The importance of reciprocity in relationships between community-based midwives and mothers

Traumatic experiences, quality of life, and organizational commitment among midwives: A cross-sectional study

BACKGROUND

The work of midwives is emotionally challenging. Midwives share moments of joy, when a baby is born, and attend complex events of loss and trauma. Exposure to childbirth complications, emergencies, and loss can affect their professional quality of life and functioning. This aspect of midwives' practice has not been sufficiently researched.

AIM

To examine the associations between exposures to traumatic events, post-traumatic symptoms, and personal resilience with professional quality of life and organizational commitment among hospital midwives.

METHODS

Participants in this cross-sectional study conducted in 2020 included 131 midwives from three large hospitals in central Israel. Data were collected using a structured self-administered questionnaire that examined socio-demographic characteristics, exposure to traumatic events during childbirth, personal resilience, post-traumatic symptoms, professional quality of life, and organizational commitment.

RESULTS

The three most traumatic events for midwives were: neonatal death or feared death, maternal death or feared death, and stillbirth. The more frequent the exposure to traumatic events, the more numerous and intense the post-traumatic symptoms. The more numerous and intense the post-traumatic symptoms, the higher the level of professional burnout and compassion fatigue and the lower the compassion satisfaction. Higher compassion satisfaction and lower professional burnout were associated with higher organizational commitment. Personal resilience, country of birth, post-traumatic symptoms, and organizational commitment predicted compassion satisfaction.

CONCLUSIONS

Midwives' exposure to traumatic events is associated with the onset of post-traumatic symptoms, impaired professional quality of life, and reduced organizational commitment, and is accompanied by burnout and compassion fatigue. There is a need to address this issue in training programs and to develop organizational support and policies to improve midwives' well-being and quality of care.

Sources of attitudes towards parent-child co-sleeping and their effects: A systematic scoping review

Parent-child co-sleeping is a common practice in many cultures, although in Western countries, families who engage in parent-child co-sleeping can encounter attitudes about co-sleeping that feel critical from the people around them, as it is not commonly accepted and often stigmatized. This systematic scoping review examined and synthesized the available literature on the attitudes about parent-child co-sleeping that people encounter, their origins, and their effect on parents' own attitudes and behaviors. A total of 9796 abstracts were screened, and 33 studies were included. While the scope of the literature on this topic was narrow, this review demonstrated that parents/caregivers mostly encounter encouraging attitudes about co-sleeping from their extended family members and within their culture and discouraging attitudes from healthcare professionals. Findings suggest that encouraging attitudes enhance the likelihood of parents engaging and continuing with co-sleeping behavior, while discouraging attitudes can lead to the avoidance of parents discussing sleep with their healthcare professionals and can cause conflicts with other family members, including partners. Based on these findings, we conclude that further research is needed in several areas related to co-sleeping in Western culture, most specifically in how external attitudes influence the decision to co-sleep, as well as other behaviors and cognitions such as engagement with healthcare professionals, family satisfaction, parental self-efficacy, and overall mental health.

Mobilising Communities Prior to Healthcare Interventions: Reflections on the Role of Public Health Midwives Working With Vulnerable Communities of Sri Lanka

Background: Public health midwives (PHMs) play a frontline role in the Sri Lankan public healthcare system, ensuring the health of children and women at the community level. However, cultural differences in diverse social contexts necessitate PHMs for customised interventions to ensure optimum child and maternal health, particularly in most vulnerable communities.Purpose: The objective of the present study is to explore how PHMs have adapted their roles as community change agents to facilitate community mobilisation before implementing healthcare interventions for children and mothers in the estate sector (a marginalised and vulnerable community) of Sri Lanka.Research Design and methods: Using an exploratory qualitative research design, data were collected through in-depth interviews with 16 participants. The thematic analysis revealed two main themes that describe how PHMs engage in community mobilisation in addition to their designated role as healthcare officials in the estate sector of Sri Lanka.Results: The first theme highlights PHMs' involvement in community mobilisation through context-relevant advocacy for effective service implementation. The second theme illustrates how PHMs' role has been reshaped as advocates to intervene in making the family a supportive institution for child and maternal health. PHMs who work in the estate sector in the country are morally committed to engaging in community mobilisation and advocacy. However, this obligation can be neglected due to the lack of formal arrangements and training in sociocultural determinants of health and working with vulnerable communities.Conclusions: The role of a PHM in the estate sector differs significantly from that in the urban and rural sectors, given the significance of their interventions in family health. Also, community mobilisation is a prerequisite for implementing health policies for child and maternal health in vulnerable communities. Both community-level and family-level advocacy interventions and mobilisation efforts are equally important to establishing a supportive environment, without which any child and maternal healthcare interventions are difficult to implement.

Midwives', obstetricians', and nurses' perspectives of humanised care during pregnancy and childbirth for women classified as high risk in high income countries: A mixed methods systematic review

Women classified as 'high risk' or 'complicated' in pregnancy and childbirth have increased difficulty in accessing humanised care/humanisation in childbirth due to perceptions that this approach rejects the use of intervention and/or technology. Humanised care recognises the psychological and physical needs of women in pregnancy and birth. A mixed methods systematic review using a convergent segregated approach was undertaken using the Joanne Briggs Institute (JBI) methodology. The objective of the review was to identify the presence of humanisation for women with high risk pregnancy and/or childbirth in high income countries. Studies were included if they measured humanisation and/or explored the perspectives of midwives, obstetricians, or nurses on humanisation for women classified as having a high-risk or complicated pregnancy or childbirth in a high income country. Qualitative data were analysed using a meta-aggregative approach and a narrative synthesis was completed for the quantitative data. All studies were assessed for their methodological quality using the MMAT tool. Four databases were searched, and nineteen studies met the inclusion criteria. A total of 1617 participants from nine countries were included. Three qualitative findings were synthesised, and a narrative synthesis of quantitative data was completed. The integration of qualitative and quantitative data identified complimentary findings on: (i) the importance of developing a harmonised relationship with women; (ii) increased time counselling women on their choices; and (iii) fear of professional reputational damage if caring outside of protocols. Negotiating with women outside of protocols may have a wider impact on the professional than first thought. Understanding how healthcare professionals individualise care for women at risk in labour requires further investigation.

