Table 1 Political system factors that influence the roles of midwives within the health system

 Government structures

• Indigenous self-government allows communities to make decisions and implement midwifery services

• Variation in government structures can lead to differences in midwifery policy – relates to policy instruments (legislation and regulation)

•

• Self-government and political autonomy in Nunavik helped Inuulitsivik implement midwifery services during a time where midwifery was not a regulated profession (Canada) [34,35,36]

[34,35,36,37,38,39]

 Policy legacies

• Past policies about the value of midwives creates interpretive effects, shaping the way midwifery care is organised in the health system

• Values include SRHR policies that reinforce structural gender inequalities in a medical model, payment systems privileging physician-provided and hospital-based services

• Policy legacies ties closely to ideas as the values/mass opinion about ‘what ought to be’ are shaped by legacies of gender equality/inequality and vice versa

• Lack of professional recognition limited the establishment of midwifery (Bangladesh and Nepal) [40], consistent with gender inequality (Morocco) [41] and midwives faced gender discrimination and violence in the workplace [42,43,44]

• Destruction of the health system as a result of conflict, which forbade education for women and resulted in a significant loss of the midwifery workforce (Afghanistan) [45, 46] and societal reconstruction post conflict (Cambodia) [13]

• Policies in HICs that supported the medicalisation of birth, including hospital-based and physician-led care [47,48,49,50,51,52,53]

• Historical prioritisation of training physicians over other health professionals [11, 54]

• Loss of Indigenous midwifery as a result of colonisation and assimilation policies (e.g. evacuation of pregnant women out of the community and the residential school system) (Canada and Australia) [34, 54,55,56,57,58]

• Caste system devalued midwifery because the profession is traditionally led by women caring for women (India) [59]

• Midwives faced structural barriers to integration as a result of previous restrictive policies (e.g. midwives did not have a budget code in Mexico until 2011) [38, 60]

• Lack of gender-sensitive and rights-based policies reinforced structural gender inequalities (i.e. created barriers to respectful maternity care and participation in policy-making) [42,43,44]

• Policy legacies that valued midwives and home births influenced the way the health system was organised (Netherlands) [49]

• Midwifery as a tool to empower women and advance gender equality [61]

• Professionalisation of midwifery began in the eighteenth century (Sweden) [62]

• Universal Rights of Childbearing Women in the Respectful Maternity Care Charter, recognised that issues related to gender equity and gender violence were at the centre of maternity care – ‘safe motherhood’ extends to basic human rights for pregnant women [42, 63, 64]

• The State of the World’s Midwifery 2014 was a global policy initiative that increased the status of midwifery at country levels and international policy dialogue [65, 66]

[11, 13, 34, 40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66]

 Interests

• Interests include societal interest groups (e.g. consumer and religious groups), researchers, professional and international associations, and donor agencies

• Policies are influenced by interests that have concentrated benefits and diffuse costs

• Interest groups play a role in supporting or opposing the integration of midwifery in the health system

• In LMICs, bilateral and multilateral donors work alongside local governments

• In HICs, professional associations play a strong role in political lobbying

• Interests are closely related to institutions (policy networks) as well as ideas as interest groups often reflect and/or can influence societal values

• Interest groups play an important role in advancing midwifery in the health system by (1) creating partnerships to improve SRHR [45, 67]; (2) promoting regulation and accreditation (e.g. accreditation requirements, setting standards, policies and guidelines) [63, 68,69,70]; (3) capacity-building, including midwifery research [71, 72]; (4) policy leadership and decision-making [43]; and (5) lobbying governments/advocacy [73, 74]

• Strong physician and hospital interest groups created a monopoly over maternity care (United States, Canada, Australia, and Mexico) [37, 38, 51, 55, 75,76,77] and impede midwives from practicing to their full scope [78, 79]

• Tensions within the profession between nurse midwives and midwives (United States) [80]

• Marginalisation of midwifery through dominant stakeholder groups [50]

• Competing interests from nursing organisations created interprofessional tensions (Nepal) and limited establishing midwifery as an independent profession [81]

• Barriers existed in accessing evidence published by African midwives (e.g. African nursing and midwifery research is often published in non-indexed journals) [72]

• Creation of interest groups to participate in the policy-making process [4] and strengthening existing groups in order to participate in the decision-making process (Nepal) [81, 82]

• Consultations with interest groups to create culturally safe midwifery care (Canada) [34, 56,57,58]

• Professional interest groups came together to strengthen health systems through (1) awareness campaigns; (2) lobbying (agenda-setting); and (3) training, advocacy and coalitions of interested stakeholders to inform education and policy [11, 66,67,68, 83]

• Midwifery organisations used counter social movements to influence public opinion [49]

• Researchers advocated for evidence-informed policies on midwifery [47]

• Collaborative networks of health professional groups raised awareness of rising caesarean rates (Latin America) [84]

• Professional associations and donor agencies advocated for scale-up and capacity-building of midwifery [61, 66, 73, 85] and supported local governments in the development of policies, regulatory activities, education and guidelines [11, 41, 45, 68, 69, 71, 86,87,88,89]

• Strong leadership from midwifery professional associations engaged in policy dialogue and decision-making to advance universal health coverage and meeting health-related UN Sustainable Development Goals [8, 63, 66, 71, 90]

• Equitable alliance between midwifery and physician groups (Sweden) [62] and collaborative professional development (United Kingdom) [76]

• Increase in the number of midwifery professional associations in LMICs, which were enablers to advocacy and linking policy and implementation [87, 91]

• Twinning (Tanzania Midwives Association and the Canadian Association of Midwives) strengthened midwifery professional associations and increased midwifery capacity [92]

• Increase of research capacity by midwives supported teaching and clinical practice [72, 93]

[1, 4, 6, 8, 11, 12, 34, 35, 37, 38, 45, 47, 50, 51, 55, 57,58,59, 61, 63, 66, 67, 69, 70, 72, 73, 75,76,77,78, 80, 81, 83, 85,86,87,88,89,90,91, 93,94,95,96,97,98]

 Ideas

• Societal values regarding gender equality (e.g. women’s roles within society) as well as the medical model (e.g. the medicalisation of the birth process and associated valuing of physician and hospital-based care)

• Ideas relate to both political and health system factors by influencing the values of citizens and either valuing or devaluing gender and the medical model

• Social construction of gender — the status of midwives in a given jurisdiction often reflected the value placed on women within the society (i.e. ‘gender penalty’) [8, 11, 41, 43, 46, 48, 61, 71]

• Some cultures did not allow women to receive care from men yet there were few health professionals that were women due to lack of educational opportunities [45]

• Health system priorities as well as changing values were based on the medical model and normalisation of medical interventions, which favoured care by physicians and within hospital settings [41, 48,49,50, 75, 78, 99,100,101]

• Incongruence between international recommendations for skilled birth attendants and needs of Mayan population in Guatemala for intercultural healthcare from traditional birth attendants [102]

• Nordic maternity care systems’ non-medical models and women dominated professional groups [37]; respect of gender equality and informed choice [86]

• Increasing consumer demand for midwifery-led care [77]

• Reclaiming Indigenous midwifery and bringing birth back to the community (Canada and Guatemala) [35, 103]

[1, 3, 6,7,8, 10,11,12,13, 35, 37, 38, 41,42,43, 45,46,47,48,49,50, 54,55,56,57,58, 61, 62, 68, 71, 75, 77, 78, 84, 86, 94, 95, 97, 99, 100, 102,103,104,105]