Midwife Educators ’ perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh

Introduction: Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions. Method: Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data. Results: The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators ’ understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement. Conclusion: There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.


Introduction
The Objective Structured Clinical Assessment (OSCA) is an evaluative tool that first emerged in 1991 [1,2] as a means of comprehensively assessing the performance of nursing students.OSCA was as a way of evaluating students or clinicians in how they were carrying out their duties.Over the years this tool has developed and in 2020 a psychometric-tested OSCA examination scale for nurses was published [3].OSCA has been used to assess, in formative and summative evaluations [4], the clinical competency of both nursing and medical students around the world.Numerous studies show that an OSCA can be effective both as a learning tool and a technique for identifying communication and clinical skill gaps and shortcomings.
The International Confederation of Midwives (ICM) sets global standards for clinical midwifery care, education and regulation.These standards are for use by those working to strengthen midwifery in the areas of maternal healthcare education and regulation [5].In order to provide midwifery educators in Bangladesh with the required ICM competences, a Swedish university has worked in partnership with government authorities to train midwifery educators.Since 2016 162 midwifery educators have successfully completed a two year part-time master's program equivalent to 60 Swedish university credits in Sexual, Reproductive, Perinatal Health (SRPH) from Dalarna University, Sweden.As a result, 38 educational institutes across Bangladesh are now able to provide midwifery education, much of which conforms to ICM standards.For example, 85% of the education institutes organized their skills labs around the ICM midwifery competences.One out of three (34%) of these institutions were able to ensure that their midwifery students had fulfilled all of the required clinical components prior to graduation [6].This master's program was grounded in work that started in 2013 when a formal midwifery education program in Bangladesh was initiated.Its goal was to enhance and improve midwifery competencies and skills so that midwife practitioners could provide evidence-based maternal and newborn care.A postgraduate diploma program in midwifery was created and rolled out to over 150 private and public education sites.At the time of writing over 16,000 midwives have completed this program.However, once gaining a master's degree, most midwives are reassigned to senior staff nursing positions.They are not always employed on maternity wards or as dedicated midwifery educators.Their skills and expertise are not fully utilized to enhance maternal and newborn health at a clinical level [7,8].Of the midwives with BSc and MSc degrees who teach at nursing and midwifery training institutes, only 12.7 per cent (53) teach only midwifery courses.The rest are obliged to teach in the general nursing program.Only 33 (8%) of the students who have graduated from the Dalarna University master's program are currently working as midwifery educators [6].Many midwifery educators still lack higher strategic and theoretical skills and experience.Assessing midwifery students requires more than just clinical competence.Developing these skills has been a goal of government and local Non-Government Organisations (NGOs) but there are still challenges faced by many midwifery educators [6][7][8].
Facilitators of and barriers to providing high-quality midwifery education in Southeast Asia has been described in a recent literature review [9].The Southeast Asian countries in this review tended not to fully comply with the ICMs global standards.Their midwifery education was not separated from nursing training and educators lacked formal qualifications in midwifery.The review by Bogren et al (2022) found that for midwifery educators, higher academic education and mentorship programs improved their pedagogic and assessment skills and enabled them to focus on developing students' critical thinking, reflection, and decision-making abilities [9].Bangladesh certainly fits this profile.There is a continued challenge for midwifery educators in the teaching and assessment of midwifery students [6].With this background, the aim was to examine how midwifery educators perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

Study design
This study used an exploratory inductive qualitative design [10] to examine how midwifery educators felt about using OSCA as an assessment device for student performance in life-saving midwifery interventions.Individual interviews were conducted with midwifery educators who were responsible for theoretical and clinical midwifery teaching at their respective educational institutions.The study received ethical approval from the Directorate General of Nursing and Midwifery in Bangladesh.Ethical clearance number 170228.

Participants
A purposive sampling technique where the researchers used their expertise for the inclusion of specific respondents from different educational institutions and clinical sites, was used for meeting the goal of this study [10].In the preparation phase, 8 students in the Dalarna University master's program in sexual, reproductive, and perinatal healthcare were selected for pilot interviews.Following the completion of the pilot interviews, 47 midwifery educators responsible for theoretical and clinical learning at their respective educational institutions were examined of how they felt about using OSCA as an assessment device for student performance in life-saving midwifery interventions.They were invited via email and consented to take part in the study.All of the participants already had experience of assessing midwifery students with OSCA, through a part of midwifery training program called a "skills lab".They also all had previous experience of midwifery care through working in clinical practice sites.Their ages varied between 37 and 55 years.Their teaching experiences ranged from 1 to 10 years and their clinical experience ranged from 1 to 6 years.

Setting
The participants were employed at public nursing institutes in Bangladesh that offer a diploma program in midwifery.As part of the curriculum, students on the midwifery courses are expected to take part in a skills lab for each OSCA.This involves them carrying out lifesaving interventions based on different intrapartum scenarios in each year of the three years education program.Prior to the lab they are given several theoretical lectures outlining the key priorities and actions to take when encountering a life-threating situation or other complications.The midwifery students are introduced to the OSCA tool as part of the diploma midwifery education, and how the OSCA tool in the curriculum would be used in this lab OSCA scenario.After the preparation phase was finished, the OSCA commenced.

Data collection
The interviews examined how midwifery educators perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.The overall question asked was about the educators' perception of using OSCA in midwifery education, with probing questions about strength, potential gaps and areas of improvements.
Emails were sent to the participants prior to the interview explaining the aim of the study and how it was organized.Participants were informed that participation was voluntary and that project data would be kept confidential.They were also informed of the time and place of the scheduled interview.At the start of the interview, participants were once again reminded of the aim of the study and assured confidentiality.They were informed that their interview would be audio recorded and transcribed verbatim and that for this their written consent was required.They were also told that they could withdraw from the study at any time without giving any explanation.The interviews were conducted during June and July 2022 at the participant's home institute or clinical site.Each interview lasted between 25 and 60 min and mobile phones with a voice recorder were used to record the interviews.Three students, currently studying for the midwifery master's degree, conducted the interviews using a pre-developed interview guide.The participants were encouraged to speak freely and express their experiences about OSCA in relation to the aim of the study.

Analysis
The interviews were transcribed verbatim and translated from Bangla to English according to WHO guidelines [11].Qualitative Content analysis inspired by Elo and Kyngas was used to analyze the data [12].

C. Borneskog Sinclair et al.
As such the first step of the analysis focused on familiarization.To make sense of the content and become immersed in the data, the transcripts were read several times.Secondly, all text referring to the aim was extracted from the interview transcripts and then condensed.In step three, the condensed texts were given individual codes.Then, similar codes were shaped into categories based on their respective content.An overarching main category was formulated based on the content of all of the identified categories.To ensure credibility of the translation [13,14], a bilingual master's degree holder in anthropology with knowledge of Bangla and English read through the transcripts.Several adjustments to the language were made as a result.With focus on reflexivity, all authors were involved in the analysis and discussions among the authors ensured that all information derived from the interviews and not from the opinion of the authors.

Results
The results of the interviews can be summarized under one main category and thereafter described in five sub-categories.These subcategories describe how midwifery educators perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

The ability to perform effectively life-saving skills in an OSCA examination is related to student understandings of the concept of midwifery
The main category that emerges from the analysis of the interviews is that to be effective in the training of professional midwives, the midwifery educator must integrate theoretical knowledge with a practical approach to teaching life-saving midwifery interventions.Educators need the pedagogical skills to be able to effectively synthesize the practical skills of life saving and theoretical midwifery knowledge when teaching life-saving midwifery interventions to students.The analysis of the interviews has revealed that all of the participants cited physicians' superior profession relative to midwife as the reason for not initiate lifesaving intervention with chest-compression in the absence of a physician.The fear of being blamed for any adverse outcomes was the primary factor behind this reluctance.To address this issue, reflective sessions with midwives and physicians can, according to the respondents, highlight the negative impact of hierarchal structures on maternal and new-born mortality and morbidity.Additionally, to ensure the continued success of the OSCA evaluation, it is, according to the midwifery educators, essential that the instructions and curriculum be translated from English to Bangla.Using OSCA in a midwifery education context might mean using it with an overall skills lab scenario or with just the lifesaving algorithm or both.

