Background: This study examined whether the introduction of professional midwives with and without facility mentorship improved care quality and availability in sub-district hospitals in Bangladesh. It also analysed the experiences of non-midwife maternity care providers and managers. Methods: Using mixed-methods, differences between hospitals without midwives, with midwives, and with mentorship were explored. Quantitative analysis comprised observations of facility readiness and clinical care to assess implementation of World Health Organization maternity care guidelines. Participants also completed a survey on their knowledge, perceptions, and utilization of the guidelines. Focus groups and interviews explored midwives’ experiences of their roles, and the experiences of the maternity staff and managers in relation to the midwives and the improved care practices they introduced. Logistic regression was used to identify differences between hospital types following the deployment of midwives and also mentoring. Results: There were 641 clinical observations, 237 completed surveys, 18 interviews and five focus groups. The analysis found facilities without midwives to be the least likely to implement quality care practices, and those with midwives and facility mentoring to be the most likely. Of the eight quality practices, hospitals with midwives but no mentors were significantly more likely than hospitals without midwives to use four: partograph (56% vs. 14%; p<0.001), upright labour (94% vs. 63%; p=0.001), delayed cord clamping (88% vs. 11%; p<0.001), skin-to-skin (94% vs. 13%; p<0.001). Hospitals with mentors were significantly more likely to use six: ANC card (84% vs. 52%; p<0.001), partograph (97% vs. 14%; p<0.001), upright positioning for labour (95% vs. 63%; p=0.001), delayed cord clamping (98% vs. 11%; p<0.001), skin-to-skin contact following birth (93% vs. 13%; p<0.001), and upright positioning for birthing (86% vs. 26%; p<0.001). In addition, attitudes among the other maternity staff and managers toward midwives’ capabilities and improving quality of care were found to be more positive with mentoring. Conclusion: Facilities with professional midwives had better availability and quality of maternity care across multiple components of the health system. Care quality further improved with facility mentors who created enabling environments, provided training, and facilitated supportive relationships between existing maternity staff and managers and the newly deployed midwives.

Mixed Methods - Qualitative: The sampling for the focus groups and interviews was purposeful. Midwives, doctors and nurses participated in focus groups; hospital managers were recruited for interviews. Focus groups and interviews provided the opportunity to discuss feelings and perceptions about improving the quality of clinical care. They also illuminated the experience of working with the new midwives, or being deployed as a new midwife, with the different groups of health care providers. The focus groups allowed for the development of understanding on the providers’ ideas, how they interacted on the different topics and their collective understanding. Interviews were largely used for the busy hospital managers and doctors who were less likely to be willing to participate in focus groups. The topics for the focus groups and interviews were similar, but managers were more open when they could share their perceptions and feelings alone. Quantitative: Convenience sampling was used for the quantitative component of this study. The three quantitative tools included 1) a facility readiness tool, 2) a clinical observation tool, and 3) a survey. The first two sought to answer the first research question concerning improved availability and quality of maternal and newborn care and the survey explored perceptions and experiences. The facility readiness tool consisted of direct observations and service utilization data logged in register books. Facility readiness, such as availability of life saving medicines and dedicated space for newborn resuscitation, aimed to detail readiness for managing emergencies and whether the needed space and equipment were in place. Service utilization data were only collected for normal deliveries and gave a sense of how busy the facilities were and if the numbers of births were increasing more in facilities with midwives and mentoring. The intention for collecting these data was to indicate if availability and or quality were affected by the midwives’ deployment, and the influence of mentoring, through increases in service utilization. The clinical observation tool aimed to collect information on which clinical interventions were being provided and allowed for the comparison of care provided with that guided by the World Health Organization (WHO). The survey enabled understanding of health care providers’ and managers’ perceived knowledge, attitudes, and reported use of clinical behaviours as related to quality maternity care. The survey helped to answer the second research question concerning the experiences of midwives and the maternity staff (doctors and nurses) and managers that they joined.