. Conversely, education level and work experiences did not affect the option to have antenatal care. Conclusion: Self-concept influences midwives’ perspective of making decisions about ANC providers. This study shows there is a limited understanding of the philosophy of midwifery care which reflects on the decision-making of the midwives in regard to the care received during the pregnancy.

Challenges experienced by midwives working in rural communities in the Upper East Region of Ghana: a qualitative study

BACKGROUND

In 2017, a total of 295,000 women lost their lives due to pregnancy and childbirth across the globe, with sub-Saharan Africa and South Asia accounting for approximately 86 % of all maternal deaths. The maternal mortality ratio in Ghana is exceptionally high, with approximately 308 deaths/100,000 live births in 2017. Most of these maternal deaths occur in rural areas than in urban areas. Thus, we aimed to explore and gain insights into midwives' experiences of working and providing women-centred care in rural northern Ghana.

METHODS

A qualitative descriptive exploratory design was used to explore the challenges midwives face in delivering women-centred midwifery care in low-resource, rural areas. A total of 30 midwives practicing in the Upper East Region of Ghana were purposefully selected. Data were collected using individual semistructured interviews and analysed through qualitative content analysis.

RESULTS

Five main themes emerged from the data analysis. These themes included were: inadequate infrastructure (lack of bed and physical space), shortage of midwifery staff, logistical challenges, lack of motivation, and limited in-service training opportunities.

CONCLUSIONS

Midwives experience myriad challenges in providing sufficient women-centred care in rural Ghana. To overcome these challenges, measures such as providing adequate beds and physical space, making more equipment available, and increasing midwifery staff strength to reduce individual workload, coupled with motivation from facility managers, are needed.