The role and scope of practice of midwives in humanitarian settings: a systematic review and content analysis

Abstract

BackgroundMidwives have an essential role to play in preparing for and providing sexual and reproductive health (SRH) services in humanitarian settings due to their unique knowledge and skills, position as frontline providers and geographic and social proximity to the communities they serve. There are considerable gaps in the international guidance that defines the scope of practice of midwives in crises, particularly for the mitigation and preparedness, and recovery phases. We undertook a systematic review to provide further clarification of this scope of practice and insights to optimise midwifery performance. The review aimed to determine what SRH services midwives are involved in delivering across the emergency management cycle in humanitarian contexts, and how they are working with other professionals to deliver health care.MethodsFour electronic databases and the websites of 33 organisations were searched between January and March 2017. Papers were eligible for inclusion if they were published in English between 2007 and 2017 and reported primary research pertaining to the role of midwives in delivering and performing any component of sexual and/or reproductive health in humanitarian settings. Content analysis was used to map the study findings to the Minimum Initial Service Package (MISP) for SRH across the three phases of the disaster management cycle and identify how midwives work with other members of the health care team.ResultsFourteen studies from ten countries were included. Twelve studies were undertaken in conflict settings, and two were conducted in the context of the aftermath of natural disasters. We found a paucity of evidence from the research literature that examines the activities and roles undertaken by midwives across the disaster management cycle. This lack of evidence was more apparent during the mitigation and preparedness, and recovery phases than the response phase of the disaster management cycle.ConclusionResearch-informed guidelines and strategies are required to better align the scope of practice of midwives with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP, to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle.Electronic supplementary materialThe online version of this article (10.1186/s12960-018-0341-5) contains supplementary material, which is available to authorized users.

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

“…the medicalisation of the birth process and associated valuing of physician and hospital-based care) • Ideas relate to both political and health system factors by influencing the values of citizens and either valuing or devaluing gender and the medical model • Social construction of gender — the status of midwives in a given jurisdiction often reflected the value placed on women within the society (i.e. ‘gender penalty’) [ 8 , 11 , 41 , 43 , 46 , 48 , 61 , 71 ] • Some cultures did not allow women to receive care from men yet there were few health professionals that were women due to lack of educational opportunities [ 45 ] • Health system priorities as well as changing values were based on the medical model and normalisation of medical interventions, which favoured care by physicians and within hospital settings [ 41 , 48 – 50 , 75 , 78 , 99 – 101 ] • Incongruence between international recommendations for skilled birth attendants and needs of Mayan population in Guatemala for intercultural healthcare from traditional birth attendants [ 102 ] • Nordic maternity care systems’ non-medical models and women dominated professional groups [ 37 ]; respect of gender equality and informed choice [ 86 ] • Increasing consumer demand for midwifery-led care [ 77 ] • Reclaiming Indigenous midwifery and bringing birth back to the community (Canada and Guatemala) [ 35 , 103 ] [ 1 , 3 , 6 – 8 , 10 – 13 , 35 , 37 , 38 , 41 – 43 , 45 – 50 , 54 – 58 , 61 , ...…”

“…midwives collecting or sharing data) [ 43 , 65 , 90 ] • Midwives were unable to practice to full scope because of inconsistent standards of education and professional regulation [ 78 , 91 , 106 ] • Globally, there was a general lack of knowledge regarding the International Confederation of Midwives’ Global Standards for Midwifery Education, which was a barrier to the provision of quality midwifery education [ 53 , 66 , 87 , 107 , 108 ] • Midwives were not practicing to their legislated full scope of practice (Canada), barriers included (1) hospitals — scope restrictions; (2) capping of the number of midwives granted hospital privileges; (3) capping the number of births attended by midwives; and (4) inconsistent midwifery policies across hospitals [ 52 , 77 ] • Healthcare reforms increased the centralisation of decision-making, which created barriers to change (Australia) [ 95 ] • Combination of regulatory processes and health systems that promoted birth as a natural process; favoured professional midwifery care (Nordic countries) [ 8 , 62 , 86 , 91 , 99 ] • Accreditation mechanisms supported midwifery education programmes and institutional capacities [ 63 , 70 , 93 , 107 ] • Environments that allowed midwives to practice autonomously and to full scope of practice [ 74 ] • Expanded scope from providing skilled delivery care to include SRHR ranging from abortion, family planning, screening (diabetes and several forms of cancer), immunisations, palliative care, and public health and promotion [ 10 – 13 , 55 , 74 , 94 , 109 – 113 ] • Increased contraceptive prevalence rate (Nigeria) by engaging midwives in provision of family planning services [ 114 ] • Engagement of midwives within broader humanitarian emergency contexts (e.g. conflict, epidemics, and natural disasters) [ 46 ] •...…”

“…task-shifting, interprofessional teams); and (3) where care is provided (e.g. hospital based, integration of services and continuity of care) • Delivery arrangements link with ‘institutions’, ‘interests’ and ‘ideas’ in that they influence the delivery of healthcare services • Unmet need for SRHR services in sub-Saharan Africa due to health workforce supply and demographic trends [ 117 ] • Re-emergence of traditional midwives as a result of limited skilled birth attendant workforce [ 46 ] • Midwives experienced role strain due to increasing workloads [ 48 ], burn out [ 43 , 118 ] and lack of support to practice autonomously [ 75 , 104 ] leads to disempowerment [ 43 ] • Lack of equipment in schools and facilities can create gaps in teaching quality and practice [ 119 ] • Medical model prioritised physician-led care in hospitals and created friction between midwives and physicians [ 38 , 50 , 52 ] and also minimised the roles of midwives in primary care [ 99 ] • When compared with eight HICs, midwifery in Canada played a relatively minor role in the provision of SRHR [ 6 ] • Rising caesarean rates in Latin America and medically induced labours [ 84 ] • Collaborative care involved interprofessional groups (e.g. midwives working with physicians and nurses) [ 10 , 34 , 55 , 74 , 75 , 100 , 116 ] • Based on statistical modelling, the projected effect of scaling-up midwifery will deliver the most impact on maternal, newborn and child health [ 2 , 73 ] • Task-sharing of HIV, tuberculosis [ 96 ], abortion-related (medication abortion and vacuum aspiration abortions) services to midwives [ 12 , 110 , 111 , 120 ] • Midwifery (led by Indigenous midwives) is returning culturally safe and appropriate SRHR to Inuit communities (Canada) [ 34 – 36 , 54 ] • Midwives increased access t...…”

“…• Destruction of the health system as a result of conflict, which forbade education for women and resulted in a significant loss of the midwifery workforce (Afghanistan) [ 45 , 46 ] and societal reconstruction post conflict (Cambodia) [ 13 ]…”

“…• Social construction of gender — the status of midwives in a given jurisdiction often reflected the value placed on women within the society (i.e. ‘gender penalty’) [ 8 , 11 , 41 , 43 , 46 , 48 , 61 , 71 ]…”