Midwifery competence is demonstrated in the context of midwifery education, regulation and practice to support the quality delivery of care to women. Midwives with appropriate competencies can deliver up to 80% of maternal health services. The pre-service education programmes in Kenya offers different midwifery competencies for the various programmes, influencing expected outcomes in practice.
This study aimed to assess midwives’ perceived level of competence based on the International Confederation of Midwives (ICM) standards in Kenya.
The study was conducted in selected public health facilities in Kenya.
An observational cross-sectional design was used. A multi-stage sampling technique was used to select the counties and health facilities and random sampling to determine 576 midwives. Data were collected using a self-administered assessment tool adopted from the ICM competency domains.
A total of 495 (85.9%) midwife respondents participated in this study, of which 389 (78.6%) respondents in all training categories were highly competent in the four ICM domains. The midwives’ qualifications and facility level were associated with their self-perceived competence during practice. Those trained in the direct-entry midwifery programme were more competent,
Midwives’ competence was influenced by the level of education and facility where they practice. All pre-service midwifery programme graduates must meet the essential ICM competencies and need to enhance continuous professional development (CPD) programmes and facility-based mentorship for the midwives.
To optimise midwifery-led practice in primary health care, midwifery competence should be enhanced in pre-service and in-service education for improved health outcomes.
Globally, over 70% of maternal deaths are caused by complications of pregnancy and childbirth and complications of preterm birth account for more than 85% of newborn deaths.
Midwives are integral in providing quality maternal and neonatal health (MNH) care and reducing preventable maternal and perinatal mortality and morbidity. Midwives are the majority providers of MNH, offering over 83% of the care needed by women and newborns.
The ICM has set global standards for minimum essential competencies for midwifery practice to provide high-quality, evidence-based health services for women, newborns and childbearing families.
Proficiency in these domains is expected to equip midwives with the necessary competencies and confidence to enhance the care of the woman and the neonate. A competent midwife will contribute to achieving the third sustainable development goal (SDG),
However, there are inadequacies in midwifery education in low- and middle-income countries. These include deficient curriculum with tutors confident in theoretical teaching and not practical skills teaching with limited exposure to clinical practice for students.
Because of the overwhelming need for midwifery services in primary health care, midwives often function independently and take responsibility for clinical decisions and management of women and newborns. Therefore, enhancing their competencies and practice within their scope of practice is essential as an autonomous profession.
Confidence and competence of a midwife are required for optimal performance of a task.
Evidence from developed countries showed low levels of competence among graduate nurses in legal and ethical practice and advocated for support to enhance the competence as they enter practice.
In Kenya, a national confidential enquiry into maternal deaths (CEMD) in 2017 revealed that 92% of mothers received suboptimal care from skilled health personnel, with midwives providing most of the care. Inadequate clinical skills, inadequate monitoring and lack of timely intervention for mothers with prolonged abnormal observations were identified as the main contributing factors to the maternal deaths.
This article reports on a component of phase 1 of an explanatory, sequential, mixed-methods study. Phase 1 of the study was a quantitative, observational, descriptive, cross-sectional study design focused on self-perceived competence and confidence of midwives. The other quantitative component in phase 1 on self-perceived confidence of midwives on knowledge and skills has already been published.
Health care in Kenya is offered at primary (dispensaries and health centres), secondary (sub-county and county referral hospitals) or tertiary (national teaching and referral hospitals) levels.
Private and faith-based facilities were excluded, as midwives could not always practise autonomously in these settings. Midwives in Kenya train and qualify at certificate, diploma, higher diploma or degree (bachelor, master or doctoral) levels and are licensed to function at all levels of health care facilities. Common midwife cadres in Kenya include Kenya Registered Midwifery (KRM), Kenya Registered Community Health Nursing (KRCHN) and Bachelor of Science of Nursing (BScN). The KRCHN and BScN programmes are integrated and train nurses or midwives who qualify with general nursing, midwifery, mental health and community health competencies. The KRM programme only trains students who are to be midwives.
The study population included midwives working in public secondary or tertiary health facilities. As of 2019, Kenya had 20 775 registered midwives distributed by qualifications: 432 KRMs, 19 477 KRCHNs and 866 BScNs.
The sample size was calculated for midwives with each qualification to ensure precise competence estimation across all programmes. According to a similar study in Ethiopia, 31.6% of midwives attained the minimum required competency score, and this proportion was used in the sample size calculation.
