A metasynthesis of midwife-led care

Perceptions of quality of care in Midwife-led Birth Centres (MLBCs) in Uganda: Why do women choose MLBCs over other options?

BACKGROUND

Midwife-led birth centres (MLBCs) are associated with reduced childbirth interventions, higher satisfaction rates, and improved birth outcomes. The evidence on quality of care in MLBCs from low and middle-income countries (LMIC) is limited.

AIM

This study aimed to explore the perceptions of women and midwives regarding the quality of care in four MLBCs in Uganda.

METHODS

A qualitative study was conducted in four MLBCs in Uganda. We conducted interviews with women and midwives in the MLBCs to explore their perceptions and experiences related to care in the MLBCs. The study obtained ethical approval. Deductive thematic analysis was used for data analysis.

RESULTS

Three key themes were identified regarding the perceptions of women and midwives about the quality of care in the MLBCs: providing respectful, and dignified care; a focus on woman-centred care; and reasons for choosing care in the MLBC. Women valued the respectful and humane care characterised by dignified and non-discriminatory care, non-abandonment, privacy, and consented care. The woman-centred care in the MLBC involved individualised holistic care, providing autonomy and empowerment, continuity of care, promoting positive birth experience, confidence in the woman's own abilities, and responsive providers. Women chose MLBCs because the services were perceived to be available, accessible, affordable, with comprehensive and effective referral mechanisms.

CONCLUSION

Women perceived care to be respectful, woman-centred, and of good quality. Global attention should be directed to scaling up the establishment of MLBCs, especially in LMIC, to improve the positive childbirth experience and increase access to care.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Understanding the co-construction of safety in the paediatric intensive care unit: A meta-ethnography of parents' experiences

BACKGROUND

Children experiencing critical illness or injury may require admission to a paediatric intensive care unit (PICU) to receive life-sustaining or life-saving treatment. Studies have explored the experience of parents with a child in PICU but tend to focus on subgroups of children or specific healthcare systems. Therefore, we aimed to undertake a meta-ethnography to draw together the published research.

METHODS

A systematic search strategy was developed to identify qualitative studies, which had explored the experiences of parents with a critically ill child treated in a PICU. A meta-ethnography was undertaken following the structured steps of identifying the topic; undertaking a systematic search; reading the research; determining how the studies relate and translate into each other; and synthesising and expressing the results.

RESULTS

We identified 2989 articles from our search and after a systematic series of exclusions, 15 papers remaining for inclusion. We explored the original parent voices (first order) and the interpretation of the study authors (second order) to identify three third-order concepts (our interpretation of the findings), which related to technical, relational and temporal factors. These factors influenced parents' experiences, providing both barriers and facilitators to how parents and caregivers experienced the time their child was in the PICU. The dynamic and co-constructed nature of safety provided an analytical overarching frame of reference.

CONCLUSION

This synthesis demonstrates novel ways in which parents and caregivers can contribute to the vital role of ensuring a co-created safe healthcare environment for their child when receiving life-saving care within the PICU.

UK midwives' perceptions and experiences of using Facebook to provide perinatal support: Results of an exploratory online survey

Seeking support from Facebook groups during pregnancy is now widespread and social media has been widely used by the United Kingdom National Health Service (NHS) maternity services to communicate with service users during the COVID-19 pandemic. Despite this, little is currently known about midwives' attitudes towards, and experiences of social media in practice. Research is needed to understand barriers and solutions to meeting mothers' expectations of online support and to improve services. This study explored midwife involvement in Facebook groups, exploring experiences and perceptions of its use to communicate with and support mothers. An online survey consisting of open and closed questions was completed by 719 midwives and student during August- September 2020. Quantitative questionnaire data was analysed descriptively using SPSS v26. Qualitative data gathered from free text responses was analysed using reflexive thematic analysis. Few participants were involved in providing Facebook support, and most of these were unpaid. There was a consensus on a range of benefits for mothers, but widespread concern that engaging with mothers online was a personal and professional risk, underpinned by a lack of support. Experience of being involved in midwife moderation increased belief in its benefits and reduced fear of engaging online, despite a lack of renumeration and resources. Midwives and students felt they were discouraged from offering Facebook support and sought further training, guidance and support. Although limited, experiences of providing Facebook group support are positive. Perceptions of risk and a lack of support are significant barriers to midwives' involvement in using Facebook groups to support mothers. Midwives seek support and training to safely and effectively engage with mothers using Facebook. Engaging with mothers via social media is embedded in UK national policy and NHS digital strategy, and progress is needed to fulfil these, to improve services and meet mothers' expectations. Midwives' experiences suggest extending opportunities to provide Facebook support would benefit midwives, services and families. Consultation to revise local policy to support midwives and students in line with strategic goals is recommended.

"She was there all the time". A qualitative study exploring how women at higher risk for preterm birth experience midwifery continuity of care

PROBLEM

There is a paucity of research on experiences and views of women at higher risk of preterm birth of midwifery continuity of care.

BACKGROUND

Midwifery continuity of care (MCoC) has been associated with improved maternal outcomes and with lower levels of preterm births and stillbirths. The majority of MCoC studies have focused on women without risk factors and little has been published on women with obstetric complexities. The aim of this study is to explore the views and experiences of women identified as a higher risk of preterm birth who have had continuity of care from midwives.

