Table 1

Considerations for the planning, development, implementation and evaluation of gender transformative continuing education interventions for midwives

Theme	Applying the theme
Positioning midwives within their specific political and health system’s context so that interventions are appropriate	Map the context of midwifery by governance, service delivery and financial arrangements (eg, scope vs role of midwives in the health system). Include the impacts of policy legacies, status of women in society, and other intersects such as indigeneity Understand and include impacts of external forces such as climate change, pandemics, conflict, etc.2–4 28 32 34 36 39 40 46 53–57 Involve midwifery stakeholders, especially professional associations, to ensure breadth and accuracy of the mapping phase2–4 22–28 46 54–56 58 Use these findings to inform the intervention as well as the evaluation framework to maximize long-term skills integration and broader health and political system impacts of the training2 4 30 32 54
	Gender transformative considerations Do the stakeholders represent the full range of midwives’ voices, with an emphasis on midwives who are oppressed by racist, colonial, patriarchal, or heteronormative systems? Does the intervention include gender transformative components such as leadership, safety in the workplace, remuneration and other working conditions?
	Illustrative quotation ‘They (the association) are successful because they understand the issue. They understand the issue, but also, they tie their passion to the issue.’ (KI#6)
Tailoring midwifery specific content empowers midwives to understand the role of their profession, fosters leadership skills and increases understanding of the impacts of gender discrimination	Co-create content and design with midwifery stakeholders3 28 46 55 56 59 Include elements specific to the needs of midwifery in the given context. For example, scope-of-practice, role of midwives at the service level, financial challenges or solutions, remuneration, professional self-awareness, midwifery philosophy of care, and leadership competencies such as advocacy or communication2 3 6 20 27 28 38 40 47 54–56 60–63 Consider (in collaboration with stakeholders) conducting midwifery only training alone or prior to interprofessional training and on-site longer-term interventions, which improve integration and increase visibility of midwives in facility3 6 27 28 33 35–38 41 48 58 63–74
	Gender transformative considerations Does the content and design of the training align with the current status of midwifery in the country or region? Can tools be created or adapted to suit the needs of the specific context? Has space been made for all midwives, especially those who have been oppressed by racist, colonial, patriarchal, heteronormative systems, to explore and provide solutions? Consider intersectionality in position, such as how gender and other intersects of oppression impacts the midwife’s social, economic and professional life?
	Illustrative quotation ‘We would have a different approach to development that would be the change … individualizing problems to a midwifery model, a scope of practice, …and informed consent and all the things that are implicated in that. I think that's the core values that we want to drive our programming.’ (KI#13)
Midwife-led continuing education interventions, with relevant and safe supports, leads to better integration of skills, and by extension facility functions	Incorporate training of midwife facilitators Midwives who teach or are taught by other midwives are empowered. Midwives show increased confidence to apply their skills, improved understanding of their role, stronger connections to other midwives, and more motivation to be involved in their association and midwifery more broadly27 28 35 38 46 66 75 Training midwives as supervisors and mentors improves the integration of skills over time Midwife supports have an intimate understanding of their unique situation and challenges and midwives are more likely to share inadequacies, gender/professional discrimination, ongoing educational needs or system supports35 36 38 65 66
	Gender transformative considerations Do the midwife trainers, supervisors and mentors represent people who are: living in rural, remote, or working in smaller centres? of colour and/or Indigenous? part of the 2SLGBTQI+ spectrum? practicing with a disability? the range of ages and stages of the midwifery career? in midwifery professional bodies and midwifery leadership? Are midwife trainers, supervisors and mentors appropriately remunerated for their time? Are midwife trainers, supervisors and mentors provided with an environment to safely engage in and contribute to?
	Illustrative quotation ‘When you have disempowered midwives, you don't have good quality care. You really just don't, and you don't have any opportunity to input into national programs or local programs because there is not a respect for the midwives who would like to have their voices heard at those tables.’ (KI#22)
Understanding the specific challenges and solutions to supporting skills integration of midwives, while incorporating evaluations with a highly explanatory component	Process evaluations or ‘most significant change’ evaluation, and positive deviancy better capture the specific solutions and challenges related to supporting skills integration These include unofficial types of leadership, better working conditions for midwives and advances in gender equity, changes in morale and professional burnout, or better internal professional awareness and empowerment.3 37 46 48 64 66 76–78 Evaluate outcomes within the midwifery associations or professional bodies including how they’ve impacted other health system components such as the workforce, interprofessional relationships, midwifery model of care, and leadership Evaluate the evolving capacity of the professional body during the implementation of continuing education programs6 64 Well tested evaluation frameworks such as the Kirkpatrick evaluation and variations of, can be used, but would need to be adapted to the midwifery and country context during the mapping phase7 79 80
	Gender transformative considerations Does the evaluation have explanatory or transformative components and include perspectives of those that have been suppressed by racist, colonial, patriarchal, or heteronormative systems? Have you ensured data sovereignty and equitable knowledge exchange plans including publications and presentations? This is essential for Indigenous-led bodies
	Illustrative quotation ‘There are other things, other less orthodox methods. Like most significant change, or outcome harvesting, which are other approaches that have often, in fact, been developed internationally…and which would probably have been more relevant to apply in the context.’ (KI#5, translated from French)
Housing continuing education interventions for midwives within a midwifery association is an effective approach to longer term integration of skills and improvements to the profession in the health system	Midwifery associations, as experts of their health profession, can ensure curriculum content is adapted accordingly to train and mentor midwife trainers, supervisors, and mentors within the association6 26 54 Midwife-led supervision and mentorship that also represents the midwifery association can serve as advocates, leveraging their position to help trained midwives to improve their working conditions including the purchasing of equipment. This also serves to strengthen the connection of members to their association, returning to the organisation and increasing the capacity of the organisation to respond to the needs of its members27 64 Over time, as midwifery associations sustain continuing education programmes, they address system barriers to practice and mentor new midwifery leaders6 26 27 46 54 64 To properly sustain continuing education interventions, supporting associations to improve their technical and organisational capacity is important to the sustainability of the association. This includes research and policy capacity led by and for midwives6 27 64
	Gender transformative considerations Does the midwifery association require support to implement gender transformative policies or by-laws within the organisation and for its members? Is the midwifery association’s executive board representation inclusive of people of colour, Indigenous, geography, ages and stages of the midwifery career, 2SLGBTQI+, and people practicing with a disability? Does the midwifery association require support in obtaining operational funds to provide financial stability for its working members? Are there safe administrative structures and working environment within the midwifery association free of harassment?
	Illustrative quotation ‘We used to take it to the association from time to time, to tell them that no, we still need further strengthening internally…. So it helped us to really improve the working life of our colleagues… we are now strengthening the service provider on the ground by identifying its weaknesses…. we are always in contact with the field.’ (KI#2, translated from French)

2SLGBTQI+, Two-Spirit, lesbian, gay, bisexual, transgender, queer (or questioning). The plus sign represents other sexual identities, such as pansexual or asexual.