Introduction

Reports have identified that strengthening midwifery is critical to improved maternal and newborn health, globally [1,2,3]. However, poor quality midwifery care remains a major contributor to high maternal and neonatal death, especially in Low- and Middle-Income Countries (LMICs) [4, 5] despite evidence suggesting that 87% of the incidence of Maternal Mortality Ratio (MMR) (MMR) can be alleviated through quality midwifery care provided by midwives that have been educated, trained, regulated and licensed according to the International Confederation of Midwives (ICM ) global standards for midwifery education [6]. Recently, the world recorded a 34% (223/100,000 live birth) reduction in MMR. While this is appreciable, it is insignificant in terms of realizing the promising Sustainable Development Goal (SDG) which aims to achieve reduced maternal death to less than 70/100,000 live births by 2030 [7]. Progress in improving maternal health remains stalled in LMICs where almost 95% of all maternal deaths occur from preventable causes, 70% of which disturbing statistics is accounted for by sub-Saharan Africa [8]. Midwives played a pivotal role in achieving the millennium development goals and their efforts have continued to be recognised as the most cost-effective solution to meet SDG targets [2]. However, to enable midwives to contribute significantly, quality midwifery education has been identified as an important approach to promoting quality midwifery care [9, 10]. This approach involves improving the quality of midwifery education to international standards to prepare future midwives so that they are equipped with the appropriate competencies to enable the delivery of safe and high quality sexual and reproductive care required to achieve international SDG efforts [11].

The ICM with support from the World Health Organization (WHO) advocate the need to strengthen midwifery globally through the provision of standards for midwifery education and practice [12, 13]. The Confederation maintained this vision over the years by communicating these global Standards for Midwifery Education with an emphasis on Competency-Based Education (CBE) to ensure consistency in practice and education of midwives [14,15,16]. However, nations are expected to interpret and adapt these global standards to midwifery educational programmes wherever these are located to prepare qualified midwives [16]. The title “qualified midwife” is appropriate for use by an individual who has been able to complete his/her midwifery education programme. And demonstrate competency in the practice of midwifery satisfactorily to earn a midwifery certificate and is registered and licensed to practice midwifery in the country where the education was obtained [17]. Midwives can acquire the specific knowledge and skills to become fully qualified midwives through three major educational pathways [18]. A direct-entry programme for midwifery, a post-nursing programme and a combined programme of Nursing and Midwifery [19]. However, regardless of the chosen pathways, it is expedient that countries meet the predetermined standards in CBE in midwifery curriculum to ensure the competency-based outcomes of midwifery education are equivalent [16, 20]. Unfortunately, several inconsistencies apply to the implementation and sustainability of CBE Midwifery education with most countries still following the Traditional Based Approach (TBA) [16] probably due to poor planning and implementation process especially in Africa.

Competency-based education compared to Traditional-Based Approaches (TBA) continues to remain relevant, especially in professional healthcare education programmes including midwifery education [21, 22]. There are four basic principles distinguishing CBE from TBA highlighted by Frank and colleagues which are CBE’s focus on outcomes of education and training, the learner’s capabilities against predetermined standards [23]. Furthermore, CBE requires a flexible curriculum with reduced emphasis on time and promotion of learners-centeredness The increasing popularity of CBE and the paradigm shift were necessary in response to the dynamic labor market that requires flexible, adaptive, and competent employees that can respond swiftly to the ever-changing work environment [22, 24, 25]. CBE in the professional health care education programme has focused on health care professionals with adequate capabilities necessary to provide high-quality care and ability to meet the population’s health demands [26]. CBE prepares graduates by focusing on the competencies acquired during their educational experience that are assessed against knowledge, skills, attitude, and achievement standards as outcomes of the curriculum [21, 23].

Competency-based education is described as a curriculum or training program that provides comprehensive tasks to practice all the required competencies [26]. For the midwifery profession, competency-based education is an educational program of studies that is based on a complex combination of knowledge and skills acquisition, demonstration, values, and attitude in all aspects relating to the essential competencies required to become a qualified midwife [27]. The theory of CBE is an individualized programme, that aims to assess the theoretical and clinical competency of each midwifery student until competency proves satisfactory [27, 28]. Faculties, including educators and clinical preceptors, involved in the training and clinical experience of students ought to work harmoniously to sustain CBE for midwifery educational programs [29, 30]. Although proper implementation of CBE promises to realize the outcomes of education and training. However, studies have found that these expectations are difficult to achieve in reality due to inadequate knowledge of assessment of competency [31,32,33,34,35]. Despite the proven benefits of CBE, little is known about the implementation of CBE, especially in Africa, where poor investment in quality midwifery education has been reported [36]. Hence, this study will review the existing literature concerning the implementation of competency-based education for midwifery programs and its sustainability in Africa.

