Childbearing traditions of Indian women at home and abroad: An integrative literature review

BackgroundThe percentage of overseas-born mothers giving birth in Australia has increased to 31.5% in 2012 and Indian women represent 10% (the highest proportion). It is important for midwives in Australia to be aware of the childbearing traditions of Indian women and how these influence Indian women birthing in Australia.AimTo explore childbearing practices in India and Indian women's experience of giving birth abroad; and to discuss the relevant findings for midwives working with Indian women in Australia.MethodAn integrative literature review was employed. 32 items, including 18 original research articles were thematically reviewed to identify commonly occurring themes relating to Indian women's childbearing traditions.FindingsFive themes relating to traditional childbearing practices of women birthing in India were identified. These themes included diversity and disparity; social context of childbirth and marriage; diet based on Ayurveda; pollution theory and confinement; and finally, rituals and customs.ConclusionIndian women giving birth abroad and by implication in Australia experience a transition to motherhood in a new culture. While adjusting to motherhood, they are also negotiating between their old and new cultural identities. To provide culturally safe care, it is essential that midwives reflect on their own culture while exploring what traditions are important for Indian women.     

Socially disadvantaged women's views of barriers to feeling safe to engage in decision-making in maternity care

BackgroundAlthough midwifery literature suggests that woman-centred care can improve the birthing experiences of women and birth outcomes for women and babies, recent research has identified challenges in supporting socially disadvantaged women to engage in decision-making regarding care options in order to attain a sense of control within their maternity care encounters.ObjectiveThe objective of this paper is to provide an understanding of the issues that affect the socially disadvantaged woman's ability to actively engage in decision-making processes relevant to her care.Research designThe qualitative approach known as Interpretative Phenomenological Analysis was used to gain an understanding of maternity care encounters as experienced by each of the following cohorts: socially disadvantaged women, registered midwives and student midwives. This paper focuses specifically on data from participating socially disadvantaged women that relate to the elements of woman-centred care-choice and control and their understandings of capacity to engage in their maternity care encounters.FindingsSocially disadvantaged women participants did not feel safe to engage in discussions regarding choice or to seek control within their maternity care encounters. Situations such as inadequate contextualised information, perceived risks in not conforming to routine procedures, and the actions and reactions of midwives when these women did seek choice or control resulted in a silent compliance. This response was interpreted as a consequence of women's decisions to accept responsibility for their baby's wellbeing by delegating health care decision-making to the health care professional.ConclusionThis research found that socially disadvantaged women want to engage in their care. However without adequate information and facilitation of choice by midwives, they believe they are outsiders to the maternity care culture and decision-making processes. Consequently, they delegate responsibility for maternity care choices to those who do belong; midwives. These findings suggest that midwives need to better communicate a valuing of the woman's participation in decision-making processes and to work with women so they do have a sense of belonging within the maternity care environment. Midwives need to ensure that socially disadvantaged women do feel safe about having a voice regarding their choices and find ways to give them a sense of control within their maternity care encounters.     

Experiences of and visions for collaboration between midwives and nurses in Nova Scotia

ProblemIn jurisdictions where midwifery and nursing are autonomous and separate health care professions, little is known about how they collaborate during the delivery of perinatal health care services.BackgroundMidwifery became a regulated profession in the province of Nova Scotia, Canada in 2009. Since regulation, midwives and nurses have worked together at three models sites for the delivery of midwifery services and perinatal care.QuestionHow do midwives and nurses collaborate during the provision of birthing care in Nova Scotia, Canada?MethodsThis was an instrumental case study guided by feminist poststructuralism. Individual interviews of 17 participants were audio-recorded and transcribed verbatim. Twenty-five documents were reviewed, and field notes were gathered. Feminist poststructuralist discourse analysis was used.FindingsMidwives and nurses collaborated well together. Participants described how positive collaborative experiences could influence a new way for midwives and nurses to work together. In this paper we present the theme Moving forward: A Modern Model for Nurses and Midwives working together, and its sub-themes of 1)’The birthing culture has changed’ and 2) ‘Allies and advocates’.DiscussionWithin the global context of strengthening midwifery and nursing, this study illustrated the potential for developing formal, collaborative perinatal models of care led by midwife and nurse teams to address inequities in perinatal health care services.ConclusionMidwives and nurses need more opportunities to collaborate and to build professional relationships. Establishing a midwife-led and nurse supported model of care may transform existing perinatal health care values, beliefs, and practices.     