DESIGN

Face-to-face, semi-structured interviews with 16 women identified as at increased risk of preterm birth and experienced continuity of midwifery care across pregnancy, birth and the postnatal period. Care had been provided by the pilot intervention group for the pilot study of midwifery practice in preterm birth including women's experiences (POPPIE) trial.

FINDINGS

Women valued continuity of midwifery care across the care pathway and described the reassurance provided by having 24 h a day, seven days a week access to known midwives. Consistency of care, advocacy and accessibility to the team were described as the main factors contributing to their feelings of safety and control.

KEY CONCLUSIONS

Recognising that known midwives were 'there all the time' made women feel listened to and actively involved in clinical decision making, which contributed to women feeling less stressed and anxious during their pregnancy, birth and early parenthood. When developing MCoC models for women with obstetric complexities: access, advocacy and time should be embedded to ensure women can build trusting relationships and reduce anxiety levels.

Implementing midwifery units in a European country: Situational analysis of an Italian case study

INTRODUCTION

Strong evidence recommends midwifery-led care for women with uncomplicated pregnancies. International research is now focusing on how to implement midwifery models of care in countries where they are not well established. In Europe, many countries like Italy are promoting midwifery-led care in national guidelines but often struggle to apply this change in practice.

METHODS

This study collected data on professional, organisational and service users' levels to conduct a situational analysis of an Italian service which is approaching the implementation of a midwifery unit. Participatory Action Research was used together with the support of the Consolidated Framework for Implementation Research to conduct data collection and analysis.

RESULTS

Forty-eight participants amongst professionals (midwives, obstetricians and neonatologists) and at organisational level (midwifery leaders and medical directors) were recruited; secondary data on service users' views was analysed via regional online surveys. Barriers and facilitators to the implementation were identified to assess the readiness of the local context.

CONCLUSIONS

This study is the first to include professionals, managers and service users in a European context such as Italy. Facilitators to the implementation of the alongside midwifery unit were found in national guidelines, allocated funding, collaborative engagement and medical support. Hierarchical structures, a prevalent medical model and lack of trust and awareness of the evidence of safety of midwifery-led models were main barriers.

Couples' experiences of pregnancy resulting from assisted reproductive technologies: A qualitative meta-synthesis

Background

Across the world, a growing number of couples are directly or indirectly affected by infertility. Advances in assisted reproductive technologies are now enabling many of them to plan to have a child. As pregnancies resulting from assisted reproductive technologies are being experienced by a growing number of couples, it is important to better understand their experiences and the difficulties they encounter during the prenatal period.

Objective

This literature review aims to synthesize the qualitative results of primary studies in order to better understand couples' experiences of pregnancy resulting from assisted reproductive technologies, after having experienced infertility.

Design

A meta-synthesis was conducted in accordance with the guidelines put forth by Sandelowski and Barroso in order to carry out an integrative analysis of the knowledge resulting from qualitative studies on this phenomenon.

Data sources

The literature search was carried out between October and November 2020. Seven electronic databases were searched (CINAHL, Medline, PsycNet, SCOPUS, ScienceDirect, CAIRN, ERUDIT) and 14 eligible articles were selected.

Review methods

The data from the "results" and "findings" sections of each of the articles were synthesized through thematic analysis to examine and summarize the topics found in the articles selected and develop the main themes.

Results

The thematic analysis is structured around four themes to describe and interpret different aspects of the experience of pregnancy resulting from ART, namely: 1) travelling a long and complex journey; 2) moving on with paradoxical emotions; 3) struggling with an emerging identity; and 4) reorganizing relationships. These results shed light on the complex issues faced by couples previously affected by infertility during a pregnancy resulting from assisted reproductive technologies.

Conclusion

The journey of a pregnancy resulting from assisted reproductive technologies must be recognized in order to offer support in line with the challenges faced by couples. This research will allow for a deeper understanding of women's experience, as well as that of their partner's, in a more specific way, and to better understand the impact on family and loved ones.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Dimensions of being a Midwife and Midwifery Practice in the United States: A Qualitative Analysis

Background

Midwives are a vital component of addressing maternal mortality crisis in the United States (US); however, there is scant understanding of the elements of midwifery practice that affect patient outcomes and the stability of the midwifery workforce in the country. This study investigates US midwives’ perceptions of factors influencing their practice and willingness to stay in the profession.

Methods

We applied a pragmatic qualitative design using summative content analysis techniques to code 1,035 comments from a national sample of 2,887 certified nurse-midwives and certified midwives. Two coders identified categories and themes of midwives’ perceptions of their practice environments, which were confirmed by an independent auditor.

Results

Eight themes emerged from the data: I love midwifery but…; feeling valued and respected…or not; workload; time and its consequences; the multilevel geography of midwifery practice; changes at odds with quality midwifery care; midwives withdrawing from practice to cope; and the ambiguity of “I just want to practice like a midwife”.

Conclusion

Midwives readily identified aspects of their practice environment that negatively impact quality of care and stability of the midwifery workforce, including not valuing midwives, high workload, regulatory restrictions, and moral distress; however, respondents expressed strong commitment to the profession of midwifery. The findings also demonstrated the lack of a universally accepted definition of midwifery care within respondents’ professional communities and among respondents. Initiatives to increase integration of midwifery into the U.S. perinatal health system will benefit from taking these findings into consideration.