Methods

The scoping methodology, as outlined by Arksey and O’Malley, was adopted to explore the extent of the literature concerning the implementation of CBE for midwifery programmes, and its sustainability in Africa [37]. The Arksey and O’Malley five-step framework for conducting scoping reviews was used, namely: (1) identify the research question; (2) identify relevant studies; (3) perform study selection; (4) extract and chart the data; and (5) collate, summarize, and report the results. This framework directed the scoping review methodology, with reference also to additional PRISMA-ScR guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [38].

Step 1: identify the Research question

This scoping review is guided by the following research questions:

  1. 1.

    What is the existing evidence of implementing CBE in midwifery education in Africa?

  2. 2.

    How has CBE for midwifery education been sustained in Africa?

Inclusion and exclusion criteria

The inclusion of eligible studies in this scoping review was determined following the Participants, Concept, and Context (PCC) framework [39]. Inclusion and exclusion criteria are listed in Table 1. The review included literature published from January 2010 to April 2024 in the English language.

Table 1 Inclusion and exclusion criteria
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Step 2: identify relevant Studies

A comprehensive report identifying the relevant studies has been published previously [40]. Systematic and literature reviews which were considered relevant had their reference lists scrutinized manually for potential studies, however, the reviews were not considered for inclusion. This review considered English-only studies in Africa from 2010 to 2024. Reports published from 2010 which captured the International Confederation of Midwives (ICM) position statement on the implementation of CBE for midwifery programmes were equally considered [29].

Step 3: perform study selection

A total of 935 citations identified through database searching were imported into EndNote (v.21; Clarivate Analytics) and screened for duplicates. The remaining citations (n = 687) were uploaded into Rayyan review software (Qatar Computing Research Institute). The two independent reviewers (WBI and OA) conducted the initial screening to assess eligibility regarding the title and abstract and then conducted a full-text review using the PCC framework. Any disagreements during the selection process were resolved through discussion with the third senior reviewer (WBN).

Step 4: extract and chart the data

A data charting table was pre-developed to extract and chart relevant information from eligible studies. The reviewers conducted a pilot test on five included studies. Eligible studies were extracted by two independent reviewers (WBI and OA), while the third reviewer (WBN) validated the data extraction results. The data charting table, Table 2, was reviewed independently and compared for consistency by the team of reviewers following the PCC framework. The year of implementation of CBE was added to existing variables (the type of study, year, setting or context, aims, study population, research design, research techniques, and summary of findings). The data charting Table 2 showed a comprehensive report of relevant information of eligible literatures. Using an iterative approach, the two reviewers independently coded the content of the data using Nvivio, seven themes were generated. The report of the review is summarized in the Figure: 1, following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) format.

Step 5: collate, summarize, and report the results

Table 1 shows the complete list of extracted articles conducted across 17 African countries from 2010 to 2024, most of which were reported in South Africa (32%). Despite not limiting the search by language, the majority of the articles were in English, except for two in Arabic and French. The research consisted mainly of qualitative studies (n = 19); eighteen (18) studies used quantitative methodology while seventeen (17) were mixed methods. Other designs included surveys (n = 6), case studies (n = 8), multi-method research designs (n = 1) and field action reports (n = 2) and conference presentations (n = 1). Figure 1 shows the report of the scoping review findings following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) format.

Results

The 935 articles originally identified from electronic database were uploaded to Rayyan, from which 138 duplicate records were removed, while a further 110 duplicates were detected and removed by automation. Of the 528remaining, 456 were eliminated: 264 of these did not relate to the concept of the study; 133 were conducted outside African countries or regions; 30 were published before 2010; 21 consisted of the wrong population (i.e., the participants were mainly nurses and others without any connection to midwifery); 8 were the wrong publication type (e.g. editorial, commentary, literature reviews). Following the grey literature search, a further 26 reports were discovered. Finally, a total sample of 72 studies were included in this scoping review. Table 2 shows the data charting table of the result.

