Women׳s views on partnership working with midwives during pregnancy and childbirth

Pandemic-related prenatal maternal stress, model of maternity care and postpartum mental health: The Australian BITTOC study

PROBLEM

Women pregnant during the COVID-19 pandemic may be at risk of elevated postpartum mental health problems.

BACKGROUND

Social support protects maternal mental health during a pandemic. It is possible that formal supports, such as continuity maternity models of care, may also support maternal wellbeing.

AIM

To investigate whether model of care moderates the association between prenatal maternal stress from the COVID-19 pandemic, and postpartum (a) depression and (b) anxiety.

METHODS

Women in Australia, pregnant during the COVID-19 pandemic (n = 3048), completed a survey detailing their COVID-19-related objective hardship and subjective distress during pregnancy and completed depression and anxiety measures at birth to six weeks ("Early"), seven to 21 weeks ("Moderate"), and/or 22-30 weeks ("Late") postpartum.

FINDINGS

Higher subjective distress was associated with elevated depression and anxiety at all timepoints. Model of care did not moderate the association of objective hardship or subjective distress and depression or anxiety at any timepoint. Compared with Standard Care, women receiving private midwifery care had a 74 % reduction in the odds of elevated anxiety in early postpartum.

DISCUSSION

Women receiving private midwifery may have experienced lower anxiety due to a greater duration of postpartum in-home care, fewer changes to service delivery, and the option of homebirth. Women pregnant during a pandemic should be screened for higher subjective distress about the event.

CONCLUSION

These results suggest that continuity of private midwifery care may be beneficial for supporting postpartum mental health during a pandemic, with implications for practice and policy for the current and future pandemics.

Attuning to the World of Peace of Mind and Trust: Women's Lived Experience of the Woman-Midwife Relationship in Japan

In Japan, many pregnant women and mothers suffer from anxiety, depression, and other postnatal issues that can be exacerbated by their birth experiences. While benefiting from advanced medical care, these women's mental and psychological health may be disregarded in their maternity care. Midwives have the potential to play a significant role in improving women's birth experiences. Hence, this study aimed to explore the meaning of the woman-midwife relationship, with a specific focus on sensing peace of mind and trust to improve women's birth experiences. Using a hermeneutic phenomenological approach, 14 Japanese women were interviewed. Sensing peace of mind and trust was one of the significant meanings of the woman-midwife relationship and is articulated across five themes: (1) attuning to the world, (2) different kinds of safety and trust, (3) relying on and entrusting midwives, (4) making a mother, and (5) an emotional bridge. The positive relationship with midwives enhanced the women's mental well-being through allowing the women to attune to the peaceful mind which directed their future perspectives and sustained them in motherhood. They became confident mothers by trusting their midwives. The maternity care system in Japan needs to shift to more relationship-based care to ensure continuity of midwifery care that will improve women's birth experiences and their long-term well-being.

Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study

OBJECTIVE

The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]).

METHODS

2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum.

RESULTS

Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care.

CONCLUSION

Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

Seeking a connection: Women's lived experience of the woman-midwife relationship in mainstream maternity services in Japan

PROBLEM

In Japan, women continue to suffer from mental health and other postpartum issues despite good clinical outcomes of maternity care.

BACKGROUND

As key care providers, midwives potentially affect women's overall birth experience. Most women in Japan give birth in hospitals or obstetric clinics where different midwives and nurses provide one woman with fragmented care. Women's lived experiences of the woman-midwife in these birth facilities are not well known in Japan.

AIM

To understand women's birth experience and relationship with midwives in the mainstream maternity care system in Japan to improve maternity care and women's birth experience.

METHODS

Face-to-face individual interviews with 14 mothers were conducted. The data were analysed using van Manen's hermeneutic phenomenological approach, which reveals the meaning of human experience in the everyday world.

FINDINGS

Four themes were derived from the hermeneutic phenomenological analysis; 1) Closed hearts and bodies in insecure relationships, 2) Alienation, 3) Hopelessness and helplessness, and 4) Women's vulnerability and desire for positive relationships.

DISCUSSION

In institutionalised and fragmented maternity care settings, it is difficult for women and midwives to develop a relationship. In such a care environment, women's birth experience with midwives is negative or even traumatic; yet, women still need and seek the midwife relationship. Respectful care-necessary for women's positive birth experience-requires positive relationship between women and midwives.

