National Midwifery Research Articles

Midwives\u2019 and patients\u2019 perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study

BackgroundIt is increasingly recognized that disrespect and abuse of women during labor and delivery is a violation of a woman’s rights and a deterrent to the use of life-saving, facility-based labor and delivery services. In Ethiopia, rates of skilled birth attendance are still only 28% despite a recent dramatic national scale up in the numbers of trained providers and facilities. Concerns have been raised that womens’ perceptions of poor quality of care and fear of mistreatment might contribute to this low utilization. This study examines the experiences of disrespect and abuse in maternal care from the perspectives of both providers and patients.MethodsWe conducted 45 in-depth interviews at four health facilities in Debre Markos, Ethiopia with midwives, midwifery students, and women who had given birth within the past year. Students and providers also took a brief quantitative survey on patients’ rights during labor and delivery and responded to clinical scenarios regarding the provision of stigmatized reproductive health services.ResultsWe find that both health care providers and patients report frequent physical and verbal abuse as well as non-consented care during labor and delivery. Providers report that most abuse is unintended and results from weaknesses in the health system or from medical necessity. We uncovered no evidence of more systematic types of abuse involving detention of patients, bribery, abandonment or ongoing discrimination against particular ethnic groups. Although health care providers showed good basic knowledge of confidentiality, privacy, and consent, training on the principles of responsive and respectful care, and on counseling, is largely absent. Providers indicated that they would welcome related practical instruction. Patient responses suggest that women are aware that their rights are being violated and avoid facilities with reputations for poor care.ConclusionsOur results suggest that training on respectful care, offered in the professional ethics modules of the national midwifery curriculum, should be strengthened to include greater focus on counseling skills and rapport-building. Our findings also indicate that addressing structural issues around provider workload should complement all interventions to improve midwives’ interpersonal interactions with women if Ethiopia is to increase provision of respectful, patient-centered maternity care.

Midwives' personal use of complementary and alternative medicine (CAM) influences their recommendations to women experiencing a post-date pregnancy.

A survey of a national midwifery association midwifery members (n=3,552) was undertaken at a midwifery conference (October 2015) and via e-bulletins (November 2015-March 2016). The self-administered survey included questions on what self-help and CAM strategies midwives discuss and recommend to women with a post-date pregnancy, midwives' confidence levels on discussing or recommending CAM, midwives' own personal use of CAM. A total of 571 registered midwives completed the survey (16%). Demographics (age, years as a midwife, state of residence) reflected Australian midwives and the midwifery association membership. Most respondents discuss (91.2%) and recommend (88.6%) self-help/CAM strategies to women with a post-date pregnancy. The top five CAM recommended were Acupuncture (65.7%), Acupressure (58.1%), Raspberry Leaf (52.5%), Massage (38.9%) and Hypnosis/Calmbirthing/Hypnobirthing (35.7%). Midwives were more likely to discuss strategies if they personally used CAM (p<.001), were younger (p<.001) or had worked less years as midwives (p=.004). Midwives were more likely to recommend strategies if they used CAM in their own pregnancies (p=.001). Midwives' personal use of CAM influenced their discussions and recommendations of CAM/self-help strategies to women experiencing a post-date pregnancy. This study has implications for inclusion of CAM in midwifery education curricula.

Comparing the Professional Role and Tasks Approved in Curriculum with the Ongoing Role and Tasks of Midwives Employed in Tabriz Health Care Units

Background: Midwives play an important role in the implementation of health programs in health care units. The objective of this study was to compare the professional role and task in curriculum with the ongoing role and task of midwives working in the health care units of Tabriz (East Azarbaijan, Iran, 2015). Methods: This cross-sectional study was done via census on all midwives working in rural and urban health units in Tabriz in 2015 (225 persons). The data was collected using a researcher-designed questionnaire based on the national midwifery curriculum approved in 2012. The questionnaire includes questions related to the use of specific teaching courses and their relevancy to the professional roles contained in the curriculum;a self-assessment of the midwives’ current performance was completed by midwives themselves. The validity and reliability of questionnaire were confirmed. Data were presented using mean (SD) and n (%) for numerical and categorical variables. Results: Professional roles and tasks contained in the curriculum were not fully relevant to current roles and tasks of midwives. The highest relevancy was related to the role of education and the lowest relevancy was seen in ongoing tasks related to disease diagnosis, care and intervention. Of the specialized courses, internships in pregnancy and childbirth and its pathology had the highest and lowest applications, respectively. Conclusion: This study showed that, midwifery specialized training courses content and professional role and tasks curriculum- based are not consistent with ongoing expected real world tasks. Therefore, it is essential that reforms are made to enhance the curriculum and efficiently align it with practical responsibilities and expectations.

