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

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

Mobile technologies and communication strategies in an urban Midwifery Group Practice setting. An exploratory study

BackgroundAround-the-clock access to a known midwife is a distinct feature of Midwifery Group Practice (MGP) and caseload midwifery settings; although the literature suggests this aspect of working life may hinder recruitment and retention to this model of care. Mobile technologies, known as mHealth where they are used in health care, facilitate access and hence communication, however little is known about this area of midwifery practice.Research questionWhich communication modalities are used, and most frequently, by MGP midwives and clients?MethodsA prospective, cross sectional design included a purposive sample of MGP midwives from an Australian tertiary maternity hospital. Data on modes of midwife–client contact were collected 24 h/day, for two consecutive weeks, and included: visits, phone-calls, texts and emails. Demographic data were also collected.FindingsDetails about 1442 midwife–client contacts were obtained. The majority of contact was via text, between the hours of 07:00 and 14:59, with primiparous women, when the primary midwife was on-call. An average of 96 contacts per fortnight occurred.ConclusionThe majority of contact was between the midwife and their primary clients, reiterating a key tenet of caseload models and confirming mobile technologies as a significant and evolving aspect of practice. The pattern of contact within social (or daytime) hours is reassuring for midwives considering caseload midwifery, who are concerned about the on-call burden. The use of text as the preferred communication modality raises issues regarding data security and retrieval, accountability, confidentiality and text management during off-duty periods. The development of Australian-wide guidelines to inform local policies and best practice is recommended.     

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.     

Sexual health-related training of Canadian midwives and its association with practice outcome

BackgroundAlthough promoting sexual health should be an integral part of midwifery practice, little is known about midwives’ preparation to address their clients’ sexual health concerns.AimsTo assess the formal and self-directed training on sexual health topics relevant to midwifery practice of Canadian midwives as well as the association between training and various practice outcomes.MethodsForty midwives registered in the Province of Ontario, Canada completed an online survey assessing their formal and self-directed sexual health training, knowledge, comfort, and practice related to 10 sexual health issues.FindingsIn terms of formal training, three of the 10 topics were coved in-depth and seven were covered in general terms only or not at all. Participants had received an average of 26.0 hours of formal training related to sexual health. Almost all (90%) participants had engaged in self-directed learning on at least one topic. Participants had asked at least one client about only 5 of the 10 topics and been asked by at least one client about 4.5 of them. Participants who reported more extensive formal training had been asked about more sexual health topics by their clients. More self-directed learning was associated with more positive attitudes toward midwives’ role in addressing sexual health concerns, feeling more knowledgeable, and being asked about and asking about more sexual health topics.ConclusionThe midwives in this sample had limited training in some important sexual health issues relevant to midwifery practice. Likely as a result, they often did not address these issues in practice.     

Drivers of job satisfaction in midwifery—A work design approach

BackgroundIdentifying common factors that influence job satisfaction for midwives working in diverse work settings is challenging. Applying a work design model developed in organisational behaviour to the midwifery context may help identify key antecedents of midwives job satisfaction.AimTo investigate three job characteristics – decision-making autonomy, empowerment, and professional recognition as antecedents of job satisfaction in New Zealand (NZ) midwives.MethodsLatent multiple regressions were performed on data from Lead Maternity Carer (LMC) midwives n = 327, employed midwives n = 255, and midwives working in ‘mixed-roles’ n = 123.FindingsWe found that professional recognition is positively linked to job satisfaction for midwives in all three work settings. At the same time, decision-making autonomy and empowerment were shown to influence job satisfaction for midwives working as LMCs only.DiscussionOur main finding suggests that the esteem generated from being acknowledged as an expert and valuable contributor by maternity health colleagues is satisfying across all work contexts. Professional recognition encompasses the social dimension of midwifery work and influences midwives job satisfaction. Decision-making autonomy and empowerment are task and relational job characteristics that may not be similarly experienced by all midwives to noticeably influence job satisfaction.ConclusionGiven that job satisfaction contributes to recruitment, retention, and sustainability, our findings show that drivers of job satisfaction differ by midwifery work context. We present evidence to support tailored efforts to bolster midwives job satisfaction, especially where resources are limited.     

Midwifery-led care in South Australia: Looking back to move forward

BackgroundFrom the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.AimTo better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.MethodsSemi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.FindingsThree overarching themes and several sub-themes were identified, these included: ‘Midwifery suffragettes’ which explored ‘activism’, ‘adversity’ and ‘advocacy’; ‘Building bridges’ captured the importance of ‘gathering midwives’, a ‘movement of women’ and ‘champions and influencers’; and ‘Recognising midwifery’ identified the strong ‘sense of identity’ needed to outface ‘ignorance and opposition’ and the importance of ‘role reformation’.ConclusionThese midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.     

Responding to catastrophe: A case study of learning from perinatal death in midwifery practice

Problem/BackgroundPerinatal death has far reaching emotional effects for all involved in this devastating event. The opportunity for learning as a result of this catastrophe, however, remains unexplored.AimTo explore midwives’ experiences of caring through, and learning from, perinatal death, to better inform the effective planning and delivery of education that optimises both midwifery and self-care.MethodsA naturalistic interpretive multiple case study design. Seventeen midwives, located in Australia, participated in an online group activity hosted as a blog, followed by telephonic focus groups and in-depth email interviews.FindingsThematic data analysis revealed seven major themes: Grappling with the reality of perinatal death; Struggling with personal and professional heartache; Seeking the space to grieve as a professional; Being with the woman and her family; Finding a new purpose; Strengthened through support; and Developing the courage to care.DiscussionThe initial turmoil and impact of loss reflected the catastrophic nature of perinatal death. Midwives uncovered a journey to acceptance and learning, realising a determination to enhance expertise and discovering value in experiential knowledge. Insecurity regarding competence and confidence to manage perinatal death and bereavement care was highlighted. However, sharing their stories revealed professional fulfilment, personal strength, and solidarity amongst midwives who have endured similar experiences.ConclusionA coordinated approach to support and the dissemination of experiential knowledge and learning could be developed within an online model of narrative sharing and discussion. Debriefing, support and sharing of expertise in this way may foster engagement within and beyond the workplace.     

Development of a tool to measure holistic reflection in midwifery students and midwives

BackgroundHolistic reflection encompasses reflection as a continuum, incorporating critical reflection, reflexivity, critical thinking and a whole-of-person approach. The development of holistic reflection in midwifery students and midwives is rarely measured in a standardised way.AimTo develop and test a tool to measure holistic reflection in midwifery students and midwives, for use in pre-registration and post-graduate education, and research.DesignThe eight-step approach to tool development by DeVellis was followed with psychometric testing of data from a cross-sectional survey.ParticipantsMidwifery students (pre-registration and postgraduate), and midwifery alumni of an Australian university.MethodsDraft items (n = 84) were generated from review of the literature, qualitative research, and a theoretical model. An expert panel (n = 19) reviewed draft items resulting in 39 items. The survey included demographic details, the draft Holistic Reflection Assessment Tool, emotional intelligence subscale, and a social desirability scale. Participants repeated the online survey at two weeks to confirm test-retest reliability.ResultsThe 187 responses were received. Exploratory factor analysis with varimax rotation revealed three factors accounting for 49% of variance. Internal consistency of the tool was high (α = .91) and test-retest reliability at two weeks (α = .93) demonstrated stability. There were low correlations between social desirability (r = .22, p < .001) and emotional intelligence (r = .21, p < .001) with the new holistic reflection scale.ConclusionsThe Holistic Reflection Assessment Tool is the first for midwifery. The tool was reliable, stable, and valid. Further research is warranted for criterion validity.     

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.     

A literature review to determine midwifery students’ perceived essential qualities of preceptors to increase confidence and competence in the clinical environment

BackgroundMidwifery students’ experiences with preceptors in the clinical environment plays an integral role in developing the confidence and competence of students. As up to 50% of the midwifery program is taught in the clinical environment, an analysis of the preceptorship role in the context of midwifery student confidence and competence may be important to inform future practice and policy.AimTo discover, whilst on clinical placement, what is required by preceptors to suitably equip midwifery students to develop confidence and competence in the clinical environment.MethodsA search of the literature was undertaken using health and midwifery related electronic databases of PubMed, CINAHL, Intermid, SCOPUS and Web of Science. Grey literature, and reference lists from studies were also part of the thorough search process.FindingsAfter critical reading of the 15 included studies, there were a number of themes identified as the preceptor qualities that contributed to student confidence and competence. Those themes include ‘belongingness’, ‘hands on experience/skill development’, ‘students’ development of professional identity’ and ‘preceptor characteristics that impact student learning’.DiscussionStudent confidence and competence can be dependent on the preceptor who supports them. There are preceptors who enable students to flourish in their confidence and competence, and there also appears to be preceptors who do not possess these qualities, which requires further enquiry.ConclusionAs the evidence appears to find that trained preceptors are optimal for student confidence and competence, further enquiry is warranted to inform policy and practice around the concept of preceptorship training for midwives.     

Experiences of and visions for collaboration between midwives and nurses in Nova Scotia

ProblemIn jurisdictions where midwifery and nursing are autonomous and separate health care professions, little is known about how they collaborate during the delivery of perinatal health care services.BackgroundMidwifery became a regulated profession in the province of Nova Scotia, Canada in 2009. Since regulation, midwives and nurses have worked together at three models sites for the delivery of midwifery services and perinatal care.QuestionHow do midwives and nurses collaborate during the provision of birthing care in Nova Scotia, Canada?MethodsThis was an instrumental case study guided by feminist poststructuralism. Individual interviews of 17 participants were audio-recorded and transcribed verbatim. Twenty-five documents were reviewed, and field notes were gathered. Feminist poststructuralist discourse analysis was used.FindingsMidwives and nurses collaborated well together. Participants described how positive collaborative experiences could influence a new way for midwives and nurses to work together. In this paper we present the theme Moving forward: A Modern Model for Nurses and Midwives working together, and its sub-themes of 1)’The birthing culture has changed’ and 2) ‘Allies and advocates’.DiscussionWithin the global context of strengthening midwifery and nursing, this study illustrated the potential for developing formal, collaborative perinatal models of care led by midwife and nurse teams to address inequities in perinatal health care services.ConclusionMidwives and nurses need more opportunities to collaborate and to build professional relationships. Establishing a midwife-led and nurse supported model of care may transform existing perinatal health care values, beliefs, and practices.     

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.     

Is it possible to incorporate evidence-based professional midwifery practices into public health services in Mexico?

Problem and backgroundDuring the past two decades, Mexico has launched innovative maternal health initiatives to improve maternal and neonatal outcomes, placing emphasis on the incorporation of professional midwifery practices into the healthcare system. This study explored the perceptions of healthcare providers and women using public birth care services regarding professional midwifery practices and how can the inclusion of evidence-based midwifery techniques improve the quality of service.MethodologyWe conducted a qualitative, cross-sectional study of three healthcare networks in Mexico. A content analysis was performed of data collected through 109 semi-structured interviews: 72 with healthcare providers and 37 with women.ResultsHealthcare providers and women had minimal knowledge of the competencies and skills of professional midwives. Medical personnel accepted the incorporation of some evidence-based midwifery practices. Women had experienced fear and anguish during childbirth so they considered that incorporating professional midwifery practices into maternal health services would be favourable in that it would render birth care more respectful.Discussion and conclusionsHealthcare providers are willing to consider the inclusion of some evidence-based midwifery practices in health services and regard assistance from professional midwives. They believe that structural conditions will complicate their incorporation. Although the women interviewed had experienced fear, anxiety and loneliness during childbirth, most of them admitted to feeling “safer” in a hospital (secondary-care health centre) setting where possible complications could be resolved. This perception of safety served to justify the delivery of healthcare in a manner that is inattentive to women’s needs, which go beyond biomedical issues and include emotions and the positive experience of childbirth.     

The impact of planning for COVID-19 on private practising midwives in Australia

ProblemThe COVID-19 pandemic response has required planning for the safe provision of care. In Australia, privately practising midwives are an important group to consider as they often struggle for acceptance by the health system.BackgroundThere are around 200 Endorsed Midwives eligible to practice privately in Australia (privately practising midwives) who provide provide the full continuum of midwifery care.AimTo explore the experience of PPMs in relation to the response to planning for the COVID-19 pandemic.MethodsAn online survey was distributed through social media and personal networks to privately practising midwives in Australia in April 2020.ResultsOne hundred and three privately practising midwives responded to the survey. The majority (82%) felt very, or well informed, though nearly half indicated they would value specifically tailored information especially from professional bodies. One third (35%) felt prepared regarding PPE but many lacked masks, gowns and gloves, hand sanitiser and disinfectant. Sixty four percent acquired PPE through social media community sharing sites, online orders, hardware stores or made masks. Sixty-eight percent of those with collaborative arrangements with local hospitals reported a lack of support and were unable to support women who needed transfer to hospital. The majority (93%) reported an increase in the number of enquiries relating to homebirth.ConclusionPrivately practising midwives were resourceful, sought out information and were prepared. Support from the hospital sector was not always present. Lessons need to be learned especially in terms of integration, support, education and being included as part of the broader health system.