Buildning a midwifery profession in South Asia

Sammanfattning: Midwives are key professionals in improving maternal and child health globally, but establishing a midwifery profession in low-income countries is proving to be difficult. The overall aim of this thesis was to explore the situation and building of a midwifery profession in South Asia, and to reveal how influential actors are connected to one another in the building of a profession, especially in Nepal and Bangladesh. A mixed-methods approach was applied, combining qualitative and quantitative methods to gather and analyse data. Study I involved data collected through three questionnaires with closed- and open-ended questions, constructed by the International Confederation of Midwives (ICM) and the United Nations Population Fund (UNFPA) Investing in Midwives Programme, used at a regional workshop in Bangladesh. Study II comprised a review of policy documents; semi-structured interviews; and structured observations of competence and equipment at university colleges and hospital maternity departments in Nepal, building of the ICM’s Global Standards, and JHPIEGO’s (Johns Hopkins Program for International Education in Gynecology and Obstetrics) site assessment tool for maternal and newborn programmes. The two last studies used a Complex Adaptive Systems approach to explore how actors representing the establishment of a midwifery profession in Nepal (Study III) and Bangladesh (Study IV) connected to one another in this establishment. Data were collected through semi-structured interviews with 17 actors in Nepal (Study III) and 16 actors in Bangladesh (Study IV). The analyses were descriptive statistics and content analysis (Studies I and II), and qualitative analysis (Studies III and IV). The results showed that none of the six countries in South Asia had obtained full jurisdiction for the midwifery profession to autonomously work within its full scope of practice (Study I). In Nepal it was feasible to establish a midwifery profession separate from the nursing profession, and the study delivered a proposed strategy to support this (Study II). The actors’ connections for the establishment of a midwifery profession in Nepal can be described with a complex set of facilitators for and barriers to promoting the establishment of a midwifery profession. A driving force for collaboration was that they had a common goal to work towards reducing the country’s maternal and child mortality. The main opposing factors were different political interests and priorities, competing interests from the nursing profession, and divergent academic opinions on a midwifery profession (Study III). In Bangladesh, the system actors for promoting the establishment of a midwifery profession connected through a common goal to reduce maternal and child mortality and morbidity in the country. To achieve this goal, actors contributed their unique competence, which resulted in curriculum development and faculty development plans. A main challenge the collaboration faced were the different interests and priorities influenced by individual philosophies versus organisational mandate (Study IV). The conclusion of this thesis is that a fundamental step in establishing a midwifery profession with professional status and formal control of the profession and its work requires a comprehensive approach. It is acknowledged that focusing on education alone is not enough to establish a midwifery profession. Support for building educational infrastructure, resources, and regulation systems are also required to establish the midwife as a separate profession that can meet the needs of women and children. A prerequisite for ensuring that midwives can meet the needs of women and children is that the profession is aligned with national policies, and that midwifery strategies are in place to guide the establishment forward. Such an approach will require close connection among all involved actors in terms of their ability to collaborate and utilise each other’s unique competence to achieve results.