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Midwife and nurse-midwife. The effect of title on perception and confidence in services provided by professional midwives. The Midwifery Research Project Group.

This study surveyed individuals in the communities of nurse-midwifery students. Students, identifying themselves as graduate students doing a telephone survey in the area of health care, posed 56 questions to 200 individuals living in New York, North Carolina, Massachusetts, and Nebraska. Survey questions were designed to assess the awareness of the terms midwife and nurse-midwife. Additionally, the survey assessed the sample's perception of the range of services provided by midwives and nurse-midwives, as well as its confidence in having these services provided by a midwife or a nurse-midwife. Demographic data were collected to describe the sample and determine the effects of age, gender, marital status, income, and race on perception and confidence with services. There was a statistically significant relationship between stated familiarity with the terms midwife and nurse-midwife and perception of scope of services and confidence in services. Increased familiarity with the terms midwife and nurse-midwife coincided with a more accurate perception of the scope of services provided by both midwives and nurse-midwives and greater confidence in services provided by midwives and nurse-midwives. Demographic factors studied did not impact on either perception or confidence in services. The data in the survey reveal a large proportion of individuals who report being uncertain about midwives' and nurse-midwives' level of education, scope of services, and relationship to the health care system. This suggests that consumer education could have a sharp impact on shaping the public perception of both midwives and nurse-midwives.

Adult↗
PubMed1996

A survey of midwives in Quebec: what are their similarities and differences?

BACKGROUND: Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec. METHODS: Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession. RESULTS: Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs. CONCLUSIONS: Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.

Health Knowledge, Attitudes, Practice↗
PubMed2003

Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives.

OBJECTIVE: To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives. DESIGN: Prospective semistructured observational study. SETTING: Labour wards of seven maternity units in the north west of England. PARTICIPANTS: All midwives working on the labour ward during the observation period in 2000. MAIN OUTCOME MEASURE: "Latent failures" within the system relating to midwifery staffing levels, deployment, and training or updating opportunities. RESULTS: Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and "near misses" were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence. CONCLUSION: Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.

Delivery Rooms↗
PubMed1999

The effect of the Maternal Care Manual of the Perinatal Education Programme on the attitude of midwives towards their work.

OBJECTIVE: In this study the changes in attitude of midwives towards their work following completion of the Maternal Care Manual of the Perinatal Education Programme (PEP), were determined. METHOD: A prospective, controlled trial was performed in a study, and two control towns in a region where PEP had not previously been used. All midwives caring for pregnant women in the three towns were included in the study. First the attitude of these midwives was determined by means of a questionnaire. Subsequent to this, the Maternal Care Manual was introduced and studied by the midwives in the study town. Following the completion of the Manual after 12 months, the attitude of all midwives was again evaluated using the same questionnaire. RESULTS: A total of 40 midwives in the study town and 53 in the two control towns were included in the study. There were no differences on comparing the ages of the midwives in the study town to those in the control towns. The attitude of the midwives in the study town improved significantly (p < 0.001). The mean result in the study town improved by 6.1 (24.4%) marks from 14.5 (58.0%) to 20.6 (82.4%). A significant shift also occurred in the range of the marks from 0-25 to 13-25. No changes were observed in the control towns. CONCLUSION: Most studies that have evaluated educational programmes measured improvement in health services, and did not evaluate changes in attitude. This study found that the attitude of midwives improved significantly in the study town. This positive attitude of midwives towards their work and their ability to perform their daily tasks must be an important component of any programme to improve the quality of care rendered to women during pregnancy, labour and the puerperium.

Adult↗
PubMed2006

A comparison of Australian and UK obstetricians' and midwives' preferences for screening tests for Down syndrome.

