gms | German Medical Science

Background: In high income countries, midwife-led continuity of care has been shown to provide several benefits for women and their babies with no adverse outcomes [1]. It is recommended that this model of care should be offered to most women in countries where midwifery services are present [2]. However, little is known about midwife-led continuity of care in low- and middle-income countries. A scoping review on outcomes of midwife-led care in low- and middle-income countries [3] showed several benefits including women’s satisfaction, lower maternal and newborn mortality and increased quality of care. However, the reality of how midwife-led care is provided in LMICs and especially around the skills and knowledge, roles and responsibilities of midwives who provide this model of care has not been widely studied.

Aim/Research Question: The aim of this paper is to explore the skills and knowledge, roles and responsibilities of midwives working in midwife-led models of care in Bangladesh, a lower middle-income country in South Asia.

Methodology: A case study design was applied using multiple sources. A multistage purposeful sampling technique was used. In total, 31 interviews and focus group discussions were conducted with 53 participants from various groups such as women (n=19), midwives (n=14), allied health professionals (n=4) and key informants involved in policy and programmes (n=16). Qualitative data were analysed using framework analysis, based on the quality maternal and newborn health care framework [4] which included the category of “care provider”.

Results: Findings around care providers are mainly based on the perspectives of midwives, allied health professionals, programme managers and policy experts. The midwife-led model of care is a recent development in Bangladesh. The care providers in midwife-led models are midwives, who have been educated based on international standards since 2016. Midwife-led models of care were seen as places to practice ‘midwifery’, to create a professional identity, to provide an optimal learning environment for midwifery students and to try out ‘innovations’. Some midwives worked on their own in this model of care but others included medical doctors in clinical decision-making especially when complications occurred and referral was needed. Sometimes midwives managed their own units but often they were not part of the leadership and management team. Mentoring of midwives working in midwife-led units and continuous professional education was seen as key to successful implementation of this new model of care.

Conclusions: In Bangladesh, the midwifery profession is undergoing a transitional process developing skills and expanding knowledge and creating roles and responsibilities. This process is influenced by other health care professionals, especially medical doctors. A supportive environment that comprises mentoring and continuous professional education will assist development of midwifery as an autonomous profession taking on leadership and management roles to ultimately provide quality care for mothers and new-born infants. Other countries with similar settings could learn from the implementation of midwife-led care in Bangladesh.

Ethics and conflicts of interest: Ethical approval was obtained in 2017 from the University of Technology Sydney’s Human Research Ethics Committee UTS HREC REF NO. ETH17-1241 and in 2018 from the James P. Grant School of Public Health at BRAC University Bangladesh Institutional Review Board 2018-021-ER. The research was supported by external funds. Study fees were granted through the University of Technology International Research scheme from 2016 to 2019; data collection was financially supported through the International Confederation of Midwives International Research Award in 2017. There are no conflicts of interest.