Rural and Remote Healthrrh.org.au
James Cook University ISSN 1445-6354

ORIGINAL RESEARCHAUTHORS
Kumiko Nakano1 MPH, Research Associate *Yasuhide Nakamura2 MD, PhD, Professor
Akiko Shimizu3 MS, Program Officer
Sojoud Mohamed Alamer4 MD, Medical Doctor

CORRESPONDENCE*Ms Kumiko Nakano kumiko@med.tohoku.ac.jp

AFFILIATIONS
1

Graduate School of Medicine, Tohoku University, Aoba-ku, Sendai, Miyagi 980-8575, Japan

2

School of Nursing and Rehabilitation, Konan Women's University, Kobe, Hyogo 658-0001, Japan

3

Japan International Cooperation Agency, Nibancho, Chiyoda-ku, Tokyo 102-8012, Japan

4

National Reproductive Health Program, PO Box 303, Khartoum 1111, Sudan

PUBLISHED
21 October 2018 Volume 18 Issue 4

HISTORY
RECEIVED: 8 December 2017
REVISED: 14 May 2018
ACCEPTED: 14 June 2018

CITATION
Nakano K, Nakamura Y, Shimizu A, Alamer SM. Exploring roles and capacity development of village midwives in Sudanese communities.
Rural and Remote Health 2018; 18: 4668. https://doi.org/10.22605/RRH4668
ETHICS APPROVAL: An agreement for the survey was signed by the Sinnar State Ministry of Health.Participants were first informed about
the purpose of the survey and their right to decline an interview. Consent to participate was obtained before participants wereinterviewed. Participants were assured that all information collected would remain confidential and their names and affiliations would beanonymised when the data were documented and disclosed for the programme purpose.
Except where otherwise noted, this work is licensed under a Creative Commons Attribution 4.0 International LicenceABSTRACT:Introduction: Home birth remains a strong preference and village
midwives are the only option for maternal and neonatal care formany rural women in Sudan. This study assessed whether

Results: Results showed the monthly average number of VMWassisted home births increased from 1.4 at the baseline survey in
October 2011 to 3.3 at the endline survey in October 2013. Theinterventions such as strengthening linkages among healthfacility/staff, skilled birth attendants and village midwives (VMWs);
strengthening the supervision system; and strengthening thegovernance capacity of local health departments improved theirannual average number of emergency cases referred by VMWs
increased from 1.6 to 3.5, and the percentage of VMWs using
official monthly reports increased from 33% to 80%. VMWs
reported improved bonds with their supervisors and relationships

service delivery, and it examined factors linked with improved
performance of VMWs in their communities.
Methods: This descriptive study comprised a cross-sectional
baseline survey, two intervention years and an endline survey. Datain the community.
Conclusion: Improved service provision may be associated with
development of supervision systems for VMWs, active provision ofcommunity activities, strengthened linkages between healthcollection involved in-depth, semi-structured questionnaireinterviews. Fifty-seven VMWs and 151 community women weretargeted for the study in Sinnar, a south-eastern state of Sudan.
Participants were interviewed about demographic information,
perceptions of operational barriers, training provided, function in

facilities and VMWs and enhanced community trust of
VMWs. Given issues such as shortages and poor retention ofhuman resources for maternal and newborn health service delivery
in particular settings, international communities should focus on
strengthening capacity of community midwives for home births as

the community, supervision and referral for emergency cases.

a realistic measure.

Keywords:
antenatal care, capacity building, community, home childbirth, maternal mortality, midwife, Sub-Saharan Africa, Sudan, supervision,
traditional birth attendant.

FULL ARTICLE:
Introduction
In many developing countries, strategies focusing on an increased
number of births assisted by skilled birth attendants (SBAs) arecommonly adopted to reduce maternal mortality1. Some countries
showed considerable reduction in maternal mortality after
employing such strategies. In Malaysia and Sri Lanka, a scaled-up
SBA program was established and sustained, resulting in notable
improvement in maternal health2. Afghanistan Ministry of Public
Health provided training for about 805 midwives between 2002
and 2007, and successfully expanded its midwifery program3. Aninternational systematic review of maternal and child healthinterventions found no rigorous evidence that an increase in the
proportion of SBAs had a definitive effect on decreased maternalmortality4; however, this may not apply in contexts such as Sudan
and many other parts of Africa where there is a shortage in SBAs
and insufficient infrastructure, emphasising the important role rural
health workers may play. Walraven and Weeks5 expressed concern
over the shift towards SBAs in international safe motherhood
initiatives and policy without adequate assessments of theeffectiveness of the training for traditional birth attendants (TBAs)
and the services they provide. Prata et al1 stated that although
there is a global trend of strengthening health systems, thisstrategy is not sufficient alone but should be considered on acountry or regional basis.
Many sub-Saharan countries are still experiencing an overall SBA
shortage. The Republic of Sudan (hereinafter referred to as Sudan)
has been in a reconstruction stage since the 2005 Comprehensive
Peace Agreement was signed after prolonged civil war. Maternaland child health indicators, such as the maternal mortality ratio

