Respectful maternity care in the UK using a decolonial lens

A systematic review of key principles relating to decolonising interventions in midwifery education

PROBLEM

Midwifery education is predominantly influenced by Eurocentric models, contributing to systemic health inequalities for marginalised groups.

BACKGROUND

The health disparities for ethnically diverse maternity service users are well documented. There are various decolonising interventions such as cultural safety education, being implemented to address these disparities by challenging colonial legacies and power imbalances that perpetuate health inequity.

RESEARCH QUESTION

What are the key principles of decolonising interventions in midwifery education, that can be applied to midwifery education on a global scale?

METHODS

This study follows a systematic literature review based on the PRISMA guidelines. Data were sourced from six databases, evaluating peer-reviewed articles between February 2014 and February 2024. The PICO framework guided the research. A thematic synthesis approach was used for data analysis.

FINDINGS

Four major themes emerged: (1) centring Indigenous knowledge, (2) cultural safety, (3) transformative learning, and (4) systemic institutional support. Workshops, yarning circles, and experiential placements were identified as effective mechanisms for promoting cultural safety and addressing discomfort. However, educators often lacked the skills and confidence to implement these changes.

DISCUSSION

Decolonising midwifery education requires ongoing reflexivity, institutional support, and curricula co-design with Indigenous communities. Barriers such as discomfort from participants and inadequate institutional structures must be addressed to ensure long-term impact.

CONCLUSION

Decolonising interventions in midwifery education fosters culturally safe care. However, further research is needed to assess the long-term outcomes on health equity and the impact of such interventions on marginalised communities.

Medical authority and expectations of conformity: crystallising a key barrier to person-centred care during labour and childbirth

Those giving birth within modern maternity systems are recognised as facing a number of barriers to person-centred care. In this paper, I argue that in order to best facilitate the conditions for positive change, work needs to be done to provide a more granular articulation of the specific barriers. I then offer a nuanced and contextually aware articulation of one key component of the overall failure to ensure person-centred care: medical authority and the expectation of conformity. Articulating these barriers with increased specificity is valuable, as it creates a stronger foundation from which to challenge existing problems which serve to constrain the autonomy of birthing individuals. The analysis offered in this paper also underscores the need for change at an institutional, rather than individual, level.

Gender-inclusive language in midwifery and perinatal services: A guide and argument for justice

Effective communication in relation to pregnancy and birth is crucial to quality care. A recent focus in reproductive healthcare on "sexed language" reflects an ideology of unchangeable sex binary and fear of erasure, from both cisgender women and the profession of midwifery. In this paper, we highlight how privileging sexed language causes harm to all who birth-including pregnant trans, gender diverse, and non-binary people-and is, therefore, unethical and incompatible with the principles of midwifery. We show how this argument, which conflates midwifery with essentialist thinking, is unstable, and perpetuates and misappropriates midwifery's marginalized status. We also explore how sex and gender essentialism can be understood as colonialist, heteropatriarchal, and universalist, and therefore, reinforcing of these harmful principles. Midwifery has both the opportunity and duty to uphold reproductive justice. Midwifery can be a leader in the decolonization of childbirth and in defending the rights of all childbearing people, the majority of whom are cisgender women. As the systemwide use of inclusive language is central to this commitment, we offer guidance in relation to how inclusive language in perinatal and midwifery services may be realized.

Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia

BACKGROUND

Transvaginal mesh (TVM) surgeries emerged as an innovative treatment for stress urine incontinency and/or pelvic organ prolapse in 1996. Years after rapid adoption of these surgeries into practice, they are a key example of worldwide failure of healthcare quality and patient safety. The prevalence of TVM-associated harms eventually prompted action globally, including an Australian Commonwealth Government Senate Inquiry in 2017.

METHOD

We analysed 425 submissions made by women (n = 417) and their advocates (n = 8) to the Australian Senate Inquiry, and documents from 5 public hearings, using deductive and inductive coding, categorisation and thematic analysis informed by three 'linked dilemmas' from healthcare quality and safety theory. We focused on women's accounts of: a) how harms arose from TVM procedures, and b) micro, meso and macro factors that contributed to their experience. Our aim was to explain, from a patient perspective, how these harms persisted in Australian healthcare, and to identify mechanisms at micro, meso and macro levels explaining quality and safety system failure.

RESULTS

Our findings suggest three mechanisms explaining quality and safety failure: 1. Individual clinicians could ignore cases of TVM injury or define them as 'non-preventable'; 2. Women could not go beyond their treating clinicians to participate in defining and governing quality and safety; and. 3. Health services set thresholds for concern based on proportion of cases harmed, not absolute number or severity of harms.

CONCLUSION

We argue that privileging clinical perspectives over patient perspectives in evaluating TVM outcomes allowed micro-level actors to dismiss women's lived experience, such that women's accounts of harms had insufficient or no weight at meso and macro levels. Establishing system-wide expectations regarding responsiveness to patients, and communication of patient reported outcomes in evaluation of healthcare delivery, may help prevent similar failures.

A multidisciplinary evaluation, exploration, and advancement of the concept of a traumatic birth experience

BACKGROUND

Understanding a woman's traumatic birth experience benefits from an approach that considers perspectives from various fields of healthcare and social sciences.

AIM

To evaluate and explore the multidisciplinary perspectives surrounding a traumatic birth experience to form a theory and to capture its structure.

METHODS

A multidisciplinary advanced principle-based concept analysis was conducted, including the following systematic steps: literature review, assessment of concept maturity, principle-based evaluation, concept exploration and advancement, and formulating a multidisciplinary concept theory. We drew on knowledge from midwifery, psychology, childbirth education, bioethics, obstetric & gender violence, sociology, perinatal psychiatry, and anthropology.

RESULTS

Our evaluation included 60 records which were considered as 'mature'. Maturity was determined by the reported concept definition, attributes, antecedents, outcomes, and boundaries. The four broad principles of the philosophy of science epistemology, pragmatics, linguistics, and logic illustrated that women live in a political, and cultural world that includes social, perceptual, and practical features. The conceptual components antecedents, attributes, outcomes, and boundaries demonstrated that a traumatic birth experience is not an isolated event, but its existence is enabled by social structures that perpetuate the diminished and disempowered position of women in medical and institutionalised healthcare regulation and management.

CONCLUSION

The traumatic childbirth experience is a distinctive experience that can only occur within a socioecological system of micro-, meso-, and macro-level aspects that accepts and allows its existence and therefore its sustainability - with the traumatic experience of the birthing woman as the central construct.