Angela Dawson, BA (Hons.) PhD Research Fellow
Patricia Brodie, RM PhD Adjunct Professor of Midwifery
Felicity Copeland, RM MMid. WHO MCHI Project Evaluation officer
Michele Rumsey, RN Director of Operations WHO CC
Caroline Homer, RM PhD Professor of Midwifery
World Health Organization Collaborating Centre for Nursing, Midwifery and Health
Development, Faculty of Health, University of Technology, Sydney (UTS), Sydney, New South
Wales, Australia. Email: angela.dawson@uts.edu.au
Midwifery Due 19 Feb 5,000 words in length, excluding references, tables and figures
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Collaborative Approaches Towards Building Midwifery Capacity in Low
Income Countries: A Review of Experiences
ABSTRACT 251 OK within limit of 300
Objective
To explore collaborative approaches undertaken to build midwifery education, regulation
and professional association in low income countries and identify evidence of strategies that
may be useful to scale-up midwifery to achieve MDG 5.
Design
An integrative review involving a mapping exercise and a narrative synthesis of the
literature was undertaken. The search included peer reviewed research and discursive
literature published between 2002 and 2012.
Findings
Fifteen papers were found that related to this topic: 10 discursive papers and 5 research
studies. Collaborative approaches to build midwifery capacity come mainly from Africa and
involve partnerships between low income countries and between low and high income
countries. Most collaborations focus on building capacity across more than one area and
arose through opportunistic and strategic means. A number of factors were found to be
integral to maintaining collaborations including the establishment of clear processes for
communication, leadership and appropriate membership, effective management, mutual
respect, learning and an understanding of the context. Collaborative action can result in
effective clinical and research skill building, the development of tailored education
programs and the establishment of structures and systems to enhance the midwifery
workforce and ultimately, improve maternal and child health.
Key conclusions
Between country collaborations are one component to building midwifery workforce
capacity in order to improve maternal health outcomes.
Implications for practice
The findings provide insights into how collaboration can be established and maintained and
how the contribution collaboration makes to capacity building can be evaluated.
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INTRODUCTION
The 2011 State of the World’s Midwifery Report called for scaling-up the global midwifery
workforce to reduce maternal mortality, thereby addressing Millennium Development Goal
5 (MDG5). MDG5 cannot be achieved without midwives and midwifery organisations
coming together to support midwifery education, regulation and professional association
efforts in low and middle income countries (LMIC).
Capacity building is critical to scaling up the midwifery workforce and improving maternal
and child health. A number of meetings have sought to develop ways to build midwifery
capacity through collaboration. This includes the 2010 meeting of the Global Advisory Group
for Nursing and Midwifery Development that focused on developing policy and technical
guidance in key areas including inter-professional collaboration (WHO 2011). Various
strategic World Health Organization (WHO) forums have emphasised partnerships through
pairing organizations (twinning), networking as well as bilateral and global collaboration.
(WHO 2008; WHO 2010; WHO 2012).
While considerable efforts are being put into building midwifery capacity through
collaboration through organisations like the International Confederation of Midwives (ICM)
and member associations, there is little high level evidence about the effectiveness of such
strategies. Such information is essential to guide investments and direct strategic decision
making for current collaborations and for future endeavours. This information would also
assist in designing the most effective model of partnership.
Partnership has been noted as an important concept in collaborative practice (D'Amour,
Ferrada-Videla et al. 2005). At an international level, progress towards a global partnership
for development is central to achieving MDG 5 as well as MDG 8. Our focus was on
partnerships between midwifery organizations and midwives in LMIC (South-South
partnerships) or in LMIC and HIC (North-South partnerships) (WHO 2010) for the purpose of
capacity building (Potter and Brough 2004). In this review collaboration is defined as the
engagement of midwifery professional organizations, and/or health facilities providing
midwifery care and/or accredited midwifery training institutions in a formal program
designed to build the skills, education and regulation of midwives or nurse-midwives in
LMICs.
This paper therefore presents the first critical review of collaborative and partnership
approaches towards midwifery capacity building in developing countries. The aim of this
review is to:

map approaches and activities taken to building midwifery workforce capacity that
involve international partnerships or collaborations with midwifery organizations
across high income countries and low middle income countries