Skills and knowledge of midwives at free-standing birth centres and home birth: A meta-ethnography

PROBLEM

When midwives offer birth assistance at home birth and free-standing birth centres, they must adapt their skill set. Currently, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings.

BACKGROUND

Midwifery care at home birth and in free-standing birth centres requires context specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings.

AIM

To synthesise existing qualitative research that describes the skills and knowledge of certified midwives at home births and free-standing birth centres.

STUDY DESIGN

We conducted a systematic review that included searches on 5 databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the data set, and a line of argument synthesis was developed.

RESULTS

The search identified 13 papers, twelve papers from seven countries, and one paper that included five Nordic countries. Three overarching themes and seven sub-themes were developed: 'Building trustworthy connections,' 'Midwife as instrument,' and 'Creating an environment conducive to birth.'

CONCLUSION

The findings highlight that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centres. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of labouring women. Further research is needed to elicit how midwives develop these proficiencies.

Toward a contextualized understanding of well-being in the midwifery profession: An integrative review

Our integrative review synthesizes and evaluates two decades of empirical research on well-being in the midwifery profession to reveal (1) how researchers have studied midwives’ well-being; (2) key findings of research on midwives’ well-being; (3) underlying assumptions of this research; and (4) limitations of this research. We find that research on midwives’ well-being is disproportionately focused on individual midwives, who are assumed to be largely responsible for their own well-being, and that well-being in the midwifery profession is generally equated with the absence of mental health problems such as burnout, anxiety, and stress. Researchers have largely taken a narrow and instrumental approach to study midwives’ well-being, focusing on work-related antecedents and consequences, and overlooking the influence of nonwork factors embedded in the broader socioeconomic and cultural environment. Drawing on more comprehensive and contextualized well-being frameworks, we propose a research model that (1) expands the well-being construct as it applies to midwives and (2) situates midwives’ well-being in broader social, economic, political, and cultural contexts. Although developed in the midwifery context, our proposed research model can be applied to a host of professions.

A Bibliometric Analysis of Research Articles on Midwifery Based on the Web of Science

Objective

This study aimed to bibliometrically analyse the main features of the 100 top-cited articles on the midwifery index on the Web of Science.

Methods

Academic articles on midwifery' research published from 1985 to 2020 were included. VOSviewer 1.6.15, SPSS 22.0 software and a homemade applet were used to identify, analyse and visualise the citation ranking, publication year, journal, country and organisation of origin, authorship, journal impact factor and keywords along with the total link strength of countries, organisations and keywords.

Results

Among the 100 top-cited articles, the highest number of citations of the retrieved articles was 484. The median number of citations per year was 5.16 (interquartile range: 3.74-8.38). Almost two-thirds of the included articles (n = 61) centred on nursing and obstetrics/gynaecology. The top-cited articles were published in 38 different journals, the highest number of which was published by Midwifery (15%). Australia was the most productive country (24%). According to the total link strength, the sequence ran from the United States (28) to England (28) to Australia (19). The University of Technology Sydney and La Trobe University in Australia topped the list with four papers each. Hunter B was the most productive author (n = 4), and the average citations were positively related to the number of authors (r = 0.336, p < 0.05).

Conclusion

This study identified the most influential articles on midwifery and documented the core journals and the most productive countries, organisations and authors along with future research hotspots for this field; the findings may be beneficial to researchers in their publication and scientific cooperation endeavours.

'After last time, would you trust them?' - Rebuilding trust in midwives after a traumatic birth

AIM

To explore the processes pregnant women used to rebuild their trust in midwives and obstetricians, after a previous traumatic birth.

DESIGN

A longitudinal feminist constructivist Grounded Theory methods study, using semi-structured interviews to investigate how women made sense of their journeys through pregnancy and maternity care, when they had previously experienced a traumatic birth.

SETTING

Nine UK women were recruited in early pregnancy via the internet and social media, and were interviewed three times during the perinatal period.

FINDINGS

During pregnancy, participants re-analysed their previous birth experience(s) in order to plan for this pregnancy and birth. Once they had conceptualised their plans, they sought out healthcare professionals who could offer support, and used naturally occurring or engineered trust diagnostic situations to establish whether trust could be rebuilt.

CONCLUSION

Without a trusting relationship, midwives and obstetricians cannot deliver appropriate and efficient healthcare to pregnant people. Understanding the processes that pregnant women utilise to rebuild trust may help healthcare professionals to better understand their role in re-establishing these relationships.

Reducing midwife burnout at organisational level - Midwives need time, space and a positive work-place culture

BACKGROUND

Maternity care organisations have a responsibility to ensure the health and welfare of their staff. Rates of burnout are high in midwifery compared to other professionals. Therefore, exploring how it can be reduced is imperative.

AIM

To explore with midwives the contributors to burnout and how best to reduce burnout in a maternity hospital in Ireland.

METHODS

A Participatory Action Research study involving Co-operative Inquiry meetings (n = 5) with practising midwives (n = 21) between October 2018 and March 2019, in a large, urban teaching maternity hospital in Ireland. The transcribed data were analysed using Thematic Network Analysis.

FINDINGS

Several recommendations were made for maternity organisations, to reduce or prevent burnout. These include improving workplace culture, increasing support and acknowledgement, offering time and space for debriefing and reflection and regular rotation of staff. Consistent staff shortages are, however, a barrier to adhering to these recommendations.

CONCLUSION

This study is the first of its kind to offer an in-depth exploration with midwives into the main contributors of burnout and what can be done at an organisational level to reduce burnout among midwives. The findings of this study highlighted the importance of working relationships. Additionally, owing to the nature of midwifery practice, time and space need to be created for midwives to debrief and reflect. However, there is an urgent need for healthcare systems to combat staffing shortages in order for these strategies to be successful.

