Cue acquisition: A feature of Malawian midwives decision making process to support normality during the first stage of labour.

OBJECTIVE: to explore Malawian midwives decision making when caring for women during the first stage of labour in the hospital setting. DESIGN AND METHODS: this focused ethnographic study examined the decision making process of 9 nurse-midwives with varying years of clinical experience in the real world setting of an urban and semi urban hospital from October 2013 to May 2014.This was done using 27 participant observations and 27 post-observation in-depth interviews over a period of six months. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation. FINDINGS: analysis revealed a six-stage process of decision making that include a baseline for labour, deciding to admit a woman to labour ward, ascertaining the normal physiological progress of labour, supporting the normal physiological progress of labour, embracing uncertainty: the midwives' construction of unusual labour as normal, dealing with uncertainty and deciding to intervene in unusual labour. This six-stage process of decision making is conceptualised as the 'role of cue acquisition', illustrating the ways in which midwives utilise their assessment of labouring women to reason and make decisions on how to care for them in labour. Cue acquisition involved the midwives piecing together segments of information they obtained from the women to formulate an understanding of the woman's birthing progress and inform the midwives decision making process. This understanding of cue acquisition by midwives is significant for supporting safe care in the labour setting. When there was uncertainty in a woman's progress of labour, midwives used deductive reasoning, for example, by cross-checking and analysing the information obtained during the span of labour. Supporting normal labour physiological processes was identified as an underlying principle that shaped the midwives clinical judgement and decision making when they cared for women in labour. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the significance of this study is in the new understanding and insight into the process of midwifery decision making. Whilst the approach to decision making by the midwives requires further testing and refinement in order to explore implications for practice, the findings here provide new conceptual and practical clarity of midwifery decision making. The work contributes to the identified lack of knowledge of how midwives working clinically, in the 'real world setting. These findings therefore, contribute to this body of knowledge with regards to our understanding of decision making of midwives.

Are staffing shortages changing the culture of midwifery?

The effects of budgetary changes on midwives' practice environment have raised concerns in many settings. A survey of midwives and student midwives in the UK and Republic of Ireland in 2014 produced 280 responses. Staffing shortages were regarded as underpinning many changes, one of which was that of previously optional 'extra' activities, such as unpaid overtime, becoming mandatory. Shortages were aggravated in less acute areas by the transfer of midwives to more acute settings. One of the fears expressed by midwives was that a permanent change in the culture of midwifery would result. These phenomena are the everyday experiences of practising midwives, but they have failed to be addressed in the documents published by regulatory and review bodies.

Navigating the self in maternity care: how Chinese midwives work on their professional identity in hospital setting.

OBJECTIVE: to explore the strategies Chinese midwives employed to work on their professional identity in hospital setting and the consequence of such identity work. DESIGN AND METHODS: this paper draws upon findings from a Constructivist Grounded Theory study that explored the professional identity construction of 15 Chinese midwives with a mixture of midwifery experiences, practising in three different types of hospital settings in a capital city in Southeast China. The accounts from participants in the form of in-depth individual interviews were collected. Work journals voluntarily provided by three participants were also included. FINDINGS: in everyday practice, hospital midwives in China were working on their professional identity in relation to two definitions of the midwife: the external definition ('obstetric nurse'), bound up in the idea of risk management under the medical model of their work organisations; and the internal definition ('professional midwife'), associated with the philosophy of normal birth advocacy in the professional discourse. Six strategies for identity work were identified and grouped into two principle categories: 'compromise' and 'engagement'. The adoption of each strategy involved a constant negotiation between the external and internal definitions of the midwife, being influenced by midwifery experiences, relationships with women, opportunities for professional development and the definition of the situation. A 'hybrid identity', which demonstrated the dynamic nature of midwifery professional identity, was constructed as a result. KEY CONCLUSIONS AND IMPLICATIONS: this paper explored the dynamic nature of midwifery professional identity. This exploration contributes to the body of knowledge regarding understanding the professional identity of hospital midwives in China, while also extending the current theoretical knowledge of identity work by elaborating on the various strategies individuals use to work on their professional identity in the workplace.

Who listens to parents and is anything done?