Characteristics of patients receiving midwife-led prenatal care in Canada: results from the Maternity Experiences Survey (MES)

BackgroundThe aim of this study was to determine the characteristics of women in Canada who received care from a midwife during their prenatal period.MethodsThe findings of this study were drawn from the Maternity Experiences Survey (MES), which was a cross-sectional survey that assessed the experiences of women who gave birth between November 2005 and May 2006. The main outcome variable for this study was the prenatal care provider (i.e. midwife versus other healthcare providers). Demographic, socioeconomic, as well as health and pregnancy factors were evaluated using bivariate and multivariate models of logistic regression.ResultsA total of 6421 participants were included in this analysis representing a weighted total of 76,508 women. The prevalence of midwife-led prenatal care was 6.1%. The highest prevalence of midwife-led prenatal care was in British Columbia (9.8%), while the lowest prevalence of midwife-led prenatal care was 0.3% representing the cumulative prevalence in Nova Scotia, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Saskatchewan, and Yukon. Factors showing significant association with midwife-led prenatal care were: Aboriginal status (OR = 2.26, 95% CI: 1.41–3.64), higher education with bachelor and graduate degree attainment having higher ORs when compared to high-school or less (OR = 2.71, 95% CI: 1.71–4.31 and OR = 3.17, 95% CI: 1.81–5.55, respectively), and alcohol use (OR = 1.63, 95% CI: 1.17–2.26). Age, marital status, immigrant status, work during pregnancy, household income, previous pregnancies, perceived health, maternal Body Mass Index (BMI), and smoking during the last 3 months of pregnancy were not significantly associated with midwife care.ConclusionsIn general, women who were more educated, have aboriginal status, and/or are alcohol drinkers were more likely to receive care from midwives. Since MES is the most recent resource that includes information about national midwifery utilization, future studies can provide more up-to-date information about this important area. Moreover, future research can aim at understanding the reasons that lead women to opt for midwife-led prenatal care.

Application of objective structured clinical examination in clinical practical examination for national midwifery standardized training

Objective To explore the application effect of objective structured clinical examination (OSCE) in the clinical practical examination for national midwifery standardized training and its significance for the training work. Methods A total of 89 candidates participated in 2016 national midwifery exam were recruited and investigated by self-designed questionnaire included general information, evaluation of measurement and effect of OSCE, and self evaluation. Results Candidates gave a high degree of evaluation and approval on OSCE, and it also had a positive guiding significance for further improving the midwifery training scheme. Conclusions The application of OSCE is in accordance with the practice demand for midwifery talents, thus it has popular value in the midwifery training and exams. Key words: Nurse midwives; Inservice training; Objective structured clinical examination (OSCE); Standardized training

Continuing professional development and challenges facing newly graduated midwives in Papua New Guinea

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The Maternal Mortality Ratio in Papua New Guinea (PNG) in 2008 was estimated at more than 700 deaths per 100,000 live births. In recognition of the high MMR, a Ministerial Taskforce was established in 2009 with recommendations to urgently address the workforce capacity in regard to maternal and child health services. In 2010, a new competency-based Bachelor of Midwifery curriculum was introduced into four universities in PNG and an increase in the numbers of midwifery students took place over a four year period.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Aim: &lt;/strong&gt;The aim of this study was to explore the experiences of Papua New Guinean midwifery graduates from the 2012 and 2013 Bachelor of Midwifery cohorts. These graduates were among the first to complete the revised national midwifery curriculum designed to improve the knowledge and skills of a registered midwife graduate.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Method: &lt;/strong&gt;A descriptive exploratory study was undertaken to explore the experiences of 174 graduates in the first two years post-graduation. All graduates that were able to be contacted were provided with information about the study, consented and were interviewed either face-to-face or by phone/email. Quantitative data were analysed using simple descriptive statistics in SPSS and qualitative data underwent content analysis and coding by the research team.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;Almost all (90%) graduates were working as midwives with 39% of graduates working in rural and remote locations across PNG. Midwifery education prepared graduates well for their work as midwives, but many commented that the course needed to be longer to improve feelings of competence. Professional support during their graduate year varied depending on location and motivation of supervisors. Many graduates, particularly those in rural areas, expressed the desire to work under clinical supervision in a hospital setting for a period of 6-12 months at the end of their training to become more skilled and confident prior to seeking employment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;Most midwifery graduates from the new curriculum found employment as midwives. Only a minority of graduates have had opportunities for continued professional development or support from a mentor of senior colleague. Regular, ongoing professional development and supervision needs to be initiated for the provision of skilled and evidence based care. Support and incentives for staff to work in rural and remote areas should be considered.&lt;/p&gt;

