Background
Methods
Design
Setting
Sampling and recruitment of participants
Participant | Rationale for inclusion | Bunia | Aru | Adja | Total |
---|---|---|---|---|---|
Provincial Health Office Staff | Responsible for recruiting and deploying health workers within the Province, including midwives | 3 (3 M) | 0 | 0 | 3 |
Provincial Reproductive Health Coordination staff (PRHC) | Oversee in-service training of midwifery cadres within the province | 2 (1 M; 1W) | 0 | 0 | 2 |
DHMT members | Responsible for human resources for health management at district level | 1 (W) | 3 (3 M) | 3 (3 M) | 7 |
Church medical coordination staff | Church owns many health facilities in the province and employs midwives | 0 | 1 (M) | 1 (M) | 2 |
NGOs focusing on maternal health | Collaborate with PRHC to provide in-service training for midwives and improve their working conditions | 1 (W) | 1 (W) | 2 (1W; 1M) | 4 |
Head nurses | Direct managers of midwives | 3 (1 M; 2W) | 7 (2 M; 5W) | 3 (3 M) | 13 |
Nursing school staff | Responsible for the training of midwives | 0 | 2 (1 M; 1W) | 0 | 2 |
Midwives | Provide maternal healthcare services | 5 (1 M; 4W) | 5 (1 M; 4W) | 6 (6W) | 16 |
Total | 15 | 19 | 15 | 49 |
Data collection
Bunia workshop | Aru workshop | Adja Workshop |
---|---|---|
DHMT delegate, Provincial Health Office delegates, NGO delegate | DHMT delegates, NGO delegate, church medical coordination delegate, nursing schools’ delegates | DHMT delegates, NGO delegate, church medical coordination delegate, head nurses |
Head nurses and midwives | Midwives | Midwives |
Head nurses |
Data analysis
Ethics approval
Results
Midwifery, maternal healthcare situation and policy implementation in Ituri province
“As you may know, policies are developed at the national level, and our roles in the district health level is to implement. But, we cannot implement if there are no funds for the implementation.” (DHMT, Man, Aru)
“If only they implemented remote and rural placement allowances, things would have changed automatically. It is just on paper, and nothing is really done on that” (Midwife, Woman, Bunia).“… most health workers working in urban areas receive their risk allowances compared to those in rural areas …” (Head Nurse, Man, Adja)
“At the provincial level, normally they should promote recruitment of different health workers’ categories according to the staffing standards, but the way different health workers are being recruited does not help to cover the gaps at the health district level” (Provincial Health Office, Man, Bunia)
“At the health district level, they should also respect and control HRH [human resources for health] staffing in different health facilities, making sure that they do not have a plethora of qualified health workers in urban health areas, they should work on convincing qualified health workers to go to serve in rural areas.” (Head nurse, Man, Aru)
“As you can realise, in different nursing schools for secondary level, they only had nursing programme, there was none on midwifery” (DHMT, Male, Aru)
“When I look at all challenges that are described in this study [as described in the workshop], I find them being real realities. When you are a midwife, especially in rural areas, you face all those challenges. My concern is on the profession of midwives. They [the government] should really consider their profession seriously, especially as they deal more with women and babies’ lives.” (Midwife, Woman, Aru)
Strategies for attraction and retention of midwives in remote and rural areas
Categories of intervention | Proposed strategies | Challenges | Possible solutions | |
---|---|---|---|---|
National | Local/district | |||
Education | Promotion of nursing schools organising midwifery in rural areas | Recruiting and training rural background students | Poverty Community ignorance Lack of children to be recruited Conflict generated from selection candidates | Community-based education sponsorship scheme for recruited students |
Regulatory | Registration of rural-based midwives | Recruiting and integrating TBAs in facilities | No salary for TBAs Continuation of providing home delivery | Salary from user fees Local authority involvement to ban home delivery |
Financial incentives | Salary of health workers from the central government Implementation of rural placement allowances | Increased salary from income generated from user fees | Lack of funding from the government Flat rates imposed by NGOs Poverty of the rural population | Difficult to overcome Increased local income generated from user fees |
Professional and personal support | Better living conditions Safe and supportive working environment | Good relationship at the facility and with the community Good leadership at different levels (communities, facilities, DHMTs) | Lack of funding from the central government Unrest or insecurity | Community/church mobilisation to improve building conditions and houses for health workers District initiative on fund raising Lobbying to NGOs Difficult to overcome insecurity Strengthening supportive supervision and in-service training by church medical coordination and NGOs in the area |
