Search results
Systematic literature searches for the critical interpretive synthesis were completed by 2 September 2020 and results are shown in figure 2. Fifty-seven documents were eligible for inclusion. Most documents (84%) were published after 2010, and none before 2000. Thirty-seven per cent were primary research (n=21), including: qualitative research (n=13), mixed-methods research (n=5) and descriptive studies (n=3). Within secondary research, 14% were systematic reviews (n=8) and one was a cross-sectional study. The remaining documents were non-research (n=27), including 10 ‘other’ (eg, toolkits, manuals, strategic plans, etc), 6 editorials, 5 theoretical papers and 5 non-systematic reviews. In accordance with WHO regions, the majority (n=28) focused on Africa, 10 on the Americas, 10 on South-East Asia, 6 on the Eastern Mediterranean, 1 on the Western Pacific, 5 on Europe, and 36% (n=17) spanned all of the regions.
Figure 2Literature search and study selection flow diagram.
Key drivers for midwifery association strengthening
Outer context
Results showed that sustainable midwifery associations are influenced by the role, regulation and integration of midwifery within a given context, which is shaped by the political system (where decisions about midwifery integration will be made), health system arrangements (where midwives provide SRHR services)19 27 and the education system (where midwives are educated).
Political structures including international agreements, public policies, and the governmental agendas of dominant political parties shape the development of the midwifery workforce and profession, and influence efforts to strengthen midwifery services.2 Midwifery associations are agents for the profession, whose capacity to influence policy is determined by surrounding institutions and structures.27 Interview data showed changes in government created delays in achieving midwifery associations’ goals such as regulation of the profession or involvement in national SRHR decision-making processes.
The overarching categories of health system arrangements are inter-related and include: (1) governance, which is focused on health system structures including policy and professional authority; (2) financial includes health financing and health professional payment mechanisms; and (3) health services delivery including how and where services are provided.28 Governance arrangements regulate health professions such as midwifery, however, in many countries midwives are inappropriately regulated or there is no legislation recognising midwifery as an autonomous profession.16 Our findings showed that the lack of understanding of midwifery as an autonomous profession led to the disappearance of midwifery on political agendas by health system decision-makers within governance structures. This disregard resulted in downstream impacts on other health system arrangements. For example, participants noted a lack of clarity about the definition and role of a midwife within the health system, resulting in inappropriate deployment and remuneration. Lastly, with respect to the context where services are delivered, multiple barriers were raised (lack of personal safety, water, electricity, equipment and materials) which rendered the work of midwives impossible to carry out.
Inadequate remuneration of midwives impacted their ability to pay membership dues and become association members, which negatively impacted midwifery associations’ financial viability and increased their precariousness. In contrast, strong midwifery associations played a key role negotiating appropriate work conditions and salaries for midwives with governments.16 Our results showed that midwifery associations advocated for effective mechanisms for regulation and for improved service delivery arrangements, including: (1) how midwives are deployed; (2) if midwives are appropriately positioned (eg, rather than filling in nursing positions); (3) the skill mix (eg, role performance, expansion and working in interprofessional teams); (4) the availability of and timely access to midwifery care (eg, workforce supply and distribution); (5) how midwifery care is provided and (6) where care is provided (eg, site of health service delivery, physical structure and equipment).
Six key areas in which midwifery associations enhanced the quality of midwifery education to enhance credibility and facilitate integration into health systems included: (1) advocating for accredited education programmes; (2) advising on quality standards for clinical learning; (3) providing continuing professional development; (4) creating student chapters within associations hereby attracting quality students and young leaders to the profession; (5) participating in national policy SRHR dialogues and (6) establishing professional competency assessments.1 2 6 8 9 14 16 29–42 Access to continuing education through midwifery associations was strongly linked with empowerment, increased sense of professional belonging, and respect and status of the profession, thereby influencing the status of the association.38
Forces and events outside of the political and health system can influence midwifery associations’ capacity-building efforts or reorient their strategic planning. Specifically, external shocks to the system, such as pandemics, climate change, global economic crises, and natural disasters can erode women and girls’ stability and safety (eg, by increasing gender-based violence). Shifts in resource allocation away from SRHR services delivery further impact the viability and power of midwifery associations. Conversely, our observations identified that some external shocks (eg, COVID-19 pandemic) presented a window of opportunity for midwifery associations to support quality clinical care through training, providing personal protective equipment to frontline midwives and creating practice guidelines.
Organisational context
Within the organisational context, we defined the capacity of midwifery associations as two reciprocal concepts, organisational and technical, which are further divided into key subcomponents outlined.6 Organisational capacity is the ability of the association to operate sustainably as an organisation.6 A base-level organisational capacity is needed to grow technical capacity and thus increase the organisation’s sustainability and impact in strengthening the profession. We identified eight elements within organisational capacity: (1) administrative infrastructure3 6 7 17 39; (2) governance43–46; (3) financial management18 43; (4) democratic participation43 44 46; (5) funding8 43 47; (6) membership43; (7) communications3 43 44 48 and (8) gender.
