Sexual & Reproductive Healthcare 16 (2018) 45–49

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Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc

Opportunities, challenges and strategies when building a midwifery T

profession. Findings from a qualitative study in Bangladesh and Nepal
⁎
Malin Bogren , Kerstin Erlandsson
School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The aim of this paper was to identify opportunities and challenges when building a midwifery pro-
Midwifery profession fession in Bangladesh and Nepal.
Midwifery strategy Methods: Data were collected through 33 semi-structured interviews with government officials, policy-makers,
Health workforce donors, and individuals from academia and non-government organizations with an influence in building a
South Asia
midwifery profession in their respective countries. Data were analyzed using content analysis.
Bangladesh
Nepal
Findings: The opportunities and challenges found in Bangladesh and Nepal when building a midwifery profes-
sion emerged the theme “A comprehensive collaborative approach, with a political desire, can build a midwifery
profession while competing views, interest, priorities and unawareness hamper the process”. Several factors
were found to facilitate the establishment of a midwifery profession in both countries. For example, global and
national standards brought together midwifery professionals and stakeholders, and helped in the establishment
of midwifery associations. The challenges for both countries were national commitments without a full set of
supporting policy documents, lack of professional recognition, and competing views, interests and priorities.
Conclusion and clinical application: This study demonstrated that building a midwifery profession requires a
political comprehensive collaborative approach supported by a political commitment. Through bringing pro-
fessionals together in a professional association will bring a professional status. Global standards and guidelines
need to be contextualized into national policies and plans where midwives are included as part of the national
health workforce. This is a key for creating recognized midwives with a protected title to autonomously practice
midwifery, to upholding the sexual and reproductive health and rights for women and girls.

Introduction
Two South Asian countries were in focus in this research –
Bangladesh and Nepal. Both countries have achieved significant im-
provements in maternal mortality ratio (MMR) between 1990 and 2015
[1], and both countries have decided that investing in professional
midwives as a separate profession is the key to making further im-
provements [2,3] in women’s sexual and reproductive health and
rights.
Recent decades have seen significant achievements in the
Millennium Development Goals and targets. Some of these have led to
better access to sexual and reproductive health care, with fewer un-
wanted pregnancies, improved access to safe and legal abortion, and a
reduction in maternal and newborn mortality. These improvements can
be explained by developing health policies and can contribute to the
discussion on regulatory frameworks [4,5] to increase the availability
of family planning, safe abortion, antenatal care, and skilled attendance
during pregnancy, childbirth, and the post-partum period [6,7].
However, for women from poor, marginalized communities, and those
living in remote locations, reproductive health-related morbidity and
mortality remain a serious challenge [8].
The global Sustainable Development Goals (SDGs) directly address
and call for universal health care, including sexual and reproductive
health, and gender equality: SDG 3, ensure healthy lives and promote well-
being at all ages, including universal access to sexual and reproductive
health care reducing maternal and neonatal mortality; SDG 5, achieve
gender equality and empower all women and girls; and SDG 10, work to-
wards reduced inequalities. With the support of the SDGs, the aim is to
reach the maternal health targets by 2030 [9].
One critical approach to achieving the SDGs is education of pro-
fessional midwives and integrating them into the national health system
for greater access to sexual and reproductive health and rights (SRHR).
Professional midwives are globally recognized as experts on sexual and
reproductive health, and are dedicated to upholding the sexual and
reproductive health rights of women and girls [7,10–12].
The establishment of the midwifery profession is hence a human

⁎
Corresponding author.
E-mail addresses: mabn@du.se (M. Bogren), ker@du.se (K. Erlandsson).

https://doi.org/10.1016/j.srhc.2018.02.003
Received 21 October 2017; Received in revised form 9 February 2018; Accepted 11 February 2018
1877-5756/ © 2018 Elsevier B.V. All rights reserved.
