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Cooperation in midwifery research between Zambia and Sweden is ongoing. Joint studies on gastric suctioning and maternity routines are used as examples, and breastfeeding is discussed from a global perspective. The midwife, who also interprets responses from mothers, is an important member of an assessment team. Cooperation over cultural boundaries is feasible and mutually rewarding.
Recent recommendations have been made which would give midwives a more central role in maternity care and a greater degree of independence than they currently enjoy. This paper argues that midwives' current attitudes to quality assurance are incompatible with this enhanced role. Research conducted in three health districts is described, which explored the perceptions of nurses, midwives and managers towards quality assurance. The findings indicate that quality assurance (in whatever form that concept is operationalized) is a demonstration of accountability. For managers this accountability is primarily for the service as a whole, whilst nurses and midwives view their accountability as being owed to patients/clients. The main methodology which the study identified as being used for monitoring nursing care was the development and auditing of explicit standards. This approach has been actively promoted by the Royal College of Nursing, enabling nurses to regain control of the purely professional aspects of the nursing profession. Midwives in the study districts showed a marked reluctance to adopt such a strategy, taking the view that as independent practitioners consensus standards would be unacceptable. It is argued that this attitude is inconsistent with the basic principle that professionals are accountable for both demonstrating and developing the quality of professional practice. It is further suggested that midwives currently have an opportunity to regain professional control of midwifery practice, which will be lost unless they are prepared to take responsibility for evaluating the standards for which they are accountable.
BACKGROUND: While nursing, midwifery and professions allied to medicine (PAMs) are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness in relation to these professions. We identified 18 evaluations of guidelines which met established quality for evaluations of interventions aimed at changing professional practice. This paper describes characteristics of guidelines evaluated and the effectiveness of different dissemination and implementation strategies used. METHODS: Guideline evaluations conducted since 1975 which used a randomized controlled trial, controlled before-and-after, or interrupted time-series design, were identified using a combination of database and hand searching. FINDINGS: It is mostly impossible to tell whether the guidelines evaluated were based on evidence. The most common method of guideline dissemination was the distribution of printed educational materials. Three studies compared different dissemination and/or implementation strategies: findings suggest educational interventions may be of value in the dissemination of guidelines and confer a benefit over passive dissemination.
In this paper, we outline three moments in the history of Western philosophy--Classical Greek, Modernity, Postmodernity--and the ways in which issues of truth, virtue and beauty have been understood within these philosophical formations. In particular, we investigate the ways in which notions of truth, virtue and beauty influenced the orthodoxy of birthing practices at these different moments. Finally, we examine current, critical reflections on the role of the intellectual in postmodern society and use these reflections as a heuristic for understanding the role of the contemporary midwife. We suggest that midwifery must reconcile two divergent demands. The first is to mobilise the positive, instrumental benefits of Western medical science to improve mortality and morbidity outcomes. The second is to remain sensitive to the cultural and social meanings attached to traditional birthing practices and to understand the roles these play in the well-being of mother and child.
A transformational model of professional identity formation, anchored and globalized in workplace conversations, is advanced. Whilst the need to theorize the aims and methods of clinical education has been served by the techno-rational platform of 'reflective practice', this platform does not provide an adequate psychological tool to explore the dynamics of social episodes in professional learning and this led us to positioning theory. Positioning theory is one such appropriate tool in which individuals metaphorically locate themselves within discursive action in everyday conversations to do with personal positioning, institutional practices and societal rhetoric. This paper develops the case for researching social episodes in clinical education through professional conversations where midwifery students, in practice settings, are encouraged to account for their moment-by-moment interactions with their preceptors/midwives and university mentors. It is our belief that the reflection elaborated by positioning theory should be considered as the new epistemology for professional education where professional conversations are key to transformative learning processes for persons and institutions.
OBJECTIVE: To explore the interpretations midwives and nurses attach to the concept of caring, how caring values are manifest clinically and might be encouraged educationally. DESIGN: Ethnographic fieldwork was undertaken in UK National Health Service palliative and maternity-care hospital settings for 12 and 10 days respectively. This involved non-participant observation, semi-structured, audio-taped interviews with seven midwives and six nurses. Ad hoc conversations with service-users were also undertaken and contextual information, such as staffing levels, was collected. The data were thematically analysed against a conceptualisation of caring developed from nursing and philosophical literature. FINDINGS: Comparison of observational and interview data across the settings identified qualitative differences in care delivery. In the palliative care setting, practice was other-centred, receptive, responsive and attentive to the patient's person and experience. In comparison, caring values appeared eroded in the maternity setting, where practice was often routinised, task-orientated and, on occasions, unresponsive to women's needs. Features existed in the palliative care setting which appeared instrumental in facilitating a caring practice culture. In particular, clinical leaders facilitated team cohesion through daily 'debrief' meetings and care enhancement against theoretical frameworks. These encompassed caring values and provided the source of problem identification and remedial strategy. No such collective, theoretical perspectives were evident in the maternity setting. DISCUSSION AND IMPLICATIONS FOR PRACTICE: Whilst acknowledging the limitations of formal theory, it is suggested that midwifery goals and priorities of care could be utilised to theoretically frame, critically evaluate and guide practice. This has the potential to heighten awareness of care deficits and enable midwives to work collectively to enhance women's experience of childbirth at both clinical and political levels.
