Factors influencing midwives' use of an evidenced based Normal Birth Guideline

Factors influencing midwives' intentions to facilitate normal physiological birth: A qualitative study

BACKGROUND

Whilst most women desire to birth vaginally, research highlights reducing rates of normal physiological birth worldwide. Previous studies have focussed largely on clinical practices associated with vaginal birth however health care professionals' intentions are also known to effect behaviour; a factor not well understood within the context of midwifery and normal physiological birth.

QUESTION/AIM

To explore factors influencing midwives' intentions to facilitate normal physiological birth.

METHODS

A qualitative study using individual interviews was conducted. The Theory of Planned Behaviour was used to develop a semi-structured interview guide to gather perceptions, thoughts, knowledge, and experience of normal physiological birth from participants. Data were analysed thematically within the theoretical constructs: attitudes, subjective norms, and perceived behavioural control.

FINDINGS

Fourteen midwives from various practice settings, models, and locations in Australia were interviewed. Major factors influencing midwives' intentions to facilitate normal physiological birth were influenced by workplace culture, values and influence of leaders, the need to prioritise collaborative interdisciplinary relationships and support autonomy in midwifery.

DISCUSSION

Factors influencing the midwives' intentions of facilitating normal physiological birth were multifaceted. Some influences are more obvious and observable through practice, while others were rooted in underlying beliefs and attitudes that were hidden in the subconscious of those involved. However, all contributing influences ultimately shape midwives' intentions and the way in which they facilitate normal physiological birth.

CONCLUSIONS

Midwives intend to support normal physiological birth; however multiple factors influence their intentions over time. Prioritising collaborative interdisciplinary relationships and supporting autonomy in midwifery could address known barriers.

Approaches to clinical guideline development in healthcare: a scoping review and document analysis

BACKGROUND

Over the past decade, an industry has emerged around Clinical Practice Guideline (CPG) development in healthcare, which has increased pressure on guideline-producing organisations to develop CPGs at an accelerated rate. These are intended to improve the quality of care provided to patients while containing healthcare costs and reducing variability in clinical practice. However, this has inadvertently led to discrepancies in CPG recommendations between health organisations, also challenging healthcare providers who rely on these for decision-making and to inform clinical care. From a global perspective, although some countries have initiated national protocols regarding developing, appraising and implementing high-quality CPGs, there remains no standardised approach to any aspect of CPG production.

METHODS

A scoping review of the literature and document analysis were conducted according to Joanna Brigg's Institute methodology for scoping reviews. This comprised two qualitative methods: a comprehensive review of the literature (using CINAHL, Scopus and PubMeD) and a document analysis of all national and international guideline development processes (manual search of health-related websites, national/international organisational health policies and documents).

RESULTS

A set of clear principles and processes were identified as crucial to CPG development, informing the planning, implementation and dissemination of recommendations. Fundamentally, two common goals were reported: to improve the quality and consistency of clinical practice (patient care) and to reduce the duplication or ratification of low-grade CPGs.

CONCLUSIONS

Consultation and communication between CPG working parties, including a wide range of representatives (including professional organisations, regional and local offices, and relevant national bodies) is essential. Further research is required to establish the feasibility of standardising the approach and disseminating the recommendations.

Causal links behind why Australian midwifery care is missed

AIMS

The aim of this study is to reliably estimate why midwifery care is missed and to crystallize those factors that have causal links to it.

BACKGROUND

Studies involving the incidences and types of missed midwifery care are sparsely described. The rationales behind these deficits in care are even less well researched.

METHODS

A non-experimental, descriptive method using a Likert developed MISSCARE scale was used to measure consensus estimates made by Australian midwives. Data analysis was undertaken using both Rasch analysis and Structural Equation Modeling.

RESULTS

Midwives' rationales behind why Australian midwifery care is missed can be quantified based on consensus estimates of participating midwives and the variances in the total scores of how important each contributing factor was in accounting for why midwifery care was missed, can be both explained and predicted.

CONCLUSIONS

Ten latent variables have significant predictor effects on why midwifery care was missed. These include insufficient human and physical care resources, increased work intensity and issues with workplace communication. These factors are further exacerbated by the midwives' teamwork satisfaction levels, work roster preferences and other midwife demographic variables. The age of midwife, their highest qualification achieved and where they obtained their midwifery credentials had no influence on their consensus estimates as to why midwifery care was missed.

