Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India

Background: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. Methods: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. Results: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. Conclusions: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.


| BACKGROUND
By 2030, maternity services in India will need to respond to approximately 35 million births per year, nearly 75% of them in rural settings. 1 India has maintained a steadily declining maternal mortality ratio (MMR) from 212 in 2009 to 130 per 100 000 live births in 2014. 2 This is high compared with global standards, and the number of maternal deaths-32 000 in 2018 3 -is large, as India accounts for one fifth of global births. This rapidly declining trend in MMR is not reflected in perinatal and neonatal mortality rates (PMR and NMR). The PMR declined from 26.2/1000 in 2001 to 23/1000 in 2016, and NMR from 40.2/1000 in 2001 to 24/1000 in 2014. These more limited declines may be due to issues around quality of care at the time of childbirth, especially for newborns. The overall MMR and PMR for India mask large variations between and within states; there are large inequities in access to quality maternal and newborn care. Action is needed to achieve the Sustainable Development Goal (SDG) 3 targets of reduction of global average MMR to less than 70 per 100 000 births and NMR to less than 12 per 1000 live births by 2030.
India is one of several countries in the WHO Global Quality of Care Network, 4 which aims to halve the rates of maternal and newborn deaths and stillbirths in targeted health care facilities within five years by improving quality of care around childbirth. This vision is underpinned by the core values of "quality," "equity" and "dignity" (QED) 5 that actively strengthen quality improvement initiatives that are critical steps toward ending preventable maternal, newborn and child deaths and achieving universal health coverage (UHC). Quality maternal and newborn services require a well-functioning health system, including investment in a strong organizational and management structure, infrastructure, a robust health management information system, water and sanitation in all facilities, and a health workforce educated and supported to have the necessary competencies, including the provision of respectful care.
To improve access to care at birth, the Indian government has promoted institutional births. The national Janani Suraksha Yojana (JSY) conditional cash transfer program, which supports institutional deliveries, and the Janani Shishu Suraksha Karyakram program, which provides free antenatal, birth, postnatal care, and care for sick neonates through 30 days after birth, as well as free medications and transport, significantly improved the proportion of institutional births, but did not result in the envisaged decline in MMR or NMR. 6 For many attending a maternity facility, there are concerns about "unsafe" birthing rooms and poor quality of care 7 which discourages use of public health facilities. Such apprehensions reflect long-standing historical, as well as more recent, concerns in India 8,9 about the skill levels of birth attendants. 10,11 One strategy to reduce maternal and neonatal mortality is the provision of midwifery care from preconception to the end of the six-week postpartum period. Evidence suggests that maternal deaths, stillbirths, and neonatal deaths could be reduced by as much as 83% if the full package of midwifery care, including family planning and maternal and neonatal health interventions, were implemented. 12 Renfrew et al 13 reported that midwifery care is most cost-effective when provided by midwives educated to international standards who are embedded in the health system with effective teamwork, functioning referral systems, and sufficient resources. However, there are multiple barriers that prevent this full package of care from being realized, especially in low-income and middle-income countries (LMICs). Filby et al 14 report how social, economic, and professional barriers combine to prevent high-quality midwifery care from being provided in LMICs.
Currently, India does not have a cadre of midwives educated to international standards. Sharma et al 8 note that India, "does not have national standards for midwifery education and lacks accreditation systems to monitor the quality of education." Instead, there are a range of practitioners providing some midwifery care: auxiliary nurse-midwives (ANMs) who have completed a two-year training program; general nurse-midwives (GNMs) with a three-year program; and Bachelor's in Nursing (BSc) practitioners who have completed a four-year program, as well as a one-year Nurse-Practitioner in Midwifery (NPM) course. Maternity services are provided by obstetricians, general physicians, and staff nurses in hospitals in India. The obstetricians are the legally recognized service providers for normal, as well as complicated, childbirth. The GNM and BSc graduates work as "staff nurses" in hospitals with dual registration of Registered Nurse (RN) and Registered Midwife (RM). The standard of education and training for these cadres is variable, and the midwifery scope of practice of staff nurses is not clearly defined but "circumstance driven," depending on several factors; one of these factors is the availability of doctors. 15 Such issues work against the provision of quality maternity care and indicate that there is an urgent need to evaluate those factors that facilitate or hinder the effective delivery of maternity services.
The Ministry of Health and Family Welfare (MoHFW) in India recognized that institutionalizing professional midwifery care, as recommended globally by WHO and the International Confederation of Midwives (ICM), could serve as a cost-effective and efficient model to provide quality care for mothers and newborns and to help achieve the SDG 2030 goals. The MoHFW, therefore, unveiled a national Midwifery Initiative in December 2018 by launching the first "Guidelines on Midwifery Care in India" 3 with the aim "to create a cadre of midwifery professionals who are skilled in accordance with ICM competencies, knowledgeable and capable of providing compassionate, women-centred, reproductive, maternal and newborn health care services and also develop an enabling environment for integration of this cadre into the public health system, in order to achieve the SDGs for maternal and newborn health." 3 This new cadre will also be termed Nurse Practitioners in Midwifery (NPMs). It is expected that providing skilled midwifery care will enable increased access to quality care for underserved populations, decongest overcrowded facilities, and effectively reduce the burden of maternal, neonatal, and perinatal mortality and morbidity.
The purpose of this systematic review was to examine facilitators of, and barriers to, providing high-quality midwifery care in India. The review aimed to identify current gaps in the competencies of care providers, factors that hinder efficient service provision, and socio-cultural factors that prevent the provision of optimal care to women and newborn infants.