CONCLUSION

Women's negative birth experience may affect their mental health and parenting. Maternity and midwifery care in Japan needs to develop relationship-based care to improve women's birth experience.

Feeling anxious'- women's experiences of having a baby in Australia during the COVID-19 pandemic using the Voqual real time app

PURPOSE

Internationally, the COVID-19 pandemic impacted maternity services. In Australia, this included changes to antenatal appointments and the reduction of support people during labour and birth. For women pregnant during the pandemic there were increased stressors of infection in the community and in hospitals along with increased periods of isolation from friends and families during lockdown periods. The aim of this study was to explore the real-time experiences of women who were pregnant and had a baby during the first wave of the COVID-19 pandemic in Australia.

METHODS

This study followed seven women throughout their pregnancy and early parenthood. Women created audio or video recordings in real time using the Voqual app and were followed up by in-depth interviews after they gave birth.

RESULTS

Using narrative analysis their individual stories were compared and an overarching theme of 'feeling anxious' was found which was underpinned by the two themes 'model of care' and 'environment'.

CONCLUSIONS

These findings highlight the protective impact midwifery continuity of care has on reducing anxiety in women during the pandemic, and that the home environment can either be secure and safe or a place of isolation.

The perceptions and attitudes of obstetric staff and midwives towards perinatal mental health disorders screening: a qualitative exploratory study in Shenzhen, China

BACKGROUND

The perinatal period is a crucial time for women, as they experience various biological, psychological, and social stressors. Due to the complexity of this vulnerable time, there is a high prevalence of depressive and anxiety disorders among pregnant women. In 2019, the Health Commission of Shenzhen initiated perinatal mental health screening programme in China. However, attitudes and perceptions of medical staff towards implementing mental health screening programme during pregnancy remain unclear. The aim of this study was to explore the perceptions and attitudes of obstetric staff and midwives towards screening for perinatal mental disorders in pregnant women, and identify their perceived needs and motivations for undertaking this task.

METHODS

This is a qualitative exploratory study. Data were collected through in-depth, semi-structured, face-to-face interviews. The dataset was analysed using inductive content analysis. Purposive sampling method was used to recruit 13 participants at a tertiary maternal hospital in Shenzhen from September to November, 2019.

RESULTS

A total of 13 obstetric staff was interviewed, including two obstetricians, three midwives, and eight nurses. Four themes were identified from this study: views on perinatal mental health disorders screening, competency in identifying and supporting high-risk groups, barriers to dealing with psychological problems during pregnancy, and the support needs of medical staff in undertaking the tasks of mental health disorders screening.

CONCLUSION

Medical staff lacked sufficient knowledge and skills in perinatal psychological health and were not well prepared for the task of screening pregnant women for mental health disorders. To address this issue, medical organisations and relevant government sectors should provide training to medical staff on perinatal mental health disorders, enhance public awareness of perinatal mental health disorders, establish a model of multidisciplinary collaboration for the screening of women's perinatal mental disorders, and provide continuous and holistic care for pregnant women.

Women's experiences of continuity of care from student midwives - A qualitative study from Norway

OBJECTIVE

The study aimed to gain a deeper understanding of women's experience of continuity of care by student midwives during the childbearing process.

METHOD

A qualitative approach was the design used in this study. In-depth interviews were conducted with nine women who had received continuity of care during their childbearing process by student midwives. The interviews were analysed with the help of systematic text condensation. The study was approved by the Norwegian Centre for Research Data (ref. 905085) and the Regional Research Ethics Committee (ref. 2019/608).

FINDINGS

Continuity of care enabled a deep relationship between the woman and the student midwife and made the care provided more individualised, giving the woman emotional support and preparing her for birth. The presence of a student midwife during labour and birth who knew the woman's story made the woman able to focus on the birth process. Even when unexpected events occurred, the woman had a positive birth experience due to the relationship between her and the student midwife. Continuity of care made the women feel safe and taken care of and was the preferred model of care.

CONCLUSION

Continuity of care contributes to individualised and personalised care, enabling all aspects of the woman's needs to be considered throughout the childbearing process. Due to the positive impact on the women in the present study, it is appropriate to implement a continuity of care model in midwifery education programmes. Further research should be conducted to examine how doing so would influence both student midwives and women.

The un-silencing of Japanese women's voices in maternity care: A hermeneutic phenomenological study of the woman-midwife relationship

OBJECTIVE

The purpose of this article is to understand the meaning of the woman-midwife relationship, with the overall aim to improve maternity care and women's birth experiences in Japan. To better understand the meaning of the woman-midwife relationship, this article presents women's and midwives' experiences of having or not having a voice in maternity care.

