Quality midwifery care during the COVID-19 pandemic in Bangladesh: A focus group study with midwives, nurses, and midwifery educators.

INTRODUCTION: Bangladesh has made remarkable strides in the development of the midwifery profession. However, the COVID-19 pandemic has had profound effects on healthcare systems worldwide, including those related to reproductive, perinatal, and maternal health. Given the recent advancements in the midwifery field in Bangladesh, it is crucial to examine the pandemic's impact on existing barriers and the capacity of midwifery professionals to deliver high-quality care. The aim of this study is to describe the possibility of midwives being able to provide quality midwifery care in Bangladesh during the COVID-19 pandemic. METHODS: To gather insights, data were collected from July to October 2020 via four qualitative focus group discussions online; 23 actively practicing midwives, nurses specializing in midwifery care, and midwifery educators, participated. The data analysis employed reflexive thematic analysis. RESULTS: The COVID-19 crisis posed significant threats to women's safety and health, with lockdowns exacerbating gender inequalities in society. Midwives faced added challenges due to their relatively low professional status and increased workloads. Insufficient policy implementation further compromised midwives' safety. Fear of contracting the virus and working during their free time also raised concerns about the quality of care provided. Nevertheless, the pandemic provided opportunities for midwives to demonstrate their ability to deliver independent midwifery care in Bangladesh. CONCLUSIONS: The pandemic underscored the importance of creating respectful and dignified working conditions for midwives. It revealed that professional midwives can work independently when provided with the necessary space and a supportive work environment. This opens the door for the implementation of a midwifery-led care model. Further research is recommended to investigate the medical safety and efficacy of independent midwifery care in the context of Bangladesh.

Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women.

OBJECTIVE: To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs. DESIGN: A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis. SETTING: The study was conducted in Sweden. PARTICIPANTS: Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth. FINDINGS: The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information. KEY CONCLUSIONS: Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns. IMPLICATIONS FOR PRACTICE: The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

Facilitators influencing midwives to leadership positions in policy, education and practice: A systematic integrative literature review.

The development of midwives as leaders is a crucial step towards achieving equality in sexual, reproductive, maternal, and neonatal health, Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). However, many midwives work only to implement policies made by others rather than being drivers of policy changes. Little is known and researched about why midwives are not involved in decision and policymaking related to sexual, reproductive, maternal, and neonatal health. Hence, with a focus on midwifery leadership within the global community and the limited opportunities for women to hold leadership positions, this research explores the facilitators influencing midwives' opportunities to become leaders in policy development, education and practice. Inspired by Whittemore and Knafl, this integrative literature review was conducted after twenty-two relevant articles were identified through a search of the following databases: PubMed, CINAHL, and Scopus. Inductive content analysis was applied to analyze data. The result indicates that for midwives to become influential leaders, they must be active in strategic planning at the highest level. This inevitably effects how far midwives can act as agents for change, even if they possess the knowledge and skills for a leadership position. Policies and regulations influence how midwives' status in society is acknowledged and recognized. A clearly articulated educational pathway will enable their professional growth and expertise, making them knowledgeable and skillful as leaders. Enabling midwives to step into leadership positions at government level requires reforms which include midwives in decision-making. Excluding midwives from decision-making processes is detrimental to the goal of achieving universal health coverage. The first step is to provide midwives with a protected title, enabling them to work autonomously in an enabling environment with normal pregnancy and birth to achieve the SDG 2030 goals.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya.

BACKGROUND: Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability. METHODS: We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD). RESULTS: At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD. CONCLUSION: Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Midwife Educators' perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh.

INTRODUCTION: Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions. METHOD: Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data. RESULTS: The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement. CONCLUSION: There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes. PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries. FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers. KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward. IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

The MIDWIZE conceptual framework: a midwife-led care model that fits the Swedish health care system might after contextualization, fit others.

OBJECTIVE: Familiarity with the unique tradition and experience of Swedish midwives during the more than 300 years in which midwife-led care has contributed to one of the lowest maternal and neonatal mortality and morbidity ratio in the world might encourage professionals in other countries to follow the Swedish example. The framework described below, reflecting the midwife's role in the Swedish health care system, might, after implementation, strengthen maternal and neonatal outcomes if contextualized to other settings. RESULTS: Using a four-step procedure we identified our topic, made a literature review, identified the key components and their internal relationship, and finally developed the MIDWIZE conceptual framework. In this framework, the midwives in collaboration with obstetricians, provide evidence-based care with continuous quality improvements during the whole reproductive life cycle. Teamwork including specialists for referral and a responsive, relational, trust-based practice is the foundation for provision of midwife-led care for healthy women with a normal pregnancy. The well-educated midwife, of high academic standard, promoting gender equality and equity is the hub in the team and the primary care provider.

The midwife's role in achieving the Sustainable Development Goals: protect and invest together - the Swedish example.

'The midwife's role in achieving the Sustainable Development Goals: Protect and Invest Together' is a report providing the reader the opportunity for understanding and appreciating the history of midwifery in Sweden and the interlinked nature of the United Nation's SDGs supporting health and wellbeing of women and children. To realise the opportunity to have a country with well-educated midwives of high academic standard, and, at the same time, promoting gender equality and equity we need to protect and invest together in midwives. This paper provides the foundation for a revitalised discussion on midwives' role for women and child health in the 21st century. The full Swedish Midwifery report was published in October 2021.

Valid and reliable neonatal near-miss assessment scale in Ethiopia: a psychometric validation.

BACKGROUND: The concept of a neonatal near miss is used to explain neonates who nearly died but survived a life-threatening complication in the first 28 days of life. We have left many ill surviving (near-miss) neonates, due to a lack of valid and reliable assessment scale, particularly in Ethiopia. AIM: We aim to psychometrically validate the neonatal near-miss assessment scale (NNMAS) for Ethiopia. METHODS: A total of 465 live birth neonates were included with the assumption of a participant-to-item ratio of 15:1. A new contextually validated NNMAS was used to collect data. The Kaiseri--Mayer--Olkin (KMO) measure of sampling adequacy with a cutoff value of ≥0.50 for each item was applied. For reliability and validity of NNMAS, exploratory factor analysis using principal component analysis with oblique varimax rotation was used. Internal consistency and reliability were assessed using Cronbach's alpha. Convergent and discriminant validity was assessed using composite reliability (CR) and average variance extracted (AVE). RESULTS: The Kaiser--Mayer--Olkin (KMO = 0.74) measure of sampling adequacy and Bartlett's Sphericity test for the appropriateness of the identity matrix (χ2 = 2903.9, df = 276, and P = 0.000) were suitable for exploratory factor analysis (EFA). The correlation matrix determinant of the study was 0.002. The principal component analysis (PCA) identified six factors and together explained 54.3% of the variation in the Neonatal Near miss. The Cronbach-alpha coefficient was 0.80 for the entire scale. The composite reliability values of the factors ranged from 0.87 to 0.95. The AVEs, CR, and factor loadings were above 0.5 for all factors indicating that convergent validity was met. The square roots of the AVEs were greater than factor correlation values. It was revealed that discriminated validity was also met. CONCLUSION: The neonatal near-miss assessment scale was found to be valid and reliable in the present context. The scale can be used to identify near-miss neonates in Ethiopia.

Assessment of content validity for a Neonatal Near miss Scale in the context of Ethiopia.

