A qualitative study exploring student midwives' experiences of carrying a caseload as part of their midwifery education in England

Objective

to explore student midwives' experiences of caseloading to develop an understanding of how they perceive this educational strategy has impacted on their learning journey to becoming a midwife.

Design

a qualitative approach drawing upon the principles of grounded theory. Data were collected by in-depth semi-structured interviews.

Setting

a university in the South of England providing undergraduate pre-registration midwifery education across Advanced Diploma and BSc (Hons) programmes.

Participants

eight Caucasian female final-year student midwives aged 23–50 years who had completed their caseloading experience.

Findings

one core category (‘making it good’) and four major categories emerged: (1) ‘developing and managing caseload’, (2) ‘learning partnerships’, (3) ‘feeling like a midwife’ and (4) ‘afterwards’. The core category was reflected in all the other categories and was dependent upon them.

Key conclusions and implications for practice

students identified caseloading as a highly beneficial learning approach, facilitating application of theory to practice and acquisition of new skills promoting confidence and competence in practice. Students articulated an overwhelming desire and concern to meet and facilitate women’s expectations. Perceptions of letting the woman down evoked feelings of inadequacy and failure. Flexible working practices, on-call commitment and carrying a caseload alongside academic and home commitments was, for many, emotionally stressful. Effective preparation of students for the realities of caseloading, the development of realistic caseloads that take account of the student’s individual situation, and the provision of supportive frameworks are essential.     

Parents’ experiences of midwifery students providing continuity of care

Objective

the aim of this study was to gain knowledge and a deeper understanding of the value attached by parents to relational continuity provided by midwifery students to the woman and her partner during the childbearing process. The focus of the study was on the childbirth and the postnatal home visit.

Design/setting

in this pilot project by researchers at Sør-Trøndelag University College, Norway, six midwifery students provided continuity of care to 58 women throughout their pregnancy, birth and the postnatal period. One group interview of eight women and two group interviews of five men, based on the focus group technique, were conducted at the end of the project. Qualitative data were analysed through systematic text condensation.

Findings

the findings included two main themes: ‘trusting relationship’ and ‘being empowered’. The sub-themes of a ‘trusting relationship’ were ‘relational continuity’ and ‘presence’. For the women, relational continuity was important throughout the childbearing process, but the men valued the continuous presence during birth most highly. ‘Being empowered’ had two sub-themes: ‘individual care’ and ‘coping’. For the women, individual care and coping with birth were important factors for being empowered. The fathers highlighted the individual care as necessary to feel empowered for early parenting. The home visit of the student was highly appreciated. The relationship with the midwifery student could be concluded, and they had the opportunity to review the progression of the birth with the student who had been present during the birth. During the home visit, the focus was more on the experiences of pregnancy and birth than on what lay ahead.

Key conclusions

when midwifery students provided continuous care during pregnancy, birth and the postnatal period, both women and men experienced a trusting relationship. Relational continuity was important for women in the entire process, but for the men this was mostly important during childbirth. Individual care and coping with birth and early parenting enhanced empowerment. The limited sample size in this study means that it cannot be generalised without caution, and further research is needed.     

Being safe practitioners and safe mothers: A critical ethnography of continuity of care midwifery in Australia

Objective

to examine how midwives and women within a continuity of care midwifery programme in Australia conceptualised childbirth risk and the influences of these conceptualisations on women's choices and midwives' practice.

Design and setting

a critical ethnography within a community-based continuity of midwifery care programme, including semi-structured interviews and the observation of sequential antenatal appointments.

Participants

eight midwives, an obstetrician and 17 women.

Findings

the midwives assumed a risk-negotiator role in order to mediate relationships between women and hospital-based maternity staff. The role of risk-negotiator relied profoundly on the trust engendered in their relationships with women. Trust within the mother–midwife relationship furthermore acted as a catalyst for complex processes of identity work which, in turn, allowed midwives to manipulate existing obstetric risk hierarchies and effectively re-order risk conceptualisations. In establishing and maintaining identities of ‘safe practitioner’ and ‘safe mother’, greater scope for the negotiation of normal within a context of obstetric risk was achieved.

Key conclusions and implications for practice

the effects of obstetric risk practices can be mitigated when trust within the mother–midwife relationship acts as a catalyst for identity work and supports the midwife's role as a risk-negotiator. The achievement of mutual identity-work through the midwives' role as risk-negotiator can contribute to improved outcomes for women receiving continuity of care. However, midwives needed to perform the role of risk-negotiator while simultaneously negotiating their professional credibility in a setting that construed their practice as risky.     