Table 2 Data charting table for the scoping review on implementation of competency-based education for Quality Midwifery programmes in Africa
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Fig. 1
figure 1

PRISMA- ScR

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Reporting of the scoping review findings follows the PRISMA- ScR flow chart format(Fig. 1) Subsequent content analysis using Graneheim and Lundman approach identified seven (7) themes from the literature and a narrative report presented [41] as follows; (a) midwifery curriculum (b) competency-based education curriculum implementation process (c) pedagogical approaches in CBE (d) Benefits of CBE (e) sustainability of CBE (f) facilitators of CBE implementation (g) challenges to CBE implementation.

Theme 1: midwifery curriculum

Midwifery curriculum generated two sub-themes comprising the types of midwifery curriculum implemented and the content of the midwifery curriculum.

Sub-theme1: Type of midwifery curriculum implemented

A thorough search of the published literature in Africa on midwifery education found 17 countries 11 of which are implementing CBE (South Africa, Rwanda, Tanzania, Uganda, Lesotho, Kenya, Egypt, Morocco, Malawi, Democratic Republic of Congo, Zambia), while 5 countries (Nigeria, Ethiopia, Ghana, Benin, Sierra Leone) are using Traditional-Based Approaches. Problem-Based Learning (PBL) is the main teaching pedagogy used in Botswana.

Sub-theme 2: Content of the Curriculla. (wide disparities within and across the countries)

The findings showed that the content of the curriculum differs appreciably among training institutions within African countries. Comparing the content of the curriculum to ICM global, essential competencies for midwifery practice revealed that a wide gap exists within institutions in a nation and across the African continent. A study assessing the curriculum in four countries found that, out of the ten pre-service curricula assessed, none of the curricula included all the ICM competencies [42]. In Nigeria, of the2 institutions in the 3 selected northern states providing pre-service education for midwives, 23 competencies were found not to align with the ICM standards [43]. Similarly, in Uganda, wide disparities were noticeable in curricula compared to the ICM standards, midwives synonymous with general nurses working in the maternity unit because graduates lack competencies in the midwifery mode of professional care [44].

In an undergraduate midwifery programme in South Africa, the content of the curriculum revealed that some topics were integrated into the existing curriculum using CBE approaches. For instance, a study showed that the competency-based course materials on Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS were adequate, and that the course was found to be sustainable for undergraduate midwifery students [45]. In a similar study, PMTCT including HIV and AIDS related outcomes was recommended to be fully integrated into classroom teaching and at SDP (Service Delivery Points) for nursing and midwifery competencies, including assessment strategies [46, 47]. This study concludes that incorporation of the Nurse Initiated Management of Anti-Retroviral Treatment (NIMART) course into the undergraduate nursing programme was supported by nurse educators who expressed that the NIMART course will benefit the student nurses, the NEIs and the communities at large [48]. The Simulation Learning Package (SLP) on PPH (Post-Partum Hemorrhage) developed for undergraduate midwifery students was also found suitable [49]. In South Africa, a competency-based Curriculum Framework was found to be necessary and was developed to standardize genetics education in an Advanced Midwifery Programme [50]. In Tanzania and Uganda, Training Resource Packages (TRPs) to Strengthen Pre-service Family Planning Training for Nurses and Midwives was integrated into the pre-service curriculum using CBE approaches [51]. In Kenya, in 2021, the Nursing Council of Kenya (NCK) in collaboration with the Liverpool School of Tropical Medicine (LSTM) and multiple stakeholders reviewed and updated the nursing and midwifery degree programme focusing on strengthening the quality of training of the pre-service faculty and clinical instructors on pedagogy skills and capacity-building for the provision of competency-based Emergency Obstetrics and Newborn Care (EmONC) [52]. The study established that the curriculum component concerning the active management of the third stage of labour aspect in the curriculum was adequate [53].

Theme 2: The CBE curriculum implementation process generated five (5) sub-themes which are (a) contextual factors for curriculum reform (b) stakeholders’ engagement (c) roles of stakeholders. (d) opinion of stakeholders on CBE (e) development of intervention tool informing the model /framework

Sub-theme 1: Contextual factors for curriculum reform

This review identified the contextual factors for curriculum reform in various countries. The most prominent factor for the transition to CBE was the need to prepare competent midwives through the improvement of the quality of pre-service midwifery education to address the high burden of maternal and newborn mortality, especially in Africa, where the rates are high [52, 54, 55]. In South Africa and Rwanda, curriculum reform was borne from a demand for competent graduates, the political agenda of the countries to respond to population health, the transformation of higher education, the health care systems and undergraduate nursing education [56, 57].

