Facilitators influencing midwives to leadership positions in policy, education and practice: A systematic integrative literature review

The development of midwives as leaders is a crucial step towards achieving equality in sexual, reproductive, maternal, and neonatal health, Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). However, many midwives work only to implement policies made by others rather than being drivers of policy changes. Little is known and researched about why midwives are not involved in decision and policymaking related to sexual, reproductive, maternal, and neonatal health. Hence, with a focus on midwifery leadership within the global community and the limited opportunities for women to hold leadership positions, this research explores the facilitators influencing midwives ’ opportunities to become leaders in policy development, education and practice. Inspired by Whittemore and Knafl, this integrative literature review was conducted after twenty-two relevant articles were identified through a search of the following databases: PubMed, CINAHL, and Sco-pus. Inductive content analysis was applied to analyze data. The result indicates that for midwives to become influential leaders, they must be active in strategic planning at the highest level. This inevitably effects how far midwives can act as agents for change, even if they possess the knowledge and skills for a leadership position. Policies and regulations influence how midwives ’ status in society is acknowledged and recognized. A clearly articulated educational pathway will enable their professional growth and expertise, making them knowledgeable and skillful as leaders. Enabling midwives to step into leadership positions at government level requires reforms which include midwives in decision-making. Excluding midwives from decision-making processes is detrimental to the goal of achieving universal health coverage. The first step is to provide midwives with a protected title, enabling them to work autonomously in an enabling environment with normal pregnancy and birth to achieve the SDG 2030 goals.


Introduction
Leadership and the development of midwives as leaders have been identified as a key priority toward achieving universal health coverage and Sustainable Development Goals.Midwifery leadership, when developed and supported, can shape and strengthen the whole profession [1].The global shortage of midwives' amount to 900 000 [2] and closing this gap with midwives educated to international standards, regulated, and integrated into the health system would not only save up to 4.2 million lives every year but also avoid 67% of unnecessary maternal deaths, 64% of neonatal deaths, and 65% of stillbirths recorded globally [1,2].Midwives also contribute to a positive birth experience; they deliver about 90% of essential sexual, reproductive, and maternal, newborn and adolescent health interventions [5] and improve overall health outcomes (SDG 3).Midwives contribute to women's empowerment and gender equality (SDG 5), giving more women, adolescents, and newborns access to midwife-led care for improved quality and more efficient health service delivery [1,2].
Midwifery leadership is therefore a priority for the international community to improve Sexual and Reproductive Health and Rights (SRHR) for women and girls [3].A system-level shift from pathology focused maternal and newborn care [4,5], to the promotion of normal reproductive processes, and first-line management of complications when needed requires leadership, [5].One evident barrier to midwifery led care and midwifery leadership is the superiority of physicians in the clinical birthing setting.For example, a recent study on midwifery educators' perceptions on objective structural assessment of life-saving interventions in Bangladesh, reported that the absence of a physician in the birthing room was a reason not to start life-saving interventions.The main reason for this reluctance was the fear of being blamed for any adverse outcome [6].From a gender scientific point of view, this could be explained as a power asymmetry where medicine have a superior status in science and practice compared to midwifery science and practice [7].However, evidence-based, woman-centered, midwifery-led care have numerous times been proven to provide the best and highquality outcome for healthy women and newborns [5].
Little is still known about why midwives are not involved in decisions and policymaking related to sexual, reproductive, maternal, and neonatal health.Strengthening midwifery leadership is a key and consistent recommendation in all the 'State of the World's Midwifery' reports that investment in midwifery leadership is acknowledged as a major key to improving the quality and safety of sexual, reproductive, maternal, newborn and adolescent healthcare by midwives [1].Midwifery leadership is therefore a priority for the international community to improve Sexual and Reproductive Health and Rights (SRHR) for women and girls globally [3].
Bodies such as WHO (World Health Organisation) are constantly striving to strengthen and promote midwifery leadership as well as midwives' status.The support of professional midwifery associations is another example of strategically empowering the midwifery workforce [8].Therefore, this study is inclined to accelerate midwifery leadership and to emphasize the importance of midwives as leaders to meet global goals [9][10][11].Politicians, regulatory bodies, education institutions, researchers, midwifery associations, and clinicians need guidance in midwifery leadership which places the midwife as the central hub [12,13].With a focus on midwifery leadership from the global community and with limited opportunities for women to hold leadership positions, this study aims to explore the opportunities influencing midwives to become leaders for change in policy and practice globally.

