PROBLEM: Few midwives are given the opportunity to provide continuity of midwife care despite the suggested benefits.

BACKGROUND: Translating evidence into practice remains challenging, particularly in low-income settings where workforce limitations, structural constraints, and leadership capacity influence implementation. Although continuity of care models have gained increasing attention globally, little is known about how midwives in low-income countries perceive their readiness and capacity to initiate and sustain such models.

AIM: To explore how midwives experience and perceive their capacity to implement and lead continuity of midwife care in Ethiopia.

METHODS: A qualitative exploratory design was used. Twenty-one midwives providing continuity of midwife care participated in semi-structured individual online in-depth interviews. The data were analysed using reflexive thematic analysis.

FINDINGS: The overarching theme, "Opening the door to the full scope of midwifery practice," captured how continuity of midwife care enabled midwives to utilise their full professional capacity. Four interrelated themes described this capacity: 1) clinical competence and autonomy, 2) individualised care and trustful relationships, 3) motivation, commitment and professional pride, and 4) teamwork and structural support.

DISCUSSION: The findings suggest that midwives' capacity was shaped not only by individual competence and motivation, but depended on organisational conditions that enabled autonomy, responsibility, and continued professional development.

CONCLUSION: Continuity of midwife care can function as a liberating structure that releases midwives' existing capacity, when recognised and supported by the system. Enabling midwives to fully exercise their professional role is foundational to delivering respectful, equitable, and effective maternity care in Ethiopia and similar settings worldwide.

BACKGROUND: Midwifery models of Care (MiMoC) is not standardized in in low-resourced settings, limiting the ability to evaluate the feasibility and effective in improving maternal and neonatal health outcomes compared to a standard care model.

METHODS AND TRIAL: This article describes and discusses rationale, study protocol, and randomisation process for a study that will randomly allocate 1,654 pregnant women to receive or not receive MiMoC in four selected health facilities in Debre Berhan town, Ethiopia. Women will be randomly assigned to either the MiMoC group (Group A) or the standard care model (Group B) using a computer-generated randomisation scheme. In the MiMoC arm (intervention group), women will receive care during pregnancy, labour and birth, and immediate postnatal care from a single midwife or backup midwifes. Conversely, the standard care arm will involve care from various staff members at different times. To evaluate the effect of continuity of midwifery care, the principal maternal health outcome of the study will be the proportion of women having a spontaneous vaginal birth. The primary neonatal health outcome will be the proportion of neonates born preterm. In February 2025, we began recruiting women for the main study. The intervention group will be compared with the control group using an intention-to-treat analysis. Ors and 95% CIs will be estimated. The study was approved by Debre Berhan University's Institutional Review Board and the Swedish National Ethical Review Authority.

BACKGROUND: Respectful maternity care, as recommended by the World Health Organization, includes allowing women to give birth in the position of their choice. Dynamic birth positions, which enable women to adopt various positions during labor and delivery, are associated with improved obstetric outcomes. However, the extent of knowledge and practice regarding dynamic birth positions among Ethiopian midwives remains poorly understood.

OBJECTIVE: To assess midwives' awareness and practice of dynamic birth positions and explore their perspectives and experiences.

METHODS: A convergent parallel mixed-methods design was employed to evaluate midwives' knowledge, attitudes, and practices regarding dynamic birth positions. Quantitative data were analyzed using stepwise backward elimination logistic regression to identify key predictors, while qualitative data were examined through thematic analysis.

RESULTS: The study included 483 midwives, with 473 participating in the quantitative survey and 10 in the qualitative interviews. Fewer than half of the midwives demonstrated good levels of knowledge (45%) and attitude (49.5%), while only 22.6% reported regular practice of dynamic birth positions. Participation in training emerged as the strongest predictor of knowledge, attitude, and practice. Thematic analysis revealed six key themes: routine practices, awareness, clinical implementation, barriers, facilitators, and user needs.

