Swedish women's interest in models of midwifery care - Time to consider the system? A prospective longitudinal survey

Preferences of support and barriers and facilitators to help-seeking in pregnant women with severe fear of childbirth in Sweden: a mixed-method study

BACKGROUND

There are few support interventions for women with fear of childbirth tailored towards type of fears and parity. To inform the future development of an acceptable and relevant intervention for women with severe fear of childbirth, primary objectives were to examine: (1) pregnant women's experiences of and preferences for support and (2) barriers and facilitators to help-seeking. Secondary objectives were to examine if there are any differences based on pregnant women's parity.

METHODS

Pregnant women with a severe fear of childbirth in Sweden completed an online cross-sectional survey between February and September 2022. Severe fear of childbirth was measured using the fear of childbirth scale. Quantitative data were analysed using descriptive and inferential statistics and free answers were analysed using manifest content analysis. A contiguous approach to integration was adopted with qualitative and quantitative findings reported separately.

RESULTS

In total, 609 participants, 364 nulliparous and 245 parous women, had severe fear of childbirth. The main category "A twisting road to walk towards receiving support for fear of childbirth" was explored and described by the generic categories: Longing for support, Struggling to ask for support, and Facilitating aspects of seeking support. Over half (63.5%), of pregnant women without planned or ongoing treatment, wanted support for fear of childbirth. Most (60.2%) pregnant women with ongoing or completed fear of childbirth treatment regarded the treatment as less helpful or not at all helpful. If fear of childbirth treatment was not planned, 35.8% of women would have liked to have received treatment. Barriers to help seeking included stigma surrounding fear of childbirth, previous negative experiences with healthcare contacts, fear of not being believed, fear of not being listened to, and discomfort of having to face their fears. Facilitators to help seeking included receiving respectful professional support that was easily available, flexible, and close to home.

CONCLUSIONS

Most pregnant women with severe fear of childbirth felt unsupported during pregnancy. Findings emphasise the need to develop individual and easily accessible psychological support for women with severe fear of childbirth, delivered by trained professionals with an empathetic and respectful attitude.

The effect of a midwifery continuity of care program on clinical competence of midwifery students and delivery outcomes: a mixed-methods protocol

BACKGROUND

The midwifery continuity of care model is one of the care models that have not been evaluated well in some countries including Iran. We aimed to assess the effect of a program based on this model on the clinical competence of midwifery students and delivery outcomes in Ahvaz, Iran.

METHODS

This sequential embedded mixed-methods study will include a quantitative and a qualitative phase. In the first stage, based on the Iranian midwifery curriculum and review of seminal midwifery texts, a questionnaire will be developed to assess midwifery students' clinical competence. Then, in the second stage, the quantitative phase (randomized clinical trial) will be conducted to see the effect of continuity of care provided by students on maternal and neonatal outcomes. In the third stage, a qualitative study (conventional content analysis) will be carried out to investigate the students' and mothers' perception of continuity of care. Finally, the results of the quantitative and qualitative phases will be integrated.

DISCUSSION

According to the nature of the study, the findings of this research can be effectively used in providing conventional midwifery services in public centers and in midwifery education.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1401.460). Also, the study protocol was registered in the Iranian Registry for Randomized Controlled Trials (IRCT20221227056938N1).

Swedish midwives' attitudes towards continuity models-a cross-sectional survey

BACKGROUND

Midwifery continuity models are growing worldwide, but few such alternatives are available in Sweden. There is sparse knowledge about Swedish midwives' attitudes about midwifery continuity models.

AIM

The aim of this study was to explore Swedish midwives' attitudes toward continuity models. An additional aim was to evaluate the psychometric properties of a previously developed instrument measuring attitudes to continuity models.

METHODS

A cross-sectional survey of a national sample of 2537 midwives in Sweden. The participants completed a questionnaire online. A Principal component Analysis was performed to identify components in the instrument.

RESULTS

A fairly similar proportion of midwives worked in antenatal care (30.7%), intrapartum care (30.7%) and in other areas (31.1%). Many midwives (59%) agreed that continuity models should be available to women, but were not certain about if such models should be offered to all women or low risk women only. Two domains of the attitude scale were identified; Relationship-based Midwifery Continuity Models, and Practical and Organisational Aspects of Midwifery Continuity Models. Age, having children, marital status, length of work experience and place of work were associated with high agreement non the two components.

CONCLUSION

Many midwives in general held positive attitudes about continuity models. The relationship aspects were highly valued but midwives were also hesitant about the practical and organisational aspect of continuity models. Unbiased information to midwives about the pros and cons with continuity models should be offered, in order to limit misunderstandings about the model.

'A perfect fit' - Swedish midwives' interest in continuity models of midwifery care

BACKGROUND

Midwifery continuity models of care are highly recommended yet rare in Sweden, although approximately 50% of pregnant women request them. Before introducing and scaling up continuity models in Sweden, midwives' attitudes about working in continuity models must be investigated.

OBJECTIVE

to investigate Swedish midwives' interests in working in midwifery continuity models of care and factors influencing the midwifery workforce's readiness for such models.

METHODS

A cross-sectional online survey was utilised and information collected from a national sample of midwives recruited from two unions regarding background and work-related variables. Crude and adjusted odds ratios and logistic regression analysis were used in the analysis.

RESULTS

A total of 2084 midwives responded and 56.1% reported an interest. The logistic regression model showed that respondents' ages 24-35 years (OR 1.73) or 35-45 years (OR 1.46); years of work experience 0-3 years (OR 5.81) and 3-10 years (OR 2.04); rotating between wards or between tasks (OR 2.02) and working temporary (OR 1.99) were related to interest in continuity models. In addition, working daytime only (OR 1.59) or on a two-shift schedule (OR 1.93) was associated with such interest.

CONCLUSION

A sufficient number of midwives in Sweden appear to be interested in working in continuity models of midwifery care to align with women's interest in having a known midwife throughout pregnancy, birth and postpartum period. Developing strategies and continuity models that will address the preferences of women in various areas of Sweden is important for offering evidence-based maternity services.

Fulfilment of expectations on birth and the postpartum period - A Swedish cohort study

BACKGROUND

The fulfilment of birth expectations is important to women and strongly related to birth satisfaction.

OBJECTIVE

The aim of this study was to investigate women's expectations and experiences of birth and the postnatal period and associated factors. An additional aim was to explore if women's expectations were fulfilled.

METHODS

A longitudinal cohort study of 280 women where 226 were followed up two months after birth. Data were collected using questionnaires. Odds ratios with a 95% confidence interval were calculated between the explanatory background variables and expectations/experiences.

RESULTS

The majority (79%) rated continuity as important, but few (32%) actually had a known midwife assisting during birth. Positive birth expectations were found in 37% and a positive birth experience in 66%. Many women (56%) preferred a short postnatal stay, and 63% went home within 24 h. Thirty-six percent preferred postnatal home visits, but only eight women (3.5%) received this. Breastfeeding expectations were high with 86% rating it as important but after birth 63% reported exclusively breastfeeding. Only a few background factors were associated with women's expectations and experiences. Most likely to be fulfilled were women's expectations for a vaginal birth (83%), a positive birth experience (71%) and short length of postnatal stay (67%). Postnatal home visits (96%) and continuity of care (73%) were not fulfilled.

CONCLUSIONS

Pregnant women's expectations about continuity are fulfilled only to a minor degree. The fulfilment of postnatal expectations varied and the preference for a short postnatal stay was fulfilled whereas home visits were not.

Women's Experiences of Care During Pregnancy in a Continuity of Midwifery Care Project in Rural Sweden

BACKGROUND

In antenatal care, health checkups, information, and support is provided to women. Midwifery continuity models of care provide women access to evidence-based care.

