Midwives' perceptions of organisational structures and processes influencing their ability to provide caseload care to socially disadvantaged and vulnerable women

Barriers and facilitators when implementing midwifery continuity of carer: a narrative analysis of the international literature

BACKGROUND

Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging.

METHODS

In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence.

RESULTS

Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced.

CONCLUSIONS

By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.

The sustainability of midwifery group practice: A cross-sectional study of midwives and managers

PROBLEM

Although there is robust evidence for the benefits of midwifery group practice (MGP) caseload care, there are limited opportunities for women to access this model in Australia. There is also limited knowledge on how to sustain these services.

BACKGROUND

MGP can benefit childbearing women and babies and improve satisfaction for women and midwives. However, sustainability of the model is challenging. While MGPs are often supported and celebrated, in Australia some services have closed, while others struggle to adequately staff MGPs.

AIM

To investigate midwives and managers opinions on the management, culture, and sustainability of MGP.

METHODS

A national survey of MGP midwives and managers was distributed (2021 and 2022). Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using content analysis.

RESULTS

A total of 579 midwives and 90 managers completed the survey. The findings suggest that many MGPs do not support new graduates and students to work in MGP. Over half (59.8%) the participants (midwives and managers) reported that the women and families were the best aspect about working in MGP, while 44.3% said the effects on midwives' lifestyle and families were the worst aspect.

DISCUSSION

The relationship with women remains the major motivator for providing MGP care. However, work-life imbalance is a deterrent, exacerbated by staffing shortages. Staffing might be improved by adequate renumeration, strengthening orientation, and attracting new graduates and students through experience in MGP.

CONCLUSIONS

There is a need to attract midwives to MGP and improve work-life balance and sustainability.

Barriers and enablers to antenatal care attendance for women referred to social work services in a Victorian regional hospital: A qualitative descriptive study

BACKGROUND

Women referred to social work services during pregnancy are more likely to experience social disadvantage than those who are not, resulting in reduced antenatal care attendance. Lack of antenatal care engagement leads to poor identification and management of concerns that can have immediate and long-term health consequences for women and their babies. Identifying the barriers and enablers to antenatal care attendance for women referred to social work services is important for designing models of care that promote effective engagement.

AIMS

This study aimed to explore the barriers and enablers to antenatal care attendance by women referred to social work services from the perspectives of women, and clinicians who provide antenatal healthcare.

METHODS

A qualitative descriptive study using constructivist grounded theory methods was undertaken. Ten women referred to social work services and 11 antenatal healthcare providers were purposively recruited for interviews from a regional maternity service in Victoria, Australia.

FINDINGS

Continuity of care and healthcare providers partnering with women were central to effective engagement with antenatal care services. Three interrelated concepts were identified: 1) experiences of the hospital environment and access to care; 2) perceptions of care influence engagement, and 3) motivations for regularly attending services.

CONCLUSIONS

Continuity of care is essential for supporting women referred to social work services to attend antenatal appointments. Women are better equipped to overcome other barriers to antenatal service attendance when they have a strong partnership with clinicians involved in their care.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia

INTRODUCTION

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken.

OBJECTIVE

The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers.

DESIGN

The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services.

FINDINGS

The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'.

DISCUSSION

All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals.

CONCLUSION

This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

The impact of professional midwives and mentoring on the quality and availability of maternity care in government sub-district hospitals in Bangladesh: a mixed-methods observational study

Background

This study compared government sub-district hospitals in Bangladesh without globally standard midwives, with those with recently introduced midwives, both with and without facility mentoring, to see if the introduction of midwives was associated with improved quality and availability of maternity care. In addition, it analysed the experiences of the newly deployed midwives and the maternity staff and managers that they joined.

Methods

This was a mixed-methods observational study. The six busiest hospitals from three pre-existing groups of government sub-district hospitals were studied; those with no midwives, those with midwives, and those with midwives and mentoring. For the quantitative component, observations of facility readiness (n = 18), and eight quality maternity care practices (n = 641) were carried out using three separate tools. Willing maternity staff (n = 237) also completed a survey on their knowledge, perceptions, and use of the maternity care interventions. Descriptive statistics and logistic regression were used to identify differences between the hospital types. The qualitative component comprised six focus groups and 18 interviews involving midwives, other maternity staff, and managers from the three hospital types. Data were analysed using an inductive cyclical process of immersion and iteration to draw out themes. The quantitative and qualitative methods complemented each other and were used synergistically to identify the study’s insights.