M. Bogren, K. Erlandsson
rights concern [4]. According to evidence [11–14] there is a need for
competent, cost-effective and skilled health care professionals with the
necessary competence and resources to provide safe and high-quality
reproductive, maternal and newborn care. The midwifery profession is
identified as the key profession for providing such care. Midwives who
are educated as per international standards can provide 87% of the
essential care needed for women and newborns; investing in midwifery
education, licensing and deployment to community-based services can
potentially yield a 16-fold return on investment in terms of lives saved
and costs of cesarean sections averted [13]. Against this background,
there is a need for professional midwives [15]; i.e., those who have all
the characteristics the profession demands, such as a scientific body of
knowledge and trained skills; a license to practice; autonomy; an ethical
code; and the formal recognition of society [16]. By promoting mid-
wives, we promote the health and rights of women and girls. From a
broader perspective, this means we need to understand how to promote
countries’ abilities to reduce morbidity and mortality among women
and children by offering better strategies for building midwifery as a
separate profession. Because of the urgent need for professional mid-
wives in many low-income countries, the midwifery workforce has ra-
pidly scaled up [13]. Lessons learnt from country specific descriptions
of opportunities and challenges when scaling up has however not, to
our knowledge been assessed. For countries, building a midwifery
profession in low resource settings such lessons learnt can contribute to
the discussion on policy frameworks. To close this gap, the aim of this
paper was to identify the opportunities and challenges that arise when
building a midwifery profession in Bangladesh and Nepal.
Method
Study design
This study is based on individual interviews with policy-makers,
donors, and individuals from governments, academia and non-govern-
ment organizations with influence in building a midwifery profession in
Bangladesh and Nepal. The term influence, is in this paper referring to
promotion, advocacy, and work towards strengthening a cadre of pro-
fessional midwives. Interviews were analyzed using content analysis
[17]. The study followed ethical principles for research [18] and was
approved by the respective nursing councils in 2013 (Bangladesh) and
2014 (Nepal).
Setting
Bangladesh is a lower middle-income country [19] with approxi-
mately 3.1 million live births a year [20]. The majority of the popula-
tion resides in rural areas, which contributes to an overall low ratio of
skilled attendance at birth of 42% and a high MMR at around 176
maternal deaths for every 100,000 live births [1].
Nepal is a low-income country [19] with approximately 593,000
live births a year [21]. Most of the population resides in hill/mountain
areas, which contributes to an overall low ratio of skilled attendance at
birth of 58% and a high MMR at around 239 maternal deaths for every
100,000 live births [21].
Data collection
The study was carried out in Bangladesh in April–May 2013, and in
Nepal in April 2014. Purposive sampling [22] was used in relation to
the participants positions and policy influence in their respective or-
ganization, to ensure the selection of rich information and insights from
policy-makers, donors, and individuals from governments, academia
and non-government organizations, with influence in the establishment
of the midwifery profession in the respective countries. A total of 33
individual were invited and all agreed to participate in the study. Six-
teen individual interviews were conducted in Bangladesh and 17 in
46
Sexual & Reproductive Healthcare 16 (2018) 45–49
Table 1
Stakeholders organizational belonging.
Stakeholders organizational belonging Participants
interviewed
(n = 33)
Bangladesh Policy-makers/government officials 2
Donors 6
Academia 2
Non-Government Organizations including 6
Midwifery Association
Nepal Policy-makers/government officials 3
Donors 4
Academia 7
Non-Government Organizations including 3
Midwifery Association
Nepal (Table 1). The participants received oral and written information
about the study, including details about confidentiality in handling the
data. Only the authors had access to the data. The participants were
informed about the voluntary nature of their participation, including
the fact that they could terminate their participation at any time.
Written informed consent was obtained from each participant prior the
interview.
Data were collected by the first author through semi-structured in-
terviews using an interview guide with four key areas: (1) organization
and its resources, (2) collaboration, (3) communication channels, and
(4) future plans. The opening question was: “tell me about how your
organization contributes to strengthening the midwifery profession”.
The participants were encouraged to speak freely, and probing ques-
tions such as “please give an example”.