identify best practice in international midwifery capacity building collaborations
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METHOD
An integrative literature review was undertaken involving a structured search and analysis
of the literature. For the purposes of this paper the ICM definition of a midwife is adopted:
(IMC 2005). ICM not IMC
Search Protocol
A systematic search of the literature was undertaken of eight bibliographic databases
(MEDLINE, CINAHL, Web of Science , PubMed, Scopus, ProQuest (Health & Medical)
published between 2002 and 2012. In addition the HRH Global Resource Center
(CapacityPlus 2012), a global library of human resources for health (HRH) focused on
developing countries was searched. In addition, Google scholar was used to locate literature
alongside hand searching of the reference lists of useful research papers.
The following terms were used: “Midwifery”, “midwife”, “skilled birth attendant” and
“twinning”, “capacity building”, “mentoring”,” collaboration”, “partnership” and
“Developing country”, “low income country”, “resource poor contexts”. MeSH subject
headings were used “manpower”, “staff development”, “cooperative behaviour”
The search results were imported into the EndNote bibliographic software program, and
duplicated items were removed. One reviewer screened all remaining titles and abstracts (n
=221) to identify papers reporting empirical research findings.
As only 6 research papers were located, we undertook an additional mapping exercise to
document the diversity of experiences of international midwifery partnerships. This involved
retrieving discursive reports in peer reviewed journals to provide a rich context for the
investigation. The inclusion criterion was then adjusted accordingly and the search re-run to
identify non-research papers that were most pertinent to the review aims and focus. The
inclusion/ exclusion criterion to screen the papers is outlined at Table 1.
The PRISMA guidelines (Moher 2009) were used to report the literature search process as
shown below at Figure 1.
Quality appraisal
The 6 research papers were assessed to ascertain their alignment with the research aim and
methodology and to evaluate the recruitment, settings, data analysis, ethics, findings and
contribution to knowledge. Four mixed methods research papers (Lavender, Lugina et al.
2009; Lori, Ortiz et al. 2010; Maclean and Forss 2010; Carlson, Omer et al. 2011) were
assessed for quality using Pluye’s (2009) scoring system while the qualitative paper was
assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research
(NHS 2006). One paper (Girot and Enders 2004) was deemed low quality for inclusion in the
narrative synthesis but included in the mapping exercise.
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Papers screened as relevant for inclusion in the mapping exercises were assessed according
to being within or beyond the scope of the study aims. Full papers of 33 articles were
sourced and examined in detail by all authors resulting in the exclusion of 18 papers.
Consensus reached on the 15 to be included for the mapping exercise included the 5
research papers identified for the narrative synthesis.
Data abstraction and synthesis
The 5 research papers were initially analysed. These comprised quantitative and qualitative
study designs which meant pooling of research results was not possible. Therefore, a
narrative synthesis approach was conducted (Popay, Roberts et al. 2006). The results
sections of each of the papers were analysed to identify evidence for midwifery
international partnerships. A thematic analysis was conducted by the first author using
tables and discussed with other authors. The relationships within and between studies were
explored and coded under each theme. A concept map was used to plot patterns and
relationships across themes and sub themes.
Ten non-research papers in peer reviewed journals and the 5 research papers were analysed
in the mapping exercise. Tables were drawn up to map the characteristics of the
collaborations described in the research papers as well as the discursive papers. Key
features examined included the partners, their associated organizations, countries, activities
undertaken, strategies used and processes involved in establishing and maintaining the
collaboration.
FINDINGS
A total of 15 papers were included in the review, 5 research papers and 10 discursive. An
overview of key characteristics of all 15 papers is provided at Table 2 while details of the
methods, sample and aim of the retrieved research papers is provided at Table 3. The
results of the mapping exercise of all papers are described first followed by the findings of
the narrative synthesis of the results sections of the five research papers.
Midwifery partners and countries involved in collaborative endeavours
The papers retrieved in this review revealed a predominance of collaborations with African
nations (see Fig 2.) followed by Western Asia. High income county partners were America,
United Kingdom, Ireland and Sweden. There is little in the literature describing midwifery
collaborations in the Pacific, or partnerships with China and other countries in South
America aside from Brazil. Australian, New Zealand and Canadian Midwifery partnerships
with other LMICs were not found.
Partners involved in the various collaborations and their associated organizations are listed
at Table 2. Collaborations involving partnerships with universities and training organizations
were described in 5 papers (Girot and Enders 2004; Wright, Cloonan et al. 2005; Johnson,
Ghebreyohanes et al. 2007; Mogobe, Bruce et al. 2009; Uys and Middleton 2011), with
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partnerships involving professional associations reported in 5 papers (Lavender, Lugina et al.
2009; Requejo, Toure et al. 2010; Requejo, Toure et al. 2011; Kennedy, Stalls et al. 2012;
McCarthy and Riley 2012). Collaborations across professional networks featured in 3 papers
(Lori, Ortiz et al. 2010; Maclean and Forss 2010). The remaining papers involved
collaborations with hospitals (Carlson, Omer et al. 2011), universities, hospitals and NGOs
(Herberg 2005) and finally universities, hospitals and a Ministry of Health (Michael and
Garnett 2011).
Areas of capacity building and focus of activities
The papers were examined to identify the main focus of capacity building (see Table 2). The
development of skills, structures and systems through education and training and leadership
activities were the most common forms of capacity building. Of the nine papers outlining
skills or personal capacity building, seven described the development of clinical skills while
two focused on research skills. Three papers described projects focussing solely on
improving midwifery skills through training programs, two clinical (Johnson, Ghebreyohanes
et al. 2007; Lavender, Lugina et al. 2009) and one research skills (Maclean and Forss 2010).
Two papers describe aspects of the Collaboration in Higher Education for Nursing and
Midwifery in Africa (CHENMA) project (Mogobe, Bruce et al. 2009; Uys and Middleton
2011). These authors provide insight into the work of a community of practice to build the
research and clinical skills of midwifery educators and the capacity of training institutions
through professional exchange and leadership development. Three papers were concerned
with building the skills of midwives through training courses as well as developing structures
and systems to better support midwifery. In Griot et al’s paper (2004), nurse-midwife