The Impact of Motivation on the Work Performance of Health Workers (Korle Bu Teaching Hospital): Evidence from Ghana

Background: Motivation is a driver to health worker performance in most Ghanaian hospitals. In view of this, Ghana’s Ministry of Health has rolled out enough motivational policies to accentuate work performance of health workers. Objective: The focus of this study was to examine the impact of motivation and identify how intrinsic and extrinsic motivating factors affect the work performance of health workers at Korle-Bu Teaching Hospital (KBTH). Methods: A qualitative approach was adopted for the study, and purposive sampling was used to select fifteen (15) health workers including both medics and paramedics. An in-depth interview guide and one-on-one interviews were adopted to collect data from the staff at Korle Bu Teaching Hospital. A thematic content analysis was used to analyze the transcribed data. Results: Key findings from the study revealed that job satisfaction, logistic provision, and an enabling work environment are intrinsic motivating factors that affect the work performance of health workers; extrinsic factors such as financial reward, accommodation, and transportation also impact work performance. Furthermore, motivation is key to the work performance of nurses. Conclusion: It is recommended that the National Midwifery and Nursing Council (NMC) and the Ministry of Health (MOH) adopt motivational policies based on the intrinsic and extrinsic motivational blocks.

Women's experiences of having a Bachelor of Midwifery student provide continuity of care.

The Australian national midwifery education standards require students to complete a number of continuity of care (COC) experiences. There is increasing evidence outlining the value of this experience to the student, but there is limited research examining women's experiences of having a COC midwifery student. This study aimed to investigates the woman's experiences. A retrospective descriptive cohort design was used. A paper-based survey was posted to all women cared for by a midwifery student in 2013 (n=698). Descriptive statistics were used to explore the proportion, mean score, standard deviation and range of the variables. Construct validity of the Satisfaction and Respect Scales was tested using exploratory factor analysis. Free text responses were analysed using latent content analysis. One-third of women returned a completed survey (n=237/698, 34%). There was a significant positive correlation (p<0.05) between the number of AN/PN visits a midwifery student attended and women's levels of satisfaction. Women were very satisfied with having a student midwife provide continuity. The qualitative data provided additional insight demonstrating that most women had a positive relationship with the midwifery student that enhanced their childbearing experience. The women in this study valued continuity of midwifery care and were able to form meaningful relationships with their midwifery student. Programs leading to registration as a midwife should privilege continuity of care experiences. Not only does this benefit women but provides the future midwifery workforce with a clear understanding of models that best meet women's individual and the benefits of working in these models.

Labor Dystocia: Uses of Related Nomenclature.

Labor dystocia (slow or difficult labor or birth) is the most commonly diagnosed aberration of labor and the most frequently documented indication for primary cesarean birth. Yet, dystocia remains a poorly specified diagnostic category, with determinations often varying widely among clinicians. The primary aims of this review are to 1) summarize definitions of active labor and dystocia, as put forth by leading professional obstetric and midwifery organizations in world regions wherein English is the majority language and 2) describe the use of dystocia and related terms in contemporary research studies. Major national midwifery and obstetric organizations from qualifying United Nations-member sovereign nations and international organizations were searched to identify guidelines providing definitions of active labor and dystocia or related terms. Research studies (2000-2013) were systematically identified via PubMed, MEDLINE, and CINAHL searches to describe the use of dystocia and related terms in contemporary scientific publications. Only 6 organizational guidelines defined dystocia or related terms. Few research teams (n = 25 publications) defined dystocia-related terms with nonambiguous clinical parameters that can be applied prospectively. There is heterogeneity in the nomenclature used to describe dystocia, and when a similar term is shared between guidelines or research publications, the underlying definition of that term is sometimes inconsistent between documents. Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels. This failure is particularly problematic in light of the major contribution of this diagnosis to primary cesarean birth rates.