Most of the interviews took place in a separate room at the parti-
cipants’ workplace; they were conducted in English as the English
language was the common working language among government offi-
cials, policy-makers, donors, and individuals from academia and non-
government organizations in Bangladesh and Nepal. The interviews
were recorded and lasted 30 min to an hour.
Data analysis
All interviews were transcribed verbatim, and the transcripts were
analyzed using qualitative inductive content analysis, inspired by Elo
and Kyngas [17]. The transcripts were read several times by both au-
thors, to get a sense of the content concerning opportunities and chal-
lenges when building a midwifery profession in Bangladesh and Nepal.
The analysis was performed in the following concurrent flows: (1)
the transcripts were condensed and, with the study aim constantly in
mind, data from each individual participant were labelled separately;
(2) codes corresponding to opportunities and challenges when building
a midwifery profession in Bangladesh and Nepal were imported into a
designed coding sheet; and (3) the codes were clustered into emerging
categories. To ensure a standard approach to each step of the analysis
the two authors discussed the interpretation of the data until consensus
was established. The following categories were agreed on under the
heading “opportunities”: “Supported by global and national standards,
Bringing professionals together through a professional association and
Collaboration between stakeholders - essential for building a midwifery
profession”. And the following categories were agreed on under the
heading “challenges”: “Commitment without supporting documents,
Lack of profession recognition, and Competing views interests and
priorities”
Findings
The overall theme that emerged regarding opportunities and chal-
lenges found in Bangladesh and Nepal when building a midwifery
M. Bogren, K. Erlandsson
profession was: “A comprehensive collaborative approach, with a po-
litical desire, can build a midwifery profession while competing views,
interests, priorities and unawareness hamper the process”. The findings
supporting the theme are presented below.
Opportunities
The following categories reflect the opportunities for building a
midwifery profession: “Supported by global and national standards,
Bringing professionals together through a professional association, and
Collaboration between stakeholders - essential for building a midwifery
profession”.
Supported by global and national standards
Global standards for midwifery competencies, education and reg-
ulation supported Bangladesh’s and Nepal’s government officials,
policy-makers, donors, and individuals from academia and non-gov-
ernment organizations in their advocacy towards establishing a cadre of
professional midwives. These global standards acted as a platform
among all stakeholders in the development of the profession. More
important was the development of national policy and strategy docu-
ments, for guiding the work towards the profession being included in
the national health sector plans. This was explained by one donor as
“we support the government in the health sector program in how to fit the
midwives into the health sector, as they are a new cadre in the country”
(Bangladesh, Participant 5).
The Prime Minister’s call for educating and deploying 3000 mid-
wives in Bangladesh made the existing strategic direction for midwifery
a framework for its establishment. This was expressed by one donor as
“the strategic midwifery directions developed in 2008 really supported the
government in moving forward with the midwifery profession in Bangladesh”
(Bangladesh, Participant 13).
Bringing professionals together through a professional association
To bring professionals together was managed through the estab-
lishment of a midwifery association in respective countries. The process
of gaining professional status and developing and maintaining the
profession took place in the context of membership in the professional
midwifery association. The midwifery associations in both countries
were formally recognized by respective governments. For example, in
Nepal, the association had a twinning project with an international
midwifery association.
Examples of how midwives operated as a professional group could
include dealing with challenges such as lack of professional recognition,
inadequate formal midwifery education, and insufficient midwifery
regulation. One individual from the midwifery association in Nepal
expressed: we’re lobbying, we’re advocating, and we’re taking the initiative
to push the government to move the agenda forward, which they mentioned
in their policy and strategy in 2006 (Nepal, Participant 3).
Collaboration between stakeholders - essential for building a midwifery
profession
A prioritized political interest resulted in a joint desire to collabo-
rate in working towards the common goal of building a midwifery
profession. This was equally important between involved stakeholders
in Bangladesh and Nepal. The participants expressed that collaborative
work included negotiations about work task boundaries with other
health care professionals, collaborations around training and education,
faculty development, policy dialogues on legal frameworks, and de-
ployment with the government, policy-makers, academia, non-govern-
ment organizations and donors. As expressed by one participant re-
presented a non-government organization in Bangladesh:
The opportunity for collaboration is in standards, for example, of faculty
development; there isn’t an existing cadre of midwives who can teach in
the country because it’s no academic tradition, so how do you develop a
47
Sexual & Reproductive Healthcare 16 (2018) 45–49
good cadre of academic faculty for midwifery?