and infant mortality rate, remain high, and are among the mosturgent health issues for the country. Sudan’s shortage of qualified
human resources for health hampers provision of optimal maternaland child health care, especially in rural areas. To provide
supervision for all levels of midwives working at health facilities
and in local communities, a national strategy of supportive
supervision was institutionalised by Sudan’s Federal Ministry of
Health. Under this system, health visitors/assistant health visitors
are assigned to supervise village midwives (VMWs). One healthvisitor/assistant health visitor is assigned as the locality supervisor
for all health visitors/assistant health visitors in that locality. At thenext level, the State Ministry of Health is responsible forsupervising locality supervisors. As part of supportive supervision,
health visitors/assistant health visitors are recommended toregularly visit clients’ houses with the VMWs for supervision.
However, some health visitors/assistant health visitors faceconsiderable operational constraints in geographically widespreadcommunities with inadequate infrastructure and transportation6
This means that minimally trained VMWs are left in the community
without opportunity to receive training or supervision.
In reality, VMWs provide many basic maternal services in rural
Sudan6. Nearly half of community women chose to deliver athome with traditional birth assistants or no assistance, and many
do not receive antenatal care (ANC)6. Mwangome et al (2012)
identified a number of perceived barriers to seeking care of an SBA
at birth-in facilities such as lack of resources, customer care, andknowledge and beliefs in rural Kenya7. A previous study in Sudan
reported that lack of ANC was associated with a higher risk of
neonatal and maternal mortality, and indicated that mostdeliveries start at home and are referred to health facilities if thereare maternal complications8. This highlights the need forcommunity-based birth assistants with proper knowledge andskills to recognize abnormalities in a timely manner. This isnumber of activities were conducted in Sinnar state, including
VMW capacity building, placing medical professionals at local
hospitals, strengthening linkages between health facility/staff andespecially the case in rural Sudan, which has a serious shortage ofhuman resources as well as cultural barriers that inhibit access tohealth facilities. Arabi et al9 indicated that Sudan’s system of VMWtraining, which was started in 1921 by the government, was based

VMWs, strengthening the supervision system and linkages
between health visitors/assistant health visitors and VMWs,
providing medical equipment, repairing and maintaining facilities,
and strengthening the governance capacity of Sinnar’s Stateon selection of community women by local municipalities toattend one of the nation’s 40 midwifery schools, become VMWs
and work in their village of origin. There are around 17 000 VMWs
handling 76.6% of the total births at home in Sudan6,9. To address
pregnancy-childbirth complications and reduce maternal and

Ministry of Health. In addition, community activities wereconducted to establish a community volunteer system to ensure
the health of pregnant mothers and neonates, and a system ofpregnancy registration and emergency referral was introduced byraising and pooling funds from community members as

newborn deaths, incorporating the existing health workers (VMWs)
into the national health system/plan became urgent policy in
Sudan because health workers who come from these localities arepreparation for emergency referrals. To measure the effectivenessof the intervention, a baseline survey was conducted in October
2011 and an endline survey in October 2013.

likely to return there for work; many people cannot access formal
health facilities due to transport and cost issues, therefore
preferring to be attended at home; and there are local realities andissues that are better addressed by the people who live in the

Methods
Study setting and population

area6.

