Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo.

BACKGROUND: Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. METHODS: A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. RESULTS: The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives' living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. CONCLUSION: Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

'Being a midwife is being prepared to help women in very difficult conditions': midwives' experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo.

INTRODUCTION: Maternal and neonatal health are core focus areas in fragile and conflict-affected areas, and hence midwives are key actors. But there is currently very little evidence on midwives' experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri Province in the north-eastern part of the Democratic Republic of Congo (DRC). This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives' work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, north-eastern DRC. METHODS: As part of a qualitative approach, life history interviews with 26 midwives and 6 ex-midwives, and three focus group discussions with 22 midwives in three health districts of Ituri Province (Bunia, Aru and Adja), were conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo software. A timeline framework was deployed in the analytical process. RESULTS: Problem solving, childhood aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses, resulting in different levels and training experiences. Midwives faced many work challenges: serious shortages of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation was worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives wanted to continue working as midwives or follow further midwifery studies. Family-related reasons were the main reasons for most ex-midwives to leave the profession. CONCLUSION: Midwives play a critical role in supporting women to deliver babies safely in rural Ituri Province. They face immense challenges and demonstrate bravery and resilience as they navigate the interface between underresourced health systems and poor, marginalized rural communities. This situation requires a call to action: donors need to prioritize these contexts; and the government and other stakeholders in DRC need to invest more in improving security conditions as well as working conditions and professional support for midwives in rural Ituri Province. Only then will midwives be able to provide the critical services that women and their families need, and therefore contribute to achieving universal health coverage.