Job satisfaction and retention of midwives in rural Nigeria

BackgroundNigeria is one of the 57 countries with a critical shortage of human resources for health, especially in remote rural areas and in northern states. The National Midwifery Service Scheme (MSS) is one approach introduced by the Government of Nigeria to address the health workforce shortage in rural areas. Since 2009, unemployed, retired and newly graduated midwives are deployed to primary health care (PHC) facilities in rural areas of Nigeria. These midwives form the mainstay of the health system at the primary health care level especially as it relates to the provision of skilled attendance at birth. This study followed up and explored the job satisfaction and retention of the MSS midwives in three Northern states of Nigeria. Methodsthis was a descriptive study. Data were collected using a mixed method approach which included a job satisfaction survey, focus group discussions (FGDs) and exit interviews to explore job satisfaction and retention factors. All 119 MSS midwives deployed by the National Primary Health Care Development Agency between 2010 and 2012 to the 51 Partnership for Reviving Routine Immunisation- Maternal and Child Health (PRRINN-MNCH) programme targeted PHC facilities were included in the study. ResultsMSS midwives were very satisfied with from the feeling of caring for women and children in the community (4.56), with the chance to help and care for others (Mean 4.50), the feeling of worthwhile accomplishment from doing the job (Mean 4.44) and the degree of respect and fair treatment they received from more senior staff and/or supervisor (Mean 4.39). MSS midwives were least satisfied with the lack of existence of a (established) career ladder (Mean 2.5), availability of promotional opportunities within the scheme (Mean 2.66), safety of accommodation (Mean 3.18), and with ‘the degree to which they were fairly paid for what they contribute to the health facility’ (Mean 3.41). When asked about future career plans, 38% (n=33) of the MSS midwives planned to leave the scheme within two years, of which 16 (18%) wanted to leave within one year. However, 39% of the midwives (n=34) indicated that they would be happy to continue working even after the scheme has ended. Of these 34 participants, 18 would like to continue working in the same facility where they are now whereas the remaining 16 would like to continue working in the north but not in the facility where they are working currently. Eight themes on job satisfaction and retention emerged from the FGDs conducted with current midwives, whereas six themes emerged from the exit interviews from midwives who have left the scheme. Conclusionthe MSS programme is a short-term solution to increase SBA coverage in rural Nigeria. MSS midwives were dissatisfied with the short term contract, lack of career structure, irregular payment, poor working condition, inadequate supervision and poor accommodation being offered by the programme, which all contribute to poor retention of MSS midwives. Implications for policy and practicemidwives׳ job satisfaction and retention are critical to improving the health of mothers and their newborn. Poor job satisfaction and retention therefore requires improvements in financial and non-financial incentives, health systems, supportive supervision, ensuring job security and a career structure for midwives working in rural health facilities. Initiating effective strategies to motivate and increase the retention of rural health workers is important for Nigeria to achieve the Millennium/Sustainable Development Goals.

Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study.

BackgroundComplications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.MethodsA national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.ResultsThe average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.ConclusionsWhile designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.

Nyutdannede jordmødres vurdering av utdanning, klinisk kompetanse og arbeidsforhold

&lt;p&gt;Newly qualified midwives’ self-assessment of education, clinical competence and working conditions&lt;/p&gt;&lt;p&gt;In Norway, post-graduate nursing programmes are being transformed into master programmes. This occurs without previous evaluation of the study programmes. The level of competence and the requirements of newly qualified are being discussed, and a mentoring programme has been suggested to ensure follow-up and development of clinical competence. In central parts of the country, newly qualified midwives have difficulties getting a permanent full time position, which affects their possibilities to develop clinical competence. An evaluation study of the midwifery program at Vestfold University College has been performed to assess its relevance for professional work, as well as mapping the respondents’ working conditions and their self-assessment of clinical competence. The method used was a survey. The respondents rate the program as good. They lack competence to manage complicated conditions related to the perinatal period, and are inadequate when it comes to issues related to women’s sexual heath. These midwives work part-time, and it may take years to get a permanent position. They rate the follow-up as newly qualified as satisfying, yet they do not feel sufficiently confident during clinical practice. Comprehensive national midwifery competence will require more full time positions and better follow-up of newly qualified. To lay the basis for the content in master programmes, there is a need for a national evaluation of the midwifery programmes and a review of the professional competence of newly qualified.&lt;/p&gt;

‘Super’ communication: Every quilt tells a story

It is highly relevant that at a national midwifery conference we explore and share our innermost thoughts and ideas about midwifery. This presentation is the beginning of an ongoing documentary film project. Participants will see three short interviews with midwives that will give the viewers a very personal insight into what makes a midwife, what motivates a midwife and what maintains a midwife. The interviews will celebrate midwives, their passion and their commitment to the profession. This work will move and inspire by getting to the heart of what we call midwifery. Film is an excellent medium to communicate what is personal. The aim of the work is to create a connection between the viewer and the midwife, utilising words and pictures to tell the story and enhance the relationship so that we may have a deeper understanding of what lies inside the heads and hearts of midwives. The aim of this presentation is to honour the midwifery profession. It reminds us of the essence of midwifery and what connects all midwives. The personal interviews with three unique midwives gives the viewer a rare insight into what motivates and inspires the midwifery passion.