OBJECTIVE: to compare the experiences of women who received a new model of continuity of midwifery care with those who received standard hospital care during pregnancy, labour, birth and the postnatal period. DESIGN: a randomised controlled trial was conducted. One thousand and eighty-nine women were randomly allocated to either the new model of care, the St George Outreach Maternity Project (STOMP), or standard care. Women completed a postal questionnaire eight to ten weeks after the birth. PARTICIPANTS: women in the trial were of mixed obstetric risk status and more than half the sample were born in a non-English speaking country. FINDINGS: questionnaires were returned from 69% of consenting women. STOMP women were significantly more likely to have talked with their midwives and doctors about their personal preferences for childbirth and more likely to report that they knew enough about aspects of labour and birth, particularly induction of labour, pain relief and caesarean section. Almost 80% of women in the STOMP group experienced continuity of care, that is, one of their team midwives was present, during labour and birth. STOMP women reported a significantly higher 'sense of control during labour and birth'. Sixty-three per cent of STOMP women reported that they 'knew' the midwife who cared for them during labour compared with 21% of control women. In a secondary analysis, women who had a midwife during labour who they felt that they knew, had a significantly higher sense of 'control' and a more positive birth experience compared with women who reported an unknown midwife. Postnatal care elicited the greatest number of negative comments from women in both the STOMP and the control group. CONCLUSION: The reorganisation of maternity services to enable women to receive continuity of care has benefits for women. The benefits of a known labour midwife needs further research.
In this paper I will examine the history shared by our profession and review social changes and reproductive health needs that have had an effect on our current practice. I will propose a model that meets current needs and will build the vision for our future education. In conclusion I will focus on the strategies, tasks and commitments needed to build a common future for midwifery education throughout the world.
Facilitating a unified interpretation of new or re-designed curricula can be problematic in multi-sited universities. This paper discusses the use of the Delphi technique when implementing an innovative pre-registration midwifery curriculum. It formed one of the action research cycles of the author's doctoral study and was used in an attempt to seek the views of all midwife teachers and achieve a critical mass consensus. The most important issues that emerged from the Delphi process were grouped into four categories. These four categories (the teacher's base site, communications, staff development and administration issues) formed the agenda for a staff away day. The outcome of the process was the generation of a list of priorities and actions for curriculum implementation and the identification of ways in which staff development needs might be met more effectively. An unexpected, but equally important, outcome was the way it helped with team building and agreement on positive actions for its further development.
The midwifery system of the Netherlands, where nearly one-third of births occur at home, is widely admired by birth activists. Why has the Netherlands maintained this way of birthing babies when all other European countries have shifted to hospital-based maternity care? In this article, I examine the societal forces - both structural and cultural--that allowed the Dutch to hold on to a way of delivering maternity services that other modernizing nations discarded earlier in the first half of the 20th century.
Drawing on material from fieldwork conducted on the island of Saint Lucia, I examine how Saint Lucian nurse-midwives and student midwives negotiate multiple ways of understanding and evaluating their practices and roles in light of contradictory and powerful cultural, historical, and political forces. I argue that, although Saint Lucian nurse-midwives may not qualify as "postmodern" according to the criteria proposed by Davis-Floyd and Davis (1996), they are nonetheless struggling with postmodern conditions as they negotiate between competing healing ideologies. I illustrate the significance of these negotiations through analyzing: (1) the ways nurse-midwives understand and articulate the healing ideologies at play in Saint Lucia, (2) historical and ideological aspects of the Saint Lucian nurse-midwifery training program, and (3) a classroom discussion during which student reported on "bush-midwives."
OBJECTIVE: To evaluate Nepal's first independent midwifery unit, the Patan Hospital Birthing Centre (BC), as a model for training and service provision for low risk deliveries. Specifically, to compare its efficacy with that of an adjacent Consultant-led Maternity Unit (CMU). METHODS: Unpaired comparison of delivery procedures and outcomes at the Patan Hospital, Lalitpur. The sample was 988 women (550 at BC, 438 at CMU). Women judged to be at low risk of complications were enrolled at delivery at each facility. Information was collected by standardized interviews and record review. Main outcome measures were incidence of complications of labour, technical procedures and access to postnatal care and family planning services. RESULTS: Artificial rupture of membranes was more likely to be performed at the BC (RR 1.26, 95% CI 1.10-1.44). Augmentation of labour with oxytocin was less likely to be performed (RR 0.26, 95% CI 0.20-0.33), as was episiotomy (RR 0.64, 95% CI 0.57-0.72). The incidence of oxytocic augmentation was high at the CMU (205/438: 46.9%). The incidence of moderately or thickly meconium-stained liquor was lower at the BC than at the CMU (RR 0.62, 95% CI 0.43-0.91), a finding that was associated with oxytocic augmentation of labour. No significant differences were found for duration or complications of labour, mode of delivery, birth weight, neonatal Apgar score or admission to the special care baby unit. Women delivering at the BC were more likely to attend both postnatal (RR 1.33, 95% CI 1.18-1.51) and family planning clinics (RR 1.85, 95% CI 1.44-2.38). CONCLUSIONS: After appropriate screening, intrapartum care for low risk deliveries is effectively provided by midwives. The Birthing Centre model should be considered throughout the developing world, particularly as a site for training of skilled attendants.
