’Being a midwife is being prepared to help women in very difficult conditions’: midwives’ experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo

Introduction: Maternal and neonatal health is a core focus area in fragile and conflict-affected states and midwives are key actors. But there is currently very little evidence on midwives’ experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri region in the North-Eastern Democratic Republic of Congo. This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives’ work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, North-eastern DRC.
Methods: A qualitative approach using life history interviews with 26 midwives and 6 ex-midwives, and 3 focus group discussions with 22 midwives in 3 health districts of Ituri Province (Bunia, Aru and Adja) was conducted in 2017. Purposive sampling was used to recruit research participants.  The transcripts were digitally recorded, and thematically analyzed using NVivo. A lifeline framework was deployed in the analytical process.
Results: Problem solving, child aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses resulting in different levels and training experiences of midwives.  Midwives face many work challenges:  serious shortage of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation is worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives want to continue working as midwives or follow further midwifery studies. Family related reasons were the main reasons for most ex-midwives to leave the profession.
Conclusion: Midwives play a critical role in supporting women to deliver babies safely in rural Ituri province. They face immense challenges and demonstrate bravery and resilience as they navigate the interface position between under-resourced health systems and poor marginalized rural communities. This situation requires a call to action: donors need to prioritize these contexts; and the government and other stakeholders in DRC need to invest more in improving security conditions as well as working conditions and professional support for midwives in rural Ituri Province. Only then will midwives be able to provide the critical services that women and their families need, and therefore contribute to achieving Universal Health Coverage.