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1.
Objective
to explore midwives' concerns, experiences and perceptions of the purpose of telephone contacts with women in early labour.Design
a qualitative design based on interpretive phenomenology.Setting
two Maternity Units in the Midlands of England.Participants
three focus groups of labour ward midwife co-ordinators and labour ward midwives and nine in-depth interviews of midwives, obstetricians and labour ward receptionists.Findings
the principal finding was that midwives are trying to reconcile gatekeeping of labour wards with individual support for women and these two aspects are often in conflict. Women experiencing prolonged or painful early labour often expect to be admitted to labour wards whereas midwives operate from a belief that women should only be accepted onto labour ward in active labour. They hold this view because labour wards are busy places and being admitted early contributes to unnecessary medical intervention.Key conclusions
because midwives are trying to reconcile the two conflicting priorities of responding to women's needs and protecting the labour ward from inappropriate admissions, the potential always exists for women's needs to be ‘not heard’ or marginalised.Implications for practice
the primary recommendation is that early labour telephone triage should be a discrete service, staffed by midwives who have been trained for this service, working independently of labour ward workloads. 相似文献2.
3.
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. 相似文献4.
5.
Newburn M 《Midwifery》2012,28(1):61-66
Objective and design
an ethnographic study was undertaken in a birth centre to explore the model of care provided there from the perspectives of midwives and parents.Setting
a five birthing-room, alongside, inner-city, birth centre in England, situated one floor below the hospital labour ward, separately staffed by purposively recruited midwives.Participants
around 114 hours were spent at the birth centre observing antenatal, intrapartum and postnatal care; 11 in-depth interviews were recorded with parents after their baby's birth (four with women; seven with women and men together), including three interviews with women who transferred to the labour ward, and 11 with staff (nine midwives and two maternity assistants).Findings
most women and men using the birth centre perceived it as offering the ‘best of both worlds’ based on its proximity to and separation from the labour ward. It seemed to offer a combination of biopsychosocial safety, made evident by the calm, welcoming atmosphere, the facilities, engaging, respectful care from known midwives and a clear commitment to normal birth, and obstetric safety particularly because of its close proximity to the labour ward.Key conclusions and implications for practice
this alongside birth centre provided a social model of care and appealed strongly to a group of parents; similar birth centres should be widely available throughout the NHS. 相似文献6.
Objective
to investigate the cost-effectiveness in birth care for low-risk women, in an alongside midwife-led unit (MU) compared to a standard obstetric unit (SCU) within the same hospital.Design
economic evaluation based on the findings of a randomised trial, randomising participants either into the MU or SCU. The hospital's activity-based costing system CPP was used to estimate costs, as no data on complete resource use exists.Setting
the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway.Participants
the study population consists of 1,110 consenting healthy women, assessed to be at low-risk at spontaneous onset of labour.Measurements
effect measures; avoided caesarean sections, instrumental vaginal deliveries, complications requiring treatment in the operating room, epidural analgesia and oxytocin augmentation. Costs (€) were calculated by costs per day multiplied with length of stay, added costs for procedures performed outside the units. The results are expressed in incremental cost-effectiveness ratios (ICER) with SCU as comparator.Findings
total costs per stay were significantly lower for women at the MU (€1,672) compared to the SCU (€1,950, p<0.001). The ICER showed that MU was a dominant strategy (lower costs and reduction in clinical procedures) for all effect measures. Based on the sensitivity analysis, allocating low-risk women to MU significantly reduced costs, but was not a dominant strategy for all outcomes.Key conclusions
the MU is more cost-effective than the SCU for low-risk women without prelabour preference for level of birth care provided equal capacity at the units.Implications for practice
it is cost-effective to organise birth care for low-risk women in a separate midwife-led unit. 相似文献7.
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. 相似文献8.
9.
Background
rural auxiliary midwives are central to clinical maternal care in Mali. However, little is known about their social role within the villages they serve. Exploring the social connectedness of midwives in their communities can reveal areas in which they need additional support, and ways they could benefit their communities beyond their clinical role.Objective
to examine rural auxiliary midwives' social connectedness to the communities they serve.Design
embedded, mixed methods design combining social network case studies with semi-structured interviews.Participants and setting
midwives were recruited for semi-structured interviews during technical trainings held in Koutiala in southern Mali. Social network analyses were conducted among all adult women in two small villages purposively sampled from the Koutiala region.Methods
29 interviews were conducted, transcribed, and coded using NVivo (Version 9) to qualitatively assess social connectedness. In two villages, the complete social networks of women's friendships were analysed using UCINET Version 6 (n=142; 74). Rank-orders of actors according to multiple measures of their centrality within the network were constructed to assess the midwives' position among village women.Findings
both local and guest midwives reported feeling high levels of social integration, acceptance, and appreciation from the women in their communities. Specific challenges existed for guest or younger midwives, and in midwives' negotiations with men. In the two sociometric analyses, both the local and guest midwives ranked among the most influential social actors in their respective villages.Key conclusions and implications for practice
though they hold a unique position among other rural women, this study suggests that midwives in Koutiala are well connected socially, and may be capable of becoming effective agents of network based-behavioural health interventions. Additional support is warranted to help midwives affirm a credible professional status in a male-dominated society, especially those of local status and younger age. Programme planners and policy-makers should consider the potential of midwives in communication when designing behaviour change interventions for women in similarly underserved areas. 相似文献10.
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. 相似文献11.
12.
13.
Objective
to assess Australian midwives' attitudes towards caring for women with emotional distress and their perceptions of the extent to which workplace policies and processes hindered such care.Design
a postal survey.Setting
members of the Australian College of Midwives.Participants
815 Australian midwives completed the survey.Measurements
a modified version of the 17-item REASON questionnaire (McCall et al., 2002) that was originally developed for used by General Practitioners to measure their attitudes towards their role in the management of patients with mental health disorders.Findings
An exploratory factor analysis with Varimax rotation identified four factors that reflected midwives' (1) perceptions of systemic problems that hindered emotional care, (2) attitudes towards working with women experiencing emotional health problems, (3) perceived competence in using treatment techniques and (4) attitudes and perceived competence towards the referral of women with depression and anxiety to other health professionals.Key conclusions and implications for practice
participating midwives indicated their willingness to offer assistance and acknowledged the importance of providing emotional care to women. In practice, emotional care by midwives is impeded by perceived lack of competency rather than a lack of interest. Midwives' competency in the assessment and care of women with conditions such as depression and anxiety may be enhanced through continuing professional education. 相似文献14.
Objective
aim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands.Design
web-based and postal questionnaire.Setting
in August and September 2011 a questionnaire was sent to all midwifery practices and all obstetric departments in the Netherlands.Participants
all midwifery practices (528) and all obstetric departments (91) in the Netherlands.Measurements and findings
the response was 87.5%. Administering prophylactic uterotonics was seen as a component AMTSL by virtually all respondents; 96.1% of midwives and 98.8% of obstetricians. Cord clamping was found as a component of AMTSL by 87.4% of midwives and by 88.1% of obstetricians. Uterine massage was only seen as a component of AMTSL by 10% of the midwives and 20.2% of the obstetricians. Midwifery practices routinely administer oxytocin in 60.1% of births. Obstetric departments do so in 97.6% (p<0.01). Compared to 1995, the prophylactic use of oxytocin had increased in 2011 both by midwives (10–59.1%) and by obstetricians (55–96.4%) (p<0.01).Key conclusions
prophylactic administration of uterotonics directly after childbirth is perceived as the essential part of AMTSL. The administration of uterotonics has significantly increased in the last decade, but is not standard practice in the low-risk population supervised by midwives.Implications for practice
the evidence for prophylactic administration of uterotonics is convincing for women who are at high risk of PPH. Regarding the lack of evidence of AMTSL to prevent PPH in low risk (home) births, further research concerning low-risk (home) births, supervised by midwives in industrialised countries is indicated. A national guideline containing best practices concerning management of the third stage of labour supervised by midwives, should be composed and implemented. 相似文献15.
