Towards a midwifery profession in Bangladesh - a systems approach for a complex world

Background: The midwifery profession is crucial for a functioning health system aiming at improved maternal and child health outcomes. Complex Adaptive Systems (CAS) can be used as a tool to understand actors' interactions in the system around midwifery profession for improved maternal and child health. The purpose of this study is to explore how actors connect to promote the Bangladesh's midwifery profession. Methods: An explorative study based on the framework of CAS was performed. Data were collected through semi-structured interviews with 16 key persons representing nine different organisations promoting the establishment of the midwifery profession. Qualitative analysis was used. Results: Findings show that the actors were intertwined and driving towards a common goal; to save lives through education and deployment of 3000 midwives. The unique knowledge contributions of everyone involved were giving the system strength and power to perform. Collaboration was seen as more could be achieved compared to what an individual organisation could do. Significant results of this were that two midwifery curricula and faculty development had been produced. Although collaboration was mostly seen as something positive to move the system forward, the approach to reach the set goal varied with different interests, priorities and concerns, both on individual organisational level as well as at system level. Frequent struggles of individual philosophies versus organisational mandates were seen as competing interests for advancing the national priorities. It would appear that newcomers with innovative ideas were denied access on the same terms as other actors. Conclusions: This study illustrates that CAS thinking can be used as a metaphor to understand how to adapt more emergent ways of working instead of the traditional planned approaches to change and develop in order to deal better with a more complex world. Through examining how actors connect for establishing a midwifery profession, offers insights of shared interests towards stepping up efforts for a competent midwifery profession in Bangladesh and elsewhere. Good relationships, where everyone's expertise and innovations, are used to the full, are crucial for establishing a strong midwifery profession and thus improved maternal and child health.