The article first introduces the current global maternal and reproductive health context, with particular attention to the contributions midwives can make to improving health outcomes. It then discusses the roles professional associations can play in supporting access to quality reproductive healthcare. It then describes association strengthening practices, assessing the reported efficacy of association twinning as a strategy for strengthening healthcare professionals’ capacities. It then analyzes the specific relationship between TAMA and CAM to explore how and why twinning worked to strengthen both organizations.
The global south, and the African continent in particular, is widely recognized to be facing a crisis of human resources for health – in the face of a rapidly growing population, there is an insufficient number of healthcare workers available, and many of the healthcare workers that are present have an inadequate skill level [
1‐
3]. While Africa bears 24% of the world’s disease burden, it employs only 3% of the world’s health workforce [
4]. In Tanzania, it is estimated that only 64% of reproductive healthcare needs are met, and the continuing high rates of maternal and neonatal mortality testifies to the inadequacy of existing healthcare systems, and the obstacles healthcare professionals face in providing care [
3,
5].
International organizations including the UNFPA (United Nations Population Fund) and the International Confederation of Midwives (ICM) have emphasized that midwives are a vital resource for the struggle to improve access to reproductive and sexual healthcare. Midwives trained and regulated to international standards can provide 87% of the necessary care for mothers and babies, including antenatal care, birth, and postnatal care for mothers and infants; they can also provide a broad spectrum of sexual and reproductive health and rights services to diverse populations, including contraception and post-abortion care [
2]. Midwives can play a vital role in meeting Sustainable Development Goal (SDG) 3.1, reducing maternal mortality ratio to less than 70 per 100,000 live births, and Target 3.2, reducing neonatal mortality to 12 per 1000 live births [
6]. However, research indicates that there continues to be a significant shortage in midwives worldwide, and that practicing midwives frequently report feeling under-prepared and under-supported in their work [
7].
Twinning has been proposed as one way to strengthen the skills and capacities of midwives, but most studies of twinning have focussed on relationships between individuals within officially twinned organizations [
11]. This article argues first that professional associations are vital for improving the quality of midwifery care in a sustainable way in any national context; and secondly that long-term twinning relationships can be a powerful tool to build capacity in professional associations in the global north and the global south. In highlighting the evolving relationship between TAMA and CAM, it emphasizes that the twinning relationship was not merely beneficial for TAMA, but for CAM as well. This case study challenges conventional models of development to argue that global south-global north partnerships can be enriching for all parties involved.
Why professional associations matter
Associations are a vital component of the midwifery profession. The ICM emphasizes three pillars of midwifery – education, regulation, and association [
12]. As former UNFPA Director Babatunde Osotimehin remarked, “If one of these pillars is weak, the whole of midwifery will be weak” [
13]. Associations have a keystone function for the profession: it is associations that act as a focal point for midwives, ensuring the quality of the training and support available to pre-service and in-service midwives, and acting as a voice to represent the profession at the national level. Strong associations can safeguard the quality of education and regulation in a given national context. Despite their importance, midwifery associations have received little attention either in the academic literature or from funders, aside from the ICM. The ICM has played a major role in raising the profile of midwifery in global health, ensuring the voices of midwives are heard at the policy level, and in reinforcing the capacities and skills of midwives around the world. While international efforts have been relatively quick to fund educational programs for midwives around the world, less attention has been devoted to regulation and association.
Because midwifery is already a marginalized profession, with midwives often viewed as either merely a specialized nurse or a doctor’s assistant, midwives face particular challenges in contributing to national policy and independently regulating their profession [
14]. Although midwives and nurses provide an estimated 80% of all healthcare services worldwide, these professionals, and especially midwives, have a more difficult time in having their voice heard at a national policy level [
15]. This lack of influence persists despite compelling evidence of the benefits that high-quality and well-regulated midwifery care can provide [
16]. In particular, the lack of a professional association to unite midwives can lead to the implementation of poor quality programming, for example the replacement of skilled healthcare workers with poorly-trained general purpose workers [
17,
18]. Without a professional association to advocate for regulation, midwives may be unable to practice to their full scope, meaning midwives could be forbidden from performing lifesaving obstetrical or neonatal interventions. Equally, midwives may not be able to collect or share data, participate in maternal death reviews, or have their own practice monitored or evaluated by other midwives [
18]. Research has found that national governments in some cases do not consult with midwifery professional associations when setting maternal and child health policies, despite the expertise the associations could contribute. [
19]. Midwifery associations can both provide support to practicing midwives, ensuring they receive adequate training, and can represent the interests, and convey the expertise of, their membership at the national and international leadership and policy level [
20‐
22].
Because midwifery is in general a neglected profession, many aspects of midwifery remain under-researched [
17,
19]. This may account for the lack of research on the role and potential of midwifery professional associations, as well as the shortage of projects aimed at building association capacity. However, there is an existing body of work on other health professional associations, and the findings are directly relevant to the midwifery profession. Associations of obstetricians and gynecologists in particular have militated for a more active and engaged role for their professional associations. Members of these associations have outlined a vision for a role for associations beyond merely sites for sharing knowledge inside the profession. Instead, they have argued, professional associations can contribute directly to improvements in health care, particularly through offering professional expertise to guide governmental decision-making about maternal and reproductive healthcare [
23]. Associations can focalize the expertise of their members, practicing healthcare professionals, and relay that expert knowledge to national and international policy-makers and to the general public [
24]. Health professional associations can therefore serve a vital public health function in two directions: they can “educate up”, helping to inform and guide policy makers; and they can “educate down”, helping to share information with the general public [
23‐
28].
Inspired by this more activist vision of their role, professional associations, most notably the Society of Obstetricians and Gynecologists of Canada (SOGC), and the International Federation of Obstetricians and Gynecologists (FIGO), have developed programs to assist their fellow professional associations in the global south achieve similar strengths and similar results. The SOGC’s Organizational Capacity Improvement Framework (OCIF) was the first tool developed by a professional association to help bolster the organizational capacity of its fellow associations, and has been used in countries in Africa, Latin America, and Asia. More recently, and building on the SOGC model, FIGO launched its LOGIC (Leadership in Obstetrics and Gynecology) initiative. Over a period of several years, FIGO worked with member associations in eight countries in sub-Saharan Africa and Asia; results included association-led campaigns to roll out lifesaving medications, the development of strategic plans, advocacy plans, and increased participation in national policy-making [
29‐
31]. According to FIGO’s assessments of their projects, the FIGO LOGIC association strengthening activities led to stronger health systems in these contexts [
32,
33].
The ICM, UNFPA, and other international organizations have therefore focussed their energy in recent years on building the capacity of midwifery associations, arguing that “capacity building is critical to scaling up the midwifery workforce and improving maternal and child health” [
20]. Capacity is broadly understood as being the catalyzation or actualization of resources a group or country already has – capacity development rests on the idea that a country does not need external resources, but merely assistance in transforming their existing people, organizations, and societies [
15]. Twinning has been proposed as one way to effect such catalyzation.
However, as Dawson et al. remark, there has been very little evaluation of how capacity building can be done with midwifery associations [
20]. Indeed, little research exists on the outcomes and efficacy of transnational partnerships in the health professions; scholars and health professionals have called on organizations who have participated in such partnerships to analyze and share their results, to better inform partnership practice [
4]. This article therefore examines one successful twinning relationship to analyze how and why it worked, and what benefits it provided.