Barriers and facilitators to the implementation of midwife-led care for childbearing women in low- and middle-income countries: A mixed-methods systematic review

Abstract

BackgroundEvidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations’ Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care. AimThis systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders. MethodsA mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care. FindingsA total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs. Conclusion and implications for practice and researchThere are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.