clinical skills were not only built but a new nurse-midwives’ role and job description was
introduced at hospital and community health facilities. The work of American College of
Nurse-Midwives with 15 LMIC countries is described by Kennedy and others (2012) involving
the provision of pre and in-service education and the strengthening of midwifery and other
healthcare professional associations. A similar approach was taken by Wright et al (2005),
however professional exchange, leadership development and training was the focus rather
than professional association linkages in combination with training.
The focus on three papers is on improvements concerning structures and systems. These
papers involve South-South collaborations of professional networks to progress regulation
and strategic planning for professional associations and midwifery educational institutions
(Requejo, Toure et al. 2010; Requejo, Toure et al. 2011; McCarthy and Riley 2012). Building
midwifery leadership is a key feature of these collaborations.
Some papers included multiple components of capacity building including tools, skills, staff
and infrastructure elements. As an example, Carlson and colleagues (2011) outlined the
provision of new equipment and an incinerator alongside training courses delivered by
Sudanese doctor trainers to build the skills of Sudanese midwives in neonatal resuscitation.
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Herberg (2005) reports on a similar approach involving the provision of learning materials,
enhancing the skills of midwifery educators through training courses and strengthening the
ability of institutions to train more midwives.
Strategies employed to build capacity
The approaches to building capacity identified in the retrieved papers were categorised
according to North-South or South-South partnerships and in the case of two papers that
self-identified efforts as a community of practice (see Table 1). Seven papers outlined NorthSouth partnerships while six focused on South-South collaborations, two papers on the
same South-South collaboration. Papers by McCarthy et al. (2012) and Maclean and Forss
(2010) described a South-South collaboration that emerged from an initial North-South
partnerships. Lori et al (2010) outlined a global community of practice concerned with
evidence based midwifery. Although Lavender et al’s (2009) paper described the
involvement of UK midwives, the focus appears to be the collaboration of African midwives,
hence the effort is considered to be primarily South-South.
The establishment and maintenance of collaborations
The 15 papers provide insight into how collaborations are built and nurtured. Capacity
building in some projects emerged from collaborations with physicians (Girot and Enders
2004; Carlson, Omer et al. 2011), while others were the result of contacts (Wright, Cloonan
et al. 2005) or as part of large development projects (Herberg 2005). In other examples,
organizations were invited to attend meetings (Requejo, Toure et al. 2010; Requejo, Toure
et al. 2011) or a general call sent out to interested participants (Lori, Ortiz et al. 2010).
Strategic partnership development between midwifery organizations is evident in a number
of collaborative endeavours (Girot and Enders 2004; Lavender, Lugina et al. 2009; Maclean
and Forss 2010; Kennedy, Stalls et al. 2012; McCarthy and Riley 2012) while others were to
more broad in terms of their focus on midwifery as well as nursing (Johnson,
Ghebreyohanes et al. 2007; Mogobe, Bruce et al. 2009; Lori, Ortiz et al. 2010; Uys and
Middleton 2011).
The mapping exercise revealed important features such as the critical role of
communication. Carlson et al (2011) described the role played by Irish-based Sudanese
doctors who facilitated communication with colleagues in Sudan and an understanding of
the cultural context. Electronic communication was described as vital in the work by
Johnson and colleagues (2007) as conflict prevented US partners visiting Eritrea, while online communication formed the basis of the network established by the Global Alliance for
Nursing and Midwifery (Lori, Ortiz et al. 2010). However MacLean and Foress (2010)
emphasise the need for communication mechanisms to be clear to all partners.
Leadership and committed members with appropriate skills and experience and similar
goals with clear responsibilities and governance were identified by Maclean and Forss
(2010) as key factors in the establishment and maintenance of a research network for
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midwives across three African countries. Multidisciplinary membership (medical, midwifery,
biotechnical, paramedical, and administrative) was regarded by Carlson as key to a
collaborative endeavour involving service delivery in Sudan. Maclean and Forss (2010)
highlighted the value of starting with a small close knit group of partners, allowing
consolidation before scale-up. The inclusion of key partners also ensures sustainability of
the collaboration and its quality outcomes as mentioned by Mogobe at al. (2009) with
respect to the development of clinical masters in nursing and midwifery in Africa.
Coordination and planning was described as central to the CHENMA Project outlined in two
papers included in the review (Mogobe, Bruce et al. 2009; Uys and Middleton 2011). This
South-South collaboration aimed to build a network of nursing and midwifery education and
training institutions in Africa through pairing consortium universities with hosts in less
developed contexts. The effort was driven by The African Chapter of the Honor Society of
Nursing, Sigma Theta Tau International and was co-ordinated by a management team who
sourced funding and reported to the Directors.
Commitment, respect, trust, mutual learning and ownership were key aspects of
collaborations. In the CHENMA Project money was disbursed to each consortium university
to complete the assigned academic activities. All relevant stakeholders were involved in
situation analyses and curriculum development in CHENMA as well as the development of
the user-led distance program outlined in Lavender et al’s paper (2009). Peer to peer
learning was regarded not only as an output of collaboration but as an activity that helped
to foster and maintain the African Health Regulatory Collaborative (McCarthy and Riley
2012). Sharing experiences and mutual learning was said to help sustain health workforce
improvements and empower participants to contribute to strategic planning in their
countries (Wright, Cloonan et al. 2005; Requejo, Toure et al. 2010; Requejo, Toure et al.
2011). Collaboration was therefore vital to promote evidence based practice and share
lessons that could be transferred to other developing country contexts as well as advocating
for women’s rights to safe motherhood (Maclean and Forss 2010).
Cultural and political knowledge and an understanding of the partner’s context of care were
regarded as key to the success of collaborative efforts. Griot and others described these
qualities as important so that service users, midwives and academics can not only be
empowered to achieve the capacity building goals but do so in a way that ensures the active
participation and engagement of all stakeholders. Visits by US nursing and midwifery faculty
to Eritrea assisted with the development of an understanding of the context so that
appropriate in-country support could be set up (Johnson, Ghebreyohanes et al. 2007).
Advice to American midwives engaging in partnerships in developing contexts is provided by
