Data on the distribution of SoWMy-related stories and mentions were collected to assess the reach of the report after its national launch, exploring quantitative metrics on frequency of distribution, blog posts and academic articles.
We identified approximately 1000 public media stories or press releases mentioning SoWMy 2014, of which the majority were published within the first month after launch. Independent coverage spanned a wide range of countries and included high-visibility outlets such as Time, Reuters, Huffington Post, The Guardian, and any more. Additionally, the press release introduced after the global report’s launch was also picked up more than 300 times across a range of digital outlets. In addition, we identified 11,330 social media accounts mentioning SoWMy (predominantly within the same timeframe), 10 blog posts, and an existing media analysis of the report [
12].
From July 2014 onward, media reports and digital mentions reduced significantly – down to an average of 164 mentions per month July to December 2014, for example, and down to fewer than 5 per month by January 2015. A brief spike in social media activity occurred during the Nigerian national launch in November 2014; aside from this event, digital mentions and blog posts were largely limited to the month following the national launch of the SoWMy report.
Academic and research citations
Using Google Scholar and Scopus, an online academic database, 30 academic and scientific articles referencing or referring to the 2014 SoWMy Report were identified, an increase on the 15 citations garnered by the SowMy 2011 report. Most of these articles were published in 2015 and were presented in a variety of professional journals and publications, including
The Lancet,
Journal of Midwifery & Women’s Health,
Tropical Medicine & International Health, and
Midwifery. These articles focused on a range of topics, including identification of local maternity mortality [
13‐
17], introduction of or assessment of feasibility of changes to midwifery training and education [
18‐
21] or methods to reduce stillbirths [
22‐
24]. A significant proportion of these articles were commentaries on the provision of or policies around midwifery at national and global levels (see [
20,
22,
25‐
28]). No current publications, though, provide empirical analyses of the development, implementation or effectiveness of the SoWMy initiative.
Additionally, the SoWMy report launch date was related to the timing of The Lancet’s midwifery series, which included 10 research publications on the topic of midwifery.
Interview data
Of the 72 respondents contacted, 19 agreed to participate (a success rate of 26%) and completed either a Skype interview or a questionnaire form between December 2015 and February 2016. As outlined in Table
2 below, the 19 respondents reflected a range of geographical regions, organizational types, forms of involvement with the report, and personal characteristics.
Table 2
Characteristics of Respondents Interviewed for Evaluation
14: Female 5: Male | 6: Southeast Asia 6: Sub-Saharan Africa 3: Middle East / Northern Africa 1: East Asia 1: Latin America 1: North America 1: Western Europe | 10: National UN Agency 5: Local Midwifery Associations 2: National Government Officials 2: Academic Bodies | 12: National Involvement 5: Local Involvement 2: Global Steering Committee Members |
Of the 19 respondents, 11 were able to complete the interview via phone or Skype, while eight requested to complete written questionnaire forms. Four individuals declined the invitation to participate, and 49 did not respond to interview requests. Among the four individuals declining to participate, two were on temporary leave, one had recently departed the office, and one cited lack of time.
Most respondents were engaged in assisting with data collection, providing policy advice, supporting midwifery training and education, or advocating on behalf of midwives and other SRMNH workers. Respondents discussed how they used, or did not use the SoWMy 2014 report, the impact, if any, of the report, and if relevant the ways in which they planned to use the report to achieve policy and practice impacts. These data, together with the media and citation data, are collated in the policy impact framework to follow.
Policy impact framework
We organise our data using a policy impact framework to explore SoWMy’s particular contributions to midwifery-related efforts on the national and global levels. We then plot the data in an organised, visual format within the theory of change.
Who is impacted?
The data reveal that SoWMy impacted several groups of individuals, including policy makers (within government and otherwise), midwifery advocates and associations, and the midwives of the countries examined within the report. The mechanisms through which each of these groups is impacted varies. Midwifery advocates and interest groups were often the first set of individuals to receive and utilise the report. Using a variety of tactics (including events, localised reports, and political outreach), these individuals and groups contacted policymakers at national levels about SoWMy, aiming to achieve some level of policy or programmatic change, directly or indirectly affecting the country’s population of midwives.
Changing opinions/attitudes
Our data show that the report was often used to educate midwives, midwifery advocates, and government officials on relevant statistics related to midwifery care and maternal health within their respective countries – such as trends related to maternal or prenatal mortality, the frequency of family planning visits, gaps in midwifery workforce availability, geographic barriers to care access, and financial limitations to boosting the care workforce. This new information, which often came from the country-specific pages within the SoWMy 2014 report, formed or altered the opinions of many midwifery advocates and organisations on the necessary actions to be taken to improve maternal health on the local, regional, and national levels. Midwives and their advocates frequently reported using the report and its statistics as an educational tool to highlight challenges and influence the opinions and decisions of policymakers and government officials.