In a wider debate on defining and measuring quality in health care, there is a particular need for frameworks for understanding and managing quality in specific specialties. This article addresses the definition and measurement of quality in maternity care. It develops a pro forma for monitoring and hence managing midwifery quality.
BACKGROUND: Since the initiation of health sector reforms in Estonia in 1992, the Baltic state has experienced a steep decline in the number of midwives and midwife graduates. At the same time, there has been a rapid increase, first in sexually transmitted infections and then in human immunodeficiency virus. The aim of this study was to draw on the perceptions of Estonia's midwives and other health care stakeholders to delineate the current situation of midwifery in the country, in the context of a sexually transmitted infection/human immunodeficiency virus epidemic. MATERIALS AND METHODS: Data were obtained by sending a 32-question questionnaire, based on an agenda developed through semistructured interviews, to all midwives in Estonia. A nominal group technique was employed with key stakeholders to determine the extent of their agreement with the questionnaire's major findings. RESULTS: The response rate to the questionnaire was 75%. There was no significant association between work satisfaction and independent variables of age, ethnicity, work abroad, increased responsibility, and involvement in postpartum care and counseling. There was, however, a significant association between work satisfaction and salary. The group process revealed that although there is no agreement on the role of family doctors and midwives in antenatal care, there is a general agreement that midwives should be more involved in postpartum care and that their tasks need to be better defined. CONCLUSIONS: Almost half of the responding Estonian midwives are dissatisfied with their job, especially their salary. Increased responsibility for antenatal and postpartum counseling, with concurrent salary adjustments, may help stop the decline in the number of midwives, as could the opening up of new areas of work. A further reduction of the high abortion and sexually transmitted infection/human immunodeficiency virus rates is a critical challenge for Estonia, and midwives could be employed in services to do this, similar to their Nordic neighbors. Current indications suggest, however, that the number of midwives, especially new graduates, will continue to decline.
AIM: This paper reports a case study which examined the selection, implementation and outcomes of one university department's approach to building research capacity in nursing and midwifery. BACKGROUND: The literature identifies building nursing research capacity as an important challenge. In countries such as Australia and the United Kingdom it is taking place in the context of the move of nurse education into the university sector. Structural and cultural barriers to building academic nursing research capacity exist. Previous studies highlight the strategies that academic departments adopt to build nursing research capacity. METHODS: Using case study methodology, data were collected using documentary analysis and semi-structured interviews with a purposive sample of 27 academic and related staff and a focus group with seven staff. The data were collected between 2003 and 2005. FINDINGS: The department had adopted an inclusive approach to capacity development (allowing all teaching staff to develop their research capability), but is now moving towards a more focused path and the cultivation of "leading edge" research. Neophyte researchers described lacking confidence in undertaking research, and expressed a need for more formal support structures. The importance of effective management of capacity building was highlighted, including transparent communication and mapping of existing capacity. Key external influences included the lack of core research funding, and divergence between the university's emphasis on research and the department's desire to develop an interface between teaching, research and clinical practice. CONCLUSION: Academic leadership and educational management should work in tandem. Staff development and the provision of time and support are crucial aspects of research capacity development. The effectiveness of "inclusive" and "exclusive" approaches to research capacity development depends on the nature of each department, and they are not mutually exclusive.
OBJECTIVE: To improve the maternity emergency skills and knowledge of health service providers, without midwifery qualifications, in remote Australia. DESIGN: A descriptive paper utilising data from a needs assessment and course evaluations used to develop and refine a short course in maternity emergencies. SUBJECTS: Remote area health providers. INTERVENTIONS: A multidisciplinary short course, targeting non-midwives in remote areas, aimed at improving knowledge and skills in detection, management and referral of maternity emergencies. RESULTS: Ten courses have been delivered to 175 participants. Evaluations demonstrate a highly valued program, well received and supported by remote health staff. CONCLUSIONS: The course is an important strategy to improve the maternity services offered to women in remote Australia.
The growing pressure for changes in the care available for pregnant women at low risk found a voice in the report on maternity services from the House of Commons Health Committee published in February 1992. The demand for greater autonomy and responsibility by midwives and the need to rationalise medical working practices in the light of changes in junior doctors' hours adds urgency to the need to find ways of instituting change while maintaining safety. A visit to the Netherlands allowed first hand evaluation of aspects of the Dutch model of maternity care of relevance to establishing midwifery led care for women with uncomplicated pregnancies in the United Kingdom.
BACKGROUND: Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor. METHODS: Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching. RESULTS: 18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings. CONCLUSIONS: Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality.