Challenges and opportunities of English as the medium of instruction in diploma midwifery programs in Bangladesh: a mixed-methods study.

BACKGROUND: English is generally recognized as the international language of science and most research on evidence-based medicine is produced in English. While Bangla is the dominant language in Bangladesh, public midwifery degree programs use English as the medium of instruction (EMI). This enables faculty and student access to the latest evidence-based midwifery content, which is essential for provision of quality care later. Yet, it also poses a barrier, as limited English mastery among students and faculty limits both teaching and learning. METHODS: This mixed-methods study investigates the challenges and opportunities associated with the implementation of EMI in the context of diploma midwifery education in Bangladesh. Surveys were sent to principals at 38 public midwifery education institutions, and 14 English instructors at those schools. Additionally, ten key informant interviews were held with select knowledgeable stakeholders with key themes identified. RESULTS: Surveys found that English instructors are primarily guest lecturers, trained in general or business English, without a standardized curriculum or functional English language laboratories. Three themes were identified in the key informant interviews. First, in addition to students' challenges with English, faculty mastery of English presented challenges as well. Second, language labs were poorly maintained, often non-functional, and lacked faculty. Third, an alternative education model, such as the English for Specific Purposes (ESP) curriculum,  has potential to strengthen English competencies within midwifery schools. CONCLUSIONS: ESP, which teaches English for application in a specific discipline, is one option available in Bangladesh for midwifery education. Native language instruction and the middle ground of multilingualism are also useful options. Although a major undertaking, investing in an ESP model and translation of technical midwifery content into relevant mother tongues may provide faster and more complete learning. In addition, a tiered system of requirements for English competencies tied to higher levels of midwifery education could build bridges to students to help them access global evidence-based care resources. Higher levels might emphasize English more heavily, while the diploma level would follow a multilingualism approach, teach using an ESP curriculum, and have complementary emphasis on the mother tongue.

Testing the feasibility of a translated and culturally adapted person-centred training programme in maternal and newborn healthcare in Democratic Republic of Congo: A process evaluation.

OBJECTIVE: Ensuring quality of maternal and newborn healthcare is challenging in the Democratic Republic of Congo (DRC) as the maternal and newborn mortality and morbidity rate is high. Essential for quality care is a person-centred approach. One model of person-centred care (PCC) has been developed at Gothenburg University. To support its implementation a training programme, "Mutual Meetings", has been developed. This study aims to test the feasibility of a translated and culturally adapted version of this PCC training programme for healthcare providers in the maternal and newborn healthcare context of DRC. METHODS: The PCC programme was translated into French and tested in a workshop with 31 maternal and newborn healthcare providers in eastern DRC. The feasibility of the programme was evaluated through focus group interviews and individual interviews. The interview transcripts were analysed deductively using key components in a process evaluation framework including fidelity, dose, reach, adaptation, acceptability, and application. RESULTS: The French PCC programme exceeded the participants' expectations and was found being applicable in both teaching and clinical setting with some suggested contextual modifications. Its pedagogic structure including a participatory reflective approach, was perceived innovative and inspirational, mediated a sense of comfort, and enabled the participants to use a person-centred approach towards each other. CONCLUSION: The results show that the French on-site version of the PCC training programme was valid in terms of feasibility and how it was received by the participants. The study demonstrates the importance of contextual adaptation of complex interventions in new settings.

Attitudes towards induced abortion among gynecologists in Kurdistan region of Iraq.

BACKGROUND: Unsafe abortion is a major contributor to maternal morbidity and mortality in countries where induced abortion is restricted. In Kurdistan Region of Iraq, induced abortion is strictly forbidden except for life-threatening situations, increasing the risk of seeking unsafe abortions. Attitudes among healthcare professionals who directly encounter cases and consequences of induced abortion can be studied to improve women's access to safe abortion. This study aimed to examine attitudes towards induced abortion among gynecologists in Kurdistan Region of Iraq. METHODS: This cross-sectional facility-based study was conducted in the first quarter of 2022 in Kurdistan Region of Iraq in the cities of Erbil, Sulaymaniyah, and Duhok. Convenient sampling was used to invite 330 gynecologists to participate, with 171 ultimately completing the questionnaire, giving a response rate of 53%. Questionaries using the Taylor and Whitehead abortion attitude scale were sent in person or digitally. The data was then analyzed using Chi-square and Fisher's exact tests to determine the independence of attitudes and associations between attitudes and sociodemographic factors. RESULTS: Among 171 gynecologists, 25% of the gynecologists agreed that induced abortion is unacceptable under any circumstances. Most (71%) disagreed that a woman has the right to choose to have an induced abortion. Around 51% considered induced abortion murder, and 41% agreed that induced abortion goes against all morals. Around 57% disagreed with the legalization of induced abortion, while 43% agreed. Gynecologists who were unmarried (P = 0.025), under the age of 40 (P = 0.044), and with less than 10 years of clinical experience (P = 0.043) were more likely to support the legalization of induced abortion in Kurdistan Region. None of the variables was found to be independently associated with attitudes towards abortion legalization. CONCLUSIONS: Despite some younger gynecologists having more favorable attitudes towards induced abortion, most gynecologists in Kurdistan Region had less favorable views. Most gynecologists were willing to provide post-abortion care regardless of their legal status. We recommend conducting more studies to investigate the consequences of current abortion legislation among women in need of induced abortion in Kurdistan Region of Iraq.

Cultural adaptation and psychometric evaluation of Childbirth Experience Questionnaire 2 in Karnataka state, India.

BACKGROUND: Women's birthing experience is a sensitive indicator of the quality of childbirth care and can impact the physical and mental health of both women and their neonates. Negligible evidence exists on Indian women's birth experiences and-to the best of authors' knowledge-no questionnaire has been tested in India for measuring women's birthing experiences. This study aimed to test the construct validity and reliability of the Kannada-translated Revised Childbirth Experience Questionnaire. METHODOLOGY: A cross-sectional survey was carried out among postnatal women (n = 251, up to six months postpartum, with a live healthy neonate) who had given birth at a public or private health facility using the Kannada-translated CEQ2 in two districts of Karnataka. Data were collected at participants' homes after seeking written informed consent. Model fit was determined by Confirmatory Factor Analyses. RESULTS: The 4-factor model of the CEQ2 showed good fit after deletion of one item (item 8, subcategory "participation") with CMIN = 1.33; SRMR = 0.04; GFI = 0.92, CFI = 0.98, TLI = 0.99, RMSEA = 0.037 and p value 0.002). The Cronbach alpha values were acceptable for the four subscales (0.92, 0.93, 0.97, 0.91) as well as for the overall 21-item scale (0.84). CONCLUSIONS: The Kannada-translated CEQ2 is a reliable tool to measure the childbirth experiences among Kannada-speaking women and can serve as a reliable ongoing evaluation of women's birth experiences.

Factors affecting the provision of high-quality postnatal care services in Zanzibar: a qualitative study.

BACKGROUND: In Sub-Saharan Africa, the postnatal period is associated with high mortality and accounts for a substantial proportion of maternal deaths. Although postnatal care has been identified as critical in reducing maternal mortality, the quality of care provided is often inadequate. Tanzania and Zanzibar have not made sufficient progress towards achieving the Sustainable Development Goals on maternal health, and there is limited knowledge about the utilization and quality of postnatal follow-up. The aim of this study was therefore to explore factors affecting the provision of high-quality postnatal care services in the urban area of Zanzibar. METHODS: Five focus group discussions were performed in Swahili with 25 healthcare providers from primary healthcare units in urban Zanzibar. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis with an inductive approach. RESULTS: Factors affecting provision of high-quality postpartum care services could be divided into three generic categories. Difficulty achieving high attendance comprised three subcategories: long waiting times, low awareness among women, and out-of-pocket payment. Lack of basic resources also comprised three subcategories: shortage of healthcare providers, lack of adequate space, and inadequate medical equipment. Insufficient care routines comprised two subcategories: lack of guidelines and deficient chain of information. CONCLUSIONS: The present findings suggest that the women's perceptions of postnatal care do not align with the intended purpose of routine postnatal care. Instead, the postnatal period primarily leads to visits to health facilities only when urgent care is required, and there is a lack of awareness about the importance of postnatal care. Moreover, limited resources, including equipment, staff, and space, as well as long waiting times, hinder the delivery of high-quality care and contribute to a negative reputation of postnatal care services. To effectively reach all women and improve postnatal care, it is necessary to increase basic resources, modify health education approaches, and enhance the flow of information between different levels of care using context-specific strategies.

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.

Contextual factors influencing implementation of a university-based midwifery education programme in Central Africa: A qualitative study.

AIM: To investigate contextual factors and their influence on implementing a 90-credit midwifery education programme for nurses at a university in the eastern DRC. BACKGROUND: To improve maternal and neonatal health, there is a government policy in the Democratic Republic of Congo (DRC) to educate midwives at a higher education level according to international norms. This study investigates contextual factors and their influence on the implementation of a midwifery education programme which is based on national curriculum and has a profile of person-centred care, simulation-based learning pedagogy and information and communication technology. METHOD: A qualitative study was conducted with data collected through semi-structured interviews with 22 participants who were directly or indirectly involved in establishing the midwifery education programme. Transcribed interviews were analysed using content analysis. RESULTS: The factors influencing the implementation of the new midwifery education programme comprise facilitating and hindering factors. Facilitating factors were: (i) awareness that midwives educated at a higher education level can deliver higher-quality health care, (ii) women are motivated to seek care from well-educated midwives, (iii) the planned programme is attractive and (iv) the university has a stable academic administration and established collaborations. Hindering factors were: (i) Students' lack of prerequisites for study; (ii) objections to educating midwives at a higher education level; (iii) inadequate teaching resources; and (iv) inadequate working conditions for midwives. CONCLUSION: The facilitating factors strengthen the belief that it is possible to implement this midwifery education programme, while the hindering factors need to be addressed to run the programme successfully. The findings can guide higher education institutions starting similar midwifery education programmes in the DRC and elsewhere, although it is crucial to conduct a context study in those specific contexts.

Barriers to using postpartum family planning among women in Zanzibar, Tanzania.

BACKGROUND: Effective family planning is associated with substantial benefits, including reductions in maternal and neonatal mortality due to the avoidance of unintended pregnancies, and contributions to spacing, timing, and limiting births. However, in Zanzibar, Tanzania, the utilization of modern contraceptive methods is low. This study therefore aimed to identify barriers to using postpartum family planning among women in Zanzibar. METHODS: Five focus group discussions were conducted with 24 women who gave birth in the maternity unit at a reference hospital in Zanzibar during the first quarter of 2022. The discussions took place in Swahili, were performed with the assistance of an interview guide, and were audio recorded, transcribed in Swahili, and translated to English. Data were analysed with qualitative content analysis using an inductive approach. RESULTS: Barriers to using postpartum family planning in Zanzibar could be summarized in three generic categories. Inadequate knowledge about postpartum family planning is expressed in the subcategories: inadequate knowledge about contraceptive methods and their mode of action, insufficient quality of family planning services, and belief in traditional and natural medicine for family planning. Perceived risks of modern contraceptive methods are described in the subcategories: fear of being harmed, and fear of irregular bleeding. Limited power in one's own decision about contraceptive use consist of the subcategories: the need to involve the husband, and opposition and lack of interest from the husband. CONCLUSIONS: The participants' current knowledge of postpartum family planning was insufficient to either overcome the fear of side-effects or to understand which side-effects were real and likely to happen. The woman's power in her own decision-making around her sexual reproductive rights is of critical importance. Given the barriers identified in this study, the findings call for increased knowledge about family planning methods and their mode of action, and involvement of the husband throughout pregnancy, childbirth, and the postpartum period in postpartum family planning education and counselling, in Zanzibar and in similar settings.

Syrian women's experiences of being pregnant and receiving care at antenatal clinics in Sweden for the first time after migration.

OBJECTIVE: To describe Syrian women's experiences of being pregnant and receiving care at antenatal clinics for the first time after migration. METHODS: A phenomenological lifeworld approach was used. Eleven women from Syria enrolled at antenatal clinics, who were experiencing their first pregnancy in Sweden but who may have given birth before in other countries, were interviewed in 2020. The interviews were open and based on one initial question. Data were inductively analysed using a phenomenological method. RESULTS: The essence of Syrian women's experiences of being pregnant and receiving care at antenatal clinics for the first time after migration was the importance of being met with understanding to create trust to build a sense of confidence. The following four constituents capture the essence of the women's experiences: "It was important to feel welcomed and to be treated like an equal"; "A good relationship with the midwife strengthened self-confidence and trust"; "Good communication despite language difficulties and cultural differences was important"; and "Previous experience of pregnancy and care influenced the experience of the care received". CONCLUSION: Syrian women's experiences reveal a heterogeneous group with different experiences and background. The study highlights the first visit and emphasises the importance of this visit for future quality of care. It also points out the negative occurrence of the transferring guilt from the midwife to the migrant woman in case of cultural insensitivity and clashing norm systems.

Using process-oriented groups reflections with health care providers to improve childbirth care in the Democratic Republic of Congo - An implementation study.

OBJECTIVE: The ability to systematically reflect on care during labour and birth needs to be developed among health care providers. This study investigates the experiences of health care providers who have participated in process-oriented group reflections. The activity of group reflections was one of the three pillars of a training intervention seeking to implement evidence-based care routines during labour and birth that could contribute to reduced mortality and improved maternal and newborn health in the Democratic Republic of Congo (DRC). METHODS: Using a qualitative approach, we interviewed 131 health care providers, in focus groups (n = 19) and individually (n = 2). Analysis of transcribed interviews was conducted using qualitative content analysis according to Elo and Kyngäs. RESULTS: Group reflections added essential knowledge to the other components of the three-pillar training intervention. Through sharing and analysing care situations health care providers got increased self-awareness, tools to achieve structured and safe care routines, and to practice teamworking. CONCLUSION: Using a structured model of process-oriented group reflection for health care providers on care during labour and birth proved to be a vital aspect of the training intervention, as it added knowledge to the skills gained through theoretical and simulation-based education. The three-pillar training intervention improved care routines that supported healthy births and management of complications. We recommend that structured and secure group reflections be included in similar training activities in the DRC and elsewhere, and assessed in further studies.

Contextual factors influencing the implementation of midwifery-led care units in India.

BACKGROUND: The Government of India has committed to educate 90,000 midwives functioning in midwifery-led care units (MLCUs) to care for women during labour and birth. There is a need to consider local circumstances in India, as there is no 'one size fits all' prescription for MLCUs. AIM: To explore contextual factors influencing the implementation of MLCUs across India. METHOD: Data were collected through six focus group interviews with 16 nurses, midwives, public health experts and physicians, representing six national and international organisations supporting the Indian Government in its midwifery initiative. Transcribed interviews were analysed using content analysis. FINDINGS: Four generic categories describe the contextual factors which influence the implementation of MLCUs in India: (i) Perceptions of the Nurse Practitioner in Midwifery and MLCUs and their acceptance, (ii) Reversing the medicalization of childbirth, (iii) Engagement with the community, and (iv) The need for legal frameworks and standards. CONCLUSION: Based on the identified contextual factors in this study, we recommend that in India and other similar contexts the following should be in place when designing and implementing MLCUs: legal frameworks to enable midwives to provide full scope of practice in line with the midwifery philosophy and informed by global standards; pre- and in-service training to optimize interdisciplinary teamwork and the knowledge and skills required for the implementation of the midwifery philosophy; midwifery leadership acknowledged as key to the planning and implementation of midwifery-led care at the MLCUs; and a demand among women created through effective midwifery-led care and advocacy messages.

