Background

Maternal and newborn health care is key to sustainable development at local and global levels. Despite huge progress in improving health outcomes for women and newborns, many low-and middle-income countries (LMICs), particularly in sub-Saharan Africa, continue to struggle with high rates of maternal and newborn morbidity and mortality [1–5].

A critical progress indicator of the Sustainable Development Goals (SDG) framework is the “proportion of births attended by skilled health personnel” (SDG 3.1.2) [6]. In alignment with the SDG framework, other global initiatives also focus on maternal and newborn health and include the indicator “proportion of births attended by skilled health personnel” in their monitoring frameworks, e.g. the Global Strategy for Women’s, Children’s and Adolescents’ Health, which has described an ambitious action and measurement agenda around the three pillars “Survive, Thrive and Transform” [7] as well as the “Strategies toward ending preventable maternal mortality” (EPMM) [8], and the Every Newborn Action Plan (ENAP) [9]. The competency levels among “skilled health personnel” providing midwifery care and the definition of these providers vary across countries but especially in LMICs. This variation of competence is also revealed when looking at the length and quality of their pre-service training and the many different public and private training programmes [10]. A scoping review identified a total of 102 unique professional titles from 36 LMICs for providers who provide childbirth care and substantial heterogeneity was identified between and within countries related to education, training, as well as core competencies [11]. All the above challenges are also reflected at the global level in the current measurement of “skilled health personnel” providing childbirth care [12].

Evidence suggests that while countries report relatively high levels of birth attendance by skilled health personnel [13,14] maternal and neonatal mortality have not decreased proportionately [15,16].

Pre-service training curricula for midwifery care providers act as a foundation on which students can develop the required competencies to provide quality evidence-based care [17]. The recent 2021 State of the World’s Midwifery report called for four key areas of investment for midwives to achieve their potential. One of these key areas is education and training. The report clearly highlights the critical and urgent need for training of midwifery care providers as well as midwifery educators [18]. The World Health Organization Global Strategic Directions for Nursing and Midwifery (2021–2025) put forward four policy priorities key areas of which one is the design of education programmes that are competency-based, that apply effective learning design, that meet quality standards, and that are aligned with population health needs. [19].

To secure further reductions in maternal and newborn mortality, it is imperative to monitor and evaluate to which level and standards midwifery care providers are educated and trained prior to entering the health workforce. At the same time, it is important to ensure that they work in an enabling environment [20]. The International Confederation of Midwives (ICM) Essential Competencies Framework [21] and the ICM Global Standards for Midwifery Education [22] are prominent frameworks that are widely accepted and promoted among 124 countries which have an ICM Association. (https://www.internationalmidwives.org/about-us/membership/).

The ICM Essential Competencies Framework outlines the minimum set of knowledge, skills and professional behaviours required by an individual to use the title of a midwife as defined by ICM when entering midwifery practice.

Limited research has been conducted in LMICs to assess the content and quality of curricula for “midwifery care providers” or “skilled health personnel providing maternal and newborn care”. This paper presents a review of the evidence as a component of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project—“Positioning Midwifery.” ALERT is a hospital maternity-based quality improvement and implementation research project currently implemented in Benin, Malawi, Tanzania and Uganda [23].

The aim of this review was to map pre-service training curricula for midwifery care providers providing antenatal, intrapartum, and postnatal care in the ALERT study countries against the ICM Essential Competencies Framework [21] to inform the development of the ALERT project interventions. It also aims to inform the relevant stakeholders responsible for midwifery care providers’ pre-service education in the ALERT study countries about potential gaps in pre-service training curricula.

Background characteristics of the study countries

Very high maternal mortality ratio is indicated by all four study countries, ranging from 375 (uncertainty interval (UI) 80%: 278–523) in Uganda to 524 (UI 80%: 399–712) in Tanzania [4]. The proportion of births attended by skilled health personnel varies between the countries from 64% in Tanzania to 90% in Malawi, respectively. Stillbirth rates are far behind the 2030 target of 12 or less newborn deaths per 1 000 total births [5], as the 2019 estimates for the four countries range between 16 to 20 stillbirths per 1 000 total births.