The perspectives of parents and healthcare professionals towards parental needs and support from healthcare professionals during the first two years of children's lives

PURPOSE

The first two years of a child's life have been found to be crucial for optimal growth and development. Support from healthcare professionals is especially important during this period. This study explored the perspectives of parents with children aged 0-2 years and healthcare professionals concerning parental needs and support provided by healthcare professionals.

METHODS

A qualitative research approach was adopted, which comprised semi-structured interviews with parents (N = 25) and focus group discussions with parents (N = 4) and healthcare professionals (N = 3). The data was analysed using the principles of inductive thematic analysis.

RESULTS

Overall, we found that parents preferred support that was tailored to their personal needs and practices. Building a trusting relationship between healthcare professionals and parents was also found to be important. The healthcare professionals recognized many of the parents' experiences. Some expressed that they felt bound to adhere to professional guidelines, which hindered them to provide customized support.

CONCLUSIONS

Recommendation for establishing tailored support and trust are self-disclosure by professionals, addressing possible misconceptions openly, and showing interest in someone's considerations or family and cultural customs. Further research into how professional support for parents can be improved is recommended.

A systematic review of providers' experiences of facilitating group antenatal care

Background

Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care.

Methods

Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically.

Results

Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload.

Conclusions

Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01200-0.

Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.

A participatory action research study exploring midwives' understandings of the concept of burnout in Ireland

INTRODUCTION

In depth exploration of the burnout phenomenon among midwives is sparse. The concept has been extensively studied, but predominantly reports rates and evaluates interventions to reduce burnout. A definition has yet to be offered in the literature from a midwifery perspective.

AIMS

To explore midwives' understandings of burnout, professionally and personally, in the context of contemporary maternity care in Ireland.

METHODS

This was a Two-phase Participatory Action Research study. Five co-operative inquiry meetings were held with practising midwives (n=21) over a six-month period between October 2018 and March 2019, in a large, urban teaching maternity hospital in Dublin, Ireland.

FINDINGS

We found that multiple factors contributed to midwives' perceptions and understandings of the concept of burnout. Midwives defined burnout as persistent stress and exhaustion, with an associated reduction of their individual coping abilities, motivation, empathy and/or efficacy, is unique to the individual and is primarily, in the midwifery context, caused and inextricably linked to excessive workload.

CONCLUSION

Burnout is a complex concept with many entities and its significance and impact within the midwifery profession highlights the importance of its exploration and understanding. This study is the first of its kind to explore, with midwives, the concept of burnout. The elements of stress and exhaustion in the definition mirror existing definitions in the literature.

From Vulnerability to Disclosure: A Normative Approach to Understanding Trust in Obstetric and Intrapartum Nurse-Patient Communication

This study qualitatively examined how nurses, nurse practitioners, and nurse midwives construct the meaning of patient trust in their work caring for pregnant and laboring women. Twenty-two interviews were conducted with nurse participants employed at clinics, hospitals, and birth centers across Southeastern United States. Using a normative theoretical approach within the multiple goals framework, we identified five emergent themes that characterize trust as it shapes nurses' communicative goals: trust as the woman's acceptance of vulnerability and risk, the woman relinquishing control, the woman conceding to the nurse's expertise, the woman feeling heard, and the woman's disclosure of information. The results support previous studies, which conceptualized trust as vulnerability, risk, and disclosure whereas the remaining themes are original to this study. The results are interpreted both in light of existing links between trust and communication and the shifting and conflicting goals of nurses as they attempt to achieve their primary goal of optimal health outcomes. Passive constructions of trust that conflate it with women's acquiescent behaviors could have implications for the quality of communication between nurses and patients. In addition, trust, as understood by these participants, becomes situated as an instrumental means to achieving patient cooperation and desired health outcomes rather than a relational goal that supports women's agency throughout obstetric and intrapartum processes. This may be at odds with the modern movement toward patient-centered care and shared decision-making in U.S. maternity care.

The importance of nurturing trusting relationships to embed shared decision-making during pregnancy and childbirth

OBJECTIVE

To generate greater awareness of the contextual and relational factors that influence women's capacity to participate in shared decision-making during childbirth.

METHODS

A three-phase participatory action research approach involving in-depth interviews and co-operative inquiry meetings.

SETTING

Dublin, Ireland in a large maternity hospital.

PARTICIPANTS

Five postnatal women who gave birth to live healthy babies, and attended obstetric or midwifery-led care and 13 practising midwives.

FINDINGS

This paper presents the findings from the third phase of a three-phase action research study exploring the action's women consider necessary to embed informed choice, into practice. The findings reveal that multiple organisational and relational factors influence how women can participate in shared decision-making including the model of care they attended, continuity of carer, power dynamics, hospital policies and trust in self and others. Women's relationships with maternity care professionals reveals that exercising choice is not only defined by but contingent on the degree of trust in their relationships with maternity care professionals.

Role of midwife-supported psychotherapy on antenatal depression, anxiety and maternal health: A meta-analysis and literature review

The onset of depression and anxiety during the antenatal stage of pregnancy is common. Despite the conception of numerous interventions in the past decades, studies show no signs of decline in the prevalence of antenatal depression and anxiety. Recently, the use of midwife-supported psychotherapy to treat these psychosomatic disorders has garnered a lot of attention. However, no attempt to date has been made to synthesize the evidence evaluating the influence of midwife-supported psychotherapy on antenatal depression, anxiety, and overall maternal health-status. The aim of the present meta-analysis was to demonstrate the effectiveness of midwife-supported psychotherapy on depression, anxiety, and maternal health-status outcome during the antenatal stage of pregnancy. A systematic identification of literature was performed according to PRISMA guidelines on four academic databases: MEDLINE, Scopus, EMBASE and CENTRAL. A meta-analysis evaluated the influence of midwife-supported psychotherapy on depression, anxiety, and maternal health-status outcome as compared to conventional obstetric care. Of the 1,011 records, 17 articles, including 6,193 pregnant women (mean age: 28.9±2.2 years) were included in this meta-analysis. Eleven studies compared the effects of midwife-supported therapy on depression, 14 compared its effects on anxiety and 2 compared its effects on maternal health-status outcome. The meta-analysis reveals the beneficial effects of midwife-supported psychotherapy for reducing depression (Hedge's g: -0.9), anxiety (-0.8) and enhancing maternal health-status outcome (0.1), as compared to conventional obstetric care. The current systematic review and meta-analysis recommend the use of midwife-supported psychotherapy for the reduction of depression, anxiety and enhancing maternal health-status during the antenatal stage of pregnancy.