(Bangladesh, Participant 15)
Up to now we’ve been coordinated and have been planning for how to
make the Council establish minimum requirements and other things; up
to now we’ve been preparing some documents ourselves on how many
midwives are necessary in our country, and how we’ll distribute to them,
and how to recruit them; we move the files in our system and we dis-
seminate among our group. We need to continue working on the final
decision and dissemination to everyone.
(Nepal, Participant 5)
Because of this collaborative work, the participants in Bangladesh
stated that a six-month midwifery curriculum for existing nurses and a
three-year direct-entry midwifery curriculum had begun in Bangladesh.
Meanwhile, in Nepal, a draft curriculum based on the International
Confederation of Midwives’ (ICM) essential competencies for basic
midwifery had been developed and was awaiting approval.
Challenges
The following categories reflect challenges when building a mid-
wifery profession: “Commitment without supporting documents, Lack
of profession recognition, and Competing views, interests and prio-
rities”
Commitment without supporting documents
The commitment without supporting documents, such as acknowl-
edging the midwifery profession in the national health sector plans and
national strategies for health workforce, hampered the establishment of
the profession in Bangladesh and Nepal.
As a results of having health sector plans and national strategies not
reflecting midwives as a separate profession, participants from both
countries stated that the regulatory bodies in respective country were
lacking in the ability to regulate the profession. Thus the midwifery
profession was not yet recognized as an autonomous profession with a
protected title. For example, the participants from Nepal stated that the
country had no regulatory mechanism protecting midwives and mid-
wifery care to ensure that midwives were educated according to in-
ternational standards, no access to professional development, and no
regulated scope of practice was available:
The government lacks the budget and lacks a (midwifery) policy. The
regulation is weak, so we need to have a very good career path, de-
ployment plan, retention policy, career ladder, rotation plan, and op-
portunities for higher studies for professional growth and continuing
professional growth. Then one day we’ll definitely succeed in the field of
midwifery.
(Nepal, Participant 3)
Lack of professional recognition
According to the participants, a central challenge in the work to-
wards building a new cadre of professionals was expressed as the lack of
professional recognition among other health care providers and within
the government system in both Bangladesh and Nepal. The participants
described that one reason for lack of professional recognition was due
to lack of opportunity for professional growth and weak policy systems
recognizing midwives as professionals. In Bangladesh, the professional
association was struggling with its advocacy to increase its recognition
by the government as an autonomous profession with a protected title.
The professional association itself was lacking autonomy in
Bangladesh, and was dependent on the government for decision-making
and on donor agencies for technical and financial support. This was
expressed by one participant representing a non-government organi-
zation as “the midwifery profession is flourishing…but the midwifery as-
sociation’s capacity needs to be strengthened; they need to be able to conduct
their own advocacy – even marketing tools could be designed to show how
M. Bogren, K. Erlandsson
midwives could support the community” (Bangladesh, Participant 4).
Alternatively, in Nepal, the association had not fully convinced the
government to establish a midwifery profession separate from the
nursing profession. One wider challenge in Nepal was the perception
that Nepalese society could not distinguish between nursing and mid-
wifery, resulting in minimal public support for an independent mid-
wifery profession.
Competing views, interests and priorities
Another challenge in Bangladesh and Nepal involved competing
views, interests and priorities between the stakeholders working to-
wards building a midwifery profession. In Bangladesh, this was de-
scribed as stakeholders having different individual philosophies and
organizational mandates. This was expressed by one participant re-
presenting a donor agency as “personal relationships and personal issues
are a hinder; there’s a lot of politics going on in the midwifery development.
Partners have different agendas, and these agendas are not always obvious.
