Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth

Objectivethis study investigates the self-reported psychosocial health and well-being of obstetricians and midwives in Denmark during the most recent four weeks as well as their recall of their health and well-being immediately following their exposure to a traumatic childbirth.Material and methodsa 2012 national survey of all Danish obstetricians and midwives (n=2098). The response rate was 59% of which 85% (n=1027) stated that they had been involved in a traumatic childbirth. The psychosocial health and well-being of the participants was investigated using six scales from the Copenhagen Psychosocial Questionnaire (COPSOQII). Responses were assessed on six scales: burnout, sleep disorders, general stress, depressive symptoms, somatic stress and cognitive stress. Associations between COPSOQII scales and participant characteristics were analysed using linear regression.Resultsmidwives reported significantly higher scores than obstetricians, to a minor extent during the most recent four weeks and to a greater extent immediately following a traumatic childbirth scale, indicating higher levels of self-reported psychosocial health problems. Sub-group analyses showed that this difference might be gender related. Respondents who had left the labour ward partly or primarily because they felt that the responsibility was too great a burden to carry reported significantly higher scores on all scales in the aftermath of the traumatic birth than did the group who still worked on the labour ward. None of the scales were associated with age or seniority in the time after the traumatic birth indicating that both junior and senior staff may experience similar levels of psychosocial health and well-being in the aftermath.Key conclusions and implicationsthis study shows an association between profession (midwife or obstetrician) and self-reported psychosocial health and well-being both within the most recent four weeks and immediately following a traumatic childbirth. The association may partly be explained by gender. This knowledge may lead to better awareness of the possibility of differences related to profession and gender when conducting debriefings and offering support to HCPs in the aftermath of traumatic childbirth. As many as 85% of the respondents in this national study stated that they had been involved in at least one traumatic childbirth, suggesting that the handling of the aftermath of these events is important when caring for the psychosocial health and well-being of obstetric and midwifery staff.     

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.     

Negotiating credibility: first-time mothers’ experiences of contact with the labour ward before hospitalisation

Objectiveto explore Norwegian nulliparous women's experiences of communication and contact with midwives at the labour ward in the early phase of labour.Designa qualitative study based on in-depth interviews.Participants17 women expecting their first baby.Findingsfour themes that emerged in the collected material seem to be central to how the labouring women decided to make contact with the labour ward and how they experienced this contact with the staff: (a) negotiating on two fronts, (b) avoiding being sent home, (c) searching for regularity, and (d) experiencing vulnerability.Conclusionsthe study shows how women in labour for the first time negotiate their credibility with midwives through the requisite pattern of regularity, and also shows their vulnerability in attempting to avoid being sent home from hospital because it is ‘too soon’ to be admitted. It also argues that the midwifery profession is ambivalent about the paradigm to which it conforms in its contact with women in early labour.Implications for practicethe findings of this study show that the way in which questions are asked in this phase is very important. Midwives should be aware that if they only ask the ‘standard question’ related to the pattern of contraction regularity, they might lose vital information and also deprive the woman of the chance to verbalise her experiences and her needs as she perceives them. If the focus is shifted from the rigid instructions that women are given to an emphasis on the women's actual experiences, the need for negotiation will probably diminish. The task of assessing and evaluating women in early labour need not necessarily be performed inside the ordinary labour ward, but may be done in a more home-like environment outside the hospital or in the woman's home.     

Women’s postnatal psychological functioning: the role of satisfaction with intrapartum care and the birth experience

