Caseload midwifery in a multi-ethnic community: The women's experiences

Objective

to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area.

Design and setting

semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery.

Findings

key themes from previous work fitted well with the themes that emerged from this study. Themes included ‘knowing and being known’, ‘person-centred care’, ‘social support’, ‘gaining trust and confidence’, ‘quality and sensitivity of care’ and ‘communication’.

Key conclusions and implications

women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.     

Newly-graduated midwives transcending barriers: Mechanisms for putting plans into actions

Objective

the aim of this qualitative study was to develop theory regarding how newly-graduated midwives deal with applying a midwifery philosophy of care in their first six months of practice.

Design

the research aim signifies the study of social processes. Hence Grounded Theory methodology was employed. Data were generated from semi-structured interviews and participant and interviewer journals.

Setting

the study was conducted in Perth, Western Australia, with graduate midwives working in private and public, secondary and tertiary maternity hospital settings.

Participants

11 female midwives who were previously nurses and had recently graduated from a 12 month post graduate university-based midwifery course participated.

Theory generated

the substantive theory of transcending barriers was generated. It has three stages: ‘Addressing personal attributes’, ‘Understanding the ‘bigger picture’’, and ‘Evaluating, planning and acting’ to provide woman-centred care. An overview of the theory was presented in a previous paper. The mechanisms where ‘plans are moved into action’ which form the final sub-stage of the stage ‘Evaluating, planning and acting’ are presented in this paper.

Key conclusion

the theory of transcending barriers provides a new perspective on how newly-graduated midwives ‘deal with’ applying the philosophy of midwifery in their first six months of practice. The final sub-stage of the theoretical model highlights four mechanisms that newly-graduated midwives implement in their endeavours to provide woman-centred care, increase autonomy and develop their personal philosophy of midwifery.

Implication for practice

understanding the four mechanisms can assist health care providers to facilitate the transition of newly-graduated midwives into clinical practice.     

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.     

Midwives' perceptions of organisational structures and processes influencing their ability to provide caseload care to socially disadvantaged and vulnerable women

Objective

this study examined midwives' perceptions of organisational structures and processes of care when working in a caseload model (Midwifery Group Practice MGP) for socially disadvantaged and vulnerable childbearing women.

Design

this study used Donabedian's theoretical framework for evaluating the quality of health care provision. Of the 17 eligible midwives, 15 participated in focus group discussions and two others provided written comments. Thematic analysis was guided by three headings; clinical outcomes, processes of care and organisational structure.

Findings

midwives believed they provided an excellent service to socially disadvantaged and vulnerable childbearing women. Midwives gained satisfaction from working in partnership with women, working across their full scope of practice, and making a difference to the women. However the midwives perceived the MGP was situated within an organisation that was hostile to the caseload model of care. Midwives felt frustrated and distressed by a lack of organisational support for the model and a culture of blame dominated by medicine. A lack of material resources and no identified office space created feelings akin to ‘homelessness’. Together these challenges threatened the cohesiveness of the MGP and undermined midwives' ability to advocate for women and keep birth normal.

Key conclusions

if access to caseload midwifery care for women with diverse backgrounds and circumstances is to be enhanced, then mechanisms need to be implemented to ensure organisational structures and processes are developed to sustain midwives in the provision of ‘best practice’ maternity care.

Implications for practice

women accessing midwifery caseload care have excellent maternal and newborn outcomes. However there remains limited understanding of the impact of organisational structures and processes of care on clinical outcomes.     

Navigating a safe path together: A theory of midwives' responses to the use of complementary and alternative medicine

Objective

this paper presents the findings from a qualitative study that aimed to explain the processes midwives engaged in when considering the use of complementary and alternative medicine by pregnant women.

Design

grounded theory methodology was employed for the study. Data was generated from in-depth interviews and non-participant observation of midwives interacting with expectant mothers. Twenty-five midwives who worked in four hospitals and associated community clinics in Victoria, Australia, participated.

Findings

the theory ‘Navigating a safe path together’ offers a possible explanation of how midwives are responding. When working with women interested in the use of complementary and alternative medicine, midwives move through an iterative process of individualising pregnancy care, encountering diverse perspectives and minimising the risks associated with childbearing.

