Confidence in Care Provision Among Third-Year Midwifery Students in Western Kenya

Confidence in Care Provision Among Third-Year Midwifery Students in Western Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Confidence in Care Provision Among Third-Year Midwifery Students in Western Kenya Tozoe Marton, Tobias Odwar, Timothy Abuya, Monica Adhiambo Onyango, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7123223/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background : Safe pregnancy and childbirth are fundamental human rights, yet approximately 810 women die daily from preventable maternal causes. Despite a 40% global reduction in maternal mortality between 2000 and 2023, sub-Saharan Africa still accounts for nearly 70% of these deaths. Efforts to reduce maternal mortality in the region have emphasized increasing facility-based deliveries, which enable skilled health workers to manage complications and deliver lifesaving interventions. Professional midwifery, particularly when aligned with International Confederation of Midwives standards, has been identified as critical to achieving these goals. However, the training environment plays a significant role in shaping the confidence and competence of future midwives. This study explores the situational and institutional factors affecting final-year midwifery students' confidence in providing maternal care in Kenya, focusing on training environments in urban and rural Kenya Medical Training Colleges (KMTCs). Methods : A comparative ethnographic case study approach was employed to investigate how midwifery students' confidence in care provision is influenced by their training environments. The study was conducted at two KMTC campuses—one urban (in Kisumu County) and one rural (in Siaya County). Data collection methods included participant observation during lectures and clinical rotations, as well as in-depth interviews with final-year students, lecturers, clinical mentors, and institutional administrators. Thematic analysis was used to identify contextual influences on student confidence. Results : Students and faculty identified clinical experience as pivotal to building confidence, particularly in managing obstetric complications. Peer learning and repeated hands-on practice were consistently reported to enhance confidence. However, challenges such as reduced facility-based deliveries (exacerbated by policy shifts from the National Health Insurance Fund to the Social Health Authority), overcrowded clinical sites, staffing shortages, and misalignment between theoretical instruction and clinical realities hindered effective learning. Resource limitations forced reliance on improvised practices, which undermined student confidence and created a disconnect between training and best practices. Conclusions : Midwifery student confidence in Kenya is shaped by a complex interplay of policy, pedagogical, and infrastructural factors. Addressing systemic barriers—through curriculum reform, improved resource allocation, and stronger academic-practice partnerships—is essential to ensure students graduate with the competence and confidence needed for safe maternal care delivery. midwifery education maternal health student confidence clinical training Kenya health policy sub-Saharan Africa Figures Figure 1 Background Safe pregnancy and childbirth are fundamental human rights (Boama & Arulkumaran, 2009 ; Cook, 1998 ; Fathalla, 2006 ). Yet, each day, 810 women worldwide die due to preventable pregnancy-related issues, with 99% of these maternal deaths happening in low and lower-middle-income countries (Tessema et al., 2021 ). Despite various interventions, preventable maternal deaths in Africa remain alarmingly high, primarily due to complications such as hemorrhage, eclampsia, sepsis, and obstructed labor (Onambele et al., 2022 ). Additionally, systemic challenges—including staffing shortages, limited healthcare accessibility, and inadequate service quality—further exacerbate maternal health outcomes across many regions (Onambele et al., 2023). Though maternal mortality declined by over 40% worldwide from 2000 to 2023 (UNICEF, 2025), the rates remain unacceptably high in sub-Saharan Africa (SSA), with the region alone accounting for nearly 70% of global maternal deaths (WHO, 2025). The United Nations Sustainable Development Goals (SDGs) target 3.1 aims to reduce the global maternal mortality ratio (MMR) to fewer than 70 deaths per 100,000 live births by 2030. However, many countries in SSA remain far from achieving this target. The MMR in the SSA region was estimated at 448 deaths per 100,000 live births in 2023 (World Bank Group, 2025 ). To meet the SDG target by 2030, MMR must decline by at least 20.3% annually from 2020 (Onambele et al., 2023). However, global progress in reducing maternal mortality has stagnated, with little improvement between 2016 and 2022 (UNICEF, 2023 ). At the current rate, the world is projected to miss the SDG target, resulting in over one million preventable maternal deaths (Suzuki et al., 2023). An ongoing global initiative began in the early nineteenth century to increase facility-based delivery and reduce the high rates of maternal mortality in Africa (Hunt, 1999 ). The rationale is that facility-based births allow skilled health workers to provide impactful interventions during childbirth, such as preventing, detecting, and managing eclampsia and hemorrhage, conducting neonatal resuscitation, and intervening in other complications(Karanja et al., 2018 ; Nawagi et al., 2023 ). Professional midwifery—the practice of birth attendants trained under the International Confederation of Midwives (ICM) standards assisting in childbirth—has been identified as essential to improving maternal mortality rates. It offers services that can reduce maternal morbidity and mortality (ICM, 2019). Evidence suggests that training and regulating midwives and midwifery professionals to global standards and placing them in supportive environments reduce maternal and perinatal mortality rates (Chakraborty et al., 2023 ). Increasing midwife-led care interventions by 25% every five years can prevent 2.2 million maternal and newborn deaths by 2035, including 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths (Chakraborty et al., 2023 ). This study explores the situational and institutional factors influencing the confidence of final-year nurse-midwifery students in providing care at Kenya Medical Training Colleges (KMTC). In Kenya, midwifery education is predominantly delivered through integrated nursing and midwifery programs at both diploma and degree levels in mid-level training colleges and universities. A typical example of such a program is the Kenya Registered Community Health Nursing (KRCHN), which is a diploma-level program encompassing midwifery, nursing, and community health components. For the purpose of this discussion, these nurse-midwifery students will be referred to as midwifery students. Kenya’s maternal mortality ratio was 362 per 100,000 live births in 2022. (Masaba & Mmusi-Phetoe, 2023 ), more than four times higher than the SDG target (Reddy et al., 2022 ). Given the international and domestic push for facility-based births, the Kenyan government has made efforts to reduce the number of home births, particularly those that are assisted by traditional birth attendants—community-based workers without formal health care training (Yuen, 2022 ). Home birth rates have decreased in the country, from 56% in 1998 to 11% in 2022 (KDHS, 1998 , 2022 ). The country has also increased the number of trained midwives attending births, with a 68.5% rise in the number of new nurses from 1,745 to 2,941 between 2006 and 2015 (Ministry of Health, 2017 ). Trained midwives play a crucial role in improving women's medical outcomes and childbirth experiences (Moller et al., 2022 ; Moloney & Gair, 2015 ; Moridi et al., 2020 ). Pre-service training programs designed for midwifery care providers serve as a fundamental framework for students to develop competence, which is understood as the necessary knowledge and skills required to deliver high-quality, evidence-based care. Extensive research on the impact of training curricula on midwives’ competence generally shows that midwifery students possess a high level of competence by the time they graduate (Bäck et al., 2017 ; Baluwa et al., 2023 ; Razavinia et al., 2024 ; Tallam et al., 2022 ; Welsh et al., 2022 ; Yigzaw et al., 2015 ). However, far less attention has been given to the connection between training and midwives’ confidence, including within the Kenyan context. In midwifery, as well as in other health services, confidence can be understood as self-assurance underpinning the ability to use one’s knowledge and skills in a clinical setting (Bäck et al., 2017 ; Baluwa et al., 2023 ; Davis et al., 2012 ). Confidence is influenced by dispositional factors (attitudes, traits, and motivation), situational factors (which depend on personal time and resources), and institutional factors (educational programs’ structure and pedagogy) (Bäck et al., 2017 ). Supporting students in building confidence is essential to preparing midwives who can effectively meet women's care needs, and this must be intentionally developed during training (Bäck et al., 2017 ). This study examines the confidence of third-year midwifery students by exploring two theoretical concepts: the professionalization of midwifery and the medicalization of childbirth. The professionalization of midwifery refers to the process of establishing midwifery as a formal, regulated profession with standardized education, ethical guidelines, and integration into the broader healthcare system (Abbott, 1988 ; Prosen, 2022 ; Wertz & Wertz, 2013 ). This process has been deeply shaped by the medicalization of childbirth—the increasing dominance of biomedical interventions, technologies, and hospital-based practices in the birthing process (Busfield, 2017 ; Conrad, 1992 ; Teijlingen, 2004 ; Wertz & Wertz, 2013 ). As childbirth became more medicalized, midwives were compelled to adapt by aligning with medical standards, often shifting from community-based practices to institutional settings. This transformation has required midwives to undergo formal training and adhere to clinical protocols, which has both enabled and constrained their practice (Wertz & Wertz, 2013 ). The medicalization of childbirth and the professionalization of midwifery are linked to the training students undergo and their ability to build confidence, which underpins the use of competence. This paper examines how these broader dynamics influence midwifery education today, with particular focus on how situational and institutional factors (Bäck et al., 2017 ) at KMTC in Kisumu and Siaya Counties, Kenya, influence the confidence of third-year midwifery students. Although the KMTC curriculum is standardized across campuses located in rural and urban settings in Kenya, disparities in resource distribution affect students' learning experiences and knowledge acquisition (Jebet et al., 2023 ). Using a case study approach, the study explores how situational and institutional factors, including the availability of resources in midwifery training institutions and healthcare facilities that host clinical placements, influence final-year midwifery students’ confidence in delivering care. Methods 2.1 Study design A comparative ethnographic case study approach provided an in-depth understanding of how the training environment of midwifery students in urban and rural parts of western Kenya affects their confidence in care provision (Padgett, 2014 ). Kenya faces stark urban-rural disparities in healthcare access and care provision, with resources and quality services concentrated in urban centers despite a large rural population—approximately 30% of the population lives in urban areas, while the remaining 70% lives in rural communities (Moturi et al., 2022 ; Otieno et al., 2020 ). Due to unequal access to midwifery services in Kenya's rural and urban areas, a case study research approach is ideal for comparing the social and structural factors contributing to quality care provision. This paper examines midwifery training in Kisumu County (urban) and in Siaya County (rural). 2.2 Study setting Data collection activities occurred in Kisumu and Siaya counties located within the Lake Victoria basin in western Kenya. Kisumu County presents an urban setting, while Siaya County represents a more rural environment. Kisumu is the largest city in western Kenya, encompassing a total land area of 2,085.9 square kilometers, with a population of 610,082 (Government of Kisumu, 2023 ). Siaya County encompasses a total area of 2,529.8 square kilometers. As per the 2019 Kenya Population and Housing Census, the county had a population of 993,183. Kisumu and Siaya counties are approximately 55 kilometers apart. The geographical proximity of the counties makes logistics easier for conducting comparative studies, ensuring consistent data collection methodologies across both settings. As in other counties, the healthcare system in Siaya and Kisumu includes a mix of public, private, and community-based healthcare providers. This ensures that findings can be extrapolated to inform the understanding of the national healthcare framework. 2.3 Study population The Kenyan government has expanded the nursing workforce, increasing the number of nurses by 68.5% from 1,745 to 2,941 between 2006 and 2015 (Ministry of Health, 2017 ). Most healthcare workers providing midwifery care in Kenya are trained as KRCHN or hold a bachelor's degree in nursing through blended programs that integrate nursing, midwifery, psychiatry, and community health. These programs are primarily offered at KMTC, as well as private and other public universities in Kenya (Ministry of Health, 2017 ). A purposive sampling approach was employed to select KMTC campuses, aiming to capture variation in midwifery training environments across different geographic and resource settings. KMTC, a government institution under the Ministry of Health, trains over 85% of Kenya’s healthcare workforce through its 72 campuses nationwide (KMTC, 2023 ). From the available campuses—three in Kisumu and two in Siaya—one was selected from each county based on two key criteria: the size of the student body and proximity to a referral health facility used for clinical placements. These criteria ensured that the selected campuses offered both sufficient student engagement for observation and accessible clinical practice settings. This purposive strategy allowed the gathering of rich, context-specific data while comparing urban and rural training conditions relevant to Kenya’s broader healthcare delivery challenges. 