The role and scope of practice of midwives in humanitarian settings: a systematic review and content analysis

In 2015, 65.6 million people were forcibly displaced worldwide, with data indicating that more than 125 million people were in need of humanitarian assistance globally [1]. Seventy-five percent of those in need of humanitarian assistance are women and girls, aged 15 to 49 [2]. A lack of access to sexual and reproductive health (SRH) services and information is a leading cause of morbidity and mortality among displaced women and girls of reproductive age [3]. Sixty percent of preventable maternal deaths and 45% of neonatal deaths take place in displacement settings [4] and more than one in five refugees or displaced women in humanitarian settings experience sexual violence [5] placing them at risk of unplanned pregnancies, HIV and other sexually transmitted infections (STIs).

Motivated healthcare staff able to deliver SRH services are required throughout the health emergency and disaster risk management cycle. Before a crisis, planning and preparation may include working with communities for disaster risk reduction (DRR) and building partnerships, capacity and supply systems. The Minimum Initial Service Package (MISP) for Reproductive Health in Humanitarian Settings [6] outlines five objectives, activities and resources to address the SRH needs of people in humanitarian emergencies. In the post-crisis transition and recovery phase, skilled staff are needed to restore and strengthen SRH services to reduce vulnerability to future events [3]. However, there is a global shortage of health workers in general, estimated at 7.2 million in 2013 [7], and of skilled birth attendants in particular. The World Health Report [8] reported a global shortage of 2.4 million midwives, nurses and physicians among 57 countries below the threshold for 80% coverage of skilled birth attendants. In this context, it is unsurprising that there is also a dearth of skilled health workers during humanitarian crises [9, 10]. This shortage includes both coverage [9] and lack of health workers with the necessary skills [9‐11]. Midwives, trained to international standards and competencies, are associated with improved quality of care and efficient use of resources [12] and can potentially meet some of the shortfall of skilled health workers in humanitarian crises.

The geographic and social proximity of midwives to the communities they serve has the potential to prevent avoidable maternal deaths [13] and has been recognised as a key strength of this cadre. Global momentum toward increasing midwifery numbers and, in some contexts, introducing midwives as a defined sector in the health workforce are further evidence of the potential contribution of midwifery to sexual and reproductive health [14‐16]. Importantly, there is significant alignment between the scope of midwifery practice and the objectives and activities of the international response to SRH in humanitarian settings [17, 18]. This indicates that midwives, working alongside other health professionals and providers, have the potential to meet the sexual and reproductive health needs of people in conflict and disaster contexts, as they do in stable settings.

One review examined community midwifery workforce issues such as recruitment and retention in fragile and conflict-affected countries, drawn largely from grey literature [19]. However, there are no reviews providing insight into midwives’ scope of practice in the field or how this relates to international guidance.

Guidance on the potential scope of midwifery practice during humanitarian emergencies can be found in position statements released by the International Confederation of Midwives (ICM) and a report from the World Health Organization (WHO) [20]. One ICM position statement [21] encourages midwives to continue providing ongoing care and support to women during childbirth and to breastfeeding women, suggesting that the scope of practice of a midwife as defined by the ICM [22] is applicable to disaster contexts.

However, when the statements provided by ICM and WHO are compared against the roles and scope of practice of the SRH health workforce in crisis as outlined in multi-agency technical guidelines and consensus documents [17, 23‐25], considerable gaps exist. Table 1 provides an overview of potential workforce roles extracted from this documentation across the emergency disaster management cycle (mitigation, preparedness, response and recovery). The table identifies six areas of workforce practice before an emergency. However, little specific guidance is provided for midwives by the ICM and WHO across these areas with gaps noted in how midwives can be best engaged in population-based health education, delivering preventative measures and mobilising community members to monitor hazards. While more information is available to guide midwives in their response efforts, considerable gaps can be seen in the recovery phase of the disaster cycle. Guidance on how midwives can contribute to sustaining, consolidating and expanding SRH services, and further developing partnerships and synergies with humanitarian and development actors to ensure comprehensive SRH care and services are provided, is absent.