Key conclusion

at the heart of the theory is the meaning midwives' construct around safe childbirth and their professional roles. Despite widespread support for the therapies, midwives' actions in clinical practice are mediated by a number of factors including the context of their professional work, their beliefs and knowledge, and the woman's expectation and health.

Implications for practice

the research highlights the need for improved education and greater professional guidance to equip midwives to respond with greater understanding, and confidence to the increasing prevalence of CAM in the maternity setting.     

‘Every pregnant woman needs a midwife’—The experiences of HIV affected women in maternity care

Title

‘Every pregnant woman needs a midwife’—the experiences of HIV affected women in Northern Ireland.

Objective

to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

Design

a prospective qualitative study.

Setting

regional HIV unit in Northern Ireland.

Participants

22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

Findings

the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

Key conclusions

pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing ‘balanced care’ could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.     

Case-loading midwifery in New Zealand: bridging the normal/abnormal divide ‘with woman’

Objectives

to explore the way that case-loading midwives in New Zealand construct midwifery (and in so doing, the concepts of woman and childbirth). This paper illuminates the fundamental features of this construction (continuity and woman-centred care) and discusses this with regard to the role of midwives vis-à-vis normal/abnormal birth.

Design

semi-structured interviews and official publications constituted the ‘text’ which was analysed using a poststructural approach that was informed by theorists Foucault, Grosz and Braidotti.

Participants and setting

48 case-loading midwives practising throughout New Zealand participated in this study. These included facility-employed and self-employed midwives and those from rural and urban settings.

Findings

many midwives follow women through their maternity experience providing continuity of care regardless of whether the experience is considered ‘normal’ or ‘abnormal’.

Key conclusions

continuity and woman-centred care are fundamental features of the construction of midwifery in New Zealand.

Implications for practice

a focus on the midwifery concept of ‘with woman’ can bridge the divide between the polarising concepts ‘normal’ and ‘abnormal’ and enable a more fluid and dynamic reading of midwifery.     

Is a midwife's continuous presence during childbirth a matter of course? Midwives' experiences and thoughts about factors that may influence their continuous support of women during labour

Objective

to gain an understanding about midwives' experiences of providing a continuous supportive presence in the delivery room during childbirth, and to learn about factors that may affect this continuous support.

Design/setting

qualitative study at a maternity unit in Norway, where about 4000 births take place each year. In-depth interviews were conducted with ten midwives working in two different maternity wards. The qualitative data were analysed using systematic text condensation.

Findings

the analysis generated three main themes: relational competence, the midwife's ideology, the culture and philosophy of the maternity unit. The midwives identified being mentally present and actively developing mutual trust with the woman in labour as two very important factors for building a relationship with her. They suggested that the midwife's first encounter with the woman is a key opportunity for establishing rapport during labour. Successfully providing a continuous presence during labour fostered the midwives' perception of themselves as a ‘good midwife’; this was considered a feature of holistic care and health promotion. The workload in the unit sometimes made it difficult for them to provide a continuous presence in the delivery room. The midwives experienced feelings of inadequacy when they felt that they had too little time available for the woman in labour.

Key conclusions

midwives' skill in building a relationship with the woman in labour combined with their values and understanding of the midwifery profession are important factors influencing their decision to provide a continuous presence during childbirth. If it is policy that maternity units should provide continuous support to women in labour, managers should ensure that it is actually provided.     

Intrapartum uncertainty: A feature of normal birth,as experienced by midwives in Scotland

Objective

to explore midwives' perceptions of intrapartum uncertainty when caring for women in low risk labour.

Design

a grounded theory approach was used to capture the experiences of midwives practising in Scotland. Data were generated through unstructured in-depth one-to-one interviews and focus groups.

Setting

four Health Boards in Scotland.

Participants

19 midwives, practising in a range of maternity settings, participated in the study. The maternity settings included; obstetric led labour wards, along-side maternity units, stand-alone community maternity units, and community and independent practice. They also had a mixture of clinical experience, ranging from one to 20 years in practice.

