Epidurals during normal labour and birth — Midwives’ attitudes and experiences

BackgroundMidwives have their own beliefs and values regarding pain during childbirth. Their preferences concerning labour pain management may influence women’s choices.AimTo gain a deeper understanding of midwives’ attitudes and experiences regarding the use of an epidural during normal labour.MethodsA qualitative approach was chosen for data collection. Ten in-depth interviews were conducted with midwives working in three different obstetric units in Norway. The transcribed interviews were analysed using Malterud’s systematic text condensation.FindingsThe analysis provided two main themes: “Normal childbirth as the goal” and “Challenges to the practice, knowledge, philosophy and experience of midwives”. Distinctive differences in experiences and attitudes were found. The workplace culture in the obstetric units affected the midwives’ attitudes and their midwifery practice. How they attended to women with epidural also differed. An epidural was often used as a substitute for continuous support when the obstetric unit was busy.DiscussionMidwives estimate labour pain differently, and this might impact the midwifery care. However, midwives’ interests and preferences concerning labour pain management should not influence women’s choices. Midwives are affected by the setting where they work, and research highlights that an epidural might lead to a focus on medical procedures instead of the normality of labour.ConclusionMidwives should be aware of how powerful their position is and how the workplace culture might influence their attitudes. The focus should be on “working with” women to promote a normal birth process, even with an epidural.     

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.     

Midwives’ provision of health promotion in antenatal care: A qualitative explorative study

ProblemStudies indicate that health promotion in antenatal care can be improved. Moreover, a schism seems to exist between health promotion and prevention in antenatal care.BackgroundAntenatal care to support and improve maternal health is a core midwifery activity in which prevention as well as HP and woman-centeredness are important.AimTo explore how Danish midwives experienced antenatal care and practiced health promotion.MethodsMidwives undertaking antenatal care were interviewed individually (n = 8) and two focus groups (n = 10) were created. Thematic analysis was performed inductively, and the theoretical models from Piper’s health promotion practice Framework for midwives were used to analyse the midwives’ health promotion approach.FindingsTwo major themes were highlighted. Theme 1: ‘The antenatal care context for health promotion’ described factors contributing to quality in health promotion in antenatal care, such as communication and building relationships with the pregnant women. Theme 2: ‘The health promotion approach in antenatal care’ described both midwife-focused and woman-focused approaches to pregnant women’s health. Barriers to high-quality antenatal care and a holistic health promotion approach were identified, such as shared-care issues, documentation demands and lack of time.DiscussionThe midwives’ experiences were discussed in the context of a health promotion approach. Why midwives practice using a midwife-centred approach has many explanations, but midwives need to learn and help each other understand how they can practice woman-focused care while simultaneously providing prophylactic, evidence-based care.ConclusionMidwives mainly had a midwife-focused approach. To further promote women’s health, midwives need to focus on a woman-focused approach.     

Midwives’ experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies

ProblemWomen’s autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife’s willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines.BackgroundWomen’s reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives’ and their perception of personal/professional risk in such situations.AimTo synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations.MethodsSystematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings.FindingsEight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women’s rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of ‘being torn’, and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to.ConclusionMaternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women’s right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.     

Midwives’ comprehension of care for women with intellectual disability during pregnancy and childbirth: An open-ended questionnaire study in Sweden

BackgroundFew studies have investigated midwifery care for women with intellectual disability (ID).AimTo gain a deeper understanding of midwives’ comprehension of care for women with ID during pregnancy and childbirth.MethodsA cross-sectional study among 375 midwives at antenatal clinics and delivery wards in Sweden. Findings 2476 quotations were sorted into six categories: information; communication and approach; the role of the midwife; preparing for and performing interventions and examinations; methods and assessments; and organisation of care. The midwives affirmed that individual, clear and repeated information together with practical and emotional support was important for women with ID. The midwives planned the care as to strengthen the capacity of the women, open doors for the unborn child and reinforce the process of becoming a mother. Extra time could be needed. They tried to minimise interventions. The midwives felt a dual responsibility, to support the mother–child contact but also to assess and identify any deficits in the caring capacity of the mother and to involve other professionals if needed.ConclusionsThe midwives described specially adapted organisation of care, models of information, practical education and emotional support to facilitate the transition to motherhood for women with ID. They have a dual role and responsibility in supporting the woman, while making sure the child is properly cared for. Healthcare services should offer a safe and trusted environment to enable such midwifery care. When foster care is planned, the society should inform and co-operate with midwives in the care of these women.     

Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives

BackgroundHealth inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman’s vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care.AimTo explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand.MethodInductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care.FindingsA total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings.ConclusionMidwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.     

Midwives’ practices and knowledge about fear of childbirth and postpartum posttraumatic stress disorder

BackgroundWomen suffering from fear of childbirth and postpartum posttraumatic stress disorder are often not recognised by health care professionals.AimTo evaluate practices, knowledge and the attitudes of midwives towards women with fear of childbirth and postpartum posttraumatic stress disorder.MethodsA cross-sectional study was performed amongst midwives who work in community practices and hospitals in the Netherlands with the use of a questionnaire purposefully designed for this research aim.Findings257 midwives participated in the study, of whom 217 completed all items in the questionnaire. Midwives were better equipped to answer knowledge questions concerning fear of childbirth than posttraumatic stress disorder (regarding symptomatology, risk factors, consequences and treatment). When tending to women with fear of childbirth or (suspected) postpartum posttraumatic stress disorder, most midwives referred to another caregiver (e.g. psychologist). Most midwives expressed a positive and compassionate attitude towards women with fear of childbirth and postpartum posttraumatic stress disorder.DiscussionThe majority of midwives are well informed with respect to fear of childbirth, but knowledge of important aspects of postpartum posttraumatic stress disorder is often lacking. Midwives report no crucial issues related to their attitudes towards women with fear of childbirth and posttraumatic stress disorder. Most midwives provide adequate organisation of care and support.ConclusionMidwives should acquire more in depth knowledge of fear of childbirth and postpartum posttraumatic stress disorder. This can be achieved by including the two conditions in the program of midwifery education.     

Antenatal asthma management by midwives in Australia — Self-reported knowledge,confidence and guideline use

BackgroundAsthma affects approximately 12.7% of pregnant women in Australia. Increased maternal and infant morbidity is closely associated with poorly controlled asthma during pregnancy. Midwives are well placed to provide antenatal asthma management but data on current asthma management during pregnancy is not available, nor is the use of guidelines for clinical practice by this health professional group.AimTo explore self-reported antenatal asthma management provided by midwives across Australia and how this reflects guideline recommendations.MethodAn online survey was developed and distributed throughout Australia via the Australian College of Midwives, social media and healthcare facilities.ResultsResponses from 371 midwives were obtained. Ten percent of midwives rated their knowledge as ‘good’ and 1% as ‘very good’, with 39% ‘poor’ or ‘very poor’. Being ‘somewhat’ or ‘not at all’ confident to provide antenatal asthma management was noted by 87% of midwives. Clinical guidelines were referred to by 50% of midwives and 40% stated that their main role was to refer women to other healthcare professionals. Only 54% reported that a clear referral pathway existed. Most respondents (>90%) recognised key recommendations for asthma management such as smoking cessation, appropriate vaccinations, and the continuation of prescribed asthma medications.ConclusionAlthough midwives appear aware of key clinical recommendations for optimal antenatal asthma management, low referral to clinical practice guidelines and lack of knowledge and confidence was evident. Further research is required to determine what care pregnant women with asthma are actually receiving and identify strategies to improve antenatal asthma management by midwives.