RESEARCH DESIGN

Hermeneutic phenomenology, as described by Max van Manen, helped to uncover the meaning of the phenomenon-the woman-midwife relationship-through participants' lived experience. Individual interviews were conducted with 14 women and 10 midwives living in Japan. The interview data were interpreted and thematically analysed to reveal the meaning of the woman-midwife relationship.

FINDINGS

'Having a voice' emerged as a central theme underpinning the meaning of the woman-midwife relationship; aspects of which included, 1) being unheard, 2) losing a voice, 3) having a voice, and 4) midwives speaking for women. Although having a voice should be a legitimate right for women in maternity care, some women's voices were unheard or lost in the experience with midwives. Conversely, some women gained a voice, especially when they positively and continuously developed their relationship with their midwife. How the woman and the midwife related to each other clearly affected their experience of having a voice in maternity care.

KEY CONCLUSION

Having a voice, which portrays dimensions of choice, control, and autonomy, in their own maternity care is vital for women's positive birth experience. The woman-midwife relationship is critical in enabling women to have a voice and midwives to speak for women. Women and midwives need to develop their relationship. Moreover, the maternity care system needs to allow sufficient time and space, for instance, by ensuring midwife continuity of care to develop a positive woman-midwife relationship.

What would reduce caesarean section rates?—Views from pregnant women and clinicians in Ireland

Background

Caesarean section rates continue to rise in most parts of the world. While CS is a lifesaving procedure there is evidence that, beyond a certain threshold, CS rates may contribute to increased maternal and perinatal morbidity. This study aimed to elicit the views of pregnant women’s and clinicians’ on how CS rates might be reduced.

Methods

Pregnant women and their partners, and clinicians working with pregnant women in a maternity hospital in the Republic of Ireland of Ireland, were invited to participate in focus groups. Eligibility criteria included all women attending antenatal classes and clinicians working with pregnant women. A convenience sample was used and interviews were audio recorded, transcribed, and analysed using thematic analysis.

Results

Four focus group interviews were conducted with 30 clinicians and 15 pregnant women and two partners participated in three focus groups. A further two women were interviewed individually. Participants expressed a view that rising CS rates were impacted by a societal perception that CS had become a ‘normal mode of birth’. Suggestions for reducing CS rates were offered by clinicians and pregnant women and their partners.

Conclusions

Clinicians and pregnant women consider that CS rates can be reduced if a shared philosophy supporting normal birth is prioritised alongside adequate resourcing. Women and their partners also believe that enhanced communication with clinicians is central to reducing CS rates.

Factors affecting the mental health of pregnant women using UK maternity services during the COVID-19 pandemic: a qualitative interview study

Background

People using maternity services in the United Kingdom (UK) have faced significant changes brought on by the COVID-19 pandemic and social distancing regulations. We focused on the experiences of pregnant women using UK maternity services during the pandemic and the impact of social distancing rules on their mental health and wellbeing.

Methods

We conducted 23 qualitative semi-structured interviews from June 2020 to August 2021, with women from across the UK who experienced a pregnancy during the pandemic. Nineteen participants in the study carried their pregnancy to term and four had experienced a miscarriage during the pandemic. Interviews took place remotely over video or telephone call, discussing topics such as mental health during pregnancy and use of UK maternity services. We used reflexive thematic analysis to analyse interview transcripts.

Results

We generated six higher order themes: [1] Some pregnancy discomforts alleviated by social distancing measures, [2] The importance of relationships that support coping and adjustment, [3] Missed pregnancy and parenthood experiences, [4] The mental health consequences of birth partner and visitor restrictions, [5] Maternity services under pressure, and [6] Lack of connection with staff. Many participants felt a sense of loss over a pregnancy experience that differed so remarkably to what they had expected because of the pandemic. Supportive relationships were important to help cope with pregnancy and pandemic-related changes; but feelings of isolation were compounded for some participants because opportunities to build social connections through face-to-face parent groups were unavailable. Participants also described feeling alone due to restrictions on their partners being present when accessing UK maternity services.

Conclusions

Our findings highlight some of the changes that may have affected pregnant women’s mental health during the COVID-19 pandemic. Reduced social support and being unable to have a partner or support person present during maternity service use were the greatest concerns reported by participants in this study. Absence of birth partners removed a protective buffer in times of uncertainty and distress. This suggests that the availability of a birth partner or support person must be prioritised wherever possible in times of pandemics to protect the mental health of people experiencing pregnancy and miscarriage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04602-5.