Findings

Three categories emerged from the analysis, intrapartum uncertainty, the normality boundary and threshold pressures. Recognising the point at which a labour deviates away from normal constitutes ‘intrapartum uncertainty’. In these situations midwives develop a normality boundary that shape their clinical judgements and decisions. The boundary becomes the limit, edge or border of what they accept as normal in a labour. Therefore if midwives tolerate intrapartum uncertainty they are more likely to construct labours as normal, than midwives with a lower tolerance of uncertainty. This can be mediated by threshold pressures that expand or contract their definitions of normality. So that supportive environments and good relationships with women enable midwives to tolerate uncertainty and thus maintain normality.

Implications for practice

the reemphasise on midwifery practice as a means of supporting normal birth has been promoted as a way of ‘demedicalising’ birth for low risk women. However to maintain normality midwives need to understand the impact uncertainty has on their decision making. Supporting midwives to tolerate uncertainty, either at unit or national level, will expand definitions of normality so that birth can remain natural and dynamic.     

Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies

Objective

the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies.

Design

organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review.

Setting

a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring ‘best’ or ‘better’ performing in the Health Care Commission survey of maternity services (HCC 2008).

Participants

professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents.

Findings

each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a ‘hub and spoke’ model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence.

Key conclusions and implications for practice

maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.     

Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature

Objective

to present the literature relating to health status and pregnancy complications among sub-Saharan African women.

Background

sub-Saharan refugee women constitute a new and growing group of maternity service users in developed countries today. These women are perceived to be at high risk of pregnancy complication, based on concurrent disease and unusual medical conditions. As a result of these concerns, midwives may feel ill equipped to provide their pregnancy care.

Method

searches were conducted of CINAHL, Maternity and Infant Care, MEDLINE and PsychINFO databases using the search terms ‘migrants’, ‘Africa’, ‘sub-Saharan’, ‘pregnancy’, ‘refugees’ and ‘women’. Additional articles were located by pursuing references identified in key papers.

Findings

pregnant sub-Saharan women present as an at-risk population related to poor prior health, co-existing disease and cultural practices such as female genital mutilation. Nonetheless, principal pregnancy complications for this population include anaemia and high parity, rather than exotic disease. Higher rates of infant mortality and morbidity appear to persist following resettlement, and are not explained by maternal risk factors alone. Limited access to care is of concern.

Key conclusions

further research is warranted into the impediments to care uptake among sub-Saharan African women. It is hoped that such research will inform the development of culturally appropriate and acceptable services for African refugees.

Implications for practice

it is important that midwives are aware of common health problems among sub-Saharan women. Midwives also need to act to promote access to health services among this group. Social disadvantage and late access to care may impact on neonatal outcomes and thus warrant investigation.     

An evaluation of the satisfaction of midwives’ working in midwifery group practice

Objective

to examine changes in midwives’ attitudes to their professional role following the introduction of midwifery group practice (MGP) (a caseload model of midwifery continuity of care provided to women of all risk levels) and to explore aspects of the model that were working well and those that were not working well.

Design

the questionnaire ‘Attitudes to Professional Role’ was used to measure midwives’ satisfaction in terms of professional satisfaction, professional support, client interaction, and professional development. Open-ended questions were also included to offer an opportunity for midwives to expand on their experiences of working in the MGP model. The questionnaire was administered at five time points over the 18-month evaluation period. Round 1 was prior to the implementation of MGP, Rounds 2–4 were at three-month intervals, with Round 5 six months later. Analysis of the structured part of the questionnaire was undertaken by comparing mean scores of satisfaction ranging from −2 (very negative attitudes) to +2 (very positive attitudes), and the open-ended questions were analysed using qualitative content analysis.

Setting

the Women's and Children's Hospital, Adelaide, South Australia.

Participants

questionnaires were distributed to all midwives (n=15) working in MGP in Rounds 1, 2 and 3, and to the 12 midwives remaining from the original sample in Rounds 4 and 5. Fourteen questionnaires were returned in Round 1, 12 in Round 2, 10 in Round 3, nine in Round 4, and 10 in Round 5.

