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

From: A critical interpretive synthesis of the roles of midwives in health systems

Political system factors Relevant themes Relationships with other factors Key examples from the literature Sources
Barriers Facilitators
Institutions
 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]
  1. HICs high-income countries, LMICs low- and middle-income countries, SRHR sexual and reproductive health and rights