The Listening to parents survey, which took place in early 2014, sought the views of parents bereaved by stillbirth or early neonatal death. The findings showed the marked variation in care provided. The low response rate may call into question the authority of the findings Research into perinatal loss seems to be unlikely to be operationalised. More qualitative research may make such implementation more feasible, hopefully making optimal care more certain for grieving parents.

The politics of maternity.

Changes in the culture of health care require that, to be effective, midwifery practice should become more woman-centred. This may be facilitated by adopting a stronger community orientation. In this way the hegemony of maternity care may be addressed. This paper seeks to draw readers' attention to political developments and to inspire midwives to greater awareness and, possibly, activity.

Intrapartum uncertainty: a feature of normal birth, as experienced by midwives in Scotland.

OBJECTIVE: to explore midwives' perceptions of intrapartum uncertainty when caring for women in low risk labour. DESIGN: a grounded theory approach was used to capture the experiences of midwives practising in Scotland. Data were generated through unstructured in-depth one-to-one interviews and focus groups. SETTING: four Health Boards in Scotland. PARTICIPANTS: 19 midwives, practising in a range of maternity settings, participated in the study. The maternity settings included; obstetric led labour wards, along-side maternity units, stand-alone community maternity units, and community and independent practice. They also had a mixture of clinical experience, ranging from one to 20 years in practice. FINDINGS: Three categories emerged from the analysis, intrapartum uncertainty, the normality boundary and threshold pressures. Recognising the point at which a labour deviates away from normal constitutes 'intrapartum uncertainty'. In these situations midwives develop a normality boundary that shape their clinical judgements and decisions. The boundary becomes the limit, edge or border of what they accept as normal in a labour. Therefore if midwives tolerate intrapartum uncertainty they are more likely to construct labours as normal, than midwives with a lower tolerance of uncertainty. This can be mediated by threshold pressures that expand or contract their definitions of normality. So that supportive environments and good relationships with women enable midwives to tolerate uncertainty and thus maintain normality. IMPLICATIONS FOR PRACTICE: the reemphasise on midwifery practice as a means of supporting normal birth has been promoted as a way of 'demedicalising' birth for low risk women. However to maintain normality midwives need to understand the impact uncertainty has on their decision making. Supporting midwives to tolerate uncertainty, either at unit or national level, will expand definitions of normality so that birth can remain natural and dynamic.

Magnesium: the relevance of research.

The recent flurry of apparently conflicting research findings is likely to have left practitioners, if not at a loss, at least bemused about this topic. How best should the midwife advise the childbearing woman on the subject of magnesium supplementation during pregnancy? It is possible that the recent welter of words may not have been of very much help to any of those who read them. In this paper I suggest that the researchers may actually be missing the point as far as providing useful and usable data is concerned.

Midwifery and the LGBT midwife.

OBJECTIVE: To identify, through searching the published literature, midwifery's attitudes to gay and lesbian midwives. DESIGN: A selective literature review. FINDINGS: UK-based material was sparse. Items on midwifery and nursing and medicine and on midwifery in non-UK countries were accessed. Issues emerging include the salience of 'coming out', of education, of culture, of forming relationships with childbearing women and the difficulty of authoritative research. KEY CONCLUSIONS: The midwifery literature on LGBT colleagues corresponds with that identified in nursing almost three decades ago. The lack of recognition of LGBT midwives carries personal and organisational implications. IMPLICATIONS FOR PRACTICE: Discriminatory attitudes may be difficult to resolve by education. Research on LGBT colleagues is fraught with difficulties. Various aspects of culture affect the acceptance of the colleague who is gay or lesbian. It is uncertain whether the midwife-woman relationship is less easily achieved by the gay or lesbian midwife.

Commercialisation and entrepreneurialism in maternity.

