"How are you going to remove that cobweb?" Midwifery Services Framework implementation in Zambia: A case study

The Midwifery Services Framework (MSF) was devised by the International Confederation of Midwives (ICM) as an evidence-based tool to guide the process of improving sexual, reproductive, maternal, and newborn health services through strengthening and developing the midwifery workforce. The MSF was updated in 2020 and implemented in Zambia in 2020-2023. This study examined the process of MSF implementation in Zambia from the perspectives of individuals and organisations involved in implementation.

We used an Appreciative Inquiry approach to collect qualitative data from nine stakeholders via semi-structured interviews, including representatives of all organizations involved in implementation. Guided by a process evaluation framework, a content analysis was undertaken on the data.

The process of MSF implementation achieved or contributed to positive results at a policy and health system level. This study identified factors that contributed to these successes, including: political will, alignment with national planning cycles and existing health system structures, broad stakeholder engagement, and intentional efforts to ensure contextualisation and local ownership of the process. Still more could have been achieved with: even broader stakeholder engagement, better understanding of key midwifery and health system concepts, and stronger data systems.

Future efforts to implement the MSF and other investments in strengthening the midwifery workforce should take note of these key success factors and intentionally 'design them in' from the outset.