Professional Midwives Research Articles

BIRTH PHOTOGRAPHY AS A NORMAL MATERNITY FACILITY AT PMB

Birth photography is a new form of birth art, the emergence of birth photography as an expression of a woman's birth experience that is centered on women. Photos become a means of imaginative adventure for human experience, communication between humans and themselves, between people and even between generations. This birth memoir is a form of celebration and gift for future children, parents, or anyone else for the moment of childbirth which only happens once in a woman's life even if there are subsequent births. With current technological advances, birth documentation as a medium for capturing beautiful memories of childbirth can be easily done, using a camera or a smartphone. The data source in this study uses a literature review method which comes from several sources, both national and international journals, using published articles from Google Scholar, Radiation Oncology Journal, PubMed, and Elsevier. In this research, birth photography is used as a facility for mothers going through normal childbirth. The aim is to entice mothers to become more interested and brave in going through natural childbirth with professional midwives at PMB

Postpartum care for parent-infant dyads: A community midwifery model.

Postpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies. We conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis. A total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest. The community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

Dedication of Professional Midwives in Providing Healthcare Services in Selected Rural Communities in the Philippines: a Descriptive Qualitative Study

The majority of professional midwives in the Philippines work in public health, particularly in rural areas. In this paper, we sought to investigate and gain insights into midwives' motivations, experiences, and aspirations while working and providing client-centered care in rural areas of the Cordillera Administrative Region, one of the administrative regions in the Philippines. This study utilized a qualitative descriptive study design through in-depth interviews using a semi-structured topic guide to collect data from September–October 2021. Participants were selected based on their at least three-year work experience, current roles as midwives in public rural health settings, and willingness to participate. Phone calls were used for interviews due to travel restrictions during the COVID-19 pandemic. Data were recorded, transcribed, and analyzed through content analysis. Developed themes were confirmed and validated by the study participants. A total of seven rural professional midwives participated in this study. Three main themes emerged from the data analysis – including the process of embracing the midwifery profession, rewarding yet challenging work experiences, and aspiration for competence and better work status. This study is the first of its kind done in the country and, as such, has provided new insights and findings regarding the midwifery profession in the Philippines. Despite facing challenges in providing healthcare in the rural setting, rural midwives find their profession to be a fulfilling and gratifying work experience. They strive for greater competence and improved work status and are dedicated to serving rural areas to the best of their abilities. Enabling midwives in rural communities with support and avenues for professional growth will enhance the provision of healthcare services in geographically challenged regions.

Developing and validating a tool for assessing the confidence in the competence of midwifery tutors in India on WHO core competency domains.

Negligible quantitative research evidence exists on standardisation and psychometric validation of questionnaires that measure midwifery educators' confidence in their competence. This study developed a self-assessment of confidence in competence questionnaire in India based on the WHO Midwifery Educator Core Competencies (2014) with an aim to develop and validate a self-assessment tool measuring midwifery tutors' confidence in competence in imparting quality midwifery education. The questionnaire was developed as part of a multi-centre study to identify confident midwifery tutors for further training as educators, supporting India's rollout of professional midwives. The questionnaire underwent rigorous psychometric testing among 2016 midwifery tutors in India. Following exploratory Principal Component Analyses (PCA), the nine core competencies outlined in the WHO document were analysed separately. The results indicate that the questionnaire is psychometrically valid, with an internal consistency range of 0.81-0.93 for the nine domains. This robust testing process ensures the reliability and validity of the questionnaire. The self-assessment questionnaire can potentially be a valuable tool in India and other high-, middle-, and low-income countries. From a programmatic perspective, it can help identify key gaps and prioritise training needs, particularly in low-resource settings, so that limited resources are best utilised to fill the most prominent gaps. Furthermore, it can provide a universal platform for comparing data from different settings, facilitating global collaboration and learning in midwifery education.

A arte de endurecer sem perder a ternura: o uso de tecnologias por obstetrizes na atenção ao parto domiciliar planejado

Abstract Introduction: Given the intense medicalization of childbirth and the hegemony of a technocratic model, there is a growing need for professional midwives to promote safe pregnancy and childbirth with minimal interventions. Objective: This study aims to identify the technologies present in the toolbox of certified midwives graduated from University of São Paulo. Methodology: It consists of a descriptive-exploratory study, with a qualitative approach. Semi-structured interviews were carried out virtually with five midwives from August 2020 to May 2021. The material was analyzed using dialogical maps. Results: A very heterogeneous range of technologies was identified, which included soft, soft-hard, and hard technologies. Soft technologies include affection, effective communication (knowing how to speak, knowing how to listen), and bonding. Soft-hard technologies include basic disciplines, scientific evidence, experience, and intuition. Finally, hard technologies include human-made instruments, in addition to the use of the materiality of the body. Conclusions: Midwives tend to use hard technologies when they are unable to achieve the desired effect with the soft technologies they had available, while also using their interrelational resources throughout the entire process. Furthermore, to employ such technological resources, professionals use different kinds of knowledge, without hierarchizing them.

