Introduction
While there is ample evidence in support of the positive impacts of midwifery-led care, the profession is not well integrated into most health systems.1 The 2021, State of the World’s Midwifery report (SoWMY) cites a global shortage of 900 000 midwives with less than 75% of the current need for sexual and reproductive health services being met globally.2 This schism can in part be explained by systemic discrimination of the profession driven by the intersects of gender, race, sociopolitical, professional and economic inequities.3–5 As a result, the SoWMY report calls for the inclusion of gender transformative approaches to the process of the growth of midwifery.2 3
The SoWMY report outlines four key areas of investment essential to the growth of the profession in order to meet the universal health needs of women, childbearing people and newborns: (1) health workforce; (2) education and training; (3) midwifery-led service delivery and (4) midwifery-led governance and leadership.2 Gender transformative approaches cross cut all four areas.2 In a previous publication, our findings demonstrated when appropriately supported, midwifery associations have the capacity to address all four strategic areas outlined in SoWMY, leading to improved health systems and population health outcomes.6 This companion research discusses the role of midwifery associations and gender transformative approaches to the second SoWMY key area, education and training (specifically, continuing education) for sustainable growth of the profession.
The Canadian Association of Midwives (CAM) has engaged in reciprocal capacity building partnerships since 2008 with the National Aboriginal Council of Midwives (situated in the land that is referred to as Canada). They have since extended this collaborative approach with midwifery professional associations in seven countries (Benin, Democratic Republic of Congo, Ethiopia, Haiti, Somalia and Somaliland, South Sudan and Tanzania). CAM’s strategic vision prioritises organisational capacity building and promoting excellence in the continuing education of midwives. Most often, interventions are hosted by partner midwifery associations.6 Throughout their work, CAM observed unanticipated outcomes, such as improvement to structural gender inequities, which led them to hypothesise the overarching value to their approach with continuing education interventions (CEI) and longer term gender transformative impacts to the midwifery profession.
Scholarly knowledge regarding CEI for obstetric/neonatal health professionals, including midwives, is common.7 Yet, the literature often ignores the structural dynamics of where and how programmes are designed and executed, and by whom (ie, who gets paid to do what, who is ‘in charge’ of what). Such omissions obscure power imbalances that intersectionally impact women-led professions like midwifery. Systematic reviews show that adopting a gender transformative approach to programme interventions centres the critical examination of gender and other inequities to promote system changes, which, over time create, change and improve gender-based outcomes in policy and practice.8 This strengthens the importance of building the evidence on gender transformative approaches to CEI as a conduit for promosting enabling environments for sustaining the midwifery profession and by extension impact sexual and reproductive health and rights (SRHR).3 6
We used a three-pronged approach to create an evidence-informed framework. Our first aim was to synthesise multiple sources of evidence to address the following compass question: What are the factors that impact in-service midwifery continuing education, including comprehension, competency and integration of skills? Second, to further understand the factors identified in the first aim, we used the example of CAM’s programming related to the implementation of CEI for midwives by midwifery associations and conducted key informant interviews, focus groups, observations and document review. Our third aim was to develop a conceptual framework for considerations when implementing gender transformative CEI for midwives. The second and third aims overlapped as part of an iterative process in which stakeholders informed and provided feedback on the development of the conceptual framework.
Our work is rooted in intersectional feminist, anticolonial and collaborative lenses. We purposefully do not dichotomise between World Bank classification of countries by income groups (ie, high-income countries vs low-income and middle-income countries) as we recognise that improving access to quality SRHR is relevant to all health systems.9 The importance of context is central, along with how each country’s health system(s) and political system functions within a given context.