A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

Objective: to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

Design: systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

Setting: midwifery services in any setting in low-, middle-, and high-income countries.

Participants: midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

Interventions: task shifting to and from midwives.

Findings: thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

Key conclusions: this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

Implications for practice: evidence from the review fed into the World Health Organisation's 'Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting' guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.