Table 2

Characteristics of included studies

#	First author, year	Countries	Fragile classification	Title	Intervention	Target group	Methodology	Results/outcomes
1	Arnold, 201837	Afghanistan	Highest Fragility	Parallel worlds: An ethnography of care in an Afghan maternity hospital	Assess midwifery services to explore underlying issues for staff behaviours	Midwives, doctors and senior officials	Qualitative/critical ethnography 23 Interviews were conducted with senior doctors and midwives, resident doctors, newly qualified midwives and care assistants	Although healthcare providers generally look the same in hospitals across the globe, this study reveals they have different ways of understanding the world. They may work in a ‘caring’ profession but perceive the purpose of work from innate social norms and values, which, for example, can result in guarding their skills rather than sharing them. A sense of responsibility to strangers might clash with kinship obligations, the institutional culture, and the wider social environment. Furthermore, public health institutions may not only provide care, they may also be lucrative sources of income for political elites.
2	Arnold, 201938	Afghanistan	Highest Fragility	Villains or victims? An ethnography of Afghan maternity staff and the challenge of high-quality respectful care	Assessment of midwifery services to explore culture of care.	Midwives, doctors and care assistants	Qualitative/ethnographic study 23 Interviews were conducted with senior doctors and midwives, resident doctors, newly qualified midwives and care assistants (2 senior midwives 8 midwives with 6 months–10 years’ experience)	Most staff members were simply endeavouring to survive in a tough working environment where the lack of a shift system inevitably resulted in staff exhaustion, poor performance and the constant risk of mistakes leading to censure by management. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies and inadequate support from management.
3	Kim, 201339	Afghanistan	Highest Fragility	Assessing the capacity for newborn resuscitation and factors associated with providers' knowledge and skills: a cross-sectional study in Afghanistan	Assessment of emergency obstetric and newborn care training/services	Midwives and doctors	Quantitative/ cross-sectional study 142 midwives and 82 doctors	Over 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of preservice education (59% and 35%, respectively, p<0.001). Training was associated with greater knowledge (p<0.001) and clinical skills (p<0.05) in a multivariable model that adjusted for facility type, provider type and years of experience offering emergency obstetric and newborn care services.
4	Mansoor, 201240	Afghanistan	Highest Fragility	Midwifery training in post-conflict Afghanistan: tensions between educational standards and rural community needs	Compare performance of midwifery graduates who were selected through community mobilisation with those who admitted through a national examination.	Midwifery graduates and students	Mixed method/retrospective survey. MW student records of the 178 trainees were reviewed and data extracted for demographics, selection method, performance in knowledge and skills, and deployment status and location.	96% of midwifery graduates selected by communities were employed, compared with 74% chosen by the Institute of Health Sciences (IHS) and 82% by the National University Entrance Examination (NUEE). 63% of community-selected graduates were working in rural locations, compared with 43% recruited by IHS and 9% by the NUEE. While fewer midwifery graduates selected by communities had completed high school and their academic performance was slightly lower during training, there was no difference in their pass rates and acquisition of practical skills.
5	Thommesen, 202041	Afghanistan	Highest Fragility	‘The midwife helped me. Otherwise I could have died’: women’s experience of professional midwifery services in rural Afghanistan—a qualitative study in the provinces Kunar and Laghman	To explore experiences of midwifery care	Women	Qualitative/exploratory study 39 women participated—25 who had given birth during the last 6 months, 11 mothers-in-law and three community midwives in the provinces of Kunar and Laghman	Many of the women greatly valued the trained midwives’ life-saving experience, skills and care, and the latter were important reasons for choosing to give birth in a clinic. Women further appreciated midwives’ promotion of immediate skin-to-skin contact and breastfeeding. However, some women experienced rudeness, discrimination and negligence on the part of the midwives. Moreover, relatives’ disapproval, shame and problems with transport and security were important obstacles to women giving birth in the clinics.