Perceptions and Attitudes Toward Genetic Counselors and Genetic Testing Among Certified Professional Midwives in Vermont: A Modified Grounded Theory Study.

Increasingly, pregnant people in the United States are choosing to give at birth at home, and certified professional midwives (CPMs) often attend these births. Care by midwives, including home birth midwives, has the potential to decrease unnecessary medical interventions and their associated health care costs, as well as to improve maternal satisfaction with care. However, lack of integration into the health care system affects the ability of CPMs to access standard medications and testing for their clients, including prenatal screening. Genetics and genomics are now a routine part of prenatal screening, and genetic testing can contribute to identifying candidates for planned home birth. However, research on genetics and midwifery care has not, to date, included the subset of midwives who attend the majority of planned home births, CPMs. The purpose of this study was to examine CPMs' access to, and perspectives on, one aspect of prenatal care, genetic counselors and genetic counseling services. Using semi-structured interviews and a modified grounded theory approach to narrative analysis, we identified three key themes: (1) systems-level issues with accessing information about genetic counseling and genetic testing; (2) practice-level patterns in information delivery and self-awareness about knowledge limitations; and (3) client-level concerns about the value of genetic testing relative to difficulties with access and stress caused by the information. The results of this study can be used to develop decision aids that include information about genetic testing and genetic counseling access for pregnant people intending home births in the United States.

Quality midwifery care during the COVID-19 pandemic in Bangladesh: A focus group study with midwives, nurses, and midwifery educators.

Bangladesh has made remarkable strides in the development of the midwifery profession. However, the COVID-19 pandemic has had profound effects on healthcare systems worldwide, including those related to reproductive, perinatal, and maternal health. Given the recent advancements in the midwifery field in Bangladesh, it is crucial to examine the pandemic's impact on existing barriers and the capacity of midwifery professionals to deliver high-quality care. The aim of this study is to describe the possibility of midwives being able to provide quality midwifery care in Bangladesh during the COVID-19 pandemic. To gather insights, data were collected from July to October 2020 via four qualitative focus group discussions online; 23 actively practicing midwives, nurses specializing in midwifery care, and midwifery educators, participated. The data analysis employed reflexive thematic analysis. The COVID-19 crisis posed significant threats to women's safety and health, with lockdowns exacerbating gender inequalities in society. Midwives faced added challenges due to their relatively low professional status and increased workloads. Insufficient policy implementation further compromised midwives' safety. Fear of contracting the virus and working during their free time also raised concerns about the quality of care provided. Nevertheless, the pandemic provided opportunities for midwives to demonstrate their ability to deliver independent midwifery care in Bangladesh. The pandemic underscored the importance of creating respectful and dignified working conditions for midwives. It revealed that professional midwives can work independently when provided with the necessary space and a supportive work environment. This opens the door for the implementation of a midwifery-led care model. Further research is recommended to investigate the medical safety and efficacy of independent midwifery care in the context of Bangladesh.

"Learning a Way of Thinking"-World Café on Clinical Reasoning in Nursing and Midwifery Education and Practice across Five European Union Countries.

Clinical reasoning is a key attribute of nursing and midwifery professionals. As a part of the Erasmus plus project, we designed a study with the aim of exploring the understanding of clinical reasoning as a concept, experiences of teaching clinical reasoning and practices related to using clinical reasoning in nursing and midwifery. A qualitative study was carried out using the World Café method, involving 44 participants from five European countries. The participants represented diverse professional backgrounds, including nurses, midwives and lecturers. Our analytical approach was based on a thematic analysis. We categorized the data into three main categories, namely, "Spiral of thinking", "The learning and teaching of a way of thinking" and "Clinical reasoning in real life", all under an overarching theme, "Learning a way of thinking". This study highlighted areas of learning and teaching which can be improved in current nursing and midwifery education. Furthermore, it identified barriers, facilitators and practices from five European countries which can be used in the further development of nursing and midwifery curricula and courses with the aim of enhancing clinical reasoning competence and ultimately improving patient care.

Health System Strengthening Through Professional Midwives in Bangladesh: Best Practices, Challenges, and Successes.