While there are gaps in the guidelines to clarify the roles and scope of practice of midwives to deliver SRH in crisis settings that may constrain the contribution of midwifery, less is known about the practice of midwives in the field. Furthermore, there is ambiguity in the delineation of roles and the relationship between SRH cadres such as midwives, doctors, community health workers and lay health workers [26]. This ambiguity is partly underpinned by the inconsistent use of the term “midwife” to refer not only to fully trained and regulated midwives as defined by the ICM but in many settings is used for lesser skilled workers such as auxiliary midwives or unsupported, poorly trained midwives [12, 27]. In many settings, the scope of practice of midwives is limited by the dominance of the medical profession [28‐30]. In many Asian and South American countries, midwives are non-existent or have been marginalised, leading to a lack of understanding among other health care professionals and policymakers, of their scope of practice [12, 27]. Homer et al. [31] highlighted the unexploited potential of collaborative practice to improve SRH.

This lack of knowledge is problematic for the effective engagement of midwives within the broader humanitarian health sphere and for developing the disaster competency of the midwifery workforce. To begin to address this lack of evidence, we conducted a systematic review to examine the roles and relationships of midwives in humanitarian settings to inform a comprehensive approach to maximising the potential of midwives in such contexts. We sought to identify and describe the SRH care activities, services and resources midwives are involved in delivering in humanitarian emergency contexts, and how they work with other care providers to deliver health care.

Fourteen papers met our selection criteria and were included in this review (see Additional file 1 for details of included studies). Ten studies employed qualitative methods [42‐50] and two were each based on quantitative [51, 52] or mixed methodologies [53, 54]. As detailed in Table 4, eight papers reported findings from the response phase of the disaster, including one instance of immediate response within protracted humanitarian settings [42]. Findings were reported on the recovery phase in seven papers, and of these, one paper pertained to both the response and recovery stages of intervention [49]. Two studies closed the cycle between humanitarian and development work by detailing the roles of midwives in both preparedness and recovery [53, 54].

Twelve papers were from settings of conflict and two described the aftermath of natural disasters. According to the WHO regions, five studies were from the Eastern Mediterranean region, four each were from Africa and Southeast Asia, and one was from the Americas. Finally, and accounting for the multiple foci of some studies, 13 papers described the roles of midwives in providing maternal and newborn health services, three detailed this cadre’s role in providing family planning, one described general reproductive health work and one discussed interventions to address sexual violence and provide emergency contraception. The characteristics of the included studies are summarised in Table 4 and discussed below according to both the three phases of the emergency management cycle and the guidance and areas of action associated with each according to multi-agency guidelines, the MISP and the Granada Consensus (see Table 5).

The aim of this review was to synthesise evidence regarding the roles midwives play in humanitarian contexts and their relationship with other cadres involved in the provision of SRH information and services in these settings. Across the 14 studies, we found examples of activities undertaken by midwives during the three phases of the emergency management cycle. However, as indicated in Table 5, our review clearly demonstrates that there are important gaps between the levels of guidance provided to midwives and their organisations relating to mitigation and preparedness, and recovery. Furthermore, there were substantive gaps between guidance and evidence of on-the-ground practice in all three phases of the disaster management cycle.

There is some alignment between international guidance on what is required in humanitarian settings and what the ICM/WHO asserts is the scope of midwifery practice, particularly during the response phase despite gaps in the research evidence of midwifery activity in two areas of the MISP. We did not find guidance from ICM or WHO on the potential role midwives may play in the mitigation and preparedness phase in relation to involving the community, particularly vulnerable communities, in monitoring or in reducing risks for vulnerable communities by reducing underlying risk factors, or in providing population-based health education. Evidence from two papers that reported data on preparing midwives for disasters shows that little is known about the preparation of midwives to deliver the MISP but also in terms of how midwives are involved in integrating SRH into disaster risk reduction/mitigation preparedness and response planning and in to laws that ensure equity and access. We did not find any guidance from ICM or WHO on the potential role midwives may play in the recovery phase in relation to achieving sustainable consolidation and expansion of SRH, or in developing partnerships and synergy between humanitarian and development actors. The research evidence provides even less information on actual practice in the field. Given that the WHO recommends that nurses and midwives are supported to operate with a greater scope of practice in emergencies [20], this lack of guidance for important aspects of the emergency cycle is significant. Without such guidance, midwives are unlikely to deliver care to their full potential across all phases of the disaster management cycle.