External factors can also impact associations at an organisational capacity level (eg, sudden illness, death or disability of a key association member, loss of significant funder, allegations of malpractice of a high-profile member or misappropriation of funds).44 While organisational crises cannot be anticipated, midwifery associations can reduce their impacts through strong administrative infrastructure, governance, financial management and communications strategies.
Technical capacity is conceptualised as the association’s ‘core business,’ and refers to the ability to support and maintain effective programming and activities to strengthen the profession within political, health and education systems.6 We identified nine elements within technical capacity: (1) midwifery professional expertise2 45 49; (2) leadership6 50 51; (3) quality midwifery training6 16 44 51–53; (4) SRHR outreach activities; (5) data and evidence2 9 50; (6) research capacity and knowledge translation9 54; (7) networks1 34 41 55 56; (8) strategic advocacy (an outcome of networks)3 7 8 16 43 45 48 57 58 and (9) gender.59
The reciprocal relationship of organisational and technical capacity was revealed in our qualitative evidence. When midwifery associations housed programmes to increase in-service midwifery capacity, such as emergency skills training (emergency obstetric and newborn care (EmONC)), both the organisational and technical capacity of the association was increased. To effectively deliver EmONC training, associations were trained in programmatic and administrative skills and team building. These skills were generalisable and transferable to efficiently running the association. Furthermore, when midwifery associations trained their executive members to be EmONC facilitators, evaluators, mentors and supervisors, these midwives continued to provide training after project completion. Embedding skills in the executive membership built external recognition for the association’s capacity to train midwives to global standards.
In-service training was also identified as a way to raise associations’ profiles within facilities, hospitals and health networks. Increased visibility and credibility assisted the association to effectively carry out other activities (eg, overseeing accreditation of midwifery education programmes and lobbying governments for midwifery inclusive policies). Additionally, midwives themselves were more likely to understand the role of their association and become members. Associations were then able to better advocate for their members at the institutional and governmental levels for appropriate remuneration mechanisms. Finally, increases in membership and EmONC training became vital sources of income for the association, that then supported and sustained organisational capacity.
Gender
Gender and its intersections (ie, race, ethnicity, religion) are a unique and cross-cutting consideration impacting each context. The role of gender within society is an inseparable component of the outer context.2 19 33 34 43 60 61 The social construction of gender impacts the value placed on women in a given country, and in turn the value placed on predominately women-led midwifery associations within that society.19 Gender norms influenced the relationships that associations had with decision-makers resulting in a lack of visibility and credibility of the organisation.2 34 For example, our results showed that decision-makers within health sectors tended to be male physicians. This gender dichotomy influenced midwifery associations’ relationships with authority and leadership due to an overall lack of societal respect for women.43 Finally, strains on health systems caused by long-term events, such as conflict, political coups or market inflation, impact gender disproportionately and thus threatened associations’ sustainability.
Within the organisational context, gender considerations for organisational capacity include creating equitable governance structures within the association that support women in leadership and enhance diversity in the board and general membership. Technical capacity consisted of the association’s ability to conduct their own gender analysis and have the resources to appropriately respond to recommendations, including applying a gender lens to the association’s external environment, organisational structure, and how they provide clinical support and training for members. Our data showed that often gender analyses were an afterthought and were completed by often costly external international consultants, thereby limiting the timeliness, relevance and local applicability of findings.
Core values of midwifery associations
Midwifery associations’ core values underpin their organisational activities and outputs; align closely with the organisation’s mission, vision and strategic plan; and shape the organisation’s role in the community and the key programming/services offered. Within midwifery associations, we identified social justice, equity and anti-oppression as the most common core-espoused organisational values.8 31 32 35 37 45 59 62–65 A universal implicit value of midwifery associations is that they are working towards a common goal of improving SRHR. Importantly, each association has its own perception of the benefits that it brings to the community, and its values are highly context specific.
Despite outward organisational values, our results revealed that midwifery associations’ internal culture can be positively or negatively influenced by personal privileges and power, such as sexism, ethnicism or classism. One challenge that participants identified was the lack of transparency of an association’s board to its members and a tendency to disregard procedures for democratic succession planning. Some participants described being excluded from opportunities for leadership based on their age or social position. Members needed to have open discussions that encourage equitable distribution of leadership roles and perceived this as important to sustaining participation in the association over time.
Empowerment emerged as an important outcome of midwifery association strengthening and is identified in the literature as the ‘powerful catalyst for positive change’.59 It is founded on the sense of value and credibility association members felt as a direct product of success, both internal and external, to the organisation. For example, feeling empowered was described as having impact, being autonomous, participating in institutional decision-making and policymaking, economic opportunity, access to education and professional self-worth.38 In circumstances where midwifery associations improved their capacity via the collaboration with other midwifery associations, trust and reciprocity lead to overall mutual empowerment. Participants described their empowerment motivated them to advocate for SRHR, and for the inclusion of midwives in decision-making, leading to improved capacity of the associations. Empowerment is a positive feedback loop, and as the capacity of the association is built, individuals are empowered, and the organisational capacity improves, and so on.62