The current state of midwifery and development of midwifery research in four European countries

Objective

to describe the current state of midwifery and explore the development of midwifery research during the last two decades in four non-English speaking European countries in order to understand what factors influenced the course of establishing research as a professional activity.

Design

qualitative collective case study.

Setting

Germany, Austria, Switzerland and the Netherlands.

Findings

with the ICM Workshop in Germany in 1989 as a central starting point for midwifery research in all four countries, different courses, in timing as well as content, characterised its development in the individual countries. Major factors contributing to this development during the last decades involved the history and character of midwifery, initiatives of individual midwifery researchers, alliances with other professions and the transition of midwifery programmes into higher education. Whereas midwifery research is currently established as a professional role in all countries, future challenges involve the creation of its own profile and identity, while building up its own academic workforce and strengthening the role of midwifery in multidisciplinary alliances.

Key conclusions and implications

although a common vision was shared between the four countries in 1989, midwifery research developed as a context-specific phenomenon related to the character of midwifery and education in each country. These factors have to be taken into account in the further development of midwifery as an academic discipline at a national as well as at an international level.     

Midwives' and doulas' perspectives of the role of the doula in Australia: a qualitative study

Objective

to explore midwives’ and doulas’ perspectives of the role of the doula in Australia.

Background

doulas are relatively new in Australia; nevertheless, demand for them is increasing. Research has not previously explored the role of a doula in Australia. This research aimed to answer the question: What are midwives’ and doulas’ perspectives of the role of a doula in Australia?

Design

qualitative study using focus groups that were digitally recorded, transcribed and the data analysed using thematic analysis.

Setting

New South Wales, Australia.

Participants

11 midwives and six doulas.

Findings

the key theme that emerged was that ‘the broken maternity system’ is failing women and midwives. The system is preventing midwives from providing woman- centred care. As a result, doulas are ‘filling the gap’ and midwives feel that doulas are ‘taking our role’. Doulas fill the gap by providing continuity of care, advocating for women, protecting normal birth and by providing breast-feeding advice and emotional support in the community. Midwives are concerned that doulas are taking the caring part of their role from them and want the ‘broken’ maternity system fixed. Midwives described that doulas take their role from them by changing the relationship between themselves and labouring women, by reducing their role to obstetric nurses, by overstepping the doula role boundaries, and by holding the power at births.

Implications for practice

despite the conflict reported between midwives and doulas, both groups identified that they see the potential for future collaboration. Taking into account the continued employment of doulas, it is important to improve collaboration between midwives and doulas for the sake of childbearing women.     

One-to-one midwifery: restoring the "with woman" relationship in midwifery

One-to-One Midwifery, a model of care developed in the United Kingdom, provides a continuous and personal relationship between each woman and her midwife. The organization of care and the outcomes are relevant to midwifery policy in all industrialized countries. One-to-One Midwifery is not solo practice. An important principle of the organization of the practice is to enable individual midwives to take time off and to provide supportive structures for the midwives. Here the implications of One-to-One Midwifery for childbearing women and their families, and the midwives involved, are explored. The One-to-One Midwifery model has particular relevance for Canada because it is very similar to the model of practice being developed in at least two provinces. It may also be of importance in the United States, particularly for midwives working shifts in hospitals who may want to develop a system that allows them to provide continuity to the women they serve.     

Exploring the concept of continuous midwifery-led care and its dimensions in the prenatal,perinatal, and postnatal periods in Iran (Kashan)

Aimto explore the concept of continuous care and its dimensions in the prenatal, perinatal, and postnatal periods based on the experiences of midwives, gynaecologists, obstetricians, pregnant women and their husbands.Designa qualitative study that was part of a large scale action research which aimed to develop, use and test a continuous midwifery-led care model. Data collection and analysis were performed concurrently through undertaking semi-structured interviews and using the conventional content analysis approach.Settinghealthcare centres and hospitals affiliated to Kashan University of Medical Sciences, Kashan, Iran.Participants21 women following a recent pregnancy, five husbands, 18 midwives, and five physicians who had different official positions.Findingsthe participants’ experiences revealed five concepts for continuous midwifery-led care which included continuity, the process of care, education and informing, management, and professionalism. Each of these five concepts consisted of several categories.Conclusion and implication for practiceaccording to the study participants, continuous midwifery-led prenatal, perinatal, and postnatal care is a multidimensional and important concept. Given the differences in the health infrastructures of different countries as well as the unique characteristics of pregnancy, higher priorities are recommended to be given to continuous midwifery-led care and its dimensions.     