CONCLUSION: Awareness and practice of dynamic birth positions among Ethiopian midwives are notably low. Key barriers include limited awareness and suboptimal working conditions, whereas targeted training significantly enhances all assessed domains. To promote the adoption of dynamic birth positions, efforts should focus on increasing awareness, modifying delivery equipment, and improving the clinical environment.

BACKGROUND: Globally, the quality of maternal and newborn care remains inadequate, as seen through indicators like perineal injuries and low Apgar scores. While midwifery practices have the potential to improve care quality and health outcomes, there is a lack of evidence on how midwife-led initiatives, particularly those aimed at improving the use of dynamic birth positions, intrapartum support, and perineal protection, affect these outcomes.

OBJECTIVE: To explore how the use of dynamic birth positions, intrapartum support, and perineal protection impact the incidence of perineal injuries and the 5-min Apgar score within the context of a midwife-led quality improvement intervention.

METHODS: A cohort of 630 women with uncomplicated full-term pregnancies was recruited from a hospital in Uganda. Observations and questionnaires assessed birth positions, intrapartum support, perineal protection, health outcomes and maternal characteristics. Primary outcomes included perineal injuries and the 5-min Apgar scores. The primary outcomes were analysed using descriptive data, with trends visualised through a run chart to assess changes during the midwife-led Quality Improvement intervention. Secondary outcomes included postpartum haemorrhage, admission to neonatal intensive care, newborn resuscitation, skin-to-skin care, and breastfeeding initiation.

RESULT: A statistically significant association was found between women having intact perineum (i.e., no perineal injuries) and giving birth in a dynamic birth position [AOR; 0.6 (95% CI 0.4 - 0.90)], receiving intrapartum support [AOR; 0.9 (95% CI 0.9 - 1.0)], and using perineal protection measures [AOR; 0.3 (95% CI 0.2 - 0.5)]. Newborns with an Apgar score below seven at five minutes were significantly associated with intrapartum support [AOR; 0.8 (95% CI 0.7 - 1.0)] and perineal protection [AOR; 0.3 (95% CI 0.1 - 0.8)]. However, after adjustment, no significant association was found between Apgar score and birth positions [AOR; 0.5 (95% CI 0.2 - 1.5)]. Perineal injuries and low Apgar scores significantly decreased (p < 0.001) during the Midwife-led Quality Improvement intervention period.

CONCLUSION: This study demonstrates that low 5-min Apgar scores and perineal injuries decreased during a midwife-led Quality Improvement intervention focusing on dynamic birth positions, intrapartum support, and perineal protection strategies.

CLINICAL TRIAL: This study is registered on ClinicalTrials.gov as of 14th February 2022, under registration number NCT05237375.

BACKGROUND: The maternity continuum of care (MCC) is an integral component of universal health coverage and a crucial strategy for reducing maternal and neonatal mortality. Despite its importance, MCC coverage remains low in low- and middle-income countries (LMICs), including Ethiopia, which bear the highest burden of maternal and neonatal mortality. This underscores the need for proactive interventions. In this perspective, the primary health care (PHC) approach holds significant potential for enhancing MCC. Exploring demand- and/or supply-side opportunities for improving MCC within the PHC system could help inform policy, practice, and further research. However, there is limited evidence on these aspects in Ethiopia. Therefore, this study aims to explore demand- and/or supply-side opportunities for MCC enhancement within the PHC system in northwest Ethiopia.

METHODS: We conducted a qualitative study using an interpretive description approach within the PHC system in northwest Ethiopia from March 3 to November 27, 2022. Data collection included four key informant interviews, three focus group discussions with 29 participants, and 28 in-depth interviews, all selected through maximum variation sampling. Interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed using reflexive thematic analysis in ATLAS.ti version 7.1.4 software.

RESULTS: Three themes and 11 sub-themes have emerged. These include: (1) PHC structural enhancement with its categories: onsite mentorship, decentralized ambulance service platform, structural networks, and expansion of the scope of frontline PHC facilities; (2) PHC input enhancement with its categories: expansion of the maternity service workforce and technological advancements; and (3) PHC maternity service delivery enhancement with its categories: community engagement, approaches for reducing wait times, tailored maternity service provision in conflict-affected communities, flexible schedules for maternity service, and integrated midwifery model of care.