OBJECTIVE

The aim of this study was to evaluate women's experiences of pregnancy and antenatal care in a continuity of midwifery care project, as well as to gauge the impact the project had on the women's emotional well-being and satisfaction.

METHOD

This was a cohort study of 226 women enrolled in a continuity of care project in rural Sweden. Profiles of the women were created based on levels of depressive symptoms, worries, fear of birth, and sense of coherence. Data was collected through questionnaires. Odds ratios with 95% confidence intervals were calculated between the clusters for the explanatory variables.

RESULT

Women in the two clusters differed in some background characteristics. Women in Cluster 2 had more visits to a doctor. They also received more counseling due to fear of birth and viewed the number of midwives as “too many.” They were less satisfied with the medical, emotional, and overall aspects of their antenatal care. Perceived health, preparedness for birth, and parenthood were rated lower by women in Cluster 2.

CONCLUSION

This study found that women's assessment of their antenatal care was associated with their emotional health. Negative feelings toward changes in pregnancy were often found in women with poorer emotional health, and these women reported being less prepared for birth and parenthood. Thus, it is important to identify women with emotional distress and to provide them additional support and continuity.

Partners' expectations and experiences of the project 'Midwife All the Way': A qualitative study

INTRODUCTION

Continuity models of midwifery care are significant factors in facilitating a positive childbirth experience for birthing women. A knowledge gap exists regarding partners' experiences of continuity of midwifery care during pregnancy, birth, and after birth, although it is essential to understand the experiences of both parents in relation to continuity of care. Thus, the aim of this study was to highlight partners' expectations and experiences of having participated in a continuity of midwifery care project.

METHODS

A qualitative interview study using thematic analysis was carried out. Thirty-six partners in a rural area in northern Sweden were recruited after the closure of the local labor ward. Interviews were conducted in October 2019 and in May 2020.

RESULTS

An overarching theme: 'A partner-midwife relationship facilitated a sense of security'; and two themes 'The concept of availability' and 'The midwife's competence and professionalism' reflect partners' expectations and experiences after participating in a continuity of midwifery care project.

CONCLUSIONS

Professionalism was most highly valued, but establishing a relationship with a known midwife facilitated a sense of security. When birthing women feel safe with the known midwife, the partners also feel safe. Having to travel a long-distance to a labor ward caused concern for the partners. This highlights the importance of an organization that supports families to gain access to continuity models of midwifery care and to have a possibility to give birth closer to their residence. The results of this qualitative study further strengthen the growing evidence of the positive effects of continuity models of midwifery care.

Women's worries during pregnancy; a cross-sectional survey using the Cambridge Worry Scale in a rural area with long distance to hospital

BACKGROUND

Worries are common during pregnancy, but there is sparse knowledge of worries when the distance to hospital is long.

AIM

To assess the extent and content of worries during pregnancy. Another aim was to evaluate the psychometric properties of the Swedish version of the Cambridge Worry Scale.

METHOD

Cross-sectional study of 280 women recruited to a continuity project and completed a questionnaire in mid pregnancy.

RESULT

Women were most worried about something being wrong with the baby, giving birth and the risk of miscarriage. Women also reported worries about giving birth on the road or in the car. Two domains of the Cambridge Worry scale were identified; Socio-medical and health aspects and Socio-economic and relationship aspects. Women with high fear and depressive symptoms were most at risk for major worries.

CONCLUSION

Worries during pregnancy were mainly related to issues about pregnancy and birth, and specifically, to long distance to the labour ward. Women with depressive symptoms and fear of birth showed the highest levels of worries. When a woman expresses worries in connection to labour and birth, caregivers must be sensitive to the presence of underling fears or depressive symptoms and act to refer women to treatment or support.

A continuity of care project with two on-call schedules: Findings from a rural area in Sweden

BACKGROUND

In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare.

AIM

To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden.

METHOD

A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth.

RESULT

One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14-4.22) and the emotional (aOR 2.05; 1.09-3.86) aspects of intrapartum care, regardless of the model.