2.4 Study sample and recruitment A total of 35 participants were included in the study: 24 third-year nurse-midwifery students, three lecturers, four clinical mentors (nurses and midwives at health facilities who guide students through their clinical experience), and four administrative staff members. Following ethics approval in Kenya, the lead investigator (TM) coordinated with the Deputy Director of Research at the KMTC headquarters in Nairobi, Kenya. The Deputy Director issued letters of approval, which were delivered to the principals of each participating campus. With the principals’ assistance, the research team gained access to the student rosters for the KRCHN program—a three-year curriculum that integrates general nursing, community health, and midwifery training. By design, all students recruited for interviews were in their third year, had completed their midwifery coursework, and were actively engaged in clinical rotations at health facilities. Gender balance was also considered in the selection process to ensure equal representation of female and male students. Once the list of 12 students per campus was finalized, the principals facilitated initial contact with the students. All 24 students who were approached agreed to participate and provided informed consent prior to their interviews. Classroom lecturers, clinical mentors, and administrative staff who directly interacted with these students were recruited based on availability and also provided informed consent prior to their participation. Participants in the in-depth interviews were required to be at least 18 years of age, affiliated with either the Kisumu or Siaya campuses involved in the study, and fluent in one of the study languages, namely English, Kiswahili, or Dholuo. The student participants ranged in age from 20 to 40 years, with a mean age of 24, and were evenly distributed by gender (12 males and 12 females). All lecturers and nurse mentors were female, with ages ranging from 25 to 61 years (mean age, 48 years). On average, they had nine years of teaching experience and 21 years of professional experience in nursing or midwifery. The administrative staff participants included the Head of the Department of Nursing and the principals of the participating schools. They ranged in age from 40 to 57 years, with an average of 47 years, and had held their positions for an average of seven years. Additional demographic details of the in-depth interview participants are provided in Table 1 . Table 1 Demographic Profile of In-depth Interview Participants* Characteristics Siaya Kisumu Total Third-Year Nurse-Midwifery Students N = 12 N = 12 N = 24 Age in Years 22(2) 26(6) 24(5) Gender Female 6 6 12 Male 6 6 12 Instructors (Lecturers and Nurse Mentors) N = 4 N = 3 N = 7 Age in years 46 (15) 51 (9) 48 (12) Years as Instructor 6 (4) 13 (2) 9 (5) Years Practicing 16 (14) 27 (8) 21 (12) Years at Training Institution 11 (14) 17 (3) 14 (10) Gender Female 4 3 7 Administration Head of Departments and Principals N = 2 N = 2 N = 4 Age in years 45 (7) 50 (10) 47 (8) Years at Training Institution 5 (1) 8 (5) 7(4) Gender Female 1 1 2 Male 1 1 2 *Mean (SD); n 2.5 Data collection Prior to data collection, the research team, which included a Kenyan regulatory officer (TO) who supported the ethics approval process and two Kenyan research assistants, participated in a four-day training on the study protocol. One research assistant is an experienced qualitative researcher from Siaya County, while the other is a trained nurse and clinical researcher from Kisumu County. The three Kenyan team members brought extensive knowledge of Luo cultural norms and practices in Western Kenya, which was critical in developing culturally appropriate data collection tools and in guiding the research process. The training was designed to ensure a shared understanding of the study’s objectives, methodology, and ethical procedures. Data collection took place at the Siaya and Kisumu campuses between October and December 2024. Fieldwork at both sites was conducted concurrently. The team began in Siaya, where all members collaborated on interviews and observations during the first three days to ensure consistency in data collection techniques. Following this initial phase, the research assistants divided responsibilities: One led data collection activities in Kisumu, while the other continued fieldwork in Siaya. The lead investigator (TM) alternated between locations, providing supervision and ongoing support throughout the data collection period. Two primary types of qualitative data were collected: participant observations and in-depth interviews. 2.6 Participant Observations The research team conducted participant observation by following midwifery students from classroom lectures to their clinical rotations at local health facilities. On both campuses, we attended lectures for one week (five weekdays), specifically observing first-year, second-semester students enrolled in the midwifery component of the KRCHN program. These sessions focused on the Maternal and Newborn II unit, which covers abnormal pregnancy and childbirth. During classroom sessions, we observed the students and took detailed notes on the content delivered, instructional style, student engagement, and learning environment. Following the classroom observations, we accompanied the same cohort of students into clinical settings where they applied their knowledge in practice. At the facility staff's request, we wore student uniforms to blend in and reduce disruption, although students, faculty, and staff were aware of the research. In the facilities, we observed births and noted how the clinical learning environment supported or constrained effective learning and care delivery. We also paid close attention to the social dynamics that shaped students’ experiences. Observations were guided by a structured checklist (see Appendix A), and detailed field notes were recorded in English, documenting how both classroom and clinical environments influenced students’ confidence and preparedness to deliver maternal and newborn care. 2.7 In-depth Interviews In addition to observations, the research team conducted in-depth interviews with key stakeholders involved in midwifery training. Participants included third-year midwifery students, classroom lecturers, clinical mentors, and administrative staff at each training institution (see Appendix B for sample guides). With guidance from reproductive health researchers at the Population Council in Kenya, semi-structured interview guides were developed for each participant group. These guides explored perceptions of how classroom and clinical training environments influence students’ ability to provide care. To ensure clarity and relevance, the guides were pilot-tested with two participants prior to formal data collection. Interviews were conducted in private settings within the training institutions, using English, Dholuo, or Kiswahili, the three most commonly spoken languages in Western Kenya. This allowed participants to choose the language they felt most comfortable with. The English guides were professionally translated into Dholuo and Kiswahili, and interviews in those languages were conducted by LO and SO, who are fluent in all three languages. All interviews were audio recorded with participants’ consent. English-language interviews were transcribed verbatim by the research team, while those conducted in Dholuo and Kiswahili were transcribed and translated into English by a certified transcriptionist based in Kisumu city. As part of the interviews with students, participants were also asked to self-assess their confidence in providing care across four domains—antenatal, intrapartum, postnatal, and newborn—using a 10-point scale, on which 1 indicated no confidence and 10 represented very high confidence. 2.8 Data Analysis Data analysis was conducted iteratively by the lead investigator (TM) alongside ongoing data collection, allowing for the identification of emerging themes and the refinement of the study approach (Fife, 2005; Weiss, 1995). Ongoing rapid analysis of interview transcripts and field notes enabled the research team to detect major patterns and themes early in the process. These insights informed adjustments to subsequent interviews, including the integration of targeted follow-up questions to explore key themes in greater depth (Fife, 2005). Throughout data collection, TM, SO, and LO collaboratively drafted analytic memos to document emerging themes at each study site. Weekly team meetings were held to review and discuss these memos, laying the groundwork for the initial development of the study codebook. Following the completion of data collection, the codebook was refined through a systematic review of the data using ATLAS.ti 25.0. The lead investigator (TM) reread a sample of 10 transcripts from each site, along with accompanying field notes, to inform further revisions. This refined codebook was then applied to the entire dataset for thematic coding and analysis. The combination of iterative memoing and structured coding ensured a comprehensive interpretation of the data, capturing the complexity of midwifery training and work environments across the two sites (Weiss, 1995). To enhance the credibility and validity of the findings, preliminary results were presented to key stakeholders, including midwifery educators, students, and healthcare providers, via a PowerPoint presentation and informational flyers. A discussion session followed, during which stakeholders provided feedback on the findings. This feedback was incorporated into final revisions to the coding process, strengthening the trustworthiness of the analysis and ensuring that the results accurately reflected on-the-ground experiences in midwifery training and practice. STATA SE 18.0 was used to calculate the average confidence ratings of students. Findings 3.1 Average Confidence Ratings The students were asked to rate their confidence in providing care across four maternal care domains—Antenatal, Intrapartum, Postpartum, and Newborn—on a scale of 1 to 10, with 1 indicating no confidence and 10 indicating high confidence. While the differences in confidence ratings between students from Siaya and Kisumu were not statistically significant given the small sample, Siaya students reported slightly higher confidence levels on average in three of the four domains (see Fig. 1). Importantly, in postpartum care, Siaya students reported an average confidence rating of 8.9, one point higher than the 7.9 reported by Kisumu students. Similarly, in newborn care, Siaya students had an average confidence rating of 9.1, compared to 8.3 for Kisumu students. Qualitative analysis of interviews with students and their faculty members revealed two central themes: (1) the importance of hands-on clinical experience in fostering students' confidence, and (2) the various situational and institutional factors that influence the quality and extent of clinical exposure during their training. The findings are presented in accordance with these two themes: (1) Hands-on Clinical Experience One key theme that emerged in the interviews is the role of hands-on clinical experience in boosting the students’ confidence in care provision. Students, lecturers, clinical mentors, and administrative staff across both KMTCs emphasized that clinical rotations in healthcare facilities are a crucial component of midwifery training. These rotations offer students hands-on experience in real-world clinical settings, strengthening their practical skills and building confidence in patient care. As one lecturer in Siaya explained, “In midwifery, you learn by doing. The more you do, the more you learn” (Female lecturer, Siaya). Students at the Siaya and Kisumu KMTC campuses highlighted that clinical rotations not only allow them to learn from experienced midwives but also provide opportunities for peer learning alongside students from KMTC and other training institutions. A student from Kisumu further explained: When I was performing vaginal examinations, at first, it was hard to get the right findings, but with time, I was able to be taught by a nurse, and I was improving myself to the point that when the nurse could confirm my vaginal examination, she gets the same findings that I get. So, it gives me the confidence to do more (Female student, Kisumu). A student from Siaya added, “When you see another student delivering a woman, you feel like, ‘Ehh, this thing is so hard.’ But if you yourself try to, for the first time, you do it today, tomorrow, and then you continue, you feel like this thing is so easy. And boost your confidence” (Male student, Siaya). Being guided by qualified nurses and learning from other students helps students build their skills and boost their confidence in providing care. Students also highlighted the management of obstetric complications during clinical rotations as crucial to building their confidence as care providers. A student from Kisumu emphasized that these rotations offer firsthand exposure to maternal complications, explaining: You get to see the pregnant mother herself, how contractions occur. You get to see how the baby is born, how the cervix dilates…. if the baby develops a complication during delivery, you learn how to resuscitate the baby so that the baby can come back to life. You gain a lot of knowledge, and it builds your confidence (Male student, Kisumu). Similarly, a student from Siaya recalled managing a pregnant woman with eclampsia, describing the initial fear and uncertainty but also the learning opportunity it provided: Managing a mother with eclampsia—those are the women that mostly come with teachings…. You feel like, ‘God, I’m terrified.’ But when you see how qualified nurses manage them, it gives you more confidence (Male student, Siaya). These experiences highlight the essential role of applied clinical practice in enhancing students' learning and confidence. Gaining hands-on experience under the supervision of skilled professionals is crucial, as it allows students to develop the confidence needed for effective care provision. While all the study participants underlined the significance of hands-on experience in fostering students' confidence in care provision, they also identified various challenges both within and beyond the training institution—such as changes in health policy, resource and staff shortages, and overcrowding of students in facilities—that hinder the learning process. (2) Situational and Institutional Factors Affecting Hands-on Clinical Experience 2a. Shifts in Maternal Health Policy Data collection at the Siaya and Kisumu campuses took place between October and December 2024, during the early stages of implementing the Social Health Authority (SHA) insurance scheme. Prior to SHA, Linda Mama, which was introduced in 2013 under the National Health Insurance Fund (NHIF), offered benefits such as antenatal, delivery, and postnatal care. It was placed under SHA, which was launched on October 1, 2024, and required women to register using a personal mobile phone and a Kenyan Identification Card. Under SHA, the Linda Mama program continues, but access to these services now depends on SHA registration, a policy change that reduced women's access to healthcare. This, in turn, has implications for students’ hands-on experience during clinical rotations, as discussed here and in 2b. Students in Siaya were the only ones among the two campuses who mentioned the impact of the transition from NHIF to SHA on their hands-on clinical experience. A female student explained that mothers are “supposed to activate their details with SHA. Most of them had a challenge with that” (Female student, Siaya). Another student added, “Without SHA, mothers must pay 10,000 Kenyan Shillings [~ 79 USD] for a normal delivery and 20,000 Kenyan Shillings for a cesarean section” (Male student, Siaya). Given the rural setting of Siaya, many women cannot afford these costs. A student noted, “Some [mothers] say the charges for delivery are too high; they cannot afford them. So, some of them prefer to deliver at home” (Female student, Siaya). Another agreed, stating that mothers would “rather go to the dispensaries, their homes, or traditional [birth attendants]” (Male student, Siaya). In contrast, Kisumu students did not mention any impact of the policy shift on their clinical experience. This might be because Kisumu facilities implemented a SHA registration system at their entrances, which Siaya facilities lacked. This system allowed women to register upon arrival. During observations at the Kisumu study site, the in-charge nurse at the facility where students conducted their clinical work explained that all women must first stop at the SHA registration desk before receiving care. When asked whether this applied to women in active labor who had not registered under SHA, the nurse confirmed, “ Yes .” Because women attending these facilities could register on-site, the cost was not a barrier, and no Kisumu students reported challenges related to SHA or a decline in patient numbers. However, in Siaya, as more women opt to give birth at home or in dispensaries, fewer are seeking care at formal health facilities, reducing the number of pregnant or postpartum women students encounter during their rotations. A female student noted that she was struggling to meet the required number of deliveries before being assessed through examinations. She said, “Before you do this assessment, you have to have delivered about 15 mothers…But there are no mothers coming to the labor room…By the time you are doing the assessment, you have delivered seven women” (Female student, Siaya). She further explained that many mothers only come to the hospital after giving birth, often with complications such as retained placenta, meaning students assist with placenta delivery rather than full deliveries. As a result, Siaya students reported gaining more experience with postpartum care than with intrapartum care, which aligns with their higher self-ratings in postpartum and newborn care compared to intrapartum care (see Fig. 1). 