“[The report] contributed to improve the knowledge of the decision makers, health managers and health workers on the current situation of midwives in Viet Nam, and their important roles in the obstetric and newborn care.” (National Government Official, Viet Nam).
Production of new knowledge
The SoWMy report served an impetus for the development of new research and the creation of new reports on national midwifery progress. As noted previously, approximately 30 academic publications have referenced the findings of SoWMy 2014 since its global launch. Additionally, according to nearly all of the respondents interviewed, the process of compiling the report itself generated new knowledge related to national midwifery trends and needs, and allowed benchmarking of progress to date against the global strategy for maternal health:
“[The report] clearly revealed our status… It helps us to know where we are and what exactly we are doing with regards to maternal health problems.” (Member of Local Midwifery Association, Liberia)
The SoWMy report was reported to lead to a number of national reports and events, often designed to supplement and localise the relevance of the findings for policymakers and government officials. In some cases, where the global report was perceived as too broad-brush or inaccurate at a national level, production of local versions were politically more palatable and more likely to lead to change. Local versions of the SoWMy report have been developed In Ethiopia, Mexico, Lao PDR, Morocco, Afghanistan, and Nigeria, among other countries.
Production of concrete tangible outputs
The most common tangible outputs, according to data collected from interview respondents, were locally-tailored versions of the SoWMy report. These localised versions came in different forms. In Lao PDR, for example, the country-specific information was extracted from the global report and simply translated into a local language to enhance readership and accessibility. In Mexico, however, the national report brought in new information and provided more in-depth analysis on national challenges. Regardless of particular approach, these reports were most often used to supplement, rather than substitute, the findings within the global SoWMy report. Other tangible outputs included curricula, guidelines and policies, as detailed below.
Creating capacity and skills-building
In multiple countries, SoWMy led directly to the creation of working groups and/or midwifery organisations, which enhanced the capacity of governments and advocacy groups to highlight and suggest specific policy or programmatic changes related to midwifery and maternal health. Lao PDR, for example, drafted and approved the constitution of a Midwifery Society in late 2015. In Mexico, SoWMy inspired the creation of a National Intersectorial Group to attempt to raise the number of midwifery schools and enhance education; in Morocco, a Basic Education Curricula was approved.
Changing procedures/practice/internal policies
Several countries reported changes to midwifery curricula and training materials to enhance the quality of education -- a key aim identified within the SoWMy report. Policies to support and standardise midwifery training were instituted in several countries, and midwifery recruitment and retention were reported to be set as a policy priority in the strategic plans of several ministries of health. As described previously, new working groups were also created to facilitate changes to midwifery practices in Mexico, Lao PDR, Morocco, and elsewhere.
Change or influence on policy/government
Governments were reported to make multiple changes following the SoWMy 2014 report, including: a commitment to increase the quantity of midwives and quality schools (Viet Nam, Morocco, Mexico, Nigeria, Myanmar, Lao PDR, and more); the formation of new working groups to coordinate policy changes (Mexico, Morocco, Lao PDR, and more); enhancement of curriculum and national training materials (Nigeria, Morocco, Viet Nam, and more); greater political awareness and prioritization of the needs of midwives (as nearly all respondents indicated); greater understanding of specific challenges related to maternal health (all); and greater collaboration between midwifery advocates and government officials.
Interactions with stakeholders
Many respondents indicated that the SoWMy 2014 report facilitated enhanced and more frequent correspondence with policymakers and other key stakeholders after the global launch. These interactions appear to be an important mechanism in gaining political support and placing the issues highlighted within the SoWMy report on the political agenda.
In particular, national and regional events and workshops were consistently highlighted as an effective mechanism by which to share findings and stimulate discussion with key stakeholders. Even among countries where no national report was introduced, the global report was often sufficient for advocates to garner the attention of and create dialogue with relevant government bodies.
Changes to behaviour
Changes to everyday behaviours following the SoWMy report were not reported or observed.
Changes to social environment
The strengthening of midwives’ standing within the broader health community was one outcome of the report. In particular, advocates aimed to leverage SoWMy 2014’s findings to advance the occupational prestige of the midwifery profession and, thus, to alter its relative standing in the social environment of the health services industry [
29].
“The report was important in creating a united front in the nursing and the midwifery communities.” (Global Steering Committee Member).
Another respondent framed the strategy as an attempt to raise the profile of midwives and midwifery generally:
“One of the main aims and effects of the SoWMy 2014 report was to give visibility to the role of midwives in the health system.” (Member of Local Midwifery Association, Morocco; translated from French).
Changes to physical environment
Changes to physical environment following the SoWMy report were not reported or observed.
Changes to reputation and esteem
Enhancing the reputation and status of the midwifery profession was a common theme among interviews with respondents. Many claimed that bolstering such recognition was an important contribution of the SoWMy report, and some even deemed it a necessary step toward achieving progress with respect to midwifery-related goals. Many respondents felt that this enhanced status was a more common outcome than attributable, concrete policy change.