Design
A systematic integrative literature review inspired by Whittemore and Knafl [14] was undertaken to enhance methodological rigour and achieve the aim of the research.This systematic approach included the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results.An integrative review allows for the inclusion of sources of literature on a topic including research from various methodological paradigms.Integrative reviews assimilate research data from various research designs to reach conclusions that are comprehensive and reliable [14].

Literature search
The first step in the literature search was to identify inclusion and exclusion criteria using the PIOS approach (Population, Interventions, Outcomes, Study design).
In collaboration with a librarian, a comprehensive keyword search of the literature was conducted on five databases to identify recent studies: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar.The search was limited to articles published between 2000 and 2021 and search terms and variations of search terms included but were not limited to: 'midwives' 'nurse-midwife,' 'midwifery', 'leadership,' 'policy leadership' 'educational leadership', and 'clinical leadership'.All research articles were limited to primary studies with participants who were midwives or nurse-midwives.
For details see Table 1.
The search strategy was performed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [15].
The search identified 1283 articles.The Rayyan web application was used to do the systematic review [16].The articles were screened by title and abstract independently by authors.Before including selected articles to the analysis, a discussion between authors took place to reach consensus on article inclusion.Articles were eligible if they reported on (a) theory or theoretical leadership models; (b) developmental studies on leadership programmes; (c) studies reporting on the effects of leadership programmes; (d) management leadership in midwifery.The search was conducted in October 2021 with an updated search in February 2023 and three new articles were included.Sixty (60) articles were included for eligibility assessment, Fig. 1 shows the PRISMA flowchart of the study selection and inclusion process.

Data evaluation
The method of evaluating quality in the articles included in this integrative review was the use of quality appraisal tool for Mixed Methods Appraisals (MMAT).The MMAT is a critical appraisal tool that includes 25 criteria in five study categories that include qualitative, quantitative, and mixed-methods studies [17].It is an instrument that is easy to use and internationally accepted.The articles answer 10-11 questions regarding the method and how the data is interpreted.This tool makes the user reflect on research ethics.The articles were independently appraised by the authors.A "quality score" was calculated from the ratings of each criterion according to study type and was multiplied by 100 to calculate a percentage score.All studies included scored 70% and above.Table 2 presents the characteristics and quality appraisals of all articles included.

Data analysis
The data analysis was guided by Whittemore and Knafl [14].The data from the original articles was read several times in order to become familiar with the material and to be able to distinguish between what should be used and what should be excluded from the whole set of identified text.Texts related to the opportunities influencing midwives to become leaders for change in policy and global practice were selected, coloured and sorted with codes.These codes were collated into subcategories and then merged into categories based on their relationship.The authors read the articles independently, the outcome of the reading and selection of texts were then reviewed and if it differed, it was discussed and agreed upon by the authors.Extracted data from included articles were categorized as opportunities which were coded accordingly to analyze the processed data.The quantitative articles were descriptive and the extracted data were responding to the aim of this study (see Table 3).

Results
Twenty two articles were included in the results of this review and located in articles from India (n = 1), Indonesia (n = 1), South Pacific regions (n = 2), United Kingdom (n = 3), Sweden (n = 2), Norway (n = 1), Belgium (n = 2), Ireland (n = 1), Rwanda (n = 1), Australia (n = 5), United States (n = 1), Morocco (n = 1) and South Africa (n = 1).Illuminated in the first main category was that facilitators for midwifery leadership occurred when "Polices, practice, education and finance all came together making "midwives as leaders incorporated in high level strategies".Illuminated in the second main category "Act as agents for change", were the personal traits of motivation and drive for change in midwives with leadership skills.The third category, "Having status in society, being acknowledged and recognized" highlights midwives as autonomous practitioners, collaborating with doctors.The fourth main category "Midwives' having possibilities for a career path" illustrates the professional growth of midwives to become knowledgeable and skilled leaders (see Fig. 2).