| METHOD
We searched for primary studies of barriers to, and facilitators of, the provision of midwifery services in India. We also included the WHO South-East Asia Region (SEAR) to locate multiple country studies that included India.

| Search strategy
We searched the following online research databases during November 2018: MIDIRS; MEDLINE and MEDLINE In Process (via OVID); CINAHL (via EBSCO); CDSR (via the Cochrane Library); DARE (via the Cochrane Library); HTA database (via the Cochrane Library); Social Science Citation Index (via Web of Knowledge); PsycINFO (via OVID); HMIC (via OVID); ASSIA (via ProQuest); Social Policy and Practice (via OVID); British Nursing Index (via ProQuest); Research Councils UK-Gateway to research (via http://gtr. rcuk.ac.uk/); OAIster (via http://oaist er.world cat.org/); and OpenGrey (via http://www.openg rey.eu/). Search terms adopting the following search architecture were mapped to existing subject headings in each database.
1. provider terms: eg, "midwife" OR "midwives" 2. barriers and facilitators: eg, "barrier" OR "challenge" 3. location filter: eg, "India" OR "South East Asia" The final search strategy involved headings that were specific to each database, key words, and free text search terms; truncation and wild cards were used to increase sensitivity (see Table S1 for example search used).

| Screening process
Two reviewers independently screened the titles and abstracts and reviewed full texts that met the inclusion criteria. Studies were included if they focused on issues relevant to the provision of midwifery care and were published in the English language. We did not limit by year of publication. We examined reviews to identify primary studies that were set in India and met the inclusion criteria.

| Quality assessment
The methodological quality of studies was assessed by one reviewer, using domains appropriate to study research design. Quantitative studies (nearly all were surveys) were assessed as being: √ = low risk; X = high risk; ? = unsure treat as high risk for the following domains: Selection bias: representativeness of sample to target population Study design: appropriate method used to answer the study questions Data collection method: valid and reliable method of data collection Confounding: possible sources of confounding explored statistically For qualitative studies, we performed global assessment of study quality, dichotomized according to whether they appeared to be "strong" or "weak." Strong studies included clear exposition of methods of data generation and analysis, triangulation of data, respondent validation, and reflexivity. We assessed the nature of the evidence reported in the qualitative studies in terms of the "typologies" of their findings classified on a continuum of data transformation, from findings that are not qualitative (no finding, topical survey), to ones that are exploratory (thematic survey), descriptive (conceptual/thematic description), or explanatory (interpretive explanation). 16