Midwifery Practice and Education in Antwerp: Forecasting Its Future With Scenario Planning

BACKGROUND

Midwifery across the world is facing changes and uncertainties. By recognizing plausible future options, a contemporary and strategic scope of midwifery practice and education can be established. The city of Antwerp, Belgium, was the indicative case for this study. Key drivers were identified to serve as input for scenarios.

METHOD

Structuration theory and intuitive logics scenario planning methods were used to structure contextual midwifery scenarios.

RESULTS

Six certain and six uncertain variables were identified. A two-dimensional framework showed these factors: (a) maternity care services and organization and (b) the society of child-bearing women and their families. Three scenarios described the plausible future of midwifery: (a) midwife-led care monitoring maternal health needs, (b) midwife-led holistic care, and (c) midwife/general practitioner-led integrated maternity care.

CONCLUSION

All of the scenarios show the direction of change with a strategic focus, the importance of midwifery authenticity, and digital adaptability in maternity services. Also, the coronavirus disease 2019 (COVID-19) pandemic cannot be ignored in future midwifery. [J Contin Educ Nurs. 2022;53(1):21-29.].

Kairos care in a Chronos world: Midwifery care as model of resistance and accountability in public health settings

BACKGROUND

In the United States (US), pregnancy-related mortality is 2-4 times higher for Black and Indigenous women irrespective of income and education. The integration of midwifery as a fundamental component of standard maternity services has been shown to improve health outcomes and service user satisfaction, including among underserved and minoritized groups. Nonetheless, there remains limited uptake of this model in the United States. In this study, we examine a series of interdependent factors that shape how midwifery care operates in historically disenfranchised communities within the Unites States.

METHODS

Using data collected from in-depth, semi-structured interviews, the purpose of this study was to examine the ways midwives recount, describe, and understand the relationships that drive their work in a publicly funded urban health care setting serving minoritized communities. Using a qualitative exploratory research design, guided by critical feminist theory, twenty full-scope midwives working in a large public health care network participated. Data were thematically analyzed using Braun & Clarke's inductive thematic analysis to interpret data and inductively identify patterns in participants' experiences.

FINDINGS

The overarching theme "Kairos care in a Chronos World" captures the process of providing health-promoting, individualized care in a system that centers measurement, efficiency, and pathology. Five subthemes support the central theme: (1) the politics of progress, (2) normalizing pathologies, (3) cherished connections, (4) protecting the experience, and (5) caring for the social body. Midwives used relationships to sustain their unique care model, despite the conflicting demands of dominant (and dominating) medical models.

CONCLUSION

This study offers important insight into how midwives use a Kairos approach to maternity care to enhance quality and safety. In order to realize equitable access to optimal outcomes, health systems seeking to provide robust services to historically disenfranchised communities should consider integration of relationship-based strategies, including midwifery care.

Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death 2 (PARENTS 2) study: a mixed-methods study of implementation

OBJECTIVE

When a formal review of care takes places after the death of a baby, parents are largely unaware it takes place and are often not meaningfully involved in the review process. Parent engagement in the process is likely to be essential for a successful review and to improve patient safety. This study aimed to evaluate an intervention process of parental engagement in perinatal mortality review (PNMR) and to identify barriers and facilitators to its implementation.

DESIGN

Mixed-methods study of parents' engagement in PNMR.

SETTING

Single tertiary maternity unit in the UK.

PARTICIPANTS

Bereaved parents and healthcare professionals (HCPs).

INTERVENTIONS

Parent engagement in the PNMR (intervention) was based on principles derived through national consensus and qualitative research with parents, HCPs and stakeholders in the UK.

OUTCOMES

Recruitment rates, bereaved parents and HCPs' perceptions.

RESULTS

Eighty-one per cent of bereaved parents approached (13/16) agreed to participate in the study. Two focus groups with bereaved parents (n=11) and HCP (n=7) were carried out postimplementation to investigate their perceptions of the process.Overarching findings were improved dialogue and continuity of care with parents, and improvements in the PNMR process and patient safety. Bereaved parents agreed that engagement in the PNMR process was invaluable and helped them in their grieving. HCP perceived that parent involvement improved the review process and lessons learnt from the deaths; information to understand the impact of aspects of care on the baby's death were often only found in the parents' recollections.

CONCLUSIONS

Parental engagement in the PNMR process is achievable and useful for parents and HCP alike, and critically can improve patient safety and future care for mothers and babies. To learn and prevent perinatal deaths effectively, all hospitals should give parents the option to engage with the review of their baby's death.

"Cos You're Quite Normal, Aren't You?": Epistemic and Deontic Orientations in the Presentation of Model of Care Talk in Antenatal Consultations

Women's involvement in decision-making around antenatal care is an issue of ongoing debate and discussion. Most research on the topic has used interview and focus group methods to examine women's perspectives. The present study uses a different kind of evidence. By analyzing recordings of actual antenatal consultations, this paper presents a preliminary exploration of model-of-care talk in a hospital setting where a policy of woman-centered care underpinned practice. Conversation Analysis was used to examine how model-of-care pathways were introduced by midwives and discussed with women in consultations. Drawing on interactional work on deontic (i.e., the rights and responsibilities of speakers to determine courses of action) and epistemic (i.e., speakers' claims to knowledge) orientations, this paper offers an account of how woman-centered care is accomplished in a hospital setting. The findings demonstrate how midwives routinely relied on their epistemic knowledge regarding women's health to invoke a "normal" categorization that worked to position midwifery-led care as an appropriate pathway. Examination of model-of-care talk also demonstrated how authority to choose a pathway was typically managed so as to reside with the woman. Talk that topicalized epidural forms of pain management were also examined, as institutional policy around where birth could occur in the hospital system under study restricted women's options (a planned epidural precluded woman access to midwifery-led care during delivery). The findings demonstrate the various ways in which midwives created opportunities for woman-centered care in an institutional setting in which there were logistical restrictions on women's choices.