Policies, practice, education and finances
Facilitators for midwifery leadership were "Polices, practice,  education and finance".They all came together in the main category "midwives as leaders incorporated in high level strategies".Policies and regulations emerged from strategies and impacted widely.Strategies guided strategic operations which inevitably influence workable opportunities for midwives' and their mandates to take lead in maternal health [18,20,25,29,30,31] since physicians tend to be employed as decision-makers for maternal health [36].
A Study from England [27] highlighted that the role of 'Director of Midwifery' for midwives is more strategic and policy influencing than the designated 'Head of Midwifery' used by most units.This is essential for maternity services to incorporate a stronger policy, aimed at giving midwives visible leadership roles [27].
Other studies pointed out the importance of midwives regulating the midwives' practice and regulatory structures in a country [35,36].Regulations facilitated midwives to be autonomous providers of care related to normal labour and birth [37].
Midwives could take a lead in evaluating midwifery programmes and to work collectively in groups with the power to formulate clinical policies.This was a way to lead the profession in providing quality midwifery care [18].Introducing midwifery leadership, gender equality and women empowerment in a country were parts of the high-level strategies as a prerequisite for facilitation of midwifery leadership.Gender equality and women empowerment needed to be incorporated in the education and finance system as well [18,19,20,21,22,23,24,27].
International confederation of midwives (ICM) encouraged their members to contextualise standards for midwifery education, regulation, and association.This created opportunities for midwives to strengthen their leadership skills and the profession [19].Legislation, registration and regulation of the midwifery profession on the other hand, increased self-governance and a high-level strategy contributing to uphold the autonomy of the midwife profession.[20].Incorporating midwifery leadership into the midwifery student curriculum was another main strategy to strengthen the midwife's profession [21].Ownership was created when midwives took part in designing and implementing the curricula in the midwife education programmes.How the content of midwifery leadership was taught played a significant role in enabling new midwives to become competent and confident in taking individual responsibility for the full scope of midwifery practice and self-leadership.Presenting midwives' leadership as safeguarding the advancement of the midwifery profession and science, played a significant role in the graduates' advanced autonomous practices [21].Seeing midwives in prominent, influential positions provides a role model for younger colleagues [41].Adaptive tools, curriculum, and innovative study appliances(?)are prioritized.[41].Gender equality and the empowerment of women in a society [18,19,20,21,22,23,24,27], are essential in formulating policies for clinical practice and midwifery education.However, evaluating midwifery programme outcomes, designing, and implementing curricula [18,21] into international standards required financial resources [19].Providing funding for in-service skills training for midwives increased midwives' willingness to take on leadership roles at the clinical site [24].Overall enhancing midwives' leadership skills at workshops on for instance the adaptation of decisionmaking tools [22] and leadership strategies, structures, and models, acted as facilitators for midwifery leadership [23].

Personal traits
Personal traits of motivation, trust-orientated leadership, individual practical skills, a willingness to take the lead, and to engage in critical maternal situations make midwives frontline executives in clinical situations.[24,28].Another trait mentioned was the midwives adaptability to various cultures, situations and political solutions [25].Engaging in life-long learning, team-work and adapting to the organizational culture was another appreciated midwifery leadership style [26].The ability to adapt to changes to overcome obstacles that arose during the process of change [19] and the personal traits of trustfulness, honesty, integrity and compassion were all facilitators for leadership [27].

