Randomised control trial indicates micronutrient supplementation may support a more robust maternal microbiome for women with antenatal depression during pregnancy.

BACKGROUND AND AIMS: We investigated the effects of high dose dietary micronutrient supplementation or placebo on the human gut microbiome in pregnant women who had moderate symptoms of antenatal depression. There is a significant absence of well-controlled clinical studies that have investigated the dynamic changes of the microbiome during pregnancy and the relationship among diet, microbiome and antenatal depression. This research is among the first to provide an insight into this area of research. METHODS: This 12 - week study followed a standard double blinded randomised placebo-controlled trial (RCT) design with either high dose micronutrients or active placebo. Matching stool microbiome samples and mood data were obtained at baseline and post-treatment, from participants between 12 and 24 weeks gestation. Stool microbiome samples from 33 participants (17 in the placebo and 16 in the treatment group) were assessed using 16s rRNA sequencing. Data preparation and statistical analysis was predominantly performed using the QIIME2 bioinformatic software tools for 16s rRNA analysis. RESULTS: Microbiome community structure became increasingly heterogenous with decreased diversity during the course of the study, which was represented by significant changes in alpha and beta diversity. This effect appeared to be mitigated by micronutrient administration. There were less substantial changes at the genus level, where Coprococcus decreased in relative abundance in response to micronutrient administration. We also observed that a higher abundance of Coprococcus and higher alpha diversity correlated with higher antenatal depression scores. CONCLUSIONS: Micronutrient treatment appeared to support a more diverse (alpha diversity) and stable (beta diversity) microbiome during pregnancy. This may aid in maintaining a more resilient or adaptable microbial community, which would help protect against decreases or fluctuations that are observed during pregnancy.

Efficacy and safety of a mineral and vitamin treatment on symptoms of antenatal depression: 12-week fully blinded randomised placebo-controlled trial (NUTRIMUM).

BACKGROUND: Broad-spectrum micronutrients (minerals and vitamins) have shown benefit for treatment of depressive symptoms. AIMS: To determine whether additional micronutrients reduce symptoms of antenatal depression. METHOD: Eighty-eight medication-free pregnant women at 12-24 weeks gestation, who scored ≥13 on the Edinburgh Postnatal Depression Scale (EPDS), were randomised 1:1 to micronutrients or active placebo (containing iodine and riboflavin), for 12 weeks. Micronutrient doses were generally between recommended dietary allowance and tolerable upper level. Primary outcomes (EPDS and Clinical Global Impression - Improvement Scale (CGI-I)) were analysed with constrained longitudinal data analysis. RESULTS: Seventeen (19%) women dropped out, with no group differences, and four (4.5%) gave birth before trial completion. Both groups improved on the EPDS, with no group differences (P = 0.1018); 77.3% taking micronutrients and 72.7% taking placebos were considered recovered. However, the micronutrient group demonstrated significantly greater improvement, based on CGI-I clinician ratings, over time (P = 0.0196). The micronutrient group had significantly greater improvement on sleep and global assessment of functioning, and were more likely to identify themselves as 'much' to 'very much' improved (68.8%) compared with placebo (38.5%) (odds ratio 3.52, P = 0.011; number needed to treat: 3). There were no significant group differences on treatment-emergent adverse events, including suicidal ideation. Homocysteine decreased significantly more in the micronutrient group. Presence of personality difficulties, history of psychiatric medication use and higher social support tended to increase micronutrient response compared with placebo. CONCLUSIONS: This study highlights the benefits of active monitoring on antenatal depression, with added efficacy for overall functioning when taking micronutrients, with no evidence of harm. Trial replication with larger samples and clinically diagnosed depression are needed.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia.

BACKGROUND: Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging. STUDY DESIGN AND METHODS: Randomized pilot trial with feasibility surveys. INCLUSION: hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable. EXCLUSION: ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. PRIMARY OUTCOME: number of recruits; proportion of those approached; proportion considered potentially eligible. SECONDARY OUTCOMES: fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation. RESULTS: Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Maori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9). DISCUSSION: Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

Building positive respectful midwifery relationships: An analysis of women's experiences of continuity of midwifery care in Aotearoa New Zealand.