Evaluation of accuracy of mediolateral episiotomy incisions using a training model

BackgroundEpisiotomy is one of the most commonly performed surgical procedures worldwide. In the UK the use of episiotomy is selective, rather than routine, and a right mediolateral episiotomy (RMLE) is considered standard practice. According to The National Institute of Health and Care Excellence (NICE, 2007) guideline for intrapartum care such an episiotomy should be cut at an angle between 45° and 60° to the vertical axis. Recent evidence suggests that the angle of incision of mediolateral episiotomy (MLE) is associated with risk of obstetric anal sphincter injury (OASIS). Objectiveto assess the accuracy of individual practitioner׳s techniques when performing a RMLE. Designan audit of practice against nationally set standards. Settingat a national midwifery conference and prior to three multiprofessional perineal repair training workshops in the West Midlands region of the UK. Participants144 midwives and 53 obstetric trainees. Measurementspractitioners were asked to perform a RMLE incision on a bespoke training model, which is designed to give a realistic representation of a stretched perineum at crowning of the baby׳s head. Four parameters were measured: (1) distance of the starting point from the midline; (2) angle subtended to the perpendicular; (3) length and (4) shape of the incision (curved, straight or J-shaped). Findingsof the 197 incisions performed only 12.7% (14.6%, n=21/144 of midwives and 7.5%, n=4/53 of obstetricians) complied with the defined technique of a RMLE for correctness of angle and placement. A 2-sided Fisher׳s exact test showed no significant difference between previous attendance at perineal management training and incision accuracy.

Mapping for maternal and newborn health: the distributions of women of childbearing age, pregnancies and births.

BackgroundThe health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed.MethodsThis paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies.Results and conclusionsThese estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project.

‘Twin2twin’ an innovative method of empowering midwives to strengthen their professional midwifery organisations

Backgroundmidwives need professional support from a national midwifery organisation to be able to provide the services that are by regulatory mechanisms and accreditation expected of them. Not all midwives in the world are united in a professional organisation. The aim of this project was to strengthen the midwifery organisations of Sierra Leone and the Netherlands. During the process of the project it was realised that the development of a platform of exchange at organisational level would be enhanced by introducing personal exchange between individual midwives. In response to this new insight the original project plan was adjusted by incorporating the twin2twin method. Methodtwin2twin is a feminist methodology of mutual exchange between twenty pairs of midwives from different organisations (in this case Sierra Leone and the Netherlands). The method can be distinguished by 10 specific steps. It was developed, used and (re)evaluated through focus group discussions, storytelling and written evaluations. Findingstwinning of organisations was strengthened by adding a human component to the process. With the use of the ‘twin2twin’ method, midwives were encouraged to invested in a professional and personal bond with their ‘twin sister’. This bond was independent and went beyond the relatively short four year project period. Through personal engagement and mutual exchange of knowledge and skills, midwives empowered each other to build and strengthen their midwifery organisations both in Sierra Leone and the Netherlands. (Empowerment refers to the expansion in people's ability to make strategic life choices in a context where this ability was previously denied to them (Narayan, 2005); organisational empowerment includes processes and structures that enhance members' skills and provides them with the mutual support necessary to effect community level change (Zimmerman, 1995).). Conclusion and implications for practicedespite challenges we are convinced that twin2twin can be of additional benefit for the success of other projects involved in strengthening midwifery organisations in the long term. It can be used independently or alongside other forms of (co)development not only in midwifery but also in other professions.