Distribution of midwives in Mongolia: A secondary data analysis

INTRODUCTION

Midwives are at the core of strengthening the health system, especially in the crucial period around pregnancy, childbirth, and the early weeks of life. In 2016, the national-level maternal mortality ratio in Mongolia was 48.6 deaths per 100,000 live births, but this was much higher (up to 212.9 deaths/100,000) in some rural provinces of the country. The wide variation in maternal mortality between urban and rural areas of Mongolia might be related to the distribution of midwives and equity of access to maternity care.

OBJECTIVES

In the present study, we aimed to determine the distribution of midwives in each province of Mongolia and to examine inequality in the distribution of midwives nationwide.

DESIGN

A secondary data analysis.

METHODS

Data from the Centre of Health Development and the National Statistical Office of Mongolia were obtained and analysed. First, we assessed the distribution of midwives at provincial and regional levels, along with the association between these distributions and the maternal mortality ratio in 2016. We then calculated the inequality of these distributions using the Gini coefficient and examined trends for the years 2010-2016. We compared results for urban, suburban, and rural provinces. Rural areas are sparsely populated and enormous in size, so it may be difficult access to basic healthcare services. It was considered important, therefore, to assess the number of midwives per 1000 km² as well as the commonly used indicator of per 10,000 population.

RESULTS

When the land area in each province was taken into consideration rather than only the population, wider variations between urban, suburban, and rural provinces became apparent. Provinces varied according to the number of midwives per 10,000 population by a factor of three (range 2.0-6.2/midwives); while provinces varied according to the number of midwives per 1000 km² by a factor of approximately 300 (range 0.2-61.2/midwives). The Gini coefficient for the number of midwives per 10,000 population in 2016, R = 0.201, revealed "relative" equality. This was slightly reduced from R = 0.305 in 2010 and indicated a shift toward equality. However, the Gini coefficient for the number of midwives per 1000 km² area indicated "severe" inequality of R = 0.524 in 2016. This was increased from R = 0.466 in 2010, indicating that no improvement has been seen over these years.

CONCLUSIONS

Our study suggests that two different measures of midwifery distribution should be used as indicators: number of midwives "per 10,000 population" and "per 1000 km² area". In rural areas such as parts of Mongolia, geographical features and population density are important features of the local context. To deliver healthcare services in a timely manner and within a reasonable distance for pregnant women who need care, the indicator of per 1000 km² area would be more suitable for rural and sparsely populated areas than the indicator of per 10,000 population, which is commonly used for urban and settled areas. Based on our findings, to reduce the wide gap in MMR between rural and urban areas, we recommend at least one midwife per 1000 km² area in rural regions of Mongolia.

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

Widespread reports of "disrespect and abuse" in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate "respectful" care than the current emphasis on formal rights and respect.

Interventions to improve wellbeing among obstetricians and midwives at Cork University Maternity Hospital

BACKGROUND

There is an increasing body of research demonstrating stress, burnout, and compassion fatigue among those working in obstetrics and gynaecology. The literature is lacking with respect to targeted interventions aimed at improving staff wellbeing.

AIMS

To investigate whether an intervention which increases support for staff is feasible to implement and effective at improving staff wellbeing.

METHODS

This study was conducted in a tertiary university teaching maternity hospital. All doctors in training (DITs) (N = 28) and midwives (N = 69) working in the delivery suite were invited to participate. Wellbeing was assessed by measuring burnout, compassion fatigue, and perceived stress using validated questionnaires. These were distributed pre-intervention and 6 months after implementation of the interventions. The support interventions consisted of posters promoting self-care, team bonding sessions, and end of shift meetings.

RESULTS

Eighteen (64%) DITs and 22 (31%) midwives returned pre-intervention questionnaires. Thirteen (18%) midwives retuned post-intervention questionnaires, of which five midwives (7%) returned both the pre-intervention questionnaire and the post-intervention questionnaire. Eighty-seven percent of participants were experiencing emotional exhaustion pre-intervention. There was a statistically significant decrease in the Professional Quality of Life burnout score from pre-intervention (M = 25.8) to post-intervention (M = 21.4), p = 0.02. End of shift meetings were discontinued after 5 weeks due to low attendance. End of shift meetings provided an opportunity for support and debriefing; however, the timing of these sessions impaired their long-term feasibility.

CONCLUSION

DITs and midwives of this sample are experiencing high levels of burnout and compassion fatigue. End of shift meetings for midwives and team bonding sessions for DITs may positively impact on wellbeing, but in current format, they are not feasible for long-term implementation. The low level of participation highlights a challenge in implementing institution-wide support interventions.

Disempowered midwives and traumatised women: Exploring the parallel processes of care provider interaction that contribute to women developing Post Traumatic Stress Disorder (PTSD) post childbirth

BACKGROUND

Around 4% of women develop Post Traumatic Stress Disorder Post Childbirth (PTSD-PC). During childbirth a woman's perception of her care provider's interpersonal verbal and nonverbal relationship behaviours, termed 'Quality of Provider Interaction' are significantly associated with the development of PTSD-PC.

AIMS

To understand how women who develop PTSD-PC and midwives, experience their interactions during care provision. In particular, how they feel during their interactions and what this means to them.

