‘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.     

An ethnographic study of the interaction between philosophy of childbirth and place of birth

BackgroundOrganisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings.AimTo explore how childbirth is constructed and influenced by context in three birth settings in Australia.MethodThis ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6–8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16).ResultsAll home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through ‘running the gauntlet’, based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident.ConclusionsA complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.     

Exploring factors influencing adverse birth outcomes in a regional hospital setting in Ghana: A configuration theoretical perspective

BackgroundUnderstanding the complexity of factors that influence adverse childbirth outcomes at health facilities can be enhanced by the theoretical articulation of the interplay between external socio-structural and internal technical dynamics of the birthplace in context. Guided by configuration theory, this study explored the factors that influence adverse birth outcomes at a regional hospital setting in Ghana.MethodsQualitative data were collected from the Upper West regional hospital in Ghana. In-depth interviews were administered to 30 purposively selected respondents comprising 20 postpartum mothers and 10 midwives. The data was electronically audio-recorded, transcribed and analysed using thematic analysis.FindingsThe study revealed three key dimensions of socio-technical configurations shaping adverse birth outcomes within the hospital setting. These are mother-midwife personality and behavioral dynamics including personality clashes and poor communication; birth process dynamics consisting of diverse paradigms of safe birthing process and socio-technical conflicts on caesarean section; and birthplace context, comprising nature of the birthing environment, confidence in the safety of the birthplace and national health policy implementation challenges. These socio-technical interactions result in late reporting at facilities by mothers and delay in care delivery by midwives, contributing to adverse birth outcomes.ConclusionIn line with configuration theory, our study positions the influences of adverse birth outcomes in hospital settings in alignment with a subtle and iterative interplay of socio-technical factors. To comprehensively address adverse birth outcomes in hospital settings, health policymakers and practitioners need to understand and contextualise the socio-technical interactions that shape notable outcomes at specific hospital settings.     

The influence and meaning of the birth environment for nulliparous women at a hospital-based labour ward in Sweden: An ethnographic study

BackgroundLabour and birth are sensitive physiological processes substantially influenced by environmental and psychosocial factors.AimTo explore the influence and meaning of the birth environment for nulliparous women giving birth in either one of two differently designed birthing rooms at a hospital-based labour ward.MethodsFive months of ethnographic fieldwork was conducted at a labour ward in Sweden, consisting of participant observations of 16 nulliparous women giving birth in either a ‘Regular’ birthing room (n = 8) or a specially designed, ‘New room’ (n = 8). Data included field notes, informal interviews, reflective notes, and individual interviews with eight women after birth. The data was analysed through an ethnographic iterative hermeneutic analysis process.FindingsThe analysis identified the birth environment as consisting of the physical space, the human interaction within it, and the institutional context. The analytic concept; Birth Manual was conceived as an instrument for managing labour in accordance with institutional authority. Significant to the interpretation of the influence and meaning of the birth environment were two abstract rooms: an Institutional room, where birth was approached as a critical event, designating birthing women as passive; and a Personal room, where birth was approached as a physiological event in which women’s agency was facilitated.ConclusionInstitutional authority permeated the atmosphere within the birth environment, irrespective of the design of the room. A power imbalance between institutional demands and birthing women’s needs was identified, emphasising the vital role the birth philosophy plays in creating safe birth environments that increase women’s sense of agency.     

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.     

Functional discomfort and a shift in midwifery paradigm

ObjectiveTo determine and critically examine maternity attitudes surrounding labour pain and how midwives can best facilitate women navigating intrapartum discomfort without relying on ‘pain-relief’ strategies or immediate recourse for analgesic assistance.ApproachThis article examines current literature using seminal research and wider international perspectives, exploring the complex and fluctuating needs of women negotiating the composite factors of labour discomfort are investigated.FindingsFactors such as birth environment, fear, midwifery presence, and self-efficacy, have a significant impact on the uptake of intrapartum analgesia. A holistic view of intrapartum discomfort is needed to shift the current paradigm of pathologising labour pain into one which situates it as a source of positive physiology and functional discomfort.ConclusionContinuing to practice with a pharmacological outlook, aiming to rid the labouring body of discomfort, is reductionist for both midwives and women. Midwives must seek to employ a new lexicon with which to communicate and facilitate women within the dynamic and continually changing territory of labour. If this conceptual shift is realised, the subsequent positive sequalae of women rediscovering their innate birthing capabilities could create a situation where birth can be considered as an aesthetic peak experience, improving satisfaction on both sides of the midwife-mother diad.     

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.     