Objective
to explore the impacts of physical and aesthetic design of hospital birth rooms on midwives.Background
the design of a workplace, including architecture, equipment, furnishings and aesthetics, can influence the experience and performance of staff. Some research has explored the effects of workplace design in health care environments but very little research has examined the impact of design on midwives working in hospital birth rooms.Methods
a video ethnographic study was undertaken and the labours of six women cared for by midwives were filmed. Filming took place in one birth centre and two labour wards within two Australian hospitals. Subsequently, eight midwives participated in video-reflexive interviews whilst viewing the filmed labour of the woman for whom they provided care. Thematic analysis of the midwife interviews was undertaken.Findings
midwives were strongly affected by the design of the birth room. Four major themes were identified: finding a space amongst congestion and clutter; trying to work underwater; creating ambience in a clinical space and being equipped for flexible practice. Aesthetic features, room layout and the design of equipment and fixtures all impacted on the midwives and their practice in both birth centre and labour ward settings.Conclusion and implications for practice
the current design of many hospital birth rooms challenges the provision of effective midwifery practice. Changes to the design and aesthetics of the hospital birth room may engender safer, more comfortable and more effective midwifery practice. 相似文献16.
Objective
to compare cost-effectiveness of two models of maternity service delivery: Midwifery Group Practice (MGP) at a birth centre and standard care (SC).Design
a prospective non-randomised trial.Setting
an Australian metropolitan hospital.Method
women at 36 weeks gestation were approached in the birth centre or hospital antenatal clinics between March and December 2008. Of 170 consecutive women who met birth centre eligibility criteria, 70% (n=119) were recruited to the study. Women (MGP n=52 or standard care n=50) were followed through to 6 weeks postpartum. Publically funded care costs were collected from women's diaries, handheld pregnancy health records, medical records and the hospital accounting system. Main outcome measures: health-care costs to the hospital and government.Analysis
generalised linear models with covariates of age, nulliparity, private health insurance (yes/no) and household income category.Findings
women receiving MGP care were less likely to experience induction of labour, required fewer antenatal visits, received more postnatal care, and neonates were less likely to be admitted to special care nursery than those receiving standard care. Statistically significant lower costs were found for women and babies receiving MGP care compared with women receiving standard care during pregnancy, labour and birth and postpartum to 6 weeks. MGP resulted in lower costs for the hospital ($AUD4,696 vs. $AUD5,521 p<0.001) and the government ($AUD4,722 vs. $AUD5,641 p<0.001). When baby costs were excluded MGP care remained statistically significantly cheaper than standard care.Conclusion
for women at low-risk of birth complications, Midwifery Group Practice was cost effective, and women experienced fewer obstetric interventions compared with standard maternity care. The evidence suggests Midwifery Group Practice is safe and economically viable. 相似文献17.
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. 相似文献18.
Objective
to explore midwives' views on ideal and actual maternity care.Design
a qualitative hermeneutic phenomenological study based on the method of van Manen (1997) using individual in-depth interviews to gather data.Setting
Flanders, Belgium.Participants
12 purposively sampled midwives, of whom nine from three different non-university hospitals and three independent midwives conducting home births.Findings
five major themes were identified: ‘woman-centred care’, ‘cultural change’, ‘support’, ‘midwife and obstetrician as equal partners’ and ‘inter-collegial harmony’. In this paper ‘woman-centred care’, ‘cultural change’ and ‘support’ are discussed along with their subthemes. Midwives thought ideal maternity care should be woman-centred in which there were no unnecessary interventions, women were able to make an informed choice and there was continuity of care. Furthermore, ideal maternity care should be supported by midwifery education and an adequate staffing level. Also, a cultural change was wanted as actual maternity care was perceived to be highly medicalised. Barriers to achieving woman-centred care and possible strategies to overcome these were described.Conclusions
findings from this study were consistent with those of other studies on midwives' experience with obstetric-led care. Despite the medicalised care, midwives still held a woman-centred ideology. In order to be able to work according to their ideology, different barriers need to be addressed. Although midwives suggested strategies to overcome these barriers, some were considered to be very difficult to overcome. 相似文献19.
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. 相似文献20.