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.     

Reducing midwife burnout at organisational level — Midwives need time,space and a positive work-place culture

BackgroundMaternity care organisations have a responsibility to ensure the health and welfare of their staff. Rates of burnout are high in midwifery compared to other professionals. Therefore, exploring how it can be reduced is imperative.AimTo explore with midwives the contributors to burnout and how best to reduce burnout in a maternity hospital in Ireland.MethodsA Participatory Action Research study involving Co-operative Inquiry meetings (n = 5) with practising midwives (n = 21) between October 2018 and March 2019, in a large, urban teaching maternity hospital in Ireland. The transcribed data were analysed using Thematic Network Analysis.FindingsSeveral recommendations were made for maternity organisations, to reduce or prevent burnout. These include improving workplace culture, increasing support and acknowledgement, offering time and space for debriefing and reflection and regular rotation of staff. Consistent staff shortages are, however, a barrier to adhering to these recommendations.ConclusionThis study is the first of its kind to offer an in-depth exploration with midwives into the main contributors of burnout and what can be done at an organisational level to reduce burnout among midwives. The findings of this study highlighted the importance of working relationships. Additionally, owing to the nature of midwifery practice, time and space need to be created for midwives to debrief and reflect. However, there is an urgent need for healthcare systems to combat staffing shortages in order for these strategies to be successful.     

The feasibility of caseload midwifery in rural Australia: A literature review

BackgroundCaseload midwifery is a continuity of care(r) model being implemented in an increasing number of Australian maternity settings. Question for review: is caseload midwifery a feasible model for introducing into the rural Australian context?MethodIntegrative literature review.FindingsFour main categories were identified and these include the evidence for caseload midwifery; applicability to the rural context; experiences of registered and student midwives and implementation of caseload midwifery models.ConclusionThere is evidence to support caseload midwifery and its implementation in the rural setting. However, literature to date is limited by small participant size and possible selection bias. Further research, including rural midwives’ expectations and experience of caseload midwifery may lead to improved sustainability of midwifery care for rural Australian women.     

Factors associated with midwives’ job satisfaction and experience of work: a cross-sectional survey of midwives in a tertiary maternity hospital in Melbourne,Australia

BackgroundSignificant factors affecting the Australian maternity care context include an ageing, predominantly part-time midwifery workforce, increasingly medicalised maternity care, and women with more complex health/social needs. This results in challenges for the maternity care system. There is a lack of understanding of midwives’ experiences and job satisfaction in this context.AimTo explore factors affecting Australian midwives’ job satisfaction and experience of work.MethodsIn 2017 an online cross-sectional questionnaire was used to survey midwives employed in a tertiary hospital. Data collected included characteristics, work roles, hours, midwives’ views and experiences of their job. The Midwifery Process Questionnaire was used to measure midwives’ satisfaction in four domains: Professional Satisfaction, Professional Support, Client Interaction and Professional Development. Data were analysed as a whole, then univariate and multivariate logistic regression analyses conducted to explore any associations between each domain, participant characteristics and other relevant factors.FindingsThe overall survey response rate was 73% (302/411), with 96% (255/266) of permanently employed midwives responding. About half (53%) had a negative attitude about their Professional Support and Client Interaction (49%), and 21% felt negatively about Professional Development. The majority felt positively regarding Professional Satisfaction (85%). The main factors that impacted midwives’ satisfaction was inadequate acknowledgment from the organisation and needing more support to fulfil their current role.ConclusionFocus on leadership and mentorship around appropriate acknowledgement and support may impact positively on midwives’ satisfaction and experiences of work. A larger study could explore how widespread these findings are in the Australian maternity care setting.     

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.     

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.     

A grounded theory study on midwifery managers’ views and experiences of implementing and sustaining continuity of carer models within the UK maternity system

BackgroundCurrent UK health policy recommends the transition of maternity services towards provision of Midwifery Continuity of Carer (MCoCer) models. Quality of healthcare is correlated with the quality of leadership and management yet there is little evidence available to identify what is required from midwifery managers when implementing and sustaining MCoCer.AimTo develop a theoretical framework that represents midwifery managers’ experiences of implementing and sustaining MCoCer models within the UK’s National Health Service (NHS).MethodsCharmaz’s grounded theory approach was used for this study. Five experienced UK based midwifery managers were interviewed to elicit views and understanding of the social processes underlying the implementation and sustaining of MCoCer. Interviews were transcribed and analysed and focus codes developed into theoretical codes resulting in an emergent core category.FindingsThe theoretical framework illustrates the core category ‘Leading Meaningful Midwifery’. To manage MCoCer models midwifery managers require a trust and belief in woman centred philosophy of care. They need the skills to focus on non-hierarchical transformational leadership and the courage to assimilate alternative models of care into the NHS. Promoting and protecting the MCoCer model within current services is essential whilst forming a culture based on high quality, safe MCoCer.DiscussionMCoCer models that have sustained within the NHS have had supportive leadership from midwifery managers who have the necessary skills, attitudes, aptitudes and behaviours identified within the findings. Sustainable implementation of MCoCer is achieved through development of a values-based recruitment and retention policy within all areas of midwifery and encouraging midwives with previous experience in MCoCer or supportive philosophies towards it, to manage the model.ConclusionProviding the appropriate support for MCoCer is time consuming and personally demanding for midwifery managers, however, implementing and sustaining MCoCer was shown by participants who valued MCoCer models to be rewarding, bringing meaning to their midwifery leadership.     

Exploring moral distress in Australian midwifery practice

ProblemAustralian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.BackgroundMoral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.AimTo explore Australian midwives experience and consequences of moral distress.MethodsSemi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.FindingsThree key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.DiscussionIt is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.ConclusionThis study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.     

‘How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites

BackgroundProvision of personalised, continuous care focused on ‘well women’ is now central to midwifery identity and work ideals, but it remains difficult in hospital contexts shaped by increased demand and by neoliberal policies. Previous accounts of occupational and work-family conflicts in midwifery and nursing have pointed to the ‘moral distress’ associated with managing conflicting expectations in health workplaces.QuestionThis paper examines these issues in the Australian context and considers further the ethical implications of midwives not feeling ‘cared for’ themselves in health care organisations.MethodsQualitative research in several Victorian maternity units included use of interviews and observational methods to explore staff experiences of organisational and professional change. Data were coded and analysed using NVivo.FindingsMidwives reported frequent contestation as they sought to practice their ideal of themselves as caregivers in what they reported as often ‘uncaring’ workplaces. To interpret this data, we argue for seeing midwifery caring as embodied social practice taking place within ‘organisation carescapes’.ConclusionTheoretical analysis of the moral and ethical dimensions of the contemporary organisational structure of maternity care suggests that a practice-based and dialogical ethic should form the core principle of care both for women in childbirth and for their carers.     

Midwives must,obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice

BackgroundThe capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring.AimTo explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring.MethodsInstitutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n = 34) and obstetricians (n = 16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed.FindingsMidwives’ work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible.Discussion and conclusionOur findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.