The overuse of intrapartum cardiotocography (CTG) for low-risk women: An actor-network theory analysis of data from focus groups

BackgroundThere is an overuse of cardiotocography for intrapartum fetal monitoring for low-risk women in high-income countries, despite recommendations from evidence-based guidelines.AimTo understand why midwives use cardiotocography for low-risk women despite evidence-based recommendations and to understand the roles of the cardiotocograph machine.MethodThis qualitative study used focus groups for data collection. Thirty-one midwives and three student midwives participated from four different countries: New Zealand, Australia, Denmark, and Norway. Constant comparative analysis, informed by an actor-network theory framework, was the method of data analysis.FindingsCardiotocography was multifaceted and influenced all attendants in the birth environment. The cardiotocograph itself is assigned different roles within the complex networks surrounding childbirth. The cardiotocograph’s roles were as a babysitter, the midwives’ partner, an agent of shared responsibility, a protector that ‘covers your back’, a disturber of normal birth, and a requested guest.DiscussionThe application of the actor-network theory enabled us to understand how midwives perceive cardiotocography. The assigned roles of the cardiotocograph shape its everyday use more than evidence-based guidelines. Discussion of these inconsistencies must inform the use of cardiotocography in the care of women with low-risk pregnancies.ConclusionWe found that the cardiotocograph is a multifaceted actant that influences practice by performing different roles. Drawing on this study, we suggest that actor-network theory could be a helpful theoretical perspective to critically reflect upon the increasing use of technologies within 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.     

Midwives’ views of traditional birth attendants within formal healthcare in Nigeria

BackgroundDiscourses around the journey to motherhood in many poorly-resourced countries, particularly in the sub-Saharan African region, with no link to death and danger are limited. The custodians of traditional practices – the traditional birth attendants – are often blamed for the high maternal deaths in this region. Conventional institutional and international thinking about traditional birth attendants is that they are dangerous and therefore should no longer be allowed to practice.AimTo explore midwives’ views of traditional birth attendants’ place within formal healthcare settings in Nigeria.MethodsHermeneutic phenomenological and poststructural feminist approaches were used. Seven midwives volunteered for semi-structured individual face to face interviews.FindingsThe responses of the midwives were diverse and conflicting. Some midwives believe that the traditional birth attendants should be banned, arguing that they are responsible for low uptake of hospital-based maternity care by women which in turn leads to an increase in maternal deaths. Contrastingly, other midwives expressed a view that the traditional birth attendants ‘cannot be phased out’ due to their valid contributions, particularly in the rural areas where access to formal maternity care is limited by intractable structural problems.ConclusionPolicy makers need to reconsider the role of traditional birth attendants. This should involve not only their integration into formal healthcare to work alongside formally trained maternity care providers, but also fostering a healthcare atmosphere where respect and recognition of each practitioner’s skill is paramount.     

Feasibility,acceptability and sustainability of postpartum contraceptive implant provision by midwives in NSW public hospitals

BackgroundRepeat pregnancy in the first year after a birth is common. Many of these conceptions are unintended and may be prevented by providing access to contraception in the immediate postpartum period. Midwives in the hospital setting could potentially play a greater role in improving postnatal contraception information and provision.AimWe sought to implement and examine the success of a program training hospital-based midwives in immediate postpartum implant insertion.MethodsThis mixed methods study in two hospitals in New South Wales sought to explore the feasibility, acceptability and sustainability of a program that provided competency-based implant insertion training for midwives. The study documented training completion, implant insertion numbers and experience, and conducted end of study interviews with midwives and stakeholders.FindingsTwenty-seven midwives undertook training and inserted 265 implants during the study period. Interviews with 13 midwives and 11 stakeholders concluded the program to be feasible and acceptable with midwives reporting high satisfaction from their involvement. All interviewees felt that midwives were well placed to insert implants, and reported that challenges around workload and opportunities for practice were generally manageable. It was recognised that sustainability of the program would require supportive policy and regular insertion opportunities.ConclusionsMidwives successfully upskilled in implant insertions and there was widespread support for the program with expectations it would be sustained. Provision of contraceptive information and implant insertion by midwives in the immediate postpartum period is likely to increase contraceptive choice and access for women and contribute to reducing rapid repeat pregnancies.     

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.     

What are the facilitators,inhibitors, and implications of birth positioning? A review of the literature

BackgroundFrom the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position.AimTo undertake a review of the literature reporting the impact of birth positions on maternal and perinatal wellbeing, and the factors that facilitate or inhibit women adopting various birth positions throughout the first and second stages of labour.MethodsA search strategy was designed to identify the relevant literature, and the following databases were searched: CINAHL, CIAP, the Cochrane Database of Systematic Reviews, Medline, Biomed Central, OVID and Google Scholar. The search was limited to the last 15 years as current literature was sought. Over 40 papers were identified as relevant and included in this literature review.ResultsThe literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour, have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour and birth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth.ConclusionUnderstanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.     