IMPLICATIONS FOR NURSING MANAGEMENT

While this study confines itself to the Australian midwifery context, outcomes are informative for an international midwifery management audience. While the setting of the midwifery practice (be it private or public hospitals) is not significant in predicting why midwifery care is missed, resource allocation for care of mothers and their babies remains instrumental, as a factor contributing to care omissions. Midwife demographic factors including age, type of midwifery qualification and where the credentials were obtained from exerted no influence as to why care was omitted. Midwifery recruitment should focus instead on re-dressing skills and skills mix shortages. Teamwork skills within the midwifery sector requires strengthening, as problems arising from workplace communication, coupled with decreased midwifery staffing numbers and increased work intensity, are strongly thought to be significant reason for missed care.

Assessment of the quality, content and perceived utility of local maternity guidelines in hospitals in England implementing the saving babies' lives care bundle to reduce stillbirth

Introduction

The UK Department of Health have targeted a reduction in stillbirth by 50% by 2025; to achieve this, the first version of the Saving Babies’ Lives Care Bundle (SBLCB) was developed by NHS England in 2016 to improve four key areas of antenatal and intrapartum care. Clinical practice guidelines are a key means by which quality improvement initiatives are disseminated to front-line staff.

Methods

Seventy-five clinical practice guidelines covering the four areas of antenatal and intrapartum care in the first version of SBLCB were obtained from 19 maternity providers. The content and quality of guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Maternity health professionals in participating organisations were invited to participate in an anonymous survey to determine perceptions toward and experiences of the use of clinical practice guidelines using a series of Likert scales.

Results

Unit guidelines showed considerable variation in quality with median scores of 50%–58%. Only 4 (5.6%) guidelines were recommended for use in clinical practice without modifications, 54 (75.0%) were recommended for use subject to modifications and 12 (16.7%) were not recommended for use. The lowest scoring domains were ‘rigour of development’, ‘stakeholder involvement’ and ‘applicability’. A significant minority of unit guidelines omitted recommendations from national guidelines. The majority of staff believed that clinical practice guidelines standardised and improved the quality of care but over 30% had insufficient time to use them and 24% stated they were unable to implement recommendations.

Conclusion

To successfully implement initiatives such as the SBLCB change is needed to local clinical practice guidelines to reduce variation in quality and to ensure they are consistent with national recommendations. In addition, to improve clinical practice, adequate time and resources need to be in place to deliver and evaluate care recommended in the SBLCB.

Midwifery leaders' views on the factors considered crucial to implementing evidence-based practice in clinical areas

PROBLEM

The evidence-to-practice gap continues to persist in healthcare and midwives report limited knowledge and use of effective intervention strategies to support the implementation of new evidence-based practices in clinical settings.

BACKGROUND

Despite ongoing development and dissemination of high quality research findings, the translation of latest research evidence by midwives into new evidence-based practices remains sub-optimal. This inefficiency places consumers at risk of obsolete or potentially dangerous healthcare interventions.

AIM

To explore midwifery leaders' views on what information and support midwives require to lead practice change initiatives in clinical areas.

METHODS

The study formed part of a broader Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical settings. The study employed a qualitative design and was guided by the methodological underpinnings of Action Research (AR).

FINDINGS

One core finding emerged to fulfil the aim and objectives of the study. To lead implementation of evidence-based practices, midwives need practical solutions and a map of the process, packaged into a centralised web-based resource.

DISCUSSION

The findings reported in this study provide valuable insight into the specific needs of midwives wanting to improve the uptake and longevity of new evidence based practices in clinical areas. This includes information specific to evidence implementation, support networks and knowledge of Implementation Science.

CONCLUSION

To lead practice change initiatives, midwives require a web-based resource that standardises the process of evidence implementation, while providing midwives with clear direction and the support needed to confidently champion for evidence base change in clinical areas.

Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study

BACKGROUND

Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics.

METHODS AND FINDINGS

In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.

CONCLUSIONS

Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.