Sub-theme 2: Stakeholders’ engagement

The stakeholders identified are policy makers (national governments), ministries of health, ministries of education, professional regulatory bodies of the countries, commissions for the universities, institution administrators, heads of nursing and midwifery programmes, faculties (which include nurse and midwifery educators, clinical instructors and clinical staff, clinical supervisors and clinical preceptors), students’ interprofessional collaborations and partnerships [56, 58,59,60]. In Ethiopia, the stakeholders involved in the midwifery curriculum process were primarily education experts with minimal contributions from professional bodies, classroom educators and clinical preceptors, which reflected in the content lacking midwifery clinical practice [51]. While it was evident that the curricula in Ghana and Malawi received input from their professional bodies since the content comprised information on midwifery clinical practice [61]. A part of highlighting effective curriculum development processes is a focus on interprofessional collaborations within and between universities, both local and international partnerships [52, 58, 62, 63]. For instance, in Kenya, the Nursing Council of Kenya (NCK), in collaboration with an international body developed a competency-based curriculum integrating EMNOC [64]. In 2012, the Global Nurse Capacity Building Programme (GNCBP) through the Nursing Education Partnership Initiative (NEPI), was instrumental in the development of the maiden competency-based curriculum (CBC) for the post-basic Diploma in Midwifery programme in Lesotho, across all of the Nursing Education Institutions (NEIs) [65]. The NEPI further collaborated and partnered with nursing and midwifery education institutions and national health departments in other African countries such as the Democratic Republic of Congo, Ethiopia, Lesotho, Malawi, South Africa, and Zambia [63]. An exploration of nursing students’ experiences and perceptions at the school of nursing sciences in South Africa (SA) revealed that students recommended the need for inter- and intra- collaborative partnerships between professionals in the universities and clinical practice settings [66].

Sub-theme 3: Roles of the stakeholders in curriculum process

Implementation of competency-based education requires engaging all stakeholders so that they discharge their roles in the review, development and adoption of a CBE curriculum to create a national standard for teaching and learning in a particular country [55, 63, 64]. The government of the country is expected to exert its political will by making the implementation of the curriculum a policy, and ensuring compliance by all stakeholders/policy makers. Governments are expected to provide an enabling environment through capacity-building of faculties and provision of financial, human and material resources for the proper implementation of CBE [58, 62]. The role of regulatory bodies, which include professional bodies and university commissions, is to ensure that schools adopt and adapt the curriculum. With support from government and partners, Stakeholders/policy makers t should facilitate the training and retraining of faculties and distribute supplies and resources for the implementation of CBE [58, 62]. Stakeholders/policy makers should also monitor and evaluate the curriculum through consultation with other stakeholders to update the curriculum regularly [59]. The role of faculties is to adopt and integrate the CBE into the teaching and learning of students, maximizing the available support, and being committed to in-service training/retraining on CBE, including that of new faculties [67]. The students provide feedback on the CBE curriculum [66, 68].

Sub-theme 4: Opinions of stakeholders regarding CBE

The study assessed the readiness to adopt, appropriateness, feasibility and practicability, fidelity, implementation, attitude, perception, positive attitude, satisfaction, adequacy, suitability, acceptability to elicit the opinions of stakeholders on CBE. For example, in South Africa, the nurse educators showed a readiness to adopt technology-based education when asked, and participants showed a willingness to adopt it [69]. The findings in another study in South Africa confirmed that nurse educators were ready to use technology-based education (High Fidelity Simulation (HFS) but stressed that readiness does not translate to the utilization of HFS [70], while a further study found that institutions were moderately prepared to integrate simulation-based education into teaching and learning [71]. Educators established the appropriateness, feasibility, and practicability of integrating HIV/Aids into the nursing curriculum [47]. The suitability of the pedagogical approaches in CBE were explored and the study confirmed the suitability of the approach for training of nurses and midwives [72]. The appropriateness of the curriculum content was assessed for clarity, relevance, and suitability in preparing competent midwives. The findings showed that it was appropriate across all the variables of assessment [73]. While in Rwanda, findings revealed that nurses/midwife educators had good knowledge which was evident in their mastery and utilization of different teaching strategies in a CBE approach and a positive perception toward effective implementation of CBE [74].