‘Midwives are the backbone of our health system’: Lessons from Afghanistan to guide expansion of midwifery in challenging settings

Backgroundover the last decade Afghanistan has made large investments in scaling up the number of midwives to address access to skilled care and the high burden of maternal and newborn mortality. Objectiveat the request of the Ministry of Public Health (MOPH) an evaluation was undertaken to improve the pre-service midwifery education programme through identification of its strengths and weaknesses. The qualitative component of the evaluation specifically examined: (1) programme strengths; (2) programme weaknesses; (3) perceptions of the programme's community impact; (4) barriers to provision of care and challenges to impact; (5) perceptions of the recently graduated midwife's field experience, and (6) recommendations for programme improvement. Designthe evaluation used a mixed methods approach that included qualitative and quantitative components. This paper focuses on the qualitative components which included in-depth interviews with 138 graduated midwives and 20 key informants as well as 24 focus group discussions with women. Settingeight provinces in Afghanistan with functioning and accredited midwifery schools between June 2008 and November 2010. Participantsmidwives graduated from one of the two national midwifery programmes: Institute of Health Sciences and Community Midwifery Education. Key informants comprised of stakeholders and female residents of the midwives catchment areas. Findingsmidwives described overall satisfaction with the quality of their education. Midwives and stakeholders perceived that women were more likely to use maternal and child health services in communities where midwives had been deployed. Strengths included evidence-based content, standardised materials, clinical training, and supportive learning environment. Self-reported aspects of the quality education in respect to midwives empowerment included feeling competent and confident as demonstrated by respect shown by co-workers. Weaknesses of the programme included perceived low educational requirement to enter the programme and readiness of programmes to commence education. Insecurity and geographical remoteness are perceived as challenges with clients' access to care and the ability of midwives to make home visits. Key conclusionsthe depth of midwives' contribution in Afghanistan – from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence – is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.

Practical coaching by mentors: Student midwives' perceptions

ObjectiveThe objective of this paper was to explore some of the specific strategies used by midwife mentors to mediate practice learning from the perspective of a sample of student midwives. DesignAudio-diaries were completed by student midwives over ten days in practice and were transcribed using discourse analysis. A sub-sample from 19 students' learning diaries from a national midwifery education study conducted by Pope et al. (2003) has been selected as the diaries informed a separate study. ParticipantsThe sample of student midwives were studying on degree and diploma programmes at five case study sites in England. Main findingsStudents described how their mentors apparently successfully tailored their teaching to the students' needs. However, there was perceived disparity in techniques used by individual mentors to pass on their practice know-how. The findings demonstrate the pivotal role of the mentor for ‘scaffolding’ learning and also using ‘fading’ techniques within a cognitive apprenticeship model. Key conclusions and implications for practiceMentors need assistance to adapt their mentoring styles and to use a wider range of instruction strategies for student midwives. This has practical implications for mentor preparation programmes and mentorship models.

Collaboration in Maternity Care is achievable and practical

Enhancing collaboration has been highlighted as a marker for future success in maternity care, although this suggestion comes with little methodological guidance. This study assessed the efficacy of a collaborative partnership between obstetric doctors and midwives providing Midwifery Group Practice (MGP) care. A retrospective analysis was undertaken with notes from weekly case review meetings held between the obstetricians and midwives over a 12-month period; audio recordings and a prospective analysis of 16 meetings with verbal contributions of the different professions; the number and types of cases discussed and referred, medical records kept at these meetings and a professional satisfaction questionnaire. Consistency of care was measured against the Australian National Midwifery Guidelines for Consultation and Referral. Of the 337 women booked with MGP, 50% were discussed at least once. Of these, 35% were referred for consultation with an obstetrician. Women as 'Patients' were most commonly discussed, followed by educational discussions and anecdotes with equal verbal contributions from midwives and doctors. Plans for each case were recorded 97% of the time, and adhered to 90% of the time. A high level of consistency of care between similar cases (75% of the time) and with the consultation and referral guidelines (85% of the time) were achieved. Professional satisfaction with this model of care rated highly for both groups. Inter-professional collaboration between midwifery and obstetric staff is highly attainable within this model of care. This study reinforces the effectiveness of collaboration in the MGP model of care for women of all risk levels and should encourage other maternity care providers to consider adopting this collaborative model.

Workload and workforce planning: taking a national approach

In response to an Audit Scotland report, the Scottish Executive, now the Scottish Government, set up the national Nursing and Midwifery Workload and Workforce Planning (NMWWP) programme to define workload and workforce needs, and to analyse the use of bank and agency staff. After extensive research, a systematic, national approach to nursing and midwifery workload and workforce planning was recommended. This article, the first in a series of five on this topic, describes the legislation and policies that underpin the NMWWP programme, and highlights the demographic issues that are pertinent to the nursing and midwifery workforce in Scotland.