The student's learning improves by OSCA
Using an OSCA provides the students the chance to act and perform lifesaving intervention based on scenarios.They understood how important it was in these scenarios to take timely action, prioritize and demonstrate their skills and knowledge.The educators in this study believed that using an OSCA encouraged the students to demonstrate their competency and skills by acting in a simulated real-life situation.
"Here we create a scenario where a baby needs to be resuscitated, only after that the student will understand.They understand how she will take action, prioritise and the student will.
demonstrate and the examiner can ask the student for baby's colour, tone, respiratory, previously told by the examiner."(IDI 1).
According to the educators in this study, the students who want to become competent and confident midwives want to do well in this assessed activity."It appears that the student has picked up the learnings from the simulation and OSCA quite well; those who desire to become capable midwives realize they succeed in doing so.A midwife exists between life and death."(IDI 38).
The educators described OSCA as very beneficial for the students' learning.They felt that students' competence and confidence improved as a result of preparing for the skills lab and being examined through OSCA.Developing students' confidence was an area that they pointed out always needed improvement.Midwifery educators said that: "The midwife can make decisions independently and manage interventions and complications according to OSCA guidelines.In clinical situations they feel a lack of confidence in their competence.If there is an increase in competence in skills by practicing OSCA.So that creates an opportunity for providing services".(IDI 41).
The midwifery educators in this study pointed out that an OSCA examination provides students with the rare chance to practice the decision making required in a clinical situation in the safety of an educational context."Adequate equipment, teachers and clinical mentors are required".(IDI 11) Decision making means to take actions and do what you need to do in a particular situation.The educators in this study felt using OSCA guidelines enhanced student's decision-making skills.
The educators also said that an OSCA examination gave students the chance to identify the gaps in their theoretical knowledge.When the students practice the skills, they have learned in the classroom and then fail the OSCA examination of the skills lab, they are motivated to fill in these gaps.Subsequently, when the teachers offer another OSCA examination, they enjoy more the opportunity to try out their simulation skills.
"When the students perform the OSCA, her activity and working speed indicate professionalism and leadership.A professional midwife would not be afraid in a lifesaving context, so I realize she is professional when she is grabbing the kit box and communicating the situation to the doctor."(IDI 4).
The skills lab is set up with mannequins and additional equipment, sometimes a video as prerequisites for managing the life-saving intervention during the OSCA.If such a well planned OSCA is being followed by experiences in clinical placements, the students will get skilled: "We teach the student to follow some rules, show more video with multimedia, to.perform lab practice, use the dummy Mama Natalie, then prepare the student for role play.
as a mother, as a midwife and also as a family member.To understand intervention management, show the amount of blood loss, OSCA presentation."(IDI 27).

Students' skills improvements mirrored pedagogic skills among the educators
OSCA is an opportunity for midwifery educators to identify gaps in students' knowledge and skills and support students in closing these gaps.Being able to use student-friendly language and to identify and then address the areas where students were struggling were felt to be key skills that educators needed to have if OSCA was to be a success.The extent to which the students' skills improved during the pre-OSCA sessions mirrored the pedagogic skills of the educators.
"The faculty teach in the classroom according to the lesson plan and the curriculum and they practice in the skills lab room.The students are divided into groups with a peer group leader.The peer group leader is another midwifery student and not a midwifery educator.They practice in groups and the group leader identifies the gaps.The education fills the gaps of theoretical and practical teaching.The students get oriented first and thereafter the OSCA takes place."(IDI 2).
After the practice scenarios the students were encouraged by the feedback, they received from their midwifery educator about their performance in the simulation to think critically about their practice.The midwifery educators, therefore, enhanced critical thinking related to evidence-based care among their students: "During skills lab situations and simulation-based practice and OSCA we teachers try to perform systematically, relate to science and evidence-based practice." (IDI 39).
The pre-OSCA simulation sessions necessitated the use of appropriate equipment and that two educators be present.In order to lead the students through all of the steps in the OSCA guidelines, faculty members needed to demonstrate professionalism and strong leadership skills: "At first, we educate the theory about OSCA, and we provide indepth clarification like-what is the aim, what are the equipment needed, and the process.Overall, we create a scenario.In the light of this scenario, we create a few different scenarios with variation in obstetric complications."(IDI 44).
An excellent midwifery educator guides the students through the activities and simulations and addresses areas that need improvement.Life-saving skills take time to perform correctly and practice is necessary."An educational video lecture before the OSCA, the student and faculty would have benefitted from it."(IDI 33).
The midwifery educators felt that the students displayed a sense of satisfaction when they were able to demonstrate the OSAC-required competencies and skills during the simulations."If we can teach the students well in the skills lab, they do not fear anything anymore.If we do not teach them well, then they will be afraid to do OSCA and cannot perform.(IDI 21).
According to the participants, midwifery is a skills-based profession where every midwife must attain a basic competency before graduating.The OSCA evaluation requires the demonstration of a high degree of skills competence and students need to practice a great deal if they hope to pass it.If they cannot demonstrate this competency during an OSCA evaluation, the midwifery educators emphasized that there was no other alternative but to repeat the evaluation until the necessary level of competence was attained.Every educator confirmed that they worked hard so that every student passed the OSCA and no one was left behind.The midwifery educators asserted that the key to passing the OSCA lies in extensive skills practice, therefore, they recommended making it an assessment that was repeated on a yearly basis." When a student repeatedly practices in the lab to pass the OSCA she can acquire complete knowledge or skill like how to handle a mask, and what the position should have for the trachea to stay straight."(IDI 41).
The midwifery educators were able to assess their own leadership role and responsibility in guiding students through the OSCA.They emphasized that an effective midwifery educator must possess the pedagogical skills to be able to integrate practical skills with theoretical knowledge in a simulation scenario such as the OSCA presented.They saw their goal as ensuring the students understood how professionalism is the synthetization of practical skills and theoretical knowledge.

