What is a good midwife? Insights from the literature

Objective

to review the literature around what is considered to be a good midwife and in particular what women value in a midwife, in order to identify the gaps in the evidence for future research.

Design

this paper reviews the research in the area of interest over the past 30 years. The literature search focused on the concept of good midwife using synonyms and antonyms. The inclusion criteria included language (English or Italian). The examined databases were Medline, Maternity and Infant Care, Applied Social Sciences Index and Abstract and CINAHL.

Setting

studies conducted in high-income countries were taken into account. A focused review of papers which explicitly investigated what a good midwife means and a thematic analysis on what women value in a midwife were carried out.

Participants

different standpoints have been considered (midwives, student midwives, women and their partners), focusing in particular on women viewpoint.

Findings

the literature review reveals information about what is considered to be a good midwife from a range of perspectives and what women value in a midwife. A good midwife should possess several attributes: theoretical knowledge, professional competencies, personal qualities, communication skills and moral/ethical values. According to the thematic analysis around what childbearing women value in a midwife, frequent key-themes emerging from the literature were: support, possibility of choice, feeling in control and having appropriate information.

Key conclusions

the meaning of good midwife might change according to different actors involved in midwifery care and there is no agreement on the definition of what constitutes a good midwife. Furthermore, it is not clear if what women value in a good midwife corresponds to the midwives' perception of themselves as good professionals. There is a dearth of information around women's expectations and experiences specifically of a good midwife, and even less around whether this changes according to where they give birth.

Implications for practice

this literature review seeks to stimulate debate and reflection among midwives and professionals involved in the childbearing event, in order to fulfil women's expectations of their midwife and increase their satisfaction with the birth experience. The identification of the gaps in the evidence provided the starting point and allowed the development of research questions and methodology for an ongoing doctoral research. On the basis of the gaps in the evidence, the doctoral research will explore and seek to explain nulliparous women's expectations and experiences of a good midwife in the context of different planned place of birth, using a Grounded Theory methodology. It is also expected that the findings of this literature review will stimulate additional research in this area to ultimately inform midwifery practice and midwifery educational programmes.     

The longitudinal effects of midwife‐led postnatal debriefing on the psychological health of mothers

Pain has been shown to be invested with a multiplicity of meanings. This applies to labour pain as much as to any other. The meanings of pain in general and of labour pain in particular are examined in terms of religion, philosophy, spirituality, biology and culture. The possibility of the existence of political meanings is considered. An attempt is made to distinguish the meaning of labour pain for the carers and for the woman. The possibility that searching for meaning serves as a coping mechanism is explored. The argument is advanced that an understanding of the meaning of labour pain to the woman in labour is a fundamental prerequisite if the midwife is to facilitate the woman's achievement of a satisfying birth experience.     

Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital

Objectiveto evaluate mothers’ satisfaction with a caseload-midwifery scheme, and whether this varied according to the extent of continuity of care provided.Designmothers’ satisfaction with care was assessed using a postal survey, which was linked with their clinical outcomes data.Settingthe Wollongong Hospital, the major public hospital in the Illawarra region, New South Wales, Australia.Participants174 women gave birth during the evaluation period of a pilot midwifery group practice (MGP) programme at the Wollongong Hospital between 5 July 2004 and 30 April 2005. This group included 87 primiparous and 87 multiparous women, all of whom met the Australian College of Midwives’ criteria for low-risk pregnancies.Interventionthe MGP was staffed by six midwives working in two groups of three. Each midwife took on a primary caseload of 40 women per year, and provided support as a secondary midwife to women cared for by colleagues.Measurementsmothers’ satisfaction with care and adjustment to motherhood were assessed with self-completed questionnaires. Survey responses were linked with clinical data, allowing examination of the relationship between maternal satisfaction and continuity of care.Findingsthe MGP achieved high levels of continuity of care, both objectively (based on birth records) and from mothers’ perspectives. Overall, mothers’ evaluations of their care were very positive. Women indicated that their relationships with their midwives were genuinely caring and a valued source of reassurance and comfort during pregnancy, labour and early motherhood. Although continuity of care did not predict summary scores for maternal satisfaction, it was related to some individual items on the satisfaction scales. Satisfaction with control and communication was predicted by parity and the level of intervention during labour and birth.Key conclusionscontinuous care appears to facilitate the development of supportive relationships between women and their midwives. Women's perceptions about continuous and respectful treatment were related to objectively measured continuity of care. The qualitative data confirm the importance of less tangible benefits, such as the quality of relationships between women and their caregivers.Implications for practicethe viability of caseload-midwifery-led care for low-risk pregnancies depends, in part, on the model's acceptability to consumers. This study demonstrated that the caseload model is associated with high levels of maternal satisfaction. Supportive relationships with midwives in a caseload scheme are highly valued by women.     