Midwives' motivation to drive change
Pro-active midwives were always one step ahead and anticipated possible obstacles which made them autonomous and efficient [19,24,25,26,27,28].Midwives who demonstrated bravery, confidence and spoke up in critical situations, had more opportunities to become leaders and voices of change.It was also evident that midwives who took bold decisions in complicated situations proved themselves as competent workers which in turn provided opportunities to become leaders [26].Proactive behaviour in clinical work was important for midwifery leadership.Undertaking a master's degree demonstrated the personal motivation to take part in development in the field of midwifery concurrent with doctors [24].
Respected and experienced clinically working midwives had invested leisure time and their own money in their professional development.
Proactive midwives were always one step ahead in providing respectful women-centered maternity care; they anticipated barriers, saw changes as an opportunity, worked autonomously, adapted easily, and were in constant search of the most effective and qualitative state-of-the-artcare. Proactive behaviour might add a significant value to the midwife's autonomous role to overcome challenges through continuous adaption and their contribution to the quality of care of women and infants [26].
Leaders often must act as agents of change [19].The importance of facility supervisors, besides facilitating quality education, as a key actor was noticeable [21].Personal motivation to drive change was seen when facility supervisors played a vital role in the development of midwife students' skills, especially in their leadership styles, task performance, and task assignation [21].
Supportive line managers were considered to motivate midwives to drive change by negotiating a workload that recognised a sense of belonging.[28].Thus, the facility mentors were inclined to motivate the educational pursuits of midwives with a professional engagement.A facility supervisor's attitude can be a motivator for midwifery students to become good midwives as well as consider leadership roles.Notably, participants felt motivated when they were appreciated for their work [26].Motivating women to influence others can enact authentic, transformational leadership [25].

Collaboration between physicians and midwives
A midwife's autonomous practice can impact on the workplace and break the persisting domination of the medical model of care [20].Some of the studies [20,26,29] revealed midwives fears of losing their job if they questioned work practices.Sharing feelings on provision of care, in the often-contested space that was for women.Midwives struggle to navigate the increasingly complex terrain of maternity care.Midwifery philosophy, even if it may provide relief from moral distress and provide a sense of shared identity could be to step into doctors' territory [23].Collaboration between physicians and midwives could be achieved when physicians and midwives worked in partnership with women in midwife led care [20].
One example of well-functioning professional teamwork emerged from Swedish midwives who were satisfied with the midwife-physician relationship because of the teamwork [30] Collaboration between units e.g., the Midwife unit and the Obstetric unit was important for successful transfer not only of patients but also the transfer of philosophies between the Midwife Unit and the Obstetric Unit [31].Midwives were more likely to be satisfied and feel valued in the teamwork with other health care professionals when they were able to develop longitudinal relationships with them and with women, and with managers in their workplace.Collaboration between physicians and midwives, rather than rivalry, fostered relationships, networks, a culture of learning from one another and sharing new skills [32] which improved professional development and chances of accessing leadership positions for midwives.This all-enhanced midwifery leadership possibilities.Teamwork with doctors improved midwives' status and confidence [33].

Autonomous practitioners
Professional recognition was a key factor for midwives to work autonomously [20,25,29,31].Having midwifery representation in the political and policymaking landscape, free from overly utilitarian and medicalised influence, will potentially influence the society to protect women's choices, promote normalcy in pregnancy and childbirth and provide high quality woman-centred midwifery care [20].Midwives described that they felt relaxed to make decisions in midwifery unit settings where midwives were autonomously practicing their profession [31].Some international maternity systems facilitated autonomy of both women and midwives.Implementing policies to support autonomy favoured midwives to become leaders [29].
When midwives worked autonomously with normal birth it facilitated the midwife's growth in confidence and competence.Clinical midwives who exhibited an advanced level of competency had more opportunities to guide other health care professionals and to take on a leadership role [33].

Professional growth
Professional growth strengthens clinical leadership.Registered midwives have the ability to influence the care practices in the ward through clinical leadership.Midwives are employed to use their expertise to care effectively for women and babies [33].The need for midwives to have continuing professional development was discussed [32].Mentoring midwives provided opportunities for professional growth [33,34].
Improvements in leaders' competencies, skills, and confidence in their role [34] can also be triggered by enrolment in in-service training at the hospital.One study identified that the hospitals also organised 1day courses on different topics [24].This type of training develops the confidence to grow in the profession and also to take on leadership positions [32] and encouraged the willingness to make change [34].

Being knowledgeable and skillful
Academic education provided knowledge and skills in the development of projects for evaluation and the production of new research knowledge [33].Skills competency meant midwives learnt to use their 'voice' in clinical situations beneficial for the woman and the newborn [28].Programs which supported the development of communication and presentation skills, data literacy, succession, strategic and project planning will be most advantageous for midwives' professional development.[41].
Taking part in skills training, was about acknowledging the need to improve their skills [28].It was felt that clinical leaders must exhibit an advanced level of competency in clinical care and quality outcomes [33,34].
A midwifery training programme according to international standards is of 18 months duration and offered to postgraduate nurses [27].This should be the acknowledged standard.Heads of Midwifery would benefit from gaining a broader skill set in terms of transformation and business skills and advocating for a high education level [27].Adcock et al. [34] concluded that little is currently known as to what specific skills midwives in leadership positions need to acquire to be able to raise their voices to advocate a drive for change in professional midwifery.