Approximately 50% of pregnant women attend four or more antenatal care visits and less than 10% attend eight antenatal visits—just under 2% in Malawi, Tanzania and Uganda compared to 9% in Benin. Wide variation is also observed in the proportion of pregnant women who have their first antenatal care visit within the first four months of pregnancy–ranging from 24% in Malawi and Tanzania, to 32% in Uganda, to 50% in Benin [24] (Table 1).

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Table 1. Cross-country comparison of maternal and newborn health indicators.

https://doi.org/10.1371/journal.pgph.0000605.t001

Methods

Data analysis

Data from the structured online interviews were entered into Microsoft Excel at the time of interview and summarized. An extraction form in Microsoft Excel was developed to map the pre-service training curricula to the ICM Framework [21]. As summarized in Box 1. the ICM framework consists of four main categories: i) general competencies, ii) pre-pregnancy and antenatal care, iii) care during labour and birth, and iv) ongoing care of women and newborns. Within each of these four categories indicators related to knowledge and skills and behaviours are outlined. Overall, the ICM framework includes 317 indicators– 132 relate to knowledge and 185 to skills and behaviours. Data extraction was performed by the two first authors (ABM and JW) and checked by the country lead midwives (S1 Table). Each curriculum was thoroughly read several times and reviewed for content to determine if the indicators in the ICM framework were included in the curriculum. Indicators were considered as equally important–i.e. one point for each indicator—and hence the maximum score possible for a curriculum was 317 which denotes 100% alignment with the ICM framework. A curriculum was deemed to have met the essential competencies if it included similar objectives and content as the ICM framework. For each curricula summary scores and percentages (%) were calculated for knowledge components and skills/behaviours components within each competency category. In addition, summary scores for each of the four main categories as well as total scores for each curricula were calculated.

Box 1. ICM framework–competency categories and indicators [21]

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https://doi.org/10.1371/journal.pgph.0000605.t002

Results

Professional titles and years of training

The four online interviews with lead country midwives in each of the study countries, elucidated 10 different midwifery care provider professional titles among providers working in the maternity wards. Table 2. presents these professional titles, training programme, duration and academic award. Benin was the only country with just two professional titles for midwifery, compared to four in Uganda, and five in Malawi and Tanzania. Benin is also unique in the sense that midwifery is a bachelor level qualification only.

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Table 2. Professional titles and training programme.

https://doi.org/10.1371/journal.pgph.0000605.t003

Supplementary information (S2 Table) includes additional information about the educational systems, entry requirements, and details for obtaining and maintaining the professional titles. The number of years spent in pre-service training varied across countries from one and a half to four years. Registration and licensing to maintain practice also varied across the countries. In Benin the authorization to work in the public sector is provided by the Ministry of Health when pre-service training is completed and authorization to work for private clients is likewise provided by a Ministry of Health and is currently a lifetime license. In Malawi all licences are renewed yearly through the Nursing and Midwifery Council. In the case of Tanzania licence renewal is needed every three years and is subject to midwifery care providers’ continuing professional development (CPD) points. In Uganda renewal of licence is required every three years and CPD points are also required but currently the regulation is not strongly implemented. Entry requirements to pre-service training differed between countries. However, due to different schooling systems in each country, a meaningful comparison of entry requirements was not feasible.

Pre-service training competencies

The sharing of curricula is not commonplace in many countries as these are considered confidential documents within training institutions which has also been the case to a certain extent in our study countries. However, we have been fortunate to obtain pre-service curricula from ten institutions: one from Benin, two from Malawi, four from Tanzania and three from Uganda. Due to restrictions of sharing curricula, which are seen as confidential documents, we could not obtain curricula for all professional titles that provide midwifery care in each country.

The ten curricula were published between 2014 and 2020 and the pre-service training varied from two to four years. The number of hours within the training programmes varied from 4,199 to 5,430 hours for the Diploma programmes and from 5,264 to 5,713 hours for the Bachelor programmes. The ICM recommends that the minimum length of a direct-entry midwifery education programme should be 36 months which corresponds to approximately 4,600 hours acknowledging that this varies from region to region [26].

Full details about the scoring for each of the pre-service curriculum as well as the years of training can be found in S3 Table and Table 3. provides a summary of the four main categories and total scores of all indicators. We found that the percentage score of all ICM Essential Competencies for Midwifery practice included in the curricula ranged from 47% in Benin to 76% in Uganda (midwifery upgrading course), respectively. For the four main categories: i) general competencies, ii) pre-pregnancy and antenatal care, iii) care during labour and birth, and iv) ongoing care of women and newborns, none of the curricula comprehensively included all the underlying competencies.

