Table 7 Themes that emerged from the qualitative data

Imagined and experienced benefits of midwives 

Awareness among nurses and managers that midwives could be helpful was notable in that, where there were no midwives, the imagined benefits were overwhelmingly positive, whereas, where there were midwives but no mentoring, most saw the midwives as too inexperienced and not capable enough to make positive change. This is a significant finding as it leads to midwives’ scope of practice being limited by their supervisors. Where there was facility mentoring, those that commented on this topic saw the midwives as beneficial.  

Familiarity with and use of improved care quality

Midwives and mentors were associated with increased comfort with, and use of evidence-based care. This theme plays out across the continuum in that, where there were no midwives and where there were midwives and no mentors, nurses had some familiarity with WHO standard quality maternity care, but they were not comfortable using it. When midwives were introduced, all midwives expressed comfort, but some were not using it. With mentoring, the nurses were more comfortable, and the midwives were enabled to use the quality-of-care practices; thus, all stated they were providing quality care. 

Resistance to change

Entrenched habits, social/patient/family pressure, and under-the-table payments were found to lead to resistance to change. This theme also found a continuum where non-midwife maternity staff and managers in hospitals without mentors expressed similar levels of resistance to change, but with mentoring there was much less resistance. Most midwives wanted change, but without mentoring many were complacent with existing systems. With mentoring most midwives felt they were making change. 

Under-the-table fees

Under-the-table fees were a cause for increased competition between nurses and midwives as nurses lost tips if they turned over the maternity area to the midwives. In addition, the desire to provide free care for the poor arose spontaneously from some of the midwives. Mangers identified charging fees as a limitation for caring for the poor and as the reason why nurses did not want the midwives to move into autonomous roles. 

Management of obstetric emergencies

Non-midwife maternity staff described numerous barriers to caring for women with obstetric emergencies. Midwives talked about being competent and willing to manage obstetric emergencies, but those without mentoring often spoke of resistance from managers. With mentoring, most stated that they were managing emergencies. 

Barriers and facilitators to midwives practicing autonomously and to their full scope

A number of issues were identified as barriers to midwives practicing autonomously. Most commonly, youth and/or inexperience were mentioned. Managers mentioned competition between nurses and midwives limiting the midwives. Midwives spoke of not having their own separate units. Mentoring was seen by many as facilitating relationships between nurses and midwives. 

Maternity staff's, managers’, and midwives’ perceptions of midwives' competence to move into their role

Perceptions of midwives' lack of competence were expressed as a reason to limit midwives' autonomy. This was particularly notable where there was no mentoring. Nurses and midwives expressed that women were concerned about midwives’ competence. This was less prevalent in hospitals with mentoring. Midwives consistently perceived themselves as competent. 

Midwives' pride

Midwives spontaneously expressed that they felt pride in providing good care to the poor. This was true in both mentored and non-mentored sites. 

The experience of mentorship by hospital staff

The hospital staff reported a greater sense of having a supportive team, and a better understanding of midwives' competencies with mentorship.   

Midwives and other maternity staff and managers desire to care for the poor

Midwives spontaneously expressed that they wanted the poor to know that they would care for them for free. No other maternity staff or managers expressed this, though some managers and non-midwife maternity staff spoke of the limitations regarding caring for the poor.