A qualitative study exploring midwives' perceptions and views of extending their role to the examination of the newborn baby

OBJECTIVES: to explore midwives' attitudes and perceptions about extending their role to the examination of the newborn baby, as well as their general perceptions and attitudes to new role developments. DESIGN: qualitative, data collected using semi-structured interviews, which were exploratory and interactive in form. SETTING: six maternity hospitals in South-east England. PARTICIPANTS: ten midwives were purposefully selected, including five trained in the examination of the newborn baby and currently conducting examinations and five who had not. Most of the midwives had been qualified for over ten years and had a wide range of clinical experience in hospital and community settings. FINDINGS: midwives identified many benefits to themselves, to their profession and to the mothers as a result of developing their role into the examination of the newborn baby. The major benefit cited was improved job satisfaction, which was directly related to their ability to give continuity and total care to mothers and babies. Midwives also perceived that undertaking the examination strengthened their position as autonomous practitioners, by enabling them to provide total care to mothers and babies who fitted their criteria of normality. Moreover, midwives thought that improvements in the overall quality of care to mothers would result from them performing the examination, including improved communication, greater continuity of care and a more holistic examination. Although midwives were concerned about possible increase in workloads and pressure to take on new roles, the examination was generally perceived as being easily incorporated into their current practice without compromising overall standards in midwifery care. Midwives expressed concern about 'extending' practice into areas that did not fit their perceptions of normality and about being 'pressurised' into taking on new roles. IMPLICATIONS FOR PRACTICE: it would appear from this study that an important consideration for midwives in their acceptance of new roles, is the relationship of that role to their position as experts in normality. Midwives in this study viewed the examination of the newborn baby as 'fitting in' with their perceptions of the core values of midwifery.     

A randomised controlled trial of maternal satisfaction with the routine examination of the newborn baby at three months post birth

OBJECTIVE: to determine whether any differences in maternal satisfaction with the examination of a newborn baby between midwives and junior paediatricians are maintained over a three-month period. DESIGN, SETTING AND PARTICIPANTS: randomised controlled trial. Eight hundred and twenty-six mother and baby pairs in a district general hospital in South East England were randomised to a junior paediatrician or a midwife for the routine examination. Four hundred and eighty-six mothers completed a maternal satisfaction questionnaire on day-one and again three-months later. Maternal satisfaction with the examination was analysed in relation to randomised group, process and background variables. FINDINGS: high satisfaction with the examination was reported by most mothers (day-one: 82%; three-months: 79%). At day-one, mothers whose babies were examined by a midwife were more satisfied with the examination (crude odds ratio (OR) for the lowest tertile of satisfaction 0.49, 95% CI 0.32-0.73). However, after controlling for provision of health education during the examination (e.g. discussing feeding, sleeping and skin care) and continuity of care provided, maternal satisfaction was no longer related to status of examiner (adjusted OR 0.83, 95% CI 0.52-1.33). Three months later, there was no significant difference in maternal satisfaction with midwife and junior paediatrician examinations of the newborn baby (crude OR 0.89, 95% CI 0.58-1.37). Discussion of health-care issues by the examiner during the examination was significantly related to increased satisfaction even at three-months. Three month ratings of low satisfaction with the examination were most strongly predicted by current maternal depressive mood, even when other factors were adjusted for (adjusted OR 2.58, 95% CI 1.19-5.59). KEY CONCLUSIONS: from the mother's perspective, the quality of midwife examination is at least as satisfactory as that of junior paediatricians and this perception is maintained over a three-month period. Satisfaction can be significantly enhanced if the examiner provides information on behavioural and health-care issues. The examination of the newborn baby provides an important window of opportunity for sharing information on newborn behaviour and care issues.     