OBJECTIVE: To establish and compare obstetricians' and midwives' preferences for hypothetical prenatal screening tests for Down syndrome. METHODS: A cross-sectional questionnaire survey was completed by 296 obstetricians and midwives at two teaching hospitals: one in Melbourne, Australia (n = 175), and one in London, UK (n = 94). Conjoint analysis was undertaken using random effects probit regression. RESULTS: No significant differences were seen in any measurements when comparing obstetricians in Australia and the UK or midwives in Australia and the UK. Obstetricians and midwives shared similar relative values regarding the importance of the detection rate of the screening tests. However, obstetricians placed higher relative values on both timing of prenatal tests and risk associated with the subsequent diagnostic test than did midwives when considering optimal tests to offer women. Marginal rates of substitution suggest that, compared with midwives, obstetricians would wait longer and accept a greater decrease in detection rate for a test if it was safer. Younger midwives placed higher value on both detection rate and safety of prenatal tests than older midwives. Female obstetricians placed higher value on the timing of a test than male obstetricians. CONCLUSION: Obstetricians in Australia and UK placed almost identical importance on test attributes, as did the midwives in the two countries. However, different attitudes towards tests were seen between obstetricians and midwives.

Adult↗
PubMed2005

An action-research study exploring midwives' support needs and the affect of group clinical supervision.

OBJECTIVE: To explore community midwives' views and experiences of their support needs in clinical practice, and then to identify how they would wish to receive such support. Further objectives were to redress the imbalance identified by planning and facilitating a model of clinical supervision devised by the participating midwives. DESIGN: A qualitative study using an action-research approach based on collaboration and participation. Action research has the potential to facilitate understanding of, and is able to adapt to, changing situations within clinical practice. Data were collected in three phases using in-depth interviews and focus groups. SETTING: A large maternity unit in the north of England, UK. PARTICIPANTS: Eight National Health Service (NHS) community midwives working in the same team. FINDINGS: Recent and ongoing organisational change and increased demands placed on the midwives by their managers were found to be detrimental to the process of clinical supervision and working relationships with their peers and clients. These pressures also inhibited the process of change. The midwives' behaviour and coping strategies revealed an apparent lack of understanding on their part, and that of their midwifery managers, of the regulation of emotion and the amount of energy this generated. Pseudo-cohesion and resistance to change were key defence mechanisms used by the participating midwives. KEY CONCLUSIONS: A large amount of published literature supported the existence of stress and burnout in midwifery, but no research addressed ways of alleviating this situation. Effective facilitation of midwifery support is needed, which can be met through support mechanisms such as clinical supervision. During the process of clinical supervision, strong messages emerged about the necessity to ensure that midwives are prepared educationally for the difficult situations that are brought about through collaborative working. There are also messages about the cultural legacy of NHS midwifery and how this can inhibit autonomous behaviour by midwives. IMPLICATIONS FOR PRACTICE: Developing and increasing self-awareness is still not viewed as being intrinsic to the work of the midwife, and midwives are being asked to undertake a level of work for which they have not been adequately prepared. The bureaucratic pressures of working in a large maternity unit exaggerate this further. In this situation, the system is seen as more important than the midwives.

Burnout, Professional↗
PubMed2003

How well do midwives estimate the date of delivery?

OBJECTIVE: to compare expected date of delivery (EDD) and gestational age (GA) obtained by midwives with those calculated using the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) recommended formula. DESIGN: retrospective study of obstetric records and prospective study of clinical cases examined by multiple midwives. SETTING: postnatal wards, Maternity Unit, Plymouth, Devon, UK. PARTICIPANTS: two studies were performed. The first was a retrospective analysis of 115 sets of obstetric records. The second, a prospective study which included five clinical cases and 19 qualified midwives whose experience ranged from six months to 25 years. FINDINGS: in the retrospective study, 68 (59%) of the 115 obstetric case notes had sufficient information to apply the CESDI formula. The midwives'calculated EDD was interpreted to a GA and 35 (52.5%) agreed to within three days of the GA derived from the CESDI formula EDD. In the prospective study, the midwives' calculation of EDD was in good agreement with the CESDI formula in cases where last menstrual period (LMP) was known and menstrual cycle was 28 days with 17 (90%) of the 19 midwives providing the EDD to within three days of the CESDI formula. In the clinical case where LMP was known but menstrual cycle length was 33 days only two (10%) of the 19 calculated the EDD within three days of the CESDI formula. KEY CONCLUSIONS: when LMP is known and the cycle length is 28 days, midwives produce results consistent with the CESDI formula. However, when the menstrual cycle differs from 28 days or LMP is unknown, inaccurate or ambiguous and obstetric ultrasound scan (USS) information is used to calculate the EDD, the midwives show varying degrees of departure from the CESDI formula. Further, we found that the midwives tended to produce underestimates when calculating GA from EDD. This bias occurs across the range of gestations covered, including early gestations when such biases may have more important medical implications. IMPLICATIONS FOR PRACTICE: midwives' calculation of EDD and estimation of GA showed both random and systematic errors; in some cases, the errors were so large that they may have important medical consequences. If the CESDI-recommended formula for calculating EDD were used there would be improved accuracy and reliability of EDD and the calculation of GA.

Clinical Competence↗
PubMed1991

Midwife/client relationship: midwives' perspectives.

This study set out to explore midwives' understanding of the factors which affected the development of a therapeutic relationship with clients. A qualitative approach was adopted for the study to avoid placing predetermined categories upon midwives' perceptions. Because of the qualitative nature of the study in-depth interviews were conducted to allow midwives to explore in depth their perceptions of the research topic. Themes identified within the interview data indicated conflicting needs/interests which in turn seemed to cause dilemmas for the midwives interviewed. It seemed appropriate therefore to take the data analysis one step further by utilising dilemma analysis. Consideration of the situations in which the midwives experienced 'good' or 'poor' relationships revealed a complex picture of the factors affecting relationships with clients. Four main issues were identified: the nature and value of the midwives' role; recognition of authority/autonomy in practising this role; emotional involvement with clients; and maintaining personal integrity. From dilemma analysis of the data it appears that when midwives were successful in managing these issues then the relationship became 'special' and therapeutic for clients. Mismanagement of these issues in contrast led to dilemmas which then inhibited development of meaningful relationships between the midwives and clients. In view of the fact that clients and midwives value this 'special' relationship a case is made for midwives to be prepared educationally to manage effectively issues which are raised in their everyday practice. Only then will the midwife/client relationship become therapeutic.

Clinical Nursing Research↗
PubMed2001

Competencies of midwives with single or dual qualifications at the point of registration in Scotland.

OBJECTIVE: to compare and contrast competencies of midwives with single or dual qualifications at the point of registration in Scotland. DESIGN: self-completing survey using the Glasgow Royal Maternity Hospital's Skills' Inventory by midwives at the point of registration and by Supervisors of Midwives analysed using non-parametric statistical tests. Content analysis of semi-structured interviews with experienced midwives and Supervisors of Midwives. SETTING: midwifery education and practice settings throughout Scotland. PARTICIPANTS: 157 midwives at the point of registration, 166 Supervisors of Midwives. MEASUREMENTS: Mann-Whitney and Kruskal Wallis analysis of skills of midwives at the point of registration in prenatal, labour, post-natal, neonatal areas and extended skills areas. FINDINGS/IMPLICATIONS FOR PRACTICE: all newly qualified midwives in Scotland, regardless of their educational preparation, are capable of providing care for women and babies in normal midwifery situations. While support for the direct entry programmes has been clearly demonstrated, this is not unanimous, although as more direct entry midwives take up positions, attitudes are becoming more positive.

Adult↗
PubMed2003

A qualitative study exploring midwives' perceptions and views of extending their role to the examination of the newborn baby.

