Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective

Objective

to explore midwives’ experiences of facilitating normal birth in an obstetric-led unit.

Design

a feminist approach using semi-structured interviews focusing on midwives’ perceptions of normal birth and their ability to facilitate this birth option in an obstetric-led unit.

Setting

Ireland.

Participation

a purposeful sample of 10 midwives with 6–30 years of midwifery experience. All participants had worked for a minimum of 6 years in a labour ward setting, and had been in their current setting for the previous 2 years.

Findings

the midwives’ narratives related to the following four concepts of patriarchy: ‘hierarchical thinking’, ‘power and prestige’, ‘a logic of domination’ and ‘either/or thinking’ (dualisms). Two themes, ‘hierarchical thinking’ and ‘either/or thinking’, (dualisms) along with their subthemes are presented in this paper.

Key conclusions and implications for practice

this study identified some of the reasons why midwives find it difficult to facilitate normal birth in an obstetric unit setting, and identified a need for further research in this area. Midwifery education and supportive management structures are required if midwives are to become confident practitioners of normal birth.     

‘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.     

Reflexivity in midwifery research: the insider/outsider debate

Objective

to explore the challenges of conducting an observational study of postnatal interactions, between midwives and women, when the researcher was a midwife observing in familiar midwifery settings.

Background

participant observation conducted by researchers who are themselves midwives raises questions regarding the influence of ‘identity’ and ‘insider’ knowledge on the conduct of such projects. The insider/outsider status of researchers has been explored in other disciplines, yet this is an area which is underdeveloped in the midwifery literature where few attempts have been made to subject this issue to sustained analysis.

Design

a qualitative study (investigating the provision of breast-feeding support in the first week after birth) provided the opportunity for reflexive exploration of the tensions faced by midwife researchers.

Setting

two maternity units in New South Wales, Australia.

Participants

participants included 40 midwives and 78 breast-feeding women.

Findings

possessing ‘insider’ midwifery knowledge was advantageous in the ‘getting in’ and ‘fitting in’ phases of this research study however unanticipated role ambiguity, and moral and ethical challenges, arose as a result of this ‘insider’ knowledge and status. Prolonged periods of observation challenged the midwife researcher's preconceived ideas and early decisions about the advantages and disadvantages of being an ‘insider’ or an ‘outsider’ in the research setting.

Key conclusions

reflexive analysis of insider/outsider experiences revealed the middle ground which participant observers tend to navigate. Whilst professional insider knowledge and status offered many advantages, especially at the first study setting, some of the inherent embodied, and socially constructed features of the ‘midwife’ observer role, were unanticipated. Cultural competence, in these observational study settings, translated into role ambiguity, and at times, culturally entrenched role expectations.

Implications for practice

midwifery observation of clinical practice, for research, or practice development purposes, requires a degree of juggling of insider knowledge to facilitate observation and analysis. Prior to conducting observations midwives should consider how best to occupy the middle ground between insider and outsider. Within the middle ground the midwife can draw on those aspects of ‘self’ required to negotiate respectful relationships with colleagues, whilst also ensuring the maintenance of an analytical degree of distancing.     

The hardware and software implications of hospital birth room design: A midwifery perspective

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.     

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.     

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.     

The novice birthing: theorising first-time mothers' experiences of birth at home and in hospital in Australia

Objective

to explore first-time mothers’ experiences of birth at home and in hospital in Australia.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave in a public hospital and seven women who gave birth for the first time at home were interviewed and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Findings

three categories emerged from the analysis: preparing for birth, the novice birthing and processing the birth. These women shared a common core experience of seeing that they gave birth as ‘novices’. The basic social process running through their experience of birth, regardless of birth setting, was that, as novices, they were all ‘reacting to the unknown’. The mediating factors that influenced the birth experiences of these first-time mothers were preparation, choice and control, information and communication, and support. The quality of midwifery care both facilitated and hindered these needs, contributing to the women's perceptions of being ‘honoured’. The women who gave birth at home seemed to have more positive birth experiences.

Implications for practice

identifying the novice status of first-time mothers and understanding the way in which they experience birth better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing. It demonstrates how midwives can contribute to positive birth experiences by being aware that first-time mothers, irrespective of birth setting, are essentially reacting to the unknown as they negotiate the experience of birth.     

Returning birth: The politics of midwifery implementation on First Nations reserves in Canada

Objective

to explore the role of midwives in the implementation of an elective birthing programme in one remote First Nation community in Canada, and to identify current barriers and challenges to the practice of midwifery in these settings

Design

the study is a multisited ethnography based on 15 months of fieldwork in Manitoba, Canada. Thirty-nine individual qualitative, semi-structured interviews were completed. The data from the interviews were coded into themes and presented in the paper.

Setting

the study focuses on one First Nation community and their process of implementation of midwifery services. This case study is used to address broader themes of midwifery and policy at a national level.

Participants

participants included Aboriginal midwives from across Canada, policy makers from provincial and federal jurisdictions, medical professionals involved in Aboriginal health care, Aboriginal political leadership, and Aboriginal women and their families.

Findings

national policy and issues of jurisdiction among levels of government were shown to be a barrier to midwifery implementation.

Key conclusions

the current policy of evacuation in most Aboriginal communities does not effectively address the Millennium Development Goal of having a skilled birth attendant at every birth. The role of midwifery is central to the process of returning birth to Aboriginal communities, and steps must be taken at both the policy and clinical level to ensure that midwifery implementation and education can become an option for all Aboriginal communities in Canada.

Implications for practice

when considering midwifery implementation in communities, midwives must engage in both political and clinical negotiations to ensure their ability to practice effectively. Understanding the complexity of the policy discourse, along with the place of midwifery within the existing clinical guidelines is integral to the success of this process.     

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.     

The Canadian Birth Place Study: Describing maternity practice and providers' exposure to home birth

Objectives

(1) to describe educational, practice, and personal experiences related to home birth practice among Canadian obstetricians, family physicians, and registered midwives; (2) to identify barriers to provision of planned home birth services, and (3) to examine inter-professional differences in attitudes towards planned home birth.

Design

the first phase of a mixed-methods study, a quantitative survey, comprised of 38 items eliciting demographic, education and practice data, and 48 items about attitudes towards planned home birth, was distributed electronically to all registered midwives (N=759) and obstetricians who provide maternity care (N=800), and a random sample of family physicians (n=3,000).

Setting

Canada. This national investigation was funded by the Canadian Institutes for Health Research.

Participants

Canadian registered midwives (n=451), obstetricians (n=245), and family physicians (n=139).

Findings

almost all registered midwives had extensive educational and practice experiences with planned home birth, and most obstetricians and family physicians had minimal exposure. Attitudes among midwives and physicians towards home birth safety and advisability were significantly different. Physicians believed that home births are less safe than hospital births, while midwives did not agree. Both groups believed that their views were evidence-based. Midwives were the most comfortable with including planned home birth as an option when discussing choice of birth place with pregnant women. Both midwives and physicians expressed discomfort with inter-professional consultation related to planned home births. In addition, both family physicians and obstetricians reported discomfort with discussing home birth with their patients. A significant proportion of family physicians and obstetricians would have liked to attend a home birth as part of their education.

Conclusions

the amount and type of education and exposure to planned home birth practice among maternity care providers were associated with attitudes towards home birth, comfort with discussing birth place options with women, and beliefs about safety. Barriers to home birth practice across professions were both logistical and philosophical.

Implications for practice

formal mechanisms for midwifery and medical education programs to increase exposure to the theory and practice of planned home birth may facilitate evidence based informed choice of birth place, and increase comfort with integration of care across birth settings. An increased focus among learners and clinicians on reliable methods for assessing the quality of the evidence about birth place and maternal-newborn outcomes may be beneficial.     

The best of both worlds--parents' motivations for using an alongside birth centre from an ethnographic study

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.     

'She sort of shines': midwives' accounts of 'good' midwifery and 'good' leadership

Objective

to explore midwives’ accounts of the characteristics of ‘good’ leadership and ‘good’ midwifery.

Design and methods

a phenomenological interview survey. Participants were asked about what made both good and poor midwives and leaders.

Setting

two maternity departments within National Health Service trusts in the North West of England.

Participants

qualified midwives, selected by random sampling stratified to encompass senior and junior grades.

Analysis

thematic analysis, carried out manually.