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Table 3. Summary scores for the four categories and total scores of indicators in country curriculum mapped to the ICM framework and years of training programmes.

https://doi.org/10.1371/journal.pgph.0000605.t004

The best scores for all the curricula were in the third category “care during labour and birth” with the maximum score of 91% and no scores lower than 59% for all the curricula. The lowest scores within the categories were in the second category “pre-pregnancy and antenatal care” such as “promote and support health behaviours that improve wellbeing”, “assist the women and her family to plan an appropriate place of birth”, and “provide care to women with unintended or mistimed pregnancy”. A mixed picture emerged for the first main category with several indicators with relatively high scores and other indicators not included in many curricula.

The low scores indicators apply in particular to the indicators; “facilitate women to make individual choices about care”, “appropriately delegate aspects of care and provide supervision”, “reference to national and/or international guidelines and evidence to inform best practice, “care for women who experience physical and sexual violence and abuse” and “uphold fundamental human rights of individuals when providing midwifery care”.

From the review it was also observed that none of the curricula indicated information about plans and timelines for reviewing and updating content, and only two curricula acknowledge that the ICM competency framework was considered in the development of the curriculum.

In addition, the course literature reading lists were mainly based on outdated textbooks and there was little evidence of reference literature to national and international guidelines or important scientific papers.

Discussion

To the best of our knowledge, this is the first review to comprehensively map pre-service training curricula for midwifery care providers providing pregnancy, childbirth, and postpartum care in Benin, Malawi, Tanzania and Uganda against the ICM Essential Competencies Framework [21].

The review identified gaps in terms of knowledge and skills being taught, which may result in poor competence, thereby affecting the evidence-based quality care midwifery care providers are able to provide once qualified and entering the health workforce. Our findings indicate that gaps in pre-service training curricula were consistent across the study countries, with a lack of focus on woman centered care, information sharing and shared decision making, care related to women who experience physical and sexual violence and abuse as well as aspects concerning fundamental human rights when providing midwifery care. These aspects of respectful care have been described as missing in a number of studies despite being seen as very critical in relation to women’s experiences during the pregnancy, childbirth and postnatal continuum, as well as important in promoting the use of facility-based maternity care [27–31].

The curricula also reflect the legal status of abortion in the study countries [32] and competencies related to the provision of care to women with unintended or mistimed pregnancy were only partly included in five pre-service training curricula. The “additional skill” (see Box 1) in the second category was not included in any of the curricula.

We are aware that in the study countries both private and public institutions co-exist and wondered about differences in the quality of pre-service training among these institutions. As we were unable to review curricula for both public and private institutions, we cannot say if standards differ between type of institution. A review done in the African region during 2018 revealed that two, nine, 84 and 71 nursing and midwifery institutions exist in Benin, Malawi, Tanzania and Uganda respectively but no sector details are provided for these countries [33].

Assessing curricula is one track followed to measure quality of pre-service education but does not capture key information on the quality of training provided, the educational content delivered in the classroom nor in clinical practice. A recent assessment carried out in Tanzania [34] found that curricula were not implemented as intended as nursing and midwifery programme educators lacked understanding of the competency-based curriculum. In addition, educators reported that lack of time and equipment coupled with large class sizes impeded their ability to facilitate participatory teaching methods [34]. A meta-synthesis focusing on curriculum reform to competency-based curricula in the African context identified challenges such as outdated and poorly designed curricula, lack of involvement from students and educators in curricula design, and educators lacking pedagogical skills to adequately implement competency-based curricula [35].

Whilst there is a lack of research investigating the competence levels of graduating midwifery students in our study countries, evidence from Ethiopia indicates inadequate levels of competence among graduating midwifery students. The authors concluded that in-service training is required for newly graduated midwifery students as soon as they enter the profession [36]. The recently published Regional Midwifery report for East and Southern Africa concluded that in many of the countries in the region the quality of pre-service education and training do not meet global standards due to, in many instances, outdated curricula, faculty assessed as being inadequately equipped, inadequate clinic-based practice during training as well as continuing professional development. The report also highlights the need for strengthening of education accreditation systems, regular curricula reviews to ensure alignment with new evidence and recommendations for more focus on quality of care alongside respectful care [10].