Other local interventions | Promoting interactions and contacts with students at nursing schools and colleges Promoting local marriage Recruiting and integrating TBAs in facilities | Church regulations Socio-cultural-related challenges No salary for TBAs Continuation of providing home deliveries by TBAs | Community mobilisation on the importance of education and midwifery TBAs salary from user fees Local authority involvement to ban home delivery |
Education strategies
“… I think it is better that the government invests themselves in covering rural health districts with nursing schools, where they also integrate midwifery.” (DHMT, Man, Adja)
“… at this condition, the government should just encourage churches, with the big number of facilities they have, especially in rural areas, to organise nursing schools” (Head Nurse, Man, Adja)
“If the local chief could contribute to send someone, a child from the area, who knows very well the area to study midwifery. When they will complete, they will most likely go back. For instance, there is someone who has just completed her midwifery training in one of the nursing schools, she said that she is from Yekia, and would like to go to serve at Yekia as a midwife.” (DHMT, Man, Adja)
“In relation to identifying local children to send them to train midwifery in nursing schools and colleges could be community ignorance on the importance of schooling their children, especially for some specific courses; there is poverty of the local community, conflict in the community as someone’s child can be selected, and those whose children are not selected might end up not being happy.” (Midwife, Man, Bunia)
“You know that in Ituri, it maybe all over the place, women get married quickly. You know just when a lady is married, she forgets everything else. In rural areas, ladies just think of marriage while in urban areas, ladies are committed for studies.” (Provincial Reproductive Health Coordination, Bunia)
“… they could encourage the local chief to send at least one person from the area to go to study midwifery. If in each health catchment area there is one person going to study midwifery, after 4 years, the problems of shortages can be solved, as they are children who grew up in the area” (DHMT, Man, Adja)
“So, it is better in that condition to make sure that they organise community awareness, even in churches to encourage parents to send their children in schools, and also promoting girls’ education.” (DHMT, Man, Adja)
Regulation
“So, there is a real need for the government to register and pay health workers, with a special priority for those working in rural health facilities.” (Church Medical Coordination)
Financial incentives strategies
“I think that it is better for the government to pay all health workers, instead of being selective [paying only those in urban health facilities], otherwise, those who are not paid [in rural and remote areas] will get discouraged and might decide to leave and that will not contribute to improve attraction, as no one would like to commit themselves to work knowing that they will not receive salary or risk allowances from the government.” (DHMT, Man, Adja)
“I think the major challenge could be weak implication of the government in dealing with some aspects where they are responsible, such as … making sure that financial motivation of health workers working in rural health facilities are better than that of urban areas. But also, we can consider a poor budget allocated to the health sector, just around 5% of the national budget. And the budget allocated for paying health workers are also very poor, especially for nurses and midwives.” (Provincial Health Office, Man, Bunia)
“At the national level, the government should respect and implement policies they have developed. If the government respected those policies elements, they would have made some changes by now.” (Nursing School, Aru)
“… the local chief could give a piece of land so that the local population cultivates for the midwives working in the health facilities, or they can grow food for all health workers in the health facility as they do not benefit much from the health facilities.” (DHMT, Man, Adja)
Personal and professional support strategies
“I think it is important they improve living conditions of health workers, especially building houses for health workers in rural health districts. As health workers coming from urban areas were used to sleeping well in good conditions in their own houses, that is why they should improve their living conditions in relation to their housing.” (Head Nurse, Man, Aru)