Kennedy et al. (2012) who emphasise building knowledge and understanding of global
health issues and the work of key organizations involved in maternal health. Knowledge of
context is also considered essential so that the work of the collaboration can be maintained
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through an appropriate focus on the alignment of national, regional and global goals for
midwifery and maternal health improvement.
What do we know about what works? Evidence from the narrative synthesis of research.
A narrative synthesis of the findings section of the five research papers included in this
review (see Table 3) provided insight into the contribution of collaboration to midwifery
capacity building. Six themes emerged from the analysis of the findings sections; SouthSouth experiences of communities of practice; education institution development; skill
development, change in midwifery and obstetric practice, facility development, maternal
health outcomes.
South-South experiences of communities of practice
Four of the five papers described South-South experiences. Participants representing 11
East African countries at a workshop to develop a new Masters of Midwifery and Women
Health described the importance of the opportunity for sharing expertise and achieving
consensus (Lavender, Lugina et al. 2009). The sharing of expertise, knowledge of and
resources outlining evidence-based practice and lessons learned is described as an
important part of the electronic discussion’s hosted by the Global Alliance for Nursing and
Midwifery (Lori, Ortiz et al. 2010). Sharing was facilitated through simultaneous electronic
discussions in Spanish and English that resulted in the development of action plans for
midwifery leaders to implement in their own settings. Survey respondents in the
examination of the African Midwives Research Network (AMRN) highlighted issues with
internet access affecting their ability to communicate and that members made frequent
contact with African countries outside the network (Maclean and Forss 2010). The AMRN
participants also outlined strengths such as the constitution and membership but that this
could be strengthened through stenting to other African countries and institutions.
Interviews with members of the CHENMA project highlighted the empowering nature of the
community of practice. They reported that it had assisted them to exchange expertise and
help fellow African nurses and midwives to improve the quality of nursing and midwifery
leadership, community involvement and patient care (Uys and Middleton 2011). These
study findings also emphasised the generation of shared African knowledge in a cooperative
environment and participants reported interactive and enriching experiences based upon
mutual trust and respect.
Skill development
The findings of three papers provided insights into the personal skills developed from the
collaborative work. Maclean and Forss (2010) report the development of workshops to build
the research skills of midwives although there were problems including the difficulty of the
course for some and attrition due to the protracted training period. In the CHENMA
program, participants’ confidence built as a result of the collaborative exchanges (Uys and
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Middleton 2011) and workshop attendees developing the Masters program stated that the
program had enabled them to build their personal capacity in teaching and learning
(Lavender, Lugina et al. 2009).
Education institution development
The CHENMA Community of Practice was also described as having contributed to the
development of midwifery educational institutions. This included the strengthening of
courses and the enhancement of teaching and staff motivation that had led to increased
standing and international relationships (Uys and Middleton 2011). Participants attending
the workshop to develop a new Masters of Midwifery and Women Health noted the
relevance of the collaboration and how the program had helped to develop appropriate
tailored education programs identify problems with their current courses (Lavender, Lugina
et al. 2009).
Facility development
The development of health facilities providing midwifery care was only reported in Carlson
et als. paper (Carlson, Omer et al. 2011). This included the provision of equipment to aid
neonatal care and hygiene in a Sudanese hospital, along with in-service training for
midwives and doctors and quality assurance through the instigation of hygiene audits.
Change in midwifery and obstetric practice
Changes in practice over the time that the collaborations had been operational were noted
in two papers. Maclean and Forss (2010) conducted in country visits to discuss perceived
changes to midwifery practice and reported increased efficiency; involvement of fathers;
avoidance of non-evidence based procedures such as shaving and routine episiotomy; use of
active management of the third stage of labour practices and engagement of retired
midwives to follow up women postnatally. Carlson and others (2011) describe changes in
obstetric practice based upon an analysis of hospital data that showed that there was a rise
in the number of caesarean sections performed before the collaboration was initiated in
2002 that was maintained alongside a fall in the number of assisted deliveries by the end of
the project in 2009.
Maternal health outcomes
Carlson and colleagues’ paper is the only study that provided insight into maternal and
neonatal mortality and morbidity during the period of the collaboration (2011). Their paper
demonstrates that a collaborative multi-pronged program delivered over a period of 7 years
involving capacity building on a number of levels contributed to sustaining on-going health
improvements (Carlson, Omer et al. 2011). For example the annual death rate among
neonatal hospital admissions was 13% in 2009 demonstrating a 30% improvement from
2007.
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DISCUSSION
This review identified a variety of midwifery partnerships that mainly focused on building
capacity in Africa through North-South or South-South collaborations. There was little
collaboration documented in the Pacific or with high income countries other than the UK
and US and descriptions of midwifery twinning and mentoring approaches were not located.
A range of capacity building components and elements involved in developing and
maintaining collaborations for midwifery were identified. A noted gap was the lack of
research studies in this area and a paucity of evidence concerning the appropriate context
into which collaboration might emerge or be developed and how collaboration might be
assessed.
Capacity building- the goal of partnerships and collaborative endeavours
Although this review noted that collaborative efforts to build clinical skills through
education and training activities were a common feature of the programs outlined in the
retrieved papers this was often in combination with other activities. These activities
involved the provision of tools (i.e. incubators, learning materials) and the development of
midwifery education institutions; facilities providing midwifery care; regulatory systems;
professional associations and roles. The areas and activities identified in this review fall
within the components of systemic capacity building discussed by Potter and Brough (2004)
illustrating that collaborative efforts involve far more than just the provision of technical
expertise. However it is not clear if these collaborative efforts were implemented alongside