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

BACKGROUND: A necessary precursor for quality maternity care provision is high quality education. The quality of care that students are exposed to during clinical education on maternity wards shapes their competencies and professional identities. In this study, we look at the introduction of midwives educated to international standards - with facility mentorship - deployed in tertiary level teaching hospitals in Bangladesh with the intention of improving the use of World Health Organization (WHO)-recommended birth practices. AIM: To examine the outcomes of introducing midwifery services into tertiary level care facilities in Bangladesh, on the use of WHO-recommended birth practices. METHODS: A retrospective review of patient register data was carried out to understand level of changes in use of WHO-recommended birth practices after the introduction of a midwifery service. Multivariate linear regression was applied using an interrupted time series analysis, with and without a delayed effect, to assess both level and trend change following the introduction of the midwifery service. FINDINGS: A significant increase (p < 0.001) in use of WHO-recommended birth practices was found, both immediately following the midwives' introduction and after one year. Quality improvement was observed not only in births attended by midwives, but also in those attended by doctors and nurses. CONCLUSION: By introducing quality maternity care provision through midwives in clinical sites, especially in tertiary-level care hospitals with large numbers of students, international standard midwives can improve the quality of clinical education in maternity wards, a critical priority for maternal health worldwide.

Contextual factors influencing the implementation of a new midwife education programme in India: a qualitative study.

The Indian Government has committed to educate 90,000 midwives in accordance with international norms. This goal is critical as midwives provide evidence-based, high-quality midwifery care. There is a need to explore the contextual factors influencing this new midwifery education programme. Hence, the aim of this study is to explore contextual factors influencing the implementation of the national midwifery education programme for midwifery educators and the future Nurse Practitioners in Midwifery (NPMs) in India. A qualitative research design was used, with data collected through focus group discussions (n = 8) with a total of 27 participants representing seven national and international organisations supporting the Indian Government in its midwifery initiative. Transcribed interviews were analysed using content analysis. This study on contextual factors influencing the implementation of the new midwifery education programme in India showed that organisational and administrative processes are complex and the development of midwifery educators and nurse practitioners in midwifery needs to be fast tracked. The education of educators and future midwives in India, and elsewhere in similar settings, could benefit from efforts to simplify the organisational and administration processes and, in parallel, mobilize innovative teaching and learning approaches to bridge theory and practice.

Barriers and strategies needed to improve maternal health services among pregnant adolescents in Uganda: a qualitative study.

BACKGROUND: In Uganda, the uptake of maternal health services is very low, with only 41.1% of pregnant adolescent girls attending the eight antenatal visits that are recommended by the World Health Organisation. Uptake of maternal health services is essential in reducing the current level of adolescent pregnancies as well as its adverse effects on adolescent mothers and their babies, such as preterm deliveries, prolonged labour, death during pregnancy, and childbirth. No previous study has described pregnant adolescents' experiences with maternal health services in Uganda. OBJECTIVE: This study aimed to describe the barriers and strategies needed to improve maternal health services among pregnant adolescents in Uganda. METHODS: Data were collected in the Naguru Teenage Information and Health Centre in Uganda through individual interviews involving 31 pregnant adolescents. The transcribed interviews were inductively analysed through content analysis. RESULTS: The pregnant adolescents described difficulty in reaching, as well as lack of financial support to visit, the Naguru Teenage Information and Health Centre, which is a clinic providing youth friendly services. Feelings of being discriminated against and disrespected by health workers, and lack of privacy when receiving health services was major barriers that hindered their access to maternal health services. Pregnant adolescents' access to these services can be enhanced by improving health workers' working conditions, accelerating community and health worker awareness on ways to mitigate these barriers, and developing policies that encourage men's involvement in maternal health services. CONCLUSION: Adolescents in Uganda face considerable barriers to accessing improved and quality maternal health services. To mitigate these barriers, according to the adolescents, considerable efforts are required to tackle health workers' working conditions and sensitise the community on the importance of, as well as securing the availability of, maternal health services for pregnant adolescents. Future research should focus on pregnant adolescents who receive family support.