“Actually, as someone put it, rural health facilities need to be equipped with equipment and supplies, and that can also be a factor that will attract qualified midwives in rural areas.” (Midwife, Woman, Adja)
“Some more strategies to improve attraction in rural areas could be improving living conditions in rural areas, by ensuring security, and also making sure that road infrastructure conditions are improved, as that will facilitate communication between urban and rural areas.” (Provincial Reproductive Health Coordination, Bunia)
“I think they should avoid conflicts in the area. Despite the poor salary, if the person works with good relationships with the local population and other health workers in the facility, the person can be happy to continue serving” (Midwife, Man, Aru)
“So, lobbying to NGOs intervening in the area so that they contribute with equipment in health facilities, especially for maternity services, that can contribute to retain health workers.” (Midwife, Woman, Adja)“We told head nurses to take the first delivery of the month, and that delivery fee is put in the district development fund. So, we keep that money from each health facility in that development fund. Each health facility deposits per month 40,000 shillings [US $11], they bring that money in the district health office, that money is for the development of our health facilities. At the end of the month, during monitoring meeting attended by all head nurses, head nurses bring that contribution for the month, and they decide to whom to serve that money, according to their health facilities development plan.” (DHMT, Man, Adja)
“But with these conflicts, and wars, many qualified midwives and other health workers decided to leave rural health facilities and rushed either here in Bunia or in other urban areas which appeared to be safer.” (Provincial Health Office, Man, Bunia)
“We should also include youth leaders. I think they should also create employment for young people as well as development project, covering different sectors, such as agriculture, training, mechanics, sewing, and so on. Of course, we will need NGOs to support those initiatives” (DHMT, Bunia)
Other local strategies
“I would also like to add that each head nurse could make efforts to identify those who study in nursing schools and colleges, those studying midwifery, at the end of the year, they should do their best to gain their confidence. I have managed to practice that, and some actually came.” (Head Nurse, Man, Adja)
“… you also know that, as we are talking of midwives, most of them are young girls, those who just complete their training. So, they are deployed in the area as single midwife. I would say that another strategy to retain them is that men from the area should make sure they take them for marriage. Young men need to make sure they ask them for marriage as they will contribute to serve their community.” (DHMT, Man, Adja)“You know that recently there were two midwives from the referral hospital who left for marriage, because boys from the area did not make a step towards them, so other men from somewhere else came to ask them for marriage, and they had to leave.” (DHMT, Man, Adja)
“They should consider the importance of traditional birth attendants, by recruiting them and integrating them in the health facilities so that they work together with qualified midwives in maternity services, because they are very influential.” (Midwife, Woman, Adja)
“You know, in one of the areas here in Adja, the local authority has forbidden home delivery. If there is a case of home delivery, both the woman having delivered and the traditional birth attendant have to pay a fine of a goat each (30$).” (Head Nurse, Man, Adja)
Discussion
Feasibility of strategies
Need for collaboration between different levels of the health system for effective implementation of the proposed strategies
Collaborative approach to developing strategies
Implementing change
Strengths and limitations
Conclusion
Box 1 Midwifery in the Democratic Republic of Congo
- The midwifery profession, as defined by the International Confederation of Midwives (ICM) is new in DRC (since 2013) [66]. There is no legal regulatory structure to uphold the midwifery profession. It is therefore not possible to ensure a high-quality workforce of midwives in DRC [67]. - The midwifery association was established in 2000, is well connected and accepted, with 1700 members and a member of ICM, but needs more resources to function effectively. - Midwifery education is managed by two different government ministries: Public Health and Higher Education | |
Ministry of Public Health (MoPH)
|
Ministry of Higher Education (MoHEd)
|
1. Midwifery training
