title: Strengthening the midwifery workforce in fragile contexts: a mixed methods study from Ituri province, Democratic Republic of Congo
Creators: name: Baba, Amuda
Publisher: name: University of Liverpool Repository
Year: 2021

description: Skilled and motivated health workers are important to delivering quality healthcare. Ensuring their availability and equitable distribution is a key priority. Low- and middle-income countries are experiencing challenges in relation to the maternal health workforce. This situation is worse in fragile and conflict affected states. The Democratic Republic of Congo (DRC) has very high maternal mortality rates and a serious shortage of qualified skilled birth attendants. Ituri Province, in North-Eastern DRC is a fragile setting which faces conflict, Ebola outbreaks, the current COVID-19 pandemic and many challenges in attracting and retaining midwives in rural districts. This thesis aims to identify appropriate strategies to attract and retain midwives and related cadres in rural Ituri. I analysed the availability, distribution and trends relating to doctors, nurses and midwives in Ituri Province from 2013 to 2017 using secondary staffing data within three categories of districts (rural, peri-urban and urban). The analysis revealed an oversupply of doctors and nurses, and a serious shortages of midwives, particularly in rural districts, requiring further analysis to explore this situation in depth. Hence using a life history approach, I then explored midwives’ work experiences and challenges in rural Ituri Province. Midwives face immense challenges in their work, including severe shortages of qualified health workers, poor working conditions due to lack of equipment, supplies and professional support, and no salary from the government. These challenges were all exacerbated by fragility, conflict and rurality. Midwives showed bravery and resilience in navigating the interface between under-resourced health systems and poor marginalized communities. Finally, through a workshop methodology, I engaged with stakeholders in Ituri Province, to review data from these two studies, in order to identify context-specific strategies to improve staffing. Key strategies embedded in the realities of rural fragile Ituri province included: organizing midwifery training in nursing schools located in rural areas; recruiting students from rural areas; and lobbying NGOs and churches to support the improvement of midwives’ living and working conditions. Midwives are key skilled birth attendants managing maternal and newborn health care. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. Developing a holistic picture of the midwifery workforce using both quantitative and qualitative data is critical. Engaging stakeholders with this data, can facilitate the development of context-specific, feasible and potentially effective strategies to address the challenges of attraction and retention of midwives. Trusting relationships are critical to this co-production of knowledge. By implementing these strategies, only then will midwives, playing the interface between health systems and the communities, be able to provide the critical services that women and their families need, and therefore contribute to achieving Universal Health Coverage.