Discussion
The results of this integrative systematic review revealed that achieving international health goals with improved health for individuals, families, and communities requires strong and effective midwifery leadership which policies, regulations and structures can facilitate.It was evident in many of the studies included in this review [18,20,25,29,30,31] that there was a necessity for the midwifery regulatory body to campaign for midwives to be autonomous providers for care related to normal labour and birth [37].
Vermeulen et al. [37] defined midwifery regulatory functions to include setting the scope of midwifery practice, defining codes of conduct and ethical standards.setting pre-registration education standards, implementing registration of new midwives, relicensing and ensuring continuing professional education and development throughout a midwife's career as a strategy to further empower autonomous midwives and midwifery led care.
The medicalisation of pregnancy and childbirth is interfering with and an evident obstacle to autonomous midwifery practice.Fear and risk of non-conformity and litigation [20] are factors that need to be dealt with on a structural, legal and policymaking level.A shift into a view of accountability for errors and blame within the organisation and the health care system, rather than the individual midwife, can only be a healthy development for all involved.The dominance of medical general practitioners in executive positions of maternal health care not only has a negative impact on midwives' place in leadership positions [36].It also contributes to the maintaining of power imbalance between medicine and midwifery and within health care systems [28].Rumsey et al [41] also stress the necessity of giving midwives in leadership positions the right title because clarification of titles to the scope of midwifery leadership in any country is essential for midwives to have defined and not merely temporal chances of becoming leaders which are not dependant on physicians' absence or shortage.However, it is also important to emphasise that midwifery leadership is also executed in the one-to-one woman-centered midwifery led care that takes place in the birthing room and in birthing centres [43,43].
Moreover, our findings are in line with Schön's study [38] who argued that midwife's autonomy is a conduit to women's autonomy.Midwife led care, provided, and advocated through evidence-based practice, in the context of the woman's own life, ensured the principle of midwifery leadership.A previous systematic review of Jamieson [39] demonstrated that the status of midwives and midwifery-led care was enhanced, especially in birth-centres where midwives had greater autonomy.This is in accordance with Renfrew's study whose findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology, as in the hegemonic medical model, to woman-centered midwifery led care for healthy women and newborns as well as a midwife-physician team approach for women with complications, all as described in the Quality Maternal and Newborn Care framework QMNC [5].

Strength and limitations
The credibility of this study is secured by the step-by-step analysis process.The step-by-step approach also contribute to the studies replicability [40].The consultation with a librarian provides strength to the search strategy.In addition, the quality of the articles was assessed with an appraisal tool for Mixed Methods Appraisals [17].In line with Whittemore and Knafl [14], consensus on the data to include in the result were achieved by the independent assessment of both first authors.The systematic approach of the analysis phase provides strength to the coding of data, and to achieve credibility of results, a content analysis was used throughout [14].Only articles written in English were included in this review and this might be a limitation to the trustworthiness of this approach.Therefore, the interpretation of data and findings of this review must be made with caution.However, the results provide a robust illustration on how midwifery leadership can be established and enhanced for the improvement of maternal and neonatal outcomes, all in line with many other findings i.e. the Quality Maternal and Newborn Care Model [5] and the Midwife model of Midwifery Care [44].

Conclusion
Providing midwives with professional autonomy and a protected professional title will enable midwives to work towards acheiving SDG 2030.Enabling midwives to step into leadership positions at government level requires reforms where midwives are included in decisionmaking.

Ethical consideration
The whole process of this study involved ethical considerations even though no ethical approval was needed.All the included articles had ethical approval and followed the ethical principles of research.Authors were careful about the interpretion of data.Articles were handled with care and caution to avoid misinterpret data in Author's own favour.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Table 1
Inclusion and exclusion criteria.

Table 3
Example of the content analysis process.