Different organizations have different views on midwives and the profession”
(Bangladesh, Participant 5).
The main challenging factors in Nepal were described being the
different political interests and priorities, which had turned the colla-
boration into political territory. There were competing interests from
the nursing profession to have midwifery separated from nursing, and
divergent academic opinions on a midwifery profession. Such con-
flicting sentiments concerned, for instance, whether midwifery educa-
tion should entail conventional vocational training or be provided as a
higher-degree education.
Discussion
Many lessons learnt were found to facilitate the establishment of a
midwifery profession in Bangladesh and Nepal. The challenges for both
countries in this study were national commitments without a full set of
global standards contextualized into national policies and plans where
midwives were included as part of the national health workforce, lack
of professional recognition, and competing views, interests and prio-
rities. As a result, the midwifery profession had not sufficiently ac-
quired the characteristics of a profession – such as a scientific body of
knowledge and skills, a license to practice, autonomy, an ethical code,
and the formal recognition of society [16] – and had not obtained full
jurisdiction to work autonomously within its entire scope of practice
[23].
The study found that both countries were supported by global
standards, such as ICM competences for midwifery education [24], ICM
global standards for education [25], and WHO core competences for
midwifery educators [26], with support from The Lancet series on
midwifery [27]. However, these documents have no national policy
implication unless they are contextualized into national plans, which
requires a long-term commitment and clear national desire from the
governments [3]. The findings in this study highlight the importance of
bringing together the stakeholders in the policy contextualization pro-
cess. The stakeholders were policy-makers, midwifery associations,
academia, and bilateral and multilateral organizations. Further, the
collaboration between these stakeholders was essential for building a
midwifery profession. The findings indicated several strategic actions
that might contribute to overcoming the identified challenges in
building the midwifery profession.
First, the strategy for policy-makers has been identified to be the
commitment of political leadership [28], such as making midwifery a
top priority. Based on the findings in this study and supporting research
[28], the strategy we suggest would be to recognize the midwifery
profession (aligned with international standards) in the national health
sector plan. Equally important is to incorporate midwifery as a separate
profession in national strategies for human resources for health, and to
work in partnership with all involved stakeholders to develop mid-
wifery policies and strategies, including procedures to guide its
48
Sexual & Reproductive Healthcare 16 (2018) 45–49
operations. These recommendations are supported by The Lancet series
on midwifery [14,27]. Renfrew et al. [11] have provided a valuable
framework for ensuring an enabling environment to promote midwives’
contribution to reproductive and maternal health care. Based on our
findings, this implies the importance of developing the highest level of
legal framework (regulation controlling the legislative framework of
the profession) and overall coordination among the policy, organiza-
tional and institutional levels.
Second, when building a midwifery profession, the strategy for
national midwifery associations has been identified to be involved in
policy and planning, advocating for the profession and serving as the
voice of midwives [5,29]. Based on the findings in this study, there
were competing interests in Nepal from the nursing profession, and the
establishment of a separate midwifery profession turned into political
territory. Therefore, we would suggest improving not only the general
public’s awareness, but also the broader health workforce awareness
regarding the roles and responsibilities of a midwife, her full scope of
practice, and how the midwifery profession differs from that of other
health workers; these suggested strategies are supported by Lopes and
Homer [5,29]. This implies an awareness of the content of the full scope
of midwifery practice: maternal and newborn care, contraceptive ad-
vice and/or abortion, post-abortion care, and its relation to women’s
rights. Raising awareness includes the engagement of media in policy
dialogues and public debates on the need for professional midwives to
improve national health outcomes.
Third, the strategy for academia has been identified as building
midwifery educator capacity [30,31] to deliver midwifery education
according to global standards [32]. Delivering midwifery education in
Bangladesh and Nepal was not without its challenges. A comprehensive
collaborative approach and a political desire were prerequisites for
academia to provide the midwifery curriculum. In line with the findings
here as well as in other research [2], the following strategy is suggested
in order to meet this challenge: ensure that midwifery faculty have the
capacity to deliver quality and evidence-based education according to
global standards, within a faculty consisting predominantly of mid-
wives. This is particularly challenging in countries where the midwifery
faculty members are not midwives themselves, which is currently the
situation in Bangladesh [2] and Nepal [3]. Thus, the preparation of
faculty members is the key to quality midwifery education and quality
of care [31,33].
