The Impact of Professional Midwives and Mentoring on the Quality and Availability of Maternity Care in Rural Government Hospitals in Bangladesh, 2018-2019

Background: This study examined whether the introduction of professional midwives with and without facility mentorship improved care quality and availability in sub-district hospitals in Bangladesh. It also analysed the experiences of non-midwife maternity care providers and managers. Methods: Using mixed-methods, differences between hospitals without midwives, with midwives, and with mentorship were explored. Quantitative analysis comprised observations of facility readiness and clinical care to assess implementation of World Health Organization maternity care guidelines. Participants also completed a survey on their knowledge, perceptions, and utilization of the guidelines. Focus groups and interviews explored midwives’ experiences of their roles, and the experiences of the maternity staff and managers in relation to the midwives and the improved care practices they introduced. Logistic regression was used to identify differences between hospital types following the deployment of midwives and also mentoring. Results: There were 641 clinical observations, 237 completed surveys, 18 interviews and five focus groups. The analysis found facilities without midwives to be the least likely to implement quality care practices, and those with midwives and facility mentoring to be the most likely. Of the eight quality practices, hospitals with midwives but no mentors were significantly more likely than hospitals without midwives to use four: partograph (56% vs. 14%; p<0.001), upright labour (94% vs. 63%; p=0.001), delayed cord clamping (88% vs. 11%; p<0.001), skin-to-skin (94% vs. 13%; p<0.001). Hospitals with mentors were significantly more likely to use six: ANC card (84% vs. 52%; p<0.001), partograph (97% vs. 14%; p<0.001), upright positioning for labour (95% vs. 63%; p=0.001), delayed cord clamping (98% vs. 11%; p<0.001), skin-to-skin contact following birth (93% vs. 13%; p<0.001), and upright positioning for birthing (86% vs. 26%; p<0.001). In addition, attitudes among the other maternity staff and managers toward midwives’ capabilities and improving quality of care were found to be more positive with mentoring. Conclusion: Facilities with professional midwives had better availability and quality of maternity care across multiple components of the health system. Care quality further improved with facility mentors who created enabling environments, provided training, and facilitated supportive relationships between existing maternity staff and managers and the newly deployed midwives.