CONCLUSION

This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

Childbirth experience in women participating in a continuity of midwifery care project

BACKGROUND

Continuity models of care are rare in Sweden, despite the evidence of their benefit to women and babies. Previous studies have shown certain factors are associated with a positive birth experience, including continuity of midwifery care.

AIM

The aim was to investigate women's childbirth experiences in relation to background data, birth outcome and continuity with a known midwife, in a rural area of Sweden.

METHODS

An experimental cohort study. Participating women were offered continuity of midwifery care in pregnancy and birth, during selected time periods. Data were collected in mid-pregnancy and two months after birth. The Childbirth Experience Questionnaire was used to determine women's birth experiences.

RESULT

A total of 226 women responded to the follow-up questionnaire. Not living with a partner, fear of giving birth, and a birth preference other than vaginal were associated with a less positive birth experience. Having had a vaginal birth with no epidural, no augmentation and no birth complication all yield a better birth experience. Women who had had a known midwife were more likely to have had a positive birth experience overall, predominantly in the domain Professional support.

CONCLUSIONS

The results of this study showed that women who received care from a known midwife in labour were more likely to have a positive birth experience. The results also pointed out the benefits of a less medicalized birth as important for a good birth experience, and that some women may need extra support to avoid a less positive birth experience.

Birth outcome in a caseload study conducted in a rural area of Sweden-a register based study

BACKGROUND

Continuity models of midwifery care are rare in Sweden, despite its well-known positive effects. The aim was to describe pregnancy and birth outcome in women participating in a continuity of care project in a rural area of Sweden.

METHOD

A register-based study of 266 women recruited to the project and a control group of 125 women from the same catchment area. Midwives provided antenatal care and were on-call 7 a.m. to 11 p.m. for birth. Data were collected from the antenatal and birth records. Crude and adjusted odds ratios with 95% confidence intervals were calculated between women in the project and the control group.

RESULTS

There were more primiparous women and highly educated women recruited to the project, and fewer foreign-born and single women, compared to the control group. Women in the project met more midwives and were less likely to have a pregnancy complication. During intrapartum care, women recruited to the project were less likely to need labour augmentation and less likely to have an instrumental vaginal birth and elective caesarean section. They had fewer second degree perineal tears and were more likely to fully breastfeed at discharge. No differences were found in neonatal outcome. The continuity of a known midwife at birth was quite low.

CONCLUSION

This study shows that women self-recruited to a continuity of care project in a rural area of Sweden had a higher rate of normal births. There were few differences if having a known midwife or not. Long distances to hospital and lack of staff affected the level of continuity.

A modified caseload midwifery model for women with fear of birth, women's and midwives' experiences: A qualitative study

OBJECTIVE

Although fear of birth is common during pregnancy and childbirth, the best treatment for fear of birth in clinical care remain unclear. Strong evidence suggests that continuity models of midwifery care can benefit women and birth outcomes, though such models are rare in Sweden. Because women with fear of birth could benefit from such models, the aim of this qualitative study was to examine how women with fear of birth and their midwives experienced care in a modified caseload midwifery model.

METHODS

A qualitative interview study using thematic analysis. Participants were recruited from a pilot study in which women assessed to have fear of birth received antenatal and intrapartum care, from a midwife whom they knew. Eight women and four midwives were interviewed.

RESULTS

An overarching theme-"A mutual relationship instilled a sense of peace and security"-and three themes-"Closeness, continuity, and trust," "Preparation and counselling," and "Security, confidence, and reduced fear"-reflect the views and experiences of women with fear of birth and their midwives after participating in a modified caseload midwifery model.

CONCLUSIONS

For both women with fear of birth and their midwives, the caseload midwifery model generated trustful woman-midwife relationships, which increased women's confidence, reduced their fear, and contributed to their positive birth experiences. Moreover, the midwives felt better equipped to address women's needs, and their way of working with the women became more holistic. Altogether, offering a continuity model of midwifery care could be an option to support women with fear of birth.

