Article Text

Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations
  1. Cristina Mattison1,
  2. Kirsty Bourret1,
  3. Emmanuelle Hebert2,3,
  4. Sebalda Leshabari4,
  5. Ambrocckha Kabeya3,
  6. Patrick Achiga5,
  7. Jamie Robinson6,
  8. Elizabeth Darling1
  1. 1Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
  2. 2University of Quebec at Trois-Rivières, Trois-Rivieres, Quebec, Canada
  3. 3Congolese Society of Midwifery Practice, Kinshasa, Democratic Republic of Congo
  4. 4Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  5. 5Vice-secretary, South Sudan Nurses and Midwives Association, Juba, South Sudan
  6. 6Global Programs Manager, Canadian Association of Midwives, Montreal, Quebec, Canada
  1. Correspondence to Dr Cristina Mattison; mattisc{at}


Introduction Midwifery associations are organisations that represent midwives and the profession of midwifery. They support midwives to reduce maternal and newborn mortality and morbidity by promoting the overall integration of midwifery in health systems. Our objective was to generate a framework for evidence-informed midwifery association strengthening.

Methods A critical interpretive synthesis complemented by key informant interviews, focus groups, observations, and document review was used to inform the development of concepts and theory. Three electronic bibliographical databases (CINAHL, EMBASE and MEDLINE) were searched through to 2 September 2020. A coding structure was created to guide the synthesis across the five sources of evidence.

Results A total of 1634 records were retrieved through electronic searches and 57 documents were included in the critical interpretive synthesis. Thirty-one (31) key informant interviews and five focus groups were completed including observations (255 pages) and audio recordings. Twenty-four (24) programme documents were reviewed. The resulting theoretical framework outlines the key factors by context, describes the system drivers that impact the sustainability of midwifery associations and identifies the key-enabling elements involved in designing programmes that strengthen midwifery associations.

Conclusion Midwifery associations act as the web that holds the profession together and are key to the integration of the profession in health systems, supporting enabling environments and improving gender inequities. Our findings highlight that in order to strengthen midwifery (education, regulation and services), we have to lead with association strengthening. Building strong associations is the foundation necessary to create formal quality midwifery education systems and to support midwifery regulation and accreditation mechanisms.

  • health policies and all other topics
  • health policy
  • health systems
  • maternal health
  • midwifery

Data availability statement

Data are available upon request. All data contributing to the analyses in this study are stored on a secure network and not publicly available in order to protect participant confidentiality.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

Data are available upon request. All data contributing to the analyses in this study are stored on a secure network and not publicly available in order to protect participant confidentiality.

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  • Handling editor Stephanie M Topp

  • Twitter @MattisonPhD, @LizDarlingRM

  • Contributors CM, KB, JR and ED initiated the project. CM and KB designed the research, collected and analysed the data, interpreted the results, and wrote the text in collaboration with AK, AP, EH, JR, ED and SL.

  • Funding This study was funded by Mitacs (grant number: IT1531).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.