| Evidence synthesis process
To gather data pertinent to high-quality midwifery care, we mapped the findings of the included studies to two global frameworks: (a) the Framework for Quality Maternal and Newborn Care (QMNC), as detailed in The Lancet Series on Midwifery, 13 and (b) the WHO standards for improving quality of maternal and newborn care in health facilities. 17 The QMNC framework 13 considers Practice Categories; Organisation of Care; Values; Philosophy and Care Providers. The WHO standards for improving quality of maternal and newborn care in health facilities 17 comprise eight standards of care. The barriers and facilitators in the included studies were mapped to the QMNC framework and to the WHO standards to provide a comprehensive analysis of the provision of highquality midwifery care and to identify gaps in the evidence.

| RESULTS
The search strategy generated 2450 citations to be screened (see Figure 1). Of 78 full texts assessed, 13 were excluded, mainly due to an insufficient focus on the provision of quality midwifery care. A further seven studies, which were Indiabased, were found in systematic reviews. Overall, 32 Indiabased studies were included in this review.

| Characteristics of included studies
There were 25 quantitative studies, 8,9, six qualitative studies, 15,[41][42][43][44][45] and one study which used a mix of qualitative and quantitative methods. 46 The vast majority of the studies providing quantitative data were surveys (n = 22) of which two 32,39 were prospective, and the remainder were retrospective and cross-sectional in nature. Of the 20 cross-sectional surveys, one 21 was international; eight were large-scale national surveys 26,27,30,31,[35][36][37][38] ; and 11 were surveys of various Indian locales or regions. 8,9,20,22,24,25,28,29,33,34,40 The remaining four studies were service evaluations of which two 18,19 were retrospective preintervention and postintervention evaluations without controls and two 23  Of the studies providing qualitative data, five were interview studies 15,[41][42][43][44] and two 45,46 were interview studies with the addition of focus groups. Table 2 presents the methodological quality of the qualitative studies. Two studies received a global assessment of "strong" and the remaining five "weak." Of the transformation of findings, two studies were assessed as topical surveys, three as thematic surveys, one as conceptual/thematic description, and one as interpretive explanation.
The included studies were published between 2001 and 2018 with over half (n = 18) published since 2014 (see Table 3). Participants in 15 studies were either pregnant women or postnatal mothers, or women of childbearing age. In 13 studies, participants were health service providers. Four studies 38,[43][44][45] included both women and health service providers. The most frequently included cadre of health workers was ANMs (n = 7 studies). Five studies included general nurse-midwives/staff nurses, one study included graduate nurse-midwives, 15 and one study included students on diploma-level and degree-level nurse-midwife programs. 8 Chaturvedi et al 22 described their participants as birth attendants without further specification. Four studies included community health workers described as Anganwadi workers, 18 lady health visitors, 9,46 and social health activists. 45 Six studies 28,42-46 included a range of other health workers such as doctors, administrators, laboratory staff, and pharmacists.

Study
Study methods

| Barriers and facilitators to provision of high-quality maternity care
Mapping study findings to the QMNC framework 13 and the WHO standards 17 highlighted a range of barriers and facilitators to the provision of high-quality midwifery care in India (see Tables 4 and 5; Table S2). A summary of barriers and facilitators is presented in Table 6. The most frequent barrier related to the availability of a competent and motivated workforce able to provide quality midwifery care and manage complications. Two key related barriers were apparent. The first was the nonavailability of sufficient human resource to deliver high-quality services. For example, Hagopian et al 46 suggested that, in Ganjam, a district of Orissa state, the health workforce needed to be enhanced by 80 nurse-midwives. The authors commented that this was probably an underestimate as geographical barriers (which may increase travel times and require more midwives to ensure adequate coverage) were not considered. A lack of qualified midwives in Maharashtra state was also reported by Bhate-Deosthali et al 42 where, of 146 hospitals providing maternity services, 137 did not have a qualified nurse-midwife. The second barrier related to the lack of knowledge, skills, and behavior of skilled birth attendants, 9,22 as a result of the inadequacy of diploma and bachelor nurse-midwife preservice training programs. 8,34 Improving quality of training and education of midwives was reported to require more hands-on clinical practice. 21,34 Agrawal et al 19 suggested that virtual classroom training could contribute to improving knowledge and key maternal and newborn health skills. There was also a need for ongoing supervision and monitoring of staff. 32, 38 Bogren et al 21 reported from a stakeholder survey that India did not recognize the ICM definition of a midwife and lacks legislation that recognizes midwifery as an autonomous profession. The survey also highlighted that the qualification required to function as a midwifery teacher in India was a bachelor's degree in nursing.
Apart from having sufficient number of knowledgeable and skilled staff, a key characteristic for quality maternal and newborn care is that the division of roles and responsibilities is based on competence and available resources. 13 Our review found some positive examples; for example, Iyengar and Iyengar 23 suggested that trained nurse-midwives (ANMs and GNMs) can significantly improve access to skilled maternal and newborn care in rural areas and can manage maternal complications both with and without need for referral. Similarly, Pricilla et al 32 reported that trained nurse-midwives when regularly monitored, and with good referral systems, can provide high-quality antenatal care. However, there were also examples where nurse-midwives' skills were not utilized to their full potential. Pallikadavath et al 31 found that doctors were often lead professionals in antenatal care, and consequently, there was significant under-utilization of nurse-midwives. Similarly, Sharma et al 15 suggested that compared with international standards, midwifery practice of staff nurses was limited in scope resulting in loss of some skills. In a study by Purohit and Vasava,33 ANMs felt that there were unrealistic expectations for their role, with a high workload and limited opportunity for development.
The next most frequently cited category of barriers related to lack of available, accessible, acceptable and high quality care, 13 preventing every woman and newborn from receiving evidence-based care. Studies included both coverage 18,22,31 and utilization of services. [25][26][27][35][36][37]39,41,45 Chaturvedi et al 22 reported that to achieve large gains in coverage of institutional births, there was an urgent need for better skilled birth attendants, whereas Agrawal et al 18 found that coverage of antenatal home visits was positively associated with the knowledge level of community health workers. Women's use of services was influenced by perceptions of quality of care 39,45 and reputation of the provider. 41 Some studies highlighted specific aspects of care where there was poor utilization such as family planning services, 25

Setting
Main findings Chaturvedi 2014 22 Cross-sectional testing using clinical vignettes 233 birth attendant nurses at 73 facilities, with a birth rate of 10 or more deliveries a month.
Madhya Pradesh Urgent efforts are required to effectively increase the competence of birth attendants at managing obstetric complications in order to translate into large gains due to increased coverage of institutional delivery services.
The mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting > 30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care.

T A B L E 3 (Continued)
(Continues)

Main findings
Kavitha 2015  Economic status is also the strongest influence on the choice between a private-for-profit or public facility among institutional births. Thus, greater availability of obstetric services will not alone solve the problem of low institutional delivery rates. Kumar 2014 28 Cross-sectional survey 333 health care providers (of which 114 were auxiliary nurses and midwives)

Delhi
Overall job satisfaction level was relatively low in both regular and contract staff. The factors contributing to satisfaction level were privileges, interpersonal relations, working environment, patient relationship, the organization's facilities, career development, and the scarcity of human resources.
Kumar 2016  was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. Although the findings are encouraging, they also indicate the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities.