Findings

overall, a positive change in attitudes to professional role was reflected in all sub-scales in the period between start-up and 18 months later; a reduction in scores occurred in Round 3. The mean increases were significant for all sub-scales apart from professional development. Five main themes were identified across the rounds in the content analysis: ‘continuity of care’, ‘working pattern’, ‘working environment’, ‘collegiality’ and ‘issues relating to midwifery practice’. Midwives gained particular satisfaction from providing continuity of care and building relationships with women and their families, and through practising autonomously as a midwife. While there was a struggle to manage the hours worked and being on call, high levels of professional satisfaction were maintained.

Key conclusions

while there were aspects of MGP that midwives were not satisfied with and wanted to change, overall they were satisfied with the model.

Implications

there is a need for ongoing evaluation in order to monitor the short- and long-term impact on midwives of working in a caseload model of continuity of midwifery care.     

‘We just ask some questions…’ the process of antenatal psychosocial assessment by midwives

Objective

this qualitative ethnographic study describes the content and process of psychosocial assessment and depression screening undertaken by midwives in the antenatal booking visit in two maternity units in New South Wales (NSW), Australia.

Study design

participants included 34 pregnant women and 18 midwives who agreed to be observed during the antenatal booking visit. A structured observation tool and field notes were used to record observations of the assessment and screening process including the midwives' approaches (actions and interactions) communication styles, and the interactive dynamics between the midwives and the women. Midwives also participated in a brief interview after the observation.

Findings

midwives varied in their approach to psychosocial assessment. Some followed the structured format tending to deliver the questions in a directive manner, whereas others appeared more flexible in their approach and delivery of sensitive questions. In some instances midwives modified the questions. Modification appeared to occur to assist in the interpretation and comprehension of the questions.

Conclusion

midwives were observed using a range of skills when undertaking psychosocial assessment including empathetic responding, however, modification of questions may reflect a level of discomfort on the part of the midwife in asking sensitive questions and may impact on the integrity of the assessment. Further training and support is required to ‘fine tune’ the process of assessment and better respond to disclosure of sensitive information.

Implications for practice

midwives require organisational support for ongoing training and clinical supervision to effectively undertake routine psychosocial assessment.     

‘Just waiting to be hauled over the coals’: Home birth midwifery in Ireland

Objective

to describe the context of Irish home birth midwives' practise experience.

Design

ethnography derived from participant observation, unstructured interview and documentary analysis.

Setting

women and midwives' homes and meeting places in Ireland.

Participants

21 self-employed community midwives.

Measurements and findings

choice of place of birth is extremely limited in Ireland. Structural and professional supports for home birth and midwifery are lacking. Home birth midwives highly value midwifery professionalism but are professionally isolated. They promote women's birthing autonomy and choice of place of birth. However, they experience and anticipate negative, even punitive, responses from their own and other professions. This ethnography describes a particularly volatile period in Irish home birth midwifery practice.

Key conclusions

Irish home birth midwives are professionally isolated which, given wider cultural antagonism to home birth, perfuses their practice with an element of defensiveness. Strong midwifery association is a key pillar of professionalism globally. In Ireland, the lack of a strong professional body undermines autonomous midwifery practice in all settings but particularly in the home. The midwifery philosophy of ‘being with woman’ appears to run contrary to professionalising discourses where the professional ‘knows best’. Contemporary cultural expectations of professionalism such as clinical indemnification and risk averse practice protocols, bring challenges to autonomous midwifery practice.

Implications for practice

place and context of birth effects not only the woman's birth experience but the midwife's professional autonomy. Without supports for autonomous midwifery, autonomous birthing is under threat. Place of birth effects birth experience and birth quality, not least because it is that context which also influences, for good or ill, midwifery autonomy.     

Early pushing urge in labour and midwifery practice: A prospective observational study at an Italian maternity hospital

Objective

to investigate the early pushing urge (EPU) incidence in one maternity unit and explore how it is managed by midwives. The relation to some obstetric outcomes was also observed but not analysed in depth.

Design

prospective observational study.

Setting

Italian maternity hospital.

Sample

60 women (44 nullips and 16 multips) experiencing EPU during labour.