A3 midwives: Since the colonial period until late 1980s, midwifery training began at a secondary-school level (Institut de Techniques Médicales: ITM) [67] - Entry requirements: 10 years of education (6 years of primary and 4 years of secondary) - 2 years of midwifery in nursing schools training A3 level birth attendants (accoucheuses A3) - The A3 midwifery programme was abolished and replaced by a four-year midwifery education programme (A2). |
1. Midwifery training
A1 midwives (undergraduate degree) (Institut Supérieur de Techniques Médicales : ISTM) [67] - Entry requirements: A2 midwives or 12 years of education (6 years in primary and 6 years in secondary schools) - 3 years of midwifery in nursing colleges training A1. Since 2013, when the country’s educational reform took place, a three-year midwifery education (sage femme) is conducted at a higher education level, which is in line with midwifery international norms and standards |
A2 midwives (diploma level) (Institut Techniques Médicales : ITM)
- Entry requirements: 10 years of education (6 years of primary and 4 years in secondary) - 4 years of midwifery in nursing schools |
A0 midwives (Post graduate degree) (at Institut Supérieur de Techniques Médicales : ISTM)
- A1 midwives - 2-year post graduate training programme in obstetrics and gynecology (A0) in a few nursing colleges |
2. Types of training providers
- The government - Faith Based Organizations (Not-for-profit private sector) |
2. Types of training providers
- The government - Faith Based Organizations (Not-for-profit private sector) |
3. Location
- Urban areas (in a few schools only) Midwifery programme not organized in most schools) - Rural areas (in a few schools only)midwifery programme not organized in most schools) |
3. Location
- Urban areas (nursing colleges: ISTM, concentrated in urban areas) - Rural areas |
Box 2 Availability and distribution of skilled birth attendants in Ituri: key findings [33]
• The shortages of midwives are the most extreme, especially in peri- urban (24.9% of posts filled) and rural districts (7.2% of posts filled), while there is a surplus of doctors and nurses in urban and peri-urban districts (> 100%) • While the number of doctors and nurses has increased in urban, peri-urban and rural districts from 2013 to 2017, the number of midwives has decreased in peri-urban and rural districts • There is clear gender and occupational segregation: doctors and nurses are more likely to be men, whereas midwives are more likely to be women; there are more women nurses in the urban district • The projections of training outputs show a surplus of doctors and nursing increasing, whilst the shortfall for midwives remains above 75% |
Box 3 Midwives work experiences in Ituri Province: key findings [34]
• Midwives joined midwifery for different reasons, including a wish to solve problems, fulfilling childhood aspirations and wanting to be role models for their community • Midwives faced health systems-related challenges, including severe shortage of qualified co-workers, poor working conditions due to lack of equipment, supplies and professional support, and no salary from the government, apart from risk allowances received by some • Midwives also experienced socio-cultural challenges: gender norms ofmale midwives not being accepted in rural communities (most male midwives work in urban areas), married female midwives not being allowed to work due to family responsibilities, women attending antenatal services late in pregnancy or coming to the facility on their own for delivery, and a culture of blame when there are deaths or complications • Midwives have developed coping strategies such as generating income and food from farm work, lobbying local organisations for supplies and training traditional birth attendants to work in facilities |
Box 4 Policies on attraction and retention of health workers in rural and remote areas in the Democratic Republic of Congo [20, 21]
1. Education - Integrating midwifery and other courses in nursing schools 2. Regulatory - Registering eligible health workers and including them on payroll quickly so that they receive salary and allowances - Applying a standardised pay rate to health workers having the same qualification both in urban and rural areas - Equitable initial deployment of health workers in health facilities according to needs and redeployment of surplus health workers 3. Financial incentives - Ensuring regular payment of salary and allowances - Implementing rural placement allowances 4. Personal and professional support - Improving working conditions of health workers in rural areas by supplying equipment and supplies, providing supportive supervision and in-service training - Construction of staff houses at facilities 5. Others - Development and sensitisation of HRH staffing standards - Control of the deployment of registered health workers between facilities - Strengthening the HRH information system - Organising’ payment sites in rural areas close to health workplaces |