A systematic meta-thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth

AIMS

To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth.

DESIGN

A systematic meta-thematic synthesis and GRADE-CERQual.

DATA SOURCES

We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020.

METHODS

Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual.

RESULTS

Seven studies met the inclusion criteria. Nine key statements of findings were generated - one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women's physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs.

CONCLUSION

Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.

IMPACT

Understanding women's experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women's access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice.

Understanding how midwives employed by the National Health Service facilitate women's alternative birthing choices: Findings from a feminist pragmatist study

UK legislation and government policy favour women's rights to bodily autonomy and active involvement in childbirth decision-making including the right to decline recommendations of care/treatment. However, evidence suggests that both women and maternity professionals can face challenges enacting decisions outside of sociocultural norms. This study explored how NHS midwives facilitated women's alternative physiological birthing choices-defined in this study as 'birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth'. The study was underpinned by a feminist pragmatist theoretical framework and narrative methodology was used to collect professional stories of practice via self-written narratives and interviews. Through purposive and snowball sampling, a diverse sample in terms of age, years of experience, workplace settings and model of care they operated within, 45 NHS midwives from across the UK were recruited. Data were analysed using narrative thematic that generated four themes that described midwives' processes of facilitating women's alternative physiological births: 1. Relationship building, 2. Processes of support and facilitation, 3. Behind the scenes, 4. Birth facilitation. Collectively, the midwives were involved in a wide range of alternative birth choices across all birth settings. Fundamental to their practice was the development of mutually trusting relationships with the women which were strongly asserted a key component of safe care. The participants highlighted a wide range of personal and advanced clinical skills which was framed within an inherent desire to meet the women's needs. Capturing what has been successfully achieved within institutionalised settings, specifically how, maternity providers may benefit from the findings of this study.

Local guidelines for admission to UK midwifery units compared with national guidance: A national survey using the UK Midwifery Study System (UKMidSS)

OBJECTIVES

To describe the extent to which local guidelines for admission to UK midwifery units align with national guidance; to describe variation in individual admission criteria; and to describe the extent to which alongside midwifery units (AMUs) are the default option for eligible women.

DESIGN

National cross-sectional survey.

SETTING

All 122 UK maternity services with midwifery units, between October 2018 and February 2019.

OUTCOME MEASURES

Alignment of local admission guidelines with national guidance (NICE CG190); frequency and nature of variation in individual admission criteria; percentage of services with AMU as default birth setting for eligible women.

RESULTS

Admission guidelines were received from 87 maternity services (71%), representing 153 units, and we analysed 85 individual guideline documents. Overall, 92% of local admission guidelines varied from national guidance; 76% contained both some admission criteria that were 'more inclusive' and some that were 'more restrictive' than national guidance. The most common 'more inclusive' admission criteria, occurring in 40-80% of guidelines, were: explicit admission of women with parity ≥4; aged 35-40yrs; with a BMI 30-35kg/m2; selective admission of women with a BMI 35-40kg/m2; Group B Streptococcus carriers; and those undergoing induction of labour. The most common 'more restrictive' admission criteria, occurring in around 30% of guidelines, excluded women who: declined blood products; had experienced female genital cutting; were aged <16yrs; or had not attended for regular antenatal care. Over half of services (59%) reported the AMU as the default option for healthy women with straightforward pregnancies.

CONCLUSIONS

The variation in local midwifery unit admission criteria found in this study represents a potentially confusing and inequitable basis for women making choices about planned place of birth. A review of national guidance may be indicated and where a lack of relevant evidence underlies variation in admission criteria, further research by planned place of birth is required.

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.

Women's experiences of decision-making and informed choice about pregnancy and birth care: a systematic review and meta-synthesis of qualitative research

Background

The purpose of this systematic review (PROSPERO Ref: CRD42017053264) was to describe and interpret the qualitative research on parent’s decision-making and informed choice about their pregnancy and birth care. Given the growing evidence on the benefits of different models of maternity care and the prominence of informed choice in health policy, the review aimed to shed light on the research to date and what the findings indicate.

Methods

a systematic search and screening of qualitative research concerning parents’ decision-making and informed choice experiences about pregnancy and birth care was conducted using PRISMA guidelines. A meta-synthesis approach was taken for the extraction and analysis of data and generation of the findings. Studies from 1990s onwards were included to reflect an era of policies promoting choice in maternity care in high-income countries.

Results

Thirty-seven original studies were included in the review. A multi-dimensional conceptual framework was developed, consisting of three analytical themes (‘Uncertainty’, ‘Bodily autonomy and integrity’ and ‘Performing good motherhood’) and three inter-linking actions (‘Information gathering,’ ‘Aligning with a birth philosophy,’ and ‘Balancing aspects of a choice’).