OBJECTIVES: to explore midwives' attitudes and perceptions about extending their role to the examination of the newborn baby, as well as their general perceptions and attitudes to new role developments. DESIGN: qualitative, data collected using semi-structured interviews, which were exploratory and interactive in form. SETTING: six maternity hospitals in South-east England. PARTICIPANTS: ten midwives were purposefully selected, including five trained in the examination of the newborn baby and currently conducting examinations and five who had not. Most of the midwives had been qualified for over ten years and had a wide range of clinical experience in hospital and community settings. FINDINGS: midwives identified many benefits to themselves, to their profession and to the mothers as a result of developing their role into the examination of the newborn baby. The major benefit cited was improved job satisfaction, which was directly related to their ability to give continuity and total care to mothers and babies. Midwives also perceived that undertaking the examination strengthened their position as autonomous practitioners, by enabling them to provide total care to mothers and babies who fitted their criteria of normality. Moreover, midwives thought that improvements in the overall quality of care to mothers would result from them performing the examination, including improved communication, greater continuity of care and a more holistic examination. Although midwives were concerned about possible increase in workloads and pressure to take on new roles, the examination was generally perceived as being easily incorporated into their current practice without compromising overall standards in midwifery care. Midwives expressed concern about 'extending' practice into areas that did not fit their perceptions of normality and about being 'pressurised' into taking on new roles. IMPLICATIONS FOR PRACTICE: it would appear from this study that an important consideration for midwives in their acceptance of new roles, is the relationship of that role to their position as experts in normality. Midwives in this study viewed the examination of the newborn baby as 'fitting in' with their perceptions of the core values of midwifery.

Adult↗
PubMed2004

Research into EPRs: how midwives really feel.

This article describes some of the findings of a two-year research project entitled The use of electronic patient records (EPRs) in maternity services: professional and public acceptability, commissioned by the Department of Health (DH). The main methods used were: --Literature review. --A national telephone survey of heads of midwifery (HOMs) in England (2001). --Case studies of maternity services in four NHS Trusts (2002). One of the findings of the research was that midwives and HOMs considered they had little knowledge of what EPRs are, and most were confused about whether their existing maternity information system (MIS) constituted an EPR system. The exact nature of EPRs was also contested among information technology (IT) professionals and NHS Trusts' EPR development strategies varied. Each Trust was, and still is, developing their own response to Information for health (NHS executive, 1998). Broadly speaking, these fell into one of two main categories of approach to EPR development. First, a 'best of breed' approach meant that departmental information systems, such as MISs were to be part of future EPR systems, and these specialist systems would become part of an inter-connected EPR system by being gradually connected with other departmental and Trust-wide information systems. Second, a 'big bang' or 'one-system' approach meant all departmental systems were in the process of being replaced by a single supplier's system for the whole Trust, and specialist departments were expected to meet their information needs by using specialist modules within this system. The relative merits of each approach were hotly debated both locally and nationally during the course of the research project. Another finding was that midwives had little interest in EPRs, although the views expressed were contradictory. While midwives were not interested in being involved in EPR developments, they did want to see midwifery interests represented. Nearly all midwives and midwifery managers expected their perspective to be provided by the 'IT midwife'. The definition of this role varied in different services. Also, the research found that not all IT midwives were accepted by colleagues as appropriate representatives of their needs. At a time when there are increasing pressures on midwives to expand their role, (Department of Health, 1999: RCM, 2002b) we argue that midwives should play a more proactive role in the development of EPRs. The example is given of the claim that EPR systems save practitioners time (NHS executive, 1998). The research showed that maternity EPR systems consumed more time for midwives than they saved, although where midwives could see the clinical value of having the system this burden was considered more acceptable. Midwives should ask more questions about the value of the information systems they use and the new EPR systems that are being rolled out, and this needs to be encouraged by midwifery educators.

Adult↗
PubMed1995

Community midwives' views and experience of home birth.

This two-part study explored the home birth experiences of all full time practising community midwives within three health authorities. The study consisted of a self-completion questionnaire, followed by interviews with a random stratified sub-sample of the midwives. The study sample consisted of 56 midwives of whom 44 (78%) agreed to participate. The total experience of home birth by these midwives was limited. The mean number of home births undertaken in the previous year was only two and 14 midwives had not undertaken any. The average number of home births undertaken in their whole career was six. Four midwives (9%) had never undertaken any. Only two midwives (5%) routinely offered home birth at booking. Despite lack of experience, half the sample were strongly positive about home birth. Factors that influenced their feelings about home birth were more complex but were unrelated to the amount of their home birth experience, their age, training or own experience of childbirth. Positive feelings about home birth resulted from the quality of positive previous experiences, education and knowledge and an autonomous view of women and midwives. Negative feelings tended to result from a lack of specific skills, namely suturing, resuscitation and siting of IVIs, midwives' inadequate support networks, doctors' attitudes and a confused perception of the provision of emergency cover.

Attitude of Health Personnel↗
PubMed2006

Workload of primary-care midwives.

OBJECTIVE: to assess the actual workload of primary-care midwives in the Netherlands. BACKGROUND: In 2000, a strike and large demonstration before parliament convinced everyone of the shortage of midwives and their excessive workload. The government reacted by increasing the capacity of the midwifery schools and lowering the 'standard caseload' for a full-time working midwife. To assess whether this would lead to sufficient improvement of the situation, more insight was needed of the actual workload of midwives in primary care. METHOD: a 4-year prospective survey of the work of primary-care midwives, during 3 weeks each year, including all midwives working in a representative sample of midwifery practices. On average, 224 midwives participated each year. During 3 weeks in the summer and autumn, midwives kept a diary of their work, with an accurate timetable, covering 24 hours a day. They also filled out questionnaires about practice organisation, work schedules and experiences of workload. FINDINGS: primary-care midwives worked an average of 29 hours a week, and about 74% of their time (22 hours a week) was spent on client-related activities. On average, a midwife was on call during 53 hours a week, and 17 of the 29 hours of work took place during on-call-hours. This meant that an average midwife was involved in her work 65 hours a week. The time spent on direct client care increased by nearly 20%. In particular, the average time spent with a woman during labour and birth increased by almost one-third. CONCLUSION: primary-care midwives spend an average of 29 hours per week working, and this has remained constant between 2001 and 2004. In client-related care, there has been a shift towards fewer clients per midwife but more time per client.

Adult↗
PubMed1995

How midwives identify women as aboriginal or Torres Strait Islanders.

At the present time no reliable information is available about how midwives actually decide to record a person as Aboriginal or Torres Strait islander on the Perinatal Morbidity Statistics form. In 1993, Koori Health in the Department of Health and Community Services asked the Perinatal Data Collection Unit to undertake a study to determine how midwives make this decision. The study was conducted in seven country and city hospitals and two universities from August to December 1993. The hospitals ranged in size from 149 to 2359 births per year. During a routine education session the midwives were invited to take part in a focus group discussing 'Aboriginality'. Fifty-four midwives were involved in the study. Most mothers were not asked if they identified as 'Aboriginal or Torres Strait Islanders'. Midwives did ask women who they thought were 'Aboriginal' by appearance. Most midwives did not ask about 'Aboriginality' because they felt uncomfortable asking. They felt uncomfortable because they felt that both Aboriginal and non-Aboriginal women would feel ill at ease when asked if they identified as Aboriginal or Torres Strait Islanders. There were many reasons for this but they included negative perceptions of Aboriginal women. Some midwives made discriminatory comments. The conclusions of the study are that midwives need to know the reasons why they are requested to ask all women if they identify as Aboriginal or Torres Strait Islanders. Major barriers are often based on poor knowledge and understanding of definitions and issues. There was strong evidence of the existence of underlying beliefs and perceptions about Aboriginal people which 'inhibit' midwives from complying with the Data Collection Unit's explicit advice on the collection of this information.

Attitude of Health Personnel↗
PubMed2005

Midwifery at the crossroads in Estonia: attitudes of midwives and other key stakeholders.

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.

Adult↗
PubMed1989

Variations between midwives regarding administration of obstetrical analgesia.