A qualitative study exploring junior paediatricians', midwives', GPs' and mothers' experiences and views of the examination of the newborn baby

OBJECTIVE: to explore the experiences and attitudes of midwives, junior paediatricians (SHOs), GPs, and mothers to the examination of the newborn baby. To provide an appreciation of their views on several issues, in particular the purpose and value of the examination, who is thought to be appropriate to carry it out and when and where it should take place. DESIGN: qualitative using semi-structured interviews, which were exploratory and interactive, in order to examine the range and diversity of experiences and attitudes to the neonatal examination. SETTING: South-east England. PARTICIPANTS: four samples were purposefully selected to include ten each of midwives, SHOs, GPs and recently delivered mothers. SHOs were currently working in paediatric departments of a district general hospital or teaching hospital and their experience of conducting examinations of the newborn baby ranged from several months to several years. Midwives included both those trained in the examination and currently conducting examinations, and those not so trained and not carrying out the examination. Most of the midwives had been qualified for over ten years and had a wide range of clinical experience in hospital and community settings. The GPs were from ten practices in two Health Authorities and all had some experience of conducting neonatal examinations. Of the mothers, a few had had their babies examined at home by midwives, others in hospital by an SHO. Mothers included those with a family history of problems relevant to the examination, those with previous pregnancy complications and others with no problems or complications. Some were first-time mothers. FINDINGS: all groups perceived the examination to be a useful screening tool providing reassurance to parents. They considered both midwives and SHOs to be appropriate professionals to carry out the examination, if adequately trained. Most thought that midwives have a better rapport with mothers, are able to provide continuity of care and more often discuss health-care issues than do SHOs. Few SHOs reported receiving any formal training in the examination of the newborn baby. IMPLICATIONS FOR PRACTICE: the extension of the practice of midwives examining the newborn baby following relevant training would be acceptable to all stakeholders. The implications of increased demands on the midwives' workload may need to be considered.     

A Scottish study of heel-prick blood sampling in newborn babies

OBJECTIVE: to conduct a randomised-controlled trial to investigate the effectiveness of two heel-prick devices (Tenderfoot and Genie Lancet) used in the newborn-baby screening test. DESIGN: a randomised-controlled trial. PARTICIPANTS AND SETTING: the homes of 340 healthy term newborn babies discharged from the maternity unit of Stirling Royal Infirmary, Scotland. Data were collected between April and November 2003. INTERVENTIONS: babies were randomly allocated to be tested with either the Tenderfoot or Genie Lancet heel-prick device. MEASUREMENTS: primary study outcomes include (1) quality of the blood sample; (2) time taken to collect the sample; (3) number of heel pricks required to take the sample; (4) whether squeezing of heel was required; (5) pain expressed by the baby; and (6) presence of bruising. A potential intervening variable was the experience of the midwife. FINDINGS: on all outcomes, the Tenderfoot device was more effective than the Genie Lancet. Experienced midwives were more efficient in sample collection. KEY CONCLUSIONS: this study shows that the Tenderfoot device saves significant time for midwifery staff, improves baby care and reduces the need for more than one heel prick at each test, making it superior to the Genie Lancet device. IMPLICATIONS FOR PRACTICE: there is a case to be made for midwives to be issued with the Tenderfoot device for neonatal screening.     

An evaluation by focus group and survey of a course for Midwifery Ventouse Practitioners