The baseline and endline survey were conducted in one locality

This article examined a realistic strategy adopted in Sudan that
aimed to improve home-based maternal and newborn services

hospital, two rural hospitals, five health centers and two basic
health units. In total, 57 VMWs who worked at health facilities andreceived interventions in the eight communities (Gladeema, Fagad,

provided by VMWs, assessed whether VMW training and otherinterventions had an effect on improving service delivery andidentified factors linked with the improved performance of VMWs
in their communities from their own and their communities’
perspectives.
Intervention

Al Sahaba, Al Rigeeba, Fanguga, Om Rihaba, Al-Giwazat and Alazaz
Damous) in Sinnar state were surveyed. Community women who
had given birth within the previous year in the same eight
communities were also targeted; 160 community women weresurveyed at baseline and 156 were surveyed at endline. After data
cleaning, data for all 57 VMWs were analysed. Five of the targeted

The intervention discussed here was part of a larger project to156 community women were excluded from the analysis because
the validity of their responses was questioned.

provide comprehensive assistance to improve maternal and child
service delivery based on the continuum of care: integrated efforts
during the entire lifespan, in which services are provided in

Although the participants in the baseline and endline surveys were
not the same, the authors compared characteristics such as

households, communities and health facilities10-12. In this project, ademographics, residence and number of previous pregnancies toensure that they were relatively similar (Table 1).

Table 1: Characteristics of targeted community women in the baseline and endline surveys

Data collection
Semi-structured questionnaires were developed to collect data on
several domains and the same questionnaire was used for bothsurveys. For VMWs specifically, data collected related to:
general background information
their experience of in-service training
ANC
birthspostnatal caretheir experiences of referral
supervision and their relationships with supervisors
recording and reporting
VMW kits and materials
their experience of working with the community.
For the targeted community women specifically, data collected
related to:child mortality
background
ANC
delivery plan and emergency preparedness
deliverypostnatal careknowledge of key danger signs, and information gaps
comments on health services.
The survey team comprised five data collectors. A field coordinatorvisited the target communities and the surveys were usuallyconducted at health centers in a central location in each
community. Before conducting the survey, the data collectors
received 2 days of training to enable them to understand the
purpose of the survey, familiarise themselves with the content of
the questionnaires and develop their interview techniques. Data
were collected through face-to-face interviews conducted by thedata collectors. The interviews lasted approximately 30 minutes.
Interviews were conducted and transcribed in Arabic, and latertranslated into English.

In-depth interviews were conducted to gain more detailed or
background information about the data obtained from interviews
based on the semi-structured questionnaires. In-depth interviews

allow comparisons with baseline data. Qualitative data werecollected from open-ended questions in the questionnaires andfrom in-depth interviews. Free comments elicited by somewere also conducted when data from the semi-structured
questionnaire-based interviews seemed contradictory or invalid,
and necessitated further clarification and information. The durationof each in-depth interview was 15–45 minutes and followed

questions in the semi-structured questionnaires were coded andcategorized into themes, whereas free comments elicited fromother questions were simply presented as transcripts without
coding.

guidelines that had been developed to standardise the interviews
as much as possible.

Ethics approval

Data entry and cleaning

Ethics approval for the survey was obtained from the Federal
Ministry of Health Ethical Committee, Khartoum, Sudan.

The survey supervisor checked completed questionnaires at theend of each field day to ensure optimal data quality. Data collectedfrom the semi-structured questionnaires were first translated into
English and then entered into Excel 2010 or SPSS v22 (IBMParticipants were first informed about the purpose of the survey
and their right to decline an interview. Consent to participate wasobtained before participants were interviewed and participation
was voluntary. Participants were assured that all information

Corporation; https://www.ibm.com/analytics/data-science/predictive-analytics/spss-statistical-software). Some data wereconverted into numerical data to calculate basic statistics. The data
were cleaned to ensure quality and guarantee validity. In thiscollected would remain confidential and their names andaffiliations would be anonymized when the data were documented
and disclosed for the program purpose.

analysis, all of the interviewed VMWs were included as valid

Results

respondents. After careful examination of the data, invalid data
were identified and excluded from the analysis. When the datacontained contradictory or valuable information, the information

Endline interviews with VMWs revealed the average number ofyears of schooling was 3.4 years, and 30% had never received any

was checked directly with the respondents over the telephone.

formal education. More than half of the VMWs had less than
10 years of work experience, whereas others had worked as a

The data were analysed quantitatively and qualitatively. Data in the

VMW for more than 20 years. As shown in Figure 1, 33.3% of
VMWs were allocated to hospitals and 35.1% were based at healthcenters; of these, one-third received a formal salary. The number of

Excel spreadsheets were merged with that from SPSS and analysedusing both Excel and SPSS. Quantitative data were summarized

VMWs working regularly at a health facility decreased from 83%(baseline) to 60% (endline). More VMWs were working in theusing percentages or ratios. Some continuous data were analysedby categorization into equal-sized groups. Some quantitative data

community rather than in health facilities at endline comparedwith baseline.