Students' accountability to save lives can be made obvious during OSCA
The participants noted that using the OSCA provided them as educators and examiners with an opportunity to assess the student's skills and behavior.As they are expected to carefully observe students during the simulation and practice in the skills lab, they are able to analyze their performance and identify deficiencies in their behavior and practice.During the OSCA session, the midwifery educators gained a comprehensive understanding of what the students knew and did not know, as well as of their readiness to initiate a lifesaving intervention: "This is the critical thinking, this is the thinking I have that if the student does not understand her accountability for initiating lifesaving interventions.I have seen students thinking that if the child's condition is bad, she leaves the child, and because of that she could not decide where to send the child, not express what to do with the child.When we teachers understand that the student did not say anything because of her attitude not understanding her accountability she cannot be successful.We teachers must make her understand her own responsibility to be a successful midwife".(IDI 14).
The midwifery educators reflected on how important simulationbased learning in skills lab sessions with role play and OSCA is for giving students that sense of responsibility.During classroom sessions, the midwifery educators were able to tell students about the importance of possessing clinical skills: "During the simulations, students were able to understand for themselves the importance of providing secure care to women and newborns."(IDI, 1).

The OSCA instructions are not in line with the reality of the Bangladeshi workplace
When the behaviors and competences expected in a skills lab and in a clinical setting are similar, students can perform and learn more effectively, according to the respondents.In Bangladesh, life-saving interventions in clinical settings are still fraught with questions around authority and responsibility.As the midwifery educators in this study pointed out, they trained their students in the skills required for the OSCA.
"We educate our students about OSCA guideline as a theory before practice in a.
simulation lab and after learning about OSCA guideline and give scope to practice in lab.
following The educators admitted that there was a long tradition of midwives deferring to physicians.Emergency situations therefore often default to hierarchical structures and the perceived superiority of physicians.
"According to legend, chest compression occurs if the heart rate falls below 60 beats per minute.In that situation, we advise against applying chest compressions without the physician's presence; only with the physician's cooperation should you use chest compressions."(IDI 13).
All participants cited the physicians' perceived superiority over midwives as a reason for their hesitation to commence life-saving interventions.Despite possessing competence in neonatal intervention, students may not always be able to perform the procedure due to the guidelines that dictate it can only be carried out in the presence of a physician.
"So, when the preceptor tells them they will learn well?But don't give chest compression in the absence of physicians, only give ventilation.Why should we use simulation and OSCA?The physician will provide better care.The midwife might be blamed for the death of the child when she did chest compression.When there is no response from the baby, we are supposed to start chest compressions.Why should we accept the blame that has come?" (ID I 1).
As the midwifery educators pointed out, comments like these suggest that an OSCA simulation does not reflect the reality of clinical practice for trained midwives in Bangladesh.Some respondents felt that the OSCA did not adequately take into account the hierarchical issues confronting real life clinical situations and that it did not do enough to prepare students for the hard choices they might have to face.It is wellknown that an interdisciplinary team is essential for successfully managing emergency situations.Participants suggested midwives would have greater success if they were encouraged to work more collaboratively with physicians, rather than adhering strictly to hierarchies.
According to the educators in this study, OSCA did not provide a clear indication of students' decision-making skills.They felt that students need to enhance their decision-making ability if they are going to work in clinical settings where actions are still frequently determined by hierarchy and profession.
Another way, pointed out by the midwifery educators, was that an OSCA simulation does not reflect the Bangladeshi workplace is that the guidelines and instruction materials are all in English.This can make it a challenge for students to understand them properly.Many educators in this study said having the guidelines in Bangla would be a great advantage.Therefore, providing the OSCA examination in Bangla would be advantageous to the students."If I had the OSCA assessment guidelines in Bengali, my students would have understood everything."(IDI 3).Moreover, while students may have learned well in the classroom, and had an opportunity to practice their skills in a simulation assessment, it was still no replacement for the fact that they still lacked real life clinical training before gaining their qualification."If they get an opportunity to express their ability, they get more competent.So, if the clinical.
setting is appropriate for midwifery students, they would learn appropriately."(IDI 15).