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.

Implementation of a three-pillar training intervention to improve maternal and neonatal healthcare in the Democratic Republic Of Congo: a process evaluation study in an urban health zone.

BACKGROUND: Numerous quality-improvement projects including healthcare professional training are conducted globally every year, but there is a gap between the knowledge obtained in the training and its implementation in practice and policy. A quality-improvement programme was conducted in eastern Democratic Republic of Congo (DRC) to reduce maternal and neonatal mortality and morbidity. OBJECTIVE: This study explores the implementation process, mechanisms of impact, and outcomes of a training intervention addressing labour and birth management and involving healthcare providers in an urban health zone in eastern part of DRC. METHODS: In 2019, master trainers were educated and in turn trained facilitators from seven participating healthcare facilities, which received the necessary equipment. Data comprised statistics on maternal and neonatal birth outcomes for the years before and after the training intervention, and focus group discussions (n = 18); and interviews (n = 2) with healthcare professionals, at the end of (n = 52) and after the training intervention (n = 59), respectively. The analysis was guided by a process evaluation framework, using descriptive statistics and content analysis. RESULTS: The three-pillar training intervention using a low-dose, high-frequency approach was successfully implemented in terms of fidelity, dose, adaptation, and reach. Several improved care routines were established, including improved planning, teamwork, and self-reflection skills, as well as improved awareness of the influence of the care environment, of having a respectful encounter, and of allowing a companion to be present with the birthing woman. The proportions of emergency caesareans decreased and of vaginal births increased without an increase in maternal and neonatal complications. CONCLUSION: The findings of this study are encouraging and provide learnings for other healthcare facilities in DRC as well as other low-income countries. When designing similar training interventions, it is crucial to consider contextual factors such as incentives and to measure more salutogenic outcomes.

Facilitators of and barriers to providing high-quality midwifery education in South-East Asia-An integrative review.

BACKGROUND: With a diversity in midwifery education across the South-East Asia region, and with the knowledge about the lifesaving competency of the midwife profession, this study's aim is to describe facilitators of and barriers to providing high-quality midwifery education in South-East Asia. METHODS: Inspired by Whittemore and Knafl, we conducted a systematic integrative literature review including the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results. The literature searches were conducted in October 2020 in the databases CINAHL, PubMed, and Scopus. A deductive data analysis based on global standards was performed. RESULTS: The search identified 1257 articles, 34 of which were included. Countries in South-East Asia did not fully comply with the ICM global standards. Midwifery education was not separated from that of nursing, and educators lacked formal qualifications in midwifery. Curriculum implementation in the clinical area was a key barrier to achieving learning outcomes. Higher academic education for midwifery educators and mentorship programs facilitated the pedagogic and assessment process, focusing on the abilities of critical thinking, reflection, and decision-making. CONCLUSIONS: Countries in South-East Asia still have a long way to go before they can provide high-quality midwifery education. The identified facilitators can lead to a difference in students' academic achievement and confidence in their clinical work. Coordinated actions will enable the progress in achieving competent midwives matching national health priorities. The findings highlight a need for more research on midwifery education in both theory and practice across the region.

Contextual factors influencing a training intervention aimed at improved maternal and newborn healthcare in a health zone of the Democratic Republic of Congo.