Exploring routine hospital antenatal care consultations — An ethnographic study

Background

Listening to women as part of their antenatal care has been recognized as valuable in understanding the woman’s needs. Conversations as part of routine antenatal interactions offer ideal opportunities for women to express themselves and for midwives to learn about the woman’s issues and concerns. The antenatal visit and the convention of antenatal consultations for midwives have not been well explored or defined and much of what takes place replicate medical consultative processes. As a consequence, there is little to assist midwives construct woman-centred care consultations for their routine antenatal care practice. This study showed how some practices were better in promoting the woman’s voice and woman-centred care in the hospital setting.

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical,reflexive thematic analysis

BackgroundA care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one – warm perineal compresses – has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.QuestionHow does a perineal care bundle impact midwifery practice in Australian maternity hospitals?MethodsPurposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.FindingsWe interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.DiscussionThe bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants’ responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.ConclusionThe introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care.     

Midwifery-led care in South Australia: Looking back to move forward

BackgroundFrom the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.AimTo better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.MethodsSemi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.FindingsThree overarching themes and several sub-themes were identified, these included: ‘Midwifery suffragettes’ which explored ‘activism’, ‘adversity’ and ‘advocacy’; ‘Building bridges’ captured the importance of ‘gathering midwives’, a ‘movement of women’ and ‘champions and influencers’; and ‘Recognising midwifery’ identified the strong ‘sense of identity’ needed to outface ‘ignorance and opposition’ and the importance of ‘role reformation’.ConclusionThese midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.     

Midwifery Job Autonomy in New Zealand: I do it all the time

IntroductionThis research aimed to identify what supports and what hinders job autonomy for midwives in New Zealand.MethodsRegistered midwives participated in an open-ended, online survey in 2019. Anonymised participants were asked to describe an incident when they felt they were using their professional judgement and/or initiative to make decisions and the resultant actions. The data was analysed thematically.FindingsThe participants identified that autonomy is embedded within midwifery practice in New Zealand. Self-employed midwives who provide continuity of care as Lead Maternity Carers, identified they practice autonomously ‘all the time’. The relationship with women and their family, and informed decision making, motivated the midwife to advocate for the woman – regardless of the midwife’s work setting. Midwifery expertise, skills, and knowledge were intrinsic to autonomy. Collegial relationships could support or hinder the midwives’ autonomy while a negative hospital work culture could hinder job autonomy.DiscussionMidwives identified that autonomous practice is embedded in their day to day work. It strengthens and is strengthened by their relationships with the woman/whanau and when their body of knowledge is acknowledged by their colleagues. Job autonomy was described when midwifery decisions were challenged by health professionals in hospital settings and these challenges could be viewed as obstructing job autonomy.ConclusionThe high job autonomy that New Zealand midwives enjoy is supported by their expertise, the women and colleagues that understand and respect their scope of practice. When their autonomy is hindered by institutional culture and professional differences provision of woman-centred care can suffer.     

‘Stories of distress versus fulfilment’: A narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service

BackgroundSome childbearing women/birthing people prioritize out of maternity care organizational guidelines’ approaches to childbirth as a way of optimizing their chances of a normal physiological birth. Currently, there is little known about the experiences of midwives who support their choices.AimTo explore the experiences of UK midwives employed by the NHS, who self-defined as supportive of women’s alternative physiological birthing choices.MethodsA narrative inquiry was used to collect and analyse professional stories of practice via self-written narratives and interviews. Forty-five midwives from across the UK were recruited.FindingsThree overarching storylines were developed with nine sub-themes. ‘Stories of distress’ highlights challenging experiences due to poor supportive working environments, ranging from small persistent challenges to extreme situations. Conversely, ‘Stories of fulfilment’ offers a positive counter-narrative where midwives worked in supportive working environments enabling woman-centred care unencumbered by organisational constraints. ‘Stories of transition’ abridge these two polarized themes.ConclusionThe midwives’ experiences were mediated by their socio-cultural working contexts. Negative experiences were characterised by a misalignment between the midwives’ philosophy and organisational cultures, with significant consequences for the midwives. Conversely, examples of good organisational culture and practice reveal that it is possible for organisations to fulfil their obligations for safe and positive maternity care for both childbearing women who make alternative birthing choices, and for attending staff. This highlights what is feasible and achievable within maternity organisations and offers transferable insights for organisational support of out-of-guideline care that can be adapted across the UK and beyond.     

‘They follow the wants and needs of an institution’: Midwives’ views of water immersion

BackgroundA midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision.ObjectivesA three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice.MethodsCritical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results.FindingsFindings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care.ConclusionsThe insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.     