PROBLEM/BACKGROUND: Respectful woman-centred care is an expectation of the Midwifery Standards of Practice within Aotearoa New Zealand. With both the national and international expectations identifying human rights as a priority in maternity care. Mistreatment can be experienced by women in all socio-political contexts. Identifying women's experiences of their maternity service is vital when assessing the quality of these services. AIM: To explore women's experiences of continuity of midwifery care in Aotearoa NZ, whether they support the expectations within the Standards of Midwifery Practice and identify the characteristics of care that may contribute to positive or negative experiences of care. METHODS: A retrospective analysis of women's formal online feedback to their midwife using a mixed method design. Feedback forms received from the 1st January 2019 to the 31st December 2019 were analysed using descriptive statistics with free text thematically analysed. FINDINGS: A total of 7749 feedback forms were received demonstrating high levels of satisfaction overall. Three overlapping themes were identified as being central to both positive and negative feedback. Building a positive relationship involved three steps. These were the establishment and maintenance of trust, honouring decisions and empowerment. Overall, the existence of these relationship characteristics contributed to a valued woman-midwife relationship. Women who gave negative feedback identified a lack of trust and a failure to honour decisions which led to women feeling disempowered contributing to a lack of being valued in the relationship. CONCLUSION: Continuity of care in Aotearoa NZ supports the development of a respectful partnership through trust, honouring decisions and empowerment.

Nitrate contamination in drinking water and adverse reproductive and birth outcomes: a systematic review and meta-analysis.

Exposure to low levels of nitrate in drinking water may have adverse reproductive effects. We reviewed evidence about the association between nitrate in drinking water and adverse reproductive outcomes published to November 2022. Randomized trials, cohort or case-control studies published in English that reported the relationship between nitrate intake from drinking water and the risk of perinatal outcomes were included. Random-effect models were used to pool data. Three cohort studies showed nitrate in drinking water is associated with an increased risk of preterm birth (odds ratio for 1 mg/L NO3-N increased (OR1) = 1.01, 95% CI 1.00, 1.01, I2 = 23.9%, 5,014,487 participants; comparing the highest versus the lowest nitrate exposure groups pooled OR (ORp) = 1.05, 95% CI 1.01, 1.10, I2 = 0%, 4,152,348 participants). Case-control studies showed nitrate in drinking water may be associated with the increased risk of neural tube defects OR1 = 1.06, 95% CI 1.02, 1.10; 2 studies, 2196 participants; I2 = 0%; and ORp = 1.51, 95% CI 1.12, 2.05; 3 studies, 1501 participants; I2 = 0%). The evidence for an association between nitrate in drinking water and risk of small for gestational age infants, any birth defects, or any congenital heart defects was inconsistent. Increased nitrate in drinking water may be associated with an increased risk of preterm birth and some specific congenital anomalies. These findings warrant regular review as new evidence becomes available.

Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management.

BACKGROUND: The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV-iron) use in its treatment, are unknown. AIMS: To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity. MATERIALS AND METHODS: Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July-December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA. RESULTS: There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Maori for being identified as having PPA (0.46, 95% CI 0.37-0.57, P < 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV-iron only, 66 (10%) red blood cell transfusion (RBC-T) only and 155 (23%) both. Of those receiving RBC-T, 40/221 (18%) were actively bleeding. Maori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV-iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding. CONCLUSION: The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV-iron, with or without RBC-T.

Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives.

BACKGROUND: Health inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman's vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care. AIM: To explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand. METHOD: Inductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care. FINDINGS: A total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings. CONCLUSION: Midwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.

Drivers of job satisfaction in midwifery-A work design approach.

BACKGROUND: Identifying common factors that influence job satisfaction for midwives working in diverse work settings is challenging. Applying a work design model developed in organisational behaviour to the midwifery context may help identify key antecedents of midwives job satisfaction. AIM: To investigate three job characteristics - decision-making autonomy, empowerment, and professional recognition as antecedents of job satisfaction in New Zealand (NZ) midwives. METHODS: Latent multiple regressions were performed on data from Lead Maternity Carer (LMC) midwives n = 327, employed midwives n = 255, and midwives working in 'mixed-roles' n = 123. FINDINGS: We found that professional recognition is positively linked to job satisfaction for midwives in all three work settings. At the same time, decision-making autonomy and empowerment were shown to influence job satisfaction for midwives working as LMCs only. DISCUSSION: Our main finding suggests that the esteem generated from being acknowledged as an expert and valuable contributor by maternity health colleagues is satisfying across all work contexts. Professional recognition encompasses the social dimension of midwifery work and influences midwives job satisfaction. Decision-making autonomy and empowerment are task and relational job characteristics that may not be similarly experienced by all midwives to noticeably influence job satisfaction. CONCLUSION: Given that job satisfaction contributes to recruitment, retention, and sustainability, our findings show that drivers of job satisfaction differ by midwifery work context. We present evidence to support tailored efforts to bolster midwives job satisfaction, especially where resources are limited.

Midwifery Job Autonomy in New Zealand: I do it all the time.

