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

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.