In 2008, a cadre of professional midwives was introduced in Bangladesh. Since then, 120 midwifery educational programs have been established. There are 2,556 midwives serving at 667 government health facilities, and there are more midwives working in nongovernmental organizations and the private sector. This case study documents the process of establishing a midwifery profession with distinct midwifery expertise in Bangladesh and aims to guide other low- and middle-income countries in best practices and challenges. We describe the national administrative groundwork for the profession's launch, roll-out of an education program aligned with the International Confederation of Midwives, national deployment, enabling environments in deployment, and the professional association. Bangladesh's professional midwives' roles in humanitarian response and the COVID-19 pandemic are also discussed. The first and final authors were closely involved in supporting the government's establishment of the profession, and their direct experience is drawn upon to contextualize the topics. In addition, the authors conducted a desk review of documents that supported the profession's integration into the health system and documented its results. Both routine program data and existing research studies were reviewed. Outcomes show that midwives are deployed to 95% of government subdistrict hospitals. About 50% of these hospitals are fully staffed with 4 midwives, and within the hospitals, midwives are in charge of 90% of the maternity wards and attend 75%-85% of the births. Since the midwives' deployment, significant quality improvement for most World Health Organization indicators has been found, along with increases in service utilization. The experience of establishing a new midwifery profession in Bangladesh shows that it is possible for a lower middle-income country to introduce a globally standard midwifery profession, distinct from nursing, to improve quality sexual, reproductive, maternal, newborn, and adolescent health services in both humanitarian and development settings.

Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review

BackgroundThere is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems.MethodsAn integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis.ResultsFifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers.ConclusionsEffectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization.Trial registrationThe protocol is registered in PROSPERO (CRD42022367657).

Experiences of Midwives Attending Home Births in Massachusetts During the COVID-19 Pandemic.

Public interest in home birth in the United States increased during the COVID-19 pandemic. Midwives attend the vast majority of home births and are experts in providing home birth care. However, limited data are available about the experiences of midwives attending home births during the pandemic in the United States. We developed a cross-sectional survey comprising 34 questions, which included 5 open-ended questions. The survey was distributed online in June 2021 to midwives attending home birth in Massachusetts. We calculated descriptive statistics for the quantitative survey responses and identified qualitative free-text responses illustrating the results. Eighteen midwives and 2 midwife apprentices responded to the survey, approximately 50% of Massachusetts' total number of midwives known to attend homebirths. The majority of the 20 respondents reported an increase in public interest in home birth (n = 17) and higher caseloads (n = 14) since the start of the pandemic. Respondents reported an increase in the number of clients transferring to their practices at a later gestational age (n = 13) and who identified as people of color (n = 8). They described both better and worse transfer of care to hospital experiences. Work-life balance and unpredictable income were the top 2 reported obstacles to home birth practice. The results of our study indicate that midwives providing home birth care in Massachusetts witnessed a surge in demand for their services during the pandemic. Implementing policies and practices that provide support for certified professional midwives could strengthen the home birth workforce, enhance access to home birth options, and optimize transfers to hospital settings when necessary.

Urgent appeal to allow all professional nurses and midwives to prescribe pre-exposure prophylaxis (PrEP) in South Africa.

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CULTURE-PRENEURSHIP PELAYANAN KEBIDANAN MELALUI IMPLEMENTASI TRI HITA KARANA PASCA PENDIDIKAN PROFESI DI WILAYAH KERJA IKATAN BIDAN INDONESIA PROVINSI BALI CABANG DENPASAR TAHUN 2023

The characteristics of midwifery services can be modified from the various approaches adopted. An approach that is a minimum service standard that refers to pure modern ways without any consideration of the local cultural approach. The local approach that can be taken is the Tri Hita Karana approach as local wisdom which will motivate people to come for a pregnancy check-up to get the results of monitoring the state of their pregnancy as well as a sense of comfort because there are three elements of peace that will be obtained in service with this philosophical approach that is local wisdom Balinese culture. This study uses the Tri Hita Karana approach as local wisdom in the implementation of Culture-Preneurship Midwifery Services Through the Implementation of Tri Hita Karana Post Professional Education in the Work Area of the Indonesian Midwives Association Bali Province Denpasar Branch in 2023. The method used in this study is a qualitative method, with a type of phenomenology in the form of a case study. Qualitative research data are data in the form of words, sentences, narratives, gestures, facial expressions, charts, pictures and photographs. This data can be divided into two types, namely empirical qualitative data and meaningful qualitative data. The results of this study are that the delivery of midwifery services refers to the standards of the midwifery profession. Based on existing standards, professional midwives will answer the needs of their clients by adapting to midwifery practices that are local wisdom which are evidence-based and provide greater benefits by adapting both.