Matthews 2005 39
Longitudinal survey 388 women followed through delivery and traditional postpartum period Karnataka, southern India Perceived quality of care was found to be an important factor in health seeking behavior, as was wealth, caste, education, and experience of previous problems in pregnancy. Those women who experienced inadequate progression of labor pains during a home birth were most likely to proceed unexpectedly to a hospital delivery at a governmentrun primary health center or hospital. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements.

Main findings
Pallikadavath 2004  Muslim women, and women belonged to Scheduled Castes, Scheduled Tribes, and other groups of lower social status are less likely to use safe delivery services. Additionally, adolescent women from the southern region utilize more maternal health care services than the other regions.
The ongoing health care programs should start targeting households with married adolescent women belonging to poor and specific subgroups of the population in rural areas to address the unmet need for maternal health care service utilization.
Singh 2012  Orissa Key factors guiding patterns of utilization were reputation of the provider, cost, and physical accessibility. Local health provision through auxiliary nurse-midwives and male health workers was generally perceived of poor quality, with the lowest rates of resolution of health problems of all service providers. The location of a subcenter base for assistant nurse-midwives within a village had no demonstrable impact on access to services.
Bhate-Deosthali 2011 42 Interview and observation study 261 owners or senior staff of small private hospitals

Maharashtra
Of 261 hospitals, 146 provided maternity services yet 137 did not have a qualified midwife, and though most claimed they provided emergency care, including cesarean, only three had a blood bank and eight had an ambulance. There is a need to enforce existing regulations and collect information on health outcomes and quality of care before the state involves these hospitals further in provision of maternity care.

Jolivet 2018 43
Interview study Thirteen care providers (physicians, auxiliary nurse-midwives, administrators), 29 pregnant women, and 9 support people (eg, mother, mother-inlaw, husband) Vadodara city, Gujarat Introducing group ANC would be feasible and acceptable to stakeholders from various care delivery settings, including an urban primary health clinic, a community-based mother and child health center, and a private hospital, in urban India.

Nagarajan 2016 44
Interview study Health care providers (auxiliary nursemidwives, data entry operators) and clients in 12 sub-centers and two primary health centers Shahzadpur block of Ambala district, Haryana Lack of appropriate training, overburdened data entry operator and auxiliary nurse-midwife, poor Internet connectivity, slow server speed, and frequent power failures were revealed as major limitations for the effective implementation of a Mother and Child Tracking System.

Sharma 2013 15
Interview study, Grounded theory Twenty-eight service providers (obstetricians, physicians, staff nursesdiploma-level nurse-midwives-from the maternity sections of public health facilities.

Gujarat
The midwifery practice of staff nurses was limited in scope compared with international standards of midwifery. Their practice was circumstance driven, not legally defined, but they were not specifically prohibited from practice. They faced loss of skills, and deskilling when their practice was restricted. Their practice was perceived as risky, when the scope of practice was extended because it was not rightfully endorsed.

Vidler 2016 45
Interview and focus group study 23 focus groups with 48 auxiliary nursemidwives/staff nurses; 53 Accredited social health activists; 27 community leaders; 12 medical officers; and 132 women of reproductive age.
12 interviews with medical officers; private consultants; senior health administrator; district health officers; and obstetricians.

Karnataka
Factors that influenced women's care-seeking included their limited autonomy, poor access to and funding for transport for nonemergent conditions, perceived poor quality of health care facilities, and the costs of care.

