"I am tired, but we really try." Perspectives of midwives on quality of midwifery care in Malawi.

Additionally, while keeping their normal salary, they get afternoons off to attend school. Both midwives aiming to enter the upgrading course and midwives who want to enter the Generic Program benefit from this educational incentive.

The curricula have changed several times during the past decade of which one example is that of the Enrolled Nurse Midwife (ENM), who is no longer trained. Another recent change is the collaboration between MCHS Blantyre and KCN. Due to agreements on curricula, midwives who have attained their diploma at MCHS Blantyre (not at Mission Schools, MCHS in Lilongwe or Zomba Nursing School) can enter straight into the two year “Mature Entry” course to obtain their bachelor’s degree. This saves midwives four years: two years of study for an upgrading and two years of the required work experience; so it is a great improvement for midwives who want to “go up”. Now I turn to the educational training the respondents followed.

Education of the Gogo Chatinkha Maternity Wing Figure of the questionnaire.4 shows the attained education of the midwives of the questionnaire. As seen the majority of midwives (NMT) has just recently graduated. They are young and do not have a lot of experience. The 23 ENMs en NMTs who are trained in a lower cadre are in the majority. Out of the 13 midwives in the IDI’s, two are Figure 4. Highest attained training of 31 midwives in RNMs: Gift and Violet, who are SICs in questionnaire the Labour ward and ward 1A. One of the remaining 11 is enrolled in a KCN course for a diploma, this is Tiyanjane.

The other ten interviewees are five NMT trained by Mission Schools and five ENM. The respondents in the interviews all agree that the system of different cadres is complicated, and that career possibilities and entry requirements are not clear-cut. The NMT however all say they want to upgrade to be a RNM, and preferably want to a university degree so they are “in the Bachelor’s order”.

“I want to upgrade” and the hierarchy of knowledge All midwives, except for the ones who are about to retire, say they want to upgrade. The several reasons are mentioned why midwives want to upgrade, can be divided into four main arguments.

The first is that they wanted to learn more about why they had needed to do things in a particular way, so they wanted to be taught the theory behind their practice. The majority claims that after their training, they would come back to work at the ward, because they say that background knowledge is needed to advance practice at ward level (Evidence-Based Practice). They would eventually possibly want to become a SIC when they are a RNM, or want to get other managerial positions in government hospitals.

The second reason is that with a diploma and even more so with a degree, midwives say they have better career opportunities than with a certificate only. The career opportunities are even better if one gets a specialization after their degree. Going from NMT to a degree RNM is a long way, 51