OBJECTIVE: to evaluate the Midwifery Ventouse Practitioners' (MVPs) Course and the MVPs' perception of its effect on their practice. DESIGN: qualitative and quantitative. PARTICIPANTS: 18 midwives who had completed the MVP course at Bournemouth University 1998-2000. DATA COLLECTION: focus group (n=8) and postal questionnaire (n=18). FINDINGS: important issues were identified by the focus group and informed the development of the questionnaire which achieved a 100% response rate. The mean length of full-time experience as a midwife was 18.6 years (SD 6.8; range 9-33); 11 midwives were based in community maternity units and seven in consultant units. Seventeen of the MVPs had been called to assist 505 women in this capacity; 366 (72%) had an MVP ventouse-assisted birth, 129 (26%) a normal birth and 10 women (2%) needed obstetric assistance. In this regard, there were considerable differences between individual MVPs. The midwives gave high priority to woman-centred values and to the very judicious use of intervention. They felt that the course had increased their confidence in relation to their midwifery practice, in general, and their ability to define fetal position and station, in particular. They reported a high level of confidence when undertaking their first ventouse birth after completing the course. KEY CONCLUSIONS AND IMPLICATIONS: midwives who have undertaken this course do not appear to expand their role to the detriment of normal midwifery, as had been feared. Even highly experienced midwives value increasing their confidence in relation to vaginal and abdominal examination. Ambulance transfer in the second stage of labour was prevented for at least 109 women. A long-term clinical evaluation of the births to which an MVP has been called is needed.     

More than a midwife? Supervision of extended roles

This model of care completes the holistic family-centred approach to care of a woman and her baby. Powys women benefit from a known carer not only through the pregnancy experience, but also they have their known midwife as the key professional to undertake the hearing assessment and newborn examination of their baby. The newborn examination and hearing screening is incorporated into the community postnatal care package and reduces the fragmented approach of a variety of professionals. Performing these procedures within the woman's home creates an opportunity for communication that encourages and promotes the public health arena (Davies, 2000). Public health is a natural area for midwives who are educated to recognize clinical deviations, but their perspective is also long term and preventative (Kaufmann, 2002). Statutory supervision has worked in partnership with midwives in an open and transparent approach. Support and guidance is provided to undertake these extending responsibilities, while also meeting the key purpose of midwifery supervision, which is to encourage safe and competent midwifery (Health Professions Wales, 2005).     

The effect of the developing role of the maternity support worker on the professional accountability of the midwife

The recent rise in the number of maternity support workers (MSWs) in the United Kingdom (UK) has been welcomed by midwifery managers and supported by social policy surrounding improvements in maternity care. The training and role of the MSW varies considerably. Whilst most training is undertaken through clinical practice, more recent advances in the preparation of MSWs have resulted in them not only being trained to National Vocational Qualification (NVQ) Level 3, but also to foundation certificate or degree level. Consequently some MSWs are performing tasks that would traditionally be undertaken by a midwife, potentially leading to the erosion of the midwife's role in the future. From current evidence, midwives are not fully aware of how the developing role of MSWs may affect their own professional accountability. This paper therefore aims to challenge midwives into reconsidering how MSWs may be effectively incorporated into the midwifery team such that the quality of care is not compromised and the midwife's professional accountability is never put at risk.     

One-to-one midwifery care at the Wessex Maternity Centre

Independent midwifery practice can offer women greater choice, flexibility and more personalised care than may be available in NHS maternity units. The Wessex Maternity Centre offers continuity of care through paired caseloading by midwives. If women need to go into hospital, there is an arrangement whereby their midwife goes with them and continues to provide care in hospital. 50% of clients at the Centre are primiparae. The Centre's midwives have their own clinical protocols based on up-to-date research and practice.     

An ethnographic study of women's experience of partnership caseload midwifery practice: the professional as a friend

OBJECTIVES: To explore the experience of a known midwife for labour and birth as provided through the partnership caseload model of care in women who had a previous baby under an alternative system of care. DESIGN: A qualitative study using an ethnographic approach. Data were collected by tape-recorded interviews. SETTING: The maternity unit at Leicester Royal Infirmary NHS Trust, Leicester, UK in 1998. PARTICIPANTS: 10 multiparous women cared for by Birth Under Midwifery Practice Scheme (BUMPS) midwives were interviewed between eight- and 12 weeks' postpartum. KEY FINDINGS: Women's perceptions and experiences were predominantly influenced by the relationships they had with their midwives who they described as 'friends'. All other themes were filtered through these relationships, including previous negative experiences of maternity care, the valuing of a known midwife for labour and birth, their positive birth experiences, expressions of delight at their care, their liking of home antenatal care, and the appreciation of their existing children and partners meeting their midwives. IMPLICATIONS FOR PRACTICE: Partnership caseload midwifery practice has significant positive impact on women's experience of childbirth. The midwife/woman relationship that has evolved in this context is highly valued by women and challenges traditional professional roles. The model should be explored in other settings to see if its benefits to women are transferable.     

