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’ role in the provision of maternal and childhood immunisation information

ProblemInactivated influenza vaccine and diphtheria-tetanus acellular pertussis vaccine are routinely recommended during pregnancy to protect women and their babies from infection. Additionally, the hepatitis B vaccine is recommended for infants within the first week of life; however, little is known about midwives’ experiences of recommending and delivering these immunisations.BackgroundMidwives are a trusted source of vaccine information for parents and the confident provision of information about immunisation during antenatal clinic visits has been found to increase the uptake of antenatal and childhood vaccines.AimThis study aims to explore midwives’ experiences of discussing maternal and childhood immunisation with women and their partners and their confidence in answering parent’s questions.MethodsWe conducted 23 semi-structured interviews with registered Australian midwives working in public and private hospital settings, and in private practice.FindingsMidwives find negotiating the requirement to recommend immunisation within a women-centred framework challenging at times. The vast majority of midwives described their education on immunisation as inadequate and workplace issues, such as time pressure, were identified as further barriers to effective communication about immunisation.Discussion/conclusionThe provision of immunisation training within midwifery education and continued professional development is critical. Appropriately resourcing midwives with the necessary infrastructure, education and resources to fully inform parents about immunisation may have a positive impact on vaccine uptake.     

The future in their hands: Graduating student midwives’ plans,job satisfaction and the desire to work in midwifery continuity of care

BackgroundMidwife-led continuity of care models benefit women and the midwives who work in them. Australian graduate midwives are familiar with, and educated to provide, continuity of care to women although the opportunity to work exclusively in positions providing continuity of care on graduation is uncommon.AimTo explore the immediate and aspirational employment plans and workforce choices, reasons for staying in midwifery and perceptions around factors likely to influence job satisfaction of midwives about to graduate from one Australian university during the years 2012–2016.MethodsThis longitudinal study draws on survey responses from five cohorts of midwifery students in their final year of study.FindingsNinety five out of 137 midwifery students responded to the survey. Almost nine out of ten respondents either aspired to work in a continuity of care model or recognised that they would gain job satisfaction by providing continuity of care to women. Factors leading to job satisfaction identified included making a difference to the women for whom they care, working in models of care which enabled them to provide women with ‘the care I want to give’, and having the ability to make autonomous midwifery decisions.ConclusionAligning early graduate work experiences with continuity of care models may have a positive impact on the confidence and professional development of graduate midwives, which in turn may lead to greater satisfaction and retention among a workforce already committed to supporting the maternity healthcare reform agenda.     

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.     

Research capacity building in midwifery: Case study of an Australian Graduate Midwifery Research Intern Programme

BackgroundHaving the research capacity to identify problems, create new knowledge and most importantly translate this knowledge into practice is essential within health care. Midwifery, as well as other health professions in Australia, is challenged in building its research capacity to contribute evidence to inform clinical practice.AimThe aim of this project was to evaluate an innovative Graduate Midwifery Research Intern Programme offered at a tertiary obstetric hospital in Western Australia, to determine what was working well and how the programme could be improved.MethodA case study approach was used to gain feedback from graduate midwives within a Graduate Research Intern (GRI) Programme. In addition outcomes were compiled of all projects the GRI midwives contributed to. Six GRI midwives participated in a survey comprising of four open ended questions to provide feedback about the programme.ResultsFindings confirm that the GRI programme increased the graduates understanding of how research works, its capacity to define a problem, generate new knowledge and inform clinical practice. The GRI midwives’ feedback suggested the programme opened their thinking to future study and gave them enhanced insight into women's experiences around childbirth.ConclusionTo grow our knowledge as a professional group, midwives must develop and promote programmes to build our pool of research capable midwives. By sharing our programme evaluation we hope to entice other clinical settings to consider the value in replicating such a programme within their context.     

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.     

Neonatal resuscitation training for midwives in Australia: A discussion of current practice

BackgroundMore than 300,000 babies are born in Australia each year, with almost 20% of newborns requiring some form of neonatal resuscitation at birth. The most common first responders to a neonatal resuscitation emergency are midwives. While the Australian and New Zealand Council on Resuscitation guides midwives’ practice during a neonatal resuscitation, each state and territory uses varying strategies to train and assess midwives proficiency in neonatal resuscitation.AimTo examine the neonatal resuscitation training requirements for midwives and raise awareness for the lack of consistency in training in Australia.DiscussionA significant variation was found in the teaching methods and frequency of training for neonatal resuscitation across Australia. Neonatal resuscitation is mandated through a state-wide guideline or policy in only four of the states with seven formal neonatal resuscitation training programs used across seven states and territories. Although a multi-modal approach to learning is present in all of the programs, the combination of teaching methods differ.Conclusion and RecommendationsA standardised, evidence-based training program is required to ensure consistency in training for midwives in Australia. Multi-modal learning is common across all current training programs; however, the best combination of multi-modal teaching methods needs to be determined. Neonatal resuscitation training needs to occur at least annually, as recommended by the Australian and New Zealand Council on Resuscitation.     

Do midwifery International clinical placements influence students’ practice and employment decisions?