BACKGROUND: Maternal and neonatal mortality and morbidity in the Democratic Republic of Congo (DRC) are among the highest worldwide. As part of a quality improvement programme in a health zone in the DRC aimed at contributing to reduced maternal and neonatal mortality and morbidity, a three-pillar training intervention around childbirth was developed and implemented in collaboration between Swedish and Congolese researchers and healthcare professionals. The aim of this study is to explore contextual factors influencing this intervention. METHODS: A qualitative research design was used, with data collected through focus group discussions (n = 7) with healthcare professionals involved in the intervention before and at the end (n = 9). Transcribed discussions were inductively analysed using content analysis. RESULTS: Three generic categories describe the contextual factors influencing the intervention: i) Incentives motivated participants' efforts to begin a training programme; ii) Involving the local health authorities was important; and (iii) Having physical space, electricity, and equipment in place was crucial. CONCLUSIONS: This study and similar ones highlight that incentives of various types are crucial contextual factors that influence training interventions, and have to be considered already in the planning of such interventions. One such factor is expectations of monetary incentives. To meet this in a small research project like ours would require a reduction of the scale and thus limit the implementation of new evidence-based knowledge into practice aimed at reducing maternal mortality and morbidity.

Defibulated immigrant women's sexual and reproductive health from the perspective of midwives and gynaecologists as primary care providers in Sweden - A phenomenographic study.

OBJECTIVE: To capture care providers' perceptions of defibulated immigrant women's sexual and reproductive health, illuminated by their experiences as care providers for these women. METHODS: Individual interview study with 13 care providers at Swedish healthcare facilities: six gynaecologists and seven midwives caring for defibulated immigrant women, analysed with a phenomenographic method. FINDINGS: One of the care providers' perceptions of women who had been defibulated was that they had an altered genital function, meaning a wider introitus, improved vaginal intercourse, and more ease urinating and menstruating. The care providers also perceived that women who were defibulated had to balance their wellbeing, struggling between a positive self-image and handling their emotions. Existing in-between cultural values led to a fear of being excluded while at the same time having a desire to be included in the new culture. CONCLUSION: Defibulation affects women's sexual and reproductive health and calls for a holistic perspective when providing services, individualized according to the woman's care needs. Support and counselling, should include information about defibulation already during the adolescent years to promote sexual and reproductive health and well-being.

Impact of the Helping Mothers Survive Bleeding After Birth learning programme on care provider skills and maternal health outcomes in low-income countries - An integrative review.

BACKGROUND: To improve maternal health outcomes, highly competent healthcare providers are needed. One strategy used to improve performance among healthcare providers is simulation-based learning. An integrative review was designed with the aim of synthesising available research on Helping Mothers Survive (HMS), a learning programme used in low-income countries, and its impact on care provider skills and maternal health outcomes. METHOD: A systematic search was conducted in June 2020 in CINAHL, PubMed, Scopus, and Web of Science. All stages of inclusion, quality assessment, and data extraction were done independently by four reviewers. A narrative synthesis was used for the outcomes of care provider skills and knowledge, as well as maternal health outcomes. FINDINGS: The search identified 50 articles, 22 of which were excluded due to being duplicates, 16 based on their title and abstract, and two based on their full text. Eleven papers were included in the synthesis: eight quantitative, two qualitative, and one mixed-method study, originating from India, Malawi, Tanzania, Uganda, and Zanzibar. The Helping Mothers Survive-Bleeding After Birth (HMS-BAB) learning programme was found to have a positive impact on care providers' competencies and maternal health outcomes, with a reduced number of postpartum haemorrhages and a reduction in maternal mortality. CONCLUSION: The HMS-BAB learning programme has the potential to increase competence among care providers and improve maternal health outcomes in low-income settings. A successful use of the programme to maintain improved care routines for mothers requires multi-professional teams, facility readiness, a low-dose high-frequency approach, a local coordinator, and accountability and ownership.