Data analysis

are presented as median, mean, minimum and maximum values to

Figure 1: Distribution of village midwives at baseline and endline surveys.
Changing roles of VMWs in community maternal healthservices
Endline interviews with community women revealed that a large
proportion of mothers chose to give birth at home (78.1%;
Table 2). The main birth attendants at the respondents’ mostwith baseline; baseline data showed the mean number of homebirths assisted by a VMW was 1.4, which increased to 3.3 atendline. In total, 47.0% of mothers had received ANC from VMWs.
Health centers were the most common place to receive ANC(59.6%), followed by hospitals (27.2%) and the women’s own

recent births were VMWs (58.9%). The number of home births
attended by VMWs increased substantially at endline comparedhomes or a VMW’s house (25.2%). The main postnatal providers
were family members (53.0%) and VMWs (47.7%).

The improvement needed for provision of ANC services mostcommonly mentioned by VMWs was increased knowledge andconfidence in providing advice for community people or making

My supervisor always tells us to increase the awareness ofcommunity women and advises us to take any opportunity toraise awareness during social activities where community

referral decisions. VMWs also noted a need for increased
awareness among the community.

women gather, such as wedding ceremonies and baby-naming
ceremonies. (VMW in Fanguga village)
I offer ANC even without being paid because I now understandhow important ANC is. (VMW in Tererat Madani village)
Mothers understand the importance of ANC now: that’s why
they keep showing up to receive ANC. (VMW in Wadanile
village)

Table 2: Places and providers of maternal health care at endline survey (N=160).

Of the 57 VMWs interviewed, 52 had made emergency referrals in

caesarean section, in which case they refused to be referred tothe past year; 34 referrals (60%) were made during a woman’s
pregnancy, 36 (63%) during labour and 13 (23%) during the
postpartum period. The average number of emergency referrals

hospital. Despite these obstacles and misunderstandings, some
VMWs played a major role in referring mothers to hospitals.

increased from 1.55 to 3.54. VMWs were asked whether they felt it
was easier to refer emergency cases of mothers and neonates tothe hospital than it had been before. Ten VMWs (18%) answered‘yes’, whereas 46 (81%) disagreed. The main reasons why many
VMWs did not feel emergency referrals were easier concerned
community members’ lack of transportation (too expensive,
unavailable and/or inaccessible during the rainy season) and/orlack of available money to pay for transportation. In addition,some women believed that a referral would automatically lead to a

I convinced a mother to be referred because of a previous
caesarean section scar. Since the mother’s family could notafford to pay for the cost of referral, I asked for financial

repeatedly. Some people do not understand the necessity ofreferral. There are misunderstandings about referrals amongcommunity members. They think that when a mother is

support from community members. Thus, the mother was able
to borrow 350 SDGs [Sudanese pounds] from the community
fund [which was initiated as part of the project’s community
activities] and she successfully gave birth at a hospital. (VMW

referred, she will have to have a C-section and that this will bevery costly. (VMW in Abu Hujar locality)

in Fanguga village)
There was an unmarried woman who suffered from placenta
previa. I lent money to her and took her to Sinnar hospital. She
couldn’t ask for [support] from community members because

Most reasons cited by VMWs who felt referral was now easier wereto do with increased awareness among the community andimproved infrastructure, namely improvement in the availability oftransportation, ambulances and staff at health posts or healthcenters.

I am faced with a problem when I advise mothers to bereferred. In about half of the cases in which I recommend

As shown in Figure 2, more VMWs were involved in decisionmaking about where the birth would take place than husbands orother medical professionals. The endline survey showed 25.8% ofcommunity women said that their community VMW was the mainreferral, relatives of the mothers reject my advice and delay
their referral which means that I need to convince themdecision-maker about the place of birth, which was notably higher
than at baseline (3.1%).

the pregnancy of unmarried women is not socially acceptable.