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.

Experience of midwives in providing care to labouring women in varied healthcare settings: A qualitative study

BACKGROUND

Midwives are essential to timely, effective, family-centred care. In South Africa, patients have often expressed dissatisfaction with the quality of midwifery care. Negative interpersonal relationships with caregivers, lack of information, neglect and abandonment were consistent complaints. Less is known about how midwives experience providing care.

AIM

This research explored and described the experiences of midwives in providing care to labouring women in varied healthcare settings.

SETTING

Midwives practicing in the Gauteng province, South Africa, in one of three settings: private hospitals, public hospitals or independent maternity hospital.

METHODS

A convenience sample of midwives (N = 10) were interviewed. An exploratory and descriptive design, with individual semi-structured interviews conducted, asked a primary question: 'How is it for you to be a midwife in South Africa?' Transcribed interviews were analysed using thematic coding.

RESULTS

Five themes were found: proud to be a midwife, regulations and independent function, resource availability, work burden and image of the midwife.

CONCLUSION

Midwives struggle within systems that fail to allow independent functioning, disallowing a voice in making decisions and creating change. Regardless of practice setting, midwives expressed frustration with policies that prevented utilisation consistent with scope of practice, as well as an inability to practice the midwifery model of care. Those in public settings expressed concern with restricted resource appropriation. Similarly, there is clear need to upscale midwifery education and to establish care competencies to be met in providing clinical services.

CONTRIBUTION

This research provides evidence of the midwifery experience with implications for needed health policy change.

Expectant fathers' experiences of family-centred births in Estonia: a qualitative study

OBJECTIVE

One of the aims of family-centred care is to provide expectant fathers with positive experiences during childbirth, so they can support their partners and bond with their new baby. However, research in this area has been limited. This study described men´s experiences with family-centred births in Estonia, Northern Europe.

DESIGN

Qualitative study with open-ended interviews that were audio taped and analysed by inductive content analysis by Elo and Kyngäs (2008).

SETTING

Birth units at one central and one regional hospital in Estonia.

PARTICIPANTS

Twelve Estonian fathers aged 22-44, interviewed 4-12 weeks after their baby's birth.

KEY CONCLUSIONS

Fathers' experiences of family-centred care during their baby's birth focused on their transition to fatherhood, their experiences of birth as a multifactorial life event and the experiences they shared with other fathers. They discussed supporting their partners during the birth, their involvement in decision making, the attitudes of healthcare professionals and how their role in the family changed. The fathers said that the birth was a private and public event, where their own role, and the roles of healthcare professionals, were confusing. This made family-centred care difficult during the birth. Sharing experiences with other fathers decreased their fears and increased their understanding of becoming fathers. Some fathers were not ready for fatherhood and midwives needed to assess how involved fathers wanted to get during the birth.

IMPLICATIONS FOR PRACTICE

Family-centred care is important during birth, but more research is needed into how fathers see their role. The roles played by medical staff also need to be clearer. Better knowledge about what fathers expect and need, can help midwives to involve and support them at a level they feel comfortable with. Peer support can play a vital role in preparing fathers for birth and fatherhood.

Midwives' provision of health promotion in antenatal care: A qualitative explorative study

PROBLEM

Studies indicate that health promotion in antenatal care can be improved. Moreover, a schism seems to exist between health promotion and prevention in antenatal care.

BACKGROUND

Antenatal care to support and improve maternal health is a core midwifery activity in which prevention as well as HP and woman-centeredness are important.

AIM

To explore how Danish midwives experienced antenatal care and practiced health promotion.

METHODS

Midwives undertaking antenatal care were interviewed individually (n=8) and two focus groups (n=10) were created. Thematic analysis was performed inductively, and the theoretical models from Piper's health promotion practice Framework for midwives were used to analyse the midwives' health promotion approach.

FINDINGS

Two major themes were highlighted. Theme 1: 'The antenatal care context for health promotion' described factors contributing to quality in health promotion in antenatal care, such as communication and building relationships with the pregnant women. Theme 2: 'The health promotion approach in antenatal care' described both midwife-focused and woman-focused approaches to pregnant women's health. Barriers to high-quality antenatal care and a holistic health promotion approach were identified, such as shared-care issues, documentation demands and lack of time.

