Improving the Quality of Maternity Care through the Introduction of Professional Midwives and Mentoring in Selected Sub-District Hospitals in Bangladesh: A Mixed Method Study Protocol

Introduction: Bangladesh introduced professional midwives in 2018 to address gaps in sexual and reproductive health services, focusing on improved maternity care. Facility mentoring has been introduced in selected facilities within the government to enable midwives as they move into their new roles. Objectives: To describe a protocol (1) to determine if introducing international standard midwives in rural sub-district hospitals in Bangladesh, both with and without facility mentoring, improve the availability and quality of maternal and newborn health care compared to the facility without midwives; and (2) to explore the experiences of the midwives, and the maternity staff and managers that they joined, following their introduction. Methods: This will be a mixed-methods study to examine differences between selected hospitals grouped into three categories: without midwives (only nurses), with midwives, and both with midwives and mentorship. Hospital selection will be based on choosing those with the highest birth caseload. The quantitative component will consist of facility observations and clinical data extraction to assess their (hospital and midwives) readiness (birth preparedness and complication readiness) and clinical care to explore whether facilities with newly introduced midwives have improved availability and quality of care. We will use facility assessment tools to extract clinical data. In addition, we will use a structured open-ended interview guideline to conduct focus groups and in-depth interviews to understand the perceptions, attitudes, and experiences among maternity staff (e.g., nurses and paramedics) and health managers (e.g., facility manager, residential medical officer, consultants), as well as the midwives themselves toward the newly introduced midwives and the quality of care. We plan to use a fixed effect logistic regression to compare the relationship between variables in the three hospital types for each observed data point. For analyzing qualitative data, we will adopt content analysis and use NVivo to identify themes related to perceptions, attitudes, and experiences. Expected results: The introduction of professional midwives may improve the quality of maternal health care in rural settings. The addition of a mentoring program can support midwives in transitioning into their new roles and introduce improved care quality.