Avoiding disturbance: Midwifery practice in home birth settings in Norway

Objective

to explore midwifery practice in home birth settings in Norway, especially practice assumed by the midwives to promote normal labour and birth.

Design

in-depth interviews transcribed verbatim and analysed using a grounded theory method.

Setting

home birth settings in Norway.

Participants

12 midwives who regularly attended home births and who had assisted a minimum of 30 home births between 1990 and 2007.

Findings

the core category ‘avoiding disturbance’ was identified during the analyses, indicating that the midwives prevented the woman from being disturbed and protected her from disturbance if it occurred during labour. The core category must be understood in the light of the midwives’ attitudes towards and beliefs about labour and birth. The labour process could be disturbed by the midwife, the birthing woman, the partner and other supporting persons, and older children. The midwives regarded labour as work to be done by the woman, as a sexual process, and had a basic understanding that labour and birth usually had good outcomes.

Key conclusions

factors regarded as beneficial for the woman and her labour, like a partner, friends and helpers supporting the woman and doing important and necessary work, and a midwife observing the woman, fetus and course of labour, could also be perceived as sources of disturbance.

Implications for practice

the effect of a calm, undisturbed environment on the labour course should be explored further.     

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.     

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.     

Childbirth at home: A qualitative study exploring perceptions of risk and risk management among Baloch women in Iran

Objective

to explain how women who choose to give birth at home perceive and manage the risks related to childbirth.

Design

a qualitative, methodological approach drawing upon the principles of grounded theory. Data were gathered by in-depth interviews with women who had given birth at home.

Setting

the study was conducted in Zahedan, the capital of Sistan and Balochestan province in southeast Iran.

Participants

21 Baloch women aged 13–39 years who had a planned home birth were interviewed. Nine had been attended by university-educated midwives, eight by trained midwives, and four by traditional birth attendants.

Findings

concerning perceived risks, women perceived giving birth in hospital to be risky because of medical interventions, routines and ethical considerations. The perceived risks for home birth were acute medical conditions. Women made their decision to give birth at home based on existing verbal, visual, and intuitive information. The following two categories related to risk management were identified: (1) psychological preparation and (2) medical and logistican preparation. All of the women relied on their own intuition, their midwife and the sociopsychological support of their families to transfer them to hospital in the case of complications.

Key conclusions and implications for practice

the women who chose to give birth at home accepted that there was a risk of complications, but perceived these to be due to fate. Technical risks were considered to be a consequence of the decision to give birth in hospital, and were perceived to be avoidable. In addition, the women considered ethical issues as risks that are sometimes more important than medical complications. Women's perceptions of risk, and the ways in which they prepare to manage risk, are central issues to help providers and policy makers adjust services to women's expectations in order to respond to the individuality of each woman.     

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.     

Women's experiences with giving birth before arrival

ObjectiveTo explore women's experiences with giving birth before arrival.DesignA qualitative interview study.SettingIndividual semi structured interviews with women from Western Norway conducted in their homes in 2015.Participants10 women who experienced BBA-births in 2014, or the beginning of 2015. Two primiparous and eight multiparous women participated in the study.Key findingsThree themes were generated from the analysis. In the encounter with the healthcare services, the women described midwives as gatekeepers defining active labour. Giving birth before arrival was dramatic, but at some point fear of giving birth alone was replaced by feelings of coping, and in hindsight they felt empowered. The women described giving birth before arrival to be a special experience, but this was not always acknowledged by the midwives.Conclusion and implications for practiceThe findings in this study question the cost-benefit of today's maternity care system pointing towards a more differentiated and decentralised care. To enhance patient safety adequate capacity of midwives in the maternity care is essential. Furthermore, good communication skills are key to improving practice and enhancing safety. Further research must be conducted.     

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

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

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

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

‘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.     

Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time

ObjectiveTo describe Canadian nulliparous women's attitudes to birth technology and their roles in childbirth.MethodsA large convenience sample of low-risk women expecting their first birth was recruited by posters in laboratories, at the offices of obstetricians, family physicians, and midwives, at prenatal classes, and through web-based advertising and invited to complete a paper or web-based questionnaire.ResultsOf the 1318 women completing the questionnaire, 95% did so via the web-based method; 13. 2% of respondents were in the first trimester, 39. 8% were in the second trimester, and 47. 0% in the third. Overall, 42. 6% were under the care of an obstetrician, 29 3% a family physician, and 28 1% a registered midwife The sample included mainly well-educated, middle-class women The planned place of giving birth ranged from home to hospital, and from rural centres to large city hospitals. Eighteen percent planned to engage a doula. Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women's roles in their own delivery, regardless of the trimester in which the survey was completed Those women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women's roles Family practice patients' opinions fell between the other two groups. For eight of the questions, “I don't know” (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy Women in the care of midwives consistently used IDK options less frequently than those cared for by physiciansConclusionsRegardless of the type of care provider they attended, many women reported uncertainty about the benefits and risks of common procedures used at childbirth. When grouped by the type of care provider, in all trimesters, women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations     

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.     

Nordic couples’ decision-making processes in anticipation of contacting a fertility clinic

This study concerns midwives' obedience/conformity to direction from a senior person. We sought to identify whether midwives just went along with what a midwife at management level suggested, or instead altered their views to match. In the first condition, a postal Social Influence Scale‐Midwifery (SIS‐M) measured and scored 209 midwives' private responses to 10 clinical questions. In a second condition, a senior midwife successfully influenced 60 of these midwives to alter their SIS‐M decisions to agree with her suggested correct responses. In a third condition, a postal condition again measured the midwives private SIS‐M responses. The aim was to elicit whether the midwives' simply complied with the senior midwife's suggestions during interview or actually changed their opinions to match hers. A 3 (E (lowest grade), F (middle grade) & G (sister grade)) × 3 (above conditions) ANOVA found a significant main effect for conditions (F(2, 94) = 151.87, p = 0.001) with higher scores in the interview condition when the senior midwife passively influenced participant responses. Results inform that the interview manipulation had no lasting social influence effect, consistent with Milgram's transient situational argument. That is, in the presence of senior staff, midwives' decisions are profoundly influenced.     

Making physiological birth possible: Birth at a free-standing birth centre in Berlin

Background

the practical training in midwifery education in Germany takes place predominantly in hospital delivery wards, where high rates of intervention and caesarean section prevail. When midwives practice birth assistance at free-standing birth centres, they have to make adjustments to what they learned in the clinic to support women without the interventions common to hospital birth.

Objectives

the primary aim of this study was to investigate and describe the approach of midwives practicing birth assistance at a free-standing birth centre.

Methodology

a qualitative approach to data collection and analysis with grounded theory was used which included semi-structured expert interviews and participant observation. Five midwives were interviewed and nine births observed in the research period. The setting was a free-standing birth centre in a large German city with approximately 115 births per year.

Findings

the midwives all had to re-learn birth assistance when commencing work outside of the hospital. However, having been trained predominantly in hospital maternity wards, they have retained many aspects characteristic of their training. The midwives use technology, although minimal, and medical discourse in combination with 1:1, woman-centred care. The birthing woman and midwife share authority at birth. The fetus is treated as an ally of the mother, suited for birth and cooperative. Through use of objective and subjective criteria, the midwives have their own approach to making physiological birth possible.

Key conclusions and implications for practice

to prepare midwives to support low-intervention birth, it is necessary to include training in birth assistance with women who birth physiologically, without interventions common to hospital birth. The results of this study would also suggest that the rate of interventions in hospital could be reduced if midwives gain more experience with women birthing without the above-mentioned interventions.