title: Community midwifery initiatives in fragile and conflict-affected countries: a scoping review of approaches from recruitment to retention.
abstract: BACKGROUND
  Birth assisted by skilled health workers is one of the most effective interventions for reducing maternal and neonatal mortality. Fragile and conflict-affected states and situations (FCAS), with one-third of global maternal deaths, face significant challenges in achieving skilled care at birth, particularly in health workforce development. The importance of community-level midwifery services to improve skilled care is internationally recognized, but the literature on FCAS is limited. This review aimed to examine community midwifery (CMW) approaches, from recruitment to retention, in FCAS.
  
  
  METHODS
  This scoping review design adapted Arksey and O'Malley's six-stage framework. Data collection included systematic searching of seven databases, purposive hand-searching of reference lists and web sites, and stakeholder engagement for additional information. Potential sources were screened against inclusion and exclusion criteria. Included sources were appraised for methodological quality using the McGill University Mixed Methods Appraisal Tool. Data were analysed thematically, using deductive (i.e. cadre definition, recruitment, education, deployment and retention) and inductive coding (i.e. capacity, gender and insecurity).
  
  
  RESULTS
  Twenty-three sources were included, of 2729 identified, discussing community midwifery programmes in six FCAS (i.e. eight for Sudan, six for Afghanistan, three each for Mali and Yemen, two for South Sudan and one for Somalia). Source quality was relatively poor, and cadre definitions were context dependent. Major enablers for effective CMW programmes were community linkages and acceptance, while barriers included inappropriate recruitment, non-standardized education, weak supportive environment, political insecurity and violence.
  
  
  CONCLUSIONS
  While community engagement and acceptance were crucial, CMW programmes were weakened by inappropriate recruitment and training, lack of support and general insecurity. Further research and implementation evidence is needed to aid policy-makers, donors and implementing agencies in developing and implementing effective CMW programmes in FCAS.
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK.
authors.forename: Sachiko
authors.initials: S
authors.lastname: Miyake
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Speakman
authors.affiliation: Jhpiego, Technical Leadership Office, Baltimore, Jhpiego, Baltimore, MD, USA.
authors.forename: Sheena
authors.initials: S
authors.lastname: Currie
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK natasha.howard@lshtm.ac.uk.
authors.forename: Natasha
authors.initials: N
authors.lastname: Howard
mesh_terms: D003153:Community Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D003906:Developing Countries; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D008880:Midwifery / Q000193:education / Q000458:organization & administration*; D014857:Warfare
keywords: Fragile and conflict-affected; health workforce; maternal and newborn health; midwifery