The 3i framework helps to understand the political system factors that constrain or enable midwifery within health systems and consists of three main components: (1) institutions; (2) interests and (3) ideas72

• Institutions—midwifery associations can face structural barriers to integration as a result of government structures (eg, the political arrangement in a given context and mandates that influence SRHR policies) and policy legacies (eg, policies shape the way midwifery care is organised in the health system)

• Interests—collaboration across professional associations can come together and play a strong role in political lobbying (facilitator) or mitigating competing interests from other professional associations (eg, nursing), or discrimination (eg, some physician interest groups that seek to limit establishing midwifery as an autonomous profession) (barrier)

• Ideas—societal values regarding the medical model (eg, medicalisation of the birth process and associated valuing of physician and hospital-based care) and gender equity

Health systems factors include: (1) governance; (2) financial and (3) delivery28

• Governance arrangements that recognise midwifery as an autonomous profession and acknowledge the role of midwifery associations advocating for legislation that codifies self-regulation and autonomous practice

• Financial arrangements that include mechanisms to raise revenue to finance the health system and remuneration for sexual and reproductive health services by midwives, which by extension impacts the financial viability of midwifery associations

• Delivery arrangements that focus on how midwives are delivering health services within the health system, and acknowledged expertise of midwifery associations to inform appropriate scope and role of the profession

Established accreditation systems to support quality of midwifery education programmes

Adoption of ICM’s Global Standards for Midwifery Education and Essential Competencies for Midwifery Practice

Education and enhanced knowledge are linked with empowerment of the profession and midwifery associations

Recognise that the social construction of gender influences the relationship that midwifery associations have with authority and leadership

Mitigation of forces and events that can influence the sustainability of midwifery associations (eg, role of gender in society, pandemics, climate change, global economic crises, and natural disasters eroding women and girls’ stability and safety)

Establish a base-level administrative infrastructure to support technical capacity

Includes the necessary space and tools in order to be able to carry out the organisational mission

Establish best practice governance systems to manage the work of the association

The capacity of the midwifery association will determine the complexity of the governance structure

Develop a concrete plan and system for financial oversight of the association

Develop yearly budgets to align with the association’s priorities and strategic plan

Understand and address the two main factors that influence democratic participation:

• the broader sociopolitical conceptualisations of democracy and historical impacts within a given context; and

• the shared values and beliefs of the midwifery association and creating contextually relevant equitable democratic procedures

The organisational capacity of the midwifery association to generate its own funds

Support diversity of funding sources (ie, cannot be completely reliant on project funds)

Create membership recruitment activities to increase the visibility and traceability of the association

Create and maintain a membership database and track how membership needs are being met

Promote the recruitment of diverse membership (eg, attracting youth members and fostering student chapters)

Develop a communications strategy to support advocacy (technical capacity)

Four levels of communication:

• internal communications, which includes from board members communicating to each other (eg, meeting minutes), as well as communications from board to staff;

• with members regarding what is happening at the board level (eg, social media, website, WhatsApp groups and newsletter);

• to networks (eg, government and international community); and

• to the public through a range of media (public education)

Establish an equitable governance structure that ensures inclusivity and diversity of representation, particularly in terms of the gender and ethnicity of the board

Equitable governance structure reinforces equitable representation within membership

Establish a strong body of professional knowledge within midwifery (fostered by quality continuing education), and credibility and external recognition of the expertise held within the midwifery association

Advance leadership within midwifery associations, which consists of:

1. membership’s ability to influence and contribute to leadership within the broader system (political, health and/or social) through outreach activities;

2. an organisational leader to advocate to push forward the aims of the association externally in public and political spheres; and

3. the internal capacity of the association’s leadership to manage the organisation appropriately (eg, democratic processes, accountability, transparency and succession planning)

Ensure the midwifery association is working with midwifery education programmes to support quality preservice and in-service education opportunities for members

Develop association-led SRHR community outreach activities

Assist in improving overall health and legitimising the organisation’s role in the delivery of sexual and reproductive health services

The midwifery associations’ ability to own, collect and/or share data to inform local midwifery practice and standards (includes monitoring and evaluation and gender analyses)

Build research capacity of the midwifery association to develop methodological and analytical writing skills

Ability to access local research evidence in order to support continuing education and research

Publications and knowledge translation activities raise the national and international profile of the midwifery association

Develop grant writing skills to support the midwifery association’s ability to secure future funding

Create strong alliances and networks at all levels (local, provincial, national and international) through strategic activities

Twinning, particularly partnerships of similar contexts are a powerful alliance tool

Strong leadership from midwifery associations to engage in policy dialogue and decision-making to advance agendas related to achieving universal health coverage and meeting the Sustainable Development Goals by 2030

Advocacy involves individual dedication to effectively influence the midwifery association’s own membership, policy and governmental services

Develop the skills within the association to create a gender equity and social inclusion policy and undertake their own gender analysis

Includes having the appropriate resources to implement recommendations from the analysis

Values are embedded and at the core of midwifery as a profession and the association by extension

Midwifery associations can build core values centred on principles of:

• social justice;

• gender equity; and

• anti-oppression