In terms of collaboration and conflict with co-workers, there were three main issues: the re-emergence of traditional midwives due to shortage of skilled birth attendants, collaboration of midwives and nurses resulted in midwives assuming care that is beyond the scope of midwifery practice, and tensions between midwives and medical personnel resulting in limits to the scope of midwifery practice. Such tensions were reported in Afghanistan, possibly reflecting a lack of recognition of the role of midwives who are re-emerging as a profession in Afghanistan, as well as gender inequality [55, 56]. We did not find any research that focussed directly on describing the role of midwives in relation to other cadres. Such research could inform future guidance for midwives operating in these contexts and seeking to contribute to building the resilience of their communities.

Our review found evidence of midwife shortages that led to the re-emergence of traditional birth attendants, lack of support for midwives and challenges around lack of recognition of the role and scope of midwives’ practice. In many countries, these issues are not specific to emergency settings [12, 27] but reflect wider issues. There is an urgent need to scale-up all midwifery training to address shortages and to ensure that midwives have the necessary knowledge and skills to function to their full potential in non-emergency contexts as well as across all phases of emergency management. In contexts where there is a lack of midwives, a short-term solution could be to train other healthcare workers such as nurses, doctors and community health workers to provide aspects of SRH [57]. However, considerable investment is needed globally to prioritise midwifery and build capacity so that midwives are a highly competent, qualified workforce as per ICM standards [18, 27, 58].

Lessons from successful midwifery training in emergencies must be shared and scaled up, especially those reported directly from the field [55, 59]. However, while there are excellent clinical packages available to assist the training of midwives to deliver the MISP including the SRH clinical outreach refresher training (S-CORT) [60] and m-health applications [61], supportive strategies such as supervision are necessary to enable midwives to transfer their learning into practice [62]. Midwifery education for humanitarian training must also be incorporated into basic education and training. Leadership is necessary to achieve this. While the voices of midwives need to be represented at high-level international fora, the ICM is well positioned to support professional associations of midwives in nations across the world to strengthen quality midwifery education, care guidelines and protocols for emergencies. Midwifery associations and regulatory bodies and the Ministries of Health particularly those in LMIC can be supported by country offices of United Nations agencies such as WHO and UNFPA to better locate the roles of midwives in high-level disaster preparedness and response planning and coordination activities. The Inter-Agency Working Group for Reproductive Health (IAWG) is also an important player to assist coordination with humanitarian actors and provide technical guidance.

Implementation research is required to address the evidence gap concerning the effective delivery of midwifery-led sexual and reproductive health care in crises settings by testing workforce interventions to support midwives to deliver the Minimum Initial Service Package and strengthen collaboration and referral pathways. Workforce interventions need to be assessed alongside interventions to strengthen the health information system to generate data to inform immediate and future responses to SRH in crisis [63]. Finally, these need to be adequately costed so that financing benchmarks can be established to mobilise, accumulate and allocate money to cover the SRH needs [64].

A limitation of this review is language bias as we only included papers written in English. The search returned few papers highlighting the emerging nature of this research field and as such decisions were made to include studies that despite being methodologically “weak” provided important contextual data. The review did not allow for theorising due to the largely descriptive nature of the data. However, the use of a framework for analysis derived from the phases of emergencies and international guidelines has delivered useful insights for midwifery policy and practice in humanitarian settings.

This systematic review identified considerable gaps in the guidance that defines midwifery scope of practice in crises in ICM and WHO documentation particularly for the mitigation and preparedness, and recovery phases of an emergency. As shown in Table 5, there is a lack of evidence that examines midwifery interventions across the disaster management cycle, in particular, during mitigation and preparedness, and recovery phases. Research-informed guidelines and strategies are required to better align the midwifery scope of practice with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle.