Causes of moral distress among midwives: A scoping review.

Numerous studies have evidenced moral distress among midwives; however, to date no research synthesis on causes of moral distress among midwives has been conducted. A scoping review was carried out to identify, comprehensively map, and categorize possible causes of moral distress among midwives, and to identify knowledge gaps. Six data bases were searched using Boolean logic. To be included, studies had to (a) present empirical findings on (b) causes of moral distress (c) among midwives (d) in English, German, French, or Italian. We included a final set of 43 studies. The vast majority of studies came from high-income countries (83.7%) and used a qualitative approach (69.8%); 48.8% of the studies were published in the past 5 years. Identified single reasons of moral distress were grouped into eight broader clusters, forming a coherent framework of reasons of moral distress: societal disregard, contemporary birth culture, resources, institutional characteristics, interprofessional relationships, interpersonal mistreatment of service users, defensive practice, and challenging care situations. These clusters mostly capture moral distress resulting from a conflict between external constraints and personal moral standards, with a smaller proportion also from an intraindividual conflict between multiple personal moral standards. Despite projected increases in demand for midwives, the midwifery workforce globally faces a crisis and is experiencing substantial strain. Moral distress further exacerbates the shortage of midwives, which negatively affects birth experiences and birth outcomes, ultimately rendering it a public health issue. Our findings offer points of leverage to better monitor and alleviate moral distress among midwives, contributing to reducing attrition rates and improving birth experiences and birth outcomes. Further research is essential to explore the issue of ecological moral distress, develop evidence-based interventions aimed at alleviating moral distress among midwives, and evaluate the effects of both individual and system-level interventions on midwives, intrapartum care, and service users' outcomes.

Pandemic-related prenatal maternal stress, model of maternity care and postpartum mental health: The Australian BITTOC study.

PROBLEM: Women pregnant during the COVID-19 pandemic may be at risk of elevated postpartum mental health problems. BACKGROUND: Social support protects maternal mental health during a pandemic. It is possible that formal supports, such as continuity maternity models of care, may also support maternal wellbeing. AIM: To investigate whether model of care moderates the association between prenatal maternal stress from the COVID-19 pandemic, and postpartum (a) depression and (b) anxiety. METHODS: Women in Australia, pregnant during the COVID-19 pandemic (n = 3048), completed a survey detailing their COVID-19-related objective hardship and subjective distress during pregnancy and completed depression and anxiety measures at birth to six weeks ("Early"), seven to 21 weeks ("Moderate"), and/or 22-30 weeks ("Late") postpartum. FINDINGS: Higher subjective distress was associated with elevated depression and anxiety at all timepoints. Model of care did not moderate the association of objective hardship or subjective distress and depression or anxiety at any timepoint. Compared with Standard Care, women receiving private midwifery care had a 74 % reduction in the odds of elevated anxiety in early postpartum. DISCUSSION: Women receiving private midwifery may have experienced lower anxiety due to a greater duration of postpartum in-home care, fewer changes to service delivery, and the option of homebirth. Women pregnant during a pandemic should be screened for higher subjective distress about the event. CONCLUSION: These results suggest that continuity of private midwifery care may be beneficial for supporting postpartum mental health during a pandemic, with implications for practice and policy for the current and future pandemics.

Midwifery educators' knowledge of antenatal exercises in selected Nigerian midwifery schools.

