In the twinning project of the JMA and the MMA, we conducted an obesity prevention programme during pregnancy as a strategic method for strengthening the MMA that involved all members of the MMA branch offices nationwide for three consecutive years, from 2015 to 2018. By building a joint platform as a place for interaction, such as twinning consultations between the JMA and the MMA [11], we promoted the project in dynamic ways and cultivated good relationships.
As a result, more positive outcomes than expected were observed. The outcomes were clear through the evaluation of the items of the MACAT, and the opinions and impressions of the MMA members, as elicited by the interviews. In particular, the MACAT, which is an index for organisational evaluation, was set as an easy-to-understand index, such that the goals that the MMA should aim for could be clearly presented.
As of 2015, the focus was on strengthening the five major items in which less than 50% of the sub-items were achieved. They were the following: Governance (32.1%), Management Practice and Leadership (16.6%), Financial Resources Management (37.5%), Functions (12.5%), and Sustainability (0.0%). In 2015, MMA was achieving approximately 30% of all MACAT items, but by the end of 2018, this percentage had reached 70%. It can be said that the MACAT was an appropriate index for organisational evaluation. The ICM introduced the MACAT evaluation in 2011, but so far no studies have been conducted using this evaluation. While applying the factors of the positive organisational strengthening to the factors that lead to the success of the ICM’s twinning project, we combined evaluations from the MACAT, qualitative data analysis of the focus group interviews conducted with the MMA’s board members and general members, and the opinions at the platform meetings.
Factors that have succeeded in strengthening the organisation in the twinning project
The following factors, which are expected in the ICM twinning project, have been achieved in our project as well.
- Visibility of midwives and midwifery
With regard to the Governance items in the MACAT, the MMA was an organisation with no annual general meetings and no clear vision or mission statements. The JMA explained the importance and significance of holding an annual general assembly and urged it to be held. Finally, under the pressure of the former organisational power, the MMA’s president was officially elected at its first general assembly in 2016. This was a big step and a historic change towards the MMA becoming a recognised professional organisation. With this reform, the MMA was able to replace its former board members with members from a younger generation, thereby establishing its vision, mission, goals, and strategies. The MMA clarified the position of the organisation in the medical profession. In this international joint research with the JMA, it was the first time that the MMA applied for a research proposal to an ethics committee at the Mongolian National University of Medical Sciences, which impressed the existence of midwives in the academic field. Through the obesity prevention programme during pregnancy, the midwives learnt that it was important to provide accurate information directly to pregnant women using brochures and apps for guidance. The midwives found that midwifery care centred around the delivery room expanded the scope of health guidance and led to the improvement of quality care, and that it was essential for normal pregnancy, childbirth, and puerperium. The midwives also demonstrated the value of the existence of a midwife not only to pregnant women, but also to their families, and became advocates in the society for the protection of pregnant women and their children. Doctors and healthcare professionals working together in clinical sites were also inspired by the power of the midwives and the changes in their clinical practice.
- Professional confidence in the association
With regard to the item of Management Practices and Leadership in the MACAT, the MMA was able to clarify its authority and accountability as professionals, and consider human resources as members. The qualitative survey also showed that the midwife-led practice of health guidance improved the awareness of specialists, and the importance of midwifery skills, leadership, and autonomy. As a result, the nationwide survey showed that pregnant women and their families had more confidence in their midwives. In addition, considering the item of Financial Resource Management in the MACAT, the annual budget was recorded appropriately by raising the membership fee, and the number of members also increased annually due to a stronger financial base. This may be the result of being able to consider member services.
- Accessibility of resources
It was not easy to obtain external funds for operating the twinning project. However, in addition to the limited funds of the JMA and the MMA, a limited amount of funding was also obtained from other funds. The operating cost was shown as transparency, and the seminar and national survey were conducted with the agreement of both associations. With regard to the item of Sustainability in the MACAT, the MMA, through the twinning project, learnt from the collaborative research project on obesity during pregnancy, and used this learning in a sustainable way in the next ‘Happy Birth and Happy Baby’ project, which was a training programme in which all member midwives acquired the Neonatal Cardio-Pulmonary Resuscitation (NCPR) skills.
- Unity among midwives of different nations
We worked on the twinning project as an international joint research initiative, which included about 800 MMA midwives of branch offices nationwide. Recognising the importance of health guidance in particular, the MMA members worked on the obesity prevention programme during pregnancy, and were able to improve the overall work of the midwives and appeal for their expertise. Through the twinning project with the JMA and the seminars/workshops conducted nationwide, the MMA’s board members as well as general members mentioned that being a part of the organization was an important contributor to their experience of growth and pride as a midwife. This positive outcome was also shown as the growth in the achievement of the sub-item of Communication in the major item ‘Functions’ of the MACAT from 20% to 100%.