Meeting the EPMM [37] and the ENAP targets by 2025 [38] as well as the SDG targets by 2030 [6], will require accelerated efforts to ensure reductions in stillbirth, and maternal and newborn mortality and morbidity [39].

Ensuring midwifery care providers level-up their training to international and/or national standards after their pre-service education needs specific interventions and broader evaluation. Curriculum assessment will play a critical part as a first step to identify competence gaps, but should not be the only component when evaluating standards of education [22,26]. Other components such as the programme governance, teaching capacity in both theory and clinical practice, programme resources and the physical teaching environment, teacher’s qualification, entry requirements, pedagogical methods and assessment strategies, quality improvement and others are all factors which interact and should be considered to ensure well trained midwifery care providers who can deliver positive maternity experiences and contribute to decreases in maternal and newborn morbidity and mortality.

The strengths of this review lie in the first-time use of a comprehensive and systematic mapping of the included curricula using the four ICM Essential Competencies categories [21], which include 317 knowledge, and skills and behaviours indicators. The limitations of the mapping review include our inability to review curricula for all healthcare professionals who provide midwifery care in the study countries. Additionally, the study has not comprehensively covered evidence/curricula from all types of institutions providing midwifery training and education (e.g., private for profit and private non-profit institutions/faculties). The majority of the curricula were published and implemented before the ICM competency framework 2019 was released and consequently the assessment may to some extent not reflect the current available recommendation at the time of drafting the curricula. However the review revealed that only two curricula acknowledged the used of the ICM competency framework when developing the curriculum hence the previous ICM global standards for midwifery education framework (2013) [40] may not have impacted and influenced the content. A study published in 2019 confirm the limited use and implementation of ICM education standards to ensure quality midwifery education [41]. As all of these curricula are currently in use, we see value in using the 2019 ICM competency framework to assess gaps that could be taken into consideration when planning in-service training and at the time of curriculum revision.

The mapping of the curricula provides theoretical knowledge of the intended learning outcomes but does not provide information about the educators’ academic qualifications, the teaching environment, access to evidence for best care, training equipment, and clinical practice.

There are also other important aspects that this study did not cover such as the regulation of training programmes, the assessment of training institutions and accreditation. However, a recent study highlighted the need for better global, regional and national alignment with professional regulation and practice as the current systems have hindered service delivery and progress towards achieving universal health coverage [33]. Midwife trainees and pre-service training educators perspectives on the curricula content, usefulness and implementation were not assessed in this review, and would be important views to further illuminate, enhance and elaborate on our review findings.

This study also does not enable an analysis of student supervision and mentorship during both theoretical teaching and clinical practice placements which are essential components of pre-service training and more insight into these aspects is warranted.

Several gaps in the curricula were identified and countries are urged to try to address these aspects. However, positive aspects of the curricula should also be stressed. Many institutions have included many pertinent stakeholders in the development and design of the curricula, and should be encouraged to continue to update as well as develop the content according to local health workforce needs and the education system expansion.

Conclusion and implications for policy

Despite limitations, this study provides important policy and programme planning measures that could be the first step to a more comprehensive assessment of factors that impact how prepared midwifery care providers are once qualified and starting their first job. Improved pre-service education in many training institutions is needed to ensure that midwifery care providers are competent to provide quality evidence-based maternal and newborn care. When developing, designing or updating curricula training institutions and stakeholders could use the ICM Essential Competencies as the guiding framework as basic knowledge, skills and behaviours which are critical in all settings are integrated into the framework. To further enhance the curricula it would be critical to ensure that latest evidence based guidelines related to maternal and newborn care and literature are reflected and accessible to midwifery students as well as educators. However, to better inform national and local policies and programmes, additional information is needed to understand the differences between what is included in the curricula and what is taught in the classroom and in clinical practice.

Additional research would also support a better understanding of the academic level and competencies of faculty educators, the learning environment, the access to new evidence and skill labs, clinical practice as well as supervision and mentorship.

The World Health Organization designated 2020 as the International Year of the Nurse and the Midwife [42] and 2021 as the International Year of Health and Care Workers [43]. These high-visibility campaigns will hopefully inspire future action and research into effective interventions and strategies that target midwifery pre-service education to improve maternal and newborn care and outcomes.

Supporting information

Acknowledgments

We would like to thank the training institutions which kindly shared curriculum for this review.