Challenges
While SoWMy 2014 was clearly influential in stimulating changes to policies and programmes related to midwifery and SRMNH, respondents noted a number of challenges associated with the data collection and analysis for the report, with promotion and use of the report, and with the overall context within which the global strategy was developed and implemented.
Timing and length of data collection
The most frequent set of challenges concerned the data collection process during the development of the report. Some respondents felt that the overall process of data collection was too short, leading to incomplete or unsatisfactory data collection. The timeframe meant that it was difficult to mobilise resources effectively, as indicated by one respondent:
“You cannot plan, and you have reasons why it’s so difficult… The government doesn’t have this data ready. It’s not readily available, it’s also not transparent, and they don’t display it on any website, so you really have to dig into papers, literally.” (Member of National UN Agency, Southeast Asia)
Still, other respondents mentioned that the length of time between the data collection process and the release of the global report might have contributed to hesitancy of some political leaders to accept the report.
“During that time [between data collection and the launch of the global report], lots of things changed… with the following consequence: the government said, “Well, this is not right anymore,” and we had to say yes, but this is how we did the data collection.” (Member of National UN Agency, Southeast Asia).
Complexity
Multiple respondents commented on the complexity of the data questionnaire. This questionnaire was said by some to be too difficult or too long to easily complete.
“It could be simplified by far… they are so complicated and so in-depth, and some of it the countries don’t find relevant, and that’s quite demotivating in getting the data.” (Member of National UN Agency, Southeast Asia).
Another respondent added to the concern of complexity, noting that it was unclear how certain metrics within the report were calculated. This harmed the perceived authenticity of the results, according to the respondent.
Involvement of additional stakeholders
Finally, multiple respondents noted that the data collection process might have benefited from inclusion of other types of participants, such as local stakeholders, government officials, and, from a technical perspective, more statisticians and midwifery researchers.
Aside from data-related concerns, several respondents also noted that communications-related support after the global SoWMy launch could have abetted their efforts to utilise the report.
Other challenges that respondents brought up had less to do with the development or promotion of SoWMy and more to do with intra-country deficits that inhibited them from acting on the report’s suggestions: contextual challenges. Some, for example, noted that structural and geographical challenges within their countries, such as lack of necessary infrastructure in rural regions, limited their efforts. Additionally, many also referenced a lack of resources and funding as key obstacles.
Pre-launch
Activities prior to the launch of the 2014 SoWMy – such as the data collection process and data workshops – began to shape perceptions of the eventual report in positive and negative ways.
For many, the data collection process necessarily involved governmental support and, thus, made it easier to gain political buy-in once the report’s findings were unveiled. In certain countries, however, frustrations with the timing of the data collection or the lack of clarity in how certain metrics were calculated prompted hesitancy among national organisations and government bodies.
Global launch
The report was introduced at a global launch event in Prague as part of the International Confederation of Midwives. A key strategy of the launch was to garner media coverage of the report. As detailed in the Results section, the press release highlighting the report received more than 300 pickups, while stories featuring the report were published independently in several high-visibility outlets. Interview respondents cited this media coverage as important in providing national organisations with momentum and tools to prepare the mechanisms by which they would attempt to achieve progress within their country.
The data within the policy impact framework reveal that the launch and subsequent media coverage also helped to generate a global sense of momentum, which, according to many respondents, helped them to push efforts forward within their own countries. SoWMy added a sense of importance and urgency to the midwifery profession, prompting government officials to be more receptive to calls for policy or programmatic change, according to respondents.
Initial response
The initial response of stakeholders reflects how they perceived and utilised the report after its global launch.
Most common was the use of SoWMy as an advocacy resource within countries. Stakeholders frequently used the report to make calls for policy and programmatic changes, or to bolster their case for acting on previously recommended changes.
As noted in the policy contribution framework, SoWMy was also influential in pinpointing particular country-specific weaknesses with respect to midwife practices. These findings sometimes led directly to outcomes, such as mechanisms to improve the quality of education related to midwifery training. More often, though, it simply served as an impetus for government officials and advocacy groups to begin the process of determining how to address the revealed weaknesses.
Finally, some countries also decided to create a localised version of the SoWMy report, as previously detailed. Thus, SoWMy provided an impetus for the local production of an evidence base.
Mechanisms for change
As observed, acquiring government support and facilitating stakeholder interaction were near-universal steps in generating productive outcomes related to midwifery or maternal health. Regardless of the responses to SoWMy or tactics chosen within countries, gaining the support of these prominent groups appeared to be a necessary condition for change.
Interview respondents suggested that gaining government support and involving key stakeholders could be achieved in different ways. National events and workshops, though, appeared to be the most effective method of achieving government support, engaging stakeholders, and generating concrete policy or programmatic outcomes.
Finally, the increased status of midwifery profession, often cited a result of the global momentum that SoWMy generated, was both an outcome of the report and a propeller of additional progress.