The OSCA assessment means you either know or you don't lifesaving skills
In speaking with these midwifery educators it was clear that they felt that life-saving skills were something that midwifery students either knew and could demonstrate or they did not.The OSCA guidelines that they had been given by the Bangladesh Nursing and Midwifery Council made it clear how a student was expected to perform."If a student does not pass, get "not achieved", She is reviewed and given the chance to come back to Excellent or Achieve.I can easily assess a student."(IDI 2).
Students were expected to achieve 'excellent' on 90-100% of the OSCA criteria and if they could not, then they had to fail.
"You either know it or you don't.Basically, when we grade a student, we follow the examination guideline provided by Bangladesh Nursing and Midwifery Council.We mark 'That is excellent, achieve & not achieve."(IDI 2).
Failing students, in a sense, showed that the OSCA was working.It was identifying students who had not acquired the requisite knowledge to work in clinical practice.The key to success, however, was for the educators to then provide these failing students with feedback on how they could improve and to encourage them to engage in self-reflection about their future performance.Thus, students who did not pass the OSCA requirements were offered extra skills lab sessions.During OSCA the midwifery educators checked the student's ability to lead and instruct others in the scenario: "We failed 4 students the first time we did the OSCA but we gave them 2 repeat skills labs sessions where we showed them what they had done wrong and what they could do better.They then got another chance to try the OSCA simulation and the students then passed.They just needed a bit more practice."(IDI 19).
Moreover, the educators used the specific checklists for assessment and the checklists served as a measurement tool."In the lab, instruments are practiced on mannequins.We, teachers, observe the step-by-step steps as per the OSCA guidelines."(IDI 13).
The midwifery educators identified gaps in the students' performances, provided the students with appropriate feedback and ensured that they had a chance to refine and repeat the simulation/skills lab session before they were formally assessed again.The significant point the midwifery educators made here concerns quality assessment and that the midwifery educators did not pass underperforming students.
"If student covers all the steps in her performance according to checklist, if she carries.
strongly 90 to 100 marks and if she has been able to cover all the steps in excellent, whether she had good activity, perform, correct role, from the overall assessment of.

