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PubMed2004

Midwifery care: development of an instrument to measure quality based on the World Health Organization's classification of care in normal birth.

AIMS AND OBJECTIVES: The aim of the study was to develop an instrument to measure midwifery care in relation to World Health Organization's classification of care in normal birth and to test the instrument for content validity and inter-rater reliability. METHODS: The Delphi method was used for development of the instrument and to elicit evidence of content validity. Six experts from three different geographical regions in Sweden, representing clinically working midwives, lecturers in midwifery and obstetricians, participated in the first part of the study. The instrument was tested for inter-rater reliability in an exploratory study by two midwives and one of the authors. Data were analysed using percentage of agreement level and the Kappa coefficient. RESULTS: Five expert rounds were needed to reach consensus for content validity. The inter-rater reliability test showed high agreement levels (95.9, 94.2 and 95.7%) and good to very good Kappa coefficients (0.74-1.0). The final instrument consisted of 78 items divided into five sections: background (five items); practices which are demonstrably useful and should be encouraged (55 items); practices which are clearly harmful or ineffective and should be eliminated (five items); practices for which insufficient evidence exists to support a clear recommendation and which should be used with caution while further research clarifies the issue (four items); and finally practices which are frequently used inappropriately (nine items). CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: The instrument can be used at a labour ward to measure documented care and quality of midwifery care. The results can be used to identify areas for improvements, to develop guidelines towards evidence-based care and to improve documentation. However, the present study should be regarded as an exploratory study and the feasibility of the instrument remains to be tested in empirical studies.

Attitude of Health Personnel↗
PubMed2000

Action research to improve the pre-registration midwifery curriculum Part. 2: Case study evaluation in seven sites in England.

OBJECTIVE: To identify factors which facilitate and inhibit the effectiveness of current pre-registration midwifery programmes. DESIGN: The case study part of an action research project. SETTING: Seven case study institutions in England. PARTICIPANTS: Student midwives, midwives, midwifery managers/supervisors of midwives, midwife teachers, collaborators in the study. FINDINGS: It emerged, following a synthesis of all data, that the pre-registration midwifery curriculum should have five key outcomes: students should feel confident and competent as midwives; students must have achieved the statutory requirements for registration; students should be committed to undertaking the whole role and responsibilities of a midwife; students must be equipped to take responsibility and accept accountability for their actions; students must recognise the need for career long learning. Whilst overall these new programmes were considered to be effective in preparing students for their role as midwives, there was variability in the degree to which these five key outcomes were achieved by the case study students. IMPLICATIONS FOR PRACTICE: There needs to be agreement as to what constitutes fitness for practice at the point of registration; assessment schemes, particularly those relating to practice capabilities, need to be valid, reliable and robust with the benefit of the doubt being given in favour of childbearing women when students are 'borderline'; fitness for purpose requires clarification to avoid employers having unreal expectations of new qualifiers which may result in attrition due to excessive stress; review of curricula should take account of the importance of personal qualities and learning strategies which enable students to cope with complexity, uncertainty, decision making and 'being a midwife' before course completion.

Curriculum↗
PubMed2001

Evaluation of a problem-based curriculum in midwifery.

OBJECTIVE: to evaluate the implementation of a 'problem-based' learning (PBL) curriculum within midwifery. DESIGN: a 'realistic evaluation' model based on cost-effectiveness models of economics, and incorporating both qualitative and quantitative methodology. The design used historical comparison, comparing students following the new curriculum with a baseline of previous student cohorts and exploring staff and student experiences. SETTING: a 'new' university, providing a degree-level 18 month pre-registration midwifery programme for an intake of about 40 students per cohort. PARTICIPANTS: all students in the cohort qualifying immediately before the implementation and all those in the first cohort following the new curriculum were invited to participate fully. Assessment outcomes for three cohorts of students qualifying before and the first three cohorts qualifying following the change were analysed. All clinical staff directly involved in mentoring the relevant student groups, all academic staff involved in delivering the new curriculum and the course external examiner were invited to participate. INTERVENTION: the evaluation studied a major change in the way the overall midwifery curriculum was delivered, widely described as PBL. MEASUREMENTS: students' experiences and perspectives were sought through review of routine evaluation documents, nominal group technique exercises and focus group discussions at about six months following qualification. Clinical staff experiences and perspectives were sought through written structured questionnaires. Academic staff views were sought through personal semi-structured interviews. Participant observation of the process, review of course documents and of staff reflective commentaries were also conducted. Data on student completion rates and final grade were analysed. FINDINGS: although students' views of the curriculum were generally positive, they experienced some discomfort and difficulty in adjustment to a new style of learning. Small group learning, independence and skills in using and conveying information and research evidence were valued aspects of the new approach. Quality of clinical placement experience and university-practice links were an important area of positive experience or concern. Clinical staff views of the curriculum showed considerable stability, with major concerns being the balance of theory and practice time and skills which were not influenced by the curriculum change. At both points, ability to critically evaluate and use evidence in practice was regarded highly. Student outcomes showed some evidence of possible divergence of grades in the new curriculum. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the manner and context of implementation of educational change may have important implications for student experiences and outcomes and the experiences of educators. Adequate preparation at all levels for a different, more independent style of learning is important and students are likely to need clear guidance and feedback on their progress in the early stages of the curriculum, to monitor progress and to provide reassurance. Longer-term research is needed to assess the impact of PBL on theory-practice links and on the midwives as practitioners.