health system reform, systematic building and scale-up of maternal health efforts and
building a country’s internal ability to make its own decisions to strengthen, create, adapt
and maintain capacity over time (OECD 2006).
There are a number of additional capacity building areas to strengthen midwifery
workforces in developing nations that were not identified in the papers in our review (DayStirk (2010). These include a focus on the social determinants of health including improving
the status of women; the provision of opportunities to enter quality midwifery training
programs and information systems to assess the progress attained through skilled birth
attendance. Collaborative efforts may need to integrate their work more closely with health
systems strengthening efforts and the promotion of gender equality to maximise the impact
midwives can make to health outcomes at a population level.
Collaborative strategies to build midwifery capacity
Three collaborative strategies were identified in our mapping exercise illustrating a fairly
even distribution between North-South and South-South partnerships with the concept of a
community of practice clearly articulated in one paper. South-South collaboration has
become an important way of building capacity by learning from the experiences of other
LMICs and harnessing the expertise of other nations in the region. Although the concept is
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not described in relation to midwifery or nursing in the literature, this has become a way of
reducing the reliance on economically and politically dominant northern, or developed,
countries, favouring instead South-South partnerships that synergize strengths and augment
competitiveness (Thorsteinsdottir, Melon et al. 2010). Despite a community of practice
being explicit in Lori et al’s (2010) and Uys et al’s (2011) papers, the narrative synthesis
indicated that this concept was important to other South-South partnerships to help
support social interaction among members, knowledge sharing, knowledge creation, and
identity building. North-South collaboration or partnerships between LMIC and HIC appear
to be a well acknowledged form of working with developing countries to build midwifery
capacity. An early example in a paper Sterky and Ransjö-arvidson (1991) describes
cooperation involving the provision of technical expertise by midwife researchers in Sweden
to support the skill development of Zambian colleagues.
WHO’s Nursing Midwifery Services: Strategic Directions 2010-2015 outlines various SouthSouth and North-South cooperation strategies to build capacity in LMIC, as well as the
“twinning of nursing and midwifery schools and partnerships with WHO Collaborating
Centres;” (WHO 2010). Our review was unable to locate an example of twinning in
international midwifery contexts. Twinning appears to be a long standing approach in
midwifery, first mentioned in the literature by Tyler (1991), and most recently in terms of
“association-to-association twinning” relationships discussed at the 2012 ICM meeting at
The Hague (Anon 2012). A three year evaluation of a Chinese-US hospital twinning program
found that immersing nurse-leaders in each other’s practice field via professional exchanges
improved the leadership skills of Chinese nurses and increased their role and impact on
hospital management (Jiang, Ives Erickson et al. 2012). In another example a CanadianJordanian hospital twinning exercise involving e-mail exchanges led to richer discussion of
complex cases that informed paediatric neuro-oncology care(Qaddoumi and Bouffet 2009).
Mentoring across international boundaries has been described as one way of strengthening
individual and institutional research environments and capacities in nursing (Etowa 2011).
Establishing and maintaining collaborative partnerships
Collaboration has been defined as being comprised of five underlying concepts - sharing,
partnership, power, interdependency, and process (D'Amour, Ferrada-Videla et al. 2005).
Successful collaborations are said to be characterized by clear communication, true
dialogue, active listening, an awareness and appreciation for differences, and an ability to
negotiate options (Keleher 1998) that enable co-operation. Collaborative endeavours have
been found to be successful if partners have respect for each other’s strengths (Berendsen,
Benneker et al. 2007). The construction of a collective identity where the goals of individuals
and the organisation are shared has been noted as critical to the development of
collaborative relationships and the achievement of organisational objectives (Hardy,
Lawrence et al. 1998). These characteristics may be used to inform the development and
maintenance of collaborative midwifery undertakings by aiding partners to consider
Page 12 of 27
important aspects and how they may be addressed and incorporated into the project
design.
Collaboration and the Influence of power
Empowerment was found to be an important aspect of collaborative capacity building
efforts in our review (Wright, Cloonan et al. 2005; Uys and Middleton 2011). However there
was little discussion in the papers included in our review of how this may have affected
particularly North-South collaborations. Psaltis, Bender and others (2007) discuss the
concept of power and social relations in connection with international collaboration drawing
on the work of Piaget and Habermas. Psaltis et al presents a framework for analysing
collaboration that highlights the power held by each partner suggesting that this may be of
particular concern in international development where one partner may be wealthy and the
other resource poor. Power imbalances between partners can constrain the transmission of
knowledge and skills that may comprise the goals of the program, raising the possibility of
colonialist practice whereby decisions are made by expert program administrators.
Disempowerment may result that ultimately constrains development and prevents
collaboration.
A framework, such as that offered by Psaltis, for identifying these power imbalances
alongside strategies for mitigating their effect would be useful to those who are planning to
establish collaborative programs for midwifery. However approaches that involve a more
even distribution of power may be more useful such as that offered in the example of the
African Health Regulatory Collaborative (McCarthy and Riley 2012). The notion of
collaboratives, or an organized group of people or entities who collaborate towards a
particular goal, can invoke concepts of co-operation, mutual respect and trust and a
symmetrical relationship between partners. Wilson and colleagues (2003) study identified
seven features of collaboratives that show similarities with the factors that were said to help
maintain collaboration as described by the authors of papers included in our review. These
include membership, senior leadership support, the appropriate area of work and on-going
learning. However appropriate sponsorship was also highlighted in Wilsons et als. study and
its ability to improve the credibility or perceived importance of a collaborative effort. This
could be taken in to consideration in the early stages of strategic collaboration planning
alongside other features outlined by Wilson and colleagues including the development of
mechanisms for making improvements.
Implications for practice: Towards a framework for the design and evaluation of
midwifery collaborations