2b. Overcrowding of Students within Facilities The government’s rapid expansion of nursing training institutions in Kenya that began in 2006, which was not coupled with an expansion in the number of health facilities or in the size of existing ones, has led to overcrowding of students at sites available for clinical placement. As a result, although students can observe clinical practice, they often have fewer opportunities to practice essential procedures, such as deliveries, themselves. An administrative staff member from Kisumu highlighted this challenge, stating: You find that the hospitals are not growing [in number], but the nursing training is growing. We have so many students, but the clinical areas [meaning the facilities that host clinical training] are not growing so much (Female administrative staff, Kisumu). A student from Siaya echoed this concern, explaining, “[This] hospital is a teaching and referral hospital, so many KMTCs come here for their [clinical] rotation” (Female student, Siaya). This overcrowding can hinder effective training, as a nurse mentor from Siaya noted, “It’s difficult sometimes to train a large group” (Female nurse mentor, Siaya). The issue is further exacerbated by staffing shortages and a limited number of women seeking care at these facilities. A nurse mentor from Kisumu described the challenge of providing adequate supervision, explaining: In KMTC you get the number of lecturers is very few, so it’s really a challenge for them to make a follow-up in the clinical setup. Now, that means that nurses in the clinical setup do a lot of the support for the students. They should mentor the students and do their work at the same time, which is really a big challenge (Female nurse mentor, Siaya). Similarly, a lecturer from Siaya emphasized the overwhelming workload faced by qualified nurses, which restricts their ability to train students effectively. She said: Sometimes, the workload down there [at the facility] does not allow for proper guidance and training by the nurse. Sometimes, you find one nurse in the labor ward, running from taking the mother to the theater, receiving the baby, and conducting deliveries….you find students on their own because of the workload and the staff shortages there. (Female lecturer, Siaya) Another lecturer from Siaya reinforced this concern, noting, “The staff issue also affects the degree to which the students can have a one-on-one mentorship with the supervisors” (Female lecturer, Siaya). Compounding these challenges is the low number of women attending facilities for care, particularly at the Siaya training site. A female student described the imbalance between students and patients, stating, “In [a] shift, you can find yourself, you’re almost 15 students. The mothers who are in the labor ward, there are two mothers, so you cannot all deliver” (Female student, Siaya). Another student added, “Even during duty allocation, you’ll find one patient against even five students” (Female student, Siaya). Due to this shortage of clinical opportunities, many students struggle to meet their required number of deliveries. One student recalled, “So far, I have delivered only seven deliveries. But you are supposed to have at least 10 before you get to do your assessments” (Female student, Siaya). Without sufficient hands-on experience, students may graduate lacking the confidence and skills needed for independent practice, highlighting the urgent need to improve situational and institutional factors, such as overcrowding during clinical rotations and the shortage of qualified midwives. 2c. Gaps Between Classroom Instruction and Clinical Practice In Siaya and Kisumu, participants pointed out a major gap between classroom instruction and real-world practice. This institutional factor remains a major concern for participants on both campuses, although more students in Siaya discussed the issue than those in Kisumu. One student from Siaya pointed out that some medications discussed in class have already become obsolete by the time they begin clinical practice. This student stressed the importance of lecturers staying updated alongside regular textbook revisions to ensure students receive current medical knowledge. Students also described instances where they challenged qualified nurses about certain medications or procedures during clinical placements, only to find that the information they had been taught was outdated. One student illustrated this issue with an example from suturing: When suturing, for example, the earlier practice, which most of the lecturers here know and always teach us, is that when suturing, you get cotton and pad inside to prevent the blood from oozing outside. But the recent practice says that we do not pad because there might be postpartum hemorrhage, and it might be obstructed (Male student, Siaya). Another student reinforced this concern, specifically mentioning discrepancies in how labor progression is monitored, “Maybe in class, we learned that we start partograph at four-[centimeters] dilation of the cervix. When you go to work [at the facility], they [qualified nurses] tell you, ‘No, that is outdated. Nowadays, it starts at six or five” (Male student, Siaya). Lecturers also acknowledged this issue, recognizing the challenge of keeping academic instruction aligned with evolving clinical guidelines. A lecturer from Siaya explained: There are a lot of updates and a lot of changes happening day in and day out. The updates do not focus much on the lecturers; they focus on the clinical area. So, you could be training in the use of a partograph according to what is in the books, and there are already changes. You are telling them [the students] that the active phase of labor begins at four centimeters. When you go to the clinical area to assess them, you find that it’s now five centimeters (Female lecturer, Siaya). Similarly, a lecturer from Kisumu emphasized the lack of collaboration between classroom instructors and healthcare facilities that provide clinical training. She noted: What I noticed most of the time, there needs to be a collaboration with the hospitals so that in case of a training, the lecturers are also involved in the training. Otherwise, I find you are just giving old information (Female lecturer, Kisumu). The disconnect between classroom teaching and clinical practice often leads to confusion for students when they encounter discrepancies between what they’ve learned in class and what’s expected in healthcare settings. Students highlighted that this disconnect between classroom instruction and real-world clinical practice directly affects their confidence. A student from Kisumu described how conflicting guidance from lecturers and clinical mentors undermines their confidence, stating: There is a conflicting interest because you'll explain to the midwife, ‘We were taught like this,’ and then he's telling you, ‘Leave that alone, you shouldn't do this.’ So, it drains your confidence in doing things…because I'm not sure whether what I'm going to do is right or maybe [there’s] another way of thinking (Male student, Kisumu). Beyond these discrepancies, students and faculty also acknowledged that resource constraints further contribute to the gap between theoretical knowledge and practical application. An administrative staff member from Siaya explained: We teach ideal according to the nursing council manual….We go to our skills lab; we do ideal. But now, when you go to the clinical area, because of shortage of resources, [nurses take] shortcuts. So now the students, because they are there for a longer time than what we have here [at the school], they end up adopting the shortcuts. So, when you go for assessments, the students are confused. You taught about this in class, and you taught about this in the skills lab, but they've never seen it in the clinical area. (Female administrative staff, Siaya). A student from Kisumu echoed this concern, emphasizing the challenges posed by limited resources: There’s the ideal and the actual thing that is happening. You find in the hospital, we don’t do the ideal. We do what is there; we improvise because the ideal is expensive or we don’t have the machinery for the ideal thing (Male student, Siaya). Importantly, faculty members at both campuses acknowledged that unequal resource distribution between urban and rural areas impacts students’ training experience. A lecturer from Kisumu explained this situational factor stating: Maybe the training in rural in terms of facilities [and]equipment, are not available, as opposed to urban. You might find that it can impact [the students’ confidence]. If you have this student who has just trained in the rural, then maybe they are not as exposed as the one in the urban, because in the urban, they have more equipment [and] facilities. You [as a student] see things like incubators [in urban facilities], but in the rural [facilities], incubators are not there, and that's why you find, say you have a baby delivered preterm in the rural, they are not able to manage...They refer [the baby to another facility] (Female Lecturer, Kisumu). Though this view is commonly held by faculty on both campuses, students in Siaya rated their confidence in providing care slightly higher in three out of four areas of maternal health: antepartum, postpartum, and newborn care, as noted previously (see Fig. 1). Discussion This study aimed to explore the situational and institutional factors influencing midwifery students’ confidence in care provision in their final year of training. Midwifery students and their faculty members emphasized the crucial role of hands-on clinical experience in developing midwifery students’ competence and confidence in care provision. Clinical rotations provide opportunities to apply theoretical knowledge and to observe experienced professionals, including their management of women experiencing obstetric complications such as severe eclampsia, PPH, and neonatal resuscitation. Students consistently reported that repeated practice and peer learning in clinical settings significantly boosted their confidence. However, several situational and institutional factors limit the effectiveness of this experience. Policy changes, particularly the transition from NHIF to SHA, reduced facility-based deliveries in Siaya County due to increased out-of-pocket costs, limiting students’ exposure to labor and delivery. Additionally, overcrowding in clinical sites at both study locations, exacerbated by the rapid expansion of training programs without corresponding facility growth, limits students’ practice opportunities. Staff shortages further compound this issue, limiting mentorship and supervision. Another prominent challenge is the gap between classroom instruction and clinical realities, with students reporting outdated theoretical content and inconsistencies between what they are taught and what they observe in practice. Resource constraints also contribute to the adoption of improvised practices that deviate from ideal protocols, especially in rural facilities where resource insufficiencies are more dire. These misalignments can lead to confusion and diminished confidence among students. Policy shifts such as Kenya’s transition from the NHIF to the SHA have significant implications for maternal health access and, by extension, midwifery training. While SHA continues to provide benefits similar to the Linda Mama program—originally designed to eliminate user fees for maternal healthcare—its new registration requirements introduced barriers for many rural women in Siaya, ultimately reducing the number of facility-based deliveries. As students in Siaya reported, challenges such as a lack of mobile phones or national identification cards made it difficult for mothers to register, pushing many to deliver at home or in lower-level facilities. This decline in hospital-based births directly limited students' exposure to practicing intrapartum care, making it harder to meet clinical requirements and shifting their practical learning toward postpartum and newborn care. In contrast, the Kisumu facility mitigated this barrier by facilitating on-site SHA registration, thereby helping to maintain access to care. These findings align with broader evidence that disruptions in health insurance, whether due to coverage gaps or administrative changes, can hinder timely access to services, particularly during critical periods such as childbirth (Jeung et al., 2022 ). As noted in prior research, the removal of user fees in SSA has been instrumental in improving service utilization and health outcomes (Calhoun et al., 2018 ). However, as this case study illustrates, such gains can be reversed if new policies inadvertently reintroduce financial or administrative obstacles. These changes negatively impact midwifery students’ training experiences, affecting their competence and confidence in care delivery, a phenomenon that has not been documented previously. Strengthening maternal health policy environments in low- and middle-income countries requires not only supportive access policies but also clear implementation mechanisms that ensure continuity of care and minimize unintended disruptions (Creanga et al., 2023 ). These findings also highlight the importance of understanding how national policies are experienced and implemented differently across diverse local contexts within the same country. The study underscores the need for ongoing, systematic efforts to gather information about local conditions that influence policy implementation. Additionally, the rapid expansion of nursing and midwifery training institutions in Kenya has outpaced the growth of clinical training sites, resulting in significant overcrowding during student placements. This mismatch—fueled by a national push to professionalize nursing through diploma and degree programs —has led to limited hands-on learning opportunities, particularly in essential procedures such as deliveries. The impact is especially acute in high-traffic facilities, such as teaching and referral hospitals, where students from multiple colleges converge, overwhelming the available resources. This overcrowding, compounded by chronic staffing shortages and an insufficient number of patients, undermines the quality of clinical learning. Nurse mentors described the dual burden of providing care while simultaneously supervising students. In several instances, students reported being left unsupervised or struggling to meet minimum delivery requirements due to the low patient-to-student ratio. These findings echo similar challenges reported in other countries, including Botswana, Malawi, and Malaysia, where over-enrollment in clinical settings led to poor supervision and hindered students’ ability to apply theoretical knowledge in practice (Chuan & Barnett, 2012 ; Mbakaya et al., 2020 ; Rajeswaran, 2017 ). The quality of clinical supervision is directly linked to the learning environment, and when the number of students exceeds available staff and equipment, educational outcomes suffer (Abuosi et al., 2022 ). In Kenya, health system decentralization has further exacerbated disparities, as county governments vary widely in how resources are allocated, with some facilities facing dire shortages in nurse staffing and infrastructure (Mbuthia et al., 2023 ). Without addressing these situational and institutional factors, including aligning student intake with placement capacity, improving staffing ratios, and ensuring adequate supervision, the country risks graduating underprepared nurses—a concerning prospect for the confidence of midwifery students and broader maternal health outcomes. Lastly, the persistent disconnect between theoretical instruction and clinical practice emerged across both Kisumu and Siaya, with students and faculty alike expressing concern over outdated classroom content and inconsistent practices in health facilities. Students highlighted instances where medications and procedures taught in lectures were no longer aligned with current clinical guidelines. Faculty members acknowledged this gap, attributing it in part to the lack of coordinated updates and collaborative training between academic institutions and clinical sites. The problem is exacerbated by resource limitations in health facilities, where students must improvise or observe nurses taking shortcuts, which undermines the ideal procedures learned in