Attitude↗
PubMed2002

An evaluation by focus group and survey of a course for Midwifery Ventouse Practitioners.

OBJECTIVE: to evaluate the Midwifery Ventouse Practitioners' (MVPs) Course and the MVPs' perception of its effect on their practice. DESIGN: qualitative and quantitative. PARTICIPANTS: 18 midwives who had completed the MVP course at Bournemouth University 1998-2000. DATA COLLECTION: focus group (n=8) and postal questionnaire (n=18). FINDINGS: important issues were identified by the focus group and informed the development of the questionnaire which achieved a 100% response rate. The mean length of full-time experience as a midwife was 18.6 years (SD 6.8; range 9-33); 11 midwives were based in community maternity units and seven in consultant units. Seventeen of the MVPs had been called to assist 505 women in this capacity; 366 (72%) had an MVP ventouse-assisted birth, 129 (26%) a normal birth and 10 women (2%) needed obstetric assistance. In this regard, there were considerable differences between individual MVPs. The midwives gave high priority to woman-centred values and to the very judicious use of intervention. They felt that the course had increased their confidence in relation to their midwifery practice, in general, and their ability to define fetal position and station, in particular. They reported a high level of confidence when undertaking their first ventouse birth after completing the course. KEY CONCLUSIONS AND IMPLICATIONS: midwives who have undertaken this course do not appear to expand their role to the detriment of normal midwifery, as had been feared. Even highly experienced midwives value increasing their confidence in relation to vaginal and abdominal examination. Ambulance transfer in the second stage of labour was prevented for at least 109 women. A long-term clinical evaluation of the births to which an MVP has been called is needed.

Adult↗
PubMed1999

Integrating the creative arts into a midwifery curriculum: a teaching innovation report.

The practice of midwifery has long been recognized as both art and science. However, educational programmes for midwifery are most often undertaken within an academic health sciences environment, and tend to be based on knowledge derived from the sciences (e.g. life sciences, biomedical sciences, behavioural sciences and social sciences). These scientific perspectives, while essential to the preparatory and on-going education of midwives, do not necessarily fully prepare midwives to fulfil their practice roles. This paper reports a teaching innovation aimed at facilitating student exploration of fundamental, complex and ethereal concepts which are essential to the effective and skillful practice of midwifery. Through the exploration of the arts and humanities, students were encouraged to engage with concepts such as 'caring', 'empathy', 'suffering', 'motherhood', 'pain', 'love', 'attachment', 'health' and 'illness'. Students were also encouraged to explore cultural and social symbols pertaining to parenthood and family life. Evaluation revealed that students valued the course, and that they gained insights which assisted them to develop understanding of key concepts. Implications for practice and education are drawn from this paper.

Art↗
PubMed2000

An ethnography of midwifery work patterns during organisational redesign.

Despite a substantial increase in midwifery research since the early 1990's, there remains a lack of available research into the everyday practice of midwives. In general, hospitals are striving to reduce costs and increase efficiencies, so many hospital-based midwives are being exposed to hospital restructuring processes. The primary purpose of my research was to learn about the work patterns of hospital midwives during organisational redesign. A large Brisbane hospital, as part of its hospital-wide organisational redesign plan, merged two postnatal wards to create a new, larger unit. With this amalgamation, the ward midwives were exposed to several service delivery changes. Midwifery work patterns during this organisational change revealed a milieu characterised by a culture of business. The impact of change introduced ritual and personal elements that influenced midwifery work patterns.

Anthropology, Cultural↗
PubMed2001

Midwifery across the generations: a modernizing midwife in Guatemala.