Results

Quantitative analysis found that, of the eight quality practices, hospitals with midwives but no mentors were significantly more likely than hospitals without midwives to use three: upright labour (94% vs. 63%; OR = 22.57, p = 0.001), delayed cord clamping (88% vs. 11%; OR = 140.67, p < 0.001), skin-to-skin (94% vs. 13%; OR = 91.21, p < 0.001). Hospitals with mentors were significantly more likely to use five: ANC card (84% vs. 52%; OR = 3.29, p = 0.002), partograph (97% vs. 14%; OR = 309.42, p = 0.002), upright positioning for labour (95% vs. 63%; OR = 1850, p < 0.001), delayed cord clamping (98% vs. 11%; OR = 3400, p = 0.003), and skin-to-skin contact following birth (93% vs. 13%; OR = 70.89, p < 0.001) Qualitative analysis identified overall acceptance of midwives and the transition to improved quality care; this was stronger with facility mentoring. The most resistance to quality care was expressed in facilities without midwives. In facilities with midwives and mentoring, midwives felt proud, and maternity staff conveyed the greatest acceptance of midwives.

Conclusion

Facilities with professional midwives had better availability and quality of maternity care across multiple components of the health system. Care quality further improved with facility mentors who created enabling environments, and facilitated supportive relationships between existing maternity staff and managers and the newly deployed midwives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05096-x.

A grounded theory study on midwifery managers' views and experiences of implementing and sustaining continuity of carer models within the UK maternity system

BACKGROUND

Current UK health policy recommends the transition of maternity services towards provision of Midwifery Continuity of Carer (MCoCer) models. Quality of healthcare is correlated with the quality of leadership and management yet there is little evidence available to identify what is required from midwifery managers when implementing and sustaining MCoCer.

AIM

To develop a theoretical framework that represents midwifery managers' experiences of implementing and sustaining MCoCer models within the UK's National Health Service (NHS).

METHODS

Charmaz's grounded theory approach was used for this study. Five experienced UK based midwifery managers were interviewed to elicit views and understanding of the social processes underlying the implementation and sustaining of MCoCer. Interviews were transcribed and analysed and focus codes developed into theoretical codes resulting in an emergent core category.

FINDINGS

The theoretical framework illustrates the core category 'Leading Meaningful Midwifery'. To manage MCoCer models midwifery managers require a trust and belief in woman centred philosophy of care. They need the skills to focus on non-hierarchical transformational leadership and the courage to assimilate alternative models of care into the NHS. Promoting and protecting the MCoCer model within current services is essential whilst forming a culture based on high quality, safe MCoCer.

DISCUSSION

MCoCer models that have sustained within the NHS have had supportive leadership from midwifery managers who have the necessary skills, attitudes, aptitudes and behaviours identified within the findings. Sustainable implementation of MCoCer is achieved through development of a values-based recruitment and retention policy within all areas of midwifery and encouraging midwives with previous experience in MCoCer or supportive philosophies towards it, to manage the model.

CONCLUSION

Providing the appropriate support for MCoCer is time consuming and personally demanding for midwifery managers, however, implementing and sustaining MCoCer was shown by participants who valued MCoCer models to be rewarding, bringing meaning to their midwifery leadership.

Job satisfaction and sustainability of midwives working in caseload models of care: An integrative literature review

BACKGROUND

Demand for caseload midwifery care continues to outstrip supply. We know little about what sustains midwives working in caseload models of care.

AIM

This review systematically identifies and synthesises research findings reporting on factors which contribute to job satisfaction, and therefore the sustainability of practice, of midwives working in caseload models of care.

METHODS

A comprehensive search strategy explored the electronic databases CINAHL Plus with Full Text, MEDLINE, PubMED, Cochrane Database of Systematic Reviews, and Scopus. Articles were assessed using the Crowe Critical Appraisal Tool. Data analysis and synthesis of these publications were conducted using a narrative synthesis approach.

