The experience of maternity care for migrant women living with female genital mutilation: A qualitative synthesis.

BACKGROUND: Increasing numbers of childbearing women with a history of female genital mutilation (FGM) are accessing maternity services in high-income countries across the world. For many of these women, their first contact with the health services in their host country is when they are pregnant. While the clinical consequences of certain categories of FGM are well documented, how high-risk maternity services - designed to mitigate the obstetric consequences of FGM - impact upon women's experience of childbearing is less clear. METHODS: Using a meta-synthesis approach, this paper synthesizes 12 qualitative research papers, conducted in 5 high-income countries, to explore how migrant women with a history of FGM experience maternity care in their host countries. RESULTS: One over-arching theme and four discrete subthemes of migrant women's experience of the maternity services in their host country were identified: feelings of alienation; fatalism and divine providence, positive and negative feelings about maternity care, different understandings of the birthing process, and feelings about FGM. CONCLUSIONS: The findings illustrate that migrant women with a history of FGM frequently encounter negative attitudes when accessing the maternity services in their host countries. Women's experiences suggest a concerning absence of sensitive and empathetic care; a more woman-centered approach is recommended.

Ethnographic study of the use of interventions during the second stage of labor in Jeddah, Saudi Arabia.

BACKGROUND: Routine use of medical interventions during labor has been identified as a clinical area for concern, since such routinized practice is not consistent with an evidence-based approach to care and continues to increase despite efforts to encourage normal childbirth. Therefore, the aim of our study was to explore maternity health professionals' use of interventions during the second stage of labor in two hospitals in Jeddah, Saudi Arabia, to understand what influences their decision-making and practices. METHODS: This was an exploratory study using an ethnographic approach. Data collection methods included participant observations of 19 labors and births (n = 8 at City Hospital and n = 11 at King's Hospital) and semi-structured interviews with 29 health care professionals. In addition, the hospital labor and delivery ward policies and guidelines from those hospitals were collected. Data were analyzed thematically. RESULTS: Medical interventions were used during the second stage of labor routinely, regardless of clinical indication. Three core influences that shaped the clinical decision-making were identified as follows: (a) organizational culture, (b) a medical concept of birth, and (c) a hierarchical system of control. We suggest that the clinical decision-making and routine practice in this setting arises out of the interface between these three core influences whereby hierarchical control and clinicians' exercise of power and feelings of powerlessness are fundamental drivers for an organizational culture of medicalized childbirth, despite the differing models of childbirth which professionals described. CONCLUSIONS: Clinical decisions relating to the use of interventions during childbirth are both complex and socially negotiated. The findings reflect the complexity of the use of interventions during the second stage of labor and the multiple influences on professionals' practices. We have shown how three key influences interact to shape clinical decision-making during the second stage of labor in this cultural setting and how the use of medical interventions can be analyzed as an illustration of the power dynamic in the maternity health care system. We suggest that written policies are insufficient to bring about evidence-based practice and approaches to change need to take into account these different levels of influence.

Midwifery education and technology enhanced learning: Evaluating online story telling in preregistration midwifery education.

BACKGROUND: A major issue regarding the implementation of blended learning for preregistration health programmes is the analysis of students' perceptions and attitudes towards their learning. It is the extent of the embedding of Technology Enhanced Learning (TEL) into the higher education curriculum that makes this analysis so vital. OBJECTIVES: This paper reports on the quantitative results of a UK based study that was set up to respond to the apparent disconnect between technology enhanced education provision and reliable student evaluation of this mode of learning. DESIGN: Employing a mixed methods research design, the research described here was carried to develop a reliable and valid evaluation tool to measure acceptability of and satisfaction with a blended learning approach, specifically designed for a preregistration midwifery module offered at level 4. METHODS: Feasibility testing of 46 completed blended learning evaluation questionnaires - Student Midwife Evaluation of Online Learning Effectiveness (SMEOLE) - using descriptive statistics, reliability and internal consistency tests. RESULTS: Standard deviations and mean scores all followed predicted pattern. Results from the reliability and internal consistency testing confirm the feasibility of SMEOLE as an effective tool for measuring student satisfaction with a blended learning approach to preregistration learning. CONCLUSIONS: The analysis presented in this paper suggests that we have been successful in our aim to produce an evaluation tool capable of assessing the quality of technology enhanced, University level learning in Midwifery. This work can provide future benchmarking against which midwifery, and other health, blended learning curriculum planning could be structured and evaluated.

Expertise in physiological breech birth: A mixed-methods study.

BACKGROUND: The safety of vaginal breech birth depends on the expertise of birth attendants, yet the meaning of "expertise" remains unclear and subjectively defined. The objective of this study was to define expertise and the roles experts may play in expanding access to this service. METHODS: We performed an integrative analysis of two strands of data concerning expertise in physiological breech birth, including the following: survey data from a Delphi study involving 26 very experienced clinicians (mean experience = 135 breech births) and 2 service user representatives, and interviews from a grounded theory study of 14 clinicians more moderately experienced with physiological methods (5-30 upright breech births). Data were pooled and analyzed using constant comparative methods. RESULTS: Expertise is defined by its ongoing function, the generation of comparatively good outcomes, and confidence and competence among colleagues. Although clinical experience is important, expertise is developed and expressed in social clinical roles, which expand as experience grows: clinician, mentor, specialist, and expert. To develop expertise within a service, clinicians who have an interest in breech birth should be supported to perform these roles within specialist teams. CONCLUSIONS: Specialist breech teams may facilitate the development of expertise within maternity care settings. Evaluation of expertise based on enablement of women and colleagues, as well as outcomes, will potentially avoid the pitfalls of alienation produced by some forms of specialist authority.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study.

PROBLEM: Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems. BACKGROUND: Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear. QUESTION: How do professionals develop competence and expertise in physiological breech birth? METHODS: Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition. RESULTS: Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners. DISCUSSION: The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices. CONCLUSION: Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

Innovation in preregistration midwifery education: Web based interactive storytelling learning.

BACKGROUND: through a critical description of the implementation of a web based interactive storytelling learning activity introduced into an undergraduate, preregistration midwifery education programme, this paper will explore how low-cost, low-fidelity online storytelling, designed using Moodle, can be used to enhance students' understanding of compassion and empathy in practice. SAMPLE: cross sectional sample of first year undergraduate Midwifery students (n111) METHOD: drawing from both research and audit data collected in an Higher Education Institution in London England, the paper presents the case for using web based technology to create a sustainable model for midwifery education. FINDINGS: initial results indicate that it is both the low cost and positive student evaluations of web based interactive storytelling, which make this approach to preregistration midwifery education which suggests that this approach has significant potential for learning and teaching in midwifery education in diverse settings around the world. Or how about: global relevance? .

Effectiveness of vaginal breech birth training strategies: An integrative review of the literature.

BACKGROUND: The safety of vaginal breech birth depends on the skill of the attendant. The objective of this review was to identify, synthesize, and report the findings of evaluated breech birth training strategies. METHODS: A systematic search of the following on-line databases: Medline, CINAHL Plus, PsychINFO, EBM Reviews/Cochrane Library, EMBASE, Maternity and Infant Care, and Pubmed, using a structured search strategy. Studies were included in the review if they evaluated the efficacy of a breech birth training program or particular strategies, including obstetric emergency training evaluations that reported differentiated outcomes for breech. Out of 1040 original citings, 303 full-text articles were assessed for eligibility, and 17 methodologically diverse studies met the inclusion criteria. A data collection form was used to extract relevant information. Data were synthesized, using an evaluation levels framework, including reaction, learning (subjective and objective assessment), and behavioral change. RESULTS: No evaluations included clinical outcome data. Improvements in self-assessed skill and confidence were not associated with improvements in objective assessments or behavioral change. Inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births. CONCLUSIONS: As a result of the heterogeneity of the studies available, and the lack of evidence concerning neonatal or maternal outcomes, no conclusive practice recommendations can be made. However, the studies reviewed suggest that vaginal breech birth training may be enhanced by reflection, repetition, and experienced clinical support in practice. Further evaluation studies should prioritize clinical outcome data.

Sarah's birth. How the medicalisation of childbirth may be shaped in different settings: Vignette from a study of routine intervention in Jeddah, Saudi Arabia.

BACKGROUND: The expansion of the medicalisation of childbirth has been described in the literature as being a global phenomenon. The vignette described in this paper, selected from an ethnographic study of routine intervention in Saudi Arabian hospitals illustrates how the worldwide spread of the bio-medical model does not take place within a cultural vacuum. AIM: To illuminate the ways in which the medicalisation of birth may be understood and practised in different cultural settings, through a vignette of a specific birth, drawn as a typical case from an ethnographic study that investigated clinical decision-making in the second stage of labour in Saudi Arabia. METHODS: Ethnographic data collection methods, including participant observation and interviews. The data presented in this paper are drawn from ethnographic field notes collected during field work in Saudi Arabia, and informed by analysis of a wider set of field notes and interviews with professionals working in this context. FINDINGS: While the medicalisation of care is a universal phenomenon, the ways in which the care of women is managed using routine medical intervention are framed by the local cultural context in which these practices take place. DISCUSSION: The ethnographic data presented in this paper shows the medicalisation of birth thesis to be incomplete. The evidence presented in this paper illustrates how local belief systems are not so much subsumed by the expansion of the bio-medical model of childbirth, rather they may actively facilitate a process of localised reinterpretation of such universalised and standardised practices. In this case, aspects of the social and cultural context of Jeddah operates to intensify the biomedical model at the expense of respectful maternity care. CONCLUSION: In this article, field note data on the birth of one Saudi Arabian woman is used as an illustration of how the medicalisation of childbirth has been appropriated and reinterpreted in Jeddah, Saudi Arabia.

Principles of physiological breech birth practice: A Delphi study.

OBJECTIVE: to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth. DESIGN: three-round Delphi e-survey. SETTING: multi-national. PARTICIPANTS: a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives. METHODS: an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement). FINDINGS: the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth. CONCLUSION: the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.

The fear factor of risk - clinical governance and midwifery talk and practice in the UK.

OBJECTIVE: Through the critical application of social theory, this paper will scrutinise how the operations of risk management help to constitute midwives׳ understandings of childbirth in a particular way. DESIGN AND SETTING: Drawing from rich ethnographic data, collected in the southeast of England, the paper presents empirical evidence to critically explore how institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth. Observational field notes, transcribed interviews with various midwives, along with material culture in the form of documentary evidence will be used to explore the unintended consequences of clinical governance and its risk management technologies. KEY CONCLUSIONS: Through this analysis the fear factor of risk in midwifery talk and practice will be introduced to provide an insight into how risk management impacts midwifery practice in the UK.

Standards for maternity care professionals attending planned upright breech births: A Delphi study.

OBJECTIVE: to establish a consensus of opinion on standards of competence for professionals attending upright breech births. DESIGN: a three-round Delphi e-survey. SETTING: multinational. PARTICIPANTS: a panel of 13 obstetricians, 13 midwives and two user representatives. Clinicians had attended >20 upright breech births, or >10 upright among >40 total breech births. Mean level of experience=135 breech births, median=100 breech births. METHODS: an initial survey contained open-ended questions. Answers were coded and amalgamated to form 164 statements in the second round and 9 further statements in the third round. Panellists were asked to evaluate their agreement with each statement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating agreement or strong agreement with the statement. FINDINGS: the panel returned a consensus-level agreement on 63 statements under the theme, 'Standards of Competence.' Panellists supported teaching breech as a 'normal' skill rather than an emergency, including optimal mechanisms and breech-specific progress measures, upright variations of classical manoeuvres, the initiation of resuscitation with the umbilical cord intact, birth videos as learning tools, and the development of breech teams to support the wider team in all maternity care settings. CONCLUSIONS: although every health professional should maintain basic competence to assist unanticipated breech births, establishing enhanced training and standards for those who support planned breech births may help protect users and providers of maternity services, while introducing greater choice and flexibility for women seeking the option of vaginal breech birth.

'She can't come here!' Ethics and the case of birth centre admission policy in the UK.

Using ethnographic data lifted from an investigation into midwifery talk and practice in the South of England, this paper sets out to interrogate the ethics underpinning current admission policy for Free Standing (midwifery led) Birth Centres in the UK. The aim of this interrogation is to contest the grounds upon which birth centres admissions are managed, particularly the over-reliance on abstract calculations of risk--far removed from the material lived experience of the mother wishing to access these birth centre services.

The swan effect in midwifery talk and practice: a tension between normality and the language of risk.

Midwifery activity in the labour room coalesces around routine surveillance practices. When engaging in such practice, midwives have to cope with attempting to instil a sense of confidence in the mother's embodied ability to give birth to her baby spontaneously while concurrently attending to an array of risk-focused tests and measurements. Midwives are vigilant about the potential harm that may come to mother and baby while at the same time they are responsible for facilitating a normal birth. This article sets out to explore the tension between these two tasks and shows how routine midwifery practice during labour can communicate certain understandings about birth. Using empirical evidence taken from an ethnographic study of midwifery talk and practice, attention is given to how midwives' activity during labour and birth implicitly introduces a sense of danger, an imagined risk that confines practice and operates to unsettle normality.