METHODS

The qualitative method of Interpretative Phenomenological Analysis that incorporates a reflective approach, was used to gain deep understanding of the lived experience of care provider interaction. Six women who met full diagnostic criteria for PTSD-PC and six midwives who provided intrapartum care, participated in individual face-to-face interviews.

RESULTS

Two key findings were identified: 1) Failing to recognise and meet the human needs of both women and midwives, results in poor quality interactions from midwives and poor perception of care provider interaction by women; 2) The study groups of women and midwives both identified the quality of their relationship as central to positive interactions. RECOMMENDATIONS FOR PRACTICE: (1) Raise the status of psychological wellbeing for childbearing women and make it of equal importance to physical wellbeing, with clear focus upon care provider interaction; (2) Create a midwife centred system that enables midwives to provide optimal care provider interaction and improve relationship-based care; and (3) Challenge underlying toxic cultures that currently persist in the maternity services system, which undermine the work of midwives and consequently the experience of women.

CONCLUSION

Failure to recognise and meet the human and relationship needs of both childbearing women and midwives contributes to poor care provider interactions offered by midwives and negative perceptions of care provider interactions by women. In response, NHS maternity services need to highlight the importance of the quality of care provider interaction alongside perinatal psychological wellbeing. This requires improved working environments for midwives, so they can optimise their quality of interaction with childbearing women. This will in turn impact upon the incidence and levels of trauma and PTSD-PC experienced by women.

'Scrutinised, judged and sabotaged': A qualitative video diary study of first-time breastfeeding mothers

OBJECTIVE

To explore how support impacted on mothers' breastfeeding experiences in the first few weeks following birth.

DESIGN

A qualitative approach explored real-time experiences of breastfeeding captured by five first-time mothers in the South of England on camcorder as video diaries. A multi-dimensional approach involving thematic analysis ensured both the audio and visual elements of the data were analysed.

FINDINGS

Mothers felt 'under surveillance' by the biomedical approach to support from the healthcare team. At best mothers felt reassured that they were 'on the right track'. When mothers felt their breastfeeding was constantly being examined, criticised and threatened they felt 'scrutinised, judged and sabotaged'. When they found it difficult to access healthcare support, or they avoided it altogether to circumvent further scrutiny, they felt 'abandoned and alone'.

KEY CONCLUSIONS

Collecting audio-visual data in real-time adds fresh insights into how support impacts mothers' experiences of breastfeeding. The biomedical approach to support for breastfeeding is not effective. Scrutinising, judging and/or sabotaging mothers' attempts to breastfeed can have long-lasting effects on maternal emotional wellbeing.

IMPLICATIONS FOR PRACTICE

Breastfeeding support might be improved by adopting a more social model of care. Future research needs to explore how relationship-based support can be provided by the health service.

"It Can't Be Like Last Time" - Choices Made in Early Pregnancy by Women Who Have Previously Experienced a Traumatic Birth

Background: A significant number of women experience childbirth as traumatic. These experiences are often characterized by a loss of control coupled with a perceived lack of support and inadequate communication with health care providers. Little is known about the choices women make in subsequent pregnancy(s) and birth(s), or why they make these choices. This study aimed to understand these choices and explore the reasons behind them. Methods: A longitudinal grounded theory methods study involving nine women was conducted. Over half of the participants had a formal diagnosis of post-traumatic stress disorder (PTSD) and/or PND related to the previous birth. Interviews were carried out at three timepoints perinatally. These findings are from the first interviews at 12-20 weeks. Results: From the first days of pregnancy, this cohort of women were focused on concerns that this birth would be a repeated traumatic experience. The women were deliberately searching out and analyzing information about their choices in this pregnancy and birth, and making plans which had two aims; firstly to avoid a repeat of their previous birth experience and secondly to avoid a loss of control to other people during the birth. The women considered a range of birth choices, from elective cesareans to freebirth. Some women felt well supported by those around them, including care providers, partners, friends, and family. Others did not feel supported and were anticipating conflict in trying to assert their birth choices. Many early relationships with healthcare professionals were characterized by fear and mistrust. Discussion: If women who have previously experienced a traumatic birth become pregnant again, they have a strong desire to avoid a repeat experience and to feel in control of their birth choices. Access to robust information appears to help reduce uncertainty and arm women in their discussions with professionals. Similarly making plans and seeking to have them agreed with care providers at an early stage is used a way to reduce the risk of having a further traumatic experience. Implications for practice include supporting women in formulating and confirming pregnancy and birth plans at an early stage to reduce uncertainty and foster a sense of control.

Midwifery abdication - is it acknowledged or discussed within the midwifery literature: An integrative review

INTRODUCTION

In this review we explore the concept of Midwifery Abdication and whether it is acknowledged or discussed within the midwifery literature.

METHODS

A modified Whittemore and Knafl integrative review framework of 2005 enabled consideration of quantitative and qualitative literature. A total of 1508 papers were located. Duplicate records were removed, leaving 1197 records. All titles, abstracts, or case facts were reviewed using a framework derived from the definition of Midwifery Abdication. Three qualitative studies were selected for analysis; the NICE Quality Appraisal Checklist was used to determine study quality.

RESULTS

Midwifery Abdication occurs, as reported within the wider midwifery literature, and indicated in three studies from different countries. However, the original constructs need to be widened to include: 'external perceptions of midwifery practice' and 'how can reflection facilitate change'. The extent of philosophy in these environments leads to the adoption of midwifery philosophy failure. Such an environment impacts on a midwife's ability to fully exercise autonomy, and to advocate for normality and women. This renders Midwifery Abdication almost inevitable or at least very difficult to prevent. A midwife's professional identity, environmental hierarchy and associated culture of social obedience, acceptance and finding one's place, all act as influencing factors in abdication.

CONCLUSIONS

Midwifery education needs to ensure that midwives are prepared and able to embrace their professional status as independent practitioners. Promotion of reflexive practice to facilitate personal and professional change is warranted. Practice policies that are not supportive of a midwife's professional autonomy and scope of practice reinforce the technocratic work environment.