AimThe aim of this study was to investigate whether an International two-week clinical maternity placement enhances, and is beneficial, to midwifery students’ future practice and employment decisions during the final year of an undergraduate degree.BackgroundInternational placements are common in undergraduate pre-registration nursing midwifery university curricula, with the emphasis on preparing students to work with diverse women in multicultural environments whilst incorporating cultural competence. However, little is known as to whether an International placement influences future graduate’s work place choice.MethodsUsing a qualitative approach, focus groups were undertaken with 16 final year midwifery students from a University in Western Australia who had experienced a two-week International clinical midwifery placement in Tanzania (Africa) or Manilla (Philippines). Data was analysed using thematic analysis.FindingsThe results of the study revealed eight over-arching themes that revealed an increase in midwifery student’s confidence; an awareness of the need to consolidate knowledge and skills, reinforcement of their own career aspirations, midwifery beliefs and trust in women and physiological birth.ConclusionThis study confirms the benefits of overseas clinical placements, which provide opportunities beyond developing cultural sensitivity. Midwifery students are challenged to develop not only practical competence, but confidence to trust in themselves and the process of physiological birth. These experiences validate theoretical learning and provide opportunity to reflect on the possibilities of future employment and decision making as a midwife.     

Midwives’ perceptions of the performance- and transition into practice of newly qualified midwives,a focus group study

ProblemNewly qualified midwives in the Netherlands perceive the adaptation to new responsibilities as difficult due to the autonomous nature of- and required accountability for the work they face in practice.BackgroundAll Dutch newly qualified midwives are accountable for their work from the moment of registration while usually working solistically.AimThis paper explores the perceptions of experienced midwives regarding: (1) the performance- and transition into practice of newly qualified midwives, and (2) their supporting role in this transition.MethodsThe design of this study is qualitative with focus groups. Experienced midwives’ perceptions were explored by means of seven semi-structured focus groups (N = 46 participants) with two meetings for each focus group.FindingsCommunity-based and hospital-based midwives perceived newly qualified midwives as colleagues who did not oversee all their tasks and responsibilities. They perceived newly qualified midwives as less committed to the practice organisation. Support in community-based practices was informally organised with a lack of orientation. In the hospital-based setting, midwives offered an introduction period in a practical setting, which was formally organised with tasks and responsibilities. Experienced midwives recognised the need to support newly qualified midwives; however, in practice, they faced barriers.DiscussionThe differences in experienced midwives’ expectations of newly qualified midwives and reality seemed to depend on the newly qualified midwives’ temporary working contracts and -context, rather than the generational differences that experienced midwives mentioned. Dutch midwives prioritised their work with pregnant individuals and the organisation of their practice above supporting newly qualified midwives.     

Midwives and sexual violence: A cross-sectional analysis of personal exposure,education and attitudes in practice

BackgroundAround one in three women experience sexual violence during their lifetime. They may need trauma-sensitive maternity care that takes sexual trauma triggers into account. Midwives are similarly likely to have experienced sexual violence in their lifetime. It is unknown whether midwives with a personal sexual violence history have a different professional approach to the topic than their colleagues without such history.AimTo explore whether midwives with a personal sexual violence history are more likely to have received or need education about sexual violence and whether they approach sexual violence differently in practice.MethodsAn exploratory online survey was conducted amongst practicing midwives in high resource countries. Odds ratios were calculated for differences between midwives with and without a personal sexual violence history.FindingsOf the 288 participating midwives, 48.6% disclosed a personal sexual violence history. Midwives with a personal sexual violence history showed higher uptake of post-graduate education (OR 2.05, 95% CI 1.23–3.44), more accurate prevalence estimation (OR 3.42, 95% CI 2.10–5.57) and more confidence to identify sexual violence history (OR 1.94, 95% CI 1.19–3.15). We found no differences in requiring future education, screening practices, other aspects of confidence or time and discomfort barriers.ConclusionsAs fellow survivors, midwives with a personal sexual violence history have a unique standpoint towards sexual violence in maternity care practice that may make them more sensitive to the issue.     

Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience

BackgroundOne of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area.AimThe aim of the study was to explore experienced midwives’ decision-making processes in their assessments for episiotomy during birth.Methods43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes.FindingsFour themes were identified, ‘Optimising Perineal Function’, ‘Red Flags to Stimulate Decision-Making’, ‘The Midwives’ Episiotomy’ and ‘Infiltration as a Catalyst for Birth’.DiscussionMidwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth.ConclusionThis study provides valuable insight into the cues that guide experienced midwives’ decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.     

Facilitators of and barriers to providing high-quality midwifery education in South-East Asia—An integrative review

BackgroundWith a diversity in midwifery education across the South-East Asia region, and with the knowledge about the lifesaving competency of the midwife profession, this study’s aim is to describe facilitators of and barriers to providing high-quality midwifery education in South-East Asia.MethodsInspired by Whittemore and Knafl, we conducted a systematic integrative literature review including the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results. The literature searches were conducted in October 2020 in the databases CINAHL, PubMed, and Scopus. A deductive data analysis based on global standards was performed.ResultsThe search identified 1257 articles, 34 of which were included. Countries in South-East Asia did not fully comply with the ICM global standards. Midwifery education was not separated from that of nursing, and educators lacked formal qualifications in midwifery. Curriculum implementation in the clinical area was a key barrier to achieving learning outcomes. Higher academic education for midwifery educators and mentorship programs facilitated the pedagogic and assessment process, focusing on the abilities of critical thinking, reflection, and decision-making.ConclusionsCountries in South-East Asia still have a long way to go before they can provide high-quality midwifery education. The identified facilitators can lead to a difference in students’ academic achievement and confidence in their clinical work. Coordinated actions will enable the progress in achieving competent midwives matching national health priorities. The findings highlight a need for more research on midwifery education in both theory and practice across the region.     

Talking testing: Impact of a training intervention on midwives’ antenatal HIV,hepatitis B and hepatitis C screening practice

BackgroundMidwives play a critical role in ensuring that HIV, hepatitis B and hepatitis C screening occurs during early pregnancy, in accordance with national consensus guidelines and policies. Limited opportunities exist for midwives to gain the knowledge, skills and confidence required to initiate testing discussions at the first antenatal visit.AimTo design, deliver and evaluate a workforce education intervention to build midwives’ capacity to initiate testing for HIV and viral hepatitis.MethodVictorian midwives were invited to enrol in an intervention which comprised a pre-learning package and a one-day study day covering clinical, epidemiological and psychosocial aspects of HIV, hepatitis B and hepatitis C testing in early pregnancy. A pre-/post-test design, incorporating a survey with eight knowledge items and four confidence items, was used to measure impact.FindingsOf the 69 participating midwives, 55 completed the pre-survey, 69 completed the post-survey and 19 completed a three-month follow up survey. Participant knowledge improved across all domains, with the most significant increases in the areas of HIV and viral hepatitis testing, transmission and treatment. Midwives’ confidence levels increased following the intervention, and this was generally sustained among the smaller sample at the three-months.ConclusionOur findings demonstrate that short educational interventions, designed and delivered by content experts, result in longer-term improvements in clinical practice which are crucial to ensuring women and their partners are given adequate information and recommendations about screening for HIV, hepatitis B and hepatitis C and during pregnancy.     

Midwifery in Middle Eastern and North African countries: A scoping review

BackgroundWhile midwives are positioned as critical providers for improving sexual, reproductive, maternal and newborn health outcomes in the Middle East and North African (MENA) countries, the standards of midwifery have not been explored systematically in this region.AimThe purpose of this scoping review was to provide an overview of existing literature on midwifery practice, education, and regulation in MENA countries in the context of ICM standards.MethodsA search was conducted inclusive of English and Persian written studies published between 2000 and 2019 in CINAHL plus; Ovid MEDLINE; PubMed; Scopus; and grey literature. Title and abstract and full-text review were performed in Covidence, and data extraction and synthesis performed using NVivo 12.ResultsThe initial search identified 7,994 articles. Overall, 139 studies were included in the review. Although, the primary concept of most included studies was “midwifery practice”, “midwifery regulation” was addressed in limited way. Approximately 90% were from Middle Eastern countries. Forty-two per cent of studies used cross-sectional designs, and most originated from Iran, Jordan, and Palestine. Diversity was found in midwifery education, practice and regulation across the MENA countries. Midwives from different nations had uneven levels of proficiency, scope of practice, and education. Midwifery curricula were aligned with ICM competencies in some countries. Most countries had midwifery associations and were members of ICM. Some countries had regulations recognising midwifery as an autonomous profession.ConclusionMidwifery practice, education and regulation in MENA countries were not always comparable with ICM standards, although some progress was evident.     

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 an evidence-based intervention to reduce caesarean section rates in Ireland

ProblemA worldwide increase of caesarean section (CS) rates has been estimated at a rate of 4% per year and numerous interventions to reduce the rates have not been successful, perhaps because they are not acceptable to clinicians.BackgroundA caesarean section (CS) can be a life-saving operation, but has been associated with short- and long-term risk factors and shown to affect subsequent pregnancies.AimTo explore midwives’ views on CS rates and evaluate the feasibility and acceptability of an evidence-based intervention programme (REDUCE) designed to decrease overall CS rates in Ireland by 7%.MethodsFollowing ethical approval, a qualitative exploratory design was used to seek midwives’ views of the evidence-based intervention. A total of 28 midwives from one large tertiary maternity hospital took part in four focus group interviews. Data were analysed using thematic analysis.FindingsFive themes emerged, illustrating the midwives’ views of what could be improved in the present system and how CS rates could be reduced in future. The themes included: (i) Induction of labour; (ii) Education; (iii) Auditing of practice; (iv) Clinical practice; (v) Midwife-Obstetrician collaboration.DiscussionThis study noted a rising CS rate year on year, with a rate of 37% at the time of the study, and the midwives voiced their very real concerns over the increased high rates.ConclusionThe study provided support for the evidence based ‘REDUCE’ intervention, which now needs to be tested empirically within this Irish population.