Women with fear of childbirth might benefit from having a known midwife during labour

AIM

Having a known midwife at birth is valued by women across the world, however it is unusual for women with fear of childbirth to have access to this model of care. The aim of this study was to describe the prevalence and factors related to having access to a known midwife for women referred to counseling due to childbirth fear. We also wanted to explore if women's levels of childbirth fear changed over time.

METHODS

A pilot study of 70 women referred to counseling due to fear of birth in 3 Swedish hospitals, and where the counseling midwife, when possible, also assisted during labour and birth.

RESULTS

34% of the women actually had a known midwife during labour and birth. Women who had a known midwife had significantly more counseling visits, they viewed the continuity of care as more important, were more satisfied with the counseling and 29% reported that their fear disappeared. Fear of birth decreased significantly over time for all women irrespective of whether they were cared for in labour by a known midwife or not.

CONCLUSIONS

Although the women in the present study had limited access to a known midwife, the results indicate that having a known midwife whom the women met on several occasions made them more satisfied with the counseling and had a positive effect on their fear. Building a trustful midwife-woman relationship rather than counseling per se could be the key issue when it comes to fear of birth.

Factors influencing decision-making for caesarean section in Sweden - a qualitative study

BACKGROUND

Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden.

METHODS

A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin.

RESULTS

The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes.

CONCLUSION

Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.

Intrapartum midwifery care impact Swedish couple's birth experiences - A cross-sectional study

BACKGROUND

Parents' birth experiences affect bonding with their infant, which in turn may influence the child's future health. Parents' satisfaction with childbirth is multi-dimensional and dependent on both expectations and experiences. Increasing involvement of partners in intrapartum care may lead to an assumption that the birthing couple shares attitudes and expectations of intrapartum care. There is a limited knowledge regarding the uniformity of couples' experiences of labour and birth.

AIM

To describe and compare uniformity in couples' birth experiences of the quality of intrapartum midwifery care.

METHOD

A quantitative cross-sectional study nested within a randomised controlled trial. In total 209 healthy primiparous mothers and their partners were recruited. A quality of care index was generated from an on-line questionnaire administered as a follow-up to the randomised controlled trial. Uniformity and differences were identified regarding the coupleś experiences of birth and their preferences for intrapartum care RESULTS: A high level of uniformity between the mothers and their partners was revealed. Birth was a positive experience for 79% of partners and 73% of mothers whom were more likely to have experienced a spontaneous vaginal birth. Partners and mothers with a less positive birth experienced deficiencies regarding: being in control, receiving information about labour progress and midwife's presence in labour room.

DISCUSSION

Midwives can enhance couples' feeling of being in control during labour and birth by being attentive, present and continuously providing adequate information and emotional support.

Caseload midwifery for women with fear of birth is a feasible option

OBJECTIVE

Continuity with a known midwife might benefit women with fear of birth, but is rare in Sweden. The aim was to test a modified caseload midwifery model of care to provide continuity of caregiver to women with fear of birth.

METHODS

A feasibility study where women received antenatal and intrapartum care from a known midwife who focused on women's fear during all antenatal visits. The study was performed in one antenatal clinic in central Sweden and one university hospital labor ward. Data was collected with questionnaires in mid and late pregnancy and two months after birth. The main outcome was fear of childbirth.

RESULT

Eight out of ten women received all antenatal and intrapartum care from a known midwife. The majority had a normal vaginal birth with non-pharmacological pain relief. Satisfaction was high and most women reported that their fear of birth alleviated or disappeared.

CONCLUSION

Offering a modified caseload midwifery model of care seems to be a feasible option for women with elevated levels of childbirth fear as well as for midwives working in antenatal clinics as it reduces fear of childbirth for most women. Women were satisfied with the model of care and with the care provided.