A randomised-controlled trial in England of a postnatal midwifery intervention on breast-feeding duration

OBJECTIVE: To determine whether postnatal 'hands off' care by midwives on positioning and attachment of the newborn baby improves breast-feeding duration. DESIGN: Mothers were randomised at the first postnatal feed to receive either care by a midwife trained in the experimental protocol or by a control midwife undertaking routine care. SETTING: Eight wards in four English Midlands hospitals. PARTICIPANTS: 370 primiparous mothers with term babies who intended to breast feed, and could sit out of bed to do so. INTERVENTIONS: Experimental protocol of verbal-only advice on positioning and attachment, delivered at the first postnatal ward feed compared with routine care by a qualified midwife. MAIN OUTCOME MEASURES: Duration of breast feeding up to 17 weeks as assessed by diaries and interviews with mothers and protocol adherence from self-completed checklist by the midwife. The mothers' self-reported experience of care and support before, during and after delivery were assessed at 6 weeks, and feeding outcomes and employment status at 17 weeks. FINDINGS: Experimental group mothers more often held the baby across their lap and received 'hands off advice', but fewer babies in the experimental than control groups attached and fed: 59% (106/180) vs. 67% (118/175), p=0.1. No significant differences were found in the numbers of mothers breast feeding at 6 or 17 weeks in the experimental and control groups (stopped exclusive breast feeding: 76% (130/172) vs. 77% (126/163) at 6 weeks; 96% (167/174) vs. 96% (161/168) at 17 weeks; odds ratio 1.02, 95% CI 0.77 to 1.22; p=0.8; stopped any breast feeding: 35% (61/172) vs. 32% (53/167) at 6 weeks; 63% (109/173) vs. 60% (101/167) at 17 weeks; odds ratio 1.10, 0.84 to 1.45; p=0.5). There were no significant differences in the incidence of problems with breast feeding and care experienced by mothers before or during hospitalisation (other than at the first postnatal ward feed), nor after discharge home. CONCLUSIONS: No significant beneficial effect was found on breast-feeding duration of the verbal- only advice on positioning and attachment, perhaps because aspects of the intervention are already within routine UK practice. Other care practices at subsequent feeds may negate benefits of care at earlier feeds. 'Hands off' care at the first feed may be less important to subsequent feeding than achieving a first feed under supervision in the postnatal ward. IMPLICATIONS FOR PRACTICE: Midwives can be trained in a 4-hr workshop to achieve improved knowledge of 'hands off' positioning and attachment care, and these can be translated into clinical practice. Future studies should differentiate the elements of the care that are effective in achieving postnatal feeds, and apply this advice consistently at successive feeds.     

Treatment of umbilical cords: a randomised trial to assess the effect of treatment methods on the work of midwives

The national code of practice for midwives practising in England and Wales defines duties during the postnatal period for the care of mothers and their babies. This period is a minimum of 10 days, and up to 28 days. Visits after the 10th day are at midwives' discretion, but a survey of heads of midwifery services suggests that most midwives would extend postnatal care beyond the 10th day if the baby's umbilicus was not healed. Methods used for routine treatment of the umbilical cord in the newborn babies vary widely. Previous studies suggest that the rate of healing depends on the treatment method used. This, in turn, can affect the workload of midwives responsible for the care of newborn babies. Babies born in the Royal Berkshire Hospital in the summer of 1984 were allocated at random to have their cords treated by one of four dusting powders, one of three cleansing methods and one of two frequencies of treatment, in a trial with a factorial design. The effect of treatment on the time to separation of the cord and the number of midwives' visits was estimated. It was found that the treatment method used could significantly affect the healing process and therefore the number of visits made by midwives after the 10th day, and that the choice of cord powder could significantly affect the midwifery workload in the district. The difference would be enough to account for the work of one whole-time equivalent community midwife for every 3000–5000 births.     