The educators acknowledged the positive influence of IT in nursing education and showed a good attitude toward IT use [75] (Singh and Masango, 2020). A study concluded that nurse educators perceived the incorporation of the NIMART course into the undergraduate nursing programme as a good idea and approved its incorporation [48]. A study on the fidelity of implementing the Community-Based Nursing Education (CBNE) programme during the COVID-19 pandemic found that the nurse educators satisfactorily maintained the fidelity of implementing the CBNE framework within the context of COVID-19 [76]. In Uganda, the implementation of CBE by educators in institutions was explored, and the literature indicated that the CBE curriculum had been analytically planned and implemented, which was evident in major similarities amongst institutions in the country [77]. Study results highlighted that nurse educators in KwaZulu-Natal have positive attitudes toward utilizing technology to support teaching and learning, provided that the technology is readily accessible [78].

Other studies assessed students’ opinions on CBE implementation. A study conducted on case-based learning (CBL) showed that students had positive perceptions of and supported CBL, while they highlighted the importance of group dynamics as a key success factor to successful implementation [79]. Concerning Problem-Based learning (PBL), the majority of the students had a positive perception of PBL, with a few students feeling confident in utilizing most of the PBL processes [80]. In this experimental study, students who participated found simulation method more satisfactory than students who did not participate [81]. In a study by Gudayu, it was discovered that students’ satisfaction and confidence was average in the use of simulation among midwifery students [82]. In South Africa, students expressed that educator supported the use of creative pedagogical approaches but would appreciate further training and support to equip them to use and gain mastery of a range of creative teaching strategies [67].

Sub-theme 5: Development of a framework/model/theory

The development of the model or framework was identified as critical for CBE curriculum implementation. In Lesotho, following two years of integration of CBE, implementers had difficulty implementing and sustaining CBE. This called development of an evidenced-based framework to direct the implementation and sustainability of a competency-based curriculum for higher education in midwifery [83]. An integration model for including HIV and AIDS into the nursing curriculum was developed by Modeste [84]. The model proved useful in enhancing the competencies of nurses in the provision of HIV and AIDS-related care and management [84]. A framework was developed to enhance the incorporation of simulation in nursing education and the development of clinical competence in a low resource setting [85, 86]. A model to facilitate transformative learning in nursing education was developed and found to be adaptable to all settings of clinical practice, research, and education [87]. Phaladi-Digamela (2015) developed a curriculum framework to standardize genetics’ education in the advanced midwifery programme [50]. Rakhudu and colleagues developed a model of collaboration to implement PBL in nursing education [66]. In Rwanda, a middle-range theory was developed to guide the implementation of a competency-based curriculum in pre-service nursing education [88]. A framework to guide the assessment of clinical competence and to track student clinical experience in neonatal nursing clinical teaching was developed [89].

Theme 3: Pedagogical approaches in CBE

The pedagogical approaches identified in CBE include the use of IT in nursing education [75] and other forms of IT, such as e-learning [90, 91] and nursing and midwifery informatics [92]. Educational board games [93], narrative case studies [94], value clarification through ‘Difficult Dialogues’ strategies [95] are also some of the approaches discussed including technology-based education [69, 78] such as Simulation Based-Learning [81, 82, 96] and High-Fidelity Simulation [70]. Other approaches mentioned are case-based learning which includes group work, reflection, and student presentation [79, 97] and problem-based learning [66, 80, 98, 100], as well as direct observation of procedural skills as an appropriate tool to assess student clinical competence [101]. The OSCE method was mentioned as a popular assessment tool to evaluate the clinical competence of students [102, 103].

Theme 4: benefits of CBE

Some of the literature reviewed expressed the outcomes of CBE as including educators’ increased competencies and confidence in teaching [52, 64, 104]. The literature further revealed that orientation on all teaching strategies increased knowledge, thus informing the importance of using a variety of teaching strategies by faculties [105]. A study on the value clarification process concerning abortion-related services in South Africa reports that CBE promotes transformative learning and improves intellectual growth among learners [95]. Midwifery educators described their experiences with the OSCE development process as an exercise that equips them with leadership skills and knowledge which is critical to the midwifery practice and education [102]. The use of educational board games was found to be cost-effective and to assist in translating knowledge to care provision [93]. The results of a study on PMTCT competency-based course materials showed that it promotes higher-order thinking, improves communication skills, teamwork and learning among students [98]. A study on High Fidelity Simulation infers that it promotes experiential and contextual learning, encourages self-directed learning and reflective learning [99, 106]. These findings further confirm that Simulation-Based Learning develops student skills and confidence to manage complex real-life emergencies because it offers an opportunity for learners to be immersed in an environment that is closer to reality [96]. Problem-based learning through simulation also promotes teamwork among students and the ability to render holistic nursing care to patients [100]. The developed simulation learning package (SLP) on PPH was found suitable for undergraduate nursing students, as it also encourages active learning, collaboration, and multiple teaching techniques, feedback, critical thinking, self-confidence, and satisfaction [49].