Conclusions

Despite the increasing research on decision-making, informed choice is not often a primary research aim, and its development in literature published since the 1990s was difficult to ascertain. The meta-synthesis suggests that decision-making is a dynamic and temporal process, in that it is made within a defined period and invokes both the past, whether this is personal, familial, social or historical, and the future. Our findings also highlighted the importance of embodiment in maternal health experiences, particularly when it comes to decision-making about care. Policymakers and practitioners alike should examine critically current choice frameworks to ascertain whether they truly allow for flexibility in decision-making. Health systems should embrace more fluid, personalised models of care to augment service users’ decision-making agency.

Midwife-moderated social media groups as a validated information source for women during pregnancy

BACKGROUND

Widespread use of the internet has fundamentally altered the way people access health information and communicate with health providers. Pregnant women are a group who are particularly highly motivated to seek out information online. However, where mothers actually obtain their information, who they trust to supply it, and whether or not it actually fulfils their needs is often unclear. This paper examines the experiences of women accessing advice and information on pregnancy and childbirth through a dedicated social-media platform, mediated by qualified midwives. The study formed part of a larger research project that focussed on professionally moderated online learning in maternity care, and the role of online communities. This paper reports on aspects of midwife mediated information provision in the context of these online communities.

METHODS

Two secret (i.e. private / invitation only) Facebook groups were created. Both groups were moderated by 2 qualified midwives. One group had 17 mothers and the other 14 mothers. Both groups ran for 35 weeks.

DATA AND ANALYSIS

The data included the written and spoken words of group participants and midwife-moderators in i) face-to-face (n = 4) and online (n = 4) post-intervention focus groups; ii) one-to-one interviews with group participants and midwife moderators (n = 24); iii) the complete corpus of text-based interaction across both groups; iv) a sub-set of private message sessions (n = 24) between individual participants and midwife-moderators. Thematic analysis was applied to the combined dataset.

FINDINGS

Participants found engagement with midwives and other pregnant women via a social media group convenient and accessible. The groups provided a safe space for the sharing and validation of maternity relevant information. Members trusted their midwife-moderators to ensure information was reliable. For many members, the group became the primary source of pregnancy related information.

CONCLUSION

Midwife-mediated social media groups offer a highly effective way of providing individualised information provision and social support for pregnant woman. Access to a group can also significantly impact on perceptions of relational continuity.

Midwifery-led care can lower caesarean section rates according to the Robson ten group classification system

INTRODUCTION

Midwifery-led care is recognised as the best choice of maternity care for low-risk women. Robson’s Ten Group Classification System (TGCS) is an internationally recognised audit tool, however there is no midwifery-led service presenting their statistics in this way. The objective of this study was to analyse caesarean section rates for the women attending midwifery-led care at the National Maternity Hospital Dublin, Ireland, using the Robson TGCS.

METHODS

This is a retrospective study of electronic records for a total of 1097 women who were booked to attend the community midwife team in the National Maternity Hospital, during 2016 and 2017.

RESULTS

The rate of caesarean section in low-risk nulliparous women (Robson Group 1) was under 6%, without affecting the perinatal outcome. The induction rate in nulliparous women (Group 2) was 36%, less than the national average the cesarean rates were quadruple in this group.

CONCLUSIONS

Low-risk women who attend midwifery-led services, have a low caesarean section rate in this study. This was achieved with continuity of care, good antenatal preparation, and support throughout labour and birth by a dedicated team of midwives. Outcomes can only be truly compared if we use the same criteria to measure them. The TGCS demonstrates the effectiveness of midwifery-led care.

A community of practice in a midwifery led unit. How the culture and environment shape the learning experience of student midwives

OBJECTIVE

To explore the teaching and learning experience of midwifery mentors and student midwives in a midwifery led unit. The aim of this paper is to discuss how a conceptual framework emerged from the findings of the study.

DESIGN AND METHOD

Ethnography. Non-participant observation of the daily work of an alongside midwifery led unit (AMU) over 14 months, and direct observation of episodes of care involving ten dyads of midwifery mentors and student midwife dyads. These observations were followed by individual semi structured interviews with participants.

SETTING

An alongside midwifery led unit in a Health Board in Wales, UK. This is an option for place of birth in the National Health Service in the UK.

SAMPLE

Ten dyads of midwifery mentors and student midwives.

FINDINGS

A conceptual framework emerged from the data in relation to the powerfully shared goals and ethos of the midwives working in this AMU. The framework gave shape and form to the particular nature of the teaching and learning experience in the midwifery led setting. The concept of a community of practice, firmly rooted in the authoritative knowledge and understanding of physiological birth, resulted in positive working practices and happy, motivated midwives who enhanced the birth experience for women. This supported the clinical and socially situated learning of student midwives and new colleagues through legitimate peripheral participation.

IMPLICATIONS FOR PRACTICE, POLICY, EDUCATION AND RESEARCH

Positive, committed and autonomous midwives make for a nurturing working environment and may therefore enhance the experience of birthing women. Midwives need to be able to work in an environment and community of practice which mirrors their own philosophy of care to promote professional wellbeing, and to develop the expert knowledge and skill in that area of practice over time.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Empowering LGBTQ parents: How to improve maternity services and child healthcare settings for this community – ‘She told us that we are good as a family’

Parental empowerment plays an essential role in maternity and child healthcare. Professionals delivering these services are ideally placed to improve parents' empowerment and well-being. This study aims to describe the supporting factors of parental empowerment from the perspective of self-identified lesbian, gay, bisexual, trans, or queer (LGBTQ) parents in Finland. The study was conducted using a qualitative inductive design, and 22 parents participated. Interviews were conducted between July and September of 2016 and analysed using inductive content analysis. Four categories emerged: 1) Parents' willingness to create socially recognized families, 2) Parenthood support, 3) Respectful partnership with all parents, and 4) Accessible services. Services were more empowering when parents were treated with dignity. This focus requires gender-neutral communication and a clear sense of security for parents. The findings indicate more education on LGBTQ-related issues is still needed.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

Introduction

Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods

This study was a secondary analysis of data from the population‐based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife‐attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates.

Results

Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making.

Discussion

Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

The cost of vaginal birth at home, in a birth centre or in a hospital setting in New South Wales: A micro-costing study

BACKGROUND

Women want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings.

AIM

The aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales.

METHODS

A micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy.

FINDINGS

The median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings.

CONCLUSION

In this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.

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.

Disconnection: Exploring transfer from midwifery-led to consultant-led care a phenomenological study of women's views

BACKGROUND

Understanding women's feelings during the transfer process can illuminate women's perspectives thus minimising the risk for postnatal psychological and emotional morbidity, and inform midwifery practice.

AIM

To explore the meaning women ascribe to their feelings when transferred from an environment emphasising a social model of pregnancy and birth in a Midwifery Led Unit, to a contrasting, more 'medicalised' setting of a Consultant Led Unit.

METHODS

The study adopted an idiographic focus, by conducting semi-structured interviews with new mothers. A purposive sample of eleven women was recruited via participating midwifery led units and their 'Facebook' page. An interpretative phenomenological approach was selected to explore mothers' individual perceptions of experiences.

FINDINGS

Participants described feeling a strong sense of community in the midwifery led unit, where they enjoyed a sense of belonging, safety, and support. The overarching theme of 'disconnection' signified feelings of muted agency when transferred to a different environment. Women used adaptive processes to reconcile themselves to a medicalised ideology. The impact of the transfer also resulted in a sense of alienation and 'not belonging'.

CONCLUSION

Adjustment to a different model of care meant women needed to rapidly amend their notions of normality and agency, at the same time as entering motherhood. Raising awareness about the possible psychological adjustments women have to make during at this time could provide reassurance to other women. It also highlights the need for support during and after transfer. Strengthening continuity of care could help facilitate the adjustment process.

The role, practice and training of unregulated birth workers in Australia: A mixed methods study

BACKGROUND

In Australia, the provision of homebirth services by unregulated birthworkers (doulas, ex-registered midwives, traditional midwives and lay workers) has increased. Accessing a homebirth with a registered midwife via mainstream services is limited. Concern is growing that new legislation aimed at prohibiting unregulated birthworkers practice may result in homebirth going underground.

AIM

To explore the role, practice and training of unregulated birthworkers in Australian and establish what they would do if legislation prohibited their practice.

METHODS

This study used a mixed methods sequential exploratory design to explore the practice, training and role of unregulated birthworkers in Australia. In phase one, four unregulated birthworkers were interviewed in-depth and the findings informed the development of a survey in phase two. This was distributed nationally through two consumer websites, social media, Facebook and email. Data from both phases were integrated.

FINDINGS

Unregulated birthworkers in Australia provide homebirth services to women with high and low-risk pregnancies when this choice is unavailable or unacceptable within mainstream services. They operate covertly to protect their practice and avoid the scrutiny of authorities. Unregulated birthworkers can be experienced and trained in childbirth care and practice, much like a midwife working within a holistic paradigm of care.

CONCLUSION

Unregulated birthworkers believe they provide women with the homebirth service they want but cannot access. Mainstream service providers need to listen to consumer criticisms, as women seek answers outside the system. Change is needed to improve and align services with women's expectations of homebirth.

Continuity of midwifery carer moderates the effects of prenatal maternal stress on postnatal maternal wellbeing: the Queensland flood study

Poor postnatal mental health is a major public health issue, and risk factors include experiencing adverse life events during pregnancy. We assessed whether midwifery group practice, compared to standard hospital care, would protect women from the negative impact of a sudden-onset flood on postnatal depression and anxiety. Women either received midwifery group practice care in pregnancy, in which they were allocated a primary midwife who provided continuity of care, or they received standard hospital care provided by various on-call and rostered medical staff. Women were pregnant when a sudden-onset flood severely affected Queensland, Australia, in January 2011. Women completed questionnaires on their flood-related hardship (objective stress), emotional reactions (subjective stress), and cognitive appraisal of the impact of the flood. Self-report assessments of the women's depression and anxiety were obtained during pregnancy, at 6 weeks and 6 months postnatally. Controlling for all main effects, regression analyses at 6 weeks postpartum showed a significant interaction between maternity care type and objective flood-related hardship and subjective stress, such that depression scores increased with increasing objective and subjective stress with standard care, but not with midwifery group practice (continuity), indicating a buffering effect of continuity of midwifery carer. Similar results were found for anxiety scores at 6 weeks, but only with subjective stress. The benefits of midwifery continuity of carer in pregnancy extend beyond a more positive birth experience and better birthing and infant outcomes, to mitigating the effects of high levels of stress experienced by women in the context of a natural disaster on postnatal mental health.

Assessing Evidence-Informed Practices to Reduce Routine Interventions in Labor and Childbirth: Validating the Content of the Keeping Birth Normal Tool

Background:

The overuse of interventions in labor and childbirth increase the risk of mortality and morbidity in women. There are wide variations in the use of routine interventions locally, regionally, and globally. The reasons for this are complex and multifactorial. This study focuses its investigations at the microcosm of practice. It outlines the validation of the content of a new Tool to assess and support the implementation of evidence-informed practices by health-care professionals.

Methods:

Seven experts and eight women user representatives used a 4-point ordinal scale of relevance to rate 50 items in the Keeping Birth Normal (KBN) Tool. Item-level content validity index (I-CVI), an average scale-level content validity index (S-CVI/Ave), and qualitative comments were used to delete and improve items.

Results:

Eleven experts analyzed all 50 items. Four experts rated 35–49 items. The initial scale received an S-CVI/Ave of 0.88. Two items were deleted, improvements were made to 45 items, some were merged, and 7 new items were added. The final scale with 36 items received an S-CVI/Ave of 1.0 post item deletion and improvement.

Discussion:

The items in the KBN Tool are construct relevant and will undergo plausibility testing in a future study. Other forms of validity evidence on response processes and internal structure, which may be gathered, will depend on its further application in practice and research.

'Keeping birth normal': Exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit

OBJECTIVES

to gain understanding about how participants perceived the value and effectiveness of 'Keeping Birth Normal' training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations.

DESIGN

exploratory interpretive.

SETTING

inner-city maternity service.

PARTICIPANTS

31 midwives attending a one-day training package on one of three occasions.

METHODS

data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers.

FINDINGS

We identified six themes contributing to the workshop's effectiveness as perceived by participants. Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3) 'less is more.' And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to influence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most effective.

A qualitative interview study into experiences of management of labor pain among women in midwife-led care in the Netherlands

INTRODUCTION

Many pregnant women are concerned about the pain they will experience in labor and how to deal with this. This study's objective was to explore women's postpartum perception and view of how they dealt with labor pain.

METHODS

Semistructured postpartum interviews were analyzed using the constant comparison method. Using purposive sampling, we selected 17 women from five midwifery practices across the Netherlands, from August 2009 to September 2010.

RESULTS

Women reported that control over decision making during labor (about dealing with pain) helped them to deal with labor pain, as did continuous midwife support at home and in hospital, and effective childbirth preparation. Some of these women implicitly or explicitly indicated that midwives should know which method of pain management they need during labor and arrange this in good time.

DISCUSSION

It may be difficult for midwives to discriminate between women who need continuous support through labor without pain medication and those who genuinely desire pain medication at a certain point in labor, and who will be dissatisfied postpartum if this need is unrecognized and unfulfilled.

Compassion fatigue in nurses: A metasynthesis

AIMS AND OBJECTIVES

To interpret the body of qualitative work focusing on compassion fatigue to distil a common understanding that could then be applied to nursing care.

BACKGROUND

Complex demands place extraordinary stress on nurses struggling to work in overburdened healthcare systems. The result can be the inability to care well for others, leading to compassion fatigue, burnout and increased numbers leaving the profession. Metasynthesis offers a means of more fully illuminating compassion fatigue and further understanding of practices which might reduce its negative consequences.

DESIGN

Metasynthesis.

METHOD

As a method designed to facilitate knowledge development, metasynthesis allowed for integration of qualitative study findings conducted between 1992-2016 using defined search terms. Six databases were searched for articles published in English. Nine papers met the criteria for review and metasynthesis was conducted using the meta-ethnographic approach detailed by Noblit and Hare.

RESULTS

Four themes related to compassion fatigue were found by consensus discussion. The themes included: physical ("just plain worn out") and emotional symptoms ("walking on a tightrope"), triggering factors ("an unbearable weight on shoulders" and "alone in a crowded room"), and measures to overcome/prevent ("who has my back?").

CONCLUSIONS

Compassion fatigue is a concept of documented relevance to those in nursing and represents a basic inability to nurture others and engenders a temporal component. Synthesis of studies provides evidence of the veracity of the concept for application to clinical practice and research related to nursing care.

RELEVANCE TO CLINICAL PRACTICE

Findings provide insight into the clinical milieu needed to prevent compassion fatigue. A theoretical model is presented which can be used to guide future research, as well as the creation of clinical practice policies which might mitigate the development of compassion fatigue and its potential consequences.

Midwife-led maternity care in Ireland - a retrospective cohort study

Background

Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites.

Methods

MLU data for the six years 2008–2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables.

Results

During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman’s wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit.

All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1–2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%).

Conclusions

Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction.

Coping together with hearing loss: a qualitative meta-synthesis of the psychosocial experiences of people with hearing loss and their communication partners

OBJECTIVE

To examine the psychosocial experiences of hearing loss from the perspectives of both the person with hearing loss and their communication partner.

DESIGN

A meta-synthesis of the qualitative literature.

STUDY SAMPLE

From 880 records, 12 qualitative papers met the inclusion criteria, (i) adults with hearing loss, communication partners, or both, and (ii) explored psychosocial issues.

RESULTS

Four themes related to the psychosocial experience of hearing loss were found, (i) the effect of the hearing loss, (ii) the response to hearing aids, (iii) stigma and identity, and (iv) coping strategies. Hearing loss affected both people with hearing loss and communication partners. Hearing aids resulted in positive effects, however, these were often outnumbered by negative effects. Non-use of hearing aids was often influenced by stigma. Coping strategies used were related to how the person with hearing loss perceived their self and how the communication partner perceived the relationship. Aligned coping strategies appeared to have a positive effect.

CONCLUSIONS

Hearing loss affects both people with hearing loss and their communication partners. Aligned coping strategies can facilitate adjustment to hearing loss.

Identifying Barriers and Enablers as a First Step in the Implementation of a Midwife-Led Psychoeducation Counseling Framework for Women Fearful of Birth

BACKGROUND:Around 20% of women report high levels of childbirth fear. An evidence-based psychoeducation intervention delivered by midwives reduced maternal childbirth fear and increased confidence for birth. Implementation of the intervention into practice is now required. Translating evidence into practice, however, remains challenging.

AIM:This study aimed to explore organizational factors, including barriers and possible solutions that may impact on the successful application of the midwife psychoeducation intervention in practice.

METHODS:Mixed methods data collection included a self-administered survey (n= 62), clinician-led focus groups (n= 28), and interviews with key stakeholders (n= 5). Simple descriptive statistics were used to analyze the quantitative data. Latent content analysis was used to analyze the qualitative data.

RESULTS:Midwives were perceived to be best placed to deliver psychoeducation to women fearful of birth. Support for normal birth was high. There was, however, disparity between positive attitudes toward evidence-based practice in theory and its clinical application. Similarly, although the workplace learning culture was generally assessed as positive, many participants believed changing practice was difficult and reported a low sense of agency for challenging or facilitating change. Participants reported that barriers to implementing the evidence included time constraints and heavy workloads. There was a lack of awareness and confidence to implement evidence-based practice (EBP) with participants identifying that resistance to change was often the result of clinician fear and self-interest. The way services were routinely structured was considered problematic as fragmentation actively worked against midwives forming meaningful relationships with women. Enablers included organizational support, education, local champions, and continuity of midwifery care.

CONCLUSION:The study identified the clinicians’ readiness, barriers, and possible solutions to the widespread implementation of an evidence-based psychoeducation intervention delivered by midwives for women fearful of birth at one maternity facility in South East Queensland, Australia. Many of the identified barriers were commensurate with the international literature on translating evidence into practice.

Setting the stage for health: Salutogenesis in midwifery professional knowledge in three European countries

There is a lack of systematic evidence concerning health orientation in maternity practice in the current climate of risk avoidance. The midwifery professional project is orientated toward the preservation of normal physiological processes during the maternity episode. This study investigates accounts of midwives who were working in health-orientated birth settings, to examine if and how they frame a health orientation in professional practice. Twenty-seven narrative interviews were conducted with midwives working in pre-, peri-, and postnatal care in different maternity care settings in Switzerland, Austria, and Germany. In-depth and comparative pattern data analyses were conducted. The distinct practice orientation of the participants was revealed in three main concepts, underpinned by a common framework mirroring the three parameters of the Sense of Coherence (comprehensibility, manageability, and meaningfulness) described in Aaron Antonovsky's salutogenic theory. The midwives’ implicit salutogenic knowledge shaped their reported actions in supporting mothers, fathers, and families to have health-promoting experiences in maternity care. These results suggest that an implicit health orientation in maternity care practice can be prefered through examination of the practice reports of midwives working in settings that have a health-promoting philosophy. Implications for midwifery practice and research are discussed. Consideration is given to the relevance of the results for debates about avoiding overtreatment and for the operationalization of salutogenic theory in health care practice.

Encourages and guides, or diagnoses and monitors: Woman centred-ness in the discourse of professional midwifery bodies

OBJECTIVE

the purpose of this study was to conduct a preliminary exploration of the language used by midwifery professional bodies to define the scope of practice of midwives in relation to woman-centred care.

DESIGN

this is a qualitative study in which Critical Discourse Analysis and Transitivity Analysis from the Systemic Functional Linguistics tradition were used. Data were sampled from nine international midwifery professional bodies.

FINDINGS

three general types of definitions of scope of practice were identified; a formal type which focused on midwifery practice in which the midwife and woman were largely absent as agents, a second, less formal type which focused on the midwife as agent, from which the woman was largely absent as an active participant and one exception to the pattern which featured the woman as agent. The main type of verb used in the definitions was Doing Processes such as monitor, diagnose. Saying (advise), Sensing (identify), and Being (be able to) processes were much less frequent in the data. The definitions of scope of practice explored in this study (with one exception) revealed a general lack of woman-centeredness and more of a focus on an orientation to birth as a medically managed event.

KEY CONCLUSIONS

definitions of scope of practice statements by professional bodies are systematically developed through much conscious thought and discussion by the writers on behalf of a community of practice and are formulated specifically for the purpose of being available to the general public as well as midwives. It can be assumed that the choices of wording and content are carefully constructed with public dissemination in mind. These ideologies communicated via the professional body texts emanate from a socio-cultural context that varies from country to country and professional bodies construct the definitions by drawing on the available, circulating discourses. Although woman-centred care is a key focus in contemporary maternity care, many definitions of scope of practice reveal a continuing orientation to a medical model of pregnancy and birth and a synonymisation of midwife-led care with woman centred care.

IMPLICATIONS FOR PRACTICE

by analysing statements of scope of practice by professional bodies and the contexts in which they are produced, we can continue to reveal the underlying social, political, and historical forces that influence midwifery practice. This paper examines some key examples of the professional discourse of midwifery in relation to the definition of the midwife and scope of practice in order to reflect on what these examples may tell us about the professional culture of midwifery and the implications for woman-centred care.

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.

Midwife-led continuity models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.

OBJECTIVES

To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.