Abstract
Background: Global findings indicate that midwife-led care significantly improves outcomes for both mothers and newborns. Considering this worldwide evidence, the Indian Ministry of Health and Family Welfare has set a goal to implement midwife-led care as a nationwide strategy to enhance the quality of maternity care. Understanding women's pre-existing knowledge, views, and preferences about this model is essential for effectively implementing and scaling up midwife-led care. However, research on the user's perspective remains limited to date, suggesting a crucial area for further exploration, especially given the variations in adopting this model of care.Aim: This study aims to explore the attitudes and beliefs of women from two Indian states about the implementation of midwife-led care.
Methods: This research employed a mixed-methods approach. Before conducting the main study, a systematic review in low- and middle-income countries (LMICs) was undertaken. The insights gained from the systematic review were pivotal in informing and guiding the subsequent mixed-methods main study. The systematic review was conducted to identify the barriers and facilitators affecting the implementation of midwife-led care from the perspectives of care consumers, care providers and key stakeholders. The review involved a thorough search of seven electronic databases, and the reporting followed the PRISMA guidelines. The methodological quality of the included studies was assessed using the Mixed-methods Appraisal Tool (MMAT). The Supporting the Use of Research Evidence (SURE) framework guided data analysis and synthesis.
The primary study was conducted in two phases using a convergent mixed-methods design.
Phase 1: A descriptive cross-sectional survey was carried out to assess the attitudes and beliefs of women of reproductive age regarding midwife-led care in two Indian states chosen for their contrasting healthcare approaches. Specifically, one state had implemented midwife-led care while the other had not, providing a unique opportunity to compare perceptions of this care model. Participants were recruited through social media platforms from March to July 2022. Data were gathered using an online questionnaire informed by the Theoretical Domains Framework and utilised 5-point Likert scales. Data analysis was performed using SPSS (the Statistical Package for the Social Sciences).
Phase 2: A descriptive qualitative study was conducted to explore women's views about implementing midwife-led care in depth. Twenty-three participants who participated in Phase 1 were selected for in-depth interviews. These interviews were conducted online via Zoom, using a semi-structured interview schedule. The data collected were analysed using the framework method, allowing for a structured interpretation of views shared by the participants.
Finally, the findings from the quantitative survey and qualitative interviews were integrated using a narrative and side-by-side joint display method. This integrated data was interpreted by investigating data convergence, expansion, and divergence.
Results: The systematic review encompassed 31 studies from 21 LMICs. The findings of this review indicated that effective implementation of midwife-led care in LMICs required increased collaboration among key stakeholders, including funders, government officials, professional associations, and community leaders. However, lack of continuous funding, social constraints and political instability hindered its implementation in LMICs. Key findings included the need for care recipients to have adequate knowledge and confidence to utilise midwife-led care. These insights, particularly from childbearing women, significantly influenced and informed the main study's questionnaire and the interview schedule, ensuring they were relevant in exploring the attitudes and beliefs towards midwife-led care.
The quantitative survey involving 307 participants revealed that participants held positive views towards midwife-led care in India, as evidenced by the mean scores on a Likert scale ranging from 'strongly agree' to 'strongly disagree'. The perceived benefits of midwife-led care for women and newborns were rated positively, with a mean score of 3.7 (SD: 0.98). They also perceived this care model would be helpful for women during pregnancy, childbirth, and postnatal period (Mean:3.5; SD:1.10). About 54% indicated a willingness to accept care from a midwife. However, the survey also uncovered perceived barriers such as midwives' inadequate knowledge (43%) and lack of skill (49%). Additionally, 56% of participants reported lacking information about midwife-led care. These perceptions varied geographically, indicating different acceptance and understanding levels in various regions.
The qualitative findings indicated that participants knew about midwives; however, their understanding of midwife-led care varied demographically. For instance, participants from urban settings with a clearer understanding of this model of care recognised it as a model of care encompassing prenatal, birth and postnatal services. While those in rural communities uncertain about midwife-led care associated it with traditional childbirth methods. Participants perceived that building confidence and developing a trusting relationship with midwives was essential to accepting care from a midwife. These participants believed certified and experienced midwives and respectful and equal care were key facilitators in transforming their perceptions into positive acceptance. Some participants raised concerns about the midwives' lack of knowledge and skill, with environmental constraints such as long distances, limited transport facilities, and insufficient facilities also identified as potential barriers. The findings indicated a need for detailed information about this model of care, preferably through social media and government campaigns.
Conclusions: This thesis explores the socio-cultural and economic factors influencing women's perceptions of midwife-led care in India, highlighting the need for culturally sensitive, region-specific interventions for effectively promoting and implementing midwife-led care for women from diverse communities. Key enabling factors for an effective and sustainable implementation of midwife-led care in India include the presence of experienced, well-trained midwives, adequate resources, including sufficient midwife-led care units, and the provision of equality of care, ensuring all women receive high standards of midwife-led care and have equal access to these services, irrespective of their socio-cultural and economic backgrounds. The study also highlights the significance of government engagement and advocates for multi-channel communication strategies to optimise this model of care effectively. Lastly, this research identifies areas of improvement for future research, such as exploring the long-term outcomes of midwife-led care, investigating the cost impacts of this care model by integrating it into national healthcare systems and further studies focussing on the perspectives of key stakeholders to gain a more holistic understanding of the challenges and opportunities in implementing midwife-led care in India.
| Date of Award | 1 Jan 2025 |
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| Original language | English |
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| Supervisor | Maria Duaso (Supervisor), Shawn Walker (Supervisor) & Claire Feeley (Supervisor) |