Contraception provision in the postpartum period: Knowledge,views and practices of midwives

BackgroundWomen are susceptible to unintended pregnancies in the first year after giving birth, particularly as consideration of contraception may be a low priority during this time. Discussing and providing contraception before women leave hospital after giving birth may prevent rapid repeat pregnancy and its associated risks. Midwives are well placed to assist with contraceptive decision-making and provision; however, this is not routinely undertaken by midwives in the Australian hospital setting and little is known regarding their views and experiences in relation to contraception.MethodsAn anonymous survey was conducted with midwives at two urban hospitals in New South Wales to better understand their contraceptive knowledge, views and practices regarding midwifery-led contraception provision in the postpartum period.FindingsThe survey was completed by 128 midwives. Most agreed that information about contraception provided in the postpartum period is valuable to women, although their knowledge about different methods was variable. The majority (88%) believed that midwives have a role in providing contraceptive information, and 79% reported currently providing contraceptive counselling. However, only 14% had received formal training in this area.ConclusionFindings demonstrate that most midwives provide some contraception information and believe this is an important part of a midwife’s role. Yet most have not undertaken formal training in contraception. Additional research is needed to explore the content and quality of midwives’ contraception discussions with women. Training midwives in contraceptive counselling would ensure women receive accurate information about available options. Upskilling midwives in contraception provision may increase postpartum uptake and reduce rapid repeat pregnancies.     

“I guess baby was just too comfy in there…”: A qualitative study of women's experiences of elective late-term induction of labour

BackgroundThe frequency of induction of labour (IOL) in late-term pregnancy has increased significantly, but little is known about how women with uncomplicated pregnancies experience IOL for late-term indication alone.AimTo explore how women with uncomplicated pregnancies experienced late-term IOL.MethodsQualitative interviews were conducted with 23 women who all had labour induced on late-term indication only. Participants were recruited from two Danish hospitals who offered an outpatient induction regime. The women were interviewed 4–8 weeks after birth. Data were analysed using thematic analysis.ResultsAll women had hoped for a spontaneous birth. Prolonged pregnancy was understood as the body/baby “not being ready”, but generally, the women were not worried at that point. Most women felt adequately informed about the reasons for IOL, but some requested more information and time to consider their options. The majority considered IOL to be both an offer and a recommendation. One-third of the participants were initially hesitant but chose/accepted IOL because of weariness from pregnancy and the impatience to deliver a healthy child. The opportunity of outpatient induction was generally appreciated as it allowed the women to continue everyday activities while waiting for labour to begin. Nineteen women reported having a good birthing experience. Two women felt that negative birthing experiences were partly related to IOL.ConclusionsMost women considered the late-term IOL to be a positive experience. Some women requested more information and time to consider alternatives. These women should be provided with supported opportunities to consider the options.     

Late-term pregnancy: Navigating in unknown waters — A hermeneutic study

BackgroundLate-term pregnancy is related to increased risk of serious complications for babies and women, as pregnancies proceed. Pregnancy is an individual, complex and existential situation for women, who may experience late-term pregnancy as a mentally strenuous period, characterised by worries and anxiety. However, there is a lack of studies in this area.AimTo describe women’s experiences of late-term pregnancy ≥41 gestational weeks.MethodsA lifeworld hermeneutic approach was used. Qualitative interviews were performed with ten women, two to seven months after the birth.FindingsSix themes emerged from the analysis Doubting the body’s ability to cope with the transition from pregnancy to giving birth, The importance of their partner’s support during the sea voyage, Lacking clear guidelines for the voyage, Worrying about the cargo at the end of the voyage, How the voyage turned out and Thoughts related to a future voyage.ConclusionThe women did not feel sufficiently empowered to trust their body’s ability to make the transition from late pregnancy to birth. It is vital that midwives provide clear guidance and empower women to trust the ability of their body to give birth. This transition is important in relation to positive thoughts about future pregnancies and births.     

The role of support person for Ngaanyatjarra women during pregnancy and birth

BackgroundThis study took place in a remote community on the Ngaanyatjarra Lands, Western Australia. Ngaanyatjarra women's cultural practices have been subject to erosion during the past 70 years. Women are now expected to birth hundreds of kilometres from home and, due to financial barriers, without family support. Older women lament their lack of input into, and control of, contemporary birthing services.Research questionIn order to provide culturally appropriate maternity services we asked: What issues would the Ngaanyatjarra women of the community like to see resolved in the area of antenatal and birthing services?Participants and methodsEligible participants were any Ngaanyatjarra women of the study community who had birthed at least once. We utilised a participatory research methodology. 36 women were interviewed.FindingsThis paper discusses one finding related to support for child-bearing women. The role is important in many ways. Ngaanyatjarra women did not traditionally have their support persons with them during labour and birth, nor do they necessarily expect them to be present in current times. Most women do, however, wish to have a support person with them during antenatal checkups and when they travel to town to await birth.ConclusionAboriginal women from remote communities should be able to have a support person with them when they access regional birthing services, but the nature of this role must not be assumed. A culturally appropriate service has input from the community, provides options and respects choices.