Our review found a lack of clarity regarding the assessment of the process of collaboration
and its related contributions to midwifery and maternal health improvements in
international capacity building projects. Such insight would assist with identifying the inputs
required to ensure that appropriate outcomes are achieved. There are some indications in
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the literature of ways forward in terms of the evaluation of collaborations, however this
does not appear to have been discussed in terms of capacity building in the context of
international midwifery practice. We discuss possible ways forward for collaborative
practice drawn from work in health promotion.
Leurs at al (2008) have proposed a Diagnosis of Sustainable Collaboration (DISC) model to
enable comprehensive monitoring of public health collaboratives. This model may provide
insight into how midwifery partnerships can be institutionalised and sustained through
surveys of participants and stakeholders to measure the setting, collaborative processes as
well as the resultant outcomes. The authors present a range of constructs and indicators to
examine external factors: the context; how change is managed; project management;
perceptions of support; intentions to commit, change and develop trust; and actions
demonstrating adaption, innovation and resource allocation.
Other authors (Kendall, Muenchberger et al. 2012) have produced a matrix to guide the
development and management of partnerships derived from seventeen published models
of collaborative capacity building. A user friendly manual has been produced by the US
Center for Disease Control and Prevention designed to evaluate partnerships in asthma
control programs (CDC 2012). This manual points to indicators for evaluation including
assessing the definition of partner roles and responsibilities, shared vision, conflict
resolution activity and supportive group dynamics. The manual also proposes measuring the
results of partnership activity in terms of policy and/or procedural changes, resource
mobilisation and increased credibility and community/stakeholder support of the activity
being undertaken. Few authors have described the elements of successful partnership for
capacity building in international contexts. One exception is Horton (2003) who outlines
process orientated elements of partnerships such as flexibility, perseverance, openness to
learning joint decision making that could be integrated into a framework for evaluation.
However work is required to adapt and test the suitability of these approaches in
international collaborative midwifery environments.
Conclusion
This review has highlighted a lack of evidence regarding the outcomes and impact of
midwifery collaborations to build workforce capacity in LMIC. A mapping exercise and
synthesis of primary research provides insight into some of the lessons learned particularly
in Africa. However there is a great need to rigorously assess the contribution collaboration
makes to the development of midwifery capacity in order to design effective interventions
that can progress MDG 5.
Page 14 of 27
Table 1. The inclusion/ exclusion criterion adopted for this review
INCLUDE
Papers that describe partnerships focussing
on, or including, midwives or nursemidwives
EXCLUDE
Papers that focus on doctors with midwifery
skills, traditional birth attendants or building
the skills of other staff engaged in maternal
and reproductive health i.e. auxiliary nurses
undertaking reproductive work
Partnerships that involve all forms of
capacity building – tools, skills, staff,
infrastructure, structures and systems must
include midwives / midwifery as the focus
Not solely infrastructure building i.e. health
centres birthing units and provision of
equipment
Papers where partners are recognised
institutions providing midwifery training,
midwifery professional associations or
health facility providing midwifery care by
midwives
Papers where partner is involved only as a
funder
Research and discursive papers in peer
reviewed journals
Exclude grey literature reports and
conferences presentations
Page 15 of 27
Table 1. Distribution of partners and associated countries
Partners and countries involved
(Carlson, Omer et al.
2011)
(Girot and Enders 2004)
(Herberg 2005)
Khartoum, Sudan
Strategy
NorthSouth
Faculty of Health and Social Care, University of the West of England, Bristol UK
Nursing School, University of Rio Grande do Norte in Natal, Brazil.
NorthSouth
 JHPIEGO, Baltimore US, UNICEF, USAID, International Medical Corps NGO, Aga
NorthSouth
 Cork University Maternity Hospital Ireland/ Omdurman Maternity Hospital,
Khan Development Network, Institute of Health Sciences), Malalai Maternity
Hospital, Kabul Afghanistan
(Johnson,
Ghebreyohanes et al.
2007)
(Kennedy, Stalls et al.
2012)
 Stony Brook University, New York US, and the University of Asmara, Eritrea
NorthSouth
 American College of Nurse-Midwives, Silverspring MD US, Ghana, Ethiopia,
NorthSouth
(Lavender, Lugina et al.
2009)
 ICM/ East Central and South Africa Regional association of midwives Tanzania,
(Lori, Ortiz et al. 2010)
 Global Alliance for Nursing and Midwifery Community for Making Pregnancy
Malawi, Tanzania, Zambia, Zimbabwe, Nigeria Uganda, Senegal, Eritrea, Vietnam,
Pakistan, Afghanistan, Indonesia, Morocco
Uganda, Zimbabwe, Seychelles, Mauritius, Kenya, Swaziland, Malawi, Zambia,
Namibia and South Africa
Safer USA Canada Western Sub-Saharan Asia- Pacific Latin America/Caribbean,
North Africa/Middle East, Eastern Europe
(Maclean and Forss
2010)
 Karolinska Institute Sweden/Africa Midwives Research Network Tanzania,
(McCarthy and Riley
2012)
 US Centers for Disease Control and Prevention, Emory University Atlanta, the
(Michael and Garnett
2011)
 St Mary’s Hospital Link, Isle of Wight, UK Fetal Medicine Foundation, UNFPA,
(Mogobe, Bruce et al.
2009) (Uys and
Middleton 2011)
CHENMA Project
University of Pretoria , University of the Witwatersrand, University of KwaZulu-
Uganda, Zambia, Sweden
Commonwealth Secretariat / East, Central and Southern African College of Nursing
formed the AHRCNM, Arusha Tanzania
JICA, AUSAID, WHO, South Sudan Ministry of Health
Natal, North West University, University of the Free State South Africa, Moi, East
Africa (Baraton) and Nairobi Universities Kenya, Muhimbili College of Health
Sciences and Kilimanjaro Christian Medical Centre in Universities Tanzania,
SouthSouth
Global
Community
of Practice
SouthSouth
SouthSouth
NorthSouth
SouthSouth /
Community
of Practice
Page 16 of 27
University of Botswana Botswana, Rwanda, Niger, Lubumbashi Technical Medical
Institute Democratic Republic of the Congo
(Requejo, Toure et al.
2010)
 International Healthcare Professions (ICM, FIGO), Partnership for Maternal,
(Requejo, Toure et al.
2011)
 PMNCH, Arab Association of Obstetrics and Gynecology Societies (AAOGS), ICM,
(Wright, Cloonan et al.
2005)
 Centre for Intercultural Education & Development (CIED) at Georgetown
Newborn and Child Health (PMNCH), Regional Healthcare Professional Associations
Afghanistan, Bangladesh, India, Nepal, Pakistan; Myanmar
Representative from professional association from Iraq, Jordan, Morocco, Palestine,
Somalia/ Somaliland, Sudan, United Arab Emirates, and Yemen
University Washington US/ Albania, the Dominican Republic, Haiti, Honduras,
Macedonia, Nicaragua, and Romania
SouthSouth
SouthSouth
NorthSouth
Page 17 of 27
Table 2. Map of international midwifery collaborative interventions
Capacity building
components
References
tools
skills
Staff /
infrastructure
Research papers
(Carlson, Omer
et al. 2011)