Norwegian midwiveś experiences of encounter and support women with fear of childbirth during birth

ObjectiveTo describe midwiveś experiences of encountering and supporting women with fear of childbirth (FOC) during the birth. MethodQualitative study with a phenomenological approach, using 10 individual semi-structured interviews with midwives who had cared for women with FOC during the birth. All midwives worked in birth clinics or maternity wards. The data was analysed using Malterud́s systematic text condensation (STC). ResultsThe findings present in three main themes: taking on a professional role as a midwife to take care of women; time matters for safety and trust; and to encounter and see women without prejudices. Themes to describe a ‘professional midwife’ included self-confidence, control, competence/experience, independence, promoting normal birth, and motivation. Time played a crucial role in enabling a calm approach and a relationship built on trust, as well as in creating a sense of continuity and being present. Individual care and equality among the women was of importance to prevent prejudices, as was having control of the term FOC. Self-awareness was also important for evaluating the quality of the relationship, and the midwives’ wanted clear guidelines for handling women with FOC. ConclusionAspects related to professional midwifery skills, organisational factors such as time to establish safety and trust, and use of the concept of FOC, are all important for midwives when encountering and supporting women with FOC at birth. All these aspects need to be improved in the care of women with FOC, and clearly defined guidelines for handling such cases need to be developed.

Effect of a web-based fertility preservation training program for medical professionals in Japan.

Our web-based training program called "Educating Medical Professionals about Reproductive Issues in Cancer Healthcare" aims to help healthcare professionals communicate promptly with patients and survivors who are adolescents and young adults, with information pertinent to reproductive health issues such as the risk of infertility and fertility preservation. The study participants were professional healthcare providers, including physicians, nurses, pharmacists, social workers, midwives, psychologists, laboratory technicians, genetic counselors, and dieticians. Pre- and post- and 3-month follow-up tests consisting of 41 questions were administered to measure changes in knowledge and confidence. The participants also received a follow-up survey that covered confidence, communication techniques, and practice habits. A total of 820 healthcare providers participated in this program. The mean total score from the pre-test to the post-test grew significantly (p < 0.01), and participants' self-confidence increased. In addition, there was a change in the behavior of healthcare providers, who began asking about patients' marital status and parity. Our web-based fertility preservation training program improved knowledge and self-confidence regarding fertility preservation issues among healthcare providers caring for adolescents and young adult cancer patients and survivors.

Home-based postnatal midwifery care facilitated a smooth succession into motherhood: A Swedish interview study.

If a family is discharged from a hospital earlier after birth, close supervision by a skilled midwife is essential. The aim was to describe mothers' overall experience receiving postnatal care in a Swedish home-based midwifery care model. A descriptive qualitative study was conducted. Mothers meeting the inclusion criteria for a new home-based postnatal care model at a hospital in Stockholm, Sweden, were included. In total, 24 healthy mothers participated in a semi-structured telephone interview, averaging 58 minutes. Data were analyzed using thematic analysis, according to Braun and Clarke. The main theme explored, 'The home-based postnatal care model facilitated a smooth succession into motherhood', is explained by the themes: 1) Mothers felt 'not left adrift' when cared for by the home-based postnatal midwives; 2) Professional midwives with authority guided the way into motherhood; and 3) The home, a safe and secure space for new mothers. Mothers valued the well-structured home-based postnatal midwifery care. Important for mothers was to receive health checks, adequate information, and that midwives have a kind and individual approach to the families. Midwives play an important role for mothers in the early days after the birth of their baby.

The commitment to a midwifery centre care model in Bangladesh: An interview study with midwives, educators and students.

Midwifery-led care is a key factor in reducing maternal and new-born mortality globally. In Bangladesh, only a third of births are attended by professionals and almost 70% of births occur outside healthcare facilities. Midwifery is a relatively new profession in Bangladesh and a midwifery centre care model has only recently been introduced. This study aims to explore the willingness within the healthcare system to support a greater role for midwifery centres in maternity services. Data were collected through individual semi-structured interviews with 55 midwives, midwifery educators and final year midwifery students. Two of the midwifery educators were principals of nursing institutes involved in the government's midwifery leadership and considered as experts in the midwifery care system. The data was analysed using qualitative content analysis. The transcribed interviews comprised 150 pages. The study received ethical approval from the Directorate General of Nursing and Midwifery in Bangladesh. One main category emerged from the study: "The foundations of a midwifery centre care model need to be strengthened for the sustainable implementation of midwifery centres in Bangladesh to continue". Five additional categories were identified: 1) The midwifery centre care model is inaccessible for communities, 2) Striving for acceptable standards of care within a midwifery centre care model is not a priority 3) Respectful, woman-centred care is weak, 4) Community engagement with the midwifery centre care model is insufficient, and 5) The midwifery centre care model is not integrated into the healthcare system. These categories were supported by the identification of 11 sub-categories. The willingness to commit to a midwifery centre care model is not yet in place in Bangladesh. Advocacy, information, and education about the benefits of normal birth assisted by professional midwives is needed at all levels of Bangladeshi society.