skills labs. These misalignments not only compromise students’ understanding but also diminish their confidence and ability to apply knowledge, an outcome well-documented in the literature on nursing education (Saifan et al., 2015 ; Singh et al., 2024 ). Students reported feelings of anxiety and inadequacy when clinical realities conflicted with academic instruction, a phenomenon that contributes to what some scholars describe as "transition shock" during the move from theory to practice (Jia et al., 2025 ; Ko & Kim, 2022 ; McCaugherty, 1991 ; Odetola et al., 2018 ). Further complicating the issue is the unequal distribution of training resources and patient volumes between urban and rural areas, which affects the breadth of clinical exposure and reinforces disparities in learning opportunities. These findings echo broader challenges identified in sub-Saharan Africa, where unresponsive curricula, faculty shortages, and a lack of academic-practice collaboration have strained the productive capacity of nursing education (Bvumbwe & Mtshali, 2018 ). Addressing these challenges will require deliberate investment in faculty development, infrastructure, and—critically—stronger partnerships between nursing colleges and health facilities to ensure training remains evidence-based, current, and contextually relevant. These findings prompt a critical reflection on the broader rationale behind promoting institutional births attended by skilled health professionals. The global push toward medicalizing childbirth and professionalizing midwifery has been driven by the goal of reducing maternal and neonatal mortality through timely, evidence-based interventions (Davis-Floyd, 2022 ; Hunt, 1999 ). Institutional births are intended to ensure that complications such as eclampsia, PPH, and neonatal distress are managed promptly by trained providers equipped with the necessary tools and skills (Karanja et al., 2018 ; Nawagi et al., 2023 ). In theory, this shift should improve the quality and safety of maternal care. However, the realities observed in this study call that assumption into question. While clinical placements offer students exposure to these life-saving procedures, their ability to fully participate is often undermined by structural barriers, such as reduced patient volumes combined with high numbers of students, which results in fewer opportunities for hands-on clinical experience. These constraints challenge the notion that institutional births, on their own, guarantee high-quality care. This aligns with the work of medical anthropologists and sociologists who emphasize the sociopolitical conditions shaping care delivery. In Senegal, Malawi, and Nigeria, scholars such as Suh ( 2021 ), Wendland ( 2010 ), and Oni-Orisan ( 2023 ) document how shortages of basic supplies and systemic neglect affect obstetric practice, impacting not only care provision but also women’s experiences of care, and healthcare outcomes for mothers and babies. Limitations This study has several limitations that should be acknowledged. First, the findings are based on data collected from two purposively selected KMTC campuses—one urban (Kisumu) and one rural (Siaya). While these sites were chosen to reflect contrasting training environments, their selection limits the generalizability of the results to other KMTC campuses or midwifery training institutions across Kenya and beyond. Second, our observations were limited to one component of the midwifery coursework—abnormal pregnancies and labor—thereby restricting our understanding of how other parts of the curriculum shape students’ learning experiences and confidence. We followed one cohort of first-year, second-semester students enrolled in the midwifery component of the KRCHN program from the classroom to clinical settings. However, to gain a broader perspective on how training environments influence students over time, we also conducted interviews with final-year students. This mix of observational and retrospective data may limit the comparability of findings across training stages. Lastly, we acknowledge that our presence within both the training institutions and health facilities may have impacted the settings and the behavior of participants. The lead investigator (TM) was transparent about her identity as a PhD student and her institutional affiliation, which may have influenced how students, instructors, and facility staff engaged with her during the study. Conclusion This study highlights the complex interplay between policy, infrastructure, and pedagogy in shaping midwifery students’ confidence and preparedness in Kenya. While clinical experience remains central to developing competence, systemic challenges—such as overcrowded clinical sites, outdated classroom instruction, staffing shortages, and resource constraints—limit students’ ability to translate theory into practice. Policy shifts like the transition from NHIF to SHA further restrict access to clinical learning opportunities, especially in rural settings. Bridging the gap between education and practice will require coordinated investment in academic-practice partnerships, curriculum updates, and equitable resource allocation to ensure midwifery training equips students to deliver safe, evidence-based maternal care with competence and confidence. Abbreviations International Confederation of Midwives (ICM) Kenya Demographic Health Survey (KDHS) Kenya Medical Training Colleges (KMTC) Kenya Registered Community Health Nurses (KRCHN) Maternal Mortality Ratio (MMR) National Commission for Science, Technology, and Innovation (NACOSTI) Sub-Saharan Africa (SSA) Sustainable Development Goals (SDGs) Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The study protocol received ethical approval from the Brandeis University Institutional Review Board (IRB Protocol #24251R-E Perloff [Marton], approved May 2024) and the Maseno University Scientific and Ethics Review Committee (MSU/DRPI/MUSERC/01394/24, approved September 2024). Additionally, a research license was granted by the National Commission for Science, Technology, and Innovation (NACOSTI). Final approvals were obtained from the County Governments of Siaya and Kisumu, the KMTC Headquarters, and the administrations of participating health facilities. All participants were informed about the study’s purpose and procedures and provided both written and verbal informed consent. Their contributions were anonymized to protect confidentiality. They were informed that participation was voluntary and that they could withdraw at any time. All participants were literate and able to give consent. All research materials were securely stored during data collection and reporting, and recorded audio files were deleted after transcription. A certified professional transcriptionist was hired to transcribe and translate the interview conducted in Kiswahili and Dholuo. The transcriptionists were bound to protect the confidentiality of study participants whose words they typed and translated. Availability of data and materials The data supporting the findings of this study are available upon request from the corresponding author, (TM). The data are not publicly available because they contain information that could compromise the privacy of research participants. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the American Association of University Women. The lead investigator, TM, was chosen as a recipient of the American Dissertation Fellowship for the years 2025–26. Authors' contributions TM conceptualized the study, led data collection and analysis, and drafted the initial version of the manuscript. TO assisted with data collection and analysis, and contributed to drafting the manuscript and interpreting the results. TA, MAO, CEW, and JP served as mentors to TM, supporting the study's conceptualization and providing valuable feedback on multiple drafts of the manuscript. 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UNICEF DATA. https://data.unicef.org/topic/maternal-health/maternal-mortality/ Welsh J, Hounkpatin H, Gross MM, Hanson C, Moller A-B. Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000–2020. BMC Med Educ. 2022;22(1):725. https://doi.org/10.1186/s12909-022-03772-2 . Wendland CL. (2010). A Heart for the Work: Journeys through an African Medical School. University of Chicago Press. https://press.uchicago.edu/ucp/books/book/chicago/H/bo8854910.html Wertz R, Wertz D. (2013). Notes on the decline of midwives and the rise of medical obstetricians. In The Sociology of Health and Illness . https://us.sagepub.com/en-us/nam/the-sociology-of-health-and-illness/book258978 WHO. (2025, April 7). Maternal mortality . https://www.who.int/news-room/fact-sheets/detail/maternal-mortality World Bank Group. (2025). Sub-Saharan Africa . World Bank Gender Data Portal. https://genderdata.worldbank.org/en/regions/sub-saharan-africa Yigzaw T, Ayalew F, Kim Y-M, Gelagay M, Dejene D, Gibson H, Teshome A, Broerse J, Stekelenburg J. How well does pre-service education prepare midwives for practice: Competence assessment of midwifery students at the point of graduation in Ethiopia. BMC Med Educ. 2015;15(1):130. https://doi.org/10.1186/s12909-015-0410-6 . Yuen E. (2022). Kenya and Maternal Health: Delivering Results | Think Global Health . Council on Foreign Relations. https://www.thinkglobalhealth.org/article/kenya-and-maternal-health-delivering-results Additional Declarations No competing interests reported. Supplementary Files AppendixAObservationChecklists.docx AppendixBInDepthInterviewGuides.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Editor invited by journal 18 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7123223","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501764176,"identity":"b068ba93-30d8-4cf7-8ef3-86fddacf8cda","order_by":0,"name":"Tozoe Marton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBADOQMQycMgAaIM8CrlAREHGBiMSdeSuAHOI6TFXuzws88fKu6kb5c+/OzBmwoLewb25m0SeG2RTjOeceDMs9ydfWnmhnPOSCQ28BwrI6AlwZjhYNvh3A1nGMykedskEhgkcswIaEn/DNKSbnCG/Zs07z8Jewb5N4S05IBtSTA4wwO0pUGCsUGCh4CW2znFDGfOHDbc2cNTJjnnmERiG09asQU+Leyz0zczVFQcljfnYd8m8aamzp6f/fDGG/i0YAI20pSPglEwCkbBKMAGAC15QxbgcAF9AAAAAElFTkSuQmCC","orcid":"","institution":"Brandeis University","correspondingAuthor":true,"prefix":"","firstName":"Tozoe","middleName":"","lastName":"Marton","suffix":""},{"id":501764177,"identity":"0aabfb67-2968-47d6-97ec-0c2ff410d49f","order_by":1,"name":"Tobias Odwar","email":"","orcid":"","institution":"Kisumu County","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Odwar","suffix":""},{"id":501764179,"identity":"2cd0df5d-da86-472e-9f86-faf72e0fb5bf","order_by":2,"name":"Timothy Abuya","email":"","orcid":"","institution":"Population Council - Kenya","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"","lastName":"Abuya","suffix":""},{"id":501764181,"identity":"1b522e07-8129-462f-97a2-956af68d0bc7","order_by":3,"name":"Monica Adhiambo Onyango","email":"","orcid":"","institution":"Boston University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"Adhiambo","lastName":"Onyango","suffix":""},{"id":501764182,"identity":"a7be0b5b-ad81-481b-a5d7-2f8c602333a5","order_by":4,"name":"Charlotte E Warren","email":"","orcid":"","institution":"Population Council Inc","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"E","lastName":"Warren","suffix":""},{"id":501764183,"identity":"16d59429-8c85-4b3e-b280-69b309dbe610","order_by":5,"name":"Jennifer Perloff","email":"","orcid":"","institution":"Brandeis University","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Perloff","suffix":""}],"badges":[],"createdAt":"2025-07-14 16:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7123223/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7123223/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89390457,"identity":"a101733e-f1c6-4f5e-9043-3192190113de","added_by":"auto","created_at":"2025-08-19 12:55:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84969,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7123223/v1/97b5cc452f280986a6227fe9.png"},{"id":89391063,"identity":"91074c34-8e15-463c-953b-eca212d34265","added_by":"auto","created_at":"2025-08-19 13:03:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":948833,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7123223/v1/e72a5e45-1a21-4a49-b01f-ef30da0d74ab.pdf"},{"id":89385484,"identity":"d4afe86d-98e8-4a6f-962c-d5e2cf1b9e36","added_by":"auto","created_at":"2025-08-19 12:31:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":32065,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixAObservationChecklists.docx","url":"https://assets-eu.researchsquare.com/files/rs-7123223/v1/1207d88dff526dc17691b760.docx"},{"id":89385483,"identity":"9b6456bd-b9f0-4df9-8086-31345c8903e9","added_by":"auto","created_at":"2025-08-19 12:31:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26675,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixBInDepthInterviewGuides.docx","url":"https://assets-eu.researchsquare.com/files/rs-7123223/v1/3a33aea1fcfdf19f57a30c99.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Confidence in Care Provision Among Third-Year Midwifery Students in Western Kenya","fulltext":[{"header":"Background","content":"\u003cp\u003eSafe pregnancy and childbirth are fundamental human rights (Boama \u0026amp; Arulkumaran, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Cook, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Fathalla, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Yet, each day, 810 women worldwide die due to preventable pregnancy-related issues, with 99% of these maternal deaths happening in low and lower-middle-income countries (Tessema et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Despite various interventions, preventable maternal deaths in Africa remain alarmingly high, primarily due to complications such as hemorrhage, eclampsia, sepsis, and obstructed labor (Onambele et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, systemic challenges\u0026mdash;including staffing shortages, limited healthcare accessibility, and inadequate service quality\u0026mdash;further exacerbate maternal health outcomes across many regions (Onambele et al., 2023). Though maternal mortality declined by over 40% worldwide from 2000 to 2023 (UNICEF, 2025), the rates remain unacceptably high in sub-Saharan Africa (SSA), with the region alone accounting for nearly 70% of global maternal deaths (WHO, 2025).\u003c/p\u003e\u003cp\u003eThe United Nations Sustainable Development Goals (SDGs) target 3.1 aims to reduce the global maternal mortality ratio (MMR) to fewer than 70 deaths per 100,000 live births by 2030. However, many countries in SSA remain far from achieving this target. The MMR in the SSA region was estimated at 448 deaths per 100,000 live births in 2023 (World Bank Group, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). To meet the SDG target by 2030, MMR must decline by at least 20.3% annually from 2020 (Onambele et al., 2023). However, global progress in reducing maternal mortality has stagnated, with little improvement between 2016 and 2022 (UNICEF, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). At the current rate, the world is projected to miss the SDG target, resulting in over one million preventable maternal deaths (Suzuki et al., 2023).