Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.

BACKGROUND: Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios. METHODS: For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world's maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. FINDINGS: We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly concentrated in the group B countries, which currently account for a large proportion of the world's population and have high mortality rates compared with group C. INTERPRETATION: Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. FUNDING: New Venture Fund.

Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis.

BACKGROUND: Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally. OBJECTIVE: To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care. DESIGN: Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively. FINDINGS: Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery. KEY CONCLUSIONS: There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective.

BACKGROUND: Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider's perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care. METHODS AND FINDINGS: A systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care. CONCLUSIONS: Significant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

Invest in adolescents and young people: it pays.

This year's Women Deliver conference made a strong call for investing in the health and development of adolescents and young people. It highlighted the unique problems faced by adolescent girls and young women-some of the most vulnerable and neglected individuals in the world-and stressed the importance of addressing their needs and rights, not only for their individual benefit, but also to achieve global goals such as reducing maternal mortality and HIV infection.In response to an invitation from the editors of Reproductive Health, we-the sixteen coauthors of this commentary-put together key themes that reverberated throughout the conference, on the health and development needs of adolescents and young people, and promising solutions to meet them.1. Investing in adolescents and young people is crucial for ensuring health, creating prosperity and fulfilling human rights.2. Gender inequality contributes to many health and social problems. Adolescent girls and boys, and their families and communities, should be challenged and supported to change inequitable gender norms.- Child marriage utterly disempowers girls. It is one of the most devastating manifestations of gender discrimination.- Negative social and cultural attitudes towards menstruation constrain the lives of millions of girls. This may well establish the foundation for lifelong discomfort felt by girls about their bodies and reticence in seeking help when problems arise.3. Adolescents need comprehensive, accurate and developmentally appropriate sexuality education. This will provide the bedrock for attitude formation and decision making.4. Adolescent-centered health services can prevent sexual and reproductive health problems and detect and treat them if and when they occur.5. National governments have the authority and the responsibility to address social and cultural barriers to the provision of sexual and reproductive health education and services for adolescents and young people.6. Adolescents should be involved more meaningfully in national and local actions intended to meet their needs and respond to their problems.7. The time to act is now. We know more now than ever before about the health and development needs of adolescents and young people, as well as the solutions to meeting those needs.