(Girot and
Enders 2004)
(Herberg 2005)


(Johnson,
Ghebreyohanes
et al. 2007)

(Kennedy, Stalls
et al. 2012)

(Lavender,
Lugina et al.
2009)
(Lori, Ortiz et al.
2010)

(Maclean and
Forss 2010)

Focus of activity for midwives in
LMIC
Structures
/systems
Prof
exchange
E&T



Prof
Assoc.
Research


Leadership












Outcome
Educational and research exchanges and the application of evidence-based practice. 450 doctors
trained, Seven instructor Neonatal Resuscitation Program (NRP) courses delivered, two provider
NRP courses, 83 midwives trained, four obstetrical management and, emergency courses, along
with improvements in infrastructure and equipment. Improvements in health care outcomes
preceded the partnership programme. However, these gains in health outcomes were sustained
and consolidated during the partnership years (2002–2009).
15 Brazilian obstetric nurses trained as nurse-midwives (NMs) by midwives from Bristol. Brazilian
nursing and medical team introduced an in-house post-graduate specialization to train NMs. NM
role established in university maternity hospital, community hospital and 7 community health units
in Natal. Plans to introduce a nurse-led clinic in a neighbouring city, led by six specialist NMs
In 2002, there were 150 students in the programme, with the majority in year one. A consultant
JHPIEGO), in conjunction with UNICEF and USAID, revised the midwifery curriculum worked with a
group of physician ‘trainers’ and the IHS midwifery faculty on clinical teaching methodologies. Five
IHS midwifery faculties were mentored by physician trainers and targeted to eventually take over
the clinical training roles. Learning materials purchased.
9 of 10 students selected by the University of Asmara(UA) graduated from the Stony Brook
University (SBU) distance learning program in 2004. A computer learning lab was set up within the
UA for the sole use of SBU students. Physicians in relevant specialties were selected by the UA and
Eritrean health care leaders to serve as qualified preceptors as APNs did not exist. UA set up
discussions with the MoH to develop APN role that included midwifery speciality.
(1) development and implementation of in-service training systems,(2) integrated pre-service
education, (3) strengthening of midwifery and other healthcare professional associations and (4)
community education and mobilization.
A user-led distance learning programme was developed by adopting a participatory approach to
developing a curriculum for a Masters in Midwifery and Women’s Health.
382 members from 79 countries shared their experiences and challenges of implementing
evidence in two simultaneous discussions held in Spanish and English on 1) traditional midwifery
and 2) active management of the third stage of labour. Developing institutional commitment and
providing training were; short term strategies selected to be the focus of work during 2008-2009
1500 midwives have benefited from educational programmes at regional or national level. This
includes research methodology, evidence-based practice, scientific writing and communication
skills. Attention needs to be given to some aspects of governance and organization and
communication strategies including websites and newsletters. Technical support from the
Karolinska Institute in Stockholm provided cost effective support.
Page 18 of 27
Page 19 of 27
Capacity building
components
References
tools
skills
Staff /
infrastructure
Descriptive papers
(McCarthy and
Riley 2012)
Structures
/systems
Prof
exchange
E&T


