A critical interpretive synthesis of the roles of midwives in health systems

Abstract

Background: Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidenceinformed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system. Methods: A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction. Results: A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession. Conclusions: Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations

“…8 18 However, while midwifery associations globally strive for stronger involvement in the SRHR policymaking process, their contributions are hindered by lack of professional recognition or understanding of the role of midwifery in health and political systems, 2 16 19 and marginalisation of the profession driven by gender inequality and the substandard status of women-dominated health professions. 19 52 60 67 68 These inequities give rise to other structural challenges such as lack of governance or absence of regulatory frameworks, and result in poor integration of the profession into health systems (eg, lack of midwifery education accreditation mechanisms, absent or poor remuneration, restrictions on midwives' autonomy and limited ability to generate research). 19 69 Our framework's attention to the role of gender provides direction to addressing the challenges outlined above.…”

“…19 52 60 67 68 These inequities give rise to other structural challenges such as lack of governance or absence of regulatory frameworks, and result in poor integration of the profession into health systems (eg, lack of midwifery education accreditation mechanisms, absent or poor remuneration, restrictions on midwives' autonomy and limited ability to generate research). 19 69 Our framework's attention to the role of gender provides direction to addressing the challenges outlined above. Capacity assessments require a feminist process, using a gender lens which also accounts for intersecting identities (eg, ethnicity, indigeneity and disability).…”

“…Outer context Results showed that sustainable midwifery associations are influenced by the role, regulation and integration of midwifery within a given context, which is shaped by the political system (where decisions about midwifery integration will be made), health system arrangements (where midwives provide SRHR services) 19 27 and the education system (where midwives are educated).…”

“… 8 In health systems in Canada, midwives have struggled for professional recognition and integration. 19 CAM’s twinning relationships challenge traditional models for international development, highlighting that support and growth for the profession is bidirectional. 8 While association strengthening is becoming a growing focus and area of interest of international programming activities, there is limited scholarship to guide the integration of midwifery through strengthening midwifery associations.…”

Current Resources for Evidence‐Based Practice, January/February 2021

“…What struck me from the critical synthesis was this quote: “lack of gender‐sensitive and rights‐based policies reinforced structural gender inequalities (i.e. created barriers to respectful maternity care and participation in policy‐making).” 4 (p 7) There has been much recent discussion about structural inequalities, particularly related to racism. However, we cannot ignore the great deal of disrespectful care experienced by 1 in 6 of all persons giving birth in US hospitals 13 .…”