In addition, the important elements of our twinning project were the members’ attitudes, including their enthusiasm, sincerity, humility, and gratitude. Regarding enthusiasm, the young midwives had a desire for the MMA to reach the level of global standards by participating in the ICM International Convention, and to gain more knowledge about the ICM Global Standards by interacting with the JMA [12]. We were especially thankful to Ms Chieko Nohno, a Japanese midwife and a member of the Japanese parliament who was devoted to the establishment of the MMA, and the strength of our willingness to carry out her aspiration.
Further, importantly, both the JMA and the MMA empowered and motivated each other, maintained good relationships, and produced positive outcomes.
- Good human resources that resolve the barrier of language
This was a new factor discovered in our research. The language barrier was large and there were very few Mongolian midwives who could understand English. Fortunately, the MMA president’s best friend had the experience of studying abroad in Japan and was able to communicate fluently in Japanese. From the beginning to the end, this individual helped us in multiple ways, bridging the language barrier and arranging a proper interpreter. It can be said that we were blessed with reliable personnel who contributed to ensuring a well-functioning relationship between the JMA and the MMA.
The concept of ‘equality’ as a limitation in the twinning project
The twinning project is expected to result in an equal sharing of knowledge and skills with one another, and consequently, in an equal amount of growth [3,13–16]. It is indicated as ‘a two-way mutually beneficial exchange started on an equal footing’ in the ICM’s operational manual 2014 for twinning [3]. However, there is considerable misunderstanding regarding the concept of ‘on equal footing’, which insists on mutual ‘equality’ as a prerequisite for the twinning project [11,17]. In general, the twinning project is a co-operative relationship between developed and developing countries. There are huge differences in all aspects between the two countries in terms of maternal and child health, life expectancy, and socio-economic status. In addition, the JMA has a long history of midwives’ association dating back approximately 100 years, while the MMA was established only 14 years ago. It seems that this concept of ‘equality’ is the reason behind twinning projects being slow to progress globally. We also experienced difficulties in this regard during our first twinning project with the VAM (2011–2014).
Accordingly, it may be more reasonable if we strive towards promoting ‘equity’ instead of ‘equality’ in twinning projects [18]. Crespo [19] noted that equity is the leading attribute of reciprocity, which involves a system of giving, receiving, and returning. The relationship between the JMA and the MMA can be thought of as one between elder and younger sisters who carefully teach each other. With a commitment to improve maternal and child health in the Asian region, the JMA has taken the lead in fulfilling its roles of leadership, and nurturing and helping the members of its sister associations who wish to grow into world-class midwives [13,20]. It was a pleasure for us to raise funds for the operation of the twinning project, and to provide knowledge, skills, and research methods to the MMA. Moreover, it was surprising, joyful, and inspiring to see our sisters grow beyond our expectations whenever we met. This process seemed similar to an empowerment circle wherein our objectives continued to expand and get bigger than before [20]. Hence, within the context of this discussion, ‘equity’ can be described as both a tangible and intangible leading attribute of reciprocity.
While conducting the twinning project, we adopted a mentorship approach with the twinning programme as the backbone [11]. A mentor is defined as an individual with expertise who can help develop the career of a mentee by the Centering on Mentoring Presidential Task Force established by the American Psychological Association in 2006 [21]. The mentor is a coach who provides advice to enhance the mentee’s professional performance and development in career-related functions; the mentor further acts as a role model for the mentee in psychological functions [18]. Mentorship can also serve as the key to success in international co-operation. Our twinning project provided a platform that enhanced mutual understanding and empowerment of the two organisations through the concept of equity and a mentorship approach.
Future research participants
In the last 10 years in Mongolia, midwives’ education had been suspended and midwifery work had been restricted due to government policies. However, recently, the medical law has changed, midwifery expansion has been strengthened, and the need for midwifery expertise has been increasingly noted. Currently, the ‘Happy Birth and Happy Baby’ project has been conducted nationwide to acquire NCPR skills for the advanced certification as a profession to reduce infant mortality in pursuit of the SDGs. An accreditation system has been devised and implemented for this training. Even during the coronavirus disease 2019, training has steadily continued at each facility, and more than 80% of the members have already participated and acquired NCPR skills. This programme follows a leader system wherein NCPR-approved midwives become leaders and guide newly graduated midwives and midwives who have not yet acquired NCPR certification. It is expected that the sustainability of the major items on the MACAT will improve in the future because the ‘Happy Birth and Happy Baby’ project is being implemented as a sustainable programme led by midwives.
It is difficult to describe the outcomes of international co-operation projects in a short span of three years, and it is necessary to follow such international co-operation in the long term [22]. International co-operation needs a sustainable plan to support the autonomy of the partners involved in the project.