FINDINGS

Twenty-two articles were reviewed. Factors which contribute to the job satisfaction and sustainability of practice of midwives working in caseload models are: the ability to build relationships with women; flexibility and control over own working arrangements; professional autonomy and identity; and, organisational and practice arrangements.

CONCLUSION

Insights into the factors which contribute to the job satisfaction and sustainability of practice of midwives in caseload models of care enables both midwives and healthcare administrators to more effectively implement and support midwifery-led caseload models of care which have been shown to improve outcomes for childbearing women.

Midwife experiences of providing continuity of carer: A qualitative systematic review

PROBLEM

Continuity of carer models present positives and challenges for midwives working in them, and are difficult to sustain.

BACKGROUND

Research shows midwifery continuity of carer improves perinatal outcomes and experiences, and is considered the optimal model of care.

AIM

To synthesise existing research on midwives' experiences of providing continuity of carer and generate further understanding of what sustains them in practice.

METHODS

Protocol for the review was developed using PRISMA guidelines and registered with PROSPERO. 22 studies were included with original themes and findings extracted using JBI tools and synthesised using meta-ethnographic techniques. GRADE CERQual assessment of review findings showed high confidence.

FINDINGS

Midwives identified working in continuity of carer models as both fulfilling and challenging. Professional autonomy and ability to develop meaningful relationships were the most commonly cited positives, while lack of work life balance and conflict with the wider maternity team were the main challenges. 15 studies identified strategies employed by midwives which sustained them in practice.

DISCUSSION

Midwife experiences of providing continuity are impacted by personal and professional factors. Of paramount importance to sustainability of the model is the support of the wider organisation, and their alignment with principles of person-centred, relational care.

CONCLUSION

Relational models of care are desired by midwives, service users and are recommended in policy. Relational models of care must be responsive to midwives needs as well as birthing people, and therefore need to be designed and managed by those working in them and supported by the whole organisation to be sustainable.

Providing woman-centred care in complex pregnancy situations

OBJECTIVE

Midwifery philosophy and practice is grounded in providing woman-centred care. The available evidence was reviewed to better understand how to provide Woman-centred midwifery care in complex pregnancy situations. Complexity in this context is defined as psychosocial or biomedical risk factors that place the mother and/or her baby at increased risk for adverse outcomes.

DESIGN

A comprehensive integrative review was undertaken to identify peer reviewed research in English over the last 5 years. The quality of the studies was assessed using the Critical Appraisal Skills Programme Tool.

SETTING/PARTICIPANTS

Published studies which discussed enablers and barriers to woman-centred care for pregnant women with complex needs. 13 papers met the inclusion criteria for this review.

FINDINGS

This review identifies that Organisational and Professional power differentials create barriers to woman-centred care and provoke professional boundary tensions. For a woman with a complex pregnancy, this places her at risk for 'falling through the gaps' between maternity services, models of care and health providers.

KEY CONCLUSIONS

Women, birth and midwifery care are still largely constrained within a biomedical model of maternity care. Whilst barriers to woman-centred care have been identified, for women with complexity in pregnancy there appear to be few solutions when care requires multi-specialist input and crossing the boundaries and silos of healthcare.

Management and sustainability of midwifery group practice: Thematic and lexical analyses of midwife interviews

BACKGROUND

Although there is high-level evidence supporting positive perinatal outcomes for midwifery group practice (MGP) care, not all women can access this model due to a failure to implement or sustain it. The way that MGPs are managed could be an important factor in whether they are successful in the long-term.

AIM

To explore what determines optimal management of MGP in Australia, and the influence it has on sustainability of MGP.

METHODS

Interviews were conducted with MGP midwives (n=8). Transcriptions of the audio recordings were analysed thematically and lexically for triangulation.

FINDINGS

Following a thematic analysis of the data, an over-arching theme emerged - namely - being valued and supported, with three sub-themes: a nice little sweet spot, someone to stand up for you, and building relationships and support beyond the model. This revealed that value and support by all stakeholders, including the midwives themselves, was necessary to sustain an MGP. The lexical analysis revealed the themes: support, the system, and the caseload. This analysis highlighted the importance of the system - specifically, the impact of the institution on how MGP is operationalised.