A qualitative study of factors that influence midwives' practice in relation to low-risk women's oral intake in labour in Australia

BACKGROUND

Restriction of food and fluids during labour increases women's discomfort, anxiety and stress which are associated with obstruction of the normal process of labour. Whilst research evidence and clinical guidelines recommend that normal uncomplicated labouring women should not be limited in their oral intake during labour, some midwives continue to restrict or discourage women's oral intake. To promote best practice, it is important to understand the influencing factors which affect midwives' decision-making processes.

OBJECTIVE

This study aimed to investigate the influences that affect midwifery practice regarding oral food and fluid intake for low-risk labouring women.

DESIGN

An interpretive descriptive approach employed 12 semi-structured interviews with registered midwives with current labour and birthing experience in Australia. Data was analysed using thematic analysis.

FINDINGS

Three themes were identified: midwives' knowledge and beliefs; work environment and women's expectations of care. Midwives' practice was affected by their knowledge and values developed from professional and personal experiences of labour, their context of practice and work environment, the clinical guidelines, policies and obstetric control, and women's choice and comfort.

CONCLUSION

This study indicates that midwives' decision-making in relation to women's oral nutrition during labour is multifaceted and influenced by complicated environments, models of care, and power relations between doctors and midwives, more so than clinical guidelines. It is important for midwives to be aware of factors negatively influencing their decision-making processes to enable autonomy and empowerment in the provision of evidence-based care of labouring women.

Midwives' use of best available evidence in practice: An integrative review

AIMS AND OBJECTIVES

To synthesise international research that relates to midwives' use of best available evidence in practice settings and identify key issues relating to the translation of latest evidence into everyday maternity care.

BACKGROUND

Midwifery is a research-informed profession. However, a gap persists in the translation of best available evidence into practice settings, compromising gold standard maternity care and delaying the translation of new knowledge into everyday practice.

DESIGN

A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute (JBI) for conducting systematic reviews, was used to facilitate development of a search strategy, selection criteria and quality appraisal process, and the extraction and synthesis of data to inform an integrative review.

METHODS

The databases CINAHL, MEDLINE, Web of Science, Implementation Science Journal and Scopus were searched for relevant articles. The screening and quality appraisal process complied with the PRISMA 2009 checklist. Narrative analysis was used to develop sub-categories and dimensions from the data, which were then synthesised to form two major categories that together answer the review question.

RESULTS

The six articles reviewed report on midwives' use of best available evidence in Australia, the UK and Asia. Two major categories emerged that confirm that although midwifery values evidence-based practice (EBP), evidence-informed maternity care is not always employed in clinical settings. Additionally, closure of the evidence-to-practice gap in maternity care requires a multidimensional approach.

CONCLUSION

Collaborative partnerships between midwives and researchers are necessary to initiate strategies that support midwives' efforts to facilitate the timely movement of best available evidence into practice.

RELEVANCE TO CLINICAL PRACTICE

Understanding midwives' use of best available evidence in practice will direct future efforts towards the development of mechanisms that facilitate the timely uptake of latest evidence by all maternity care providers working in clinical settings.

Implementing an intervention to promote normal labour and birth: A study of clinicians' perceptions

OBJECTIVE

Prior to implementation of a Normal Labour and Birth Bundle (NLBB) at a regional maternity service in Victoria, Australia, this study aimed to understand clinician factors that may influence the uptake, acceptance and use of the NLBB.

DESIGN

This was a mixed methods study in which The Theory of Planned Behaviour (TPB) provided the framework for the conduct and analysis of the staff survey and focus groups. Descriptive and multiple regression were used to analyse the survey data and thematic analysis was used for the focus group data.

PARTICIPANTS

Participants for the survey and focus groups included clinicians providing publicly funded care and management of labour for women birthing at the health service. Maternity care clinicians were invited to participate in both the survey and the focus groups.

FINDINGS

Seventy-six clinicians (88.8%) responded to the survey. Mean scores for TPB constructs were well above the mid-scale score of 4, indicating strong positive attitudes, high levels of self-efficacy and positive social pressure to use the NLBB and strong intentions to use it in the future. Self-efficacy was the strongest independent predictor (β = 0.45, p < 0.001) of intention to use the NLBB (overall model R2=0.38). A valued consequence of implementing standardised and objective guidelines, highlighted in the focus groups, was the positive impact on clinicians' confidence in their decision-making.

