title: The scope of practice and workload of nurse midwives in low- and middle-income countries. Case studies from Bangladesh and Malawi
Creators: name: Kana, Theresa
Publisher: name: University of Liverpool Repository
Year: 2024

description: Background
International attention increasingly recognises that midwives are ‘the single most critical person for effective care at the time of birth’ and that in countries with the best pregnancy outcomes, midwives are the primary providers of care to pregnant women. However, there are many midwifery and nursing cadres that contribute to this midwifery workforce. This research has focused on nurse midwives as they are recognised as one of the main midwifery cadres and therefore it is essential to understand their contribution and factors that influence their practice. 

Methods
This research has used a mixed methods approach. The narrative literature review provides a global overview of the current evidence of the health workforce providing midwifery care in low- and middle-income countries. It presents details on their scope of practice, workload and working environment. 

The countries of Bangladesh and Malawi were opportunistically selected to represent one Asian and one African low-income country to explore the context of midwifery practices in each setting. The document analysis of policies, and professional and regulatory documentation presents the legislative requirements for midwifery cadres working in Bangladesh and Malawi. This was complemented with a questionnaire to capture the scope of practice and workload of nurse midwives during one working shift and then diary-keeping and key informant interviews and small group discussions were used to explore the views of nurse midwives and their managers on their work environment.

The questionnaire was administered to 1,316 nurse midwives working in maternity areas of 12 districts of each country and focused on the range and number of tasks performed (scope of practice), workload (number of women seen by type of care provided) and the overall job satisfaction of nurse midwives when working as a midwife.
Seventy-five nurse midwives completed a diary over five shifts, 34 key informant interviews were conducted with national and district level officials and 22 small group discussions were held at the facility level with nurse midwives. 

Results
In both Bangladesh and Malawi, the scope of practice of the nurse midwife is clearly defined. Their education pathways to become midwives is clearly set. Minimal information was found on the workload of nurse midwives and other midwifery cadres. Nurse midwives described being busy with large volumes of patients to manage. Their daily practice is influenced by factors such as the type of facility, the different cadres in the workforce where they are based and the shift they are working. This is further impacted by their work environment including factors such as the availability of running water and constant electricity, functioning equipment and sufficient supplies of essential drugs and non-medical supplies, teamwork, and having enough nurse midwives and support staff on duty. 

Conclusion
The ability of nurse midwives to function and provide midwifery care is compromised by their working environment i.e., the enabling environment. Generally, most nurse midwives enjoyed their work but felt overwhelmed by the daily infrastructural challenges they face, the lack of mentoring and supportive supervision as well as minimal access to upskilling their midwifery skills. All these factors impact on the quality of care provided. 

This research has identified that there is limited information available on the workload of nurse midwives and other midwifery cadres in low- and middle-income countries. This knowledge is essential to improve the quality of care women and their newborn receive and better plan the deployment and support to the midwifery workforce.