How Tanzanian Nurse-Midwives and Obstetricians Develop Postpartum Relationships With Women

Nurse-midwives and obstetricians are the primary postpartum health-care providers for mothers and babies in Tanzania. It is imperative that mothers and babies receive adequate information and support in order to save lives. Feminist poststructuralism and discourse analysis were used to conduct and analyze 13 semi-structured interviews from nurse-midwives and obstetricians at three clinics in Dar es Salaam, Tanzania. Establishing friendly supportive relationships enabled nurse-midwives and obstetricians to work effectively with mothers postpartum. Participants explained the importance of including family members in postpartum care and about the strategies they used in a clinic environment that was not always supportive of including family. Effective relational maternity care focused on families during the postpartum period can facilitate the delivery of information and save lives.

Midwifery one-to-one support in labour: More than a ratio

OBJECTIVE

To explore midwifery one-to-one support in labour in a real world context of midwife-led birth environments.

DESIGN

Ethnographic study. Data was collected from 30 observations inside and outside the birth environments in three different birth settings. Semi-structured interviews were completed following the births with 29 low-risk women and 30 midwives with at least one year labour support experience to gain their perspectives. Twenty-seven maternity records were also analysed.

SETTING

An alongside midwife-led unit, freestanding midwife-led unit and women's homes in England.

FINDINGS

Six components of care were identified that required balance inside midwife-led birth environments: (1) presence, (2) midwife-woman relationships, (3) coping strategies, (4) labour progress, (5) birthing partners and (6) midwifery support. Midwives used their knowledge, experience and intuitive skills to synchronise their care for the six components to work in balance. Balancing of the six components have been translated into continuums representing the labour care and requirements.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Midwifery one-to-one support in labour is more than a ratio when translated into clinical practice. When the balance of the six components were tuned into the needs of women, women were satisfied with their labour and birth experience, even when it did not go to plan. A one midwife to one woman ratio should be available for all women in labour.

The midwife-woman relationship in a South Wales community: Experiences of midwives and migrant Pakistani women in early pregnancy

BACKGROUND

In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife-woman relationships for migrant and minority ethnic women in the UK.

METHODS

A focused ethnography was conducted in South Wales, UK, including semi-structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection.

FINDINGS

The midwife-woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health-care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors.

CONCLUSIONS

Findings provide new theoretical insights into the complex factors contributing to the health-care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

A Framework for Describing the Influence of Service Organisation and Delivery on Participation in Fetal Anomaly Screening in England

Objective. The aim of this research was to explore the influence of service organisation and delivery on providers and users' interactions and decision-making in the context of Down's syndrome screening. Methods. A qualitative descriptive study involving online interviews conducted with a purposive sample of 34 community midwives, 35 pregnant women, and 15 partners from two maternity services in different health districts in England. Data were analysed using a combination of grounded theory principles and content analysis and a framework was developed. Results. The main emerging concepts were organisational constraints, power, routinisation, and tensions. Providers were concerned about being time-limited that encouraged routine, minimal information-giving and lacked skills to check users' understanding. Users reported their participation was influenced by providers' attitudes, the ambience of the environment, asymmetric power relations, and the offer and perception of screening as a routine test. Discordance between the national programme's policy of nondirective informed choice and providers' actions of recommending and arranging screening appointments was unexpected. Additionally, providers and users differing perceptions of emotional effects of information, beliefs, and expectations created tensions within them, between them, and in the antenatal environment. Conclusions. A move towards a social model of care may be beneficial to empower service users and create less tension for providers and users.

Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives

BACKGROUND

Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives.

AIM

To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress.

METHODS

Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms.

FINDINGS

More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma.

DISCUSSION

Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder.

CONCLUSION

Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced.

Sustainability and resilience in midwifery: A discussion paper

BACKGROUND

midwifery workforce issues are of international concern. Sustainable midwifery practice, and how resilience is a required quality for midwives, have begun to be researched. How these concepts are helpful to midwifery continues to be debated. It is important that such debates are framed so they can be empowering for midwives. Care is required not to conceptually label matters concerning the midwifery workforce without judicious scrutiny and diligence.

AIM

the aim of this discussion paper is to explore the concepts of sustainability and resilience now being suggested in midwifery workforce literature. Whether sustainability and resilience are concepts useful in midwifery workforce development is questioned.

METHOD

using published primary midwifery research from United Kingdom and New Zealand the concepts of sustainability and resilience are compared, contrasted and explored.

FINDINGS

there are obvious differences in models of midwifery care in the United Kingdom and New Zealand. Despite these differences, the concepts of resilience and sustainability emerge as overlapping themes from the respective studies' findings. Comparison between studies provides evidence of what is crucial in sustaining healthy resilient midwifery practice. Four common themes have been identified that traverse the different models of care; Self-determination, ability to self-care, cultivation of relationships both professionally and with women/families, and a passion, joy and love for midwifery.

CONCLUSIONS

the impact that midwifery models of care may have on sustainable practice and nurturing healthy resilient behaviors remains uncertain. The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives 'to toughen up' in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife. The findings invite further examination of contextual influences that affect the wellbeing of midwives across different models of care.

Mothers’ expectations of midwives’ care during labour in a public hospital in Gauteng

BACKGROUND

Mothers develop expectations regarding midwives’ care during labour and when these are not met mothers become dissatisfied and eventually have negative experiences of their labour. It is only when mothers’ voices are heard by midwives in the labour ward that efficient and quality care will be provided. To ensure mothers have a positive experience of labour, midwives should include mothers’ expectations when caring for them.

OBJECTIVE

The purpose of the study on which this article is based was to determine mothers’ expectations of midwives’ care during labour. To achieve this purpose the researcher sought to explore and describe mothers’ expectations of midwives’ care during labour in a specific public hospital in Gauteng.

