Pre-service education and continuous professional development on female genital mutilation/cutting for maternal health professionals in OECD countries: A scoping review.

BACKGROUND: Female Genital Mutilation/Cutting can cause sequalae throughout pregnancy, childbirth, and the postpartum period. Due to changing patterns in migration flows, the practice evolved into a global phenomenon. Health professionals should ensure high quality of care during maternity service provision. OBJECTIVE: This scoping review aimed to map available evidence on pre-service and continuous professional development education about Female Genital Mutilation/Cutting for maternal health professionals and identify developmental needs for topic inclusion into teaching. METHODOLOGY: The review was conducted in accordance with the PRISMA-ScR guidelines. A protocol was developed and is publicly available (medRxiv 2022.08.16.22278598). Three databases (CINAHL, Embase, Medline) and other educational sources were searched. During the final stages of the review an ethical application was submitted and approved. Expert interviews were added to gain insights from practice. RESULTS: The search identified 224 records. After title and abstract screening, 33 studies were selected for full-text review, resulting into the inclusion of 4 studies and 12 non-research educational sources. Scoping the topic revealed that Female Genital Mutilation/Cutting is often included ad-hoc or stand-alone during trainings and it remains unclear, who owes the responsibility. There is lack of knowledge about which competencies are needed for the different levels of health cadres, how competencies are achieved and outcomes measured. CONCLUSION: More transparency into training on Female Genital Mutilation/Cutting and about how competency levels are achieved, maintained and evaluated is required. Further research and interdisciplinary collaboration could focus on the development of specific modules and lead to service improvement.

Developing the midwifery Unit Self-Assessment (MUSA) Framework: A mixed methods study in six European midwifery units.

OBJECTIVE: Evidence indicates that midwifery units are associated with improved health outcomes and experiences; however, there are barriers to their development and scale-up. Guidelines are crucial to their implementation, ensuring that they are developed and integrated sustainably and safely. This study aimed to evaluate and explore the use of a self-assessment tool and improvement process for midwifery units in Europe. METHODS: A mixed methods study was conducted with six midwifery units located in Europe. Quantitative and qualitative data were collected and analysed concurrently, and each informed the other, making the approach both interactive and iterative. The six midwifery units were invited to complete the self-assessment tool, the responses of which were analysed descriptively, and implement an improvement process into practice. Interviews were conducted with midwives using the tool and analysed thematically. RESULTS: Findings indicate benefits and potential feasibility of an improvement process for midwifery units, and suggest that the self-assessment tool is a generative and reflexive practice for midwives. However, issues were identified around limitations of the tool, structural barriers and professional autonomy. Midwifery units require a framework to guide and support their implementation, improvement and scale-up. CONCLUSION: Results highlight the need for more consideration of how macro-level barriers, encompassing social, legal and political dimensions of maternity care, factor locally in the implementation and scale-up of midwifery units. More research is needed to evaluate the feasibility and outcomes of implementing a self-assessment and improvement framework in midwifery units across Europe.

Implementing midwifery units in a European country: Situational analysis of an Italian case study.

INTRODUCTION: Strong evidence recommends midwifery-led care for women with uncomplicated pregnancies. International research is now focusing on how to implement midwifery models of care in countries where they are not well established. In Europe, many countries like Italy are promoting midwifery-led care in national guidelines but often struggle to apply this change in practice. METHODS: This study collected data on professional, organisational and service users' levels to conduct a situational analysis of an Italian service which is approaching the implementation of a midwifery unit. Participatory Action Research was used together with the support of the Consolidated Framework for Implementation Research to conduct data collection and analysis. RESULTS: Forty-eight participants amongst professionals (midwives, obstetricians and neonatologists) and at organisational level (midwifery leaders and medical directors) were recruited; secondary data on service users' views was analysed via regional online surveys. Barriers and facilitators to the implementation were identified to assess the readiness of the local context. CONCLUSIONS: This study is the first to include professionals, managers and service users in a European context such as Italy. Facilitators to the implementation of the alongside midwifery unit were found in national guidelines, allocated funding, collaborative engagement and medical support. Hierarchical structures, a prevalent medical model and lack of trust and awareness of the evidence of safety of midwifery-led models were main barriers.

What are the strategies for implementing primary care models in maternity? A systematic review on midwifery units.