A Survey of Midwives in Quebec: What are Their Similarities and Differences?

Background: Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec. Methods: Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession. Results: Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs. Conclusions: Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.     

Labour and delivery routines in English consultant maternity units

A survey of midwifery policies in English Health Districts shows that consultant maternity units vary in the extent to which aspects of care during labour and at delivery come within the scope of unit policies. In addition, the details of policies vary considerably, to the extent that a midwife moving from one maternity unit to another might find herself dealing with a policy that was diametrically opposed to that in the unit from which she had come. The implications of these variations are discussed.     

Midwives’ experiences as preceptors and the development of good preceptorships in obstetric units

ObjectiveTo study midwives’ experience in their role as a preceptor and their perception on how to best support midwifery students in obstetrics units. Obstetric units are an important learning area for student midwives but knowledge on how to become a good midwife preceptor is limited.DesignThis qualitative study explores midwife preceptors’ experience of supervising midwifery students in three obstetric units in Sweden. Following ethical approval seventeen midwife preceptors were interviewed and data were analysed thematically.FindingsThematic analysis of the interviews resulted in the identification of two themes and five subthemes: (1) self-efficacy in the preceptor role which involves (a) being confident in the professional position and (b) having the support of management and colleagues and (2) supporting the student to attain self-confidence and independence which entails (a) helping the student to grow, (b) facilitating reflection in learning situations, and (c) “taking a step back”.Key conclusionGood preceptorship occurs when midwives achieve full self-efficacy, when they master the preceptor role, and when they have enhanced their abilities to help, the student reach confidence and independence.Implications for practiceHealth care organisations needs to develop and support midwifery preceptorships.     

The Experience of Pregnancy and Birth with Midwives: Results from the Canadian Maternity Experiences Survey

Abstract: Background: In Canada maternity care is publicly funded, and although women may choose their care providers, choices may be limited. The purpose of this study was to compare perceptions of maternity outcomes and experiences of those who received care from midwives with those who received care from other providers. Methods: Based on the 2006 Canadian census, a random sample of women (n = 6,421) who had recently given birth in Canada completed a computer‐assisted telephone interview for the Maternity Experiences Survey. The sample was stratified according to province or territory where birth occurred, age, rural or urban residence, and presence of other children in the home. Those who were 15 years of age and older, gave birth to a singleton baby, and were living with their infant were eligible for inclusion. Results: Women whose primary prenatal providers were midwives had fewer ultrasounds and were more likely to attend prenatal classes and have at least five or more prenatal visits. They were also more likely to rate satisfaction with their maternity experience as “very positive” and be satisfied with information provided on a variety of pregnancy and birth topics if their primary prenatal provider was a midwife. They were almost half as likely to experience induction and 7.33 times more likely to experience a medication‐free delivery. They were more likely to initiate and maintain breastfeeding at 3 and 6 months. Conclusions: Evidence shows that midwifery outcomes and levels of satisfaction meet or exceed Canadian maternity care standards. Facilitation of the continuing integration of midwives as autonomous practitioners throughout Canada is recommended. (BIRTH 38:3 September 2011)     

Vorgehen bei Verdacht auf Kindestötung

Since 1^st April 1998 infanticide is categorized under §213 StGB (Penal code: less serious case of manslaughter). Mothers who kill their newborn babies are mostly young woman living either alone or at their parent’s house. Commonly the existence of the pregnancy is denied or blocked out the whole time. In cases of suspected infanticide the subject matter of forensic examination is the newborn baby as the object of a crime. The examination of a suspected woman after birth and also the diagnosis of a suppressed pregnancy should always be performed by a gynecologist. A concluding assessment of the medical findings and/or possible injuries should result from cooperation with a forensic medical expert if necessary.     

Perceptions of nearly graduated fourth year midwifery students regarding a ‘good midwife’ in the Netherlands

ObjectiveMidwifery students have the challenge to learn to be autonomous and capable midwives to ensure a safe and emotionally satisfying experience for mothers (to be) and their babies. They have to develop and acquire knowledge and skills for practice, and they have to adopt and internalize the values and norms of the midwifery profession in order to socialize as a midwife.In this study we explored conceptualisations of ‘good midwives’ among nearly graduated final year midwifery students as a result of their professional socialization process.DesignA cross-sectional study consisting of an one open-ended question was undertaken. Data was analyzed qualitatively, inductively and deductively by using Halldorsdottir’s theory of the primacy of a good midwife.SettingOne of three midwifery academies in the Netherlands in July 2016 were included.ParticipantsAll midwifery students (N=67) in their final year were included.FindingsStudent midwives gave broad interpretations of the features of a good midwife. Three themes - next to the themes already conceptualised by Halldorsdottir - were revealed and mentioned by nearly graduated Dutch midwifery students. They added that a good midwife has to have specific personal characteristics, organizational competences, and has to promote physiological reproductive processes in midwifery care.Key ConclusionsStudents’ views are broad and deep, reflecting the values they take with them to real midwifery practice. The results of this study can serve as an indicator of the level of professional socialization into the midwifery profession and highlight areas in which changes and improvements to the educational program can be made.     

The experiences of midwives in integrated maternity care: A qualitative metasynthesis

ObjectivesTo conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice.DesignA qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice.Sample and SettingParticipants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner.FindingsThree overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down.Key conclusionsThe findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women.Implications for practiceIntegrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.     

Creating Guardians of Physiologic Birth: The Development of an Educational Initiative for Student Midwives in the Netherlands

Women want positive birth experiences with high quality maternity care that is neither too much, too soon, nor too little, too late. Research confirms the effectiveness of midwifery care, and the midwifery approach to birth as physiologic may counter the upward trend of the unnecessary medicalization of birth. The role of guardian of physiologic birth is seen as central to midwifery practice; however, medical hegemony has led to the subordination of midwives, which inhibits them in fulfilling the role as guardian of physiologic birth. Learning to become powerful advocates of physiologic birth creates midwives able to speak up for effective, evidence‐based maternity care and challenge the unnecessary use of obstetric intervention. Midwifery education has a role to fulfil in molding midwives who are able to assume this role. This brief report describes the development of an educational prototype aimed at increasing student midwife agency as an advocate of physiologic birth. This was done using rapid prototyping (RP) methodology, in which important stakeholders gave input and feedback during the educational design and development process. Input from stakeholders led to the inclusion of persuasive communication strategies and discussion and debate as teaching methodologies in order to increase student midwife agency to argue for physiologic birth. Reflective evidence‐based practice, using the Optimality Index‐Netherlands, allowed students to reflect on their practice while providing a framework for discussion. Working with the RP methodology allowed for the development of a prototype that reflected the needs of midwifery stakeholders and was mindful of material and human resources.     

Applicants to A Nurse‐Midwifery Education Program Disclose Factors that Influence Their Career Choice

The purpose of this study was to explore the factors that influenced nurses to choose midwifery as a career path. Forty‐two application essays to the Frontier School of Midwifery and Family Nursing were reviewed. Content analysis was used to identify themes and to explore motivational factors. Six themes concerning motivation to become a midwife were identified. These included personal birth experience, love of maternity nursing, seeing midwifery as a calling, encouragement from others (especially midwives), an epiphany moment, and using nursing as a stepping stone to midwifery. The six themes were seen in more than 20% of the application essays. Several potential recruitment strategies stem from these themes, especially the importance of nurse‐midwives'encouragement of others to pursue a midwifery career.