Supporting breast-feeding women from the perspective of the midwife: A systematic review of the literature

IntroductionIn 2003 the World Health Organization (WHO) recommended that infants should be fed exclusively with breast milk until the age of six months. However, breast feeding rates remain lower than recommended. The crucial period for breast feeding support is the first two weeks after birth. During this period breast feeding support from the midwife is needed. The aim of this paper is to gain an in-depth understanding of the role of midwives in their support of breast-feeding women, from their own perspective.MethodsTwo researchers independently conducted a systematic and comprehensive literature search. Studies needed an empirical qualitative research design (1), had to focus on the role of the midwife in the support of the breast-feeding woman from the midwife’s perspective (2), and had to be published between January 2005 and December 2014 (3) in order to be included. Language restrictions were English, Dutch, German and French. Eight qualitative research studies were included, using mainly focus group and in-depth interview studies, which were reported in 11 papers representing 231 midwives and 24 maternity nurses. All but one study concerned midwives working in hospital settings. A critical appraisal was performed of each study.FindingsMidwives value breast feeding education and breast feeding support as a significant part of their role as a postnatal midwife. However, the ways in which a midwife approaches and supports the breast-feeding woman vary. We distinguished two perspectives: ‘the midwife as technical expert’ and ‘the midwife as a skilled companion’. The ‘technical expert’ midwife is mainly breast centred, focuses on techniques, uses the hands on approach and sees a woman as a novice. The ‘skilled companion’ midwife is woman centred, focuses on the mother – infant relationship and uses a hands off approach during the breast feeding support.The midwives working in a hospital setting face many barriers when performing breast feeding support, such as time restraints, which makes it difficult for them to carry out their preferred role as a ‘skilled companion’. These barriers can influence the breast feeding support negatively. Supporting factors, such as evidence based breast feeding guidelines, have a positive influence on the breast feeding support.ConclusionOn the basis of findings of a synthesis of qualitative research studies, we conclude that the majority of the midwives provide breast feeding support as a technical expert and a minority as a skilled companion. Midwives prefer to be a skilled companion but face many barriers in their working contexts.     

All that I need exists within me: A qualitative study of nulliparous Norwegian women's experiences with planned home birth

ObjectiveThe aim of this study was to gain knowledge regarding how Norwegian nulliparous women experience planned home birth and why they choose this route of giving birth.DesignA qualitative approach was used, and the study data were derived from semi-structured individual interviews, which were analysed through systematic text condensation.ParticipantsTen Norwegian women aged nineteen to thirty-nine years were interviewed. They had each gone through with a successful planned home birth of their first child within the last two years. These women all resided in the middle, western and eastern areas of Norway. A certified midwife was present throughout the labour and birth, and no transfer to the hospital was necessary.FindingsThe following two main themes were identified: ‘inner motivation’ and ‘giving birth in safe surroundings’. The women in this study had a strong inner faith in the normal physiological processes of labour and birth and had educated and prepared themselves carefully for their planned home birth. To be able to enter one's own inner world was considered crucial for labour, and the trusting relationship they had with their midwife made this possible.Key conclusions and implications for practicePlanned home birth may be experienced as a very positive occurrence for nulliparous women, and the care those women in this study received contained several elements that can help to promote normal labour and birth at a time in which reducing interventions in maternity care is of importance. Their positive birth experiences gave the women confidence both in their transition to motherhood as well as in other aspects of life.     

Going back to work after childbirth: women’s lived experiences

Objective: The study aimed at understanding the experiences of first-time mothers who returned to work after paid maternity leave. It explored the challenges new mothers faced during the transition of having a baby, taking 14 weeks of paid maternity leave and then returning to work. Background: Traditionally women left paid employment and stayed at home while their children were still young, but recent times have seen a change in local women’s labour force participation and the actual lived experiences of Maltese women in the context of transition to parenthood had not been explored. Society still seems to expect that the idea of balancing work and family life is principally a women’s issue as traditional gender roles still appear to prevail. Methods: The qualitative paradigm was used to conduct the study by means of a semi-structured interview schedule at three different phases throughout the experience. Ten women were chosen to participate in this study by purposive sampling. The theoretical framework used to guide this thesis included phenomenology, transitional theory as described by van Gennep and feminism. Interpretative phenomenological analysis was used during the analysing phase. Results: The resulting three super-ordinate themes identified how after childbirth maternity leave is ‘a time of preparation and planning ahead’ followed by a period when ‘lightening strikes on rejoining the workforce’ and ‘weathering the storm’ via an attempt to balance work and family life. Conclusion: Findings showed that while society encourages mothers to return to work after the birth of their children, few attempts have actually been made to support them during this delicate transition. This study identified the need to improve local policy with regards to family-friendly measures and the importance of an increase in local maternity leave duration. Moreover, the midwife was identified as an important figure that can help empower mothers and prepare them for what is yet to come.     