CONCLUSIONS: This study finds that there are several structural, input, and service delivery opportunities for enhancing the MCC within the PHC system in northwest Ethiopia. These opportunities indicate potential pathways to strengthen PHC resilience for MCC. Widespread utilization of these opportunities could significantly improve the existing MCC within the PHC system. We also recommend further research to assess the impact of these opportunities on MCC.

COVID-19 vaccines significantly reduced COVID-19 related morbidity and mortality. Although purposeful response measures like movement restrictions affected delivery of other health services, few studies have investigated the association between COVID-19 vaccination as a response strategy and continuity of other immunization services. We aimed to assess the association between the COVID-19 vaccine rollout and continuity of routine immunization services and describe the interventions instituted to maintain delivery in Uganda. This was a cross-sectional study conducted in Wakiso District, Central Uganda. We applied an explanatory, sequential mixed-methods design. We analyzed routine childhood immunization data by computing the percentage change in vaccine doses given for Bacille Calmette-Guerin (BCG), Diptheria, Tetanus Toxoid Pertussis (DPT3), Polio 0, Polio 1, Polio 2 and Polio 3 between March 2021 and April 2021. This was followed by 19 interviews with health workers and 3 focus group discussions with altogether 33 mothers using the World Health Organization Health System Building Blocks as a guiding framework. We found that the COVID-19 vaccine rollout was associated with changes in the trends of routine vaccine uptake. The number of DPT3 vaccine doses reduced by 4.3% between March 2021 and April 2021 after the COVID-19 vaccine rollout while that for Polio 1 vaccine doses reduced by 5.5%, Polio 2 vaccine doses reduced by 5.8% and Polio 3 doses reduced by 5.6%. The challenges to continuity included increased workload, competition for cold chain and storage capacity and impact on perceptions about vaccination. Interventions to sustain demand included engaging community health workers, community mobilization, health education, and prioritizing routine immunization services. Interventions to maintain delivery included integration of services, increasing health workforce and separating resources for routine vs COVID-19 vaccination. In conclusion, the COVID-19 vaccine rollout was associated with infrastructural and logistical challenges which affected delivery of routine immunization services. Introduction of the COVID-19 vaccines was also associated with negative perceptions about routine childhood vaccines. Deployment of new medical countermeasures should integrate interventions to predict and mitigate effects on existing supply systems like the human resources and infrastructure. Medical countermeasures deployment should also involve education and sensitization that addresses misconceptions and sustains demand for existing health services.

OBJECTIVE: The aim of this study is to explore the impact of barriers and facilitators on the quality of midwifery care in The Gambia, from the perspectives of clinical midwives, midwifery students, educators, and leaders.

METHODS: A qualitative study based on focus group discussions with 29 clinical midwives, midwifery students, educators and leaders analysed with content analysis. The study was conducted in The Gambia.

RESULTS: The analyses led to three main categories outlining barriers and facilitators for the quality of midwifery care: 1) the gap between theory and practice, 2) working in a harsh environment and 3) facilitating factors that can pave ways forward. The results are described in generic categories: 1a) national plans and facility-based guidelines, 1b) midwifery education, 1c) becoming a skilled midwife, 2a) scarcity of resources, 2b) encountering community barriers, 2c) midwives - a passionate but demotivated profession, 3a) positive assets for quality midwifery care, 3b) women in leadership as a tool for a motivated midwifery workforce and 3c) teamwork.

CONCLUSIONS: Addressing the gaps between theory and practice, and strengthening the incentives for midwives to remain in their profession are central for improved quality of midwifery care in The Gambia. Guaranteed employment after completing education, equal opportunities for men and women to become midwives and the significance of passion are assets which need to be carefully maintained within the health care system.