\u003c/p\u003e\u003cp\u003eAn ongoing global initiative began in the early nineteenth century to increase facility-based delivery and reduce the high rates of maternal mortality in Africa (Hunt, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). The rationale is that facility-based births allow skilled health workers to provide impactful interventions during childbirth, such as preventing, detecting, and managing eclampsia and hemorrhage, conducting neonatal resuscitation, and intervening in other complications(Karanja et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Nawagi et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Professional midwifery\u0026mdash;the practice of birth attendants trained under the International Confederation of Midwives (ICM) standards assisting in childbirth\u0026mdash;has been identified as essential to improving maternal mortality rates. It offers services that can reduce maternal morbidity and mortality (ICM, 2019). Evidence suggests that training and regulating midwives and midwifery professionals to global standards and placing them in supportive environments reduce maternal and perinatal mortality rates (Chakraborty et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Increasing midwife-led care interventions by 25% every five years can prevent 2.2\u0026nbsp;million maternal and newborn deaths by 2035, including 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths (Chakraborty et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e This study explores the situational and institutional factors influencing the confidence of final-year nurse-midwifery students in providing care at Kenya Medical Training Colleges (KMTC). In Kenya, midwifery education is predominantly delivered through integrated nursing and midwifery programs at both diploma and degree levels in mid-level training colleges and universities. A typical example of such a program is the Kenya Registered Community Health Nursing (KRCHN), which is a diploma-level program encompassing midwifery, nursing, and community health components. For the purpose of this discussion, these nurse-midwifery students will be referred to as midwifery students. Kenya\u0026rsquo;s maternal mortality ratio was 362 per 100,000 live births in 2022. (Masaba \u0026amp; Mmusi-Phetoe, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), more than four times higher than the SDG target (Reddy et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Given the international and domestic push for facility-based births, the Kenyan government has made efforts to reduce the number of home births, particularly those that are assisted by traditional birth attendants\u0026mdash;community-based workers without formal health care training (Yuen, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Home birth rates have decreased in the country, from 56% in 1998 to 11% in 2022 (KDHS, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1998\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The country has also increased the number of trained midwives attending births, with a 68.5% rise in the number of new nurses from 1,745 to 2,941 between 2006 and 2015 (Ministry of Health, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrained midwives play a crucial role in improving women's medical outcomes and childbirth experiences (Moller et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Moloney \u0026amp; Gair, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Moridi et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Pre-service training programs designed for midwifery care providers serve as a fundamental framework for students to develop competence, which is understood as the necessary knowledge and skills required to deliver high-quality, evidence-based care. Extensive research on the impact of training curricula on midwives\u0026rsquo; competence generally shows that midwifery students possess a high level of competence by the time they graduate (B\u0026auml;ck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Baluwa et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Razavinia et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Tallam et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Welsh et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yigzaw et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, far less attention has been given to the connection between training and midwives\u0026rsquo; confidence, including within the Kenyan context. In midwifery, as well as in other health services, confidence can be understood as self-assurance underpinning the ability to use one\u0026rsquo;s knowledge and skills in a clinical setting (B\u0026auml;ck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Baluwa et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Davis et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Confidence is influenced by dispositional factors (attitudes, traits, and motivation), situational factors (which depend on personal time and resources), and institutional factors (educational programs\u0026rsquo; structure and pedagogy) (B\u0026auml;ck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Supporting students in building confidence is essential to preparing midwives who can effectively meet women's care needs, and this must be intentionally developed during training (B\u0026auml;ck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study examines the confidence of third-year midwifery students by exploring two theoretical concepts: the professionalization of midwifery and the medicalization of childbirth. The professionalization of midwifery refers to the process of establishing midwifery as a formal, regulated profession with standardized education, ethical guidelines, and integration into the broader healthcare system (Abbott, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Prosen, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wertz \u0026amp; Wertz, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This process has been deeply shaped by the medicalization of childbirth\u0026mdash;the increasing dominance of biomedical interventions, technologies, and hospital-based practices in the birthing process (Busfield, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Conrad, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1992\u003c/span\u003e; Teijlingen, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Wertz \u0026amp; Wertz, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). As childbirth became more medicalized, midwives were compelled to adapt by aligning with medical standards, often shifting from community-based practices to institutional settings. This transformation has required midwives to undergo formal training and adhere to clinical protocols, which has both enabled and constrained their practice (Wertz \u0026amp; Wertz, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The medicalization of childbirth and the professionalization of midwifery are linked to the training students undergo and their ability to build confidence, which underpins the use of competence.\u003c/p\u003e\u003cp\u003eThis paper examines how these broader dynamics influence midwifery education today, with particular focus on how situational and institutional factors (B\u0026auml;ck et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) at KMTC in Kisumu and Siaya Counties, Kenya, influence the confidence of third-year midwifery students. Although the KMTC curriculum is standardized across campuses located in rural and urban settings in Kenya, disparities in resource distribution affect students' learning experiences and knowledge acquisition (Jebet et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Using a case study approach, the study explores how situational and institutional factors, including the availability of resources in midwifery training institutions and healthcare facilities that host clinical placements, influence final-year midwifery students\u0026rsquo; confidence in delivering care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Study design\u003c/h2\u003e\n \u003cp\u003eA comparative ethnographic case study approach provided an in-depth understanding of how the training environment of midwifery students in urban and rural parts of western Kenya affects their confidence in care provision (Padgett, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Kenya faces stark urban-rural disparities in healthcare access and care provision, with resources and quality services concentrated in urban centers despite a large rural population\u0026mdash;approximately 30% of the population lives in urban areas, while the remaining 70% lives in rural communities (Moturi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Otieno et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Due to unequal access to midwifery services in Kenya\u0026apos;s rural and urban areas, a case study research approach is ideal for comparing the social and structural factors contributing to quality care provision. This paper examines midwifery training in Kisumu County (urban) and in Siaya County (rural).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Study setting\u003c/h2\u003e\n \u003cp\u003eData collection activities occurred in Kisumu and Siaya counties located within the Lake Victoria basin in western Kenya. Kisumu County presents an urban setting, while Siaya County represents a more rural environment. Kisumu is the largest city in western Kenya, encompassing a total land area of 2,085.9 square kilometers, with a population of 610,082 (Government of Kisumu, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). Siaya County encompasses a total area of 2,529.8 square kilometers. As per the 2019 Kenya Population and Housing Census, the county had a population of 993,183. Kisumu and Siaya counties are approximately 55 kilometers apart. The geographical proximity of the counties makes logistics easier for conducting comparative studies, ensuring consistent data collection methodologies across both settings. As in other counties, the healthcare system in Siaya and Kisumu includes a mix of public, private, and community-based healthcare providers. This ensures that findings can be extrapolated to inform the understanding of the national healthcare framework.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Study population\u003c/h2\u003e\n \u003cp\u003eThe Kenyan government has expanded the nursing workforce, increasing the number of nurses by 68.5% from 1,745 to 2,941 between 2006 and 2015 (Ministry of Health, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). Most healthcare workers providing midwifery care in Kenya are trained as KRCHN or hold a bachelor\u0026apos;s degree in nursing through blended programs that integrate nursing, midwifery, psychiatry, and community health. These programs are primarily offered at KMTC, as well as private and other public universities in Kenya (Ministry of Health, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eA purposive sampling approach was employed to select KMTC campuses, aiming to capture variation in midwifery training environments across different geographic and resource settings. KMTC, a government institution under the Ministry of Health, trains over 85% of Kenya\u0026rsquo;s healthcare workforce through its 72 campuses nationwide (KMTC, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). From the available campuses\u0026mdash;three in Kisumu and two in Siaya\u0026mdash;one was selected from each county based on two key criteria: the size of the student body and proximity to a referral health facility used for clinical placements. These criteria ensured that the selected campuses offered both sufficient student engagement for observation and accessible clinical practice settings. This purposive strategy allowed the gathering of rich, context-specific data while comparing urban and rural training conditions relevant to Kenya\u0026rsquo;s broader healthcare delivery challenges.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Study sample and recruitment\u003c/h2\u003e\n \u003cp\u003eA total of 35 participants were included in the study: 24 third-year nurse-midwifery students, three lecturers, four clinical mentors (nurses and midwives at health facilities who guide students through their clinical experience), and four administrative staff members. Following ethics approval in Kenya, the lead investigator (TM) coordinated with the Deputy Director of Research at the KMTC headquarters in Nairobi, Kenya. The Deputy Director issued letters of approval, which were delivered to the principals of each participating campus. With the principals\u0026rsquo; assistance, the research team gained access to the student rosters for the KRCHN program\u0026mdash;a three-year curriculum that integrates general nursing, community health, and midwifery training. By design, all students recruited for interviews were in their third year, had completed their midwifery coursework, and were actively engaged in clinical rotations at health facilities. Gender balance was also considered in the selection process to ensure equal representation of female and male students. Once the list of 12 students per campus was finalized, the principals facilitated initial contact with the students. All 24 students who were approached agreed to participate and provided informed consent prior to their interviews. Classroom lecturers, clinical mentors, and administrative staff who directly interacted with these students were recruited based on availability and also provided informed consent prior to their participation. Participants in the in-depth interviews were required to be at least 18 years of age, affiliated with either the Kisumu or Siaya campuses involved in the study, and fluent in one of the study languages, namely English, Kiswahili, or Dholuo.\u003c/p\u003e\n \u003cp\u003eThe student participants ranged in age from 20 to 40 years, with a mean age of 24, and were evenly distributed by gender (12 males and 12 females). All lecturers and nurse mentors were female, with ages ranging from 25 to 61 years (mean age, 48 years). On average, they had nine years of teaching experience and 21 years of professional experience in nursing or midwifery. The administrative staff participants included the Head of the Department of Nursing and the principals of the participating schools. They ranged in age from 40 to 57 years, with an average of 47 years, and had held their positions for an average of seven years. Additional demographic details of the in-depth interview participants are provided in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Profile of In-depth Interview Participants*\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSiaya\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKisumu\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eThird-Year Nurse-Midwifery Students\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eN\u0026thinsp;=\u0026thinsp;12\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eN\u0026thinsp;=\u0026thinsp;12\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eN\u0026thinsp;=\u0026thinsp;24\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in Years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstructors (Lecturers and Nurse Mentors)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears as Instructor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears Practicing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears at Training Institution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministration Head of Departments and Principals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears at Training Institution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e*Mean (SD); n\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Data collection\u003c/h2\u003e\n \u003cp\u003ePrior to data collection, the research team, which included a Kenyan regulatory officer (TO) who supported the ethics approval process and two Kenyan research assistants, participated in a four-day training on the study protocol. One research assistant is an experienced qualitative researcher from Siaya County, while the other is a trained nurse and clinical researcher from Kisumu County. The three Kenyan team members brought extensive knowledge of Luo cultural norms and practices in Western Kenya, which was critical in developing culturally appropriate data collection tools and in guiding the research process. The training was designed to ensure a shared understanding of the study\u0026rsquo;s objectives, methodology, and ethical procedures.\u003c/p\u003e\n \u003cp\u003eData collection took place at the Siaya and Kisumu campuses between October and December 2024. Fieldwork at both sites was conducted concurrently. The team began in Siaya, where all members collaborated on interviews and observations during the first three days to ensure consistency in data collection techniques. Following this initial phase, the research assistants divided responsibilities: One led data collection activities in Kisumu, while the other continued fieldwork in Siaya. The lead investigator (TM) alternated between locations, providing supervision and ongoing support throughout the data collection period. Two primary types of qualitative data were collected: participant observations and in-depth interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6 Participant Observations\u003c/h2\u003e\n \u003cp\u003eThe research team conducted participant observation by following midwifery students from classroom lectures to their clinical rotations at local health facilities. On both campuses, we attended lectures for one week (five weekdays), specifically observing first-year, second-semester students enrolled in the midwifery component of the KRCHN program. These sessions focused on the \u003cem\u003eMaternal and Newborn II\u003c/em\u003e unit, which covers abnormal pregnancy and childbirth. During classroom sessions, we observed the students and took detailed notes on the content delivered, instructional style, student engagement, and learning environment.\u003c/p\u003e\n \u003cp\u003eFollowing the classroom observations, we accompanied the same cohort of students into clinical settings where they applied their knowledge in practice. At the facility staff\u0026apos;s request, we wore student uniforms to blend in and reduce disruption, although students, faculty, and staff were aware of the research. In the facilities, we observed births and noted how the clinical learning environment supported or constrained effective learning and care delivery. We also paid close attention to the social dynamics that shaped students\u0026rsquo; experiences. Observations were guided by a structured checklist (see Appendix A), and detailed field notes were recorded in English, documenting how both classroom and clinical environments influenced students\u0026rsquo; confidence and preparedness to deliver maternal and newborn care.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e2.7 In-depth Interviews\u003c/h2\u003e\n \u003cp\u003eIn addition to observations, the research team conducted in-depth interviews with key stakeholders involved in midwifery training. Participants included third-year midwifery students, classroom lecturers, clinical mentors, and administrative staff at each training institution (see Appendix B for sample guides). With guidance from reproductive health researchers at the Population Council in Kenya, semi-structured interview guides were developed for each participant group. These guides explored perceptions of how classroom and clinical training environments influence students\u0026rsquo; ability to provide care. To ensure clarity and relevance, the guides were pilot-tested with two participants prior to formal data collection.\u003c/p\u003e\n \u003cp\u003eInterviews were conducted in private settings within the training institutions, using English, Dholuo, or Kiswahili, the three most commonly spoken languages in Western Kenya. This allowed participants to choose the language they felt most comfortable with. The English guides were professionally translated into Dholuo and Kiswahili, and interviews in those languages were conducted by LO and SO, who are fluent in all three languages. All interviews were audio recorded with participants\u0026rsquo; consent. English-language interviews were transcribed verbatim by the research team, while those conducted in Dholuo and Kiswahili were transcribed and translated into English by a certified transcriptionist based in Kisumu city. As part of the interviews with students, participants were also asked to self-assess their confidence in providing care across four domains\u0026mdash;antenatal, intrapartum, postnatal, and newborn\u0026mdash;using a 10-point scale, on which 1 indicated no confidence and 10 represented very high confidence.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e2.8 Data Analysis\u003c/h2\u003e\n \u003cp\u003eData analysis was conducted iteratively by the lead investigator (TM) alongside ongoing data collection, allowing for the identification of emerging themes and the refinement of the study approach (Fife, 2005; Weiss, 1995). Ongoing rapid analysis of interview transcripts and field notes enabled the research team to detect major patterns and themes early in the process. These insights informed adjustments to subsequent interviews, including the integration of targeted follow-up questions to explore key themes in greater depth (Fife, 2005). Throughout data collection, TM, SO, and LO collaboratively drafted analytic memos to document emerging themes at each study site. Weekly team meetings were held to review and discuss these memos, laying the groundwork for the initial development of the study codebook.\u003c/p\u003e\n \u003cp\u003eFollowing the completion of data collection, the codebook was refined through a systematic review of the data using ATLAS.ti 25.0. The lead investigator (TM) reread a sample of 10 transcripts from each site, along with accompanying field notes, to inform further revisions. This refined codebook was then applied to the entire dataset for thematic coding and analysis. The combination of iterative memoing and structured coding ensured a comprehensive interpretation of the data, capturing the complexity of midwifery training and work environments across the two sites (Weiss, 1995). To enhance the credibility and validity of the findings, preliminary results were presented to key stakeholders, including midwifery educators, students, and healthcare providers, via a PowerPoint presentation and informational flyers. A discussion session followed, during which stakeholders provided feedback on the findings. This feedback was incorporated into final revisions to the coding process, strengthening the trustworthiness of the analysis and ensuring that the results accurately reflected on-the-ground experiences in midwifery training and practice. STATA SE 18.0 was used to calculate the average confidence ratings of students.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Findings","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Average Confidence Ratings\u003c/h2\u003e\n\u003cp\u003eThe students were asked to rate their confidence in providing care across four maternal care domains\u0026mdash;Antenatal, Intrapartum, Postpartum, and Newborn\u0026mdash;on a scale of 1 to 10, with 1 indicating no confidence and 10 indicating high confidence. While the differences in confidence ratings between students from Siaya and Kisumu were not statistically significant given the small sample, Siaya students reported slightly higher confidence levels on average in three of the four domains (see Fig.\u0026nbsp;1). Importantly, in postpartum care, Siaya students reported an average confidence rating of 8.9, one point higher than the 7.9 reported by Kisumu students. Similarly, in newborn care, Siaya students had an average confidence rating of 9.1, compared to 8.3 for Kisumu students.\u003c/p\u003e\n\u003cp\u003eQualitative analysis of interviews with students and their faculty members revealed two central themes: (1) the importance of hands-on clinical experience in fostering students' confidence, and (2) the various situational and institutional factors that influence the quality and extent of clinical exposure during their training. The findings are presented in accordance with these two themes:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(1) Hands-on Clinical Experience\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne key theme that emerged in the interviews is the role of hands-on clinical experience in boosting the students\u0026rsquo; confidence in care provision. Students, lecturers, clinical mentors, and administrative staff across both KMTCs emphasized that clinical rotations in healthcare facilities are a crucial component of midwifery training. These rotations offer students hands-on experience in real-world clinical settings, strengthening their practical skills and building confidence in patient care. As one lecturer in Siaya explained, \u003cem\u003e\u0026ldquo;In midwifery, you learn by doing. The more you do, the more you learn\u0026rdquo;\u003c/em\u003e (Female lecturer, Siaya). Students at the Siaya and Kisumu KMTC campuses highlighted that clinical rotations not only allow them to learn from experienced midwives but also provide opportunities for peer learning alongside students from KMTC and other training institutions. A student from Kisumu further explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eWhen I was performing vaginal examinations, at first, it was hard to get the right findings, but with time, I was able to be taught by a nurse, and I was improving myself to the point that when the nurse could confirm my vaginal examination, she gets the same findings that I get. So, it gives me the confidence to do more\u003c/em\u003e (Female student, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eA student from Siaya added, \u003cem\u003e\u0026ldquo;When you see another student delivering a woman, you feel like, \u0026lsquo;Ehh, this thing is so hard.\u0026rsquo; But if you yourself try to, for the first time, you do it today, tomorrow, and then you continue, you feel like this thing is so easy. And boost your confidence\u0026rdquo;\u003c/em\u003e (Male student, Siaya). Being guided by qualified nurses and learning from other students helps students build their skills and boost their confidence in providing care.\u003c/p\u003e\n\u003cp\u003eStudents also highlighted the management of obstetric complications during clinical rotations as crucial to building their confidence as care providers. A student from Kisumu emphasized that these rotations offer firsthand exposure to maternal complications, explaining:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eYou get to see the pregnant mother herself, how contractions occur. You get to see how the baby is born, how the cervix dilates\u0026hellip;. if the baby develops a complication during delivery, you learn how to resuscitate the baby so that the baby can come back to life. You gain a lot of knowledge, and it builds your confidence\u003c/em\u003e (Male student, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSimilarly, a student from Siaya recalled managing a pregnant woman with eclampsia, describing the initial fear and uncertainty but also the learning opportunity it provided:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eManaging a mother with eclampsia\u0026mdash;those are the women that mostly come with teachings\u0026hellip;. You feel like, \u0026lsquo;God, I\u0026rsquo;m terrified.\u0026rsquo; But when you see how qualified nurses manage them, it gives you more confidence\u003c/em\u003e (Male student, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThese experiences highlight the essential role of applied clinical practice in enhancing students' learning and confidence. Gaining hands-on experience under the supervision of skilled professionals is crucial, as it allows students to develop the confidence needed for effective care provision. While all the study participants underlined the significance of hands-on experience in fostering students' confidence in care provision, they also identified various challenges both within and beyond the training institution\u0026mdash;such as changes in health policy, resource and staff shortages, and overcrowding of students in facilities\u0026mdash;that hinder the learning process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2) Situational and Institutional Factors Affecting Hands-on Clinical Experience\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e2a. Shifts in Maternal Health Policy\u003c/h3\u003e\n\u003cp\u003eData collection at the Siaya and Kisumu campuses took place between October and December 2024, during the early stages of implementing the Social Health Authority (SHA) insurance scheme. Prior to SHA, Linda Mama, which was introduced in 2013 under the National Health Insurance Fund (NHIF), offered benefits such as antenatal, delivery, and postnatal care. It was placed under SHA, which was launched on October 1, 2024, and required women to register using a personal mobile phone and a Kenyan Identification Card. Under SHA, the Linda Mama program continues, but access to these services now depends on SHA registration, a policy change that reduced women's access to healthcare. This, in turn, has implications for students\u0026rsquo; hands-on experience during clinical rotations, as discussed here and in 2b.\u003c/p\u003e\n\u003cp\u003eStudents in Siaya were the only ones among the two campuses who mentioned the impact of the transition from NHIF to SHA on their hands-on clinical experience. A female student explained that mothers are \u003cem\u003e\u0026ldquo;supposed to activate their details with SHA. Most of them had a challenge with that\u0026rdquo;\u003c/em\u003e (Female student, Siaya). Another student added, \u003cem\u003e\u0026ldquo;Without SHA, mothers must pay 10,000 Kenyan Shillings [~\u0026thinsp;79 USD] for a normal delivery and 20,000 Kenyan Shillings for a cesarean section\u0026rdquo;\u003c/em\u003e (Male student, Siaya). Given the rural setting of Siaya, many women cannot afford these costs. A student noted, \u003cem\u003e\u0026ldquo;Some [mothers] say the charges for delivery are too high; they cannot afford them. So, some of them prefer to deliver at home\u0026rdquo;\u003c/em\u003e (Female student, Siaya). Another agreed, stating that mothers would \u003cem\u003e\u0026ldquo;rather go to the dispensaries, their homes, or traditional [birth attendants]\u0026rdquo;\u003c/em\u003e (Male student, Siaya).\u003c/p\u003e\n\u003cp\u003eIn contrast, Kisumu students did not mention any impact of the policy shift on their clinical experience. This might be because Kisumu facilities implemented a SHA registration system at their entrances, which Siaya facilities lacked. This system allowed women to register upon arrival. During observations at the Kisumu study site, the in-charge nurse at the facility where students conducted their clinical work explained that all women must first stop at the SHA registration desk before receiving care. When asked whether this applied to women in active labor who had not registered under SHA, the nurse confirmed, \u0026ldquo;\u003cem\u003eYes\u003c/em\u003e.\u0026rdquo; Because women attending these facilities could register on-site, the cost was not a barrier, and no Kisumu students reported challenges related to SHA or a decline in patient numbers.\u003c/p\u003e\n\u003cp\u003eHowever, in Siaya, as more women opt to give birth at home or in dispensaries, fewer are seeking care at formal health facilities, reducing the number of pregnant or postpartum women students encounter during their rotations. A female student noted that she was struggling to meet the required number of deliveries before being assessed through examinations. She said, \u003cem\u003e\u0026ldquo;Before you do this assessment, you have to have delivered about 15 mothers\u0026hellip;But there are no mothers coming to the labor room\u0026hellip;By the time you are doing the assessment, you have delivered seven women\u0026rdquo;\u003c/em\u003e (Female student, Siaya).\u003c/p\u003e\n\u003cp\u003eShe further explained that many mothers only come to the hospital after giving birth, often with complications such as retained placenta, meaning students assist with placenta delivery rather than full deliveries. As a result, Siaya students reported gaining more experience with postpartum care than with intrapartum care, which aligns with their higher self-ratings in postpartum and newborn care compared to intrapartum care (see Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003e2b. Overcrowding of Students within Facilities\u003c/h3\u003e\n\u003cp\u003eThe government\u0026rsquo;s rapid expansion of nursing training institutions in Kenya that began in 2006, which was not coupled with an expansion in the number of health facilities or in the size of existing ones, has led to overcrowding of students at sites available for clinical placement. As a result, although students can observe clinical practice, they often have fewer opportunities to practice essential procedures, such as deliveries, themselves. An administrative staff member from Kisumu highlighted this challenge, stating:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eYou find that the hospitals are not growing [in number], but the nursing training is growing. We have so many students, but the clinical areas [meaning the facilities that host clinical training] are not growing so much\u003c/em\u003e (Female administrative staff, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eA student from Siaya echoed this concern, explaining, \u003cem\u003e\u0026ldquo;[This] hospital is a teaching and referral hospital, so many KMTCs come here for their [clinical] rotation\u0026rdquo;\u003c/em\u003e (Female student, Siaya).\u003c/p\u003e\n\u003cp\u003eThis overcrowding can hinder effective training, as a nurse mentor from Siaya noted, \u003cem\u003e\u0026ldquo;It\u0026rsquo;s difficult sometimes to train a large group\u0026rdquo;\u003c/em\u003e (Female nurse mentor, Siaya). The issue is further exacerbated by staffing shortages and a limited number of women seeking care at these facilities. A nurse mentor from Kisumu described the challenge of providing adequate supervision, explaining:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eIn KMTC you get the number of lecturers is very few, so it\u0026rsquo;s really a challenge for them to make a follow-up in the clinical setup. Now, that means that nurses in the clinical setup do a lot of the support for the students. They should mentor the students and do their work at the same time, which is really a big challenge\u003c/em\u003e (Female nurse mentor, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSimilarly, a lecturer from Siaya emphasized the overwhelming workload faced by qualified nurses, which restricts their ability to train students effectively. She said:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eSometimes, the workload down there [at the facility] does not allow for proper guidance and training by the nurse. Sometimes, you find one nurse in the labor ward, running from taking the mother to the theater, receiving the baby, and conducting deliveries\u0026hellip;.you find students on their own because of the workload and the staff shortages there.\u003c/em\u003e (Female lecturer, Siaya)\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAnother lecturer from Siaya reinforced this concern, noting, \u003cem\u003e\u0026ldquo;The staff issue also affects the degree to which the students can have a one-on-one mentorship with the supervisors\u0026rdquo;\u003c/em\u003e (Female lecturer, Siaya). Compounding these challenges is the low number of women attending facilities for care, particularly at the Siaya training site. A female student described the imbalance between students and patients, stating, \u003cem\u003e\u0026ldquo;In [a] shift, you can find yourself, you\u0026rsquo;re almost 15 students. The mothers who are in the labor ward, there are two mothers, so you cannot all deliver\u0026rdquo;\u003c/em\u003e (Female student, Siaya). Another student added, \u003cem\u003e\u0026ldquo;Even during duty allocation, you\u0026rsquo;ll find one patient against even five students\u0026rdquo;\u003c/em\u003e (Female student, Siaya).\u003c/p\u003e\n\u003cp\u003eDue to this shortage of clinical opportunities, many students struggle to meet their required number of deliveries. One student recalled, \u003cem\u003e\u0026ldquo;So far, I have delivered only seven deliveries. But you are supposed to have at least 10 before you get to do your assessments\u0026rdquo;\u003c/em\u003e (Female student, Siaya). Without sufficient hands-on experience, students may graduate lacking the confidence and skills needed for independent practice, highlighting the urgent need to improve situational and institutional factors, such as overcrowding during clinical rotations and the shortage of qualified midwives.\u003c/p\u003e\n\u003ch3\u003e2c. Gaps Between Classroom Instruction and Clinical Practice\u003c/h3\u003e\n\u003cp\u003eIn Siaya and Kisumu, participants pointed out a major gap between classroom instruction and real-world practice. This institutional factor remains a major concern for participants on both campuses, although more students in Siaya discussed the issue than those in Kisumu. One student from Siaya pointed out that some medications discussed in class have already become obsolete by the time they begin clinical practice. This student stressed the importance of lecturers staying updated alongside regular textbook revisions to ensure students receive current medical knowledge. Students also described instances where they challenged qualified nurses about certain medications or procedures during clinical placements, only to find that the information they had been taught was outdated. One student illustrated this issue with an example from suturing:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eWhen suturing, for example, the earlier practice, which most of the lecturers here know and always teach us, is that when suturing, you get cotton and pad inside to prevent the blood from oozing outside. But the recent practice says that we do not pad because there might be postpartum hemorrhage, and it might be obstructed\u003c/em\u003e (Male student, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAnother student reinforced this concern, specifically mentioning discrepancies in how labor progression is monitored, \u003cem\u003e\u0026ldquo;Maybe in class, we learned that we start partograph at four-[centimeters] dilation of the cervix. When you go to work [at the facility], they [qualified nurses] tell you, \u0026lsquo;No, that is outdated. Nowadays, it starts at six or five\u0026rdquo;\u003c/em\u003e (Male student, Siaya). Lecturers also acknowledged this issue, recognizing the challenge of keeping academic instruction aligned with evolving clinical guidelines. A lecturer from Siaya explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eThere are a lot of updates and a lot of changes happening day in and day out. The updates do not focus much on the lecturers; they focus on the clinical area. So, you could be training in the use of a partograph according to what is in the books, and there are already changes. You are telling them [the students] that the active phase of labor begins at four centimeters. When you go to the clinical area to assess them, you find that it\u0026rsquo;s now five centimeters\u003c/em\u003e (Female lecturer, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSimilarly, a lecturer from Kisumu emphasized the lack of collaboration between classroom instructors and healthcare facilities that provide clinical training. She noted:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eWhat I noticed most of the time, there needs to be a collaboration with the hospitals so that in case of a training, the lecturers are also involved in the training. Otherwise, I find you are just giving old information\u003c/em\u003e (Female lecturer, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe disconnect between classroom teaching and clinical practice often leads to confusion for students when they encounter discrepancies between what they\u0026rsquo;ve learned in class and what\u0026rsquo;s expected in healthcare settings. Students highlighted that this disconnect between classroom instruction and real-world clinical practice directly affects their confidence. A student from Kisumu described how conflicting guidance from lecturers and clinical mentors undermines their confidence, stating:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eThere is a conflicting interest because you'll explain to the midwife, \u0026lsquo;We were taught like this,\u0026rsquo; and then he's telling you, \u0026lsquo;Leave that alone, you shouldn't do this.\u0026rsquo; So, it drains your confidence in doing things\u0026hellip;because I'm not sure whether what I'm going to do is right or maybe [there\u0026rsquo;s] another way of thinking\u003c/em\u003e (Male student, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eBeyond these discrepancies, students and faculty also acknowledged that resource constraints further contribute to the gap between theoretical knowledge and practical application. An administrative staff member from Siaya explained:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eWe teach ideal according to the nursing council manual\u0026hellip;.We go to our skills lab; we do ideal. But now, when you go to the clinical area, because of shortage of resources, [nurses take] shortcuts. So now the students, because they are there for a longer time than what we have here [at the school], they end up adopting the shortcuts. So, when you go for assessments, the students are confused. You taught about this in class, and you taught about this in the skills lab, but they've never seen it in the clinical area.\u003c/em\u003e (Female administrative staff, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eA student from Kisumu echoed this concern, emphasizing the challenges posed by limited resources:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026rsquo;s the ideal and the actual thing that is happening. You find in the hospital, we don\u0026rsquo;t do the ideal. We do what is there; we improvise because the ideal is expensive or we don\u0026rsquo;t have the machinery for the ideal thing\u003c/em\u003e (Male student, Siaya).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eImportantly, faculty members at both campuses acknowledged that unequal resource distribution between urban and rural areas impacts students\u0026rsquo; training experience. A lecturer from Kisumu explained this situational factor stating:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eMaybe the training in rural in terms of facilities [and]equipment, are not available, as opposed to urban. You might find that it can impact [the students\u0026rsquo; confidence]. If you have this student who has just trained in the rural, then maybe they are not as exposed as the one in the urban, because in the urban, they have more equipment [and] facilities. You [as a student] see things like incubators [in urban facilities], but in the rural [facilities], incubators are not there, and that's why you find, say you have a baby delivered preterm in the rural, they are not able to manage...They refer [the baby to another facility]\u003c/em\u003e (Female Lecturer, Kisumu).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThough this view is commonly held by faculty on both campuses, students in Siaya rated their confidence in providing care slightly higher in three out of four areas of maternal health: antepartum, postpartum, and newborn care, as noted previously (see Fig.\u0026nbsp;1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the situational and institutional factors influencing midwifery students\u0026rsquo; confidence in care provision in their final year of training. Midwifery students and their faculty members emphasized the crucial role of hands-on clinical experience in developing midwifery students\u0026rsquo; competence and confidence in care provision. Clinical rotations provide opportunities to apply theoretical knowledge and to observe experienced professionals, including their management of women experiencing obstetric complications such as severe eclampsia, PPH, and neonatal resuscitation. Students consistently reported that repeated practice and peer learning in clinical settings significantly boosted their confidence. However, several situational and institutional factors limit the effectiveness of this experience. Policy changes, particularly the transition from NHIF to SHA, reduced facility-based deliveries in Siaya County due to increased out-of-pocket costs, limiting students\u0026rsquo; exposure to labor and delivery. Additionally, overcrowding in clinical sites at both study locations, exacerbated by the rapid expansion of training programs without corresponding facility growth, limits students\u0026rsquo; practice opportunities. Staff shortages further compound this issue, limiting mentorship and supervision. Another prominent challenge is the gap between classroom instruction and clinical realities, with students reporting outdated theoretical content and inconsistencies between what they are taught and what they observe in practice. Resource constraints also contribute to the adoption of improvised practices that deviate from ideal protocols, especially in rural facilities where resource insufficiencies are more dire. These misalignments can lead to confusion and diminished confidence among students.\u003c/p\u003e\u003cp\u003ePolicy shifts such as Kenya\u0026rsquo;s transition from the NHIF to the SHA have significant implications for maternal health access and, by extension, midwifery training. While SHA continues to provide benefits similar to the Linda Mama program\u0026mdash;originally designed to eliminate user fees for maternal healthcare\u0026mdash;its new registration requirements introduced barriers for many rural women in Siaya, ultimately reducing the number of facility-based deliveries. As students in Siaya reported, challenges such as a lack of mobile phones or national identification cards made it difficult for mothers to register, pushing many to deliver at home or in lower-level facilities. This decline in hospital-based births directly limited students' exposure to practicing intrapartum care, making it harder to meet clinical requirements and shifting their practical learning toward postpartum and newborn care. In contrast, the Kisumu facility mitigated this barrier by facilitating on-site SHA registration, thereby helping to maintain access to care. These findings align with broader evidence that disruptions in health insurance, whether due to coverage gaps or administrative changes, can hinder timely access to services, particularly during critical periods such as childbirth (Jeung et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As noted in prior research, the removal of user fees in SSA has been instrumental in improving service utilization and health outcomes (Calhoun et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, as this case study illustrates, such gains can be reversed if new policies inadvertently reintroduce financial or administrative obstacles. These changes negatively impact midwifery students\u0026rsquo; training experiences, affecting their competence and confidence in care delivery, a phenomenon that has not been documented previously. Strengthening maternal health policy environments in low- and middle-income countries requires not only supportive access policies but also clear implementation mechanisms that ensure continuity of care and minimize unintended disruptions (Creanga et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These findings also highlight the importance of understanding how national policies are experienced and implemented differently across diverse local contexts within the same country. The study underscores the need for ongoing, systematic efforts to gather information about local conditions that influence policy implementation.\u003c/p\u003e\u003cp\u003eAdditionally, the rapid expansion of nursing and midwifery training institutions in Kenya has outpaced the growth of clinical training sites, resulting in significant overcrowding during student placements. This mismatch\u0026mdash;fueled by a national push to professionalize nursing through diploma and degree programs \u0026mdash;has led to limited hands-on learning opportunities, particularly in essential procedures such as deliveries. The impact is especially acute in high-traffic facilities, such as teaching and referral hospitals, where students from multiple colleges converge, overwhelming the available resources. This overcrowding, compounded by chronic staffing shortages and an insufficient number of patients, undermines the quality of clinical learning. Nurse mentors described the dual burden of providing care while simultaneously supervising students. In several instances, students reported being left unsupervised or struggling to meet minimum delivery requirements due to the low patient-to-student ratio. These findings echo similar challenges reported in other countries, including Botswana, Malawi, and Malaysia, where over-enrollment in clinical settings led to poor supervision and hindered students\u0026rsquo; ability to apply theoretical knowledge in practice (Chuan \u0026amp; Barnett, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Mbakaya et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Rajeswaran, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The quality of clinical supervision is directly linked to the learning environment, and when the number of students exceeds available staff and equipment, educational outcomes suffer (Abuosi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Kenya, health system decentralization has further exacerbated disparities, as county governments vary widely in how resources are allocated, with some facilities facing dire shortages in nurse staffing and infrastructure (Mbuthia et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Without addressing these situational and institutional factors, including aligning student intake with placement capacity, improving staffing ratios, and ensuring adequate supervision, the country risks graduating underprepared nurses\u0026mdash;a concerning prospect for the confidence of midwifery students and broader maternal health outcomes.