National plans and facility-based guidelines.

The need for an updated national plan and synchronized guidelines across institutions was emphasized. Leaders expressed their lack of awareness regarding the content of the Midwifery Act, which dates back to 1989 [18], as well as other national plans.

“Is there a national plan that you are aware of, to safeguard quality midwifery care in The Gambia? - I think it is a national plan to safeguard quality midwifery care in The Gambia, yes there is something in place….” (Midwifery leader)

The contents of the national plan and facility-based guidelines were not being disseminated effectively, and the information from the national plan was not being adequately filtered down to the midwives providing care. All participants emphasized the importance of keeping knowledge and skills up to date throughout their careers. There was a clear call for increased engagement from policymakers to update and ensure the quality of midwifery care guidelines.

“(…) people are not updated with new knowledge in regards to midwifery, because sometimes you are aware that this is what we are used to do, this is what we are doing. But that may have changed and that information is not filtered down to the service providers.” (Midwifery educator)

Midwifery education.

Keeping knowledge and skills up to date throughout their working life by applying lifelong learning and continuous in-service training was a described challenge.

“(…) we have a theory and practice gap. For me I think it’s much bigger - when people graduate from the schools. I think we have a serious problem with the quality of training at institutional level.” (Midwifery leader)

All participants were aware of the varying lengths of different midwifery education programs. This inconsistency posed a challenge in maintaining the quality of midwifery care and could result in midwives having to perform care measures for which they might not be sufficiently competent, despite holding the same overall title. To ensure students felt adequately prepared for practical clinics, there was a consensus among participants that sufficient materials and access to skills lab activities prior to clinical placements were necessary.

Midwives at practical clinics also needed to provide students with more hands-on experience with different procedures to prevent gaps in their education. Another barrier identified was the presence of too many students at the practice site simultaneously. Additionally, the limitation of students’ hands-on experience was partly due to midwives’ uncertainty about the students’ ability to perform procedures as expected. There was also concern that if a student failed, the supervising midwife might face repercussions.

“(…) to avoid themselves running into trouble, they (the midwives) try to restrict the students at some point. So, because of that students are not given the opportunity to learn more.” (Midwifery student)

The students reported gaining practical experience in various clinics, where they received supervision and guidance, effectively bridging the gap between theoretical learning and practical application. They believed that as long as midwifery students made good use of their study time, there was no doubt that skilled midwives would be produced.

Becoming a skilled midwife.

The transition from student to independent midwife, where the newly graduated midwife was given the chance to develop over time before being given excessive responsibilities too early, was lacking according to some participants. This was linked to the urgent need in the availability of midwives in the country, especially in the rural areas. This meant that as a recent graduate, you could be appointed as the head of a clinic without prior work experience, which was perceived as highly unsafe.

For instance, you graduate as an as registered midwife today and then you are posted to a clinic where you are made head of the clinic, and head of the labour ward. Everyone answers to you, and you have never even practised! (midwifery leader)

In contrast, a leader described an ongoing transition program at selected hospitals in the country, which takes place after the completion of education. Passing a licensing exam organized by the Nursing and Midwifery Council after graduation was seen as a requirement to obtain a license to practice. This examination serves to ensure that midwives have acquired the minimum knowledge and competence necessary to deliver high-quality midwifery care.

“(...) when we graduate our BSc students, we don’t just send them like that. We have six months’ internship placement at selected hospitals so that it is routine where we monitor them closely. Then from there, after the six months internship you must be certified by the health facility that you were attached to before your training institution writes to the Nursing and Midwifery Council for you to be eligible to sit to the Licensing examination.” (Midwifery educator)

Lack of access to in-service education for already graduated midwives prevented them from acquiring vital knowledge and much desired certifications as recognitions of their knowledge and skills. The participants expressed the need for on-going education in emergency obstetric care, neonatal emergency care and resuscitation, infection control, and safe birthing practices. They believed that enhancing their knowledge in these areas was crucial.

“(…) you may not have adequate knowledge needed for that practice. So, if you are in a facility where that might have been the only solution to that woman’s problem in that time, you can’t offer that solution, so it means that there is lot of delays that are going to be involved, because you (…) could not give this help.” (Clinical midwife)

Scarcity of resources.

The scarcity of resources, including equipment, mannequins, and ambulances, contributed to the inability to provide quality midwifery care, the majority of the participants claimed. This shortage not only affected the work of midwives but also hampered women’s comfort and led to delays in pregnant women seeking care.

“When you have all the equipment to provide quality midwifery care, it makes your work easy. We do not always have all we need to provide quality midwifery care.” (Clinical midwife)

Some of the participants linked the scarcity to the country’s bureaucratic system and the lack of opportunities to generate the money needed for midwifery education - which was originally provided free to all students. Other limitations were obtaining adequate resources for supervised, guided, and supported clinical practices for students; a challenge related to an increasing number of students. “…there are a lot of students on practice. So that opportunity (to meet the requirements) will be diminished if all of them want to participate or practice at anything.” (Clinical midwife)

Encountering community barriers.

The participants disclosed that some women in The Gambia tended not to prepare for pregnancy, which posed challenges for midwives in delivering quality care.

“One of the things that affects our care delivery in the Gambia most of the time I would start with the clients we have. Most of them do not know the importance of going for pre-antenatal visit and also antenatal visit.” (Midwifery student)

Women often delayed registering for maternity care as they desired to keep their pregnancies confidential until it became noticeable. Women in labour tended to delay entering the birth room as much as possible, so they would not have to spend so much time in the facility, resulting in limited opportunities for immediate treatment in case of complications.

“(…) a woman actually said she will sit home until she knows that she is fully dilated (…). So they will say if you go early, you stay long, so they will stay behind, by the time they already have complications have come in.” (Midwifery student)

The participants described how the midwives strived to educate and provide guidance to patients on improving their health. Pregnant women nevertheless in some cases prioritized advice from older family members, regarding food taboos, over healthcare professionals’ advice.

“Some of them believe so much in these food taboos, taboos of like the family adults, so because of that it makes it very difficult the advice they give them in the health facilities” (Midwifery student)

Among some women, low income prevented them to seek care.

“There are women who definitely need care but they cannot afford the expense of the care.” (Midwifery student)

Though the partners support was considered important for the woman’s well-being and truly contributed to an advantage in being able to maintain quality midwifery care, the participants described they rarely accompanied their pregnant woman to the clinic.

“That social mobilization where the husbands understand the needs for these services. If a woman is pregnant, it needs collaboration from the family. More importantly the husband. The husband’s collaboration is also necessary to ensure quality midwifery care.” (Clinical midwife)

Midwives—A passionate but demotivated profession.

All participants highlighted the shortage of midwives, which stemmed from demotivation despite their passion for the profession, negatively impacting the quality of midwifery care. While midwives’ passion was evident, it was not sufficient to maintain the quality of care in the long run. Recognition from the government and society was necessary. High workloads, long workdays, limited rest, and burnout, coupled with insufficient salaries, led midwives to leave their jobs.

“At some point you feel like all that tiredness compared to the motivation in terms of finance that you are earning, it doesn’t add up. So, at some point you feel demotivated. You want to leave.” (Midwifery student)

The lack of employment insurance and sickness allowances was perceived as demotivating for midwives who work diligently. Additionally, workplace bullying in the event of a mistake further discouraged midwives from continuing in the field.

“(…) it’s sad to say, but the nurses and general midwives are not insured. With all this hard work we do, if you get sick, you are responsible for yourself. Because there is no insurance, there is no motivation, there is a kind of bullying, everything that demotivates people. And then when there are greener pastures somewhere, people leave” (Midwifery student)

Being assigned to a specific workplace without being involved in the decision-was an additional factor for being disillusioned.

“You have the choice to reject wherever they take you. Rejecting means you can be rebellious, that you wouldn’t go, that’s what the rejecting would be, but you don’t have a choice. (…) most of the time the Chief Nursing Officer or the Director of Nursing will say “no you have to go there or else your service will be terminated” and you wouldn’t want that”. (Midwifery student)

Positive assets for quality midwifery care.

Midwives were entrusted with the responsibility of being women’s advocates and their passionate, solution-oriented and woman-centered care was an asset. Improved infrastructure and expanded healthcare facilities in rural areas made it easier for women to access midwifery care although not always easy for midwives posted far away from the capital.

“(…) health facilities have increased. We have more facilities and in the periphery like in the villages, there is always a focal person in each village who will be a companion to who ever is in need.” (Midwifery educator)

Competent midwives in the workforce played a significant role also in conducting group education sessions with women. Supportive policies guided midwives in physiological and complicated births, ensuring the provision of quality midwifery care and especially helpful in rural areas. Equal educational opportunities within the field of midwifery for both women and men were another asset described.

Leadership as a tool for a motivated midwifery workforce.

Good leadership, permeating all levels of management, education and care could improve the quality of midwifery care through guidance and support of the midwifery workforce.

The organization will depend on the leadership. If the leadership is weak, it will come down. It’s the key, they are very essential. Because the leadership organize every aspect of service delivery. (Clinical midwife)

A number of different aspects were mentioned. Having clean wards was an example of practical leadership that had made it easier to maintain good hygienic standards and had improved the possibilities to provide quality midwifery care. Being looked after by the employer and being valued and recognized as a midwife was highlighted as vital. The existence of formal equal gender opportunities within the field of midwifery even at higher levels and in leadership positions were described.

“I think the (gender)gap is now being bridged... In almost every part of the country here you have female leaders. You go to a healthcare setting, you have female leaders that are administrators. You go to a labour ward, you find female who are labour-ward-in-charge…Even at the policy level, there are so many women” (Clinical midwife)

Functioning structures for continuous education and skills-training in life saving skills, boosting of already held skills, and supervision in care of both mother and child, during and after childbirth, were sought for as it could motivate and uphold the provision of quality care, and also be life-saving.

“We have been trained in school, but if you can have follow-up training in maternal complications, how to identify some of these problems, and also neonatal care. Because we are dealing with two lives. The mother and the unborn baby.” (Clinical middwife)

The need for clinical career paths was mentioned, and housing and mortgage assistance were other considered beneficial incentives for midwives to remain in the profession; and an area in need of improvements.

“You spend the salary before even the month has end and you be taking loans you know. And the other major issue is, is the issue of transportation. That is also a BIG problem for us. Not everybody can afford a car. And you can leave your house like 7 a clock and you might get to work 9 a clock.” (Midwifery educator)

Teamwork.

Although the doctor’s decision was ultimately final, it often relied on the suggestions provided by the midwife, with doctors listening to the midwives’ suggestions. It was concluded that the respect for each other’s professions was vital. To enhance teamwork, patience and harmonious collaboration were necessary to guide each other in providing the best care, with the welfare of the woman always at the centre. To achieve harmonious teamwork, it was important to stop blaming each other.

“Sometimes you will find a midwife who is working very hard, everybody recommends her (…). So just because of one mistake they bully you a lot. So because of that then the person is demoralised, the person is no more encouraged.

…So if that is removed, let’s say, the person makes a mistake, you address the mistake in a nice way, and then you see ways forward.” (Midwifery student)

In case of deviations, witnesses were to inform the responsible manager about the issues to improve and prevent their recurrence. The Ministry of Health could support in enhancing teamwork and ensuring professional boundaries were respected by clarifying the responsibilities of different professions.