METHOD

A qualitative, exploratory, descriptive and contextual study design was used. Face-to-face, in-depth individual interviews were conducted with mothers about their expectations of midwives’ care during labour. Data were then analysed with an open descriptive method of coding (Tesch’s eight steps) that is appropriate for qualitative research to identify categories. The data was also analysed by an independent coder. The categories were subsequently placed within a holistic health promotive nursing theory that encompasses body, mind and spirit.

RESULTS

The findings revealed the provision of comfort and support as the two main aspects that the mothers expected from the midwives’ care. The mothers expected midwives to improve their communication skills with them (mothers) as well as with fathers or partners if they were available. The mothers expected midwives to facilitate bonding between mother, father and baby, and also encouraged the midwives to improve their (midwives’) knowledge, skills and morale.

CONCLUSION

The results of this study should assist midwives in providing holistic quality care to mothers during labour, thus providing satisfaction and positive experiences of the mothers’ labour.

An evaluation of a teaching strategy: The use of literature when teaching pre-registration midwifery students on pregnancy and loss

Facilitating emotional intelligence and insight in midwifery can be challenging, and the purpose of this paper is to illustrate how this can be nurtured through the use of poetry, in particular Seamus Heaney's poem Elegy for a Still Born Child. Students' ability to gain insight into the experience of bereaved parents and achieve an emotional grasp of the situation through vicarious experience were evaluated. Qualitative data from evaluations was content analysed and significant themes emerged. Students' comments clearly support the suggestion that use of this poem has enhanced emotional intelligence. The data also indicates that vicarious experience gained through reading this poem has helped to nurture sensitivity and professional insight into the impact of still birth on a father.

Making use of expertise: a qualitative analysis of the experience of breastfeeding support for first-time mothers

There is now a body of research evaluating breastfeeding interventions and exploring mothers' and health professionals' views on effective and ineffective breastfeeding support. However, this literature leaves relatively unexplored a number of questions about how breastfeeding women experience and make sense of their relationships with those trained to provide breastfeeding support. The present study collected qualitative data from 22 breastfeeding first-time mothers in the United Kingdom on their experiences of, and orientation towards, relationships with maternity care professionals and other breastfeeding advisors. The data were obtained from interviews and audio-diaries at two time points during the first 5 weeks post-partum. We discuss a key theme within the data of 'Making use of expertise' and three subthemes that capture the way in which the women's orientation towards those assumed to have breastfeeding expertise varied according to whether the women (1) adopted a position of consulting experts vs. one of deferring to feeding authorities; (2) experienced difficulty interpreting their own and their baby's bodies; and (3) experienced the expertise of health workers as empowering or disempowering. Although sometimes mothers felt empowered by aligning themselves with the scientific approach and 'normalising gaze' of health care professionals, at other times this gaze could be experienced as objectifying and diminishing. The merits and limitations of a person-centred approach to breastfeeding support are discussed in relation to using breastfeeding expertise in an empowering rather than disempowering way.

Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women׳s views

OBJECTIVES

to gain insight into low risk nulliparous women׳s experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision.

DESIGN

postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study.

SETTING AND PARTICIPANTS

participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007.

FINDINGS

most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women׳s perception of their pregnancy progression and the relationship developed with their midwife.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women׳s experience of antenatal care.

What Makes for Good Collaboration and Communication in Maternity Care? A Scoping Study

BACKGROUND: Good communication and collaboration are critical to safe care for mothers and babies.

OBJECTIVE: To identify factors associated with good collaboration and communication among maternity care professionals and between both professionals and parents.

METHOD: Scoping study. We searched PubMed and Web of Science for peer reviewed, quantitative and qualitative, original, primary research in Western societies on communication and collaboration in maternity care among professionals (Search 1) and between professionals and parents (Search 2).

FINDINGS: The 40 studies (14 in Search 1; 26 in Search 2) that met our selection criteria highlighted several factors associated with good communication and collaboration. We grouped these factors into 6 categories: Expertise, Partnership, Context, Attitude, Trust, and Communication style. Studies of communication and collaboration among professionals foregrounded work-related aspects, whereas studies examining collaboration between professionals and parents paid more attention to interpersonal aspects. Before 2012, few studies covered positive aspects of communication and collaboration. We also found an underrepresentation of parents in study populations.

CONCLUSION: Our study is part of a growing trend of identifying the positive aspects of communication and collaboration in maternity care. As the study of collaboration in practice continues, researchers need to be sure to involve all stakeholders, including parents.

Immigration and Continuing Inequalities in Maternity Outcomes: Time to Reexplore the Client–Provider Relationship?

The United Kingdom has seen a substantial rise in immigration over the past 10 years. This new population has a high percentage of women of childbearing age (Office for National Statistics, 2012b), consequently placing an increased demand on U.K. maternity services. Previous research suggests lower satisfaction and worse maternity outcomes for migrant and minority ethnic women both in the United Kingdom and abroad. Most papers exploring ethnic health inequalities have centered on causal factors such as differences in socioeconomic status and host country language ability. Health care policies to tackle inequalities in the United Kingdom, based on these assumptions, have had limited success. Consequently, alternative causal factors need to be explored. This article discusses ethnic inequalities in maternity outcomes in the United Kingdom and proposes that research exploring the client–provider relationship in migrant women’s maternity care could provide important new insights.

Developing and piloting the multiple mini-interview in pre-registration student midwife selection in a UK setting

BACKGROUND

Published research has demonstrated that the multiple mini-interview (MMI) is a reliable assessment instrument in medical and nursing student selection. There is a dearth of evidence specifically relating to the advancement and subsequent evaluation of MMIs in the context of student midwife selection.

OBJECTIVES

To develop, pilot and examine the reliability of MMIs in pre-registration student midwife selection in a UK setting.

DESIGN AND SETTING

DeVellis' framework for questionnaire development underpinned the generation of MMI scenarios. BSc (Hons) Midwifery Studies students at a Higher Education Institution in the UK volunteered to participate in 'mock' MMI circuits during the first week of their programme.

