Midwize : a midwife-led intervention to improve the quality of care during labour and childbirth in Uganda

Background and aim
Despite global efforts, gaps in the quality of maternal and newborn care during labour and birth persist, both worldwide and in Uganda. These gaps are partly driven by the underuse of evidence-based midwifery practices, which negatively impact maternal and neonatal outcomes. This thesis explores how midwife-led quality improvement interventions in Uganda can integrate evidence-based midwifery practices during labour and birth and improve women's and newborn health outcomes.

Method

The thesis comprises four papers: I) a qualitative exploration of systemic barriers to midwife-led care in Eastern Africa, II) a qualitative study on the co-creation process of the midwife-led quality improvement intervention in Uganda, and III) a quantitative observational study examining intervention uptake, and IV) women's and newborns' health outcomes, including perineal injuries and Apgar scores.

Data for Papers I and II were collected through focus groups, observations, and interviews, while Papers III and IV used observations and structured questionnaires with women. Data were analysed using inductive and deductive content analysis, descriptive statistics, and binary logistic regression to explore uptake, outcomes, and associations.

The intervention was implemented at a public hospital in Kampala and targeted three midwifery practices with an evidence-to-practise gap: dynamic birth positions, intrapartum support, and perineal protection. A group of midwives, known as the Midwize Ambassadors, led the intervention while receiving mentorship in quality improvement methods and clinical midwifery skills.

Results

The results indicate that systemic barriers, including professional hierarchies, weak organisational and leadership structures, and gender disparities, limit midwives' ability to lead and deliver quality care. These barriers may be mitigated by fostering role models, mandating midwives to lead clinical care improvements, creating platforms for experience-sharing and ensuring midwives have access to leadership and decision-making roles (I). Co-creating the midwife-led quality improvement intervention involved a four-step process, including a needs assessment that guided the selection of the improvement areas and informed the roles, responsibilities, dose, and strategies of the intervention (II). The midwife-led quality improvement intervention led to significant and sustained increases in the use of the evidence-based midwifery practices. Dynamic birth positions increased from 0% to 79%, intrapartum support from 0% to 62%, and perineal protection from 62% to 92% (III). Simultaneously, maternal and neonatal outcomes improved, with reduced perineal injuries among women and higher Apgar scores at five minutes for newborns (IV). Mechanisms contributing to the increased uptake of the improvement areas included co-creating the intervention to ensure broad engagement, using a train-the-trainer approach, having a team of champions (the Midwize Ambassadors) lead the intervention, peer mentoring to share skills and foster greater involvement, information sharing with women and birth companions through various formats and stages, active involvement of birth companions, and regular updates to staff and policy representatives, all underpinned by a structured QI method that promoted continuous learning and adaptability.

Conclusion
Midwife-led quality improvement interventions in Uganda can help bridge the gap between evidence and practice during labour and birth while enhancing care quality and improving maternal and newborn outcomes. The positive outcomes of this intervention were driven by co-creation with broad engagement across sectors and professions, midwifery leadership development and empowerment of both midwives and women, peer learning, and collaboration with hospital colleagues, all within a structured quality improvement method. Future research should focus on scaling and adapting similar interventions in diverse settings to extend its benefits to more women, newborns, midwives and healthcare systems.

List of scientific papers

I. Blomgren, J., Gabrielsson, S., Erlandsson, K., Wagoro, M. C. A., Namutebi, M., Chimala, E., Lindgren, H. (2023). Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda. Midwifery, 124, 103734. https://doi.org/10.1016/j.midw.2023.103734

II. Blomgren, J., Wells, M. B., Erlandsson, K., Amongin, D., Kabiri, L., Lindgren, H. (2023). Putting co-creation into practice: lessons learned from developing a midwife-led quality improvement intervention. Global Health Action, 16(1), 2275866. https://doi.org/10.1080/16549716.2023.2275866

III. Blomgren, J., Lindgren, H., Amongin, D., Erlandsson, K., Lundberg, C., Kanyunyuzi, A. E., Muwanguzi, S., Babyrie, V., Ogwang, K., Aineomugasho, D., Namutosi, C., Wells. M. B. (2024). Midwife-Led Quality Improvement: Increasing the Use of Evidence-Based Birth Practices in Uganda. Midwifery, 104188. https://doi.org/https://doi.org/10.1016/j.midw.2024.104188

IV. Blomgren, J., Wells, M. B., Amongin, D., Erlandsson, K., Wanyama, J., Afrifa, D. A., Lindgren, H. (2025). Improving Apgar scores and reducing perineal injuries through midwife-led quality improvements: an observational study in Uganda. BMC Public Health, 25(1), 19. https://doi.org/10.1186/s12889-024-21137-w