Prof
Assoc.
Research


(Michael and
Garnett 2011)
(Mogobe, Bruce
et al. 2009)
Focus of activity for midwives in
LMIC



Leadership





(Requejo, Toure
et al. 2010)


(Requejo, Toure
et al. 2011)


(Uys and
Middleton
2011)




(Wright,
Cloonan et al.
2005)



Outcome

African Health Regulatory Collaborative for Nurses and Midwives (AHRCNM) convenes leaders
responsible for regulation from 14 countries in East, Central and Southern Africa. It provides a high
profile, south-to-south collaboration to assist countries in implementing joint approaches to
problems affecting the health workforce. Supports four to five countries per year in implementing
locally-designed regulation improvement projects
Placement of International United Nations Volunteer Midwives (IUNVs) within the health care
system to provide clinical midwifery leadership and technical support to those managing these
services. Establishment of Juba College of Nursing and Midwifery. Forty qualified candidates were
selected (20 for each programme - Midwifery and Nursing). The college also recruited five tutors,
three international and two nationals with one of them being the Principal of the College.
Completion of the draft Curriculum for Midwifery Diploma Programme.
Collaborate to establish at least one clinical master’s programme in host universities in
nursing/midwifery. Nurses visited RSA for 4-6 weeks to work alongside experienced clinical nurse
specialists in their elected areas .A staff member from each host university obtained a doctoral
degree before taking over the programme.
Workshops on organizational strengthening, planning, and improvement of service quality, human
resources, and advocacy with examples of lessons learned presented. Countries developed
strategic action plans with feasible and measurable actions that could improve their ability to
contribute to the improvement of MNCH in a 1-2-year time span. Included Enhancing contribution
of midwives.
Workshop identified the lack of a standardized category of midwives and the proliferation of
midwifery categories not meeting ICM standards. Countries developed strategic action plans with
feasible and measurable actions that could improve their ability to contribute to the improvement
of MNCH
An effective community of practice had been established, focused on the major knowledge domain
of nursing and midwifery in Africa, and sharing the perception that their work was empowering
and collaborative. The community had established its own ways of working, and articulated major
institutional and individual benefits
International Capacity Building Program for Nurses 3-month, full-time summer programme, 1)
educate teams of nursing and midwifery leaders in international health and curriculum design 2)
support development of strategic plans for the advancement of nursing education and practice.3)
facilitate the development of a nursing network among the participants with Georgetown
University and other centres. Resulted in faculty growth and nurse empowerment, professional
association development
Page 20 of 27
Table 3. Summary of research papers in the review
Reference
(Carlson, Omer et
al. 2011)
(Lori, Ortiz et al.
2010)
(Lavender, Lugina
et al. 2009)
(Maclean and
Forss 2010)
(Uys and
Middleton 2011)
Methodology
Mixed methods. Retrospective
descriptive study, quantitative
review of facility data and
qualitative review of program
outputs
Mixed methods. Review of
electronic discussion
documentation, web based survey
of participants
Sample/ participants
All women who delivered at Omdurman Maternity
Hospital, and their newborn infants, from July 1957
to October 2007, comprising 339 448 births,
program outputs 2002-2009
Study objective
To present 50 years of hospital-based maternal and perinatal
outcomes in Sudan, and the role of an international
collaboration with an Irish maternity hospital, over the period
2002–2009, in recent health-indicator improvements.
59 on-line discussion participants from LMIC and
HIC
Mixed methods. Descriptive
qualitative and quantitative:
stakeholder consultation, notes
from workshops, interviews, survey
Mixed methods. Descriptive
qualitative study, interviews, nonparticipant observation, an internet
survey and review of records and
documentation
East Central and South African Stakeholder, heads
of higher education institutes, midwives from 11
ECSA countries
To describe the experiences from two simultaneous discussions
held in Spanish and English within the MPS-CoPs, results of a
brief survey taken by members following the bilingual
discussions and strategies for building capacity and lessons
learned over the past four years
Report the results of an evaluation of the process of developing
a user-led distance learning curriculum for a Masters in
Midwifery and Women’s Health
Descriptive qualitative study
involving group interviews
Interview with AMRN chairperson and secretariat
in Zambia. Interviews with stakeholders in Zambia,
Tanzania and Uganda. Observation of midwifery
practice and discussions with women, relatives,
doctors, and midwives in clinical settings in 3
countries. Internet survey of 80 individuals in 29
countries in the network. Review of ARN reports.
Interviews were also carried out at Sida and at KI in
Stockholm.
Academics from the consortium of universities in
Southern and Central Africa
To evaluate the strengths and limitations of the Africa
Midwives Research Network (AMRN) and provide feedback and
direction to the network and the funding body.
To explore whether an international partnership, involving a
community of practice partnership model can contribute to the
understanding of internationalization as a symmetrical process
of engagement in learning/teaching in nursing/ midwifery
education.
Page 21 of 27
Fig. 1 The literature search process
Page 22 of 27
Fig. 2 Countries and regions involved in midwifery collaborations
Map from Wikipedia commons http://en.wikipedia.org/wiki/File:BlankMap-World-162E-flat.svg
Page 23 of 27
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