Objective: To investigate the relationship between women’s postnatal psychological well-being and retrospective, self-reported satisfaction with intrapartum care and the birth experience. Background: The period immediately following childbirth can be marked by various problems that can affect a woman’s happiness and functioning. Previous research has suggested that aspects of the maternal experience of childbirth may act as predictors for specific indicators of women’s postnatal functioning. This study aimed to determine the relationship between satisfaction with labour and birth care and the general childbirth experience and a broad, comprehensive measure of subsequent psychological functioning. Methods: Data for this study was taken from relevant items in the Having a Baby in Queensland 2009 Pilot Survey. Researchers assessed maternal socio-demographic characteristics, perceptions of labour and birth care, satisfaction with labour and birth care, and perceived positivity of the birth experience. A dichotomous, composite measure of postnatal psychological functioning was derived from women’s responses to five separate survey items. Results: The multivariate logistic regression analysis showed that women who felt they were looked after ‘very well’ and women who rated their birth experience as ‘very positive’ were significantly more likely to experience high postnatal functioning than women who did not rate their intrapartum care and birth experience as highly. Conclusions: Reducing the risk factors for dissatisfaction is critical in order to improve the likelihood of high maternal postnatal functioning. The findings of this study emphasise the importance of intrapartum care in the development of positive functioning in women who have recently given birth.     

Project 20: Midwives’ insight into continuity of care models for women with social risk factors: what works,for whom,in what circumstances,and how

IntroductionContinuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems.ObjectiveTo explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women’s outcomes.DesignRealist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London.FindingsThree main themes were identified: ‘Perceptions of the model of care, ‘Tailoring the service to meet women’s needs’, ‘Going above and beyond’. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women’s outcomes, and how women with different social risk factors respond to these mechanisms.Conclusions/implications for practiceOverall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women’s outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.     

Midwives’ experiences of working in an obstetric high dependency unit: A qualitative study

Objectivesto understand the challenges experienced by midwives providing obstetric high dependency care and identify the training they perceive is needed for work in an obstetric high dependency unit.Designsixteen midwives who worked in the obstetric high dependency unit participated in one of three focus groups. Focus groups lasted 60–90 minutes and were conducted in the workplace and facilitated by author (IE). Data were digitally recorded, transcribed and analysed manually by author (IE), specifically using a ‘codebook’ model to generate codes, categories and themes.Settinga purpose built, two-bed obstetric high dependency unit located in the delivery suite of a large, urban tertiary teaching hospital in New Zealand.Findingsfive themes were conceptualised: Theme 1: ‘high dependency care is not our bread and butter’; the midwives felt that working in the obstetric high dependency work did not constitute ‘normal’ midwifery work. Theme 2: ‘we are family… embracing the baby and partner in HDU’; the midwives recognised that an obstetric high dependency unit enabled the mother and infant to be cared for together, was beneficial for maternal psychosocial wellbeing, and supported mother-infant bonding and breastfeeding. Theme 3: ‘primum non nocere; First, do no harm’; the midwives voiced concern that they lacked the skills and training to provide obstetric high dependency care and considered this a potential risk to sick women in their care. Theme 4: ‘graceful swans and headless chickens’; the midwives reported feelings of stress, anxiety, fear and of being overwhelmed by the demands of obstetric high dependency care. The more experienced midwives were able to portray calmness and poise despite lots going on beneath the surface. This was in contrast to other, often less experienced midwives, who appeared confused and less organised. Theme 5: ‘please sir, can I have some more training?’; the midwives unanimously sought training in the provision of obstetric high dependency care and saw facilitation of training to be a responsibility of the hospital.Key conclusionsmidwives who are competent in obstetric high dependency care are well placed to provide holistic care to sick women within an obstetric high dependency unit. Midwives found this work challenging and identified the need for specific knowledge and skills beyond those required in the provision of care to well women. The midwives sought post-registration training in obstetric high dependency care. These findings are consistent with other studies reported in the literature.Implications for practicepost-registration training must be made available to midwives providing high dependency care to sick women to ensure they have the specialised skills and knowledge for practice. Responsibility to facilitate training rests with hospitals providing this service.     

