Implementing midwifery services in public tertiary medical college hospitals in Bangladesh: A longitudinal study

Evaluating an internal quality assurance process for achieving national accreditation standards in midwifery education: a study protocol

The World Health Organization and the International Confederation of Midwives emphasize the importance of accreditation to enhance quality in midwifery education. In midwifery education programmes, internal self-assessments are used to meet accreditation criteria. However, research on this topic is scarce. Therefore, this paper describes how we plan to conduct an evaluation of an internal quality assurance process in midwifery education aimed at achieving national accreditation standards in Bangladesh. This study has a longitudinal exploratory design and will be guided by the principles of process evaluation of complex interventions. An internal quality assurance self-assessment intervention will be introduced at 31 private and public education institutions in Bangladesh. To ensure a sustainable implementation, the Plan-Do-Study-Act cycle will be introduced. Data will be collected using self-administered questionnaires and focus group discussions with midwifery faculty and final-semester students. Descriptive statistics and regression models will be performed for the quantitative data, and the qualitative data will be analysed using content analysis. It is anticipated that, without internal quality assurance of midwifery education programmes, accreditation alone is unlikely to enhance quality. We aspire for this research project to illustrate a process that the midwifery institutes can implement themselves for sustainable transformation towards high-quality midwifery education in countries where such internal quality assurance processes have not yet been integrated into the education system.Trial registration: The study was registered retrospectively with the ISRCTN registry on 26 August 2024. The registration number is: ISRCTN14492910.

Exploring care quality in midwifery clinical practice settings in Ghana - a qualitative study

BACKGROUND

High-quality care is a significant factor in reducing maternal and neonatal mortality. There are known barriers affecting midwives' ability to provide quality care in low- and middle-income countries. The presence of qualified and competent midwives, coupled with the elimination of barriers, is essential for enhancing care quality, especially in education program clinical practice settings.

AIM

To explore factors that affect Ghanaian midwifery students' provision of high-quality care while on clinical rotation.

METHOD

Six focus-group discussions were conducted with a total of 36 midwifery students in Accra, Ghana. Data were analyzed using deductive content analysis applying a conceptual framework identifying social, economic and professional factors influencing the provision of high-quality care.

RESULTS

Social factors identified patient resistance to student midwives, class-based discrimination, traditional practices being preferred over evidence-based care, communication barriers, and poor security. Economic factors were unexpected expenses and inadequate compensation. Professional factors were lack of necessary materials, insufficient number of staff, and a theory-practice gap between classroom learning and hands-on experiences.

CONCLUSION

Factors impacting Ghanaian midwifery students' ability to provide high-quality care in clinical settings were summarized, highlighting social, economic, and professional challenges. Key issues include patient resistance, class-based discrimination, inadequate compensation, theory-practice gaps, and lack of materials. The findings emphasize the need for improved support, resources, and quality clinical learning environments. There needs to be investment in infrastructure and prioritization of pedagogy in clinical settings to enhance midwifery education and care quality in Ghana and more broadly in low- and middle-income countries.

CLINICAL TRIAL NUMBER

Not applicable.

Individual- and system-level determinants of breastfeeding in a low-resource setting

The benefits of breastfeeding are widely established and therefore the World Health Organization recommends that every child be exclusively breastfed for the first 6 months of life and continue breastfeeding up to 2 years of age or beyond. However, the rate of exclusive breastfeeding is low globally and has declined in Bangladesh in recent years. In this review, Bangladesh is used as an example to demonstrate the complex individual- and system-level determinants of breastfeeding in a low-resource setting. Mothers face barriers to breastfeeding within the context of marketing by commercial milk formula companies, limited safe alternatives to breastfeeding directly from the breast, and insufficient resources to support breastfeeding in the hospital, community, and workplace setting. Future research and implementation science is required to investigate the overlapping effects between breastfeeding and the high antibiotic use and Caesarean section rates in Bangladesh, along with public health efforts to promote breastfeeding based on robust evidence.

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.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries

BACKGROUND

Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration.

METHODS

Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality.

RESULTS

In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country.

CONCLUSIONS

A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

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.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

The protocol is registered in PROSPERO (CRD42022367657).

The Impact of Introducing Midwives and also Mentoring on the Quality of Sexual, Reproductive, Maternal, Newborn, and Adolescent Health Services in Low- and Middle-Income Countries: An Integrative Review Protocol

INTRODUCTION

Midwives have the potential to significantly contribute to health-delivery systems by providing sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) care. However, scant research finds barriers to understanding what midwives need to realize their full potential. There are gaps in the definition of a midwife and an understanding of effective means to support the implementation of midwifery care. Mentorship has been found to support systems and healthcare providers to improve care availability and quality.

OBJECTIVES

We describe the methodology of an integrative review that aims to generate evidence of the impact of introducing midwives and also on-site facility mentoring to better understand facilitators and barriers to implementation of the quality and availability of SRMNAH services in low- and middle-income countries (LMICs).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be used to carry out the integrative review. Four electronic bibliographic databases, PubMed MEDLINE, EMBASE, Scopus, and CINAHL, will be used to identify eligible studies. All types of qualitative or quantitative studies will be considered. Eligible studies will be screened according to Population, Intervention, Comparison, and Outcome (PICO) inclusion criteria, and data will be extracted against a predetermined format. The aspects of health system strengthening in providing improved SRMNCH care will be examined in this review to generate evidence on how midwives and mentorship can improve routine care and health outcomes using the World Health Organization's Six Building Blocks approach. The quality of the articles will be thematically analyzed in four areas: coherence and integrity, appropriateness for answering the question, relevance and focus, and overall assessment using the Gough weight-of-evidence framework.

EXPECTED RESULTS

The literature review will consider assessing both upstream health systems regulators and downstream effectors for implementing midwifery interventions. Within this building block framework, this research will report on the outcomes and experiences of introducing midwives and the effectiveness of mentoring midwives and other staff in midwives' roles in improving care quality and health outcomes.