Figure 2: Decision-makers regarding place of birth.
Improvement of supportive supervision and reporting
The findings indicated that the frequency of supervision provided
by the Sinnar State Ministry of Health had increased over the study
period. Occasionally, VMWs received supervision such as follow-up
training (67%), periodic meetings at health facilities (40%) or when
they were visited by their supervisors (29%). The main reasons
VMWs gave for calling their supervisors were to seek advice
regarding difficult/emergency cases (45%) and discuss or ask forassistance with monthly reports (35%). Supervision mainly took
place at health facilities such as health centers (51%) or hospitals(49%). More than 80% of VMWs knew their supervisor’s contact
number at endline, compared with 60% at baseline.
The presence of supervisors helps me a lot when I deal withemergency cases and decisions about referral. (VMW in AlAbassiah village)
At endline, many more VMWs (81%) were recording information

about deliveries using the national monthly reporting format
provided by the Sinnar State Ministry of Health compared with atbaseline (33%), which was mainly in notebooks or on pieces of
paper. The report submission rate increased by 7% over the study
period. Some VMWs reported that repeated instructions from theirsupervisors about how to compile the reports made it easier forthem to follow the report format. The Sinnar State Ministry of
Health follow-up training and more frequent periodic meetings at
health facilities for VMWs was promoted as a part of theinterventions.
The report format is easy to understand. Now I can evencalculate percentages. (VMW in Wadanile village)
Enhanced mother–VMW relationships and community
participation
At the time of the endline survey, VMWs reported that they felt it
was easier to work in the community than it had been beforebecause of increased awareness and respect towards VMWs
among community members. Some VMWs mentioned that
increased awareness and support from the community had

the health of many mothers in countries where there is scarcity of
SBAs and/or geographical and financial barriers14,15,19,20.

contributed to improvement of their working situation.
Improvement in their skills and knowledge may also have led toenhanced trust of VMWs by community members.

In Sinnar state, VMWs, sometimes considered to be trained TBAs,
are the most important workforce for maternal care in ruralcommunities, despite that fact that they do not meet the WHO
criteria for SBAs. The results of the present survey indicate that theMothers began to respect me and are satisfied with myperformance now. That is why they follow my diagnosis. All of
this is due to the increased awareness of healthcare among
mothers. (VMW in Al Rigeeba village)

number of emergency referrals for mothers by VMWs increased at
the endline because VMWs had more opportunity to gain
knowledge and maintain their skills. More VMWs appear to havemade proper judgements about when to refer emergency cases.
VMWs were encouraged to hold community activities to raise

They [community members] trust our work and men ask us[VMWs] to give advice to their wives. (VMW in Wadanile
village)awareness about health care to complement other social activities
held in the community. Intervention efforts resulted in VMWs’
increased knowledge and enhanced self-efficacy to provide proper

Now they [community members] support us [VMWs] morefinancially and have started paying for our work andappreciating our important role. (VMW in Wadanile village)maternal healthcare services in their communities. The national
policy of strengthening VMWs’ capacity to assist births at home,along with recommendations for primigravidas, multigravidas andpregnancies with complications to give birth at health facilities,

At endline, a higher proportion of VMWs were conducting
activities to increase community awareness. Eleven VMWs ran

may be a sustainable and realistic measure in the context of rural
Sudan, where more than half of women choose to give birth atcommunity awareness activities in schools, 10 in public spaces andeight in health facilities. A greater proportion of VMWs were using

home. Throughout the intervention period, the local government
promoted capacity building of VMWs and supervisors and withhealth facilities for such activities at endline than at baseline, whichmight have contributed to strengthening linkages between

follow-up training through a strengthened supportive supervisionsystem, which are considered to result in increased knowledge andfacilities and VMWs. The main topics covered by VMWs in suchactivities were awareness of maternal health, followed by nutrition,
health education and community emergency funds.

self-efficacy.

The majority of VMWs felt that their clinical skills (eg sterilisation

structure of the health system may not have significant effects on
improved maternal care in the community21,22. Dietsch pointed
out the importance of relationships between TBAs and SBAs thattechniques, blood pressure measurement and physicalexamination techniques) had improved after they received training.
Increased knowledge, such as a better understanding of thereferral system and improved self-efficacy, was also reported.
In-service training was a turning point in my life. I gained selfconfidence. (VMW in Fagad village)
I gained knowledge and also a sense of responsibility from thetraining. (VMW in Al-Abassiah village)
Findings suggest that in-service training enhanced self-confidence
and fostered a greater sense of responsibility in some VMWs, andproduced changes in their work ethics and attitudes.
Discussion
There was a period when the WHO and many safe motherhood
advocates encouraged TBA training, and so the number of TBA
training programs increased in most developing countries in the
1970s13,14. However, in 1997 the WHO shifted its policy topromote training for SBAs, and TBAs were excluded from thedefinition of ‘skilled birth attendant’14,15. The effectiveness of TBA
training remains controversial. Some authors have argued that the
number of robust studies with adequate assessments to reveal true
outcomes is limited15-17, whereas others18 argued that theemphasis on training SBAs is supported by theory, without noncausal data. Other studies claimed TBAs play an important role in