Theme 5: Sustainability of CBE curriculum

Only two literature sources categorically discussed the sustainability of CBE [83, 107]. Other literature sources report on the issues challenging the implementation of CBE. In Lesotho, inadequate support and monitoring of a newly implemented CBC within the midwifery programme threatened its sustainability among NEIs in the country [59]. In the Democratic Republic of Congo, despite CBE being widely promoted by the Ministry of Public Health, an insufficient budget and inadequate educators trained in CBA methodology were highlighted as major factors accounting for the continued use of the traditional approach (Ministry of Public Health [108]. The same was reported for Morocco and South Africa despite the necessary support and training in CBE, implementers continue to implement TBA such as the lecture method and demonstration in teaching across all subject areas [55, 67].

Theme 6: facilitators of CBE implementation

Sub-theme 1: Broad stakeholder support

Much Emphasis is placed on broad stakeholder support both locally (local capacity building) and internationally, which should be intentional and sustained for longer periods. Broad stakeholder support has been stressed as an important facilitator to CBE implementation. This includes governmental support of the nursing and midwifery council through capacity building of faculties and supply of equipment [70, 91] as well as established and functional interprofessional collaborations, both locally and internationally [91, 109]. Students also need adequate educator support in terms of being exposed to more practical sessions, as such practices boost competency, satisfaction, and confidence [53, 82].

Sub-theme 2: Functional monitoring system:

A functional monitoring system was identified as a notable facilitator which involves extensive coordination among all stakeholders to promote strong ownership and acceptability of the CBE project [91]. This study found that poor support and a weak monitoring system, especially in relation to professional regulatory councils, jeopardizes CBC sustainability. The previous literature on sustaining the implementation of a competency -based midwifery programme revealed a lack of accountability for the new curriculum from implementers during classroom teaching, throughout the programme. This was traceable to the lack of expertise of the educators which resulted in them returning to the traditional method [107].

Sub-theme 3: Availability of Guidelines Informing the Frameworks /Models

The availability of guidelines that inform frameworks or models that communicate nationally or globally, is recognised as a facilitator to the implementation and sustainability of CBE [107]. A framework for implementing and sustaining a competency-based curriculum was developed in Lesotho to serve as guide [83].

Sub-theme 4: Motivation and Recognition:

The need for motivated staff students, tutors and other stakeholders was also mentioned to sustain the enthusiasm and interest for CBE programme implementation [91, 109]. Further factors are the awareness that midwives are able to deliver quality midwifery care if educated and motivated, and women’s demand for quality maternity care from highly competent and motivated midwives [109].

Theme 7: Challenges Concerning the Implementation of CBE

Sub-theme 1: Poor Knowledge of CBE

The findings showed that educators and clinical preceptors involved in the training and clinical facilitations have sub-optimal knowledge of active learning methods of the various pedagogical approaches which have been identified for implementing CBE which inevitably challenges the proper implementation of a nursing and midwifery CBE curriculum [97, 110]. In Tanzania, educators were unable to deliver the prescribed allocations of the nursing and midwifery CBET curriculum due to poor understanding and interpretation of the CBC [111]. In Ethiopia, the majority of the classroom educators and clinical preceptors had low teaching competency in CBE especially in relation to student-centered learning, e-learning and gender studies [112]. In another study, both staff and clinical preceptors reported that they were poorly oriented regarding the implementation of a competency-based curriculum in supervision and evaluation of midwifery students [61]. Some educators claimed they were unfamiliar with the Problem-Based Learning (PBL) approach [98]. In a study on integrating a Training Package for Family Planning using competency-based teaching methods into their curricula, the educators from nursing and midwifery training institutions were unable to integrate the training packages successfully, because they were not familiar with the incorporation process for such approaches [51]. In a study conducted by Milly and others, the stakeholders within and NEIs had challenges integrating CBE into teaching and learning which was reflected in the wide disparities in implementation of curriculum content/subject areas in the various institutions [73].