T A B L E 3 (Continued)
(Continues)
Difficulties in physical accessibility, excessive cost of services, lack of transport, and low women's autonomy were all associated with constraints to women's use of services. 20,45 Two studies highlighted the importance of respectful care and interpersonal skills 24,40 in improving women's satisfaction. Socio-demographic characteristics associated with maternity service utilization included maternal age, mother's education, religion, caste, household wealth, parity, and exposure to health care messages. 35,36 Kesterton et al 27 reported that economic status is a stronger determinant of service use than access and concluded that availability of maternity services alone without addressing quality and financial barriers would not tackle low institutional delivery rates. Lim et al 30 analyzed the JSY program and found increased uptake of antenatal care and facility births; they emphasized the need for improved targeting of the poorest and least educated women and attention to quality of obstetric care in health facilities to increase its success. A significant component of quality maternal and newborn care is the availability of adequate resources, 13 including competent human resources and the physical work infrastructure. Five studies highlighted this aspect. 28,29,33,38,42 Singh 38 identified the lack of availability of basic infrastructure, drugs, and equipment in 18 068 health sub-centers in rural areas, whereas Bhate-Deosthali 42 reported that of 146 hospitals in Maharashtra state providing emergency services, including cesarean, only three had a blood bank and eight had an ambulance. Poor facilities and resources were found to impact staff job satisfaction, stress, morale, and motivation. 28,29,33 Lack of data and obstacles to data collection on health outcomes and quality of care were further barriers. 42,44

| DISCUSSION
Major barriers found in this review were poor quality of education, including preservice and in-service training, lack of supervision, constraints to deployment of a cadre of professional midwives, lack of recognition of midwives as an autonomous profession, and lack of appropriate roles to enable them to work to their full scope of practice. Regarding service provision, barriers included lack of access and quality of some services, poor work environments, lack of motivation and confidence due to uncertain employment, and lack of equipment and supplies. Other issues concerned barriers to uptake of services, including lack of autonomy of women, lack of access to transportation, and cost.
This review provides evidence of the existing gaps in quality competency-based midwifery education, training, and service provision and serves as a baseline on which to build a strong, newly formed cadre of midwives in India. Findings from this review suggest that in order to realize the significant potential of implementing professional midwifery

Mixed-methods studies
Hagopian 2012  T A B L E 3 (Continued) services in India, action needs to be taken on several fronts. There is an urgent need for midwives educated to international standards, licensed, and regulated accordingly. In India, with a projected 35 million births per annum by 2030, 1 this is an urgent and critical undertaking. Current nurse-midwifery education courses lack adequate midwifery training, and there is a need for hands-on clinical experience, without which midwives will lack the competence and confidence to function as autonomous practitioners. The quality of midwifery education programs needs to be enhanced to meet international standards. 47 This is likely to depend on nurse and medical educators and/or on midwifery educators trained in other countries until there are sufficient numbers of nationally qualified midwifery faculty. A more feasible approach could be to strengthen the midwifery component in BSc and GNM courses currently taught, paired with continuing, onthe-job mentoring to ensure a steady supply of well-trained nurse-midwives flowing into the health system. A stepwise approach to reach international standards would require that midwifery program leads be qualified midwifery teachers and that midwifery faculty are legally recognized as self-governing and responsible for developing and leading the curriculum. 47 Consideration could also be given to providing opportunities for interprofessional learning which has been suggested to increase efficient and collaborative teamwork, especially in remote and rural areas. 48 Interprofessional involvement and effective referral to higher level facilities for women and newborns experiencing emergency complications are critical to provide a continuum of care that covers emergencies beyond the scope of midwifery care, and which ensures optimal maternal and neonatal outcomes. Studies from Bangladesh support these findings. [49][50][51][52][53][54] In 2008, the government of Bangladesh made a commitment to educate and deploy 3000 midwives as a strategy to reduce maternal and neonatal mortality. 55 Many other countries in South Asia are looking to emulate this professional midwifery model to improve maternal and neonatal outcomes. Experience in Bangladesh suggests, however, that training sufficient midwives will not have the desired impact if consideration is not given to how they are deployed, including ongoing professional development. 21 Similar initiatives in India to introduce professional midwives have not been sustained due to a lack of recognition and job opportunities. 56 The creation of funded posts for professional midwives in the public sector is required, and other members of the multi-disciplinary team need to understand the role, expertise, and scope of practice of midwives. 14 Advocacy is also needed to increase awareness in communities about the availability of skilled midwives and to promote their acceptance as caregivers throughout pregnancy, childbirth, and the postpartum period with reliable referral in case of complications. Without this, the scope of practice of the new cadre of professional midwives in India may be limited or there may be unrealistic expectations leading to high levels of stress and burnout-both of which will impact recruitment, retention, and provision of quality care. 14 There are several actions that can mitigate these challenges: introduction of interprofessional learning at preservice and continuing professional development levels; continued mentoring and support of midwives after qualification; and embedding midwives in the health system with clear lines of responsibility and accountability. 13 The findings of our review indicate challenges related to access, coverage, and quality of services. While there was a focus on labor and birth, other specific services mentioned in studies included family planning services, antenatal care, and health education. There was limited focus on postnatal care. Renfrew et al 13 highlighted the importance of midwifery care across the continuum of care from preconception to beyond the postnatal period, and Homer et al 12 found that the inclusion of family planning services significantly increased the potential of midwifery to reduce maternal and newborn mortality. Other issues in our review related to quality of care were as follows: lack of respectful care, poor quality of communication between service providers and service users, and lack of resources such as equipment and supplies. Therefore, considerable investment in the entire gamut of health services strengthening is indicated. Our findings suggest inequity in service use based on socio-demographic characteristics such as age, education, household income, and rurality. Kesterton et al 27 have suggested that economic status is a stronger determinant of service use than access to services. As such, measures that provide high-quality midwifery services must be accompanied by reductions in financial inequities.
One of the strengths of our review is that we mapped the findings of studies against two global evidence-informed frameworks. This enabled us not only to highlight the key barriers and enablers, but also to identify gaps in the literature. In terms of the Lancet Series' framework for quality maternal and newborn care, 13 there was little evidence from studies in India relating to optimizing biological, psychological, social, and cultural processes, strengthening women's capabilities, or on continuity of care, and respectful care or communication. An important gap in the review related to the WHO standards 17 was that there were no relevant findings regarding emotional support. There was also very little evidence related to functional referral systems and effective communication. Research is therefore needed in these areas to provide baseline information and to enable the monitoring of progress on respectful maternity care. As India moves toward implementing an exclusive program of midwifery care T A B L E 5 Studies mapped to WHO standards for improving quality of maternal and newborn care in health facilities