Findings

the total EPU incidence percentage was 7.6%. The single midwives' incidences range had a very wide margin, noting an inverse proportion between the number of diagnoses of EPU and midwife's waiting time between urge to push and vaginal examination. Two care policies were adopted in relation to the phenomenon: the stop pushing technique (n=52/60) and the ‘let the woman do what she feels’ technique (n=8/60). In case of stop pushing techniques, midwives proposed several combined techniques (change of maternal position, blowing breath, vocalisation, use of the bath). The EPU diagnosis at less than 8 cm of cervical dilatation was associated with more medical interventions. Maternal and neonatal outcomes were within the range of normal physiology. An association between the dilatation at EPU diagnosis and obstetric outcomes was observed, in particular the modality of childbirth and perineal outcomes.

Conclusions and implication for practice

this paper contributes new knowledge to the body of literature around the EPU phenomenon during labour and midwifery practices adopted in response to it. Overall, it could be argued that EPU is a physiologic variation in labour if maternal and fetal conditions are good. Midwives might suggest techniques to woman to help her to stay with the pain, such as change of position, blowing breath, vocalisation and use of the bath. However, the impact of policies, guidelines and culture on midwifery practices of the specific setting are a limitation of the study because it is not representative of other similar maternity units. Thus, a larger scale work should be considered, including different units and settings. The optimal response to the phenomenon should be studied, considering EPU at different dilatation ranges. Future investigations could also focus on qualitative analysis of women and midwives' personal experience in relation to the phenomenon.     

Towards a relational model of decision-making in midwifery care

Objective

current individualistic ideas of autonomy and decision making do not fit within the context of decision-making in the midwife–woman relationship. This article critically explores current issues around decision-making and proposes a relational decision-making model for midwifery care.

Design

qualitative prenatal and postnatal interviews around decision-making within childbirth in general, and the third stage of labour in particular.

Participants

eight midwife–woman pairs in urban settings in New Zealand.

Findings

a range of relational, social and political factors that are not present within existing decision-making models were highlighted. The themes included ontological and philosophical influences on decision-making; uncertainty, vulnerability and relational trust; and socio-political and cultural influences. Inconsistencies in knowledge arising from social, cultural and familial considerations as well as identities, beliefs, values, conversations, and practices were found to produce uncertainties around potential courses of action, expected consequences and outcomes. ‘Unplanned’ birth experiences decreased client autonomy and increased vulnerability thereby intensifying relational trust within decision-making. The political context may also open up or close down possibilities for decision-making at both national and local levels.

Conclusion

decision-making for women and midwives is influenced by complex human, contextual and political factors. This study supports a relational model of decision-making that is embedded in understandings of choice as ‘entangled’. A relational model enables consideration of how factors such as identity projects, individual practices, the organisation of maternity care, local hospital cultures, medicalised childbirth, workforce shortages, funding cuts and poverty shape the way in which care decisions are made.     

The impact of peer support in the context of perinatal mental illness: A meta-ethnography

Objective

this paper is a report of a systematic review and meta-ethnography to explore the impact of peer support in the context of perinatal mental illness (PMI).

Method

systematic review methods identified five qualitative studies about women's experiences of PMI, and the impact peer support has on their journey towards emotional well-being. Findings from the identified studies were synthesised into themes, using meta-ethnography.

Synthesis and findings

the meta-ethnography produced four themes; ‘Isolation: the role of peer support’, ‘Seeking validation through peer support’, ‘The importance of social norms of motherhood’, and ‘Finding affirmation/a way forward; the impact of peer support’. These themes represent women's experiences of PMI, their encounters with peer support groups within that context, and the impact of such encounters on their mental health status.

Key conclusion

recognising the risk of isolation and having pathways of referral to peer support networks is important, as are practitioners roles in nurturing peer support networks in perinatal care. More research is required to establish the most successful formats/structures of peer support. Practitioners should also recognise their individual and collective professional duty to challenge stereotypical depictions of motherhood wherever they arise, as this ‘gold standard’ benchmark of good mothering engenders guilt about not being good enough, often leaving women feeling inadequate.

Implications for practice

isolation is a key factor in PMI. Practitioners should be instrumental in their acceptance and development of peer support for PMI, ensuring these networks are valued, nurtured and encouraged. This study illustrates the powerful effect of professional and social forces on how new mothers feel about themselves.