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Midwives' perspectives on the practice, impact and challenges of delivering respectful maternity care in Malawi

Bradley, S. (2018). Midwives' perspectives on the practice, impact and challenges of delivering respectful maternity care in Malawi. (Unpublished Doctoral thesis, City, University of London)


In low-income countries, lack of respectful maternity care (RMC) is a key deterrent in women’s access to, and satisfaction with, facility-based birth, undermining global efforts to tackle maternal mortality. Much of what we know about RMC and disrespect in the labour ward has been informed by women’s perspectives. Midwives’ voices are largely missing from the discourse.

This thesis poses two overarching questions: How do Malawian midwives conceptualise, practice and value RMC? What constraints and enablers do they face in providing RMC? I used a qualitative, critical realist approach to foreground midwives’ voices. Narrative (n=21) and critical incident technique (n=23) interviews with midwives were supplemented by 26 key informant interviews. The theoretical frame of postcolonialism provided the key anchor point for interpreting the data.

Many midwives aspire to RMC but face significant challenges. A clash between traditional values and democracy manifests in poor attitudes to the public sector, inadequate leadership and lack of accountability, while student recruitment processes allow entry of ‘just a job’ midwives - both factors allow poor behaviour and attitudes to become normalised. Midwifery’s low status and professional invisibility under a dual-qualification nurse-midwife model, plus lack of a united vision for the future of midwifery, leave midwives feeling unvalued and demotivated. Unconducive work environments, low staff numbers, lack of support and horizontal violence block professionalism and good practice at facility level.

Policies to strengthen health systems and strategic consideration of the midwifery profession’s future are needed, as well as explicit attention to fostering teamwork and positive organisational cultures. Malawi’s labour ward dynamics are contingent upon the historical, cultural and health systems factors prevailing in this postcolonial context. An inter-disciplinary perspective to research in this area has been lacking but is crucial to frame and devise more appropriate interventions to improve the intrapartum experience for both women and midwives.

Publication Type: Thesis (Doctoral)
Subjects: R Medicine > R Medicine (General)
Departments: Doctoral Theses
School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses
School of Health & Psychological Sciences > Midwifery & Radiography
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