BACKGROUND:  Exercise during pregnancy is beneficial to both the pregnant woman and the foetus. Midwifery educators play a crucial role in ensuring that midwifery students receive the knowledge and training needed to demonstrate antenatal exercises. To ensure that their students understand and deliver adequate antenatal care, midwifery educators should be highly knowledgeable in pregnancy-related exercises. OBJECTIVES:  The study was conducted to determine the knowledge of midwifery educators about antenatal exercise. METHOD:  A descriptive cross-sectional study was conducted of the knowledge about antenatal exercises by midwifery educators. A purposive total population of 54 midwifery educators from three midwifery schools in Cross River State, Nigeria, was included in the study. Questionnaires were used for data collection, and Statistical Package for Social Sciences (SPSS) version 27 was used for data analysis. Ethical issues and rigour were maintained. RESULTS:  The study revealed that antenatal exercises are included in the midwifery curriculum and exercise demonstration were mainly done by midwifery educators and clinical instructors. The majority (n = 34, 66.7%) of the respondents were knowledgeable about World Health Organization (WHO) guidelines for exercise during pregnancy and had an average knowledge of the ideal antenatal exercises. CONCLUSION:  Midwifery educators have average knowledge of the ideal antenatal exercises, which prompts the development of an exercise programme to guide midwifery training and practice. Midwifery educators should collaborate with exercise specialists to teach and demonstrate antenatal exercises.Contribution: The study highlighted the need for midwifery educators to obtain more information on antenatal exercises to adequately prepare midwifery students for evidence-based exercise care for pregnant women.

Investigating the associations between early labour onset symptoms and self-diagnosed labour onset in a cohort study of primiparas.

OBJECTIVE: The early recognition of possible labour onset symptoms may be pivotal to identifying the beginning of early labour and are usually recognised by the birthing women themselves. The present study illustrates the interrelationship among five labour-onset symptoms and explores the association of these labour-onset symptoms with the self-diagnosed labour onset of primiparas. METHODS: A prospective cohort study on a sample of 69 primigravida in Giessen, Germany, expecting spontaneous onset of labour at term. The participants filled in a diary from ≥37 + 0 weeks gestation until self-diagnosed labour onset. Descriptive, bivariate and inferential analysis explored association of labour onset symptoms with self-diagnosed labour onset while accounting for maternal and newborn characteristics. RESULTS: Self-diagnosed labour onset was positively associated with all symptoms and clinical characteristics, apart from irregular pain and maternal weight and age. Moreover, regular pain was negatively correlated with irregular pain; having regular pain increased the odds of self-diagnosed labour onset substantially (OR: 10.18, 95 % CI: 2.39-66.27), followed by gastrointestinal symptoms (OR: 2.07, 95 % CI: 0.40-13.10) and emotional symptoms (OR: 2.05, 95% CI: 0.30-13.98). CONCLUSION: Being the initiator of intrapartum care without any birth experience, primiparas are prone to experiencing dissatisfaction in care and may enter professional care too late or too early. The present study showed that regular pain may signify primiparas to self-diagnose labour onset within 24 h and indicate early labour symptoms that may be relevant for a self-diagnosed labour onset.

Midwifery student engagement with digital interactive books: A cross sectional survey.

AIM: To explore the benefit and engagement of undergraduate students' use of H5P interactive books for student learning. DESIGN: An evaluation study of technology enabled learning for first year undergraduate Bachelor of Midwifery students in Australia. METHODS: Students were invited to complete an online evaluation survey of their use and engagement with H5P interactive books. The survey included the long form User Engagement Scale which has four subscales of focused attention, aesthetic appeal, reward factor and perceived usability scored on a 5-point Likert scale. Content analysis was used to analyse the text comments given to five open text questions. RESULTS: There were 21 students who completed the survey. There was a high overall User Engagement Scale score of 73.1 % with aesthetic appeal and reward factor being the highest scoring subscales. The content analysis showed students found the interactive books engaging and easy to navigate. Areas for improvement identified were not including a large amount of content and providing downloadable content. CONCLUSIONS: This study demonstrates the valuable and engaging use of H5P Interactive Books for undergraduate students in higher education. Students who used H5P Interactive Books identified their ease of use, organised layout and engaging format.

Exploring clinical practice education for student midwives: Hospital and community opportunities and challenges.

Understanding the experiences of student midwives during clinical training is crucial amid evolving midwifery practices in the Philippines. This training is a vital component of their education, offering real-world experience in hospital and community settings. Although existing literature covers various aspects of midwifery training, detailed accounts of the specific challenges and opportunities faced by Filipino student midwives are limited. This study explores the experiences of student midwives across different levels of training in public and private institutions, focusing on the opportunities and challenges they encountered. A qualitative descriptive research design was conducted with 26 purposively selected student midwives. Data collected through in-depth interviews were analyzed to identify recurring themes. Key themes included the importance of a supportive learning environment, exposure to diverse cases, and the acquisition of practical skills. Challenges such as hierarchical barriers and communication challenges, role confusion, resource limitations and adaptation struggles, balancing autonomy and supervision, emotional toll of challenging situations and limited community experiences were highlighted. The findings stress the need for a more supportive and resourceful training environment. Addressing these challenges through targeted interventions could enhance the learning experience and better prepare student midwives for their professional roles. Collaborative efforts with other healthcare professionals and continuous learning opportunities are also essential for their development. This study offers valuable insights for educators and healthcare institutions to optimize midwifery training programs, ultimately fostering the holistic growth of future midwives.

Severe adverse maternal and neonatal outcomes according to the planned birth setting being midwife-led birth centers or obstetric-led units.

INTRODUCTION: The establishment of midwife-led birth centers (MLBCs) is still being debated. The study aimed to compare severe adverse outcomes and mode of birth in low-risk women according to their birth planned in MLBCs or in obstetric-led units (OUs) in France. MATERIAL AND METHODS: We used nationwide databases to select low-risk women at the start of care in labor in MLBCs (n = 1294) and in OUs (n = 5985). Using multilevel logistic regression, we compared severe adverse maternal and neonatal morbidity as a composite outcome and as individual outcomes. These include severe postpartum hemorrhage (≥1000 mL of blood loss), obstetrical anal sphincter injury, maternal admission to an intensive care unit, maternal death, a 5-minute Apgar score <7, neonatal resuscitation at birth, neonatal admission to an intensive care unit, and stillbirth or neonatal death. We also studied the mode of birth and the role of prophylactic administration of oxytocin at birth in the association between birth settings and severe postpartum hemorrhage. RESULTS: Severe adverse maternal and neonatal outcome indicated a slightly higher rate in women in MLBCs compared to OUs according to unadjusted analyses (4.6% in MLBCs vs. 3.4% in OUs; cOR 1.36; 95%CI [1.01-1.83]), but the difference was not significant between birth settings after adjustment (aOR 1.37 [0.92-2.05]). Severe neonatal morbidity alone was not different (1.7% vs. 1.6%; aOR 1.17 [0.55-2.47]). However, severe maternal morbidity was significantly higher in MLBCs than in OUs (3.0% vs. 1.9%; aOR 1.61 [1.09-2.39]), mainly explained by higher risks of severe postpartum hemorrhage (2.4 vs. 1.1%; aOR 2.37 [1.29-4.36]), with 2 out of 5 in MLBCs partly explained by the low use of prophylactic oxytocin. Cesarean and operative vaginal births were significantly decreased in women with a birth planned in MLBCs. CONCLUSIONS: In France, 3 to 4% of low-risk women experienced a severe adverse maternal or neonatal outcome regardless of the planned birth setting. Results were favorable for MLBCs in terms of mode of birth but not for severe postpartum hemorrhage, which could be partly addressed by revising practices of prophylactic administration of oxytocin.

Care pathways for reduced fetal movements: A cost-consequence analysis.

OBJECTIVE: This study aimed to evaluate the costs and consequences of a new midwife-navigator-facilitated care pathway for reduced fetal movements. MATERIALS AND METHODS: This study was conducted at a tertiary obstetric centre in Queensland, Australia and modelling occurred for this and smaller services. Two months of data from pre (n = 112 in 2019) and post (n = 141 in 2020) implementation of the care pathway were analysed with T-tests and logistic regression models to evaluate maternal and neonatal outcomes. A Markov model was built to estimate the costs and consequences of the intervention. Sensitivity analysis was conducted to test various scenarios including modelling for smaller centres. RESULTS: There were no statistically significant differences in clinical outcome between the intervention and usual care groups. Intervention patients spent one hour and eight minutes less time in hospital (P < 0.001). This resulted in a saving to the centre of AU$135 per patient (AU$159 083 annually). One-way sensitivity analysis suggested that cost savings would be found in all scenarios except for smaller units providing services for less than 1900 births per annum. CONCLUSION(S): To our knowledge, no other care pathway involving acute obstetric care has been economically evaluated to date. Our model based on real-world presentations for reduced fetal movements confirms that midwife-navigators may be an economically beneficial implementation strategy for dealing with common obstetric conditions.

Tanzanian midwives' clinical practices and experiences in caring for women with antepartum hemorrhage: a critical incident technique study.

BACKGROUND: Antepartum hemorrhage (APH) is an obstetric emergency that complicates pregnancy worldwide and continues to lead to hemorrhagic conditions in parts of Tanzania. Midwifery education received by midwives consists theoretical knowledge on the subject but with no or minimal practical skills in the laboratory, which may reduce their practical capacity as graduated midwives. This study therefore aimed to explore midwives' clinical actions and experiences regarding the care of women with APH in Mwanza region. METHOD: Qualitative, inductive approach with critical incident technique was used. Data were analysed using the critical incident technique, and a question guide consisting of eleven open-ended questions was used to collect data from 44 out of 60 midwives who graduated not less than one year. A total of 522 critical incidents, with 199 actions and 323 experiences, were identified and categorized into five main areas. Ethical approval was obtained. RESULTS: Midwives' clinical actions and experiences in caring for women with APH are affected by the knowledge and skills obtained during training at school. They have insufficient theoretical knowledge and practical skills, leading to inadequate identification of the problem and the implementation of care. A need for additional preventive care is described and structural issues, such as co-operation, referral to other instances, access to equipment and relevant treatments need to be improved. CONCLUSION: The actions taken to provide care for women with APH were related to their ability to identify problems, implement care and carry out structural initiatives. However, the midwives' experience was influenced by an attempt to understand the seriousness of the situation and the existence of an organizational challenge. The results can provide knowledge and tools to improve midwives' education and clinical practice and in the long run, prevent complications, improves health and minimize suffering in women with APH.

Facilitating home birth in perinatal palliative care: A case report.

BACKGROUND: Perinatal palliative care can offer compassionate support to families following diagnosis of a life-limiting illness, to enable them to make valued choices and the most of the time that they have with their newborn. However, home birth is usually only offered in low-risk pregnancies. CASE: A couple who received an antenatal diagnosis of hypoplastic left heart syndrome and who had made a plan to provide palliative care to their baby after birth requested the option of a home birth. POSSIBLE COURSES OF ACTION: Recommend birth at hospital or explore the possibility of a home birth with perinatal palliative care support. FORMULATION OF A PLAN: Multidisciplinary discussion and collaboration enabled a plan for home birth to be made which anticipated potential complications. OUTCOME: The baby was born at home and died on day 5 of life receiving outreach nursing, paediatric and palliative care support and buccal and oral opioids for symptom management. We include reflections from the family on the importance of this experience. LESSONS: We provide a list of potential criteria for considering home birth in the setting of perinatal palliative care. VIEW: Facilitating a home birth in the setting of perinatal palliative care is an option that can be hugely valued by families, but this service may be practically difficult to deliver in many contexts. Further research is needed to understand the preferences of women and families receiving perinatal palliative care.

Dr Bonté Elgood (1874-1960): First woman doctor in Egypt and pioneer of maternal and child care.

Bonté Elgood, née Amos, was one of the early women doctors who qualified from the progressive London School of Medicine for Women, established in 1874. She chose to practice in Egypt which was then under British administration. When she arrived in 1900, Egyptian medical provision for mothers and children was rudimentary where it existed at all. For over 50 years, Bonté Elgood played an important role in setting up maternity care and child health services, first in Cairo and later in the whole country. For her work, she was awarded the OBE and CBE by the British government, and she also received decorations from the French and Egyptian governments.

The midwifery capabilities theory: How midwives enact woman-centered care to address systemic inequity.

BACKGROUND: Healthcare for childbearing women with complex needs demands a multi-disciplinary approach requiring transitions between care providers, paradigms, and models of care. These transitions may create disconnects between women and the maternity care "system." Poorly managed care transitions can lead to women becoming hostage to the power struggles between healthcare organizations and the professionals working within them, further increasing the risk of poor outcomes. This paper presents the findings of a study that aimed to better understand how midwives provide woman-centered care for women with complex needs in the real world of maternity services. METHODS: A constructivist grounded theory approach, using Clarke's situational analysis to extend critical and feminist perspectives in data analysis. Qualitative data were obtained from two sources: publicly available data, and individual interviews with providers of care (midwives) and recipients of care (women with complex pregnancies). RESULTS: Woman-centered care is defined as care in which the woman is seen, heard, and known. "The midwifery capabilities theory" describes the process whereby midwives create opportunities to develop women's capabilities. Capabilities are enabled through the midwifery relationship creating space, moments in time, and equalizing power and positionality. CONCLUSIONS: Aligning with contemporary theories surrounding the provision of midwifery care, the midwifery capabilities theory recognizes the individual health and social status of women and the rights to self-determination. This centers care around each individual's needs, which, in addition to improving health and well-being outcomes, contributes to improved self-confidence, enhancing engagement through authentic professional relationships.

"Removing the home court advantage": A qualitative evaluation of LEGO® as an interprofessional simulation icebreaker for midwifery and medical students.

AIM: The study aimed to evaluate the use of LEGO® as an educational tool for midwifery and medical students. BACKGROUND: The concept of LEGO® SERIOUSPLAY® ® was conceived in 1996 when Swiss Professors Roos and Victor explored using LEGO® as a strategic planning tool. We adapted this concept as an icebreaker activity for interprofessional education workshops at an Australian university. METHOD: Using a qualitative evaluation, we used cross-sectional pre- and post-surveys to gain midwifery and medical students' perspectives and insights. Students were divided into mixed discipline groups at the commencement of a one-day birthing and birthing complexities workshop and asked to design and build a birthing room using LEGO®. A pre-and post-workshop survey asked students about their experiences using LEGO® as a learning tool for team communication and collaboration. RESULTS: Pre-workshop responses demonstrated intrigue as to how LEGO® could be used for learning. Post-workshop feedback was overwhelmingly positive and students described how it helped them develop communication and collaboration skills and understand the other disciplines' priorities and values. CONCLUSION: Using LEGO® as an icebreaker activity enabled open discussion and connection, promoting easy-going conversation and aiding a collaborative team-building process before students worked together in an interprofessional birthing simulation workshop. The findings indicated that the icebreaker activity enhanced the students' awareness and appreciation of learning about each other's perspectives, values and roles for future collaboration in the clinical workplace.

Midwife-led quality improvement: Increasing the use of evidence-based birth practices in Uganda.

BACKGROUND: Addressing the evidence-to-practice gap in midwifery is vital for improving maternal and newborn health outcomes. Despite the potential of involving midwives in quality improvement interventions to address this gap, such interventions are understudied. In a Ugandan urban hospital, midwifery practices with a significant evidence-to-practice gap have been identified as areas for clinical improvement. OBJECTIVES: The primary objective of the Quality Improvement was to increase the uptake of identified and essential midwifery practices through a quality improvement approach led by midwives. PARTICIPANTS: We enrolled 703 women aged 18 years and older with uncomplicated full-term pregnancies (between 37+0 and 42+0 weeks) who gave birth at the facility. INTERVENTION: The intervention focused on evidence-based practices with an identified evidence-to-practice gap: dynamic birth position, including women's involvement in birth position decision-making, perineal protection and intrapartum support. A team of midwives led a seven-month co-created quality improvement intervention. The intervention used Plan-Do-Study-Act (PDSA) cycles, following the Model for Improvement and included a train-the-trainer approach and weekly online support meetings. DATA COLLECTION: In this single-case prospective observational study, we compared pre-, during and post-intervention uptake of evidence-based practices. Trained research assistants collected data through interviews and observations. RESULTS: We observed improvements in the uptake of all clinical improvement areas. Dynamic birth positions increased from 0 % to 79 %, decision-making of birth positions from 0 % to 75 %, perineal protection measures from 62 % to 92 % and intrapartum support from 7 % to 67 %. CONCLUSION: A multifactorial midwife-led Quality Improvement resulted in significant and sustained improvements in the uptake of evidence-based practices in maternal and newborn healthcare. If given the mandate and time, midwives can successfully lead Quality Improvements, which enhance the quality of care and close the evidence-to-practice gaps in maternal and newborn health. The study's results underscore the significance of developing effective strategies to enhance care quality and promote the adoption of evidence-based midwifery practices.

Health professionals' experiences and views on obstetric ultrasound in Victoria, Australia: A cross-sectional survey.

BACKGROUND: Obstetric ultrasound is an important tool, aiding in screening, diagnosis, and surveillance throughout pregnancy. AIMS: To explore obstetric doctors', midwives', and sonographers' experiences and views of obstetric ultrasound in Victoria, Australia. To investigate the increasing role of obstetric ultrasound for clinical management, and the adequacy of resources and training for appropriate use of ultrasound in clinical management. MATERIALS AND METHODS: This cross-sectional study forms part of a multi-national CROss-Country Ultrasound Study (CROCUS) exploring the views of consumers and health professionals from high-, middle- and low-income countries. Qualitative studies conducted in several countries informed the construction of a quantitative survey. These quantitative surveys were distributed to 16 hospitals across regional and metropolitan Victoria, Australia. Descriptive statistics were analysed from the responses. RESULTS: There were 354 questionnaires returned from 106 doctors, 222 midwives, and 26 sonographers. Overall, 72% of respondents held concerns about the potential loss of focus on clinical skills with increasing ultrasound use. Midwives were more concerned about the contribution of ultrasound to medicalisation of pregnancy than were doctors (P < 0.001). Many respondents noted that geographical factors (71%), rather than income levels (53%) influenced access to obstetric ultrasound. Over 90% of doctors and midwives believed additional training for their respective professions in ultrasound would enhance its reach and effectiveness. CONCLUSIONS: Our survey findings confirm that clinicians place high levels of trust in the diagnostic findings of obstetric ultrasound antenatal care in Australia. Access to routine ultrasound could be improved for women in rural and lower-income areas.

The use of long-arm (indirect) supervision for nursing, midwifery and allied health professionals in health and social care settings: A systematic literature review.

BACKGROUND: Internationally, critical shortages of healthcare workers have been reported. Indirect supervision is one educational approach which has the potential to expand placement opportunities for the future healthcare workforce. However, its use across healthcare professions is yet to be systematically reviewed. OBJECTIVES: To evaluate the use of indirect supervision across nursing, midwifery and allied health professionals in health and social care settings. DESIGN: Systematic review. REVIEW METHODS: Searches in six databases (CINAHL, MEDLINE, APAPsych Info, Web of Science, Scopus and PubMed) were conducted. Grey literature and handsearching were also conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for this review. A total of 493 titles and abstracts were screened. The quality of the included studies was evaluated using the Quality Assessment with Diverse Studies (QuADS) tool. RESULTS: A total of 25 articles were included. Three overarching themes were identified: (1) Professional identity, (2) Educational approaches and (3) Educational outcomes. Approaches to what constitutes indirect supervision varied widely and inconsistencies were found in the reporting of the placement model. Supervision, support and preparation were perceived as vital for positive outcomes of these placements. Higher levels of learning were reported, although challenges were also discussed. CONCLUSIONS: This review highlights the variability in approaches to indirect supervision. Positive perceptions around using indirect supervision in health and social care settings has been widely reported, however further research is warranted to explore this across professions. Systematic review registration PROSPERO: CRD42023418302.

"In an ideal world": A qualitative exploration of shared decision-making and weight stigma in antenatal care.

BACKGROUND: Shared decision-making supports women's autonomy in antenatal care, but several barriers to shared decision-making have been identified in practice. Women with high body mass index experience a higher rate of interventions, which could provide more opportunities for shared decision-making in antenatal care. However, weight stigma may exist as a barrier to shared decision-making, limiting access to collaborative care. AIM: To explore how shared decision-making is implemented and whether body mass index influences maternity clinicians' use of shared decision-making when providing antenatal care for women. METHODS: Maternity clinicians were recruited via purposive sampling from two sites in metropolitan Melbourne, Australia. Semi-structured interviews were audio recorded, transcribed, and analysed using reflexive thematic analysis. FINDINGS: Twelve maternity clinicians consented to participate. Three themes and ten sub-themes were identified. The themes were: 1) Whose choice is it anyway? 2) Pregnancy as risky 3) Excess weight as a diseased state. DISCUSSION: Maternity clinicians in this study view pregnancy through a risk management lens that complicates women's involvement in decision-making, demonstrating inherent beliefs that may further limit options for women with high body mass index. CONCLUSION: Shared decision-making is difficult to implement in the current antenatal clinic setting and requires significant structural consideration to become a reality for women. Clinicians may inadvertently limit meaningful opportunities to engage in shared decision-making with women with high body mass index due to preconceived perceptions of risk and stigmatising beliefs about women with high body mass index.

Improving maternal health literacy among low-income pregnant women: A systematic review.

Previous studies on maternal health have highlighted the need to improve health literacy, particularly among women from lower socioeconomic backgrounds. Some crucial factors for improving maternal health literacy are midwife capacity and systems support that can help ensure women's ability and motivation to access timely health services. However, the extent of roles midwives need and the system that must be developed require further elaboration. The aim of this systematic review was to investigate approaches for enhancing maternal health literacy in low-income pregnant women. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the systematic search was conducted on two databases: PubMed and ScienceDirect. All English articles published from 2011 to 2023 were searched using the keywords pregnant, antenatal, prenatal, perinatal, midwife, health literacy, midwife-led care, helpline, and photo novel. Of the 1,539 articles, 15 were included in the final assessment. The results suggested that improving maternal health literacy among low-income pregnant women was related to: (a) empowering low-income women; (b) empowering midwives as frontline care providers engaging with low-income pregnant women; and (c) empowering the health care system as a health literacy organization. In conclusion, improving the healthcare system and strengthening midwives' leadership as proximal caregivers is crucial for improving maternal health literacy among low-income pregnant mothers. These efforts could be realized with support from government roles, educational institutions, and professional associations.

Storytelling as an educational strategy for midwifery students: A qualitative study.

BACKGROUND: Narratives can provide a framework to teach the concepts of patient-centered care to the students. This article describes the experiences of midwifery students from employing of purposive storytelling as a teaching strategy in the education program. MATERIAL AND METHODS: This qualitative study used an in-depth interview method to collect the experiences of midwifery students engaged in a narrative medicine training program. The narrative-based teaching activities focused on three patients to teach four themes (clinical manifestations, treatment options, prevention strategies, and ethics), and related to MMR (maternal mortality rate) concept offered to students from Guilan University of Medical Sciences in 2022-2023. At the end of the course, all students were invited to provide experiences regarding the teaching method. Conventional content analysis was performed simultaneously with data collection. Four-dimension criteria (Lincoln and Guba) were used to evaluate the rigor of the findings. RESULTS: Data analysis led to the extraction of three main categories and eight sub-categories: effective learning (extended learning, a safe learning environment, and boosted motivation for midwifery role), challenges on the way of learning (contagious sadness, shattered cohesion, and executive monopoly), and challenges on the way of performance improvement (the necessity of interdisciplinary education and the inevitability of a strong foundation). CONCLUSIONS: Narrative-based teaching may improve the learning experience of students, but it is not possible to train all the course content by this method, and it should ideally be a supplement to other educational methods, such as lecturing.