A number of previous studies argued that trained TBAs without the
support of skilled back-up services or networks outside the formal

are based on mutual respect and collaborative practice to improvematernal service delivery in rural areas, yet many examples ofabusive, disrespectful behaviour of SBAs towards TBAs areobserved around the world23. A number of authors asserted thatteams or continuous supervision have advantages over
performance of community health workers for joint problemsolving, improved delivery of preventive health services andprovision of consistent health education messages24-26. Benefits ofteamwork have been discussed in many studies, including
reinforcing individual capabilities, creating the feeling ofparticipation and involvement, better decision-making andgenerating a diversity of ideas for a common purpose27,28.
The results revealed that the interventions, which included regularsupervision and training for VMWs by health visitors/assistanthealth visitors, had a positive knock-on effect of cultivating mutual
relationships between health visitors/assistant health visitors and
VMWs, and community promotion activities provided by VMWs.
Sinnar health facilities became a hub for health workers (including
VMWs) to exchange and gain information on various occasions.
VMWs are considered an integral part of the formal obstetrichealthcare system in Sudan and receive regular supervision fromhealthcare professionals such as health visitors/assistant healthvisitors who work as their superiors and as a team in their assigned
areas. Health facility staff had become a part of the team withineach community, bridging VMWs, health visitors/assistant healthvisitors and community members, and conveying vital messages tothe communities.

This study had some limitations. First, the community women
selected as participants for the baseline and endline surveys were
not identical, which raises questions of reliability. Although the twoThis study indicated that, through interventions, VMWs had beenencouraged by their supervisors to hold (and they actually didhold) more community activities to encourage women to receive

groups of community women in the baseline and endline surveys
are similar, it is possible that the changes may be partially due tothe interventions as well as minor differences between the twogroups. In addition, the sampled VMWs were not fully

ANC at health centers or recommend facility births. This led toenhanced linkages between VMWs, the community and healthfacilities. VMWs provided knowledge and maternal care services
close to mothers and communities, and almost all the interviewed
women reported an increased level of respect towards VMWs. Thisenhanced trust might be attributable to the improvement in
VMWs’ skills and knowledge but also to these community
activities. Training for VMWs also appears to have contributed toincreased respect for and recognition of the improved work of
VMWs, enabling them to convince women to attend healthfacilities in a timely manner at a times of emergency, and to
ultimately save lives of mothers and newborns in communities.

representative of all VMWs in Sinnar; therefore, the findings cannot
be generalized to all VMWs in Sinnar or Sudan as a whole. It is also
uncertain if the observed improvement will be translated into alower maternal mortality ratio. Future studies and quantitative
analyses are required to confirm whether improved skills and work
conditions of VMWs positively affect maternal mortality.
Conclusions
Issues of shortage and retention of healthcare providers arecontinuous challenges in many rural areas in developing
countries. Maternal care provided by SBAs at health facilities isrecommended by international donor communities. Important

Walraven and Weeks5 stated that maternal healthcare providers

implications from the authors’ experience in a resource-scarce area

need to have the trust and respect of the community to provide
services. A previous study reported that some healthcare providers
from outside community occasionally felt fear during homeof Sudan are that some positive effects and changes have been
observed in the quality of maternal care being provided by trained
VMWs as frontline healthcare providers. Regular and adequate

visits29. Kok et al30 argued that trust and respect from thecommunity can be major factors contributing to the success ofsupervision and follow-up within a supervision system embodied
by local government improved community participation andtraining of community health workers and enhancing theirmotivation. The UN Population Fund31 stated that mutual trust
between midwives and the community is important for theprovision of midwifery services in the community, and thatmidwives who do not belong to the community sometimes do notgain trust from clients. In some low-income countries, retention inrural or remote areas is challenging because SBAs often move tourban areas seeking higher payment, better living conditions andcultural familiarity32. Afghanistan’s midwifery model recruited
candidates from communities where they would eventually be
deployed, which may be a central to ensuring a high retention
rate2. In Sudan, midwifery school candidates are usually recruitedfrom their hometown, and eventually return to their community
and are more easily accepted by that community, which results inretention of VMWs in communities and aids mutual trust between
VMWs and community members.

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The project received funding from the Japan International
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