Finally, the strategy for bilateral and multilateral organizations is to
promote preventive approaches to allow women and girls to have
control over their sexual and reproductive health [34,35]. It is therefore
suggested that bilateral and multilateral organizations support coun-
tries on a system level to ensure that midwives are integrated into the
national health system to secure universal access to quality health care.
Limitations
The main limitation of this study was that it was conducted in 2013
and 2014, and certain elements of country-level policy, regulation and
education may have changed since the data were collected. To achieve
confirmability [22], all interviews were conducted by the same inter-
viewer in English but the national languages were Bangla and Nepali.
Language barriers can be a threat to the credibility of an interview.
Although all participants in this study were fluent in English. However,
it was critical that the researcher respectfully paid attention not only to
linguistic barriers but also to cultural, historical and social differences
to overcome this threat. This study used purposive selected sampling
based on the criterion of being an influential stakeholder promoting a
midwifery profession. This strengthens the credibility and transfer-
ability of the results [36].
Conclusion and clinical implications
This study demonstrated that building a midwifery profession
M. Bogren, K. Erlandsson Sexual & Reproductive Healthcare 16 (2018) 45–49

requires a political comprehensive collaborative approach supported by informed framework for maternal and newborn care. Lancet
a political commitment. Through bringing professionals together in a 2014;384(9948):1129–45.
[12] ten Hoope-Bender P, et al. Improvement of maternal and newborn health through
professional association will bring professional status. Global standards midwifery. Lancet 2014;384(9949):1226–35.
and guidelines need to be contextualized into national policies and [13] UNFPA, The state of the world's midwifery. A Universal Pathway. A Women Right
plans where midwives are included as part of the national health to Health; 2014. < http://www.unfpa.org/sowmy > .
[14] Homer C, et al. The projected effect of scaling up midwifery. Lancet
workforce. This is a key for creating recognized midwives with a pro- 2014;384(9949):1146–57.
tected title to autonomously practice midwifery, to upholding the [15] International Confederation of Midwives. Essential competencies for basic mid-
sexual and reproductive health and rights for women and girls. wifery practice; 2010 [cited 1st of April 2015].
[16] Abbott A. The system of professions- an essay on the division of expert labour.
Chicago: The University of Chicago Press; 1988.
Conflict of interest [17] Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs
2008;62(1):107–15.
[18] National Commission for the Protection of Human Subjects of Biomedical
None.
Behavioral Research, The Belmont Report: Ethical principles and guidelines for the
protection of human subjects of research, in J Am Coll Dent. Department of Health
Funding Education Welfare; 2014. p. 4–13.
[19] World Bank, List of Economics, 2016. http://bit.ly/2CRS2Sv [viewed September
2017].
No funding was received for this study. [20] Ministry of Planning, Government of the Peoples’s Republic of Bangladesh.
Bangladesh Bureau of Statistics (BBS), The Sample Vital Registration System
Acknowledgments Report. Dhaka; 2015.
[21] Ministry of Health, Nepal, 2017. Nepal Demographic and Health Survey 2016.
Kathmandu, Nepal: Ministry of Health, Nepal. < https://dhsprogram.com/pubs/
The authors are grateful to the stakeholders participating in this pdf/FR336/FR336.pdf > .
study. [22] Polit D, Beck C. Nursing research-generating and assessing evidence for nursing
practice, Lippincott Williams & Wilkins, Philadelphia; 2012.
[23] Bogren MU, Wiseman A, Berg M. Midwifery education, regulation and association
Appendix A. Supplementary material in six South Asian countries-a descriptive report. Sex Reprod Healthc
2012;3(2):67–72.
