Midwives voices, midwives realities. Findings from a global consultation on providing quality midwifery care

BackgroundSkilled birth attendance has been shown to have a positive impact of on maternal and newborn health outcomes, however to date there has been little focus on researching the perspectives of midwifery staff about what is needed to  support them to provide quality care to women and newborns.This research was developed by the World Health Organization (WHO) in collaboration with the International Confederation of Midwives (ICM) and the White Ribbon Alliance (WRA) to address this gap in the literature.MethodsIn 2013, a joint WHO-ICM-WRA session at the 2013 Women Deliver Conference in Kuala Lumpur was held to find out if midwifery providers felt empowered, respected and safe while delivering their maternity care. This meeting and subsequent mapping of the literature by the WHO led to the development of an analytical framework looking at how social, economic and professional burdens can lead to moral distress and burn out among midwifery providers.In 2014, this framework was explored further through a joint WHO-ICM-WRA multilingual participatory workshop at the ICM Congress in Prague, Czech Republic, and also through an accompanying global online survey for midwifery professionals in four languages. A total of 2470 respondents from 93 countries contributed to the online survey, making this the largest global survey involving midwifery personnel to date. The majority of respondents identified themselves as midwives, however their titles varied by region.Key findings

• Midwifery professionals are committed to providing the quality care to women, newborns and their families and they are frustrated by the barriers they face in doing so
• Some midwives reported poor working conditions due to a range of issues, including staff shortages, disorganised health systems, poor management, inadequate supervision, poor quality training, and lack of equipment and supplies
• On top of these problems, midwives also reported facing issues such as working within complex hierarchies of power and gender dynamics, for example 36% of survey respondents reported receiving a lack of respect from senior medical staff and about a quarter felt that they were also discriminated against because they were women
• Over a third of respondents (37%) reported having experienced harassment at work. Midwives in Africa in particular reported that disrespect in the workplace extended to verbal bullying and physical or sexual abuse which had a negative effect on their ability to provide quality care
• Midwives reported other factors which impacted on their ability to provide quality care, including trouble juggling their jobs with domestic and family responsibilities; insufficient salaries meaning many had to find other sources of income; and having inadequate and unsafe accommodation which left them isolated from family support.
• Respondents reported some good practices and improvements: increases in midwifery personnel in some places, more training and professional development, and delegation of less specialised tasks to maternity support staff
• Midwives expressed concern that their profession was undervalued by health systems and other cadres of health care professionals
• Many midwives also felt that there were not enough leadership opportunities for senior midwifery staff, especially in countries where midwifery was integrated into nursing structures
• While some midwives reported being listened to by other health professionals, 32% of all respondents (and 53% of African respondents) stated that they would value being listened to more

RecommendationsRespondents suggested several recommendations to support them to provide quality care:

• Ensuring midwifery is kept as a separate self-regulating profession, rather than integrated into nursing structures
• Engaging midwives in policy-making and management committees
• Making sure that education planners and researchers fully understand midwifery practice before making decisions about quality of care
• Strengthening midwifery education, including having specific midwifery educators rather than medical teachers, and integrating human rights, gender, ethics and equality into pre-service training
• Better access to higher education, workshops, courses and other professional development for midwives
• Introducing or strengthening peer support systems, for example midwifery associations
• Introducing or strengthening counselling systems, supportive supervision and mentoring for midwifery personnel
• Better pay, health insurance and social security systems for midwifery personnel
• More leadership options and positions for senior midwives, for example within government institutions
• Improved laws and protocols around midwifery

ConclusionsThe authors conclude that midwives globally have a deep understanding of what is needed in order to improve the quality of care they provide. However their voices are often not heard and therefore their realities and recommendations are missing from policy-making discussions. The authors hope this report goes some way toward giving midwifery personnel a voice to effect change.To read the report, click here.World Health Organization. (2016). Midwives voices, midwives realities. Findings from a global consultation on providing quality midwifery care. Geneva: WHO.