INTRODUCTION: This research aimed to identify what supports and what hinders job autonomy for midwives in New Zealand. METHODS: Registered midwives participated in an open-ended, online survey in 2019. Anonymised participants were asked to describe an incident when they felt they were using their professional judgement and/or initiative to make decisions and the resultant actions. The data was analysed thematically. FINDINGS: The participants identified that autonomy is embedded within midwifery practice in New Zealand. Self-employed midwives who provide continuity of care as Lead Maternity Carers, identified they practice autonomously 'all the time'. The relationship with women and their family, and informed decision making, motivated the midwife to advocate for the woman - regardless of the midwife's work setting. Midwifery expertise, skills, and knowledge were intrinsic to autonomy. Collegial relationships could support or hinder the midwives' autonomy while a negative hospital work culture could hinder job autonomy. DISCUSSION: Midwives identified that autonomous practice is embedded in their day to day work. It strengthens and is strengthened by their relationships with the woman/whanau and when their body of knowledge is acknowledged by their colleagues. Job autonomy was described when midwifery decisions were challenged by health professionals in hospital settings and these challenges could be viewed as obstructing job autonomy. CONCLUSION: The high job autonomy that New Zealand midwives enjoy is supported by their expertise, the women and colleagues that understand and respect their scope of practice. When their autonomy is hindered by institutional culture and professional differences provision of woman-centred care can suffer.

"Ashamed, Silent and Stuck in a System"-Applying a Structural Violence Lens to Midwives' Stories on Social Disadvantage in Pregnancy.

Historical and enduring maternal health inequities and injustices continue to grow in Aotearoa New Zealand, despite attempts to address the problem. Pregnancy increases vulnerability to poverty through a variety of mechanisms. This project qualitatively analysed an open survey response from midwives about their experiences of providing maternity care to women living with social disadvantage. We used a structural violence lens to examine the effects of social disadvantage on pregnant women. The analysis of midwives' narratives exposed three mechanisms by which women were exposed to structural violence, these included structural disempowerment, inequitable risk and the neoliberal system. Women were structurally disempowered through reduced access to agency, lack of opportunities and inadequate meeting of basic human needs. Disadvantage exacerbated risks inequitably by increasing barriers to care, exacerbating the impact of adverse life circumstances and causing chronic stress. Lastly, the neoliberal system emphasised individual responsibility that perpetuated inequities. Despite the stated aim of equitable access to health care for all in policy documents, the current system and social structure continues to perpetuate systemic disadvantage.

Can broad-spectrum multinutrients treat symptoms of antenatal depression and anxiety and improve infant development? Study protocol of a double blind, randomized, controlled trial (the 'NUTRIMUM' trial).

BACKGROUND: Untreated antenatal depression and anxiety can be associated with short and long term health impacts on the pregnant woman, her infant and the rest of the family. Alternative interventions to those currently available are needed. This clinical trial aims to investigate the efficacy and safety of a broad-spectrum multinutrient formula as a treatment for symptoms of depression and anxiety in pregnant women and to determine the impact supplementation has on the general health and development of the infant. METHODS: This randomised, controlled trial will be conducted in Canterbury, New Zealand between April 2017 and June 2022. One hundred and twenty women aged over 16 years, between 12 and 24 weeks gestation and who score ≥ 13 on the Edinburgh Postnatal Depression Scale (EPDS) will be randomly assigned to take the intervention (n = 60) or an active control formula containing iodine and riboflavin (n = 60) for 12 weeks. After 12 weeks, participants can enter an open-label phase until the birth of their infant and naturalistically followed for the first 12 months postpartum. Infants will be followed until 12 months of age. Randomisation will be computer-generated, with allocation concealment by opaque sequentially numbered envelopes. Participants and the research team including data analysts will be blinded to group assignment. The EPDS and the Clinical Global Impressions Scale of Improvement (CGI-I) will be the maternal primary outcome measures of this study and will assess the incidence of depression and anxiety and the improvement of symptomatology respectively. Generalized linear mixed effects regression models will analyse statistical differences between the multinutrient and active control group on an intent-to-treat basis. A minimum of a three-point difference in EPDS scores between the groups will identify clinical significance. Pregnancy outcomes, adverse events and side effects will also be monitored and reported. DISCUSSION: Should the multinutrient formula be shown to be beneficial for both the mother and the infant, then an alternative treatment option that may also improve the biopsychosocial development of their infants can be provided for pregnant women experiencing symptoms of depression and anxiety. TRIAL REGISTRATION: Trial ID: ACTRN12617000354381 ; prospectively registered at Australian New Zealand Clinical Trials Registry on 08/03/2017.

Pulse oximetry screening in a midwifery-led maternity setting with high antenatal detection of congenital heart disease.

