Table 2 Health system arrangements that influence the roles of midwives within the health system

Governance arrangements

• Mechanisms to support accountability for state sector’s role in financing and delivery

• The regulatory process (or lack thereof) of the profession is central to the roles of midwives within the health system and many references covered regulation as well as barriers to regulation

• Accreditation systems to establish quality education

• Enabling professional environments support the International Confederation of Midwives’ three pillars (education, regulation and professional association)

• Scope of practice — expanding scope or restrictions to practicing to full scope

• Within governance arrangements, regulatory process overlaps with:

 • organisational authority – accreditation and

 • professional authority – training and licensure requirements, and scope of practice

• Regulatory process overlaps with ‘ideas’ and in some cases self-regulation was a response to growing consumer demand for midwifery services [3]

• Lack of legislation to support regulatory activities [34, 43, 48, 58, 71, 82, 87, 93, 94] limited recognition and scope [38, 87] and the ability to practice as an autonomous profession [80]

• Midwives lacked ownership and leadership to contribute to national accountability through tracking and reporting systems (e.g. midwives collecting or sharing data) [43, 65, 90]

• Midwives were unable to practice to full scope because of inconsistent standards of education and professional regulation [78, 91, 106]

• Globally, there was a general lack of knowledge regarding the International Confederation of Midwives’ Global Standards for Midwifery Education, which was a barrier to the provision of quality midwifery education [53, 66, 87, 107, 108]

• Midwives were not practicing to their legislated full scope of practice (Canada), barriers included (1) hospitals — scope restrictions; (2) capping of the number of midwives granted hospital privileges; (3) capping the number of births attended by midwives; and (4) inconsistent midwifery policies across hospitals [52, 77]

• Healthcare reforms increased the centralisation of decision-making, which created barriers to change (Australia) [95]

• Combination of regulatory processes and health systems that promoted birth as a natural process; favoured professional midwifery care (Nordic countries) [8, 62, 86, 91, 99]

• Accreditation mechanisms supported midwifery education programmes and institutional capacities [63, 70, 93, 107]

• Environments that allowed midwives to practice autonomously and to full scope of practice [74]

• Expanded scope from providing skilled delivery care to include SRHR ranging from abortion, family planning, screening (diabetes and several forms of cancer), immunisations, palliative care, and public health and promotion [10,11,12,13, 55, 74, 94, 109,110,111,112,113]

• Increased contraceptive prevalence rate (Nigeria) by engaging midwives in provision of family planning services [114]

• Engagement of midwives within broader humanitarian emergency contexts (e.g. conflict, epidemics, and natural disasters) [46]

• Effective collaboration between governmental institutions and professional associations supported quality midwifery education [107]

• Integrated data collection and analysis into regional and national health information systems supported monitoring and evaluation processes for evidence-informed decisions [63]

[1,2,3,4, 6, 8, 10,11,12,13, 34, 35, 38, 39, 43, 45,46,47,48, 50, 52, 53, 55, 56, 58, 59, 62, 63, 65, 68,69,70,71, 74, 77, 78, 80, 82, 84, 86, 87, 90, 91, 93,94,95,96,97,98,99,100, 105,106,107,108,109, 111,112,113,114,115,116]

 Financing systems

• Financing systems: (1) Medicare has been funded by a mix of federal government cash payment to provinces, province- specific taxes and federal government (Canada) [6]; (2) mixed health system — public and private financing, health insurance, and service delivery and the public system is supported by the National Health Fund, which covers almost 75% of the population (Chile) [84]; and (3) effective coverage — the proportion of the population who need the intervention and receive it [1]

• Relates to ‘governance arrangements’ (accountability in the state sector’s roles in financing and delivery)

• Marginalisation of midwifery through reframing maternity care to focus on patient safety and costs of medical malpractice (United States) [50] and shifting of professional role boundaries between obstetricians and midwives [101]

• Changes in the 1970s to the Canadian northern health services resulted in the evacuation of women from remote communities to hospitals in larger centres for childbirth [35]

• Economic barriers to the provision of quality midwifery care included low or absent wages (e.g. waiting up to 6 months for public salary), lack of financing systems through governmental support, obligatory user fees and reimbursement by fee exemption schemes [43]

• Supportive policies were implemented through community-based and institutional healthcare services, which expanded across the country and were free (reaching most remote and rural areas) (Sri Lanka) [69]

• The Government Midwifery Incentive Scheme, a nationwide results-based financing initiative increased (1) health system performance; (2) facility deliveries; and (3) skilled birth attendance (Cambodia) [115]

• Incentivising facility deliveries through governmental initiatives to remunerate midwives and providing incentives to both the health professional and the client (Cambodia) [13, 115]

• Maternity care reform enabled midwives to access Medicare and the Pharmaceutical Benefits Scheme (Australia)

[1, 2, 6, 10, 13, 35, 38, 39, 43, 50, 55,56,57,58,59, 61, 69, 73, 74, 76, 80, 84, 95, 101, 104, 109, 115]

Delivery arrangements

• The roles of midwives in health services delivery

• Delivery arrangements relate to (1) access midwifery care (e.g. workforce supply, distribution and retention); (2) how care is provided (e.g. task-shifting, interprofessional teams); and (3) where care is provided (e.g. hospital based, integration of services and continuity of care)

• Delivery arrangements link with ‘institutions’, ‘interests’ and ‘ideas’ in that they influence the delivery of healthcare services

• Unmet need for SRHR services in sub-Saharan Africa due to health workforce supply and demographic trends [117]

• Re-emergence of traditional midwives as a result of limited skilled birth attendant workforce [46]

• Midwives experienced role strain due to increasing workloads [48], burn out [43, 118] and lack of support to practice autonomously [75, 104] leads to disempowerment [43]

• Lack of equipment in schools and facilities can create gaps in teaching quality and practice [119]

• Medical model prioritised physician-led care in hospitals and created friction between midwives and physicians [38, 50, 52] and also minimised the roles of midwives in primary care [99]

• When compared with eight HICs, midwifery in Canada played a relatively minor role in the provision of SRHR [6]

• Rising caesarean rates in Latin America and medically induced labours [84]

• Collaborative care involved interprofessional groups (e.g. midwives working with physicians and nurses) [10, 34, 55, 74, 75, 100, 116]

• Based on statistical modelling, the projected effect of scaling-up midwifery will deliver the most impact on maternal, newborn and child health [2, 73]

• Task-sharing of HIV, tuberculosis [96], abortion-related (medication abortion and vacuum aspiration abortions) services to midwives [12, 110, 111, 120]

• Midwifery (led by Indigenous midwives) is returning culturally safe and appropriate SRHR to Inuit communities (Canada) [34,35,36, 54]

• Midwives increased access to SRHR services in fragile and conflict-affected states [121, 122]

[3, 4, 6, 7, 9,10,11,12,13, 34,35,36,37,38,39, 43, 45, 46, 48, 50, 51, 54, 55, 58, 59, 61, 62, 69, 73, 74, 76, 77, 79, 86, 94, 96, 97, 99, 100, 104, 105, 110, 116,117,118, 120,121,122]