Subversive acts and everyday midwifery: Feminism in content and context

BackgroundMidwives are often at the forefront of political campaigns for women's empowerment, overtly advocating for women's rights and reproductive justice. However, midwives can also be found engaging in inadvertent activism on a daily basis within routine care. When casting a feminist lens over both the content and context of midwifery practice in Australia, subversive acts and opportunities for feminist reform can be found.AimTo interrogate the significance of feminism in midwifery practice, identifying feminist successes and further opportunities for implementation including: analysis of the Midwifery Standards for Practice; the primary tenets of woman-centred care; the content versus context of midwifery in Australia; and feminist opportunities for enhanced practice. This paper will discuss the importance of feminism in midwifery practice and its significance in informing optimal midwifery care.DiscussionIncorporating women's voice and respecting women's bodies and agency in the delivery of care is a fundamental component of midwifery practice. However, while the content of midwifery practice is innately feminist in its emphasis on woman-centred care, it will be argued that the context of birthing in Australia is not. The resultant effect is the emergence of victim blaming in maternity care and the construction of an archetypal ‘good birthing woman’.Implications and recommendationsMoving away from the myth of the ‘good birthing woman’ and the act of victim blaming, midwifery could instead direct its focus towards challenging the rigid systems and structures within which midwives implement care. By further embracing feminist principles midwives will ensure a truly woman-centred future.     

Implementing midwifery continuity of care models in regional Australia: A constructivist grounded theory study

Problem/backgroundStrong international evidence demonstrates significantly improved outcomes for women and their babies when supported by midwifery continuity of care models. Despite this, widespread implementation has not been achieved, especially in regional settings.AimTo develop a theoretical understanding of the factors that facilitate or inhibit the implementation of midwifery continuity models within regional settings.MethodsA Constructivist Grounded Theory approach was used to collect and analyse data from 34 interviews with regional public hospital key informants.ResultsThree concepts of theory emerged: ‘engaging the gatekeepers’, ‘midwives lacking confidence’ and ‘women rallying together’. The concepts of theory and sub-categories generated a substantive theory: A partnership between midwives and women is required to build confidence and enable the promotion of current evidence; this is essential for engaging key hospital stakeholders to invest in the implementation of midwifery continuity of care models.DiscussionThe findings from this research suggest that midwives and women can significantly influence the implementation of midwifery continuity models within their local maternity services, particularly in regional settings. Midwives’ reluctance to transition is based on a lack of confidence and knowledge of what it is really like to work in midwifery continuity models. Similarly, women require education to increase awareness of continuity of care benefits, and a partnership between women and midwives can be a strong political force to overcome many of the barriers.ConclusionImplementation of midwifery continuity of care needs a coordinated ground up approach in which midwives partner with women and promote widespread dissemination of evidence for this model, directed towards consumers, midwives, and hospital management to increase awareness of the benefits.     

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.     

Midwife experiences of providing continuity of carer: A qualitative systematic review

ProblemContinuity of carer models present positives and challenges for midwives working in them, and are difficult to sustain.BackgroundResearch shows midwifery continuity of carer improves perinatal outcomes and experiences, and is considered the optimal model of care.AimTo synthesise existing research on midwives’ experiences of providing continuity of carer and generate further understanding of what sustains them in practice.MethodsProtocol for the review was developed using PRISMA guidelines and registered with PROSPERO. 22 studies were included with original themes and findings extracted using JBI tools and synthesised using meta-ethnographic techniques. GRADE CERQual assessment of review findings showed high confidence.FindingsMidwives identified working in continuity of carer models as both fulfilling and challenging. Professional autonomy and ability to develop meaningful relationships were the most commonly cited positives, while lack of work life balance and conflict with the wider maternity team were the main challenges. 15 studies identified strategies employed by midwives which sustained them in practice.DiscussionMidwife experiences of providing continuity are impacted by personal and professional factors. Of paramount importance to sustainability of the model is the support of the wider organisation, and their alignment with principles of person-centred, relational care.ConclusionRelational models of care are desired by midwives, service users and are recommended in policy. Relational models of care must be responsive to midwives needs as well as birthing people, and therefore need to be designed and managed by those working in them and supported by the whole organisation to be sustainable.     

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.     

Australian midwives and clinical investigation: Exploration of the personal and professional impact

BackgroundThe purpose of regulation of health professionals is public protection. Concerns regarding professional conduct or midwifery care can lead to clinical investigation. Midwifery literature reveals midwives feel ill-equipped and unprepared for clinical investigation and experience stress and abreaction.AimTo explore the lived experience of clinical investigation and identify the personal and professional impact on Australian midwives.MethodSemi-structured interviews of a purposive sample of Australian midwives. Data analysis was informed by a phenomenological conceptual framework derived from Husserl, Heidegger and Merleau-Ponty.FindingsTwelve midwives were interviewed, with seven under current investigation. Discussion involved personal and professional experiences of three or more investigations each, over a period of three to five years. Most investigations were instigated by hospitals with two complaints from women. Seven participants were alleged negligent following adverse neonatal outcomes and five had misconduct allegations. Midwives were employed or in private practice and half provided homebirth services. Themes included being safe, being connected, time and being, perception and well-being.DiscussionThe investigative process involves different health services, state and national bodies using varying powers and processes over protracted time periods. Participants discussed aspects such as disrespect, inequity, powerlessness, silence and ostracization. Midwives who successfully navigated clinical investigation developed resilience through reflection on clinical practice in a culture of safety.ConclusionThe process of regulating midwives, designed to protect the Australian public, may be harming investigated midwives. Understanding the personal and professional impact of clinical investigation needs to underpin midwifery education, clinical practice, inform policy and regulatory reform.     

“I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety

BackgroundCentral fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common.AimThis qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system.MethodsAn Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n = 50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours.FindingsThe introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives’ work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system.DiscussionThe introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety.ConclusionThis research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.     

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.     

Midwives’ views of caseload midwifery – comparing the caseload and non-caseload midwives’ opinions. A cross-sectional survey of Australian midwives.

BackgroundMidwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.AimTo compare views of caseload midwifery – those working in caseload models and those in standard care models in hospitals with and without caseload.MethodsA national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.FindingsResponses were received from 542/3850 (14%) midwives from 111 hospitals – 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.ConclusionsThere was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives’ views.     

Conflicting contexts: Midwives’ interpretation of childbirth through photo elicitation

IntroductionThis study seeks to explore midwives’ perceptions about childbirth and in particular their beliefs about normality and risk. In the current climate of increasing interventions during labour, it is important to understand the thought processes that impact on midwifery care in order to examine whether these beliefs influence midwifery clinical decision-making.Method12 Midwives who worked in a variety of metropolitan hospitals in Sydney, Australia were interviewed about how they care for women during labour. The study utilised an inductive qualitative design using photo elicitation during the interview process.ResultsSix themes emerged from the data that clearly indicated midwives felt challenged by working in a system dominated by an obstetric model of care that undermined midwifery autonomy in maintaining normal birth. These themes were: desiring normal, scanning the environment, constructing the context, navigating the way, relinquishing desire and reflecting on reality. Most midwives felt they were unable to practice in the manner they were philosophically aligned to, that is, promoting normal birth, as the medical model restricted their practice.DiscussionThe polarised views of childbirth held by midwives and obstetricians do little to enhance normal birth outcomes. Midwives in this study expressed frustration that they were unable to practice midwifery in a way that reflected their belief in normal birth. This, they cite is a result of the oppressive obstetric model prevalent in maternity care facilities in Sydney and the over use of technological interventions during childbirth.