OBJECTIVE: against an international background, to examine the implications of private sector activity for maternity care in the United Kingdom National Health Service (UK NHS). BACKGROUND: the private sector and commercial or entrepreneurial activity in maternity services have attracted limited attention in the UK compared with, for e.g., Greece and the Irish Republic. METHOD: discursive paper. KEY CONCLUSIONS: despite rhetoric to the contrary, financial costs have always featured in the UK NHS. Financial payments in maternity have increased gradually. Commercial and entrepreneurial activity in maternity now includes 'entertainment ultrasound', reflecting a greater hegemonic imbalance. The commercialisation of maternity raises organisational, professional, quality-related and systematic issues, which all carry implications for the childbearing woman. RELEVANCE TO CLINICAL PRACTICE: the childbearing woman shoulders financial costs, whose origins and implications matter to both midwife and woman. The mixed benefits of medical investigations deserve closer attention.

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study.

AIMS: to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice. SETTING: an urban hospital with 2000-3000 deliveries per year. METHOD: this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically. PARTICIPANTS: the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge. MAIN OUTCOME MEASURE: mode of birth and model of care. FINDINGS: the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as 'two-to-one' care. None of the women labouring in the standard care unit were identified as having a birth companion. DISCUSSION: the concept of 'two-to-one' care emerged as fundamental to women's experiences and utilisation of midwives' skills to promote normal birth and decrease the likelihood of a caesarean section. CONCLUSION: the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women's satisfaction with care within a context of extraordinary high caesarean section rates. IMPLICATIONS FOR PRACTICE: midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.

Views of Chinese women and health professionals about midwife-led care in China.

AIMS: To explore Chinese women's and health professionals' views of the first midwife-led normal birth unit in China to facilitate normal birth and enhance midwifery practice. METHOD: Data collection involved semi-structured interviews, questionnaires and cross-comparison with hospital data. The data were analysed thematically. SETTING: A university teaching hospital in a major city in eastern China. PARTICIPANTS: Purposive sample of 30 women, five midwives and five medical staff who accessed, provided or liaised with the midwife-led service. MAIN OUTCOME MEASURES: Participants' satisfaction, continuity of care/carers, choice and control. FINDINGS: Informants were positive about the unit, largely because the woman was supported by a midwife and a birth companion through the 'two-to-one' model of care. DISCUSSION: The concept of 'two-to-one' care emerged as fundamental to women's experiences and utilisation of midwives' skills to promote normal birth. The high vaginal birth rate and the positive feelings reported suggest that this approach serves to empower women and promote physiological birth. CONCLUSION: Women appreciated the midwife-led service, which provides an environment where they are more likely to aim to give birth without intervention. This model of care is good for its association with increased satisfaction in a context of extraordinarily high caesarean rates. IMPLICATIONS: Midwife-led care can facilitate continuity of care and carer during birth. It offers women choice and control over many aspects of the birth. Further research is required to investigate factors important to women.

Proposed continuing professional education programme for midwives in China: new mothers' and midwives' views.

BACKGROUND: Chinese midwifery is under threat and has been denigrated, with virtually all midwives practising in the labour wards. AIMS: The present study aims to inform the development of a proposed continuing professional education programme. METHOD: Questionnaire surveys and semi-structured interviews were used to investigate the views of new mothers after vaginal births and midwives. The questions focussed on midwives' education, practice and mothers' experience and knowledge of maternity care. Data were analysed using descriptive statistical techniques. PARTICIPANTS: Five researchers, 253 midwives and 214 women. SETTINGS: Ten maternity units/hospitals in seven Chinese cities. FINDINGS: Both mothers and midwives valued continuity of midwifery care. The majority of midwives were obstetric nursing educated; one-fifth had a midwifery background. A smaller minority had a maternity/childcare or obstetric education. Midwifery education is medico/nursing orientated, with only 11.6% of the curriculum midwifery-oriented. DISCUSSION: The perceived different needs reflect the different orientations of the respondents. The programme should be structured to meet mothers' and midwives' needs, cultivate midwives' lifelong learning capacity, and encourage evidence-based practice. CONCLUSION: The study has shown a fundamental problem in Chinese midwifery education, in that midwives do not have access to evidence-based material. Self-directed learning with portfolio assessment is likely to prove useful for the proposed programme; this may facilitate midwives' personal/professional development to update their knowledge, understanding and competence towards their full role as midwives.

The relationship between first-time mothers and care providers in the early postnatal phase: an ethnographic study in a Swiss postnatal unit.

OBJECTIVE: to consider the relationship between first-time mothers and care providers in an organisational context. DESIGN: an ethnographic approach was used to study the views and behaviours of providers and recipients of postnatal care. Fieldwork involved mainly conversations or qualitative interviews and observation. SETTING: a postnatal unit in a tertiary referral hospital in Switzerland. PARTICIPANTS: 10 child-bearing women and the care providers assigned to them. ANALYSIS: analysis of the data was organised using the women's expectations of care and the maternity unit's mission statement. Thematic analysis centred around two main themes: the experience of 'being on a postnatal journey' and 'caring relationships'. FINDINGS: the findings presented fall within the framework of the second theme. A caring relationship was established through 'weaving the net'. This relationship was then maintained through 'keeping the thread'. The relationship was eventually ended through 'finishing off'. KEY CONCLUSIONS: the quality of the caring relationship between a woman and a care provider influences satisfaction with received care. It determines the extent to which women feel in control of their situation at discharge. Organisational and professional factors influence this relationship, which in turn can influence a nurse's level of job satisfaction. IMPLICATIONS FOR PRACTICE: changes in the provision of postnatal care may involve organisational as well as clinical interventions to ensure continuous and consistent care.

Beginning an action research project to investigate the feasibility of a midwife-led normal birthing unit in China.

AIM: To explore issues arising during preliminary stages of a research project in order to consider the feasibility of a midwife-led normal birthing unit in mainland China. BACKGROUND: Midwife-led normal birthing units, as a route to ensuring normality, have become a feature of western maternity care, but are unknown in China. DESIGN: Action research, using a qualitative descriptive approach, was performed. Data were collected at meetings, by non-participant observation and by face-to-face semi-structured interviews. Observation was undertaken in the midwife-led normal birthing unit and a standard care setting. Data analysis was by thematic analysis using constant comparison techniques. METHODS: In the labour ward of a large general hospital in a major city, stakeholders included midwifery staff, managers, university staff and researchers. Childbearing women proved keen to use this service, but were unable to participate in the planning. The midwife-led normal birthing unit sought to provide one-to-one care in labour and support by a birth companion. Routine interventions were to be avoided. RESULTS: The midwives in the midwife-led normal birthing unit created a more suitable environment for supportive care. The midwives demonstrated high-quality communication skills. The woman's choice of position/mobility was limited. Difficulties with staffing were identified. CONCLUSIONS: The preliminary findings suggest that continuation of the project is feasible. The woman's role demonstrates passivity. The perception of staff shortage has serious implications. RELEVANCE TO CLINICAL PRACTICE: This action research project suggests that a study of a midwife-led normal birthing unit in China is feasible, with some attention to staffing issues.

A systematic review of medical diagnosis of Ogilvie's syndrome in childbearing.

OBJECTIVE: to review all published papers examining medical diagnosis of Ogilvie's syndrome and pregnancy with a view to assessing the implications of the diagnosis and the condition itself for childbearing women, midwives and medical practitioners. DESIGN: systematic review. SEARCH STRATEGY: MEDLINE, CINAHL, EMBASE, Web of Science and Cochrane databases were searched from 1950 to 2006 inclusive. Papers were read by two independent researchers and selected if they informed the link between Ogilvie's syndrome and childbearing or were concerned with other aspects of maternal mortality. FINDINGS: 23 papers fulfilled the selection criteria and were of a suitable standard. Inconsistencies in relation to the diagnosis of Ogilvie's syndrome were noted, and an increase in maternal deaths from this condition was reported up to 2002. KEY CONCLUSIONS: this paper highlights the strengths and weaknesses of medical diagnosis, as exemplified by Ogilvie's syndrome. The scientific basis of diagnoses such as Ogilvie's syndrome may deserve attention. This diagnosis has been shown to be unstable, both in temporal and aetiological terms. The midwifery and nursing reaction to the abrupt appearance of this condition is, at best, unfortunate. The attribution of blame to midwifery practices is deserving of a more robust response. IMPLICATIONS FOR PRACTICE: there may be clinical implications of the diagnosis of Ogilvie's syndrome for other aspects of maternity (including any nursing) care. A particularly significant area is the widely recognised increase in the caesarean rate with which Ogilvie's syndrome has been closely linked.