Barriers to nurses health advocacy role.

Speaking up to safeguard patients is a crucial ethical and moral obligation for nurses, but it is also a difficult and potentially dangerous component of nursing work. Health advocacy is gaining impetus in the medical literature, despite being hampered by barriers resulting in many nurses in Ghana remaining mute when faced with advocacy-required situations. We explored situations that thwart nurses from performing their health advocacy role. What would cause nurses to take no action when they witness situations that require them to act as health advocates for their clients or communities? An inductive, descriptive qualitative design was used to collect and analyse data on barriers that prevent nurses from practising their health advocacy role in Ghana. Individual one-on-one in-depth interviews were conducted using a semi-structured interview guide. The data were analysed using qualitative content analysis. Twenty-four professional nurses and midwives registered with the Nursing and Midwifery Council were recruited from three regional hospitals in Ghana. These public hospitals were chosen from the upper, middle and coastal regions. The UKZN Ethics Review Committee in South Africa and the GHS Ethics Review Committee in Ghana both gave their approval for this study. Intrapersonal barriers, interpersonal barriers, and structural barriers emerged as major obstacles that nurses experience when performing their health advocacy role. Barriers to health advocacy have undermined nurses' ability to function as health advocates and are preventing them from utilising their health advocacy position in nursing practise. Giving nursing students positive role models in the classroom and in the clinic can help them become more effective health advocates.

Identification of factors influencing core competence promotion among professional nurses and midwives: A qualitative study using the COM-B model

AimTo identify factors influencing a behaviour of improving core competencies among nurses and midwives in the Maternity and Child Health Care Hospital using the capability, opportunity, motivation and behaviour (COM-B) model. BackgroundWith the increasing number of women with pregnancy complications and the COVID-19 pandemic, nurses and midwives are being challenged and enhancing their core competencies is imperative to ensure high-quality care. To develop effective intervention strategies, it is essential to systematically explore what influences nurses and midwives to improve their core competencies. To this end, this study applied the COM-B model of behavioural change. DesignQualitative study using the COM-B model. MethodsThis qualitative descriptive study was conducted in 2022 using face-to-face interviews, including 49 nurses and midwives. Topic guides for the interviews were developed based on the COM-B model. Transcribed verbatim interviews were analysed using deductive thematic analysis. ResultsThe COM-B model captures several factors. Capability factors included clinical knowledge and self-directed learning abilities. Opportunity factors included professional education covering necessary clinical skills, adequate clinical practice, personalised training, available time, insufficient clinical learning resources, absence of scientific research resources and support from leadership. Motivational factors were access to long-term work, incentive policies based on individuals’ work values and responses to upward social comparison. ConclusionsThe findings of this study suggested that prior to developing intervention strategies to enhance the core competencies of nurses and midwives, processing barriers to nurses’ and midwives’ capabilities, opportunities and motivation can facilitate the implementation of interventions.

An analysis of the global diversity of midwifery pre-service education pathways

BackgroundThe development of competent professional midwives is a pre-requisite for improving access to skilled attendance at birth and reducing maternal and neonatal mortality. Despite an understanding of the skills and competencies needed to provide high- quality care to women during pregnancy, birth and the post-natal period, there is a marked lack of conformity and standardisation in the approach between countries to the pre-service education of midwives.This paper describes the diversity of pre-service education pathways, qualifications, duration of education programmes and public and private sector provision globally, both within and between country income groups. MethodsWe present data from 107 countries based on survey responses from an International Confederation of Midwives (ICM) member association survey conducted in 2020, which included questions on direct entry and post-nursing midwifery education programmes. FindingsOur findings confirm that there is complexity in midwifery education in many countries, which is concentrated in low -and middle-income countries (LMICS). On average, LMICs have a greater number of education pathways and shorter duration of education programmes. They are less likely to attain the ICM-recommended minimum duration of 36 months for direct entry. Low- and lower-middle income countries also rely more heavily on the private sector for provision of midwifery education. ConclusionMore evidence is needed on the most effective midwifery education programmes in order to enable countries to focus resources where they can be best utilised. A greater understanding is needed of the impact of diversity of education programmes on health systems and the midwifery workforce.