A multi-stage stratified sampling approach was used, as shown in
Multi-stage sampling framework.
The 47 counties were divided into two groups based on their facility maternal mortality ratio (FMMR). Kenya considers an average FMMR of 97.5 as a threshold for high versus low performing facilities.
All eight county referral hospitals were included in the study. Moreover, three sub-county facilities were randomly sampled from each of the eight counties. In total, therefore, the study sampled 32 facilities in the counties. The required sample of 301 from these 32 facilities was further stratified by the required qualifications – KRMs (54), KRCHN (137), BScN (110) – and the distribution of midwives between the facilities.
The tertiary hospital sample of 275 was stratified between the two hospitals based on the proportion of midwives employed; this implied a sample of 167 midwives from tertiary hospital A and 108 from tertiary hospital B. Stratification was then done according to the proportion needed with each qualification category KRM (27), KRCHN (158) and BScN (89) based on the distribution of midwives in the two facilities.
The study was conducted between November 2019 and March 2020. The questionnaire was adapted from the 2019 ICM self-assessment tool, which assessed the level of competence and confidence in knowledge, skills and behaviour in the four ICM domains. Skills were defined as the ability to perform a specific task to a measurable level of performance, while behaviour was defined as a person’s way of responding to the actions of others.
Nine experts’ panellists evaluated the questionnaire’s content validity. They were either working in the facilities as midwives, in policy or educators in midwifery in Kenya. The investigator requested the experts to independently review and critique each item to ensure the appropriateness of the content and phrasing of each item using a three-point Likert scale (3, essential; 2, useful; and 1, not necessary). The content validity ratio (CVR) was calculated for each item and a ratio of 0.8 or more was taken as acceptable.
The panel of experts adapted the tool and modifications were done in terms of the content, the phrasing of the items, the instructions for completing the questionnaire, layout, formatting and context-specific demographic data. Two items on ongoing care of the woman, which the experts indicated were inappropriate for the Kenyan context, were deleted. These items were related to the religious, cultural and socio-political environment. The removal of the two items was done before the pilot study.
A pilot study with 50 participants (10% of the sample size) further validated the questionnaire and checked the data collection process. From the pilot study, time allocated to the study was adjusted from 30 min to 45–60 min; paraphrasing some sentences and revising the instructions for filling the tool were also incorporated. These participants were from a different county, not part of the study. The pilot data were tested for reliability, and an adequate average Cronbach’s alpha coefficient of 0.87 was achieved in all four competency domains of the tool.
Research assistants (RAs) were recruited from other facilities, not part of the study. The assistants did not hold any managerial positions to minimise any power imbalance with the participants. The participant information sheet and consent form were given in hardcopy and electronically, 48 h before the start of data collection. Once the participants signed the consent form, a copy was provided. A convenient time to complete the questionnaire was agreed upon in order to not disrupt the service delivery. The research team addressed any questions on the data collection day. This was an interviewer-administered questionnaire, where the RAs administered the questionnaire to each participant in a private room at the hospital. The RA interviewed each of the participants, which took about 45–60 min and captured the data in real time using organisation network analysis (ONA) software during the interview.
Data were checked continuously during data collection, and any inconsistencies or incomplete data were corrected by following up with the respondents. Data captured in the ONA software were exported to the Statistical Package for Social Sciences (SPSS) version 26.0 for analysis.
Competence was self-rated on two dimensions, namely, knowledge and skills. Knowledge was rated according to how long ago the midwife updated her knowledge through short courses, seminars, conferences or workshops. The knowledge scale was defined as current knowledge (updated within 1 year, high score 3), updated knowledge within the last 2–3 years (moderate score 2) and updated knowledge > 3 years ago (low score 1).
The midwife’s skills were assessed according to the midwife’s self-perceived safe performance of the skill (i.e. no preventable complications and with good maternal and neonatal outcomes). Their skills were rated according to how often they were safely performed, and the scale was defined as follows: not performed skill safely within the past year (low score of 1), performed skill only once within the year (moderate score of 2) and performed skill more than once within the year (high score 3).
As defined by ICM, a holistic assessment of competence included up-to-date knowledge and experience of performing the skill.
Categorical data were summarised using frequencies and percentages. In contrast, continuous (numerical) variables were summarised using means or medians with standard deviation (s.d.) or interquartile ranges (IQR) depending on the distribution of the data.