CONCLUSION

For MGP to be sustained in Australia, it needs to be prioritised, nurtured, and embraced by the whole maternity care system. Management plays an important role in ensuring the right people are employed to pivotal positions and that midwifery-led models of care are valued and supported throughout the system.

The key components of a successful model of midwifery-led continuity of carer, without continuity at birth: findings from a qualitative implementation evaluation

BACKGROUND

Recent UK maternity policy changes recommend that a named midwife supports women throughout their pregnancy, birth and postnatal care. Whilst many studies report high levels of satisfaction amongst women receiving, and midwives providing, this level of continuity of carer, there are concerns some midwives may experience burnout and stress. In this study, we present a qualitative evaluation of the implementation of a midwife-led continuity of carer model that excluded continuity of carer at the birth.

METHODS

Underpinned by the Conceptual Model for Implementation Fidelity, our evaluation explored the implementation, fidelity, reach and satisfaction of the continuity of carer model. Semi-structured interviews were undertaken with midwives (n = 7) and women (n = 15) from continuity of carer team. To enable comparisons between care approaches, midwives (n = 7) and women (n = 10) from standard approach teams were also interviewed. Interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

For continuity of carer team midwives, manageable caseloads, extended appointment times, increased team stability, and flexible working patterns facilitated both care provided and midwives' job satisfaction. Both continuity of carer and standard approach midwives reported challenges in providing postnatal continuity given the unpredictable timing of labour and birth. Time constraints, inadequate staffing and lack of administrative support were reported as additional barriers to implementing continuity of carer within standard approach teams. Women reported continuity was integral to building trust with midwives, encouraged them to disclose mental health issues and increased their confidence in making birth choices.

CONCLUSIONS

Our evaluation highlighted the successful implementation of a continuity of carer model for ante and postnatal care. Despite exclusion of the birth element in the model, both women and midwives expressed high levels of satisfaction in comparison to women and midwives within the standard approach. Implementation successes were largely due to structural and resource factors, particularly the combination of additional time and smaller caseloads of women. However, these resources are not widely available within the resources of maternity unit budgets. Future research should further explore whether a continuity of carer model focusing on antenatal and postnatal care delivery is a feasible and sustainable model of care for all women.

Leadership and management in midwifery-led continuity of care models: A thematic and lexical analysis of a scoping review

OBJECTIVE

Although midwifery-led continuity of care is associated with superior outcomes for mothers and babies, it is not available to all women. Issues with implementation and sustainability might be addressed by improving how it is led and managed - yet little is known about what constitutes the optimal leadership and management of midwifery-led continuity models.

DESIGN

Following a systematic search of academic databases for relevant publications, 25 publications were identified. These were analysed, thematically to clarify (dis)similar themes, and lexically, to clarify how words within the publications travelled together.

FINDINGS

The publications were replete with three key themes. First, leadership - important yet challenged. Second, management of organisational change; barriers and enhancers. Third, promotors of sustainable models of care. Complementarily, the lexical analysis suggests that references to midwives and leadership among the publications did not typically travel together, as reported in the publications and were distant to one another, although management was inter-connected to both and to change. Leadership and management were not closely coupled with midwives or relationships with women.

KEY CONCLUSIONS

Midwifery leadership matters and can be enacted irrespective of position or seniority. Midwifery-led continuity of care models can be better managed via a multipronged approach. Improved leadership and management can help sustain such care. Although there was a perceived need for midwifery leadership, there did not seem to be an association between leadership and midwives in the lexical analysis. Many publications focused on the style theory of leadership and the transformational style theory.

IMPLICATIONS FOR PRACTICE

Instead of focusing on leaders and the presumption of a leadership scarcity, it might be more beneficial to start focusing within, looking with a new lens on leadership within midwifery at all levels. It might also be constructive for the profession to investigate a more progressive form of leadership, one that is relational and focuses on leadership rather than on the leader.

Midwives' views of caseload midwifery - comparing the caseload and non-caseload midwives' opinions. A cross-sectional survey of Australian midwives

BACKGROUND

Midwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.