[24] Fullerton JT, et al. The International Confederation of Midwives essential compe-
Supplementary data associated with this article can be found, in the tencies for basic midwifery practice. An update study: 2009–2010. Midwifery
online version, at http://dx.doi.org/10.1016/j.srhc.2018.02.003. 2011;27(4):399–408.
[25] ICM. Global standards for midwifery education; 2013; Available from: < http://
www.internationalmidwives.org/assets/uploads/documents/CoreDocuments/ICM
References
%20Standards%20Guidelines_ammended2013.pdf > .
[26] WHO. The Midwifery Educator Core Competencies; 2013. < http://www.who.int/
[1] Kassebaum NJ, et al. Global, regional, and national levels and causes of maternal hrh/nursing_midwifery/educator_competencies/en/ > .
mortality during 1990–2013: a systematic analysis for the Global Burden of Disease [27] Horton R, Astudillo O. The power of midwifery. Lancet 2014;384(9948):1075–6.
Study 2013. Lancet 2014;384(9947):980–1004. [28] Van Lerberghe W, et al. Country experience with strengthening of health systems
[2] Bogren M, Begum F, Erlandsson K. The historical development of the midwifery and deployment of midwives in countries with high maternal mortality. Lancet
profession in Bangladesh. J Asian Midwives 2017;4(1):65–74. 2014;384(9949):1215–25.
[3] Bogren MU, van Teijlingen E, Berg M. Where midwives are not yet recognised: a [29] Lopes SC, et al. The involvement of midwives' associations in policy and planning
feasibility study of professional midwives in Nepal. Midwifery 2013;29(10):1103–9. about the midwifery workforce: a global survey. Midwifery 2015;31(11):1096–103.
[4] Sen G, Govender V. Sexual and reproductive health and rights in changing health [30] West F, Homer C, Dawson A. Building midwifery educator capacity in teaching in
systems. Glob Public Health 2015;10(2):228–42. low and lower-middle income countries. A review of the literature. Midwifery
[5] Castro Lopes S, et al. A descriptive analysis of midwifery education, regulation and 2016;33:12–23.
association in 73 countries: the baseline for a post-2015 pathway. Human Resources [31] West F, Dawson A, Homer CSE. Building midwifery educator capacity using inter-
for Health 2016;14(37):1–6. national partnerships: findings from a qualitative study. Nurse Edu Pract
[6] Bhutta ZA, et al. Countdown to 2015 decade report (2000–10): taking stock of 2017;25:66–73.
maternal, newborn, and child survival. Lancet 2010;375(9730):2032–44. [32] Fullerton J, et al. The midwifery workforce: ACNM 2012 and AMCB 2013 core data.
[7] ten Hoope-Bender P, et al. Midwifery – a vital path to quality maternal and newborn J Midwifery Womens Health 2015;60(6):751–61.
care: the story of the Lancet Series on Midwifery. Midwifery 2014;30(11):1105–6. [33] Dawson A, et al. Midwifery capacity building in Papua New Guinea: Key achieve-
[8] Kiruja J, et al. Maternal near-miss and death incidences – frequencies, causes and ments and ways forward. Women Birth 2016;29(2):180–8.
the referral chain in Somaliland: a pilot study using the WHO near-miss approach. [34] Mattebo M, et al., Perceptions of the role of the man in family planning, during
Sex Reprod Healthc 2017;12:30–6. pregnancy and childbirth: a qualitative study with fifteen Nepali men. J Asian
[9] Silver KL, Singer PA. SDGs: start with maternal, newborn, and child health cluster. Midwives 2016;3(1).
Lancet 2014;384(9948):1093–4. [35] Sen G. Sexual and reproductive health and rights in the post-2015 development
[10] Likis FE. The Lancet series on midwifery: a momentous opportunity to improve agenda. Glob Public Health 2014;9(6):599–606.
maternal and newborn health. J Midwifery Womens Health 2014;59(5):477–8. [36] Lincoln Y, Guba EG. Naturalistic inquiry. Newbury Park: Sage Publications; 1985.
[11] Renfrew MJ, et al. Midwifery and quality care: findings from a new evidence-

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