BACKGROUND: Midwifery Units (MUs) are associated with optimal perinatal outcomes, improved service users' and professionals' satisfaction as well as being the most cost-effective option. However, they still do not represent the mainstream option of maternity care in many countries. Understanding effective strategies to integrate this model of care into maternity services could support and inform the MU implementation process that many countries and regions still need to approach. METHODS: A systematic search and screening of qualitative and quantitative research about implementation of new MUs was conducted (Prospero protocol reference: CRD42019141443) using PRISMA guidelines. Included articles were appraised using the CASP checklist. A meta-synthesis approach to analysis was used. No exclusion criteria for time or context were applied to ensure inclusion of different implementation attempts even under different historical and social circumstances. A sensitivity analysis was conducted to reflect the major contribution of higher quality studies. RESULTS: From 1037 initial citations, twelve studies were identified for inclusion in this review after a screening process. The synthesis highlighted two broad categories: implementation readiness and strategies used. The first included aspects related to cultural, organisational and professional levels of the local context whilst the latter synthesised the main actions and key points identified in the included studies when implementing MUs. A logic model was created to synthesise and visually present the findings. CONCLUSIONS: The studies selected were from a range of settings and time periods and used varying strategies. Nonetheless, consistencies were found across different implementation processes. These findings can be used in the systematic scaling up of MUs and can help in addressing barriers at system, service and individual levels. All three levels need to be addressed when implementing this model of care.

Relationships and trust: Two key pillars of a well-functioning freestanding midwifery unit.

BACKGROUND: Despite strong evidence supporting the expansion of midwife-led unit provision, as a result of optimal maternal and perinatal outcomes, cost-effectiveness, and positive service user and staff experiences, scaling-up has been slow. Systemic barriers associated with gender, professional, economic, cultural, and social factors continue to constrain the expansion of midwifery as a public health intervention globally. This article aimed to explore relationships and trust as key components of a well-functioning freestanding midwifery unit (FMU). METHOD(S): A critical realist ethnographic study of an FMU located in East London, England, was conducted over a period of 15 months. Recruitment of the 82 participants was purposive. Data collection included participant observation and semi-structured interviews, and data were analyzed thematically along with relevant local guidelines and documents. RESULTS: Twelve themes emerged. Relationships and Trust were identified as a core theme. The other 11 themes were grouped into six families, three of which: Ownership, Autonomy, and Continuous Learning; Team Spirit, Interdependency, and Power Relations; and Salutogenesis will be covered in this paper. The remaining three families: Friendly Environment; Having Time and Mindfulness; and Social Capital, will be covered in a separate paper. CONCLUSIONS: A relationship-based model of care was crucial for both the functioning of the FMU and service users' satisfaction and may offer a compelling response to high levels of stress and burnout among midwives.

A postgraduate Optimum Birth module to increase midwives' readiness to work in midwifery-led settings: A mixed-methods evaluation.

BACKGROUND: Midwifery-led birth settings have been recommended as the most cost-effective birthplaces for healthy women experiencing uncomplicated pregnancies. However, midwives complete most of their training in obstetric units where birth interventions are common. To prepare for working in a midwifery-led setting training is a key priority. This study evaluated a postgraduate-level midwifery module on Optimum Birth (defined as birth which supports physiology and empowerment, avoiding unnecessary intervention) designed to prepare midwives for supporting women in midwifery-led settings. METHODS: A mixed-methods design was employed. Pre-module and post-module questionnaires measured attitudes, knowledge, confidence, and learning outcomes. Qualitative data collection included a final-day focus group and 8- to 10-week follow-up interviews. The target for recruitment was 15 postgraduate midwives. Fifteen midwives practicing in three London boroughs enrolled of whom 14 completed the module. Pre-total and post-total scores were analyzed with paired-sample t tests. Qualitative data were analyzed using thematic analysis. RESULTS: Quantitative and qualitative data indicated that the module increased participants' self-reported skills, knowledge, and confidence in practicing Optimum Birth. Qualitative data indicated ways in which midwives were implementing changes to promote Optimum Birth in their place of work. Attitudes were highly positive pre-module and post-module. CONCLUSIONS: The Optimum Birth module provided appropriate training for preparing midwives for the shift toward working in midwifery-led settings. Midwifery leaders and managers should implement strategies to develop midwives' philosophy, knowledge, and skills to increase their readiness to work in midwifery-led birth settings.

Challenging the status quo: Women's experiences of opting for a home birth in Andalucia, Spain.

OBJECTIVE: To explore the perceptions, beliefs and attitudes of women who opted for a home birth in Andalusia (Spain). BACKGROUND: Home birth is currently an unusual choice among Spanish women. It is not an option covered by the Spanish National Health Service and women who opt for a home birth have to pay for an independent midwife. DESIGN: A qualitative study with a phenomenological approach was adopted. All participants who took part in this study had chosen to have a home birth and given written consent to take part in the study. METHODS: Data collection was conducted in 2015-16. Face-to-face, semi-structured interviews were undertaken with women who chose a home birth in the last 5 years. FINDINGS: The sample consisted of thirteen women. Seven themes were created through analysis: 1. Getting informed about home birth; 2. Home birth as a choice, despite feeling unsupported; 3. The best way to have a personalized and a physiological birth; 4. Seeking a healing and empowering experience 5. The need for emotional safety, establishing a relationship and trusting the midwife; 6. Preparing for birth and working on fears; 7. Inequality of access (because of financial implications). CONCLUSIONS: Women opted to plan birth at home because they wanted a personalised birth and control over their decision-making in labour, which they felt would not have been afforded to them in hospital settings. Andalusian maternity care leaders should strive to ensure that all pregnant women receive respectful and high-quality personalised care, by appropriately trained staff, both in the hospital and in the community.

