A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services Christopher J. Colvin a,n , Jodie de Heer a , Laura Winterton a , Milagros Mellenkamp b , Claire Glenton c , Jane Noyes d,e , Simon Lewin c,a , Arash Rashidian f a University of Cape Town, South Africa b University of Virginia, VA, USA c Norwegian Knowledge Centre for Health Services, Norway d Medical Research Council of South Africa, South Africa e Bangor University, UK f Knowledge Utilization Research Center and School of Public Health, Tehran University of Medical Sciences, Tehran, Iran article info Article history: Received 7 January 2013 Received in revised form 3 May 2013 Accepted 7 May 2013 Keywords: Task shifting Organisation of care Systematic review Qualitative research abstract Objective: to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation. Design: systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach. Setting: midwifery services in any setting in low-, middle-, and high-income countries. Participants: midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders. Interventions: task shifting to and from midwives. Findings: thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting. Key conclusions: this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater. Implications for practice: evidence from the review fed into the World Health Organisation's ‘Recom- mendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting’ guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices. & 2013 Elsevier Ltd. All rights reserved. Introduction A key obstacle to the achievement of the maternal and child health-related Millennium Development Goals (4–6) is the chronic shortage and maldistribution of health workers in many countries (WHO, 2010). One important approach to addressing this human resource problem is the redistribution of tasks between health work- ers, an idea sometimes referred to as ‘ task-shifting’ or ‘ task optimisa- tion’ . Task shifting is one way of addressing the broader question of the most effective and efficient ‘ skill mix’ in a health services context, especially in settings with chronic shortages of health workers. By re- organising tasks and responsibilities more efficiently and effectively within the health workforce, policymakers hope to make better use of existing human resources and expand and strengthen coverage of key health interventions (WHO et al., 2007). Midwives are a cadre of health worker that has long been familiar with the concept of task shifting and its attending Contents lists available at SciVerse ScienceDirect journal homepage: www.elsevier.com/midw Midwifery 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.05.001 n Corresponding author. E-mail addresses: cj.colvin@uct.ac.za (C.J. Colvin), jddeheer@hotmail.com (J. de Heer), winterton.laura@gmail.com (L. Winterton), mmm5cb@virginia.edu (M. Mellenkamp), claire.glenton@kunnskapssenteret.no (C. Glenton), jane.noyes@bangor.ac.uk (J. Noyes), simon.lewin@kunnskapssenteret.no (S. Lewin), arashidian@tums.ac.ir (A. Rashidian). Please cite this article as: Colvin, C.J., et al., A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.05.001i Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