This article examines change and continuity in midwifery knowledge and practice by comparing a mother and daughter, both of whom are local midwives, or comadronas, on a Guatemalan plantation. The daughter apprenticed with the mother, who died in 1997. Like her mother, she received a government midwifery license after attending an official training course. I discuss the applicability of the concept of "postmodern midwifery" as I trace how both mother and daughter adapted to the pressures of medicalization and modernization. The daughter negotiates with biomedical personnel and copes with increasing government regulations, and she tends to accept biomedical authority more readily than did her mother. Unlike her mother, she sometimes uses this authority to enhance her own status. Nevertheless, her acceptance of the biomedical model is not complete, for she recognizes the practical constraints of poverty, under which both she and her clients live, and she also insists upon the superiority of such practices as massage. Furthermore, biomedicalization is countered by a process of sacralization, which, I suggest, enables midwives both to contest biomedical authority and to deliver meaningful care.

Attitude of Health Personnel↗
PubMed2006

Evaluation of internet use in university education by midwifery students.

The aim of our study was to evaluate the use of the medical Internet by midwifery students with analysis of influencing factors and students' preferences. A prospective cross-sectional questionnaire study was carried out with 180 midwifery students. The response rate was 83.8%, 82% use the Internet, and 79.3% use the medical resources in their education. The mean accession to the Web is 5.3 +/- 8.4 times per month. The mean evaluation of information resources for books, journals, conferences and university courses was 6.6 +/- 3.2, 4.8 +/- 3.1, 2.7 +/- 3.0, and 6.8 +/- 3.8, respectively, as measured with the Visual Analogue Scale (p < 0.001). Age did not correlate with Internet use and its evaluation but correlated with a self-evaluation of Internet skills as a user (Rs = -0.20, p = 0.016). The evaluation of the Internet as a source of medical knowledge correlated with self-evaluation of medical search skills (Rs = 0.66, p < 0.001) and user skills (Rs = 0.61, p < 0.001). The medical Internet is used by the majority of midwifery students, but it is still a secondary source of information, after university training and medical books. The higher evaluation of Internet correlated with general computer skills and medical search skills, which suggests the need for education on Internet use by students.

Adult↗
PubMed1999

Clinical interventions and outcomes of One-to-One midwifery practice.

BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation.

Adult↗
PubMed2005

Integrating environmental health into nursing and midwifery practice.

AIM: With the recognition that environmental health has relevance to all nursing and midwifery activities, the aim of this paper is to discuss nurses' and midwives' past and present involvement in environmental health in the UK, where the international situation demonstrates good practice, and the challenges and possibilities for greater and more effective UK-based activity in the future. BACKGROUND: The association between environmental hazards and adverse health effects has received increasing attention over recent years. In the United States of America (USA), the importance of developing an environmental health role for nurses outside of the "traditional" occupational and environmental health nursing specialty has been recognized and acted upon through education, information programmes and policy developments. In the United Kingdom (UK), the same degree of interest, commitment and activity is somewhat lacking. DISCUSSION: Little nursing and midwifery activity on environmental health issues has taken place in the UK over recent years. The lack of development in this field may relate to the problems of an already overstretched disease treatment service and the lack of an upstream approach to public health. Theoretical and philosophical influences, as well as individual and organizational obstacles or constraints, exist and may hinder nurses and midwives in their efforts to address the subject. Yet nurses and midwives are the largest group in the National Health Service workforce and this gives enormous potential for effective interventions in environmental health. CONCLUSIONS: Whilst barriers and obstacles to nursing and midwifery involvement in environmental health in the UK exist, they are all surmountable and appropriate interventions could prove cost-effective in the middle and long-term. Additionally, they may be viewed as a necessary activity for nurses and midwives in response to real health threats and the expressed worries and concerns of patients and communities.

Clinical Nursing Research↗
PubMed2006

Vision, leadership and partnership: how to enhance the nursing and midwifery contribution to research and development.

AIM: This paper reports an evaluation of nursing and midwifery research and development activity in Northern Ireland. BACKGROUND: Research and development is integral to the quality of patient care. Nurses and midwives have an important contribution to make and, whilst the professional landscape has changed significantly, with improved funding and productivity, there remains much room for improvement. To advance this agenda it is necessary to evaluate progress across the spectrum of research and development activity. The policy literature gives examples of the methods by which this can be achieved, but there is less evidence about evaluation criteria, or the methods by which research and development progress is assessed at organizational, national and international levels. METHOD: A comprehensive analysis of the literature was undertaken to develop a 'Research and Development Best Practice Framework'. This was then used as the basis for structured interviews with 32 organizational leads for three main stakeholder groups: health and care providers (n = 20), education providers (n = 7) and funders of research and development (n = 5). Data collection was from March to November 2004. FINDINGS: Despite general recognition of its value, only a minority of organizations had an up-to-date corporate strategy that included nursing and midwifery research and development. There was considerable variability in the systems, support structures, capacity and productivity of nurses and midwives throughout these organizations. In most, no-one had sole responsibility for leading the professional research and development agenda but, where such leadership was in place, improved outcomes were apparent. Building effective partnerships for research and development and forward planning through developing an organizational strategy were also key indicators of success. CONCLUSION: Our findings confirm progress, but also reinforce the need to develop a clear vision, enhance leadership potential and forge effective partnerships to advance the research and development agenda in nursing and midwifery.