KEY CONCLUSIONS

This study found that midwives and obstetricians were in favour of using a normal labour and birth care bundle and perceived the bundle to align with the expectations of work colleagues and the women they care for. The findings of this study show that clinicians at the health service had strong intentions to use the normal labour and birth care bundle in the future.

IMPLICATIONS FOR PRACTICE

Implementation science is important in embedding and sustaining practice change. Understanding staff perceptions is an essential first step of this process.

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.

Midwives' experience of their education, knowledge and practice around immersion in water for labour or birth

BACKGROUND

There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

METHODS

This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia. Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire. Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth. Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

RESULTS

The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire. Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven. Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth. Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance. Phase two included two focus groups of seven and five midwives. Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.

CONCLUSIONS

This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

Trauma and fear in Australian midwives

BACKGROUND

Relatively little is known about the extent of trauma and birth-related fear in midwives and how this might affect practice.

AIM

(1) Determine prevalence of birth related trauma and fear in midwives and associations with midwives' confidence to advise women during pregnancy of their birth options and to provide care in labour. (2) Describe midwives' experiences of birth related trauma and/or fear.

METHOD

A mixed methods design. A convenience sample of midwives (n=249) completed an anonymous online survey. Descriptive and inferential statistics were used to analyse the quantitative data. Latent content analysis was used to extrapolate meaning from the 170 midwives who wrote about their experiences of personal and/or professional trauma.

RESULTS

The majority of midwives (93.6%) reported professional (n=199, 85.4%) and/or personal (n=97, 41.6%) traumatic birth experiences. Eight percent (n=20) reported being highly fearful of birth. Trauma was not associated with practice concerns but fear was. Midwives categorised as having 'high fear' reported more practice concerns (Med 23.5, n=20) than midwives with 'low fear' (Med 8, n=212) (U=1396, z=-3.79, p<0.001, r=0.24). Reasons for personal trauma included experiencing assault, intervention and stillbirth. Professional trauma related to both witnessing and experiencing disrespectful care and subsequently feeling complicit in the provision of poor care. Feeling unsupported in the workplace and fearing litigation intensified trauma.

CONCLUSION

High fear was associated with lower confidence to support childbearing women. Fear and trauma in midwives warrants further investigation to better understand the impact on professional practice.

Measuring critical thinking in pre-registration midwifery students: A multi-method approach

OBJECTIVE

Test the concurrent validity of three newly developed tools (student self-rating, preceptor rating, and reflective writing) that aim to measure critical thinking in midwifery practice.

DESIGN

A descriptive matched cohort design was used.

SETTING

Australian research intensive university offering a three year Bachelor of Midwifery programme.

SAMPLE

Fifty-five undergraduate midwifery students.

METHODS

Students assessed their ability to apply critical thinking in midwifery practice using a 25-item tool and a 5-item subscale in Motivated Strategies for Learning Questionnaire. Clinical preceptors completed a 24-item tool assessing the students' application of critical thinking in practice. Reflective writing by students was assessed by midwifery academics using a 15-item tool. Internal reliability, and concurrent validity were assessed. Correlations, t-tests, multiple regression and confidence levels were calculated for the three scales and associations with student characteristics.

RESULTS

The three scales achieved good internal reliability with a Cronbach's alpha coefficient between 0.93 and 0.97. Matched total scores for the three critical thinking scales were moderately correlated; student/preceptor (r=0.36, p<0.01); student/reflective writing (r=0.38, p<0.01); preceptor/reflective writing (r=0.30, p<0.05). All critical thinking mean scores were higher for students with a previous degree, but only significant for reflective writing (t (53)=-2.35, p=0.023). Preceptor ratings were predictive of GPA (beta=0.50, p<0.001, CI=0.10 to 0.30). Students' self-rating scores were predictive of year level (beta=0.32, p<0.05, CI=0.00 to 0.03).

CONCLUSION

The student, preceptor, and reflective writing tools were found to be reliable and valid measures of critical thinking. The three tools can be used individually or in combination to provide students with various sources of feedback to improve their practice. The tools allow formative measurement of critical thinking over time. Further testing of the tools with larger, diverse samples is recommended.