No one asked us: Understanding the lived experiences of midwives providing care in the north west suburbs of Melbourne during the COVID-19 pandemic: An interpretive phenomenology

ProblemWithin the Victorian healthcare system, a rapid response to the COVID-19 pandemic has necessitated frequent and ongoing changes to midwifery practice.BackgroundMidwives are a vital workforce at risk of burnout, attrition, and trauma. Emotional consequences of the pandemic for midwives remain largely unknown.AimTo understand the lived experiences of midwives providing care in the north west suburbs of Melbourne, Victoria during the pandemic.MethodsPurposive and snowball sampling facilitated the recruitment of eight midwives in the north west suburbs of Melbourne, Victoria. Semi-structured interviews were audio recorded and transcribed, occurring via telephone or video between September and October 2020. Interpretive phenomenology was the methodology used, informed by the writings of Heidegger and Gadamer.FindingsInsights gleaned from the data embody a range of understandings. The unknown cost of change and adaptation; waves of the virus; balancing risk; telehealth; personal protective equipment; stripping away support; the privilege of abiding by the restrictions; separation, distress, uncertainty; and, professional strength.DiscussionExperiences of midwives during the pandemic are characterised by sensations of voicelessness and professional invisibility. Distinctive differences in personal wellbeing and professional satisfaction exist between midwives working with and without continuity of care.ConclusionThis paper voices the lived experiences of Victorian midwives, in the midst of an extended lockdown, during the COVID-19 pandemic. Knowledge obtained from this research provides important understandings for leaders, policymakers, and healthcare systems, in planning a long-term response to the pandemic that supports the wellbeing and longevity of a vital workforce.     

The experience of rural midwives in dual roles as nurse and midwife: “I’d prefer midwifery but I chose to live here”

ObjectiveTo explore and describe the experiences of working in the dual role as nurse and midwife in rural areas of far north Queensland, Australia.MethodThe methodology was informed by Heidegger's interpretive phenomenological philosophy and data analysis was guided by van Manen's analytical approach. Data was generated by conversational interviews. Eight midwives working in a dual role as midwife and nurse were interviewed individually.FindingsThree themes were identified: Making choices between professional role and lifestyle: “Because I choose to live here”; Integration of maternity and general nursing: “All in together this fine weather” and: “That's part of working in a small place”.ConclusionParticipants recognized that in rural areas it is important to be a multi-skilled generalist; however they were concerned that midwifery skills could be eroded or even lost with the diminishing amounts of midwifery work available. Appropriate re-structuring of maternity services could provide better use of the midwifery workforce in rural centres, and reduce the current problems associated with transferring birthing mothers to larger facilities. Further research is needed to examine the extent to which the requirement to work in a dual, or multifaceted role is an impediment to the recruitment and retention of midwives to rural areas.     

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.     

Salutogenic qualities of midwifery care: A best-fit framework synthesis

BackgroundAlthough midwifery care is wellness-based and promotes normal physiology, it exists within a medical model that focuses on risk aversion and disease prevention. Salutogenic theory could provide an alternative approach to midwifery care, supporting health-promoting factors, rather than solely avoiding adverse events.AimsThe aim of this study was to explore women’s experiences of their midwifery care and identify salutogenic aspects of midwifery care.MethodsBest-fit framework synthesis was used to analyse 349 quotes about women’s experiences of midwifery care from 31 qualitative studies in ten high-income countries. Key salutogenic concepts of comprehensibility, manageability and meaningfulness were used as the basis for coding, and thematic analysis was used to expand and clarify the framework to best fit the data.FindingsDefinitions for the salutogenic aspects of midwifery care were developed. Comprehensibility (cognitive aspects of health): ways that midwives help women increase predictability and preparation during childbearing through apredictable caregiver, a predictable system and preparation for an unpredictable experience. Manageability (behavioural aspects of health): ways that midwives enhance and support a woman’s internal resilience, adding extra support when needed, and strengthen women’s external resources through connections to family, community and specialist care. Meaningfulness (emotional/spiritual aspects of health): ways that midwives encourage the commitment and engagement of childbearing women by providing care through a personalised relationship, by cultivating a woman’s autonomy.ConclusionFindings of this study may be used to further research into ways that salutogenic theory can bring a health and wellness-focused agenda to midwifery policy and practice.     

Socially disadvantaged women's views of barriers to feeling safe to engage in decision-making in maternity care

BackgroundAlthough midwifery literature suggests that woman-centred care can improve the birthing experiences of women and birth outcomes for women and babies, recent research has identified challenges in supporting socially disadvantaged women to engage in decision-making regarding care options in order to attain a sense of control within their maternity care encounters.ObjectiveThe objective of this paper is to provide an understanding of the issues that affect the socially disadvantaged woman's ability to actively engage in decision-making processes relevant to her care.Research designThe qualitative approach known as Interpretative Phenomenological Analysis was used to gain an understanding of maternity care encounters as experienced by each of the following cohorts: socially disadvantaged women, registered midwives and student midwives. This paper focuses specifically on data from participating socially disadvantaged women that relate to the elements of woman-centred care-choice and control and their understandings of capacity to engage in their maternity care encounters.FindingsSocially disadvantaged women participants did not feel safe to engage in discussions regarding choice or to seek control within their maternity care encounters. Situations such as inadequate contextualised information, perceived risks in not conforming to routine procedures, and the actions and reactions of midwives when these women did seek choice or control resulted in a silent compliance. This response was interpreted as a consequence of women's decisions to accept responsibility for their baby's wellbeing by delegating health care decision-making to the health care professional.ConclusionThis research found that socially disadvantaged women want to engage in their care. However without adequate information and facilitation of choice by midwives, they believe they are outsiders to the maternity care culture and decision-making processes. Consequently, they delegate responsibility for maternity care choices to those who do belong; midwives. These findings suggest that midwives need to better communicate a valuing of the woman's participation in decision-making processes and to work with women so they do have a sense of belonging within the maternity care environment. Midwives need to ensure that socially disadvantaged women do feel safe about having a voice regarding their choices and find ways to give them a sense of control within their maternity care encounters.     

Implementing midwifery continuity of care models in regional Australia: A constructivist grounded theory study

Problem/backgroundStrong international evidence demonstrates significantly improved outcomes for women and their babies when supported by midwifery continuity of care models. Despite this, widespread implementation has not been achieved, especially in regional settings.AimTo develop a theoretical understanding of the factors that facilitate or inhibit the implementation of midwifery continuity models within regional settings.MethodsA Constructivist Grounded Theory approach was used to collect and analyse data from 34 interviews with regional public hospital key informants.ResultsThree concepts of theory emerged: ‘engaging the gatekeepers’, ‘midwives lacking confidence’ and ‘women rallying together’. The concepts of theory and sub-categories generated a substantive theory: A partnership between midwives and women is required to build confidence and enable the promotion of current evidence; this is essential for engaging key hospital stakeholders to invest in the implementation of midwifery continuity of care models.DiscussionThe findings from this research suggest that midwives and women can significantly influence the implementation of midwifery continuity models within their local maternity services, particularly in regional settings. Midwives’ reluctance to transition is based on a lack of confidence and knowledge of what it is really like to work in midwifery continuity models. Similarly, women require education to increase awareness of continuity of care benefits, and a partnership between women and midwives can be a strong political force to overcome many of the barriers.ConclusionImplementation of midwifery continuity of care needs a coordinated ground up approach in which midwives partner with women and promote widespread dissemination of evidence for this model, directed towards consumers, midwives, and hospital management to increase awareness of the benefits.     

Complementary and alternative medicine: Interaction and communication between midwives and women

BackgroundMany pregnant women use complementary and alternative medicine. Although midwives are often supportive, how they communicate with women about the safe use of these therapies has received limited research attention.AimThe aim of this study was to explore how midwives interact with women regarding use of complementary and alternative medicine during pregnancy.MethodsWe utilised grounded theory methodology to collect and analyse data. Twenty-five midwives who worked in metropolitan hospitals situated in Melbourne, Australia, participated in the study. Data were collected from semi structured interviews and non-participant observations, over an 18-month period.FindingsHow midwives communicate about complementary and alternative medicine is closely associated with the meaning they construct around the woman's role in decisionmaking. Most aim to work in a manner consistent with the midwifery partnership model and share the responsibility for decisions regarding complementary and alternative medicine. However, although various therapies were commonly discussed, usually the pregnant woman initiated the dialogue. A number of contextual conditions such as the biomedical discourse, lack of knowledge, language barriers and workplace constraints, limited communication in some situations.ConclusionMidwives often interact with women interested in using CAM. Most value the woman's autonomy and aim to work in partnership. However, various contextual conditions restrain overt CAM communication in clinical practice.     

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.     

The association between midwifery staffing levels and the experiences of mothers on postnatal wards: Cross sectional analysis of routine data

BackgroundWomen have consistently reported lower satisfaction with postnatal care compared with antenatal and labour care. The aim of this research was to examine whether women’s experience of inpatient postnatal care in England is associated with variation in midwifery staffing levels.MethodsAnalysis of data from the National Maternity Survey in 2018 including 17,611 women from 129 organisations. This was linked to hospital midwifery staffing numbers from the National Health Service (NHS) Workforce Statistics and the number of births from Hospital Episode Statistics. A two-level logistic regression model was created to examine the association of midwifery staffing levels and experiences in post-natal care.ResultsThe median Full Time Equivalent midwives per 100 births was 3.55 (interquartile range 3.26–3.78). Higher staffing levels were associated with less likelihood of women reporting delay in discharge (adjusted odds ratio [aOR] 0.849, 95% CI 0.753–0.959, p = 0.008), increased chances of women reporting that staff always helped in a reasonable time aOR1.200 (95% CI 1.052, 1.369, p = 0.007) and that they always had the information or explanations they needed aOR 1.150 (95% CI 1.040, 1.271, p = 0.006). Women were more likely to report being treated with kindness and understanding with higher staffing, but the difference was small and not statistically significant aOR 1.059 (0.949, 1.181, p = 0.306).ConclusionsNegative experiences for women on postnatal wards were more likely to occur in trusts with fewer midwives. Low staffing could be contributing to discharge delays and lack of support and information, which may in turn have implications for longer term outcomes for maternal and infant wellbeing.     

The impact of three-dimensional visualisation on midwifery students’ application of knowledge of the third stage of labour to practice: Qualitative findings of a pilot randomised controlled trial

ProblemComplex physiological processes are often difficult for midwifery students to comprehend when using traditional teaching and learning approaches. Online resources for midwifery education are limited.BackgroundFace to face instructional workshops using simulation have had some impact on improving understanding. However, in the 21st century new technologies offer the opportunity to provide alternative learning approaches. Virtual and artificial realities have been shown to increase confidence in decision making during clinical practice.AimExplore the impact of using three-dimensional (3D) visualisation in midwifery education, on student’s application, when educating women about the birth of the placenta, and membranes.MethodsFace to face individual interviews were performed, to collect deep, meaningful experiences of students, learning about the third stage of labour.FindingsPrior clinical experiences impacted on student’s ability to articulate how they would discuss birth of the placenta and membranes, and the process of haemostasis with women.DiscussionThe narrative findings of this pilot study identified ways that students traditionally learn midwifery, through theory, and clinical practice. Interview narratives illustrated how midwifery students who had previous experiences of witnessing birth, had superior ability to discuss the third stage of labour with women. While students with limited birth experiences, found the 3DMVR assisted them in their understanding of the physiology of the third stage of labour.ConclusionIn an environment of increasing technological advances, clinical placements remain an essential component of midwifery education.     

Looking back moving forward: The history of midwifery in Western Australia

ProblemTo date there is has been very little research into midwifery in Western Australia (WA), therefore this paper addresses a significant gap in the literature. The aim of this paper was to gain insight into the history of midwifery in WA.BackgroundSince the beginning of recorded history midwives have assisted women in childbirth. Midwifery is recognised as one of the oldest professions; midwives are mentioned in ancient Hindu texts, featured on Egyptian papyrus and in The Bible. Up until the seventeenth century childbirth was the responsibility of midwives, but the gradual emergence of barber-surgeons, then man-midwives and obstetricians heralded a shift from women-led and community-supported birth to a patriarchal and medical model. Throughout the twentieth century childbirth practices in the Western World have continued to change, leading to a move from midwifery-led care at home to doctor-led care in the hospital.DiscussionThe first non-Indigenous Australian midwives were not formally trained; they came on ships bringing convicts to Australia and are described as ‘accidental’ midwives, as assistance in childbirth came from whoever was available at the time. This period was followed by what was called the ‘Aunt Rubina’ period where older married women helped younger women in childbirth. Throughout the early 1800s untrained or ‘lay’ midwifery care continued alongside the more formally trained midwives who had arrived with the colonists.From the early 20th century, when birth moved into the hospital, midwives in WA have been incorporated into the hierarchy of the professions with obstetrics as the lead profession and midwifery considered a speciality of nursing. The role of the midwife has been subordinated, initially controlled by medicine and then incorporated into the institutions and nursing. The increase in legislative and training requirements for midwives throughout Australia and the move from home to the hospital, gradually led to the decrease in autonomous midwives working within the community, impacting women’s choice of birth attendant and place of birth.ConclusionThe historical suppression of midwifery in Australia has impacted the understanding of the role of the midwife in the contemporary setting. Understanding the development and evolution of the midwifery profession in Australia can help future directions of the profession.     

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.     

Subversive acts and everyday midwifery: Feminism in content and context

BackgroundMidwives are often at the forefront of political campaigns for women's empowerment, overtly advocating for women's rights and reproductive justice. However, midwives can also be found engaging in inadvertent activism on a daily basis within routine care. When casting a feminist lens over both the content and context of midwifery practice in Australia, subversive acts and opportunities for feminist reform can be found.AimTo interrogate the significance of feminism in midwifery practice, identifying feminist successes and further opportunities for implementation including: analysis of the Midwifery Standards for Practice; the primary tenets of woman-centred care; the content versus context of midwifery in Australia; and feminist opportunities for enhanced practice. This paper will discuss the importance of feminism in midwifery practice and its significance in informing optimal midwifery care.DiscussionIncorporating women's voice and respecting women's bodies and agency in the delivery of care is a fundamental component of midwifery practice. However, while the content of midwifery practice is innately feminist in its emphasis on woman-centred care, it will be argued that the context of birthing in Australia is not. The resultant effect is the emergence of victim blaming in maternity care and the construction of an archetypal ‘good birthing woman’.Implications and recommendationsMoving away from the myth of the ‘good birthing woman’ and the act of victim blaming, midwifery could instead direct its focus towards challenging the rigid systems and structures within which midwives implement care. By further embracing feminist principles midwives will ensure a truly woman-centred future.     

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.