Attitude of Health Personnel↗
PubMed2004

'From the sphere of Sarah Gampism':The professionalisation of nursing and midwifery in the Colony of Victoria.

In the nineteenth century, while the Colony of Victoria was still a fledgling settlement, many of the hospitals of England, Scotland, Ireland, and Europe had instituted forms of nursing and midwifery training. When graduates of these training schemes emigrated to Australia with their knowledge, skills and experience, they found health practice to be haphazard and lacking in organisational standards. Individual immigrant women rose to prominence as managers of Victorian hospitals, and superintendents of homes for trained nurses. Through professional networks of their peers and compatriots, these women succeeded in placing the profession of nursing on a firm footing, and were instrumental in the emergence of professional organisations for trained nurses and midwives in Victoria, including the Melbourne District Nursing Society, the short-lived Nurses Association of Australasia (1892), and the Victorian Trained Nurses Association (1901). Their leadership was to have a profound influence on the way nursing and midwifery were regulated in twentieth century Victoria. In this historical review, we trace the movement to professionalise nursing and midwifery which emerged in the Colony of Victoria during the late nineteenth and early twentieth centuries.

History of Nursing↗
PubMed2005

Understanding the social organisation of maternity care systems: midwifery as a touchstone.

Theories of professions and healthcare organisation have difficulty in explaining variation in the organisation of maternity services across developed welfare states. Four countries - the United Kingdom, Finland, the Netherlands and Canada - serve as our case examples. While sharing several features, including political and economic systems, publicly-funded universal healthcare and favourable health outcomes, these countries nevertheless have distinct maternity care systems. We use the profession of midwifery, found in all four countries, as a 'touchstone' for exploring the sources of this diversity. Our analysis focuses on three key dimensions: (1) welfare state approaches to legalising midwifery and negotiating the role of the midwife in the division of labour; (2) professional boundaries in the maternity care domain; and (3) consumer mobilisation in support of midwifery and around maternity issues.

Canada↗
PubMed1998

A systematic review comparing continuity of midwifery care with standard maternity services.

OBJECTIVE: To review randomised controlled trials of alternative maternity services characterised by continuity of midwifery care. METHODS: A systematic review of randomised controlled trials, analysed on an intention to treat basis, in which the study intervention was characterised by a midwife or small group of midwives providing care from early pregnancy to the postnatal period (defined as that provided on the postnatal ward); and the controls by standard maternity care as practised in the place where the trial was conducted. The seven trials identified included 9148 women. Main outcome measures were interventions during labour, maternal outcomes and infant outcomes. RESULTS: The alternative models with continuity of midwifery care were associated with less use of obstetric interventions during labour (eg, induction, augmentation of labour, electronic fetal monitoring, obstetric analgesia, instrumental vaginal delivery and episiotomy). However, the caesarean section rate did not differ statistically between the trial groups (OR 0.91; 95% CI 0.78 to 1.05). The lower episiotomy rate in the alternative models of care (OR 0.69; 95% CI 0.61 to 0.77) was associated with a significantly higher rate of perineal tears in the pooled alternative groups (OR 1.15; 95% CI 1.05 to 1.26). The percentage of intact perineums was very similar for the two groups (OR 1.11; 95% CI 1.00 to 1.24). There was no maternal death, and rates of maternal complications based on unpooled estimates did not show any statistically significant differences. The proportion of babies with an Apgar score < 7 at five minutes after the birth was approximately the same in the pooled alternative groups as in the control groups (OR 1.13 95% CI 0.69 to 1.84). Admission to intensive care or special care baby unit was similar (OR 0.86; 95% CI 0.71 to 1.04). The difference in perinatal deaths was bordering on statistical significance (OR 1.60; 95% CI 0.99 to 2.59). CONCLUSION: Continuity of midwifery care is associated with lower intervention rates than standard maternity care. No statistically significant differences were observed in maternal and infant outcomes. However, more research is necessary to make definite conclusions about safety, for the infant as well as for the mother. This review illustrates the variation in the different models of alternative and standard maternity care, and thus the problems associated with pooling data from different trials.