DISCUSSION

The midwives' experiences were discussed in the context of a health promotion approach. Why midwives practice using a midwife-centred approach has many explanations, but midwives need to learn and help each other understand how they can practice woman-focused care while simultaneously providing prophylactic, evidence-based care.

CONCLUSION

Midwives mainly had a midwife-focused approach. To further promote women's health, midwives need to focus on a woman-focused approach.

A Model of Trust within the Mother-Midwife Relationship: A Grounded Theory Approach

Introduction

The mother-midwife relationship is a good experience during childbirth, but there is a lack of evidence about the trustful relationship between mothers and healthcare providers during labor and birth in Iran. The current study aimed to discover how a trustful mother-midwife relationship is formed during a vaginal delivery.

Methods

Twenty-nine women who had a vaginal delivery, midwives, and obstetricians participated in this qualitative research with the grounded theory method. Data were collected using semistructured interviews and observations. Open, axial, and selective coding was used for data analysis. Findings. The main category of "seeking trust in midwife" and three subcategories of "effective interaction," "attempt to access to healthcare provider", and "playing an active role in birth" were extracted from the data.

Conclusion

According to the findings, mothers tried to gain action/interaction strategies and increase healthcare providers' trusts during vaginal delivery. It is essential to consider the factors that improve or disrupt this relationship.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

BACKGROUND

Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia.

METHODS

The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor.

RESULTS

In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC.

CONCLUSION

This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

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.

A theory of the aims and objectives of midwifery practice: A theory synthesis

INTRODUCTION

Every discipline has a dichotomous objective by which it recognizes whether its work has been successful (Vogd, 2011). For midwifery care, no objective has been set in this way so far. This also has implications for measuring quality, because quality of care is only measurable if objectives have been identified. This paper aims to contribute to theory formation in midwifery science by analysing existing concepts and theories and preferences of women to midwifery care to answer the question of the dichotomous objective of midwifery.

METHOD AND FINDINGS

The method of theory synthesis (Walker and Avant, 2011) was used to analyse existing theories and concepts of midwifery care and literature-based preferences of women to midwifery care and synthesize them with regard to the objectives of midwifery care. The synthesis took place in the form of a means-end chain to extract the dichotomous target of midwifery care. In this way, the objectives of midwifery could be compared and linked from both the scientific and from women's perspective. The resulting means-end chain model of the process of midwifery describes the aims and objectives of midwifery from the point of view of women on three levels.

DISCUSSION

The hierarchical model of the process of midwifery presented here is a first attempt to illustrate the aims and objectives of midwifery practice in a means-end chain model in order to facilitate discussion on the topic and to make the quality of midwifery care measurable. Measurement is a first step towards improving quality of midwifery care and thereby improving women's reproductive capabilities.

Women's successful transition to motherhood during the early postnatal period: A qualitative systematic review of postnatal and midwifery home care literature

OBJECTIVE

To undertake a systematic review of available qualitative research literature to determine what women need to successfully transition to motherhood during the early postnatal period and whether postnatal home care delivered by midwives supports this process.

DESIGN

The transition from woman to mother is a significant occurrence, one that requires adjustments on physical, psychological and social levels. A qualitative systematic review design was chosen to ensure both humanistic and interactive concepts related to what women need to successfully transition to motherhood during the early postnatal period were identified. The systematic and structured search uncovered 33 research articles for detailed review. Two team members, using the qualitative research checklist from the Critical Appraisal Skills Programme, appraised the quality of the research articles. A total of 19 articles met the quality criteria and were included in the data evaluation process.

SETTING AND PARTICIPANTS

Research teams from Asia-Pacific, Europe, Middle East and North America generated the 19 qualitative journal articles.

MEASUREMENTS AND FINDINGS

Data evaluation included identification of research aim, presence of a research question, type of methodology, data collection processes, sample information, data analysis techniques and study outcomes. Data was analysed using an inductive content analysis approach. Four themes were identified from the qualitative systematic review process including: women and midwives connecting, identification and meeting of women's individual needs, family and cultural influences and, education and support.

KEY CONCLUSIONS

The ability of women to connect with midwives during the early postnatal period assisted them overcome barriers and to successfully transitioning to motherhood. Although all four themes were determined to be key to effective postnatal transition, overwhelmingly the findings showed postnatal midwifery home care to be important in women's successful transition to motherhood in the early postnatal period.

IMPLICATIONS FOR PRACTICE

Strategies are needed ensure women have access to midwives in the early postnatal period.

The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk

BACKGROUND

The measurement and interpretation of patient experience is a distinct dimension of health care quality. The Midwives @ New Group practice Options (M@NGO) randomized control trial of caseload midwifery compared with standard care among women regardless of risk reported both clinical and cost benefits. This study reports participants' perceptions of the quality of antenatal care within caseload midwifery, compared with standard care for women of any risk within that trial.

METHODS

A trial conducted at two Australian tertiary hospitals randomly assigned participants (1:1) to caseload midwifery or standard care regardless of risk. Women were sent an 89-question survey at 6 weeks postpartum that included 12 questions relating to pregnancy care. Ten survey questions (including 7-point Likert scales) were analyzed by intention to treat and illustrated by participant quotes from two free-text open-response items.

RESULTS

From the 1748 women recruited to the trial, 58% (n = 1017) completed the 6-week survey. Of those allocated to caseload midwifery, 66% (n = 573) responded, compared with 51% (n = 444) of those allocated to standard care. The survey found women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure. Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87-3.39]), quality care (2.94 [2.28-3.79]), and feeling actively involved in decision-making (3.21 [2.35-4.37]).

CONCLUSIONS

Results from the study show that in addition to the benefits to clinical care and cost demonstrated in the M@NGO trial, caseload midwifery outperforms standard care in perceived quality of pregnancy care regardless of risk.

Able to choose? Women's thoughts and experiences regarding informed choices during birth

OBJECTIVE

To gain a deeper understanding of women's thoughts and experiences regarding informed choices during childbirth.

DESIGN/SETTING

A qualitative approach with individual in-depth interviews was chosen for data collection. Ten women were interviewed three to four weeks after the birth of their first child. The transcribed interviews were analysed using systematic text condensation.

FINDINGS

Two main themes emerged based on the analysis: "women's resources and coping abilities" and "women's abilities to make informed choices during birth". Women's resources and coping abilities influenced how they retrieved information and made their own choices. Their abilities to make informed choices during birth were influenced by the course of the birth process and the fact that they were patients and submitted to the hospitals' routines.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Instead of using the term "informed choice", women in this study discussed involvement, participation and being heard and seen as individuals. How receptive women are to information during birth varies, and midwives play an important role during pregnancy in informing and encouraging them. The relationship between women and midwives influences women's abilities to make informed choices during birth. Women need individual care and should be encouraged to have realistic expectations and to gain knowledge and confidence in their ability to give birth. A model of care in which women experience greater continuity will have an impact on their expectations, decision-making and experience of birth.

A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory

BACKGROUND

Most women who have a caesarean can safely have a vaginal birth after caesarean (VBAC) for their next birth, but more women have an elective repeat caesarean than a VBAC.

METHODS

The aim of this qualitative study was to explore the experiences of women planning a vaginal birth after caesarean (VBAC) in Australia, the interactions with their health care providers and their thoughts, feelings and experiences after an antenatal appointment and following the birth. The study explored the effect of different models of care on women's relationships with their health care provider using a feminist theoretical lens. Eleven women who had previously experienced a caesarean section and were planning a VBAC in their current pregnancy used the 'myVBACapp' to record their thoughts after their antenatal appointments and were followed up with in-depth interviews in the postnatal period.

RESULTS

Fifty-three antenatal logs and eleven postnatal interviews were obtained over a period of eight months in 2017. Women accessed a variety of models of care. The four contextual factors found to influence whether a woman felt resolved after having a VBAC or repeat caesarean were: 'having confidence in themselves and in their health care providers', 'having control', 'having a supportive relationship with a health care provider' and 'staying active in labour'.

CONCLUSIONS

The findings highlight that when women have high feelings of control and confidence; have a supportive continual relationship with a health care provider; and are able to have an active labour; it can result in feelings of resolution, regardless of mode of birth. Women's sense of control and confidence can be undermined through the impact of paternalistic and patriarchal maternity systems by maintaining women's subordination and lack of control within the system. Women planning a VBAC want confident, skilled, care providers who can support them to feel in control and confident throughout the birthing process. Continuity of care (CoC) provides a supportive relationship which some women in this study found beneficial when planning a VBAC.

