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.     

Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives

BackgroundHealth inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman’s vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care.AimTo explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand.MethodInductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care.FindingsA total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings.ConclusionMidwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.     

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.     

Emotional wellbeing of student midwives during COVID-19

BackgroundMental health of students in higher education was affected during the COVID-19 pandemic.AimTo examine the emotional wellbeing of midwifery students in the Netherlands and Flanders (Belgium) during COVID-19.MethodsA cross-sectional online-based survey with 619 Dutch and Flemish midwifery students. Sociodemographic details were obtained. Anxiety and depression were measured twice (T1, T2) during the COVID-19 pandemic.FindingsFlemish students had significantly higher mean depression and anxiety scores than Dutch students during the total period of study (p < .001; p < .001). Total group mean depression and anxiety scores were significantly higher at T2 compared to T1 (p < .001; p < .001). In the Dutch student group, there was a significant increase of depression from T1 to T2 (p < .001). In the Flemish student group, both depression and anxiety scores significantly increased from T1 to T2 (p < .001; p < .001). A history of psychological problems predicted both depression and anxiety, irrespective of COVID-19 period or country (p < .001; p < .001). Being single (p.015) and having a job (p.046) predicted depression, irrespective of period or country. A history of psychological problems predicted depression (p.004; p < .001) and anxiety (p.003; p.001) during the total period of study. Being single also predicted depression during T2 (p.024).ConclusionThese findings inform how emotional wellbeing of midwifery students was affected during the COVID-19 pandemic and identify those students that might need extra attention after the pandemic, during another pandemic or similar situations with social restrictions.     

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’ 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.     

Who is at risk of burnout? A cross-sectional survey of midwives in a tertiary maternity hospital in Melbourne,Australia

BackgroundBurnout is an occupational phenomenon with the potential to affect a person’s physical and mental health, job satisfaction and quality of work. There is evidence of burnout occurring in the midwifery profession, but inadequate data on the prevalence of, and the factors associated with, burnout.AimIdentify the prevalence of burnout in a population of midwives and explore what individual and workforce characteristics, and what occupational stressors, were associated with burnout.MethodsA cross-sectional survey of permanently employed midwives was conducted in a tertiary maternity service in Melbourne, Australia in 2017. Data collected included individual and workforce-related characteristics and occupational stressors. Burnout was explored using the Copenhagen Burnout Inventory. Univariate and multivariate analyses were conducted to ascertain associations between respondents’ characteristics, stressors, and burnout levels.FindingsA total of 257/266 midwives (97%) responded. There were significant levels of exhaustion and fatigue among respondents; 68% of midwives were experiencing personal burnout, 51% work-related burnout, and 10% were experiencing client-related burnout. Being aged ≤ 35 years, and/or having inadequate support was associated with personal and work-related burnout. Having inadequate acknowledgement was associated with client-related burnout.ConclusionHealth services need to understand the risk factors for burnout among midwives, identify and support groups that are most vulnerable, and address areas that are amenable to intervention. In our context this means ensuring midwives receive adequate acknowledgement and support, particularly younger midwives. These findings need to be tested in other settings to help inform a broader understanding and ensure the sustainability of the midwifery profession.     

"一带一盟"对接合作视阈下贸易便利化对出口持续时间的影响研究

巩固发展同欧亚经济联盟经贸合作关系对于促进"一带一路"建设具有重要意义。文章建立了比较全面的贸易便利化三级指标体系,贴近欧亚经济联盟成员国的实际情况;采用CEPII-BACI数据库2007—2016年HS6分位产品层面数据,首先运用生存分析方法估计中国与欧亚经济联盟及成员国出口贸易关系持续时间,其次运用Cloglog模型着重考察贸易便利化对双边出口贸易持续时间的影响;进一步引入贸易便利化与区域经济一体化的交互项,考察欧亚经济联盟启动后贸易便利化对出口持续时间的影响,研究发现:中国与欧亚经济联盟出口持续时间普遍较短,中位数只有3年,贸易关系持续时间段超过1年占比为63.7%,超过2年占比为50.5%,下降幅度为13.2%,第9年时仅剩29.6%,不足三分之一,中国与欧亚经济联盟成员国的贸易关系持续时间较短且失败概率具有负时间依赖性;贸易便利化会显著降低中国与欧亚经济联盟出口贸易关系失败的风险,提高双边贸易关系的生存率,在微观层面上说明贸易便利化水平提高,跨国企业在国际贸易活动中所支付的交易成本降低,提升利润空间从而延长企业出口持续时间;贸易便利化对不同类型产品出口持续时间的影响程度具有异质性,从回归系数大小来看,从重到轻依次为劳动密集型产品、资本密集型产品和初级产品。当贸易便利化水平变化,价值链较长、国内附加值较高的劳动密集型产品和资本密集型产品更易受到贸易便利化引致的"技术外溢"效应影响,而对于初级产品来说,农业政策的影响效果大于贸易便利化水平,因此相对于资本密集型产品和劳动密集型产品,贸易便利化水平对初级产品的影响相对较低;进一步通过交互项模型发现,欧亚经济联盟启动后产生关税同盟效应,成员国间形成零关税五国区域大市场,促进内部企业生产要素和资源配置的优化,内部要素流动更加自由便捷高效,成员国可以获取更多的规模经济效益,同时促使中国出口商品更加快捷高效地向欧亚经济联盟内其他成员国转移,增加了中国企业出口意愿进而提升了贸易便利化对出口持续时间的促进作用。文章的研究凸显了贸易便利化提升出口持续时间的关键作用,对于"一带一路"背景下提升中国与欧亚经济联盟经贸合作水平具有一定的实践参考价值。