Adult↗
PubMed1999

Comfort in labor and midwifery art.

PURPOSE: To examine the phenomenon of comfort in the context of childbirth. Enhancement of comfort for laboring women is a valued outcome of nursing and midwifery care. Interventions that increase comfort during labor support a woman's effort to participate more fully in the birth thereby keeping her more aware of her body, emotions, and experience. ORGANIZING CONSTRUCT: The concept of comfort is analyzed and defined in the context of laboring women. Comfort studied from a feminist perspective is suggested. SOURCES: A literature review of nursing, midwifery, and medical texts from the 1920s to 1998 provides information about labor, pain in labor, and goals of providers caring for laboring women. Research articles focusing on comfort are identified as they relate to the concept of comfort in labor. Writings of contemporary feminist authors provided the ideas for designing the study of comfort from a feminist perspective. METHODS: To develop a theory of comfort during labor, early nursing and midwifery texts were searched to identify goals of care. The meaning of comfort was analyzed from the early 1920s to the present by concept analysis. Validation of findings was sought from publications on comfort research. FINDINGS: Comfort can exist in spite of great pain and nurses and midwives may be able to assist laboring women to achieve a level of comfort during labor. Intervening to promote the comfort of laboring women can empower these women during birthing. CONCLUSIONS: For clinicians caring for birthing women, particularly midwives, promotion of comfort is a high priority. Increasing comfort can redefine the meaning of pain in childbirth. Increasing comfort may create a decreased need for medical interventions and lower costs.

Clinical Nursing Research↗
PubMed2002

Differences in evidence-based care in midwifery practice and education.

PURPOSE: To examine site-specific differences in managing labor and to describe variations in intrapartum practice in the context of clinical midwifery education. DESIGN: Descriptive design based on secondary analysis of an existing data set collected to evaluate the intrapartum clinical experiences of nurse-midwifery students. The data set included 498 records collected by midwifery students in 23 sites from 1995-1998. The unit of analysis was the intrapartum record. METHODS: Students used The American College of Nurse-Midwives Clinical data Set for Intrapartum Care to collect data during clinical experiences, including patient demographic data, risk factors, and specific care processes and interventions. FINDINGS: Significant variations were found among settings despite use of the same clinical guidelines. Discrepancies between theoretical preparation of students for clinical practice and the realities of clinical practice were noted. CONCLUSIONS: Despite a stated commitment to evidence-based practice, practice patterns varied significantly. Clinicians and educators need to find common ground for combining evidence-based theory with evidence-based practice.

Evidence-Based Medicine↗
PubMed2002

Moving from codes of ethics to ethical relationships for midwifery practice.

This discussion examines the emergence of professional codes of ethics, influences that shape contemporary midwifery ethics, and the adequacy of codes to actualize values embedded in the midwifery ethics discourse. It considers the traditions of professional practice, the impact of institutionalization on health care, the application of a code of practice as a recent addition to those traditions, and the strengths and weaknesses of codes of ethics as models for ethical responses. That is, it sets out to articulate and deconstruct existing frames of ethical response. The ethics of strangers (normative theory and abstract principles) are rejected as inadequate, and the ethics of intimates (feminist-relational ethics) are proposed as a more adequate guide for well-woman centred midwifery practice.

Bioethical Issues↗
PubMed1991

The safety of team midwifery: the first decade of the Monash Birth Centre.

OBJECTIVE: To review the safety of team midwifery care, in terms of perinatal mortality, for pregnant women assessed at their first visit as being at low risk of complications. DESIGN: A cohort study. SETTING: Team midwifery unit (Birth Centre) in a tertiary hospital. PATIENTS: All women who made a booking and met the selection criteria at their first antenatal visit (3085), excluding those with spontaneous or induced fetal loss before 20 weeks (89) and those who withdrew at their own request to seek an alternative form of care (138); the 2858 remaining women gave birth to 2874 infants. MAIN OUTCOME MEASURES: Perinatal mortality rate; and birthweight specific perinatal mortality ratio with reference values being specific rates for birthweight in Victoria for 1984-1985. RESULTS: The perinatal mortality rate was 7.7 per 1000 births (95% confidence interval [CI] 4.8-11.6) for the whole cohort; for women beginning labour in the Birth Centre it was 1.3 per 1000 births (95% CI, 0.3-3.9). The birthweight standardised perinatal mortality ratio was 80 (95% CI, 50-122). CONCLUSION: Within this setting, with explicit criteria for booking and referral, and a framework for consultation, team midwifery care is as safe as the standard maternity care provided within the State.

Birth Weight↗