A qualitative exploration of the creation of calm in a continuity of carer model of maternity care in London

Objective

to explore the relationship between a one-to-one model of maternity care and the creation of calm in order to: (1) illuminate one of the mechanisms, i.e. calm, through which the provision of relational continuity may be associated with positive care outcomes; and (2) highlight a model of care, i.e. relational continuity, that is well placed to create calm (a desirable outcome in its own right).

Design

a qualitative study, using non-participant observation and semi-structured in-depth interviews.

Setting

a community midwifery practice delivering one-to-one care in London.

Participants

10 women, 21–40 years of age, six of whom had experienced a different type of care during a previous birth; seven of their birth partners; and four midwives.

Findings

calm is aspired to by women and birth partners, and experiencing calm is associated with greater satisfaction. Relational continuity is perfectly placed to create calm, as it tends to foster a sense of familiarity and enables all parties to get to know what to expect from one another. It also facilitates calm because conflicting advice is minimised and midwives are able to build their confidence and wisdom by learning from the repercussions of their own actions.

Key conclusion

since calm has been found to be a key expectation for childbirth, and since a fulfilment of expectations has been found to be linked to greater satisfaction and an enhanced mother–child relationship, creating calm should be one of the aims of maternity care.

Implications for practice

the well-known benefits of calm, and the association between relational continuity and the creation of calm found in this study suggest that relational continuity may be considered a priority within current national and international plans to expand the delivery of continuity.     

Chinese midwives’ experience of providing continuity of care to labouring women

Objective

to explore and describe Chinese midwives’ experience of providing one-to-one continuity of care to labouring women.

Design

a qualitative study using a phenomenological approach. Data were collected using open-ended, tape-recorded interviews. The analysis of the transcribed texts included searching for themes sorted into clusters for a final expression of the essential structure of the phenomenon.

Setting

Obstetrics and gynaecology hospital of Fudan University, Shanghai, China.

Participants

12 midwives, providing one-to-one continuity of care to labouring women.

Findings

two main categories were identified: (1) midwives’ feelings on providing continuity of care, and (2) impact of on-call system on midwives providing continuity of care. Key themes emerged from each main category: (1) ‘playing important roles in labour care’, ‘gaining a sense of self-achievement’, ‘falling into exhaustion and frustration’ and ‘coping with caring work’; and (2) ‘on-call syndrome’, ‘affecting personal lives’ and ‘managing on-call shift’. The midwives experienced mixed feelings of being with women and expressed their adaptation to being on-call, which was the essence of this study. They played important roles in caring for women, gained a sense of self-achievement and developed suitable coping strategies. However, they also indicated the impact of the on-call system upon them in the process of providing continuity of care.

Conclusion and implications for practice

midwives have gained both positive and negative experiences when providing continuity of care to labouring women. The positive aspects may facilitate other professional midwives working in a similar role, whereas the negative aspects may inform them of learning to live with this situation, and may also have implications for managers to develop new approaches to the organisation and provision of continuity of care to support midwives’ practice, and to fully utilise ‘flexibility’ under an on-call system.     

The perspectives of Australian midwifery academics on barriers and enablers for simulation in midwifery education in Australia: a focus group study

Objective

to describe Australian midwifery academics' perceptions of the current barriers and enablers for simulation in midwifery education in Australia and the potential and resources required for simulation to be increased.

Design

a series of 11 focus groups/interviews were held in all states and territories of Australia with 46 participating academics nominated by their heads of discipline from universities across the country.

Findings

three themes were identified relating to barriers to the extension of the use of simulated learning environments (SLEs) (‘there are things that you can't simulate’; ‘not having the appropriate resources’; and professional accreditation requirements) and three themes were identified to facilitate SLE use (‘for the bits that you're not likely to see very often in clinical’; [‘for students] to figure something out before [they] get to go out there and do it on the real person’; and good resources and support).

Key conclusion

although barriers exist to the adoption and spread of simulated learning in midwifery, there is a long history of simulation and a great willingness to enhance its use among midwifery academics in Australia.

Implications for practice

while some aspects of midwifery practice may be impossible to simulate, more collaboration and sharing in the development and use of simulation scenarios, equipment, space and other physical and personnel resources would make the uptake of simulation in midwifery education more widespread. Students would therefore be exposed to the best available preparation for clinical practice contributing to the safety and quality of midwifery care.     