6	Wood, 201342	Afghanistan	Highest Fragility	Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces	Evaluation of factors associated with midwifery (MW) deployment	Midwives and other stakeholders	Qualitative Stakeholders n=33, MW students n=35, MW currently employed n=17; MWs formerly employed n=16, CHWs n=16	Several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her preassigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife’s career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector.
7	Zainullah, 201443	Afghanistan	Highest Fragility	Establishing midwifery in low-resource settings: Guidance from a mixed-methods evaluation of the Afghanistan midwifery education programme	Evaluation of costs and graduate performance outcomes of the two types of preservice midwifery education programmes	Midwives	Quantitative analysis of midwifery graduates’ performance and cost analysis to estimate the resource required to educate a midwife. midwifery school graduates (n=138)	Graduates (n=101) achieved an overall mean competency score of 63.2% (59.9%–66.6%) on the clinical competency assessment compared with 57.3% (49.9%–64.7%) for Institute of Health Sciences graduates (n¼37). Reproductive health activities accounted for 76% of midwives' time over an average of 3 months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programmes, the estimated cost of graduating a class with 25 students averaged US$298 939, or US$10 784 per graduate.
8	Bogren, 201845	Bangladesh	Fragile Setting	Opportunities, challenges and strategies when building a midwifery profession. Findings from a qualitative study in Bangladesh and Nepal	Assess strategies for establishment of midwifery Education	Midwives	Qualitative	Global and national standards brought together midwifery professionals and stakeholders, and helped in the establishment of midwifery associations. The challenges were national commitments without a full set of supporting policy documents, lack of professional recognition, and competing views, interests and priorities.
9	Bogren, 201846	Bangladesh	Fragile Setting	What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students	Assess midwifery services in relation to quality of care	Midwifery students	Qualitative 67 midwifery students	Professional barriers include heavy workloads with a shortage of staff who were not utilised to their full capacity within the health system. The reason for this was a lack of recognition in the medical hierarchy, leaving midwives with low levels of autonomy. Economical barriers were reflected by lack of supplies and hospital beds, midwives earning only low and/or irregular salaries, a lack of opportunities for recreation, and personal insecurity related to lack of housing and transportation. The social barriers preventing midwifery quality care arise from Bangladeshi cultural norms that have been shaped by beliefs associated with religion, society, and gender norms. This puts midwives in a vulnerable position due to cultural prejudice.
10	Bogren, 201847	Bangladesh	Fragile Setting	Development of a context-specific accreditation assessment tool for affirming quality midwifery education in Bangladesh	Assess the feasibility of development of a context-specific accreditation assessment tool for midwifery education	Midwives	Mixed methods (using quantitative and descriptive questionnaire). 123 nursing educators teaching the 3 years diploma midwifery education programme.	Provides insight into the development of a context-specific accreditation assessment tool for Bangladesh. Important components to be included in this accreditation tool are presented under the following categories and domains: ‘organisation and administration’, ‘midwifery faculty’, ‘student body’, ‘curriculum content’, ‘resources, facilities and services’ and ‘assessment strategies’. The identified components were a prerequisite to ensure that midwifery students achieve the intended learning outcomes of the midwifery curriculum, and hence contribute to a strong midwifery workforce. The components further ensure well-prepared teachers and a standardised curriculum supported at policy level to enable effective deployment of professional midwives in the existing health system.
11	Bogren, 201548	Bangladesh	Fragile Setting	Towards a midwifery profession in Bangladesh—a systems approach for a complex world	Assess how stakeholders promote midwifery profession	Midwives	Qualitative/explorative study. Government n=4; academia n=3; Professional association n=3; donors n=9; NGOs n=6	Collaboration between organisations was valued, as more could be achieved compared with what an individual organisation could do. Significant results of this were that two midwifery curricula and faculty developments had been produced. Although collaboration was mostly seen as something positive to move the system forward, the approach to reach the set goal varied with different interests, priorities and concerns, both on individual organisational level and at system level. Frequent struggles between individual philosophies and organisational mandates were seen as competing interests for advancing the national priorities. It would appear that newcomers with innovative ideas were denied access on the same terms as other actors.