Recognising the challenges of providing care for Thai pregnant adolescents: Healthcare professionals' views

BACKGROUND

In Thailand, maternal complications and poor neonatal outcomes are common in pregnant adolescents. There are attempts to improve outcomes for this group through specialised antenatal clinics, however, neither the way in which these clinics are provided nor the attitudes of healthcare professionals to pregnant adolescents are known. The aim of this study was to understand the experiences of healthcare professionals in caring for pregnant adolescent women in Thailand.

METHODS

A qualitative descriptive design was used. Semi-structured interviews were conducted with 21 healthcare professionals involved in caring for pregnant adolescents across three public hospitals in Bangkok, Thailand. All interviews were analysed thematically.

RESULTS

The core concept 'recognising the challenges of providing care for young Thai pregnant women' explained the provision of care. This concept contained three main themes: 1) having an awareness of the political and societal contexts and environment of care; 2) being aware of attitudes and the need to develop psychosocial skills in caring for adolescent women; and 3) having different approaches to caring for pregnant adolescents. A lack of continuity of care was a significant barrier in terms of structure and process. Effective communication was important to provide quality care.

CONCLUSION

Healthcare professionals recognised that there were barriers to providing effective care for adolescent women. These findings may inform healthcare professionals and policymakers in Thailand in relation to the systems of care required and addressing the needs of pregnant adolescents. This would enable Thailand to meet the goal in providing a positive pregnancy experience for all women.

"It's what midwifery is all about": Western Australian midwives' experiences of being 'with woman' during labour and birth in the known midwife model

Background

The phenomenon of being ‘with woman’ is fundamental to midwifery as it underpins its philosophy, relationships and practices. There is an identified gap in knowledge around the ‘with woman’ phenomenon from the perspective of midwives providing care in a variety of contexts. As such, the aim of this study was to explore the experiences of being ‘with woman’ during labour and birth from the perspective of midwives’ working in a model where care is provided by a known midwife.

Methods

A descriptive phenomenological design was employed with ten midwives working in a ‘known midwife’ model who described their experiences of being ‘with woman’ during labour and birth. The method was informed by Husserlian philosophy which seeks to explore the same phenomenon through rich descriptions by individuals revealing commonalities of the experience.

Results

Five themes emerged 1) Building relationships; 2) Woman centred care; 3) Impact on the midwife; 4) Impact on the woman; and 5) Challenges in the Known Midwife model. Midwives emphasised the importance of trusting relationships while being ‘with woman’, confirming that this relationship extends beyond the woman – midwife relationship to include the woman’s support people and family. Being ‘with woman’ during labour and birth in the context of the relationship facilitates woman-centred care. Being ‘with woman’ influences midwives, and, it is noted, the women that midwives are working with. Finally, challenges that impact being ‘with woman’ in the known midwife model are shared by midwives.

Conclusions

Findings offer valuable insight into midwives’ experiences of being ‘with woman’ in the context of models that provide care by a known midwife. In this model, the trusting relationship is the conduit for being ‘with woman’ which influences the midwife, the profession of midwifery, as well as women and their families. Descriptions of challenges to being ‘with woman’ provide opportunities for professional development and service review. Rich descriptions from the unique voice of midwives, provided insight into the applied practices of being ‘with woman’ in a known midwife model which adds important knowledge concerning a phenomenon so deeply embedded in the philosophy and practices of the profession of midwifery.

Women's experiences of induction of labour: Qualitative systematic review and thematic synthesis

OBJECTIVES

To explore and synthesise evidence of women's experiences of induction of labour (IoL).

DESIGN

Systematic review and thematic synthesis of peer-reviewed qualitative evidence. Relevant databases were searched from inception to the present day. Study quality was appraised using the Critical Appraisal Skills Programme (CASP) qualitative research appraisal tool.

SETTING AND PARTICIPANTS

Low and high risk women who had experienced IoL in an inpatient or outpatient setting.

FINDINGS

Eleven papers (representing 10 original studies) published between 2010 and 2018 were included for thematic synthesis. Four key analytical themes were identified: ways in which decisions regarding induction were made; women's ownership of the process; women's social needs when undergoing IoL; and the importance of place in the induction process. The review indicates that IoL is a challenging experience for women, which can be understood in terms of the gap between women's needs and the reality of their experience concerning information and decision-making, support, and environment.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Providing good quality appropriately timed information and supporting women's self-efficacy to be involved in decision-making around IoL may benefit women by facilitating a sense of ownership or control of labour. Compassionate support from significant others and healthcare professionals in a comfortable, private and safe environment should be available to all women.

Better together: A qualitative exploration of women's perceptions and experiences of group antenatal care

PROBLEM

Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes.