The association between competence levels and socio-demographic characteristics, facility level and qualifications was analysed using the Pearson’s chi-square test (Fisher’s exact test where cells had counts less than 5). The difference between the dependent variable (competence levels for knowledge and skills) and the independent variables (socio-demographic characteristics, the level of the facility and midwives’ qualifications) was analysed using the Kruskal–Wallis test. Post hoc analysis was performed where there was a statistically significant difference in categorical variables. All statistical tests were tested at a 5% significance level, and a
Ethical approval to conduct the study was obtained from the following institutions: Stellenbosch University Health and Research Ethics Committee 2 (HREC2) (No. S18/10/254); AMREF Ethics and Scientific Review Committee (ESRC) (No. AMREF – ESRC P 652/2019); Moi Teaching and Referral Hospital-Moi University Institutional Research and Ethics Committee (IREC) (No. IREC/2019/000092) and Kenyatta National Hospital-University of Nairobi Ethics and Research Committee (ERC) (No. KNH-ERC/A/73). Research license was obtained from the National Commission for Science, Technology and Innovation (NACOSTI) (No. 8777616). Permission was also sought from the county government, while the respondents gave informed consent.
A total of 495 (representing 86% of the required sample size) midwives completed the questionnaire. The distribution of the midwives by qualifications was as follows: those with KRCHN – 295 (100% of the required sample size), BScN degree – 156 (78%) and those with the KRM diploma – 44 (54%).
The characteristics of the midwives are presented in
Characteristics of respondents.
Characteristics | KRM ( |
KRCHN ( |
BScN ( |
Total ( |
|||||
---|---|---|---|---|---|---|---|---|---|
% | % | % | % | ||||||
Tertiary hospitals | 15 | 34.1 | 108 | 36.6 | 73 | 46.8 | 196 | 39.6 | 0.174 |
County hospitals | 15 | 34.1 | 84 | 28.5 | 43 | 27.6 | 142 | 28.7 | - |
Sub-county facilities | 14 | 31.8 | 103 | 34.9 | 40 | 25.6 | 157 | 31.7 | - |
< 30 years | 4 | 9.1 | 54 | 18.3 | 19 | 12.2 | 77 | 15.6 | 0.015 |
30–39 years | 17 | 38.6 | 132 | 44.7 | 88 | 56.4 | 237 | 47.9 | - |
40–49 years | 14 | 31.8 | 87 | 29.5 | 40 | 25.6 | 141 | 28.5 | - |
≥ 50 years | 9 | 20.5 | 22 | 7.5 | 9 | 5.8 | 40 | 8.1 | - |
Female | 36 | 81.8 | 235 | 79.7 | 120 | 76.9 | 391 | 79.0 | 0.707 |
Male | 8 | 18.2 | 60 | 20.3 | 36 | 23.1 | 104 | 21.0 | - |
< 5 years | 8 | 18.2 | 70 | 23.7 | 25 | 16.0 | 103 | 20.8 | 0.001 |
5–9 years | 6 | 13.6 | 106 | 35.9 | 51 | 32.7 | 163 | 32.9 | - |
10–14 years | 10 | 22.7 | 40 | 13.6 | 41 | 26.3 | 91 | 18.4 | - |
15–19 years | 9 | 20.5 | 32 | 10.8 | 23 | 14.7 | 64 | 12.9 | - |
≥ 20 years | 11 | 25.0 | 47 | 15.9 | 16 | 10.3 | 74 | 14.9 | - |
Low | 11 | 25.0 | 96 | 32.5 | 36 | 23.1 | 143 | 28.9 | 0.090 |
High | 33 | 75.0 | 199 | 67.5 | 120 | 76.9 | 352 | 71.1 | - |
KRM, Kenya Registered Midwifery; KRCHN, Kenya Registered Community Health Nursing; BScN, Bachelor of Science of Nursing.
Midwives from the KRM programme (median age 40.0 years [IQR 32.5–47.0]) were significantly older than those from the KRCHN (median age 36.0 years [IQR 30.0–43.0]) and BScN programmes (median age 37.0 years [IQR 32.0–43.0]) (
The overall levels of self-perceived knowledge and skills for midwives with different qualifications are presented in
Self-perceived knowledge and skills.