12	Zaman, 202044	Bangladesh	Fragile Setting	Experiences of a new cadre of midwives in Bangladesh: findings from a mixed method study	Assess experiences of Midwifery students on their midwifery education and their first clinical post as qualified midwife	Midwives	Mixed method Interviewing 329 midwives and conducting six focus group discussions with 43 midwives and midwifery students.	Most of the midwives were satisfied with different dimensions of their education programme, with the exception of the level of exposure they had to the rural communities during their programme. Out of 329 midwives, 50% received tuition fee waivers, while 46% received funding for educational materials and 40% received free accommodation. The satisfaction with the various aspects of the current posting was high and nearly all midwives reported a desire to work in the public sector in the long run. However, a significant proportion of the midwives expressed concerns with equipment, accommodation, transport and prospect of transfers.
13	Adegoke, 202049	Nigeria	Very High Fragility	Job satisfaction and retention of midwives in rural Nigeria.	Assess job satisfaction of midwives who trained through Midwifery Service Scheme (MSS)	MSS midwives	Mixed method using job satisfaction survey, focus group discussions (FGDs) and exit interviews. This study included all the 119 MSS midwives in the 51 primary healthcare facilities.	The MSS programme is a short-term solution to increase SBA coverage in rural Nigeria. MSS midwives were dissatisfied with the short-term contract, lack of career structure, irregular payment, poor working condition, inadequate supervision and poor accommodation being offered by the programme, which all contribute to poor retention of MSS midwives.
14	Erim, 201850	Nigeria	Very High Fragility	The spill-over effect of midwife attrition from the Nigerian midwives service scheme	Assess trends in the use of obstetric (ie, antenatal and childbirth) services	Women who used obstetric services	Quantitative/retrospective analysis of Nigerian Demographic and Health Surveys	The MSS led to a 5 percentage point increase in the use of antenatal services at rural public sector clinics, corroborating findings from a previous study. This change was driven by women who would not have sought care otherwise. There was a 4 percentage point increase in the use of birthing services at urban public sector clinics, and a concurrent 4 percentage point decrease in urban home deliveries.
15	Etiaba, 202051	Nigeria	Very High Fragility	‘If you are on duty, you may be afraid to come out to attend to a person’: fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective	Adding extra security measures in health facilities	Facility managers, a programme midwife and a pre-existing (before programme) health worker	Qualitative/exploratory study. 35 in-depth interviews and 24 focus groups with purposively identified key informants. Policy-makers (n=9), programme managers (n=10), facility managers (n=8) and facility health workers (n=8). FGDs were conducted with eight groups of service users, eight groups of village health workers and eight groups of WDCs. Health workers comprised nurses, midwives and community health extension workers.	The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let people into unguarded facilities, mirrored those of pregnant women who did not use health facilities because of fear of not being let in and attended to by facility staff.
16	Exley, 201652	Nigeria	Very High Fragility	Persistent barriers to care; a qualitative study to understand women’s experiences in areas served by the midwives service scheme in Nigeria	impact evaluation of the quality of midwifery services provided by MSS	Women, midwives, policy-makers	Qualitative 73 semistructured interviews were conducted; 43 women, 16 midwives and 14 policy-makers	The majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a primary health centre, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principal reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care.
17	Baba, 202054	DRC	Very High Fragility	Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Drc	Development of strategies to attract, retain and support midwives	Midwives	Qualitative participatory research design. Participant were: managers n=12, midwives n=16 and nurses n=13, and non-governmental organisation n=4, church medical coordination n=2 and nursing school representatives n=2	The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, while a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying NGOs and churches to support the improvement of midwives’ living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges.
18	Baba. 202053	DRC	Very High Fragility	'Being a midwife is being prepared to help women in very difficult conditions': midwives' experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo	Assess experiences of current and ex-midwives to future career aspiration	Midwives	Qualitative/exploratory study. Interviews with 26 midwives and 6 ex-midwives and 3 focus group discussions with 22 midwives	Midwives faced many work challenges: serious shortages of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation was worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organisations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives wanted to continue working as midwives or follow further midwifery studies. Most ex-midwives had left the profession for family-related reasons.