AIM: To assess local and individual factors that should be considered in the design of a pulse oximetry screening strategy in New Zealand's midwifery-led maternity setting. METHODS: An intervention study was conducted over 2 years. Three hospitals and four primary maternity units participated in the study. Post-ductal saturation levels were measured on well infants with a gestation of ≥35 weeks. Infant activity and age (hours) at the time of the test were recorded. RESULTS: Screening was performed on 16 644 of 27 172 (61%) eligible infants. The age at which the screening algorithm was initiated varied significantly among centres. The probability of achieving a pass result (saturations ≥95%) in the context of no underlying pathology ranged from .94 for an unsettled infant screened <4 hours of age to .99 (P < .001) when the test was performed after 24 hours on a settled infant. Forty-eight (0.3%) infants failed to reach saturation targets: 37 had significant pathology of which three had cardiac disease. CONCLUSION: Screening practices were influenced by the setting in which it was undertaken. Infant activity and age at the time of testing can influence saturation levels. Screening is associated with the identification of significant non-cardiac pathology.

Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!"

OBJECTIVE: To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening. METHODS: Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach. FINDINGS: Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.

Feasibility study assessing equitable delivery of newborn pulse oximetry screening in New Zealand's midwifery-led maternity setting.

OBJECTIVES: The aim of this study was to conduct New Zealand-specific research to inform the design of a pulse oximetry screening strategy that ensures equity of access for the New Zealand maternity population. Equity is an important consideration as the test has the potential to benefit some populations and socioeconomic groups more than others. SETTING: New Zealand has an ethnically diverse population and a midwifery-led maternity service. One quaternary hospital and urban primary birthing unit (Region A), two regional hospitals (Region B) and three regional primary birthing units (Region C) from three Health Boards in New Zealand's North Island participated in a feasibility study of pulse oximetry screening. Home births in these regions were also included. PARTICIPANTS: There were 27 172 infants that satisfied the inclusion criteria; 16 644 (61%) were screened. The following data were collected for all well newborn infants with a gestation age ≥35 weeks: date of birth, ethnicity, type of maternity care provider, deprivation index and screening status (yes/no). The study was conducted over a 2-year period from May 2016 to April 2018. RESULTS: Screening rates improved over time. Infants born in Region B (adjusted OR=0.75; 95% CI 0.67 to 0.83) and C (adjusted OR=0.29; 95% CI 0.27 to 0.32) were less likely to receive screening compared with those born in Region A. There were significant associations between screening rates and deprivation, ethnicity and maternity care provider. Lack of human and material resources prohibited universal access to screening. CONCLUSION: A pulse oximetry screening programme that is sector-led is likely to perpetuate inequity. Screening programmes need to be designed so that resources are distributed in the way most likely to optimise health outcomes for infants born with cardiac anomalies. ETHICS APPROVAL: This study was approved by the Health and Disability Ethics Committees of New Zealand (15/NTA/168).

Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth.

OBJECTIVES: perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings. DESIGN AND PARTICIPANTS: a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand. METHODS: university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes. FINDINGS: four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported. CONCLUSION: this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic.

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

BACKGROUND: the predicted midwifery workforce shortages in several countries have serious implications for the care of women during pregnancy, birth and post partum. There are a number of factors known to contribute to midwifery shortages and work attrition. However, midwives assessment of their own professional identity and role (sense of empowerment) are perhaps among the most important. There are few international workforce comparisons. AIM: to compare midwives' sense of empowerment across Australia, New Zealand and Sweden using the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). METHOD: a self-administered survey package was distributed to midwives through professional colleges and networks in each country. The surveys asked about personal, professional and employment details and included the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). Descriptive statistics for the sample and PEMS were generated separately for the three countries. A series of analysis of variance with posthoc tests (Tukey's HSD) were conducted to compare scale scores across countries. Effect size statistics (partial eta squared) were also calculated. RESULTS: completed surveys were received from 2585 midwives (Australia 1037; New Zealand 1073 and Sweden 475). Respondents were predominantly female (98%), aged 50-59 years and had significant work experience as a midwife (+20 years). Statistically significant differences were recorded comparing scores on all four PEMS subscales across countries. Moderate effects were found on Professional Recognition, Skills and Resources and Autonomy/Empowerment comparisons. All pairwise comparisons between countries reached statistical significance (p<.001) except between Australia and New Zealand on the Manager Support subscale. Sweden recorded the highest score on three subscales except Skills and Resources which was the lowest score of the three countries. New Zealand midwives scored significantly better than both their Swedish and Australian counterparts in terms of these essential criteria. DISCUSSION/CONCLUSIONS: midwives in New Zealand and Sweden had a strong professional identity or sense of empowerment compared to their Australian counterparts. This is likely the result of working in more autonomous ways within a health system that is primary health care focused and a culture that constructs childbirth as a normal but significant life event. If midwifery is to reach its full potential globally then developing midwives sense of autonomy and subsequently their empowerment must be seen as a critical element to recruitment and retention that requires attention and strengthening.