Newly-graduated midwives transcending barriers: A grounded theory study

BackgroundMidwifery has developed its own philosophy to formalise its unique identity as a profession. Newly-graduated midwives are taught, and ideally embrace, this philosophy during their education. However, embarking in their career within a predominantly institutionalised and the medically focused health-care model may challenge this application.Question and aimThe research question guiding this study was as follows: ‘How do newly graduated midwives deal with applying the philosophy of midwifery in their first six months of practice?’ The aim was to generate a grounded theory around this social process.MethodThis Western Australian grounded theory study is conceptualised within the social theory of symbolic interactionism. Data were collected by means of in-depth, semi-structured interviews with 11 recent midwifery graduates. Participant and interviewer's journals provided supplementary data. The ‘constant comparison’ approach was used for data analysis.Theory generatedThe substantive theory of transcending barriers was generated. Three stages in transcending barriers were identified: Addressing personal attributes, Understanding the ‘bigger picture’, and finally, ‘Evaluating, planning and acting’ to provide woman-centred care. An overview of these three stages provides the focus of this article.ConclusionThe 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. A number of implications for pre and post registration midwifery education and policy development are suggested, as well as recommendations for future research.     

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.     

Strengthening midwifery in Brazil: Education,regulation and professional association of midwives

This article describes Brazilian midwives' struggle to establish their professional field in the arena of maternal and child health in Brazil. Despite the obstacles, midwives continue trying to claim their social space, seeking to maintain and strengthen the profession, and legislative aspects of practice and regulation of their profession. They seek space in the job market, support from entities of civil society, representatives of judicial and political power, and from the movements organised for improvement and change in the birth care model in Brazil.     

Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces

Objective

to examine factors that affect retention of public sector midwives throughout their career in Afghanistan.

Design

qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs).

Setting

health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul.

Participants

purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs).

Measurements and findings

several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife's career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector.

Key conclusions

Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention.

Implications for practice

Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.     

Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention

The objective of this project was to improve birth outcomes for babies in a regional referral hospital in Uganda by strengthening factors that influence the retention and application of neonatal resuscitation skills. Initial training in neonatal resuscitation is not enough on its own. In order to better understand the gap between training and effective practice, an evaluation of a neonatal resuscitation program was carried out. This included practical skill testing of local midwives using a neonatal resuscitation doll pre- and post-training, as well as follow up testing at 1 month and 12 months, followed by focus groups and interviews. Test scores revealed that participants’ knowledge grew significantly immediately following the workshop, and remained high after 1 month, but fell by 12 months post-training. Interviews with hospital staff revealed a number of facilitators and barriers to practice, namely knowledge retention and skill application. The most important barrier identified is the lack of refresher training post-workshop. Importantly, the findings demonstrated a need not for refresher training alone, but for improved organizational and administrative support for the newly assigned trainers.     

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.     

Perceptions and uses of plants for reproductive health among traditional midwives in Ecuador: Moving towards intercultural pharmacological practices

Despite the fact that plants have played an important role in midwifery in many cultures, there are very few in-depth studies on the plants traditionally used by midwives. The aim of this study is to analyse the perceptions and the uses of medicinal plants for reproductive health among indigenous midwives in the city of Otavalo, Ecuador. The article also aims to analyse the perceptions of traditional midwives regarding allopathic drugs for reproductive health and their possible overlapping uses of medicinal plants and allopathic drugs. The data are drawn from an ethnographic study carried out in Ecuador. In total, 20 traditional midwives have been interviewed. Individual and in-depth interviews also took place with a sample of 35 women as well as with five nurses and two doctors working at San Luis Hospital in Otavalo.     

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.     