BACKGROUND

Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes.

AIMS

To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women's experiences of pregnancy and antenatal care, and inform further development and testing of the model.

METHODS

A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically.

FINDINGS

Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions.

CONCLUSIONS

Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners.

Woman-centered care 2.0: Bringing the concept into focus

INTRODUCTION

Woman-centered care has become a midwifery concept with implied meaning. In this paper we aim to provide a clear conceptual foundation of woman-centered care for midwifery science and practice.

METHODS

An advanced concept analysis was undertaken. At the outset, a systematic search of the literature was conducted in PubMed, OVID and EBSCO. This was followed by an assessment of maturity of the retrieved data. Principle-based evaluation was done to reveal epistemological, pragmatic, linguistic and logic principles, that attribute to the concept. Summative conclusions of each respective component and a detailed analysis of conceptual components (antecedents, attributes, outcomes, boundaries) resulted in a definition of woman-centered care.

RESULTS

Eight studies were selected for analyses. In midwifery, woman-centered care has both a philosophical and a pragmatic meaning. There is strong emphasis on the woman-midwife relationship during the childbearing period. The concept demonstrates a dual and equal focus on physical parameters of pregnancy and birth, and on humanistic dimensions in an interpersonal context. The concept is epistemological, dynamic and multidimensional. The results reveal the concept’s boundaries and fluctuations regarding equity and control. The role of the unborn child is not incorporated in the concept.

CONCLUSION

An in-depth understanding and a broad conceptual foundation of womancentered care has evolved. Now, the concept is ready for research and educational purposes as well as for practical utility.

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.

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.

Healthcare professionals' assertions and women's responses during labour: A conversation analytic study of data from One born every minute

OBJECTIVE

Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate 'decisions' during labour.

METHODS

Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction.

FINDINGS

HCPs initiate decision-making using interactional practices that vary the 'optionality' afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through 'assertions'. An 'assertive' turn-design (e.g. 'we need to…') conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions.

CONCLUSION

The expectation of agreement set up by an assertive initiating turn can reduce women's opportunities to participate in shared decision-making (SDM).

PRACTICE IMPLICATIONS

When decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts.

How optimal caseload midwifery can modify predictors for preterm birth in young women: Integrated findings from a mixed methods study

OBJECTIVE

to identify possible mechanisms by which caseload midwifery reduces preterm birth for young childbearing women.

DESIGN

a mixed methods triangulation, convergence design was used to answer the research question 'How does the way maternity care is provided affect the health and well-being of young women and their babies?' The project generated quantitative and qualitative findings which were collected and analysed concurrently then separately analysed and published. The research design enabled integration of the quantitative and qualitative findings for further interpretation through a critical pragmatic lens.

SETTING

a tertiary maternity hospital in Australia providing care to approximately 500 pregnant young women (aged 21 years or less) each year. Three distinct models of care were offered: caseload midwifery, young women's clinic, and standard 'fragmented' care.

PARTICIPANTS

a cohort study included data from 1971 young women and babies during 2008-2012. An ethnographic study included analysis of focus group interviews with four caseload midwives in the young women's midwifery group practice; as well as ten pregnant and postnatal young women receiving caseload midwifery care.

FINDINGS

integrated analysis of the quantitative and qualitative findings suggested particular features in the model of care which facilitated young women turning up for antenatal care (at an earlier gestation and more frequently) and buying in to the process (disclosing risks, engaging in self-care activities and accepting referrals for assistance). We conceptualised that Optimal Caseload Midwifery promotes Synergistic Health Engagement between midwife and the young woman.

KEY CONCLUSIONS

optimal Caseload Midwifery (which includes midwives with specific personal attributes and philosophical commitments, along with appropriate institutional infrastructure and support) facilitates midwives and young clients to develop trusting relationships and engage in maternity care. Health engagement can modify predictors for preterm birth that are common amongst pregnant adolescents by promoting earlier maternity booking, sufficient antenatal care, greater emotional resilience, ideal gestational weight gain, less smoking/drug use, and fewer untreated genito-urinary infections.

IMPLICATIONS FOR PRACTICE

the institutional infrastructure and managerial support for caseload midwifery should value and prioritise the philosophical commitments and personal attributes required to optimise the model. Furthermore the location of visits, between appointment access to primary midwife, and back-up system should be organised to optimise the midwife-woman relationship in order to promote the young woman's engagement with maternity care.