Characteristics | Midwives’ qualifications |
||||||||
---|---|---|---|---|---|---|---|---|---|
KRM |
KRCHN |
BScN |
Total |
||||||
% | % | % | % | ||||||
Low | 0 | 0.0 | 5 | 1.7 | 0 | 0.0 | 5 | 1 | 0.019 |
Moderate | 8 | 18.2 | 68 | 23.1 | 36 | 23.1 | 112 | 22.6 | - |
High | 36 | 81.8 | 222 | 75.3 | 120 | 76.9 | 378 | 76.4 | - |
Low | 0 | 0.0 | 3 | 1.0 | 1 | 0.6 | 4 | 0.8 | 0.016 |
Moderate | 3 | 6.8 | 51 | 17.3 | 31 | 19.9 | 85 | 17.2 | - |
High | 41 | 93.2 | 241 | 81.7 | 124 | 79.5 | 406 | 82.0 | - |
KRM, Kenya Registered Midwifery; KRCHN, Kenya Registered Community Health Nursing; BScN, Bachelor of Science of Nursing.
There were, however, significant differences between qualifications in terms of knowledge status (
For knowledge status, direct-entry midwives at the diploma level (KRM) reported higher levels of knowledge (36; 81.8%) compared to KRCHNs and BSNs, respectively. Similarly, the KRMs had higher ratings of 41 (93.2%) for safe performance of skills compared to KRCHNs and BScNs.
Proportion of respondents by competence status (
ICM competency domains | Low competence |
Moderate competence |
High competence |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
General competency | 4 | 0.8 | 172 | 34.7 | 319 | 64.4 |
Pre-pregnancy and antenatal | 5 | 1.0 | 110 | 22.2 | 380 | 76.6 |
Labour and birth | 4 | 0.8 | 85 | 17.2 | 406 | 82.0 |
Ongoing care of woman and baby | 2 | 0.4 | 91 | 18.4 | 402 | 81.2 |
Overall competence | 3 | 0.6 | 103 | 20.8 | 389 | 78.6 |
ICM, International Confederation of Midwives.
The association between competence, socio-demographic characteristics and FMMR is presented in
Association between competence and socio-demographic or facility maternal mortality ratios.
Characteristics | Low competence ( |
Moderate competence ( |
High competence ( |
Total ( |
|||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
% | Median | IQR | % | Median | IQR | % | Median | IQR | % | Median | IQR | ||||||
Low | 2 | 1.4 | - | - | 26 | 18.2 | - | - | 115 | 80.4 | - | - | 143 | 100 | - | - | - |
High | 1 | 0.3 | - | - | 77 | 21.9 | - | - | 274 | 77.8 | - | - | 352 | 100 | - | - | 0.207 |
Female | 3 | 0.8 | - | - | 86 | 22.0 | - | - | 302 | 77.2 | - | - | 391 | 100 | - | - | 0.332 |
Male | 0 | 0.0 | - | - | 17 | 16.3 | - | - | 87 | 83.7 | - | - | 104 | 100 | - | - | - |
Age of the respondent | - | - | 32.0 | 30.0, 42.0 | - | - | 38.0 | 32.0, 45.0 | - | - | 36.0 | 32.0, 42.0 | - | - | 37.0 | 32.0, 43.0 | 0.229 |
Work experience | - | - | 7.0 | 4.0, 7.0 | - | - | 10.0 | 5.0, 18.0 | - | - | 8.0 | 5.0, 15.0 | - | - | 9.0 | 5.0, 15.0 | 0.140 |
IQR, interquartile ranges.
The relationship between qualifications and competence is shown in
Association between competence and qualifications levels.
The relationship between competency and facility level is shown in
Association between competence and facility levels.
Most of the midwives were highly competent in their competence, knowledge and skills. This implies that only 21% of midwives were not highly competent. The type of qualification and facility level were associated with the self-perceived competence of midwives in Kenya. Those who qualified as direct midwives had a higher median score than those who qualified as nurse midwives at the diploma and degree levels. Moreover, those who worked at the tertiary level had a higher score than those at the county and sub-county health facilities. The findings of this study are similar to studies conducted in India and Tanzania where nurse midwives from lower-level facilities had low competence and/or skills levels compared to those from higher facilities.
Globally, midwives are expected to update their knowledge and skills for safer practice and improved maternal and newborn health outcomes through continuous professional development (CPD) programmes.
