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Background: Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. Methods: A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. Results: The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives’ living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. Conclusion: Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.
The qualitative participatory research design, through a workshop methodology [26], was used to develop appropriate contextual strategies to attract, support and retain midwives in rural and fragile Ituri. Participatory qualitative research enables local people to analyse, share and enhance their knowledge of life and condition and to plan, prioritise, act, monitor and evaluate [27]. Central to participatory methods is creating an empowering environment that places participants at the centre of the research and the facilitators/researchers as learners and enablers [28, 29]. It requires the establishment of credible and trusting relationships between researchers, individuals, groups and communities [30]. We used workshop methodology (see data collection section for details of the workshop) as it brings people together – as in this case, a wide range of health systems stakeholders – to learn, acquire new knowledge, perform creative problem-solving or innovate in relation to a specific issue, in this case, the attraction, retention and support of midwives. Furthermore, this methodology is specifically designed to produce reliable and valid data about the issue under study using group interaction [26, 31]. The workshop methodology uses a collaborative approach, where the researchers and participants work together, with the researchers facilitating inputs and discussion from all participants, ensuring that the strategies that are developed are grounded in the reality of Ituri province, are feasible to implement and will have impact [32]. The authors developed relationships with the participants as part of previous research (Baba et al., Unpublished data) [33], which helped generate collaborative and productive workshops. The research was carried out in three districts in Ituri Province, one of the 26 provinces of the Democratic Republic of Congo, a large province located in North-eastern Democratic Republic of Congo with a population of 5.4 million inhabitants. Three health districts were purposively selected by the research team in collaboration with the Provincial Health Office. The following districts were selected: Bunia district, where the Provincial capital is found and where all the facilities are in the urban area, including the district health office (Bunia); the peri-urban district of Aru, where there is a concentration of people, with some facilities in remote areas (Aru); and the rural district of Adja, where all facilities are in rural and remote areas [25]. IPASC (Pan African Institute of Community Health), a faith-based organisation where some of the authors work, organises community health-related interventions in the three health districts, which means we already understand the context and have relationships with the district health management. These relationships facilitated access to these districts, which are also relatively secure. Purposive sampling was used for this study. The purposive sampling technique is the deliberate choice of participants based on features or characteristics that will enable a detailed understanding of the topic. The researcher sets out to find people who can and are willing to provide the information by virtue of knowledge or experience [34–36]. A range of decision-makers, managers and midwives were purposively selected based on their involvement in managing and supporting midwives or their experiences of being managed and providing services. Table 1 provides details of the different participants, including the reasons for their selection. In the previous study we had asked the midwives and head nurses if we could contact them again for participation in this study. We then contacted them directly by phone to recruit them to the workshops. Participants from the Provincial Health Office, Provincial Reproductive Health Coordination, District Health Management Team (DHMT), church medical coordination, non-governmental organisations (NGOs) and nursing schools were invited to the workshops through invitation letters and a participant information sheet. At the start of the workshop, the participant information sheets were shared again, discussed and written informed consent was obtained from each participant. In total, we recruited 49 participants to the three workshops, as described in Table Table11 (15 in Bunia district, 19 in Aru district and 15 in Adja district). Participants of the workshops DHMT District Health Management Team, M Man, NGO non-governmental organisation, W Woman, PRHC Provincial Reproductive Health Coordination A workshop was held in each district in November 2019. They were facilitated by AB with support from three research assistants (AA, JK and MM) and were designed so that research data and local policies were presented and discussed and then strategies were developed. Each workshop included five steps. Is step 1, the facilitators presented data from the study on midwives’ work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, north-eastern Democratic Republic of Congo. Participants discussed these findings as wall as what they had learnt and what problems the results reveal about SBAs in Ituri province. In step 2, data on the availability and distribution of SBAs in Ituri province was presented. Participants again discussed this data, highlighting the main issues. In step 3, the current policies on attraction and retention of health workers in rural areas in the Democratic Republic of Congo were presented. In step 4, participants were divided into groups (Table 2) so that they could discuss in detail the research findings and the policies. These discussions were facilitated by the research team (AB, JK and MM) using a topic guide that focused on policy implementation and reasons why some policies are implemented and others are not. The group discussions were summarised and fed back to the plenary for further discussion. Finally, in step 5, the groups discussed new and existing strategies to promote the attraction, retention and support of midwives, and how they could be implemented in their districts. They discussed challenges related to each strategy and how they could be overcome. After completion, each group reported to the other groups for further comments and discussions. Attraction and retention strategy discussion groups by district and membership DHMT District Health Management Team, NGO non-governmental organisation All discussions were recorded, stored in a password-protected computer, transcribed verbatim and then translated into English by an external translator from the Teaching College of Bunia and crosschecked by another external translator. We used the thematic framework method to analyse the data from the workshops [37]. This method facilitates rigorous and transparent analysis and uses both deductive and inductive approaches [37–39]. A coding framework was developed by all authors based on themes emerging from the data and the study objectives. Using this framework, AB coded the transcripts and shared with co-authors (JR, ST) to check coherence and meaning. When there were discrepancies in coding, the issue was discussed with all authors until a consensus was reached. The coding framework was applied to transcripts of all workshops, charts were then developed for each theme, and these charts were used to describe the themes. NVIVO 12 was used to support the analysis. Ethics approval for this study was granted by the Liverpool School of Tropical Medicine Ethics Committee (Research protocol 17–024) and the CRMD/Bunia (Centre de Recherche Multidisciplinaire pour le Développement) (018/2017). A rigorous informed consent process was followed, where all participants were given verbal and detailed written information about the nature and purpose of the research before taking part. Furthermore, participants were made aware of their right to decline answering questions and were assured that measures are in place to anonymise responses. All participants gave written consent. All data were anonymised.
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