The history and evolution of the Core Competencies for basic midwifery practice

The Core Competencies in Nurse-Midwifery were first published in 1978 to provide a standard approach to nurse-midwifery education and now serve as the template for curriculum in nurse-midwifery/midwifery education. This article is an expansion of an earlier publication documenting the development of the Core Competencies document and describes its history and use in midwifery education and professional practice. The development and continued revision of this document are a significant part of ACNM and midwifery history in the United States. It defines the competencies essential to basic practice and can be used to define the scope of midwifery practice in both professional and policy arenas.     

Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia

Objective

to explore the experiences and concerns of an African-born sample of pregnant women receiving antenatal care in Melbourne, Australia.

Design

qualitative in-depth interviews.

Setting

the African Women's Clinic located in Melbourne's western suburbs, an area known for social deprivation and high numbers of recently arrived African migrants.

Participants

18 pregnant African-born women were interviewed.

Findings

African women receiving pregnancy care in Australia undergo a process of adjustment as they travel from a view of pregnancy as not ‘special’ to valuing continuous antenatal care. Five themes were identified along the trajectory: pregnancy is not special; resettlement is a priority; childbearing is a normal process; coming to value continuous pregnancy care; and cultural sensitivity is important. Throughout each stage, valuing and acceptance of Australian pregnancy care were mediated by the women's cultural beliefs.

Conclusion

the African population in Melbourne is not homogenous, and women's experiences differ with cultural background, residential status, educational level and prior experience. All, however, seem to progress through phases of adjustment to value continuous antenatal care. In this climate of change, the provision of a supportive sensitive service appears to promote acceptance of services and attendance at appointments.     

The economic costs of intrapartum care in Tower Hamlets: A comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

Objectiveto compare the economic costs of intrapartum maternity care in an inner city area for ‘low risk’ women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital.Designmicro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes.Settingthe Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital's consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007–2010.Participantsmaternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust's eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital.Measurements and findingswomen who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units.Key conclusions and implications for practicethe study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications.     

Establishing midwifery in low-resource settings: Guidance from a mixed-methods evaluation of the Afghanistan midwifery education program

Background

the shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010.

Objective

we analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned.

Design

we performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs.

Setting

for the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development.

Participants

midwives who had graduated from either IHS or CME schools.

Findings

CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9–66.6%) on the clinical competency assessment compared to 57.3% (49.9–64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,784 per graduate.

Key conclusions

the pre-service midwifery education experience of Afghanistan can serve as a model to rapidly increase the number of skilled birth attendants. In such settings, it is important to ensure the provision of continued practice opportunities and refresher trainings after graduation to aid skill retention, a co-operative and supportive work environment that will use midwives for the reproductive health skills for which they were trained, and selection mechanisms that can identify the most promising students and post-graduation deployment options to maximise the return on the substantial educational investment.     

An evaluation of a national intervention to improve the postabortion care content of midwifery education in Nigeria

Objective

To examine the impact of a national intervention to improve the postabortion care (PAC) content of midwifery education in Nigeria.

Methods

A 3-part quantitative assessment was carried out during and post-intervention. The first baseline component developed and examined the intervention to improve teaching capacity and improve the PAC curriculum among 6 midwifery schools that were to become regional training centers. The second survey was a pre- and post-assessment conducted among midwifery instructors from all schools of midwifery in the country. In the third component, 149 midwives graduating from the 6 regional midwifery schools were interviewed once 3-9 months after graduation to evaluate whether the intervention had improved their knowledge of PAC and clinical practice, and the likelihood that they would provide PAC after graduation.

Results

Data from 6 schools of midwifery in 2003 showed that none offered PAC or had educators trained in PAC prior to the intervention. Incorporation of PAC content and teaching capacity increased in all 6 study schools during the 3 years after a national intervention. Midwifery instructors demonstrated statistically significant improvements in knowledge of and exposure to PAC and manual vacuum aspiration (MVA) after the intervention. A follow-up interview with 149 student midwives post graduation showed increased knowledge, exposure to, and use of MVA in the workplace.

Conclusion

Significant changes in graduate midwives' exposure, practice, and provision of PAC services resulted from a national intervention to improve the training environment and skills of midwifery instructors and students in the 6 schools of midwifery selected for evaluation.     

Midwives and supervisors of midwives' perceptions of the statutory supervision of midwifery within the United Kingdom: A systematic review

Within the United Kingdom, the statutory supervision of midwives has a central role in both the provision of safe, high-quality maternity services and in the regulation of midwifery practice. Despite its long history, little is currently known about how midwives and their supervisors perceive and experience the statutory supervisory process.