\u003c/p\u003e\u003cp\u003eLastly, the persistent disconnect between theoretical instruction and clinical practice emerged across both Kisumu and Siaya, with students and faculty alike expressing concern over outdated classroom content and inconsistent practices in health facilities. Students highlighted instances where medications and procedures taught in lectures were no longer aligned with current clinical guidelines. Faculty members acknowledged this gap, attributing it in part to the lack of coordinated updates and collaborative training between academic institutions and clinical sites. The problem is exacerbated by resource limitations in health facilities, where students must improvise or observe nurses taking shortcuts, which undermines the ideal procedures learned in skills labs. These misalignments not only compromise students\u0026rsquo; understanding but also diminish their confidence and ability to apply knowledge, an outcome well-documented in the literature on nursing education (Saifan et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Singh et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Students reported feelings of anxiety and inadequacy when clinical realities conflicted with academic instruction, a phenomenon that contributes to what some scholars describe as \"transition shock\" during the move from theory to practice (Jia et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Ko \u0026amp; Kim, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; McCaugherty, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1991\u003c/span\u003e; Odetola et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Further complicating the issue is the unequal distribution of training resources and patient volumes between urban and rural areas, which affects the breadth of clinical exposure and reinforces disparities in learning opportunities. These findings echo broader challenges identified in sub-Saharan Africa, where unresponsive curricula, faculty shortages, and a lack of academic-practice collaboration have strained the productive capacity of nursing education (Bvumbwe \u0026amp; Mtshali, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Addressing these challenges will require deliberate investment in faculty development, infrastructure, and\u0026mdash;critically\u0026mdash;stronger partnerships between nursing colleges and health facilities to ensure training remains evidence-based, current, and contextually relevant.\u003c/p\u003e\u003cp\u003eThese findings prompt a critical reflection on the broader rationale behind promoting institutional births attended by skilled health professionals. The global push toward medicalizing childbirth and professionalizing midwifery has been driven by the goal of reducing maternal and neonatal mortality through timely, evidence-based interventions (Davis-Floyd, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hunt, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Institutional births are intended to ensure that complications such as eclampsia, PPH, and neonatal distress are managed promptly by trained providers equipped with the necessary tools and skills (Karanja et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Nawagi et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In theory, this shift should improve the quality and safety of maternal care. However, the realities observed in this study call that assumption into question. While clinical placements offer students exposure to these life-saving procedures, their ability to fully participate is often undermined by structural barriers, such as reduced patient volumes combined with high numbers of students, which results in fewer opportunities for hands-on clinical experience. These constraints challenge the notion that institutional births, on their own, guarantee high-quality care. This aligns with the work of medical anthropologists and sociologists who emphasize the sociopolitical conditions shaping care delivery. In Senegal, Malawi, and Nigeria, scholars such as Suh (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), Wendland (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), and Oni-Orisan (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) document how shortages of basic supplies and systemic neglect affect obstetric practice, impacting not only care provision but also women\u0026rsquo;s experiences of care, and healthcare outcomes for mothers and babies.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations that should be acknowledged. First, the findings are based on data collected from two purposively selected KMTC campuses\u0026mdash;one urban (Kisumu) and one rural (Siaya). While these sites were chosen to reflect contrasting training environments, their selection limits the generalizability of the results to other KMTC campuses or midwifery training institutions across Kenya and beyond. Second, our observations were limited to one component of the midwifery coursework\u0026mdash;abnormal pregnancies and labor\u0026mdash;thereby restricting our understanding of how other parts of the curriculum shape students\u0026rsquo; learning experiences and confidence. We followed one cohort of first-year, second-semester students enrolled in the midwifery component of the KRCHN program from the classroom to clinical settings. However, to gain a broader perspective on how training environments influence students over time, we also conducted interviews with final-year students. This mix of observational and retrospective data may limit the comparability of findings across training stages. Lastly, we acknowledge that our presence within both the training institutions and health facilities may have impacted the settings and the behavior of participants. The lead investigator (TM) was transparent about her identity as a PhD student and her institutional affiliation, which may have influenced how students, instructors, and facility staff engaged with her during the study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complex interplay between policy, infrastructure, and pedagogy in shaping midwifery students\u0026rsquo; confidence and preparedness in Kenya. While clinical experience remains central to developing competence, systemic challenges\u0026mdash;such as overcrowded clinical sites, outdated classroom instruction, staffing shortages, and resource constraints\u0026mdash;limit students\u0026rsquo; ability to translate theory into practice. Policy shifts like the transition from NHIF to SHA further restrict access to clinical learning opportunities, especially in rural settings. Bridging the gap between education and practice will require coordinated investment in academic-practice partnerships, curriculum updates, and equitable resource allocation to ensure midwifery training equips students to deliver safe, evidence-based maternal care with competence and confidence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eInternational Confederation of Midwives (ICM)\u003c/p\u003e\n\u003cp\u003eKenya Demographic Health Survey (KDHS)\u003c/p\u003e\n\u003cp\u003eKenya Medical Training Colleges (KMTC)\u003c/p\u003e\n\u003cp\u003eKenya Registered Community Health Nurses (KRCHN)\u003c/p\u003e\n\u003cp\u003eMaternal Mortality Ratio (MMR)\u003c/p\u003e\n\u003cp\u003eNational Commission for Science, Technology, and Innovation (NACOSTI)\u003c/p\u003e\n\u003cp\u003eSub-Saharan Africa (SSA)\u003c/p\u003e\n\u003cp\u003eSustainable Development Goals (SDGs)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The study protocol received ethical approval from the Brandeis University Institutional Review Board (IRB Protocol #24251R-E Perloff [Marton], approved May 2024) and the Maseno University Scientific and Ethics Review Committee (MSU/DRPI/MUSERC/01394/24, approved September 2024). Additionally, a research license was granted by the National Commission for Science, Technology, and Innovation (NACOSTI). Final approvals were obtained from the County Governments of Siaya and Kisumu, the KMTC Headquarters, and the administrations of participating health facilities. All participants were informed about the study\u0026rsquo;s purpose and procedures and provided both written and verbal informed consent. Their contributions were anonymized to protect confidentiality. They were informed that participation was voluntary and that they could withdraw at any time. All participants were literate and able to give consent. All research materials were securely stored during data collection and reporting, and recorded audio files were deleted after transcription. A certified professional transcriptionist was hired to transcribe and translate the interview conducted in Kiswahili and Dholuo. The transcriptionists were bound to protect the confidentiality of study participants whose words they typed and translated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available upon request from the corresponding author, (TM). The data are not publicly available because they contain information that could compromise the privacy of research participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis research was funded by the American Association of University Women. The lead investigator, TM, was chosen as a recipient of the American Dissertation Fellowship for the years 2025\u0026ndash;26.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTM conceptualized the study, led data collection and analysis, and drafted the initial version of the manuscript. TO assisted with data collection and analysis, and contributed to drafting the manuscript and interpreting the results. TA, MAO, CEW, and JP served as mentors to TM, supporting the study's conceptualization and providing valuable feedback on multiple drafts of the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to all the midwifery students and faculty members who generously dedicated their time to participate in this study. Their involvement was indispensable to the success of this research. We also acknowledge the leadership of the Kenya Medical Training Colleges for their support, including granting permission to collect data and facilitating access to the institutions. Our thanks extend to our research assistants, Sophie Otticha and Lindah Oyango, for their diligent efforts in collecting the data. Finally, we sincerely thank Cornelia (Nina) Kammerer for her invaluable guidance on qualitative methodologies and for providing comprehensive feedback that significantly enhanced this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbbott AD. The system of professions: An essay on the division of expert labor. University of Chicago Press; 1988.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbuosi AA, Kwadan AN, Anaba EA, Daniels AA, Dzansi G. Number of students in clinical placement and the quality of the clinical learning environment: A cross-sectional study of nursing and midwifery students. 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(2025). \u003cem\u003eSub-Saharan Africa\u003c/em\u003e. World Bank Gender Data Portal. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://genderdata.worldbank.org/en/regions/sub-saharan-africa\u003c/span\u003e\u003cspan address=\"https://genderdata.worldbank.org/en/regions/sub-saharan-africa\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYigzaw T, Ayalew F, Kim Y-M, Gelagay M, Dejene D, Gibson H, Teshome A, Broerse J, Stekelenburg J. How well does pre-service education prepare midwives for practice: Competence assessment of midwifery students at the point of graduation in Ethiopia. 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Council on Foreign Relations. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thinkglobalhealth.org/article/kenya-and-maternal-health-delivering-results\u003c/span\u003e\u003cspan address=\"https://www.thinkglobalhealth.org/article/kenya-and-maternal-health-delivering-results\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"midwifery education, maternal health, student confidence, clinical training, Kenya, health policy, sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-7123223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7123223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Safe pregnancy and childbirth are fundamental human rights, yet approximately 810 women die daily from preventable maternal causes. Despite a 40% global reduction in maternal mortality between 2000 and 2023, sub-Saharan Africa still accounts for nearly 70% of these deaths. Efforts to reduce maternal mortality in the region have emphasized increasing facility-based deliveries, which enable skilled health workers to manage complications and deliver lifesaving interventions. Professional midwifery, particularly when aligned with International Confederation of Midwives standards, has been identified as critical to achieving these goals. However, the training environment plays a significant role in shaping the confidence and competence of future midwives. This study explores the situational and institutional factors affecting final-year midwifery students' confidence in providing maternal care in Kenya, focusing on training environments in urban and rural Kenya Medical Training Colleges (KMTCs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A comparative ethnographic case study approach was employed to investigate how midwifery students' confidence in care provision is influenced by their training environments. The study was conducted at two KMTC campuses—one urban (in Kisumu County) and one rural (in Siaya County). Data collection methods included participant observation during lectures and clinical rotations, as well as in-depth interviews with final-year students, lecturers, clinical mentors, and institutional administrators. Thematic analysis was used to identify contextual influences on student confidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Students and faculty identified clinical experience as pivotal to building confidence, particularly in managing obstetric complications. Peer learning and repeated hands-on practice were consistently reported to enhance confidence. However, challenges such as reduced facility-based deliveries (exacerbated by policy shifts from the National Health Insurance Fund to the Social Health Authority), overcrowded clinical sites, staffing shortages, and misalignment between theoretical instruction and clinical realities hindered effective learning. Resource limitations forced reliance on improvised practices, which undermined student confidence and created a disconnect between training and best practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Midwifery student confidence in Kenya is shaped by a complex interplay of policy, pedagogical, and infrastructural factors. Addressing systemic barriers—through curriculum reform, improved resource allocation, and stronger academic-practice partnerships—is essential to ensure students graduate with the competence and confidence needed for safe maternal care delivery.\u003c/p\u003e","manuscriptTitle":"Confidence in Care Provision Among Third-Year Midwifery Students in Western Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 12:30:58","doi":"10.21203/rs.3.rs-7123223/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-08-11T14:39:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-07T08:52:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T11:45:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T22:37:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-07-17T18:45:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"abb002dd-39f4-437d-ae2e-091280464ac4","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-19T12:30:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 12:30:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7123223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7123223","identity":"rs-7123223","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}