Autonomous and dependent–The dichotomy of birth: A feminist analysis of birth plans in Sweden

ObjectiveTo elicit pregnant women's perceptions of childbirth as expressed in their birth plans, and through a feminist lens analyse their wishes, fears, values, and beliefs about childbirth, as well as their expectations on partner and midwife.DesignThis study used qualitative content analysis, identifying subcategories, categories, and an overall theme in data gathered from women's written birth plans. A feminist theoretical framework underpinned the research.SettingA middle-sized city in northern Sweden.Participants132 women who gave birth in an obstetrician-led hospital labour ward between March and June 2016 and consented to grant access to their birth plans and antenatal and intrapartum electronic medical records.FindingsThree categories emerged: ‘Keeping integrity intact through specific requests and continuous dialogue with the midwife', ‘A preference towards a midwife-supported birth regardless of method of pain relief", and ‘"Help my partner help me" - Women anticipating partner involvement.' The overall theme linking the categories together was: ‘Autonomous and dependent - The dichotomy of birth', portraying women's ambiguity before birth -expressing a wish to remain in control while simultaneously letting go of control by entrusting partner and midwifewith decision-making regarding their own bodies.Key conclusions and implications for practiceWomen primarily desired a natural, midwife-supported birth and favoured a relationship-based, woman-centred model of care, based on the close interaction between woman, partner, and midwife. Midwives need to be aware of women's ambiguous reliance on them and the power they have to influence women's birth choices and birth experiences. Feminist theory and values in midwifery practice may be useful to inspire a maternity care based on women's wishes and expectations, acknowledging and valuing women's voices, and embracing the sanctity of birth and of the birthing woman's body.     

‘Reacting to the unknown’: experiencing the first birth at home or in hospital in Australia

Objective

to explore the experiences of a small group of first-time mothers giving birth at home or in hospital.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave birth for the first time in a public hospital and seven women who gave birth for the first time at home were interviewed, and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Results

these women shared common experiences of giving birth as ‘novices’. Regardless of birth setting, they were all ‘reacting to the unknown’. As they entered labour, the women chose different levels of responsibility for their birth. They also readjusted their expectations when the reality of labour occurred, reacted to the ‘force’ of labour, and connected or disconnected from the labour and eventually the baby.

Implications for practice

knowing that first-time mothers, irrespective of birth setting, are essentially ‘reacting to the unknown’ as they negotiate the experience of birth, could alter the way in which care is provided and increase the sensitivity of midwives to women's needs. Most importantly, midwives need to be aware of the need to help women adjust their expectations during labour and birth. Identifying the ‘novice’ status of first-time mothers also better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing.     

Validation of the Hebrew Birth Satisfaction Scale – Revised (BSS-R) and its relationship to perceived traumatic labour

ABSTRACT

Objective and background: The Birth Satisfaction Scale-Revised (BSS-R) is a multi-dimensional measure which is recommended by international clinical guidelines for global use as the birth satisfaction outcome measure of choice. The current investigation sought to develop a Hebrew version of the BSS-R for use in the Jewish–Israeli context and examine the relationship between BSS-R domains and the perception of the experience of labour as traumatic.

Methods: Following review, translation, and back-translation for linguistic equivalence, a Hebrew version of the BSS-R (H-BSS-R) was prepared and psychometrically evaluated using key indices of validity and reliability. Complete multivariate normal data from 288 first-time Jewish Israeli mothers within two years after childbirth was entered into the analysis.

Results: The H-BSS-R was found to have a good fit to the BSS-R tridimensional measurement model, excellent internal consistency, divergent and known-group discriminant validity. Moreover, women who experienced their labour as traumatic had significantly lower H-BSS-R subscale scores than women who reported that their birth experience was non-traumatic.

Conclusion: The H-BSS-R is a robust and valid measure suitable for use with Jewish–Israeli women, as well as for investigating the relationship between traumatic labour and birth satisfaction.     

Perspectives of Expectant Women and Health Care Providers on Birth Plans

ObjectiveA birth plan is a document detailing a woman's preferences and expectations related to labour and delivery. Empirical research exploring the value of birth plans has shown conflicting findings about whether birth plans have a positive or negative effect on labour and delivery, suggesting a need for further study. This study aimed to understand the perspectives of women, health care providers, and support persons regarding the use of birth plans.MethodsA cross-sectional questionnaire was distributed to a convenience sample of expectant or postpartum women, health care providers, and support persons from January 2012 to March 2012 in British Columbia.ResultsIn total, 122 women and 110 health care providers and support persons completed the questionnaire. Both women and their attendants viewed the birth plan as being valuable for acting as both a communication and education tool. However, the respondents noted that women may be disappointed or dissatisfied if a birth plan cannot be implemented. The most important elements of a birth plan identified included pain management, comfort measures (e.g., mobility during labour), postpartum preferences (e.g., breastfeeding), atmosphere (e.g., privacy), and birthing beliefs (e.g., cultural views).ConclusionThis is the first study to identify advantages and disadvantages of using a birth plan as well as the most important aspects of a birth plan from the perspectives of both women and their attendants in Canada. The findings could be applied to optimize the efficacy of birth plans in Canada and potentially internationally as well.     

Perineal management: Midwives’ confidence and educational needs

ObjectiveThe overall aim of this study was to collate information to inform the updating of a perineal management educational programme for midwives. This paper explores midwives' confidence and educational needs in managing the woman's perineum during the second stage of labour, focusing on future quality initiatives to improve midwives' experiences and expertise in the prevention of perineal trauma during birth.DesignA mixed-methods sequential exploratory design was used.Participants and SettingMidwives and clinical midwife managers assisting with births in the labour ward of a large urban university stand-alone maternity hospital in the Republic of Ireland with approximately 9,000 births per year participated in the study.MeasurementsA questionnaire and two focus groups were used to collect the data.FindingsFifty-two midwives from a total of 64 eligible labour ward midwives completed the questionnaire, a response rate of 81.2%. Midwives indicated that perineal management workshops did not cover prevention of perineal trauma, and mainly focused on suturing and repair of the perineum. The majority of midwives (85%) indicated that they would like further education on the prevention of perineal trauma. Higher levels of confidence in making a decision to perform an episiotomy, infiltrating the perineum and at performing an episiotomy were reported in experienced midwives. Midwives want improved and additional education in the management of women's perinea during the second stage of labour and made various recommendations regarding the content, format, timing and frequency of the workshop. Suggestions for further education included techniques for preventing perineal trauma during labour and birth and how to perform an episiotomy.Key conclusionsThis study provides key insights into midwives' confidence and educational needs in relation to managing the woman's perineum during the second stage of labour. The findings from this study demonstrates the appetite of midwives for additional education in the area of perineal management, particularly prevention strategies.Implications for practiceMidwives play an essential role in reducing the rates of perineal trauma through regular education. It is therefore important that midwives keep up to date with the best available evidence. Updating existing perineal management educational programmes that are tailor made to midwives' needs could not only improve clinical skills and perineal protection techniques but also midwives' confidence in decision making. The overall aim is to reduce perineal trauma in women having a spontaneous vaginal birth.     

The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery

Objectiveto explore whether women allocated to caseload care characterise their midwife differently to those allocated to standard care.Designmulti-site unblinded, randomised, controlled, parallel-group trial.Settingthe study was conducted in two metropolitan teaching hospitals across two Australian cities.Populationwomen of all obstetric risk were eligible to participate. Inclusion criteria were: 18 years or older, less than 24 week’s gestation with a singleton pregnancy. Women already booked with a care provider or planning to have an elective caesarean section were excluded.Interventionsparticipants were randomised to caseload midwifery or standard care. The caseload model provided antenatal, intrapartum and postnatal care from a primary midwife or ‘back-up’ midwife; as well as consultation with obstetric or medical physicians as indicated by national guidelines. The standard model included care from a general practitioner and/or midwives and obstetric doctors.Measurements and findingsparticipants’ responses to open-ended questions were collected through a 6-week postnatal survey and analysed thematically. A total of 1748 women were randomised between December 2008 – May 2011; 871 to caseload midwifery and 877 to standard care. The response rate to the 6-week survey including free text items was 52% (n=901). Respondents from both groups characterised midwives as Informative, Competent and Kind. Participants in the caseload group perceived midwives with additional qualities conceptualised as Empowering and ‘Endorphic’. These concepts highlight some of the active ingredients that moderated or mediated the effects of the midwifery care within the M@NGO trial.Key conclusioncaseload midwifery attracts, motivates and enables midwives to go Above and Beyond such that women feel empowered, nurtured and safe during pregnancy, labour and birth.Implications for practicethe concept of an Endorphic midwife makes a useful contribution to midwifery theory as it enhances our understanding of how the complex intervention of caseload midwifery influences normal birth rates and experiences. Defining personal midwife attributes which are important for caseload models has potential implications for graduate attributes in degree programs leading to registration as a midwife and selection criteria for caseload midwife positions.     