RESULTS

An eight station model was piloted. Communication skills were rated at each station as a generic attribute. Station specific attributes assessed included: compassion and empathy; respect for difference and diversity; honesty and integrity; intellectual curiosity and reflective nature; advocacy; respect for privacy and dignity; team working and initiative; the role of the midwife and motivation to become a midwife. Participants' responses to scenario questions were rated on a 7 point scale. Cronbach's alpha scores measuring internal consistency ranged from 0.91 to 0.97 CONCLUSION: The systematic development of the MMI model and scenarios resulted in 'excellent' reliability across all stations. These findings endorse the MMI technique as a reliable alternative to the personal interview in informing final decisions in pre-registration student midwife selection.

Continuing professional development and changed re-registration requirements: midwives' reflections

BACKGROUND

In 2010 new legislation in Australia led to the establishment of the Australian Health Practitioner Regulatory Authority standards, now used to manage nursing and midwifery registration and the annual re-registration requirements for midwives and nurses. These clearly articulate the continuing professional development (CPD) requirements together with a guiding framework. Individuals need to engage in adult pedagogy which makes explicit the need for self-examination to identify and prioritise their learning needs.

OBJECTIVES

This study aimed to investigate how existing registered midwives approach and are challenged by these changed statutory requirements in Australia, particularly completion of CPD activity.

DESIGN

This paper reports the findings from phase one of a two phase, longitudinal, case study in which midwives describe their experience during in-depth qualitative interviews.

SETTING

Australia

PARTICIPANTS

A sample of 20 female participants was recruited nationally from four states using a purposive sampling approach to provide maximum variation to explore the issue.

METHODS

Each participant took part in an in-depth interview. In order to facilitate reflection on experiences each participant was asked to discuss an object that held professional value or meaning to them.

RESULTS

A key theme in the findings is the relationship between motivation which influences the decisions that midwives are making about CPD, their ongoing registration and practice context. The findings reveal implicit values and beliefs about practice relationships and how these function as motivational factors that influence midwives' decisions about CPD and practice options.

CONCLUSIONS

The findings provide insight into the need for system wide dialogue to devise ways to support midwives to maintain as well as to continue to develop their practice, through CPD and to acknowledge the challenges faced by those midwives who currently hold dual registration as a registered nurse in the context of the changed requirements.

Midwives׳ experiences of workplace resilience

BACKGROUND

many UK midwives experience workplace adversity resulting from a national shortage of midwives, rise in birth rate and increased numbers of women entering pregnancy with complex care needs. Research evidence suggests that workplace pressures, and the emotional demands of the job, may increase midwives׳ experience of stress and contribute to low morale, sickness and attrition. Much less is known about midwives who demonstrate resilience in the face of adversity. Resilience has been investigated in studies of other health and social care workers, but there is a gap in knowledge regarding midwives׳ experiences.

OBJECTIVE

to explore clinical midwives׳ understanding and experience of professional resilience and to identify the personal, professional and contextual factors considered to contribute to or act as barriers to resilience.

DESIGN

an exploratory qualitative descriptive study. In Stage One, a closed online professional discussion group was conducted over a one month period. Midwives discussed workplace adversity and their resilient responses to this. In Stage Two, the data were discussed with an Expert Panel with representatives from midwifery workforce and resilience research, in order to enhance data interpretation and refine the concept modelling.

SETTING

the online discussion group was hosted by the Royal College of Midwives, UK online professional networking hub: 'Communities'.

PARTICIPANTS

11 practising midwives with 15 or more years of 'hands on clinical experience', and who self-identified as being resilient, took part in the online discussion group.

FINDINGS

thematic analysis of the data identified four themes: challenges to resilience, managing and coping, self-awareness and building resilience. The participants identified 'critical moments' in their careers when midwives were especially vulnerable to workplace adversity. Resilience was seen as a learned process which was facilitated by a range of coping strategies, including accessing support and developing self-awareness and protection of self. The participants identified the importance of a strong sense of professional identity for building resilience.

KEY CONCLUSIONS

this study provides important new insights into resilience within UK midwifery, of relevance to the wider profession. Some findings echo those of other resilience studies; however, there are new insights such as the importance of professional identity which may be relevant to other health care workers. Through understanding more about resilience, it may be possible to facilitate positive adaptation by midwives and ameliorate the effects of workplace adversity.

IMPLICATIONS FOR PRACTICE

This study indicates that resilience is a complex phenomenon, which warrants serious consideration from clinical midwives, managers, educators and researchers.

Being safe practitioners and safe mothers: a critical ethnography of continuity of care midwifery in Australia

OBJECTIVE

To examine how midwives and women within a continuity of care midwifery programme in Australia conceptualised childbirth risk and the influences of these conceptualisations on women's choices and midwives' practice.

DESIGN AND SETTING

A critical ethnography within a community-based continuity of midwifery care programme, including semi-structured interviews and the observation of sequential antenatal appointments.

PARTICIPANTS

Eight midwives, an obstetrician and 17 women.

FINDINGS

The midwives assumed a risk-negotiator role in order to mediate relationships between women and hospital-based maternity staff. The role of risk-negotiator relied profoundly on the trust engendered in their relationships with women. Trust within the mother-midwife relationship furthermore acted as a catalyst for complex processes of identity work which, in turn, allowed midwives to manipulate existing obstetric risk hierarchies and effectively re-order risk conceptualisations. In establishing and maintaining identities of 'safe practitioner' and 'safe mother', greater scope for the negotiation of normal within a context of obstetric risk was achieved.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The effects of obstetric risk practices can be mitigated when trust within the mother-midwife relationship acts as a catalyst for identity work and supports the midwife's role as a risk-negotiator. The achievement of mutual identity-work through the midwives' role as risk-negotiator can contribute to improved outcomes for women receiving continuity of care. However, midwives needed to perform the role of risk-negotiator while simultaneously negotiating their professional credibility in a setting that construed their practice as risky.