'Keeping birth normal': Exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit.

OBJECTIVES: to gain understanding about how participants perceived the value and effectiveness of 'Keeping Birth Normal' training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations. DESIGN: exploratory interpretive. SETTING: inner-city maternity service. PARTICIPANTS: 31 midwives attending a one-day training package on one of three occasions. METHODS: data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers. FINDINGS: We identified six themes contributing to the workshop's effectiveness as perceived by participants. Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3) 'less is more.' And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to influence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most effective.

The Midwifery Unit Network: creating a community of practice to enhance maternity services.

The Midwifery Unit Network (MUNet) is a community of practice which aims to promote and support the implementation and improvement of midwifery units (MUs) in the UK and internationally. It was launched in April 2016 and has been growing fast since its inception. In this article, three co-leads of MUNet describe why they set up the network and how they established it. The aim of the article is to inspire more midwives to consider establishing a community of practice, and to offer some guidance in doing so.

The economic costs of intrapartum care in Tower Hamlets: A comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications.

OBJECTIVE: to compare the economic costs of intrapartum maternity care in an inner city area for 'low risk' women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital. DESIGN: micro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes. SETTING: the Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital's consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. PARTICIPANTS: maternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust's eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital. MEASUREMENTS AND FINDINGS: women who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications.

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care.

OBJECTIVE: to describe and compare women's experiences of specific aspects of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. DESIGN: telephone surveys undertaken in late pregnancy and about six weeks after birth. Two separate waves of interviews were conducted, Phase 1 before the birth centre opened and Phase 2 after it had opened. SETTING: Tower Hamlets, a deprived inner city borough in east London, 2007-2010. PARTICIPANTS: 620 women who were resident in Tower Hamlets and who satisfied the Barts and the London Trust's eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. MEASUREMENTS AND FINDINGS: the replies women gave show marked differences between the model of care in the birth centre and that at the obstetric unit at the Royal London Hospital with respect to experiences of care and specific practices. Women who initially booked for birth centre care were more likely to attend antenatal classes and find them useful and were less likely to be induced. Women who started labour care at the birth centre in spontaneous labour were more likely to use non-pharmacological methods of pain relief, most notably water and less likely to use pethidine than women who started care at the hospital. They were more likely to be able to move around in labour and less likely to have their membranes ruptured or have continuous CTG. They were more likely to be told to push spontaneously when they needed to rather than under directed pushing and more likely to report that they had been able to choose their position for birth and deliver in places other than the bed, in contrast to the situation at the hospital. The majority of women who had a spontaneous onset of labour delivered vaginally, with 28.6 per cent of women at the birth centre but no one at the hospital delivering in water. Primiparous women who delivered at the birth centre were less likely to have an episiotomy. Most women who delivered at the birth centre reported that they had chosen whether or not to have a physiological third stage, whereas a worrying proportion at the hospital reported that they had not had a choice. A higher proportion of women at the birth centre reported skin to skin contact with their baby in the first two hours after birth. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: significant differences were reported between the hospital and the birth centre in practices and information given to the women, with lower rates of intervention, more choice and significant differences in women's experiences. This case study of a single inner-city freestanding midwifery unit, linked to the Birthplace in England Research Programme, indicates that this model of care also leads to greater choice and a better experience for women who opted for it.

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England. 1: Methods and women's overall ratings of care.

OBJECTIVE: to describe and compare women's choices and experiences of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. DESIGN: telephone surveys undertaken in late pregnancy and about six weeks after birth in two separate time periods, Phase 1 before the birth centre opened and Phase 2 after it had opened. SETTING: Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. PARTICIPANTS: 620 women who were resident in Tower Hamlets and who satisfied the Barts and the London NHS Trust's eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. MEASUREMENTS AND FINDINGS: women who satisfied the criteria for birth centre care and who booked antenatally for care at the birth centre were significantly more likely to rate their care as good or very good overall than corresponding women who also satisfied these criteria but booked initially at the hospital. Women who started labour care in spontaneous labour at the birth centre were significantly more likely to be cared for by a midwife they had already met, have one to one care in labour and have the same midwife with them throughout their labour. They were also significantly more likely to report that the staff were kind and understanding, that they were treated with respect and dignity and that their privacy was respected. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this survey in an inner city area showed that women who chose the freestanding midwifery unit care had positive experiences to report. Taken together with the findings of the Birthplace Programme, it adds further weight to the evidence in support of freestanding midwifery unit care for women without obstetric complications.