The kaleidoscopic midwife: A conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth. A grounded theory study

BackgroundThe literature review reveals general information about a good midwife from a range of perspectives and what childbearing women generally value in a midwife, but there is a lack of information around mothers’ perspectives of what makes a good midwife specifically during labour and birth, and even less in the context of different places of birth.AimTo conceptualise first-time mothers’ expectations and experiences of a good midwife during childbirth in the context of different birthplaces.DesignQualitative Straussian grounded theory methodology.SettingThree National Health Service Trusts in England providing maternity care that offered women the possibility of giving birth in different settings (home, freestanding midwifery unit and obstetric unit).ParticipantsFourteen first-time mothers in good general health with a straightforward singleton pregnancy anticipating a normal birth.MethodsEthical approval was gained. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos.FindingsThe model named ‘The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers’ perspectives of a good midwife during childbirth’ was developed. The model is dynamic and woman-centred, and is operationalised as the midwife adapts to each woman's individual needs in the context of each specific labour. Four pillars of intrapartum care were identified for a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. The metaphor of a kaleidoscopic figure is used to describe a midwife who is ‘multi-coloured’ and ever changing in the light of the woman's individual needs, expectations and labour journey, in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence.ConclusionThe model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is likely to have an optimum experience of birth. Future research is necessary to tease out individual components of the model in a variety of practice settings.     

The role and outcomes of music listening for women in childbirth: An integrative review

AimTo synthesise primary research on the role and use of music listening for women in childbirth.DesignIntegrative review.MethodsWhittemore and Knafl's (2005) five-stage integrative review method was utilized to complete a systematic search of the literature. Studies were included if they were (a) peer-reviewed, (b) written in the English language, (c) published between 1 January 1979 and 5 April 2019 and (d) described the use of music listening during labour and birth. Studies were appraised for quality and methodological rigor using standardised assessment tools including the Critical Appraisal Skills Programmes (CASP) checklist for the qualitative studies and the Joanna Briggs Institute Critical Appraisal Tool for the quasi-experimental studies and randomised control trials. Data extrapolation, methodological quality assessment and Thematic Content Analysis (Braun and Clarke, 2006) were carried out.FindingsA total of 931 articles were retrieved and 24 papers were included in the review (12 randomized controlled trials, 9 quasi-experimental and 3 qualitative). The quality of the studies was moderately good overall. Two overarching themes emerged including ‘outcomes of using music in childbirth’ and, ‘music application during childbirth’. Within ‘outcomes of using music in childbirth’ four subthemes are described: ‘pain’, ‘anxiety’, ‘psychological supports’ and ‘progression of labour’. Within ‘music application during childbirth’ four themes are presented: ‘timing of the music application’, ‘type of music’, ‘birth preparation using music’ and ‘mode of music listening’.Conclusion and implications for practiceThe findings indicate that music listening has a significant role to play for women in childbirth. This non-pharmacological intervention can reduce pain and anxiety while offering a multifaceted form of psychological support to alleviate stress and promote an increased sense of control in women during labour. However, further awareness is needed around the idiosyncratic nature of the music listening experience.     

Skills-based childbirth preparation reduces stress for midwives

Objectiveto explore the potential benefits of skills-based childbirth preparation on the work related stress levels of midwives.Designa questionnaire was sent out to midwives who had clients participating in an RCT of an education package for childbirth preparation (The Pink Kit (PK) Method for Birthing Better®) delivered to parents.Settingmidwives were in private practice and acted as lead maternity carers to New Zealand first time mothers.Participantsone hundred and four independent midwives participated.Measurementsa brief questionnaire using a Visual Analogue Scale to portray perceptions of work-related stress and a yes/no question about expected and/or unexpected physical complications.Findingsmidwives working with clients in the intervention group experienced less work-related stress after correction for medical complications compared to the two control groups.Key conclusionsworking with mothers who have used a programme that increased their childbirth self-efficacy decreased the work-related stress experienced by midwives.Implications for practiceencouraging pregnant women to develop childbirth skills merits further investigation in an effort to reduce the work-related stress experienced by midwives.     

How are decisions made to access a planned epidural in labour? Midwife-woman interactions in antenatal consultations

ObjectiveThe purpose of this study was to examine the ways in the decision to access a planned epidural in labour was topicalised and negotiated between pregnant women and midwives.DesignThis article uses conversation analysis to examine how decision-making unfolds in antenatal consultations in a large metropolitan hospital in South Australia. Data were sampled from naturally-occurring interactions between women and midwives in routine antenatal consultations. Analysis focused on talk about planning to access (or, avoid) an epidural during an upcoming labour.FindingsThis paper illustrates that in the context of woman-centred care, women are held unilaterally responsible for the decision to accept or reject a planned epidural in labour with little or no input from the midwife. Midwives take a step back from involvement in the discussion beyond the solicitation of a decision from the woman. Women wanting a planned epidural took a strong, assertive stance in the interaction and drew on their previous birthing experience, limiting opportunity for the midwife to engage in meaningful discussion about the risks and benefits. On the other hand, women rejecting a planned epidural were less assertive and engaged in more complex interactional work to account for their decision.Key conclusionsThe lack of involvement by midwives may be linked to the non-directive ethos that prevails in maternity care. It is argued that, in this dataset, the institutional imperative for women to know and decide on pain relief while pregnant in order to allocate to a model of care is prioritised over women's aspirations and expectations of childbirth.Implications for practiceBy analysing the ways in which midwives and women interact at the point in time at which decisions were made to plan access to an epidural we can continue to reveal underlying forces that drive the rising rates of medical interventions in childbirth. This paper also contributes to research evidence on how midwives manage the potentially contradictory dialect between supporting women's childbirth preferences while also managing institutional requirements and evidence-based practice.     

Midwives' experiences of referring obese women to either a community or home-based antenatal weight management service: Implications for service providers and midwifery practice

Objectivea variety of services to support women to undertake weight management behaviours during pregnancy have recently been implemented as a means to reduce the risks to mother and infant. In the UK, midwives lead the care of the majority of pregnant women and are seen as the ideal source of referral into antenatal services. However, midwives have reported concerns regarding raising the topic of weight with obese women and negative referral experiences have been cited as a reason not to engage with a service. This study explored midwives’ experiences of referring women to one of two antenatal weight management services.Designqualitative, cross-sectional interview and focus group study, with data analysed thematically.Settingmidwifery teams in the West Midlands, England.Participantsmidwives responsible for referring to either a home-based, one to one service (N=12), or a community-based, group service (N=11).Findingsfour themes emerged from the data. Participants generally had a positive View of the service, but their Information needs were not fully met, as they wanted more detail about the service and feedback regarding the women they had referred. Approaches to referral differed, with some participants referring all women who met the eligibility criteria, and some offering women a choice to be referred or not. Occasionally the topic was not raised at all when a negative reception was anticipated. Reasons for poor uptake of the services included pragmatic barriers, and their perception of women's lack of interest in weight management.Key conclusionsmidwives’ differing views on choice and gaining agreement to refer means referral practices vary, which could increase the risk that obese women have inequitable access to weight management services. However, midwives’ confidence in the services on offer may be increased with more detailed information about the service and feedback on referrals, which would additionally act as prompts to refer.Implications for practiceweight management services need to improve communication with their referral agents and try to overcome practical and psychosocial barriers to uptake. It would be beneficial to develop a shared understanding of the concept of ‘informed choice’ specifically regarding referral to health promotion services among midwives. Training which demonstrates effective methods of sensitively introducing a weight management service to obese women may increase midwives’ confidence to consistently include this in their practice. These measures may improve women's engagement with services which have the potential to reduce the risks associated with maternal obesity.     

Predictive factors of women’s subjective perception of childbirth experience: a systematic review of the literature

ABSTRACT

Background: Up to 33% of women report a negative or traumatic childbirth experience. Given this high prevalence and its consistent association with adverse postpartum and child outcomes, it is essential to identify predictive factors and to improve the management of the childbirth experience.

Objective: This systematic review explores and identifies risk and protective factors for women’s subjective childbirth experience and birth satisfaction by reviewing original research.

Methods: A systematic search was performed for childbirth experience literature on three online databases. Reviewed papers focused on women’s subjective childbirth experience and its predictive factors. The articles were assessed with the Mixed Methods Appraisal Tool (MMAT).

Results: Risk and protective factors are notably different depending on the study design, the country, or the method employed. The main risk factors are obstetric, such as emergency caesarean and highly perceived labour pain, and women’s dissatisfaction with social support. The main protective factors are: obstetric, including highly perceived control during labour or satisfaction regarding partner’s support. However, overall results are inconclusive for methodological or conceptual reasons.

