Midwife-led care in low- and middle-income countries with a focus on implementation in Bangladesh

  • Michaela Michel-Schuldt

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Rigorous research on midwife-led models of care in high-income countries show that they are effective and should be offered to most women, as they provide benefits for childbearing women and their newborns. There are few studies on midwife-led models of care in low- and middle-income countries (LMIC). A better understanding of midwife-led care (MLC) in LMICs is needed.

Aim: The overall aim was to explore how MLC is being implemented in LMICs. The three objectives were to systematically review the current evidence on midwife-led care in low- and middle-income countries, to assess the policies and health system efforts related to midwife-led care in a LMIC (Phase 1) and then to explore how midwife-led care was implemented in this country (Phase 2).
Method: First, two reviews were conducted. In Phase 1, a policy and health systems analysis in Bangladesh, was undertaken. Finally, Phase 2 was a case study in Bangladesh using an explanatory mixed methods design. In this primary study, a multistage purposeful sampling technique was used and face to face interviews and focus groups were conducted. Data analysis used a framework approach. A synthesis of all phases identified the essential elements of MLC in these contexts.

Findings: The reviews showed that midwife-led care may be cost-effective, is likely to improve maternal mortality and morbidity, reduce interventions and improves quality of care, although more research is needed. MLC is provided in a variety of settings: urban and rural; in primary, secondary or tertiary facilities; in the private and public sector; in free-standing or alongside midwife-led units; and midwives work alone or in teams. Workforce shortages exist and negatively impact on the provision of MLC. Standards of education, regulation and training influence the quality of care and supportive environments are important. The policy and health systems analysis highlighted the need for leadership and resource mobilisation. The case study identified four themes in relation to the implementation of MLC in Bangladesh. These were addressing the heart and soul of MLC, empowering midwives to become leaders, structuring midwife-led care and providing care across the continuum.

Conclusion: Midwife-led care in low- and middle-income countries has potential to improve outcomes in maternal and newborn health and might be cost-effective. The implementation of midwife-led care varies and supportive systems and workforce planning are key to its success. The essential elements of MLC that were identified could be applied to similar contexts.
Date of Award2021
Original languageEnglish
SponsorsUniversity of Technology Sydney & International Confederation of Midwives
SupervisorAlison McFadden (Supervisor)


  • midwife-led care
  • midwifery
  • Bangladesh

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