BACKGROUND: The concept of neonatal near miss is used to identify neonates who nearly died but survived a life-threatening complication in the first 28 days of life. Neonatal mortality is the tip of the iceberg. Quality improvement through utilization of a validated scale and reduction in adverse neonatal outcome is a priority for achieving sustainable development goals. OBJECTIVES: To develop and assess the content validity of neonatal near-miss scale in the public health hospitals in Amhara Regional State, northwest Ethiopia. METHODS: A literature review was performed prior to the development of the neonatal near-miss assessment scale. An expert panel committee was formed by health facility practitioners and by the members of the academia. Two rounds of meetings were conducted with the expert panel to reach consensus on the face and content validity. The content validity index, Kappa statistics, and the content validity ratio were computed to estimate the content validity scale of neonatal near miss. RESULTS: In this study, four domains (pragmatic, clinical, management, and lab-investigations) with 32 items were identified. The item-level content validity index ranged from 0.7 to 1. The overall scale content validity (S-CVI) (average) for the domains (pragmatic, clinical, management, and lab-investigations) were 0.98, 0.95, 0.96, and 0.96, respectively. The overall S-CVI (universal) was 0.78 to 1, whereas the overall S-CVI (average) of neonatal near miss assessment scale was found to be 0.96. The content validity ratio and Kappa statistics values ranged from 0.6 to 1 and 0.9 to 1 for the respective domains. CONCLUSION: The identified four domains and the respective items were valid enough (content-wise) to be used as identification criteria for neonatal near-miss cases. The scale will contribute to neonatal near-miss identification and also improve the quality of neonatal management care.

Findings from a context specific accreditation assessment at 38 public midwifery education institutions in Bangladesh.

BACKGROUND: In order to promote sustainable midwifery education, it is important to understand what the structural shortcomings are. In this study of 38 public nursing institutions in Bangladesh, we aim to identify a number of structural shortcomings and to discuss strategies for limiting them. METHODS: An evaluated context-specific accreditation assessment tool consisting of 37 multi-choice closed-response questions encompassing 14 educational standards aligned with international standards for midwifery education programs and competences for midwifery educators was used to assess all public nursing institutions in Bangladesh (n=38), the results of which are presented in simple descriptive statistics; number (n), percentage (%), mean, SD and minimum-maximum value. RESULTS: Provision around clinical practice sites is the key structural shortcoming within the Bangladeshi midwifery educational system. Twenty-five percent of the institutions provided no opportunity for midwifery students to practice comprehensive sexual and reproductive health care. Twenty-nine per cent of the clinical sites were not aware of the content of midwifery courses and syllabi. Finally, one third of students achieving a midwifery qualification did not meet the learning outcomes to support women in birth. CONCLUSIONS: To measure progress towards national and global milestones to ensure students are equipped with required competencies before graduating as registered midwives will be difficult to meet unless shortcomings within the educational system are addressed. We recommend (i) the inclusion of clinical placement sites in future assessments, (ii) the introduction of an integrated feedback-appeal-response system, and (iii) the development of a system for improved communication links between educational institutions and clinical placement sites.

Implementation of a context-specific accreditation assessment tool for affirming quality midwifery education in Bangladesh: a qualitative research study.

Background: Only recently did midwifery become a profession in Bangladesh. As such, sufficient quality education, both theory and practice, remains a challenge. In 2018, a context-specific accreditation assessment tool for affirming quality midwifery education was therefore developed and implemented.Objectives: To describe both the positive and negative aspects of the implementation of an accreditation process at midwifery education institutions in Bangladesh and to sketch out areas for possible improvement.Method: Forty focus group discussions were conducted with 276 policymakers, regulatory authorities and educators involved in midwifery education and services in Bangladesh. The Consolidated Framework for Implementation Research (CFIR) was used in a directed content analysis approach.Results: The accreditation assessment tool was developed using a participatory and consensus-building approach, building on existing policies, which resulted in the national ownership of its implementation. Staff from clinical sites were not included in the accreditation process; unless this changes, this will make it difficult for Bangladesh to achieve the set accreditation standards. The accreditation process has improved communication between the midwifery teaching institutions, policymakers and regulatory authorities. Educators started to visit the clinical sites more frequently. The planning process was complex and time-consuming, and emphasis was put on the importance of developing a plan of action for measuring improvements.Conclusion: In the move from the initial assessment of an accreditation process to its implementation, it is essential to make public the results found at all educational institutions. This encourages acceptance, while soliciting feedback and suggestions for future action. Only then can an accreditation process have an impact on the provision of high-quality midwifery education and services. This paper aims to encourage and guide other countries in their development, planning and implementation of a national accreditation process for midwifery education.

Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study.

OBJECTIVE: In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective. METHODS: Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia. RESULTS: Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence. CONCLUSIONS: Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.

What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students.

BACKGROUND: With professional midwives being introduced in Bangladesh in 2013, the aim of this study was to describe midwifery students perceptions on midwives' realities in Bangladesh, based on their own experiences. METHOD: Data were collected through 14 focus group discussions that included a total of 67 third-year diploma midwifery students at public nursing institutes/colleges in different parts of Bangladesh. Data were analyzed deductively using an analytical framework identifying social, professional and economical barriers to the provision of quality care by midwifery personnel. RESULTS: The social barriers preventing midwifery quality care falls outside the parameters of Bangladeshi cultural norms that have been shaped by beliefs associated with religion, society, and gender norms. This puts midwives in a vulnerable position due to cultural prejudice. Professional barriers include heavy workloads with a shortage of staff who were not utilized to their full capacity within the health system. The reason for this was a lack of recognition in the medical hierarchy, leaving midwives with low levels of autonomy. Economical barriers were reflected by lack of supplies and hospital beds, midwives earning only low and/or irregular salaries, a lack of opportunities for recreation, and personal insecurity related to lack of housing and transportation. CONCLUSION: Without adequate support for midwives, to strengthen their self-confidence through education and through continuous professional and economic development, little can be achieved in terms of improving quality care of women during the period around early and late pregnancy including childbirth.The findings can be used for discussions aimed to mobilize a midwifery workforce across the continuum of care to deliver quality reproductive health care services. No matter how much adequate support is provided to midwives, to strengthen their self-confidence through education, continuous professional and economic development, addressing the social barriers is a prerequisite for provision of quality care.

Development of a context specific accreditation assessment tool for affirming quality midwifery education in Bangladesh.

OBJECTIVE: using the International Confederation of Midwives (ICM) Global Standards for Midwifery Education as a conceptual framework, the aim of this study was to explore and describe important 'must haves' for inclusion in a context-specific accreditation assessment tool in Bangladesh. DESIGN: A questionnaire study was conducted using a Likert rating scale and 111 closed-response single items on adherence to accreditation-related statements, ending with an open-ended question. The ICM Global Standards guided data collection, deductive content analysis and description of the quantitative results. SETTING: twenty-five public institutes/colleges (out of 38 in Bangladesh), covering seven out of eight geographical divisions in the country. PARTICIPANTS: one hundred and twenty-three nursing educators teaching the 3-year diploma midwifery education programme. FINDINGS: this study provides insight into the development of a context-specific accreditation assessment tool for Bangladesh. Important components to be included in this accreditation tool are presented under the following categories and domains: 'organization and administration', 'midwifery faculty', 'student body', 'curriculum content', 'resources, facilities and services' and 'assessment strategies'. The identified components were a prerequisite to ensure that midwifery students achieve the intended learning outcomes of the midwifery curriculum, and hence contribute to a strong midwifery workforce. The components further ensure well-prepared teachers and a standardized curriculum supported at policy level to enable effective deployment of professional midwives in the existing health system. KEY CONCLUSIONS: as part of developing an accreditation assessment tool, it is imperative to build ownership and capacity when translating the ICM Global Standards for Midwifery Education into the national context. IMPLICATIONS FOR PRACTICE: this initiative can be used as lessons learned from Bangladesh to develop a context-specific accreditation assessment tool in line with national priorities, supporting the development of national policies.