Competency-based education: The essential basis of pre-service education for the professional midwifery workforce

Background

many articles published in the decade since promulgation of the Millennium Development Goals have acknowledged the distinct advantages to maternal and newborn health outcomes that can be achieved as a result of expanding access to skilled birth attendant (including midwifery) services. However, these advantages are often predicated on the assumption that the midwifery workforce shares a common definition and identity. Regrettably, a clear delineation of midwifery competencies is rarely addressed. A core set of midwifery competencies is essential to providing the high quality services that lead to the desirable health outcomes described in that body of research. Attribution of improved outcomes to access to midwifery cannot be made without a common understanding of a defined set of services provided to standard by the midwifery workforce across the inter-conceptional and childbearing time frame. The International Confederation of Midwives (ICM) has developed a clear list of competencies that delineate the domains of practice for the fully qualified, professional midwife. These domains frame the educational outcomes that must be conveyed within competency-based education programmes.

Purpose

this article explores the concept of competency-based education for midwives; first exploring the concept of competency itself, then providing examples of what is already known about competency-based approaches to curriculum design, teacher preparation, teacher support and assessment of student learning. These concepts are linked to the ICM competencies as the unifying construct for education of individuals who share a common definition and identity as midwives.     

The International Confederation of Midwives: Global Standards for Midwifery Education (2010) with companion guidelines

Objective

a 2-year study was conducted to develop Global Standards for Midwifery Education in keeping with core documents of the International Confederation of Midwives. Elements of the standards were based on evidence available in the published and unpublished literature. Companion Guidelines to assist in implementing the standards were also developed.

Design

a modified Delphi survey process was conducted in two rounds following item validation by a panel of midwifery education experts.

Setting

a global survey conducted in 88 countries.

Participants

midwifery educators and clinicians associated with midwifery education located in any of the ICM member association countries. Additional participants included an Expert Midwifery Resource Group, other Key Stakeholders, midwifery regulators and policy makers. A total of 241 individuals from 46 ICM member association countries and ten non-member countries responded to one or both of the survey rounds.

Measurements

survey respondents expressed an opinion on whether to retain or to delete any of the proposed components of the standards. Version one had 109 proposed components and version two had 111 items for consideration.

Findings

a majority consensus of .80 was required to accept an item without further deliberation. The Education Standards Task Force (expert panel) made final decisions in the four instances where this level of consensus was not reached, retaining all four items. The panel also amended the wording of selected items or added new items based on feedback received from survey respondents. The final document contains 10 Preface items, 35 glossary terms, and 37 discrete standards with 27 sub-sections.     

The International Confederation of Midwives essential competencies for basic midwifery practice. an update study: 2009-2010

Objective

a 2-year study was conducted to update the core competencies for basic midwifery practice, first delineated by the International Confederation of Midwives in 2002. A competency domain related to abortion-related care services was newly developed.

Design

a modified Delphi survey process was conducted in two phases: a pilot item affirmation study, and a global field survey.

Setting

a global survey conducted in 90 countries.

Participants

midwifery educators or clinicians associated with midwifery education schools and programmes located in any of the ICM member association countries. Additional participants represented the fields of nursing, medicine, and midwifery regulatory authorities. A total of 232 individuals from 63 member association and five non-member countries responded to one or both of the surveys. The achieved sample represented 42% of member association countries, which was less than the 51% target. However, the sample was proportionally representative of ICM's nine global regions.

Measurements

survey respondents expressed an opinion whether to retain or to delete any of 255 statements of midwifery knowledge, skill, or professional behaviour. They also indicated whether the item should be a basic (core) item of midwifery knowledge or skill that would be included as mandatory content in a programme of midwifery pre-service education, or whether the item could be added to the fund of knowledge or acquired as an additional skill by those who would need or wish to include the item within the scope of their clinical practice.

Findings

a majority consensus of .85 was required to accept the item without further deliberation. An expert panel made final decisions in all instances where consensus was not achieved. The panel also amended the wording of selected items, or added new items based on feedback received from survey respondents. The final document contains 268 items organised within seven competency domains.     

Doubling back over roads once traveled: creating a national organization for nurse-midwifery

The quest for a new national organization began in 1940 and concluded in November 1955 in Kansas City, Missouri, with the founding meeting of the American College of Nurse-Midwifery. This article looks at the conflicts with organized nursing about the place and role of nurse-midwives in the newly reorganized American Nurses Association and the National League for Nursing. Discussions and disagreements within nurse-midwifery over the need for a nonexclusive national organization that would set professional standards are examined.