AIM

To compare views of caseload midwifery - those working in caseload models and those in standard care models in hospitals with and without caseload.

METHODS

A national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.

FINDINGS

Responses were received from 542/3850 (14%) midwives from 111 hospitals - 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.

CONCLUSIONS

There was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives' views.

Subversive acts and everyday midwifery: Feminism in content and context

BACKGROUND

Midwives are often at the forefront of political campaigns for women's empowerment, overtly advocating for women's rights and reproductive justice. However, midwives can also be found engaging in inadvertent activism on a daily basis within routine care. When casting a feminist lens over both the content and context of midwifery practice in Australia, subversive acts and opportunities for feminist reform can be found.

AIM

To interrogate the significance of feminism in midwifery practice, identifying feminist successes and further opportunities for implementation including: analysis of the Midwifery Standards for Practice; the primary tenets of woman-centred care; the content versus context of midwifery in Australia; and feminist opportunities for enhanced practice. This paper will discuss the importance of feminism in midwifery practice and its significance in informing optimal midwifery care.

DISCUSSION

Incorporating women's voice and respecting women's bodies and agency in the delivery of care is a fundamental component of midwifery practice. However, while the content of midwifery practice is innately feminist in its emphasis on woman-centred care, it will be argued that the context of birthing in Australia is not. The resultant effect is the emergence of victim blaming in maternity care and the construction of an archetypal 'good birthing woman'.

IMPLICATIONS AND RECOMMENDATIONS

Moving away from the myth of the 'good birthing woman' and the act of victim blaming, midwifery could instead direct its focus towards challenging the rigid systems and structures within which midwives implement care. By further embracing feminist principles midwives will ensure a truly woman-centred future.

Midwives' Experiences of Transitioning Into Private Practice With Visiting Access in Australia: A Qualitative Descriptive Study

BACKGROUND

A national review of maternity services in Australia in 2009 resulted in legislative changes which provided midwives with an unprecedented opportunity to offer continuity of care as a private practitioner with visiting access to a public maternity hospital. However, very few midwives have taken up this opportunity.

AIM

To explore the experiences of midwives who transitioned into private practice with visiting access to a public hospital.

METHOD

Using a qualitative descriptive approach, six midwives participated in digitally recorded in-depth interviews. Data was analyzed using thematic analysis.

FINDINGS

Transitioning to private practice enabled midwives to align their core midwifery values with their practice. Midwives reported taking “a leap of faith” by venturing into private practice. Although seeking visiting access and running a small business was initially daunting, midwives were rewarded by being able to practice autonomously and provide continuity of woman centered care within a caseload model. The legislative restrictions, especially around employing other midwives posed significant challenges.

DISCUSSION AND CONCLUSIONS

Private practice with visiting access provided midwives with a service model that aligned their core midwifery values with their clinical practice. The model facilitated their ability to work as lead care professionals, provide woman centered care, and access a collaborative network of healthcare professions. However, the midwives continued to experience structural barriers that threaten the scalability and sustainability of the model. Structural barriers to midwives working to their full scope of practice and in alignment with a midwifery philosophy are a global issue. Further reforms are needed.

Women's vulnerability within the childbearing continuum: A scoping review

INTRODUCTION

The aim of this scoping review is to explore the concept of ‘vulnerability’ affecting pregnant women and to identify an appropriate definition of this term.

METHODS

Five stages were adopted for conducting the scoping review. A literature search was undertaken between 1 October 2017 and 5 January 2018, using three databases. Relevant publications were appraised, and semantic content analysis was performed to identify emergent themes and four determinants of the vulnerability concept. This involved combining items that seem to address the same issue.

RESULTS

Eleven publications were considered, and eight definitions of vulnerability were identified, and from these four themes emerged: poor health outcome or status; exposure to risk; complex social needs; and lack of resources. Further analysis of evidence found examples of groups of people considered to be vulnerable; they were reported into six matrices, mainly with social and psychological difficulties. From these, eleven themes arose. Following a semantic and content analysis of all themes, thirteen final themes were identified. They represent the characteristics associated with women considered to be vulnerable and are called indices of vulnerability. Semantic and content analysis allowed addressing the thirteen indices of vulnerability into four categories called determinants of the vulnerability concept: deficiency, need, risk exposure, and barriers.

CONCLUSIONS

The vulnerability could be defined as a lack of health, related to the presence of at least one of the four determinants. Midwives are the key to identify vulnerable women, offering appropriate care.

Implementing continuity of midwife carer - just a friendly face? A realist evaluation

Background

Good quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan.

Methods

Participatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed context-mechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context.

Results

Trusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women’s care journey, which in turn changed their perspective of how they provided care and of women’s care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed.

Conclusion

Leadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women’s care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change.

Prevalence and Predictors of Burnout in Midwives: A Systematic Review and Meta-Analysis

The prevalence of burnout in midwives has been briefly studied. Given the negative effects of burnout syndrome in the physical and mental health, and also related to the quality of care provided, rates of absenteeism and sick leave; identifying related factors for the syndrome are needed. The aim was to determine the prevalence, levels, and factors related to the burnout syndrome, measured with the Copenhagen Burnout Inventory in midwives. A systematic review and meta-analysis were selected from CINAHL, LILACS, ProQuest, PsycINFO, PubMed, SciELO, and Scopus databases, with the search equation “burnout AND (midwife OR midwives OR nurses midwives)”. Fourteen articles were found with a total of 8959 midwives. Most of the studies showed moderate levels of personal burnout. The prevalence obtained was 50% (95% CI = 38–63) for personal burnout; 40% (95% CI = 32–49) for work-related burnout; and 10% (95% CI = 7–13) for client-related burnout. Midwives’ age, less experience, and living alone constitute the main related factors, as well as, the scarcity of resources, work environment, and the care model used. Most midwives present personal and work-related burnout, which indicates a high risk of developing burnout. Personal factors and working conditions should be taken into account when assessing burnout risk profiles of midwives.

Challenges to midwives' scope of practice in providing women's birthing care in an Australian hospital setting: A grounded theory study

OBJECTIVE

To identify and explore processes midwives use to exercise their scope of practice whilst caring for women during normal birth.

METHODS

Strauss and Corbin's (1998) grounded theory approach was used. Data were collected from 17 midwife participants using participant observation of women's labour and birth care followed by semi-structured interviews.

RESULTS

The core category of promoting normal birthing: aspiring to develop a midwife-led scope of practice conceptualises midwives working to develop their scope of practice to promote and facilitate normal birthing for women. Two interrelated categories, promoting and maintaining healthy birthing and optimising scope of practice further explicate how midwives provide woman-centred care within their scope of practice.

CONCLUSIONS

The theoretical framework generates conceptual knowledge of how midwives aspire to promote healthy, safe and responsive birthing care for women in their scope of practice in a hospital setting. Findings provide greater insights into the competing perspectives of birthing care challenging midwives' capacity to provide woman-centred care, influencing the degree to which midwives are able to exercise their scope of practice in promoting normal birth.

Australian private midwives with hospital visiting rights in Queensland: Structures and processes impacting clinical outcomes

BACKGROUND

Reporting the outcomes for women and newborns accessing private midwives with visiting rights in Australia is important, especially since this data cannot currently be disaggregated from routinely collected perinatal data.

AIM

1) Evaluate the outcomes of women and newborns cared for by midwives with visiting access at one Queensland facility and 2) explore private midwives views about the structures and processes contributing to clinical outcomes.

METHODS

Mixed methods. An audit of the 'all risk' 529 women receiving private midwifery care. Data were compared with national core maternity variables using Chi square statistics. Telephone interviews were conducted with six private midwives and data analysed using thematic analysis.

FINDINGS

Compared to national data, women with a private midwife were significantly more likely to be having a first baby (49.5% vs 43.6% p=0.007), to commence labour spontaneously (84.7% vs 52.7%, p<0.001), experience a spontaneous vaginal birth (79% vs 54%, p<0.001) and not require pharmacological pain relief (52.9% vs 23.1%, p<0.001). The caesarean section rate was significantly lower than the national rate (13% vs 32.8%, p<0.001). In addition fewer babies required admission to the Newborn Care Unit (5.1% vs 16%, p<0.001). Midwives were proud of their achievements. Continuity of care was considered fundamental to achieving quality outcomes. Midwives valued the governance processes embedded around the model.

CONCLUSIONS

Private midwives with access to the public system is safe. Ensuring national data collection accurately captures outcomes relative to model of care in both the public and private sector should be prioritised.

Australian midwives' experiences of their workplace culture

BACKGROUND

A number of adverse events in Australia and overseas have highlighted the need to examine the workplace culture in the maternity environment. Little attention has been paid to the midwifery workplace culture in Australia.

AIM

The study aimed to explore the midwifery workplace culture from the perspective of midwives themselves.

METHODS

A qualitative descriptive design was used. Group and individual interviews were undertaken of urban, regional and rural-based midwives in Australia. Data were analysed thematically.

FINDINGS

The study showed that both new and experienced midwives felt frustrated by organisational environments and attitudes, and expressed strategies to cope with this. Five themes were identified from the data. These were: Bullying and resilience, Fatigued and powerless midwives, Being 'hampered by the environment', and The importance of support for midwifery.

DISCUSSION

The study discusses the themes in depth. In particular, discussion focusses on how midwifery practise was affected by midwives' workplace culture and model of care, and the importance of supportive relationships from peers and managers.

CONCLUSION

This study illuminated both positive and negative aspects of the midwifery workplace culture in Australia. One way to ensure the wellbeing and satisfaction of midwives in order to maintain the midwifery workforce and provide quality care to women and their families is to provide positive workplace cultures.

Exploring a Peer Nomination Process, Attributes, and Responses of Health Professionals Nominated to Facilitate Interprofessional Collaboration

BACKGROUND:When significant changes are required across an organization, a collaborative approach with wide stakeholder engagement may be beneficial. One of the challenges of stakeholder engagement lies with identifying the most appropriate participants who can most effectively facilitate the process of change.

AIM:This article aims to provide insight into a process of identifying individuals, and their attributes, who staff perceive to be effective collaborators, and change agents to decrease intervention in childbirth in one maternity setting in New South Wales, Australia.

METHODS:Midwives and obstetricians were invited to nominate a peer from each discipline who they believed to be an effective collaborator and describe the associated personal attributes of these individuals. The 5 highest scoring midwives and obstetricians were then invited to participate in a collaborative project.

FINDINGS:The attributes that were most recognized in the collaborators were their effective communication and overall positive attitudes. Collaborator’s skills and knowledge were described less frequently. The nominees chosen identified that they were not usually selected by management for projects with some respondents feeling visible for the first time among their peers.

CONCLUSION:This method of peer nomination to recruit participants to facilitate collaborative organizational change may offer an effective method of engaging the whole team in such processes.

Midwives’ Journey Through the First Year of a Hospital-Based Midwifery Group Practice

AIM:To explore the experiences of midwives involved in the first midwifery group practice situated at a Western Australian tertiary maternity hospital.

METHODS:A descriptive phenomenology study was undertaken to extract common themes from interview transcripts using the 6-step process by Braun and Clarke. Seven midwives participated in 2 interviews over 12 months.

FINDINGS:Six months into the midwifery group practice (MGP) journey, 5 themes were captured: “adapting to a new way of working,” “working out the glitches,” “work–life balance,” “opportunity to grow,” and “perceived benefits for women.” After 12 months, 2 themes emerged: “making progress into new ways of working” and “future sustainability.”

CONCLUSIONS:Midwives felt women must be realistically informed of what an MGP offers. Priorities were regular meetings for open communication, taking scheduled days off and leave, and providing mentoring. Insight around benefits and challenges encountered by MGP midwives can inform health services, considering offering a similar service and ensure its sustainability.

Midwifery Professional Relationships: Collaboration Across the Novice-to-Expert Continuum

This article describes the types of helpful and supportive interactions or communication strategies that characterize the collaborative relationships in which a midwife can engage across the novice-to-expert continuum of professional development. Similarities and distinctions are drawn between the various terms describing types of collaboration and discussed with respect to the added value that each relationship can have for the individual and for the health care team. A conceptual depiction of the essential components of effective teamwork or collaboration is presented. Emphasis is placed on the dynamic nature of the process of developing and sustaining these relationships across the midwife’s professional lifetime.