Experiences and wishes of women regarding systemic aspects of midwifery care in Germany: a qualitative study with focus groups

BACKGROUND

Knowledge of pregnant women's and mothers' viewpoints on midwifery care is crucial for its appropriate delivery and research. In Germany, comprehensive research to more fully understand women's needs in pregnancy, labour, birth and the postpartum period until weaning is lacking. International studies provide some knowledge of women's expectations, their choices, and subjective criteria indicating good midwifery care.

METHODS

This study explores pregnant women's and mothers' experiences, needs and wishes regarding systemic aspects of midwifery care (access, availability, choices, model of midwifery care; maternity care in the healthcare system). 50 women participated in 10 focus groups in 5 states of Germany. The groups were heterogeneous with regard to age, parity, model of maternity care used, and rating of satisfaction. Women with limited educational years (n = 9) were personally contacted by midwives and reached by social media. Also, mothers living in a mother-child home (n = 6) or attending a peer group for grieving parents (n = 5) were included. The digitally documented focus groups were systematically analysed in an itinerary hermeneutic manner.

RESULTS

Three themes were identified: (a) Knowledge or lack of awareness of midwifery care, (b) availability of and access to midwives, and (c) midwifery care in the healthcare system. Theme (a) entails the scope of midwifery care and the midwife's competence, but also a lack of information, inconsistent counselling, and difficulty identifying midwives. Theme (b) encompasses aspects such as the availability, accessibility and selection of a midwife, the effort involved in looking for a midwife, the challenge of transition points, and family midwives. Theme (c) relates interprofessional cooperation, gaps/inadequacies of care during latency phase, alternative models of care, and the importance of family and peer groups for women.

CONCLUSIONS

Midwifery care and research in Germany must address the issue of imparting relevant information about midwifery services. Interprofessional cooperation and management of transition points ought to be improved in the interests of the women concerned. Moreover, the quality of antenatal classes, support during latency phase, and intrapartum care in hospitals need to be addressed. Lastly, the special needs of vulnerable women in midwifery care must become a major focus in Germany.

Midwifery empowerment: National surveys of midwives from Australia, New Zealand and Sweden

BACKGROUND

the predicted midwifery workforce shortages in several countries have serious implications for the care of women during pregnancy, birth and post partum. There are a number of factors known to contribute to midwifery shortages and work attrition. However, midwives assessment of their own professional identity and role (sense of empowerment) are perhaps among the most important. There are few international workforce comparisons.

AIM

to compare midwives' sense of empowerment across Australia, New Zealand and Sweden using the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised).

METHOD

a self-administered survey package was distributed to midwives through professional colleges and networks in each country. The surveys asked about personal, professional and employment details and included the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). Descriptive statistics for the sample and PEMS were generated separately for the three countries. A series of analysis of variance with posthoc tests (Tukey's HSD) were conducted to compare scale scores across countries. Effect size statistics (partial eta squared) were also calculated.

RESULTS

completed surveys were received from 2585 midwives (Australia 1037; New Zealand 1073 and Sweden 475). Respondents were predominantly female (98%), aged 50-59 years and had significant work experience as a midwife (+20 years). Statistically significant differences were recorded comparing scores on all four PEMS subscales across countries. Moderate effects were found on Professional Recognition, Skills and Resources and Autonomy/Empowerment comparisons. All pairwise comparisons between countries reached statistical significance (p<.001) except between Australia and New Zealand on the Manager Support subscale. Sweden recorded the highest score on three subscales except Skills and Resources which was the lowest score of the three countries. New Zealand midwives scored significantly better than both their Swedish and Australian counterparts in terms of these essential criteria.

DISCUSSION/CONCLUSIONS

midwives in New Zealand and Sweden had a strong professional identity or sense of empowerment compared to their Australian counterparts. This is likely the result of working in more autonomous ways within a health system that is primary health care focused and a culture that constructs childbirth as a normal but significant life event. If midwifery is to reach its full potential globally then developing midwives sense of autonomy and subsequently their empowerment must be seen as a critical element to recruitment and retention that requires attention and strengthening.