Standard 1
Routine evidence-based care and management of complications during labour, childbirth and early postnatal period according to WHO guidelines.

Standard 2
The health information system enables use of data to ensure early appropriate action to improve the care of every woman and newborn.

Standard 3
Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred.

Standard 4
Communication with women and their families is effective and responds to their needs and preferences.

Standard 5
Women and newborns receive care with respect and preservation of their dignity.

Standard 6
Every woman and her family are provided with emotional support that is sensitive to her needs and strengthens the woman's capabilities No studies

Standard 7
Competent and motivated staff are consistently available to provide routine care and manage complications.

Standard 8
Appropriate physical environment with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications.
Kumar 28 Kumar 29 Purohit 33 Singh 38 Bhate-Deosthali 42 Vidler 45 by professionally competent midwives trained to international standards, there is an imperative to conduct rigorous implementation studies to ensure women, babies, and families receive high-quality care. This is the first review to focus specifically on studies conducted in India. It is encouraging that we found a relatively large number of studies. It is also encouraging that a significant proportion of the evidence involves studies that included national or regional population samples, thus increasing the generalizability of the findings.
Limitations are that, because India does not have a cadre of professional midwives educated to international standards, the studies focused on a range of health care providers including ANMs and GNMs, community health workers, and a range of other provider types. The overall quality of the included studies was mixed. Fewer than half the quantitative studies were assessed as low risk across all domains, and only two qualitative studies were assessed as of strong quality. It should also be noted that very few of these studies were prospective in nature and that most were cross-sectional.
Nevertheless, the literature that is available from India can meaningfully inform policy and practice regarding pathways toward the development of a midwifery cadre delivering high-quality midwifery services.