Conclusions: Several risk factors can be identified through pregnancy or childbirth. This underlines the importance of the quality of maternal interpersonal and professional relationships, especially with first-line perinatal health-care professionals, such as midwives.     

Swedish midwives' rating of risks during labour progress and their attitudes toward performing intrapartum interventions: a web-based survey

Objective

to study how Swedish midwives working in low-risk labour ward units rate intrapartum risks compared to their midwifery colleagues working in standard care labour wards. A second aim was to describe midwives' attitudes toward performing different types of interventions during a normal labour.

Design

an explorative study was carried out in 2009, using a web-based questionnaire containing 31 questions on midwives' risk ratings and attitudes to interventions during labour, as well as personal comments.

Setting

four labour ward units in Stockholm, Sweden. Two labour ward units with expected normal deliveries (‘low-risk’) and two standard care units with all types of deliveries.

Participants

seventy-seven registered clinically practicing midwives.

Findings

midwives in all units stated that factors to be considered for risk estimation were: previous delivery outcome, result of cardiotocography test (CTG) on admission to labour ward and quality of amniotic fluid. Midwives working at the low-risk units preferred to be more expectant during normal birth than their colleagues working at the standard care units. Examples of this were regarding second vaginal examination during labour (p=0.001) and/or amniotomy (p=0.012). Furthermore, midwives working at the low-risk units more often considered that first-time mothers could give birth without epidural analgesia during labour (p=0.019) and that the labouring woman should be encouraged to push according to her own spontaneous urge (p=0.040). Midwives at low-risk units were more reluctant to use an intravenous vein catheter than their colleagues at standard care units (p=0.001) and also to use oxytocin in order to augment contractions (p=0.013). Further, the open-ended question showed that attitudes to different types of interventions differed between midwives working at low-risk units or the standard care units working with all types of deliveries.

Conclusion

the Swedish midwives estimated risks similarly regardless of whether they worked in low-risk or in standard care units, but midwives working at low-risk units reported that they perform less routine interventions and have a more expectant attitude towards performing interventions.     

Eat Well Keep Active: Qualitative findings from a feasibility and acceptability study of a brief midwife led intervention to facilitate healthful dietary and physical activity behaviours in pregnant women

Backgroundoverweight and obesity in the pregnant population is increasing and this is a public health concern. Many women have difficulty in following the recommendation to maintain a healthy diet and to keep active, indeed some identify pregnancy as the start of their concern with being overweight.Objectiveto assess the feasibility and acceptability of the ‘Eat Well Keep Active’ intervention programme designed to promote healthy eating and physical activity in pregnant women. This brief midwife led intervention was based upon the Self Determination Theory (SDT) framework and utilised Motivational Interviewing and individualised goal setting.Designthis was a prospective qualitative study to explore women's views on the acceptability and perceived efficacy of the ‘Eat Well Keep Active’ programme obtained through one-to-one interviews 6 weeks after the delivery of the intervention. Data were also analysed to assess fidelity of the intervention to the psychological constructs of SDT; autonomy, competence and relatedness.SettingWales, UK.Participantspregnant women suitable for Midwife Led Care and therefore deemed to be ‘low risk’ were recruited from a large maternity unit in South Wales (n=20).Findingsthe results indicated that the ‘Eat Well Keep Active’ intervention programme was well received by participants who reported that it positively influenced their health behaviours. There was clear evidence of the intervention supporting the three SDT psychological needs.Key conclusionsThe Eat Well Keep Active intervention was designed to be incorporated into existing antenatal provision and findings from this study have demonstrated its acceptability. The brief midwife led intervention based on SDT was found to be acceptable by the participants who embraced the opportunity to discuss and explore their lifestyle behaviours with a midwife.Implications for practicetheoretically designed interventions that can facilitate women to pursue a healthy lifestyle during pregnancy are lacking and the ‘Eat Well Keep Active’ programme has the potential to address this. Further research is needed in order to assess the acceptability of the intervention to midwives and other groups of pregnant women prior to assessing its efficacy in changing and maintaining healthful behaviours.