Sub-theme 2: Inadequate Human and Material Resources

Other major challenges in institutionalizing CBE were reported to be human resources, financial, and material constraints [72, 73, 77, 113]. The facilitation of the training of these students requires a well- resourced clinical environment with essential medical supplies, a conducive environment, adequate faculty members for effective guidance and supervision and feedback to the students are often grossly insufficient [100, 103]. In Lesotho, over-dependence on improvision of equipment and supplies during simulation, some faulty high-fidelity simulators and inadequate staffing impacted negatively on the successful implementation of SBE [114]. In a study on the integration of NIMART into the curriculum, it was discovered that state policies on distribution of antiretroviral commodities limited the availability of antiretrovirals, thus hampering the opportunities for students to learn the practice of PMTCT competently [46], while others found the course content to be inadequate with the tutors not adequately prepared which constituted a notable challenge [92]. Another study observed that regarding the CBE approaches that require the use of the internet, such as PBL, e-learning, participants reported resources in the library and computer laboratories, internet connectivity, insufficient training, qualifications of the faculty and class sizes to be inadequate [75, 98]. The persistent shortage of qualified staff and competent clinical preceptors in the clinical settings, coupled with the lack of teaching and training resources and increased workload impacted on the quality of midwifery education [61, 111, 115, 116]. Students often need to contend with the demand for clinical experience as the midwifery student population continues to increase, exceeding the institutional capacity [51, 105].

Sub-theme 3: Lack of Motivation and Support

Lack of continuous support in using the different teaching approaches was highlighted among the challenges in implementing CBE. Nursing/midwifery educators reported that using active teaching strategies contributes to an increased workload, hence the need for continuous support [74]. Students reported that insufficient support was largely due to shortage of staff as they lacked an adequate number of tutors and clinical supervisor/preceptors, and the competent clinical preceptors necessary to support clinical and theoretical learning [72, 98]. Students further expressed a need for support in terms of constructive criticism, for educators to be patient, and correct them respectfully, as well as easy access to the simulation lab [114]. Proper implementation of CBE requires staff to be motivated; availability of funds and managerial/administrative support [71]. Staff should be supported to attain higher educational levels; teaching materials and good working conditions should be provided [109].

Sub-theme 4: Insufficient time

Insufficient time was noted by educators and students as being another major challenge [97, 111]. The educators experienced problems integrating the TRP content using CBE to include it in the family planning curriculum because the time available was insufficient, even before training began [51]. Students complained about time constraints as a challenge, since they feel pressured by the timing for delivery combined with the increased workload experienced with the implementation of CBE [97, 98]. In another study, students stated that a great amount of content in the curriculum was not covered because the curriculum was too heavily loaded and the time allocated was insufficient [115]. Insufficient hours being allotted for clinical training and teaching was another factor mentioned [114].

Sub-theme 5: Poor Accountability

Results showed that students lacked accountability for their learning and were disinterested in engaging in critical thinking [97], Studies revealed that students lacked the prerequisite knowledge for their studies [109].

Discussion

This study showed that of the 54 African countries according to the World Bank classification, the literature on CBE for midwifery programmes only spanned 17 African countries at the time of this report. South Africa, Rwanda, Tanzania, Uganda, Lesotho, Kenya, Egypt, Malawi, Democratic Republic of Congo Morocco, and Zambia were among the countries implementing CBE. However, in Botswana, Problem-based learning was integrated into its curriculum with little success recorded following the implementation. Needless to say, where CBE was claimed to be implemented, the implementation appeared questionable. This may also imply that there is limited support for the proper implementation of CBE where it is practiced, for example, in the Democratic Republic of Congo, CBE has been widely promoted by the Ministry of Public Health, yet 81% of the country’s nursing education institutions continue to use a traditional approach due to an insufficient budget and a paucity of educators trained in the competency-based approach [108]. In Lesotho, wide disparities exist in the implementation of the CBC within the midwifery programme among NEIs in Lesotho. The major components of the Competency-based midwifery programme were not fully adopted to assimilate CBE [59]. Despite the adoption of CBE since 2013 with support for implementation in Morocco, TBA continues to be the mainstay for teaching and learning [55]. These findings are similar to those of other studies which reported inconsistences in the type and nature of midwifery education despite ICM standards [117].

The findings showed that the content of the curriculum differs appreciably from ICM standards among training institutions within the various nations, while new topics integrated into existing curricula employed CBE approaches These findings build on existing evidence showing that discrepancies in the nature and content of midwifery education programmes prevail globally [14, 16, 20]. The integration of new topics using CBE approaches may suggest that faculties need more training on the various CBE approaches It could also denote that the appropriate pedagogical approach(es) for each topic/course should be properly integrated so that instructional design aligns with the competency-based curriculum to ensure utilization and accountability.

