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.     

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.     

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.     

‘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.     

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.     

Enhancing the midwife-woman relationship through shared decision making and clinical guidelines

The active and passive voice allocated to women within maternity service guidelines helps construct the nature of decision making. The aim of this paper is to demonstrate that by allocating women an active voice within practice guidelines serves the interest of all parties within the health care relationship. Clinical guidelines were reviewed, and electronic databases and text were searched. The findings of this paper support that applying the principles of a shared decision making framework, within clinical practice guidelines, can assist the development of a partnership relationship between midwives and women.     

Obstetric fistula and sociocultural practices in Hausa community of Northern Nigeria

Background

Obstetric Fistula is a childbirth injury that disproportionately affects women in sub-Saharan Africa. Although poverty plays an important role in perpetuating obstetric fistula, sociocultural practices has a significant influence on susceptibility to the condition.

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.     

Rumour of angels and heavenly midwives: anthropology of transpersonal events and childbirth

Some contemporary women can experience non-ordinary states of consciousness when childbearing. The purpose of this paper is to bring a ‘transpersonal’ frame to these non-ordinary states of consciousness (hereafter: NOSC). Transpersonal psychology is an interdisciplinary movement in Western science that studies ‘religious’, ‘peak’ or ‘healing’ experiences in different cultures and social contexts. Between 2001 and 2006 in Auckland, New Zealand, while engaged in anthropological fieldwork, I collected stories from mothers, fathers, and midwives who had participated in transpersonal events during childbirth.I will compare the local women's NOSC with ethnographic accounts of spirit-possession and its relationship to indigenous midwifery then revisit and reconstruct the witch-hunts of Medieval Europe from this perspective. Midwives are encouraged to learn to identify and support women's NOSC during labour and birth as many women find strength and wisdom by passing through these states in labour. The subject is also critical to men, whether they are present with women and birth as fathers or health professionals. The hoped for result of this inquiry is to revalorise NOSC among birth-giving mothers, and to educate birth attendants in this field.     

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.     

Providing perinatal loss care: satisfying and dissatisfying aspects for midwives

PURPOSE: There is limited midwifery research that focuses on midwives experiences and attitudes to providing care for women who experience the death of a baby. There is also limited research investigating care components, and evidence to inform the basis of clinical practice in Australia and internationally. This paper presents the qualitative findings of a small study that aimed to investigate midwives experience, confidence and satisfaction with providing care for women who experienced perinatal loss. PROCEDURE: Eighty-three Western Australian midwives responded to an open ended question asking them to describe the most and least satisfying aspects of their role when providing care to women who experienced a perinatal loss. Thematic analysis was used to analyse the data. FINDINGS: The analysis revealed that Australian midwives gained most satisfaction from providing skilled midwifery care that they considered made a difference to women. This was enabled when midwives were afforded the opportunity to provide continuity of midwifery carer to women throughout the labour, birth and early postnatal period. In terms of the least satisfying aspects of care, midwives identified that they struggled with the emotional commitment needed to provide perinatal loss care, as well as with how to communicate openly and share information with women. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Within the context of the study setting, midwifery care for women following perinatal loss reflects the care components espoused in the literature. There are, however, organisational issues within health care that require commitment to continuity of care and further education of practitioners to enhance outcomes for clients.     

Factors that may influence midwives work-related stress and burnout

Research questionTo determine the incidence and level of work-related stress and burnout in midwives and contributing and protective demographic factors that may influence those levels.Participants and methodAll registered midwives (152) working in two public hospital maternity units within the same health service district in NSW completed the Maslach Burnout Inventory Human Services Survey and a demographic survey including care model, shift work, lifestyle data and exercise level.FindingsThere was a response rate of 36.8% with 56 (56/152) midwives completing the surveys. Almost two thirds (60.7%) of midwives in this sample experienced moderate to high levels of emotional exhaustion, a third (30.3%) scoring low personal accomplishment and a third (30.3%) experiencing depersonalization related to burnout. Significant differences were found among groups of midwives according to years in the profession, shifts worked, how many women with multiple psychosocial issues were included in the midwife's workload and the midwife's uptake of physical exercise. Those midwives who had spent longer in the profession and exercised scored low burnout levels.ConclusionThe impact of years in the profession, shifts worked, how many women with multiple psychosocial issues were included in their workload and the midwife's level of exercise significantly affected how these midwives dealt with burnout and provided care for women. As the response rate was low, and the study cannot be generalised to the entire midwifery workforce but provides important insights for further research. Understanding factors related to burnout can benefit health care institutions financially and in terms of human costs, especially in view of consistent international shortages of midwives.     

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study

ProblemsComplications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings.AimWe explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage.MethodsEthnographic interviews of midwives with at least 2 years’ experience in birth centres and participant observation of birth centre care.FindingsWe interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives’ decision-making about transfers.Discussion & conclusionThese findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.     

Decision-making in Swiss home-like childbirth: A grounded theory study

Background

Decision-making in midwifery, including a claim for shared decision-making between midwives and women, is of major significance for the health of mother and child. Midwives have little information about how to share decision-making responsibilities with women, especially when complications arise during birth.