Variations among 32 midwives involved in a total of 1578 deliveries were studied regarding attitudes to and use of obstetrical analgesia. Relevant data were obtained from the register of the maternity department of a Swedish regional hospital. This was complemented with information about the midwives' attitudes to pharmacological pain relief in labour and delivery, collected by means of a mailed questionnaire. Variations between midwives (range), expressed as percentages of each midwife's total number of deliveries, were considerable: epidural block (EDA), 9-48%; Pethidine, 0-41%; Entonox (N2O/O2), 8-62%; pudendal block (PDB), 11-71%. Midwives working on night-shift used less EDA, but more pethidine, than their day-shift colleagues. 59% of all the midwives were critical of current levels of obstetrical use of analgesics in Sweden, while 41% felt the level to be about right. Night-shift midwives were rather more critical than day-shift midwives. Midwives critical of current levels of obstetric medication used EDA and PDB less often than their more enthusiastic colleagues, but the difference was not statistically significant. On the other hand, critical midwives used more Pethidine (p less than 0.05) and also more Entonox than their less critical colleagues, though again the difference was statistically non-significant.

Anesthesia, Obstetrical↗
PubMed1997

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.

OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

Abortion, Threatened↗
PubMed2004

Routine examination of the newborn: the EMREN study. Evaluation of an extension of the midwife role including a randomised controlled trial of appropriately trained midwives and paediatric senior house officers.

OBJECTIVES: To assess the implications and cost-effectiveness of extending the role of midwives to include the routine (24-hour) examination of the healthy newborn usually carried out by junior doctors. DESIGN: The study included a prospective randomised controlled trial (RCT) with mother and baby dyads randomised to either senior house officer (SHO) or midwife for the routine examination of the newborn. Midwives and SHOs were also videoed while performing the examinations and the videos were rated by an independent consultant and senior midwife. In addition extensive interviews, surveys, consultations and assessments were carried out. SETTING: A District General Hospital (for the RCT), a London Teaching Hospital, general practices and mothers' homes (for interviews); questionnaires were sent to all maternity units in England (for the National Survey). PARTICIPANTS: A total of 826 mother and baby dyads in a District General Hospital in south-east England. Midwives and SHOs, as well as midwifery managers, paediatric consultants; general practitioners (GPs) and representatives of key organisations. INTERVENTIONS: A routine examination of a newborn baby was carried out at about 24 hours from birth and a further examination for half the babies in each group, at 10-days at home by the community midwife. MAIN OUTCOME MEASURES: Referrals assessed as appropriate and as major or minor by three independent consultants. Problems identified during the first year of life assessed as identifiable at 24 hours. Quality assessment by video against an agreed written proforma. Maternal satisfaction. Opinion of professionals and mothers about aspects of the examination. RESULTS: There was no statistical difference between SHO and midwife examinations in appropriate referral rates to hospital or community or in inappropriate referral rates to hospital. Videoed assessments were assessed as carried out more appropriately by the midwives than by the SHOs. Overall maternal satisfaction was high and higher when a midwife rather than an SHO examined. Few new health problems were identified at the 10-day examination. From the National Survey, it was estimated that about 2% of babies in England are examined by a midwife. If midwives were to examine all babies where there were no complications of birth or antenatal history, there would be savings of about 2 pounds per baby born, equivalent to savings of 1.2 pounds million nationally. Were midwives to examine all babies on normal wards savings would increase to about 4.30 pounds per baby born or 2.5 million pounds nationally. Representatives of the professional bodies were of the opinion that having trained midwives carrying out the examination would be valuable. CONCLUSIONS: All component aspects of the study were consistent in showing benefits or at least no significant barriers to suitably qualified, trained midwives carrying out the examinations. Developing the role of the midwife to include examination of the newborn is likely to result in improved quality of examinations and higher satisfaction from mothers. It would slightly reduce overall health service costs, with some increased resources needed by midwifery departments, and some decrease in resource needs of paediatric departments. There is a need for further research into the value of the examination being carried out at home rather than in hospital; the overall unsatisfactory quality of the examination of the hips; and appropriate inclusion criteria for which babies' midwives should examine.

Adult↗