19	Lori. 201357	Liberia	Fragile Setting	Promoting access: The use of maternity waiting homes to achieve safe motherhood	Evaluate access and quality of services in Maternity waiting home (MWH)	Women	Qualitative/ exploratory study. eight focus groups were held with 75 participants from congruent groups of MWH users, MWH non-users and family members	The availability of MWHs decreased the barrier of distance for women to access skilled care around the time of childbirth. Food insecurity while staying at an MWH was identified as a potential barrier by participants
20	Mugo, 201855	South Sudan	Highest Fragility	Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan	Maternal and newborn health services	Maternal and child health (MCH) professionals	Qualitative/ exploratory study. 18 in-depth-interviews with MCH staff including midwives/nurses, trained traditional birth attendants, gynaecologists and paediatricians.	Limited support from the heath system, such as poor management and coordination of staff, lack of medical equipment and supplies and lack of utilities such as electricity and water supply were major barriers to provision of health services. In addition, lack of supervision and training opportunity, low salary and absence of other forms of non-financial incentives were major elements of health workers’ demotivation and low performance. Furthermore, security instability as a result of political and armed conflicts impact services delivery.
21	Nakano, 201856	Sudan	Highest Fragility	Exploring roles and capacity development of village midwives (VMW) in Sudanese communities	Evaluate comprehensive assistance to improve maternal and child service delivery based on the continuum of care	Midwives and women	Mixed-method/ cross sectional descriptive survey 57 VMWs and 151 community women were interviewed	The monthly average number of VMW assisted home births increased. The annual average number of emergency cases referred by VMWs increased from 1.6 to 3.5, and the percentage of VMWs using official monthly reports increased from 33% to 80%. VMWs reported improved bonds with their supervisors and relationships in the community.
22	Kaye, 200062	Uganda	Fragile Setting	Quality of midwifery care in Soroti District, Uganda	Assessment of quality of emergency obstetric and newborn care services	Midwives and women	Mixed method/Cross-sectional descriptive study. A total of 36 midwives out of 76 were interviewed.	Many midwives were providing care of poor quality for both antenatal and delivery care due to their inability to identify and manage women with, or at risk of, pregnancy complications.
23	Yigzaw, 201761	Ethiopia	High fragility	Quality of midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia	Assess performance was used to determine competence of midwives in providing care during labour, delivery, and the first 6 hours after childbirth	Midwives	Mixed method/cross-sectional study using multiple data collection methods. A total of 150 midwives and 56 health facilities were included in the study.	There are gaps in provision of quality intrapartum care in government health facilities in Amhara Regional State of Ethiopia. There were major deficits in availability of essential physical resources and mechanisms for continuous performance and quality improvement. A significant proportion of midwives were also found incompetent.
24	Ahmed, 201758	Pakistan	High Fragility	Community midwives' acceptability in their communities: A qualitative study from two provinces of Pakistan	Evaluation of community midwives (CMW) service utilisation	CMWs, female health supervisors and managers in maternal neonatal and child health (MNCH)	Qualitative using 34 in-depth interviews and 9 focus group discussions with 100 participants	CMWs experienced restrictions from their families, especially husbands and in-laws, to be independently available to attend to women during pregnancy and delivery. Communication between the communities and MNCH programme was found to be weak. Therefore, CMWs had to struggle to win the trust of pregnant women and persuade them to use their services. Most CMWs attributed low utilisation of their services to inherent taboos prevalent in the communities under which they relied more on unskilled traditional birth attendants. Gender sensitivity and fears of insecurity in many conflict-hit areas affected CMWs’ mobility within their own communities, which restricted the access of rural women to skilled maternal and child care.

CHW, community health worker; DRC, Democratic Republic of Congo; NGOs, non-governmental organisations.