Background: The Covid-19 pandemic has posed challenges to maternal healthcare systems worldwide, impacting women’s access to and utilisation of reproductive healthcare services, particularly highlighting health inequities among minority populations. Maternal awareness of fetal movements is a measure to evaluate fetal well-being. In Sweden, women are encouraged to contact healthcare if they experience decreased fetal movements. It is unknown whether women in Sweden faced greater challenges accessing such care during the Covid-19 pandemic. The objective of this study was to examine whether the proportion of healthcare contacts for decreased fetal movements changed during the Covid-19 pandemic, and if this varied according to women’s demographic characteristics.

Methods: This retrospective population-based cohort study included 18,791 who contacted healthcare due to decreased fetal movements before (1 January 2017 to 31 December 2019) and after (13 March 2020 to 31 March 2022) the onset of the Covid-19 pandemic in Region Stockholm. Women with a singleton pregnancy from gestational week 22 were included. Data were retrieved from the Swedish Pregnancy Register and the National Patient Register.

Results: There was no significant difference in healthcare contacts for decreased fetal movements before compared to during the Covid-19 pandemic (17.3% vs. 17.7%). Subgroup analyses showed an increase in healthcare contacts for decreased fetal movements after the onset of the pandemic among women born in Sweden, women with a university-level education, and students. In contrast, healthcare contacts among women with BMI ≥ 30.0 kg/m² significantly declined during the pandemic period.

Conclusions: Overall, contacts with healthcare due to decreased fetal movements remained consistent before and during the Covid-19 pandemic. However, variations were observed among specific subgroups, defined by BMI, region of birth, occupation, and educational level. These findings underscore the complex interplay between sociodemographic factors and maternal healthcare utilisation. To ensure equitable access to essential prenatal care during future health crises, healthcare services and communication strategies must be adapted to reflect the needs and circumstances of all demographic groups.

AIM: To explore the readiness of Bachelor in Midwifery graduates in Nepal to provide midwifery care aligned with the definition competently on graduation and to identify barriers affecting their practice.

BACKGROUND: Nepal has introduced an internationally standardised BSc midwifery education programme designed to enable midwives to work competently and independently in midwifery care on entering the profession.

DESIGN: A qualitative interview study was conducted and analysed using inductive content analysis.

METHODS: Individual interviews were conducted with 8 midwives, 5 educators and 5 students using a guide based on ICM competencies. Participants were recruited from various institutions and universities across Nepal and ethical approval was obtained.

RESULTS: Possibilities and challenges in applying programme content include seven sub-categories: Preparation before clinical education, Midwifery care, The bridging role of midwifery educators, Clinical supervision, Use of evidence-based, respectful and culturally sensitive midwifery practice, independent midwifery practice and Being a role model. The findings indicate that while the BSc programme provides strong theoretical preparation, significant challenges persist in translating this into practice.

CONCLUSIONS: While the BSc midwifery programme theoretically prepares students to work competently and independently in midwifery practice, practical challenges hinder its implementation. Addressing these issues, such as improving clinical support, recruiting qualified midwifery educators and establishing a deployment strategy, can enhance midwives' ability to work independently in midwifery care, ultimately improving health outcomes for women, families and communities.

BACKGROUND: The first bridging program for midwives in Sweden started in 2018. This made it possible for midwives educated outside of the EU/EES and Switzerland to obtain a Swedish midwifery license and become familiar with the Swedish healthcare system within a year.

AIM: To describe midwives', who have obtained their midwifery education outside of the EU/EES and Switzerland, experiences obtaining a Swedish midwifery license through the bridging program at Karolinska Institutet.

METHOD: A qualitative study was conducted utilizing semi-structured interviews with nine midwives who had completed the bridging program. Content analysis was used.

RESULTS: From the analysis, one theme emerged: Reforming professional identity. This theme encompassed four categories: A bridging program as a way of reaching the goal, experience of support, becoming familiar with a new healthcare system and learning while using a new language.

CONCLUSION: The necessity for a bridging program became apparent as the midwives encountered differences in healthcare systems and diverse approaches to interacting with birthing women. Acquiring the skill to provide consistent support was challenging, demanding proficient communication skills, with casual conversation being the greatest obstacle.