Discussion
This study adds to knowledge for action the understanding that the theory of midwifery practice needs to be merged with training in actually how to "do" midwifery for training of excellence in evidence-based midwifery skills.Midwifery educators need to use their pedagogical skills and professional knowledge to create an approach that blends the practical and the theoretical when training student midwives.As already known this combined approach is the most effective way to teach midwifery skills to students.This combined approach is also known as a global challenge [15].It is one that needs to be particularly addressed in Bangladesh.According to an assessment from 2018, nearly one-third of Bangladeshi midwifery students will graduate without achieving the competencies deemed by international standards and local regulations to function as well-performing midwives [16].One solution might be to establish formal lines of communication between educational institutes and clinical placement sites.This could include performing OSCA in lifesaving skills with an interdisciplinary team including practicing physicians, nurses, and midwives alongside midwifery students.This would address the learning requirement that students be able to function as part of an interdisciplinary team aiming to effectively and timely perform lifesaving interventions when required.In the present study, the widespread cultural understanding that a physician is "superior" to a midwife was mentioned by all participants as a reason why many practicing midwives, and midwifery students, were reluctant to start life-saving interventions without a physician present.The Netherlands, Norway, and Sweden were all able to report low maternal mortality rates by the early twentieth century.This is believed to be the result of an extensive collaboration between physicians and highly competent, locally available midwives [17][18][19].Interdisciplinary teamwork, clearly defining each team member's responsibilities, and working towards shared goals is a prerequisite for the provision of evidence-based maternal health practices that follow international guidelines [20].With due respect to the argument that national context matters these ideals are perhaps harder in developing countries [21], the evidence from areas where interdisciplinary teamwork operates strongly suggests that it should be introduced more widely, particularly in countries, regions and units where hierarchical maternal health practices still continue [22].The evidence from the midwifery educators in this study clearly indicate that reflective sessions with nurses, midwives and physicians that focus on the devastation hierarchal structures can have on maternal and newborn mortality and morbidity are warranted.When OSCA examination criteria are aligned with the national curriculum and the core competences which midwifery educators have been trained to value [23], these expectations can jar with the reality of midwifery training at clinical placement sites.This because once graduated, midwives in Bangladesh might not be allowed to exercise their knowledge of best clinical practice because of long-standing cultural hierarchies [6].This awareness is critical so that midwifery educators can develop teaching and assessment strategies that are more aligned with the reality that midwifery students will encounter in their clinical work as midwives upon graduation.As 60% of the midwifery education program is spent on clinical placements, it is crucial that midwifery educators have a clear understanding of the reality of clinical work for midwives.This understanding will allow them to better prepare their students for their future profession and equip them with the necessary skills and knowledge they need to succeed in a clinical setting [24].Greater awareness of the need to organise quality midwifery care around a philosophy of midwifery that places women and newborns at the center is essential if traditions of deference to physicians and other healthcare professionals are to be overcome.It is essential for the midwifery students to understand how care can be organised to support quality midwifery care supported by values and the midwifery philosophy in facilitates to place women and newborns at the center rather than the health care professionals [25].With this in mind, physicians may begin to approach their work mindfully and take a step back in order to support and mentor midwives and nurses.This approach can help to foster interdisciplinary teamwork and save lives in Bangladesh [26].Clinicians and educators can encourage teamwork and the use of midwifery philosophy in skills lab and OSCA sessions.An OSCA-evaluated clinical simulation exercise is a good start for practicing interdisciplinary teamwork.Leadership, ownership, responsibility and personal engagement can be implemented effectively in the OSCA of life-saving skills.A mentorship program for midwifery educators could also contribute to further implementation of the midwifery practice in Bangladesh [27].This study is of interest for clinicians and educators in general, encouraging teamwork and the use of midwifery philosophy in skills lab and OSCA sessions [28].

Strength and limitations
This is the first study to identify the importance of understanding the concept of midwifery in order for OSCA-evaluated simulations of lifesaving skills in Bangladesh to be effective and useful.Since the participants in this study have been recruited from nursing institutes across the entire country their perceptions should be reliable and transferable to any similar setting [10], although limited to some extent because of the translation and backtranslation process [11].This might be a threat to dependability despite the robust process of data gathering and analysis of 47 interviews.Not giving value to each of them could be considered a threat.The point to make here concerns the transferability of results relying on only one type of data, in this study qualitive interviews.Adding a quantitative questionnaire to the qualitative interviews could have added value for transferability of results.However, this study focuses on qualitative results with its limitations, and confirmability could be considered satisfactory.All of the authors made substantial contributions to the design, data gathering, analysis, and interpretation of the data and in the writing up of the manuscript which could be considered a strength and thus provide additional evidence for the trustworthiness of this study [10].

Conclusion and clinical implications
The study provides an illustration using an OSCA-evaluated simulation exercise of what it is like to be a new midwifery educator without being anchored in the philosophy of midwifery.Midwifery educators need to understand the principles that underpin the midwifery philosophy including leadership, ownership, responsibility and personal engagement if they are to be able to put the OSCA guidelines effectively into practice.Awareness-raising sessions with midwives and physicians that focus on legal rights and expectations/requirements, cultural attitudes surrounding the superiority of the physician and the meaning of teamwork and role divisions are recommended.Developing and training effective partnerships between midwives and physicians is the way to improve maternal and newborn healthcare in Bangladesh.A costeffective analysis is suggested for implementing an OSCA evaluation that focus on interdisciplinary teamwork with the introduction of a program of workshops and leadership training that includes a full complement of relevant healthcare professionals, including doctors, nurses and midwives.
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