Findings

ten midwives were interviewed. Sixteen codes and six sub-themes were generated. Across the responses, two clear dimensions (themes) were identified, relating on the one hand to aspects of knowledge, skill and competence (termed ‘skilled competence’), and on the other hand to specific personality characteristics (termed ‘emotional intelligence’). This study suggests that the ability to act knowledgeably, safely and competently was seen as a basic requirement for both clinical midwives and midwife leaders. The added element which made both the midwife and the leader ‘good’ was the extent of their emotional capability.

Conclusions and implications for practice

this small-scale in-depth study could form the basis for hypothesis generation for larger scale work in this area in future. The findings offer some reinforcement for the potential applicability of theories of transformational leadership to midwifery management and practice.     

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 qualified midwives' transition to qualified status and role: Assimilating the ‘habitus’ or reshaping it?

Aim

to ascribe meaning to the everyday experiences of midwives during their first year of practice as they interact with their social environment.

Design

a qualitative, ethnographic study.

Setting

a major maternity department located in the West Country, UK.

Participants

seven newly qualified midwives working in the chosen setting.

Measurements

as befits an ethnographic approach, observant participation and interviews in the field were the selected data collection tools. Reflexivity was at the hub of the research process. A field diary was kept in order to ensure that the researcher took into account both her own perceptions and the interactions with participants and significant others. This paper draws on data that illustrates some of the predispositions that may constitute the midwifery habitus.

Findings

the main themes that emerged from the data were in relation to the culture of midwifery, fitting into the culture and determining what type of midwife the neophytes wanted to be (‘what is a midwife?’). To enhance transparency, the latter theme is focused upon in this paper using a model that is a synthesis of some of the findings and Bourdieu's notion of habitus.

Key conclusions and implications for practice

this research provides insight into the professional and cultural experiences of newly qualified midwives, especially how cultural interactions, education and expectations may shape the midwifery habitus. It would seem that midwives who take a critical and reflective approach to practice are key players in the cultural re-creation of midwifery. Accordingly, to enable the aforementioned approach to practice, it is important that reflective and reflexive practices are an integral part of midwifery education. Nevertheless, the implications for practice are not merely one-dimensional. Observations in the field suggest the importance of making the quality of midwives' working lives a priority by facilitating a more supportive working environment. Moreover, midwives should not be marginalised for preferring to work in the community, the birth centre or the high-risk environment. Future planning of the maternity services needs to consider how a ‘being with the woman’ approach can be facilitated for all women, balancing the virtues of both the medical and midwifery models of care.     

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.     

Development and psychometric testing of the scales for measuring maternal satisfaction in normal and caesarean birth

Objective

to develop a scale to measure maternal satisfaction with birth to evaluate women's experiences in labour and the early postpartum period.

Design

development and psychometric assessment of a multidimensional maternal satisfaction questionnaire.

Setting

maternity unit of a university hospital in Istanbul.

Participants

500 healthy postpartum women.

Methods

five steps were taken in development of the scale: literature review, generating item pool, content validity testing, administration of draft scale and psychometric testing. Two versions of the scale were developed: the Scale for Measuring Maternal Satisfaction–normal birth and the Scale for Measuring Maternal Satisfaction–caesarean birth. Content validity was evaluated by experts. The appropriate draft scale and the Newcastle Satisfaction with Nursing Scale were administered to postpartum women before hospital discharge.

Findings

content validity index scores for the vaginal and caesarean birth scales were 0.91 and 0.89, respectively. Item-total and subscale-total scores correlated significantly for each scale. Evaluation of construct validity through factor analysis yielded 10 subscales: ‘perception of health professionals’, ‘nursing/midwifery care in labour (in caesarean version: preparation for caesarean)’, ‘comforting’, ‘information and involvement in decision making’, ‘meeting baby’, ‘postpartum care’, ‘hospital room’, ‘hospital facilities’, ‘respect for privacy’ and ‘meeting expectations’. Both scales had good internal reliability, with Cronbach's α coefficients of 0.91. The scales established their convergent validity with significant correlations with the Newcastle Satisfaction with Nursing Scale.

Conclusion

the scales are valid and reliable tools for evaluating Turkish women's experiences in labour and the early postpartum period.

Implications for practice

the scales can contribute to the assessment of women's satisfaction with different aspects of care, the quality of care and developments in maternity services.     

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.