This review revealed that for successful implementation of CBE, the following CBE curriculum implementation process must be strictly observed: identify contextual factors for curriculum reform, stakeholders’ engagement, roles of stakeholders, opinion of stakeholders of CBE and the development of intervention tools to informs the model /framework. The identified contextual factors in this review include the need for competent midwifery graduates to provide high-quality sexual and reproductive health care to combat SDG-3 goals in reducing the high burden of maternal and newborn mortality, especially in Africa, where the burden is alarming [52,54,55,]. Other factors are the transformation of higher education, the health care system and undergraduate nursing education programmes [56, 57]. This suggests that countries should critically self-examine and analyze themselves to justify the need for curriculum reform. This will serve as a motivator for planning curriculum reform, implementation, and sustainability across nations. This concurs well with similar studies on curriculum reform conducted in the United States [118, 119]. The study highlighted broad stakeholders’ involvement in the CBE implementation process and, while this is commendable, the engagement of stakeholders is presently grossly inconsistent. For example, in Tanzania, multiple stakeholders include the Tanzanian commission comprised of university, faculty, interprofessional collaborations and international partners. In Ethiopia, education experts were mainly involved in the CBE curriculum process. In Ghana and Malawi, professional organizations were the major contributors. This review further showed the relevance of identified stakeholders in the curriculum planning and implementation process by highlighting their roles and involvement in the success of the CBE implementation. This report is similar to findings from previous authors on stakeholders’ involvement in the implementation of curriculum [120,121,122]. Also, the development of an intervention tool which informs the model /framework will serve as a guide and a national template for implementers enabling them the maintenance of standards. This conforms with findings from study conducted by Dragoo and colleague on Implementing competency-based education [123]. It is hoped that proper adherence to the curriculum implementation process will promote accountability and acceptability of CBE for all stakeholders.

The study highlighted the numerous pedagogical approaches employed in the implementation of CBE. This implies that multiple approaches should be utilized in the teaching and training of midwifery students so that the approaches complement one another to achieve the best result. This is consistent with similar study on CBE [72]. All stakeholders should be cognizant and trained to utilize the various teaching methodologies, while a functioning system should be put in place to ensure accountability and sustainability of all pedagogical approaches [118]. The study revealed that the implementation of CBE offers several benefits to students, faculties, nations and the communities it serves. Hence its implementation should be widely encouraged and supported by all stakeholders to prepare competent midwifery students. This finding is in agreement with another study where the benefits of CBE were mentioned [118].

There is a paucity of literature on the sustainability of CBE, however most of the literature reported challenges with the implementation of CBE. Evidence from the literature confirmed that CBE has not been sustained in Africa. It remains a struggle to fully integrate the major components of the Competency-based midwifery programme due to inadequate support and lack of a monitoring system which challenges its implementation and sustainability.

Much emphasis has been placed on broad stakeholder support, both locally (local capacity building) and internationally, which should be intentional and sustained for longer periods. A functioning monitoring system, the availability of guidelines informing frameworks or models, adequate supervision and support for students coupled with a highly motivated and educated faculty, clinical staff, students, and other stakeholders are requirements [91]. The awareness that women demand quality maternity services from competent and highly educated midwives, and thus that the planned CBE programme is appealing and interesting was highlighted [109].

Poor knowledge of the various pedagogical approaches for implementing CBE was reported by implementers as jeopardizing the proper implementation of the nursing and midwifery CBE curriculum. Other major challenges identified in implementing and sustaining CBE were inadequate human resources, both in quality and quantity and financial and material constraints. Participants complained of insufficient time being allocated for teaching and learning, high workloads and a shortage of educators [111], while lack of motivation and support, and poor accountability on the part of the student were also cited. This finding is in line with previous authors on challenges on implementation of CBE [22, 35, 118, 123, 124].

Strengths and limitations

The study methodology involves a rigorous and contemporary search of the published literature on competency-based education for midwifery education and practice. The PRISMA-ScR extension guided this scoping review. The review was limited to studies conducted in the English language, however only three studies were found to be conducted in other languages (two in French, one in Arabic). The review included conference proceedings to obtain country representation on the subject area.

Conclusion

Competency-based education is a proven approach to preparing competent and confident graduates. The implementation and sustainability of CBE is just emerging in Africa. It is expedient that CBE implementation should be planned concurrently with its sustainability in order for it to be effective especially in Africa where resources are scarce.