Predictors of Crying Problems in the Early Postpartum Period

ObjectiveTo investigate maternal and infant factors associated with midwife-reported crying problems in the early postpartum period.DesignCase control study.SettingPostnatal home care in Switzerland.ParticipantsSeven thousand seven hundred and sixty-five mother/child dyads who received postnatal homecare by midwives (n=1,636 cases of midwife-reported crying problems, n=6,129 controls).MethodsWe investigated factors associated with infant crying problems during the postpartum period as documented in the Statistical Database of Independent Midwives' Services in Switzerland (2007). Using case control methodology, we matched all identified cases of crying problems with controls who had been cared for by the same midwife. A conditional logistic regression model was used to analyze the associations of reported crying problems with maternal and infant factors.ResultsMaternal health and mood problems in the immediate postpartum period were significantly associated with reported crying problems. Maternal health and mood problems included physical complications after birth, psychological decompensation, and depression. Further risk factors for infant crying problems were planned resumption of paid work directly after paid maternity leave (at 15–16 weeks postpartum) and immigrant status. A protective effect was observed for higher parity.ConclusionsCrying problems in the early postpartum period are associated with mothers' physical, psychological, and social conditions. Care practices that promote new mothers' physical and psychological recovery after birth could be a promising strategy to prevent early crying problems. Specific support is important for mothers with early signs of depression or decompensation, intention to return early to paid work, immigrant background, and for first-time mothers.     

Management of the third stage of labour—focus group discussions with Swedish midwives

Objectiveto explore Swedish midwives’ experiences of management of third stage of labour.Designsix focus group discussions were performed and the analysis was based on content analysis.Settingthe midwives worked at six hospitals: three university hospitals and three provincial hospitals located from the south west to the north of Sweden.Participants32 midwives with extensive experience of assisting women in childbirth.Findingsthe analysis generated three categories: ‘bring the process under control’, ‘protect normality and women's birthing experiences’ and ‘maintain midwives’ autonomy’. This study demonstrates that management of the third stage of labour varies greatly. Not all midwives were convinced that administration of prophylactic oxytocin in the third stage of labour was always the best alternative for all women who had a normal birth.Key conclusions and implications for practicethe midwives exhibited self-confidence in evaluating the physiological process, and endeavoured to leave the physiological process undisturbed if no other risks were apparent. Their decisions concerning third stage management were based on a combination of previous experience, hospital guidelines, risk assessment and sensitivity to each woman's needs. This study demonstrates that management of the third stage of labour varies greatly. The findings show the importance of reaching a balance between treating birth as a normal process and as a biomedical event.     

Assessing fetal growth impairments based on family data as a tool for identifying high-risk babies. An example with neonatal mortality

Background

Non-progressive labour is the most common complication in nulliparas and is primarily treated by augmentation. Augmented labour is often terminated by instrumental delivery. Little qualitative research has addressed experiences of non-progressive and augmented deliveries. The aim of this study was to gain a deeper understanding of the experience of non-progressive and augmented labour among nulliparas and their experience of the care they received.

Methods

A qualitative study was conducted using individual interviews. Data was collected and analysed according to the Grounded Theory method. The participants were a purposive sample of ten women. The interviews were conducted 4–15 weeks after delivery.

Results

The women had contrasting experiences during the birth process. During labour there was a conflict between the expectation of having a natural delivery and actually having a medical delivery. The women experienced a feeling of separation between mind and body. Interacting with the midwife had a major influence on feelings of losing and regaining control. Reconciliation between the contrasting feelings during labour was achieved. The core category was named Dialectical Birth Process and comprised three categories: Balancing natural and medical delivery, Interacting, Losing and regaining control.

Conclusion

A dialectical process was identified in these women's experiences of non-progressive labour. The process is susceptible to interaction with the midwife; especially her support to the woman's feeling of being in control. Midwives should secure that the woman's recognition of the fact that the labour is non-progressive and augmentation is required is handled with respect for the dialectical process. Augmentation of labour should be managed as close to the course of natural labour and delivery as possible.