The KRCHN and BScN midwives had similar competency scores but were significantly lower than the direct-entry KRM midwives. The KRCHN and BScN programmes strongly focus on nursing as a whole; thus, graduates are likely to have less exposure to midwifery competencies. Similarly, the finding of the present study is supported by a study in Pakistan, which found that direct entry to midwifery education positively influenced graduates’ perceptions of their knowledge, skills and behaviours and their practice.
Compared to county and sub-county levels, tertiary referral facilities have more expertise and specialists, who function in multidisciplinary teams. They have more resources, opportunities and structured systems for CPD that support knowledge and skills development. Regular exposure to performing skills in practice over time influences a midwife’s competence.
Although a trained midwife is assumed to have the requisite knowledge and skills for safe practice, this study showed that only 64% of midwives had a high level of competence in the general competency domain (ICM Competency 1); this domain assessed the autonomy of a midwife to practise, scope of practice and communications skills and prevention of health problems of reproduction and early life, which are fundamental in promoting the health and overall well-being of the woman and infant.
In the current study, the age of respondents, years of work experience, gender and FMMR did not influence the level of competence. Other studies have found a relationship between gender, age and the years of experience with competence.
To the best of our knowledge, this is the first study to assess the perceived level of competence among midwives in practice in Kenya. These findings and the action plan for mitigating against the low competency levels reported among midwives can be generalised to many African settings and other LMICs that suffer from similar challenges in midwifery training, midwifery workforce composition, distribution and shortage as reported in the State of the Midwifery Report 2021 that make achieving universal health coverage elusive.
Our findings revealed that the integrated nurse-midwifery degree and diploma programmes produced less competent midwives compared to direct-entry midwifery programme because their training is less focused on these specific skills set in midwifery competencies. This implies that the majority of the current workforce who provide midwifery care may not meet the competencies to practise as midwives. There is a need to expand the direct entry midwifery training at diploma and degree levels to ensure the adherence of ICM set standards.
Furthermore, the KRCHN and BScN training programmes should pay attention to local context and tailor midwifery-led practice education standards through curricula reviews to enhance midwifery competencies. Moreover, the graduates of these programmes in practice (in-service) should have more targeted CPD to ensure that their competencies in midwifery are maintained, especially in the general competency domain. Policymakers should incorporate the midwifery practitioners and educators in the policy formulation and implementation to address the gaps in training and practice.
Midwives working in tertiary facilities were more competent than those working in county and sub-county facilities. There is a need to invest in midwifery knowledge and skills acquisition among the midwives working in the county and primary level facilities through access to focused CPD programmes for competency enhancement. Moreover, low-dose high-frequency facility-based mentoring of midwives in the lower-level facilities by experienced midwives and skilled health personnel from higher facilities are effective in improving the midwives’ competencies in the provision of quality midwifery care contributing to a reduction in perinatal and maternal mortalities.
Furthermore, there is a need for the health institutions and managers to provide support systems to the midwives in maintaining their competence in practice and strive to change the organisational culture to ensure that the health facilities are learning institutions through facility-based mentoring.
A follow-up study should measure the actual competence of midwives and verify the findings of this study. This will provide further insights into current midwifery competence and contribute to a larger body of evidence that can guide midwifery education and training policy in Kenya.
Overall, 79% of midwives self-reported to have high competence. Graduates from direct-entry midwifery training programmes were more competent than those from integrated nurse-midwifery training programmes. Midwives working at the tertiary hospitals were more competent than those in the county and sub-county levels. All pre-service training programmes must ensure that graduates meet the basic ICM competencies. In-service CPD programmes must focus on midwives in the lower-level facilities and integrated nurse-midwife practitioners.
The authors appreciate the research assistants and heads of the facilities both at national and county governments who supported the data collection process. They would like to thank the midwives who were the respondents.
E.C.T. and D.K. reported no potential conflict of interest. R.M. declares his conflict being the editor for the
E.C.T. was responsible for the conceptualisation, data curation, investigation, formal analysis, methodology, supervision, resources and writing of the original draft. D.K. was responsible of the conceptualisation, methodology, data curation and writing, review and editing of the article. R.M. was responsible for the conceptualisation, methodology and writing, review and editing of the article. All authors read and approved the final manuscript to be published.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data that support the findings of this study are not openly available because of the sensitivity of human data and are available from the corresponding author (E.T.) upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.