The comparison of the interpersonal action component of woman-centred care reported by healthy pregnant women in different sized practices in the Netherlands: A cross-sectional study

BackgroundThe number of interventions is lower, and the level of satisfaction is higher among women who receive midwife-led primary care from one or two midwives, compared to more midwives. This suggests that midwives in small-sized practices practice more women-centred. This has yet to be explored.ObjectiveTo examine pregnant women’s perceptions, of the interpersonal action component of woman-centred care by primary care midwives, working in different sized practices.MethodsA cross-sectional study using the Client Centred Care Questionnaire (CCCQ), administered during the third trimester of pregnancy among Dutch women receiving midwife-led primary care from midwives organised in small-sized practices (1−2 midwives), medium-sized (3−4 midwives) and large-sized practices (≥5 midwives). A Welch ANOVA with post hoc Bonferroni correction was performed to examine the differences.Results553 completed questionnaires were received from 91 small-sized practices/104 women, 98 medium-sized practices/258 women and 65 large-sized practices/191 women. The overall sum scores varied between 57–72 on a minimum/maximum scoring range of 15–75. Women reported significantly higher woman-centred care scores of midwives in small-sized practices (score 70.7) compared with midwives in medium-sized practices (score 63.6) (p < .001) and large-sized practices (score 57.9) (p < .001), showing a large effect (d .88; d 1.56). Women reported statistically significant higher woman-centred care scores of midwives in medium-sized practices compared with large-sized practices (p < .001), showing a medium effect (d .69).ConclusionThere is a significant variance in woman-centred care based on women’s perceptions of woman-midwife interactions in primary care midwifery, with highest scores reported by women receiving care from a maximum of two midwives. Although the CCCQ scores of all practices are relatively high, the significant differences in favour of small-sized practices may contribute to moving woman-centred care practice from ‘good’ to ‘excellent’ practice.     

Health professionals’ perceptions of a midwifery model of woman-centred care implemented on a hospital labour ward

BackgroundTheoretical models as a basis for midwives’ care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts.AimTo explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals.MethodsData were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n = 16), obstetricians (n = 8), assistant nurses (n = 11) and managers (n = 8). The text from interviews was analysed using content analysis.FindingsFrom expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses.DiscussionClarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management.ConclusionsThe model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.     

Wanting to be ‘with woman’, not with machine: Midwives’ experiences of caring for women being continuously monitored in labour

ProblemSome continuous electronic fetal monitoring (CEFM) devices restrict women’s bodily autonomy by limiting their mobility in labour and birth.BackgroundLittle is known about how midwives perceive the impact of CEFM technologies on their practice.AimThis paper explores the way different fetal monitoring technologies influence the work of midwives.MethodsWireless and beltless ‘non-invasive fetal electrocardiogram’ (NIFECG) was trialled on 110 labouring women in an Australian maternity hospital. A focus group pertaining to midwives’ experiences of using CTG was conducted prior to the trial. After the trial, midwives were asked about their experiences of using NIFECG. All data were analysed using thematic analysis.FindingsMidwives felt that wired CTG creates barriers to physiological processes. Whilst wireless CTG enables greater freedom of movement for women, it requires constant ‘fiddling’ from midwives, drawing their attention away from the woman. Midwives felt the NIFECG better enabled them to be ‘with woman’.DiscussionMidwives play a pivotal role in mediating the influence of CEFM on women’s experiences in labour. Exploring the way in which different forms of CEFM impact on midwives’ practice may assist us to better understand how to prioritise the woman in order to facilitate safe and satisfying birth experiences.ConclusionThe presence of CEFM technology in the birth space impacts midwives’ ways of working and their capacity to be woman-centred. Current CTG technology may impede midwives’ capacity to be ‘with woman’. Compared to the CTG, the NIFECG has the potential to enable midwives to provide more woman-centred care for those experiencing complex pregnancies.     

Exploring Heideggerian hermeneutic phenomenology: A perfect fit for midwifery research

BackgroundHeideggerian hermeneutic phenomenology has been used widely to understand the meaning of lived experiences in health research. For midwifery scholars this approach enables deep understanding of women's and midwives’ lived experiences of specific phenomena. However, for beginning researchers this is not a methodology for the faint hearted. It requires a period of deep immersion to come to terms with at times impenetrable language and perplexing concepts.ObjectivesThis paper aims to assist midwives to untangle and examine some of the choices they face when they first come to terms with an understanding of this methodology and highlights the methodology's capacity to reveal midwifery authenticity and holistic practice.DiscussionThe illumination of a selection of various concepts underpinning hermeneutic phenomenology will inform midwives considering this methodology as suitable framework for exploring contemporary midwifery phenomena.     

Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women’s experiences and birth outcomes

IntroductionThe ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women’s experiences and birth outcomes.AimTo evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care.MethodAn anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included.FindingsThe response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6–8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes.ConclusionThis innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators.