Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo

Background: Midwifery plays a vital role in quality of care and rapid and sustained reductions in maternal and newborn mortality. Like most other Sub-Saharan African countries, the Democratic Republic of Congo (DRC) experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies which can help to attract, support and retain midwives in the fragile and rural Ituri province.

Methods: The 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 NGO, church medical coordination and nursing schools’ representatives. In these workshops, data on availability and distribution of midwives, as well as their experiences of 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 analyzed 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 rural fragile Ituri province were proposed: organizing midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and so generate more income; lobbying NGOs and churches to support the improvement of midwives’ living and working conditions; and integrating TBAs in health facilities. Contextual solutions were proposed to overcome challenges.

Conclusion: Midwives are key skilled birth attendants managing maternal and newborn health care 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 attraction and retention of health workers in fragile remote and rural settings.