'Lending the space': midwives' perceptions of birth space and clinical risk management

Understanding the barriers and facilitators related to birthing pool use from organisational and multi-professional perspectives: a mixed-methods systematic review

AIMS

To identify and synthesize the evidence regarding the facilitators and barriers relating to birthing pool use from organizational and multi-professional perspectives.

DESIGN

A systematic integrated mixed methods review was conducted.

DATA SOURCES

MEDLINE, CINAHL, PsychINFO, EMCARE, PROQUEST and Web of Science databases were searched in April 2021, March 2022 and April 2024. We cross-referenced with Google Scholar and undertook reference list searches.

REVIEW METHODS

Data were extracted from studies meeting the inclusion criteria. Barriers and facilitators to birthing pool use were mapped and integrated into descriptive statements further synthesized to develop overarching themes.

RESULTS

Thirty seven articles (29 studies) were included-quantitative (12), qualitative (8), mixed methods (7), and audits (2), from 12 countries. These included the views of 9,082 multi-professionals (midwives, nurses, obstetricians, neonatologists, students, physicians, maternity support workers, doulas and childbirth educators). Additionally, 285 institutional policies or guidelines were included over 9 papers and 1 economic evaluation. Five themes were generated: The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and tensions, Trust or Trepidation and It's your choice, but only if it is a choice. These revealed when personal, contextual, and infrastructural factors were aligned and directed towards the support of birth pool use, birthing pool use was a genuine option. Conversely, the more barriers that women and midwives experienced, the less likely it was a viable option, reducing choice and access to safe analgesia.

CONCLUSION

The findings demonstrated a paradoxical reality of water immersion with each of the five themes detailing how the "swing" within these factors directly affected whether birthing pool use was facilitated or inhibited.

Birth environments for women with complex pregnancies: A mixed-methods systematic review

BACKGROUND

Birth environments can help support women through labour and birth. Home-like rooms which encourage active birthing are embraced in midwifery-led settings. However, this is often not reflected in obstetric settings for women with more complex pregnancies.

AIM

To investigate the impact of the birth environment for women with complex pregnancies.

METHODS

This was a mixed-methods systematic review, incorporating qualitative and quantitative research. A literature search was implemented across three databases (Medline, CINAHL, Embase) from the year 2000 to June 2021. Studies were eligible if they were based in an Organisation for Economic Cooperation and Development country and reported on birth environments for women with complex pregnancies. Papers were screened and quality appraised by two researchers independently.

FINDINGS

30,345 records were returned, with 15 articles meeting inclusion criteria. Studies were based in Australia, the UK, and the USA. Participants included women and health professionals. Five main themes arose: Quality of care and experience; Supportive spaces for women; Supportive spaces for midwives; Control of the space; Design issues.

DISCUSSION

Women and midwives found the birth environment important in supporting, or failing to support, a positive birth experience. Obstetric environments are complex spaces requiring balance between space for women to mobilise and access birthing aids, with the need for medical teams to have easy access to the woman and equipment in emergencies.

CONCLUSION

Further research is needed investigating different users' needs from the environment and how safety features can be balanced with comfort to provide high-quality care and positive experiences for women.

Midwives' action-guiding orientation while attending hospital births - A scoping review

Following the "call for action to research", various aspects of maternity care should be examined so that perinatal care can be improved based on evidence. Clinical midwifery is the most common way of attending births in high-income countries. Midwives are the experts for normal labor and birth and play a central role in caring for women giving birth in a hospital setting. The aim of this scoping review was to explore midwives' action-guiding orientation in their care provision during hospital births in high-income countries. Four databases (CINAHL, PubMed, MEDLINE and PSYNDEX) were searched systematically for studies in English or German on midwives' action-guiding orientation during hospital labor and birth, published between 2000 and February 2022. Only studies from peer-reviewed journals were included. Reporting followed the PRISMA-ScR statement for scoping reviews. From a total of 1572 studies, 26 studies with 4 different research designs were included in the narrative synthesis. The synthesis shows 7 central concepts that emerge in the studies: medicalization of birth versus woman-centered care; midwives' knowledge and experience; midwives' professional identity; midwives' confidence or autonomy in practice; intra-professional and multi-professional relations; continuity of care and relationship with the woman; and working conditions and cultural context. The central concept most reflective of midwives' action-guiding orientation was "medicalization of birth versus woman-centered care." Other elements that affect midwives' action-guiding orientation and represent influencing factors at the micro, meso, and macro levels of obstetric care must be considered if one is to understand the profession and work of midwives.

Place and space in relation to childbirth: a critical interpretive synthesis

Background: In nursing and midwifery, the concept of environment is considered a meta-concept. Research findings suggest that the location is not the only important factor, as both place and space influence the practices of midwives. Moreover, research on the geography of health suggests a connection between place and health that could be extended to reproductive health. Therefore, to move beyond and expand traditional research expressions, it is beneficial to illuminate the concepts of place and space in relation to childbirth.

Purpose: This study was undertaken to produce a synthesis of previous qualitative research of issues in childbirth in relation to the concepts of place and space.

Method: In this Critical Interpretive Synthesis (CIS), four electronic databases; CINAHL, Medline, PsycINFO and Sociological abstracts, were used for the literature search. In total 734 papers were screened, and 27 papers met the final inclusion criteria after assessment.

Results: The synthesis reveals a need to create a space for childbirth underpinned by four aspects; a homely space, a spiritual space, a safe space, and a territorial space.

Conclusion: Findings from this review will provide a basis for useful dialogue in midwifery education and in clinical settings.

The birthing room and its influence on the promotion of a normal physiological childbirth - a qualitative interview study with midwives in Sweden

The birthing room is a major workplace for midwives but how it influences them in practice is not enough investigated.

Purpose: This study aimed to explore midwives´ experiences of how the birthing room affects them in their work to promote a normal physiological birth.

Methods: A phenomenological reflective lifeworld research approach was used and included individual interviews with 15 midwives working at four different hospitals in western Sweden, and of which two also assisted at homebirths. The analysis focused on the meanings of the study phenomenon.

Results: A birthing room can by its design either support a normal physiological birth or support a risk approach to childbirth. Four opposing constituents complete the essential meaning of the birthing rooms, and to which the midwives need to relate in their roles as guardians for normal birth: i) a private or a public room; ii) a home-like or hospital-like room; iii) a room promoting activity or passivity; iv) a room promoting the midwife´s presence or absence.

Conclusions: The birthing room mirrors a pathogenic-oriented care approach. A presupposition for the work to keep the birth bubble intact is to protect the mother from disturbing elements both inside and outside the room.

Space and place for health and care

Purpose: This discussion paper aims to contribute to a greater understanding of the state of the art of research engaged with conceptual matters of space and place for health and care. Method: The authors, who represent a variety of academic disciplines, discuss and demonstrate the conceptual recognition of space and place in research in health and caring sciences building upon own work and experience. Results: To explore the concepts of space and place for health and care is a research pursuit of utmost importance, and should be made through transdisciplinary research collaborations, whereby spatial theories from various disciplines could be communicated to cultivate truly novel and well-informed research. Furthermore, engaging with relational and topological perceptions of space and place poses methodological challenges to overcome in future research on health and care. Conclusions: We argue that there is a need for accelerating spatially informed research on health and care that is informed by current theories and perspectives on space and place, and transdisciplinary research collaborations are a means to achieving this.

Implementing an intervention to promote normal labour and birth: A study of clinicians' perceptions

OBJECTIVE

Prior to implementation of a Normal Labour and Birth Bundle (NLBB) at a regional maternity service in Victoria, Australia, this study aimed to understand clinician factors that may influence the uptake, acceptance and use of the NLBB.

DESIGN

This was a mixed methods study in which The Theory of Planned Behaviour (TPB) provided the framework for the conduct and analysis of the staff survey and focus groups. Descriptive and multiple regression were used to analyse the survey data and thematic analysis was used for the focus group data.

PARTICIPANTS

Participants for the survey and focus groups included clinicians providing publicly funded care and management of labour for women birthing at the health service. Maternity care clinicians were invited to participate in both the survey and the focus groups.

FINDINGS

Seventy-six clinicians (88.8%) responded to the survey. Mean scores for TPB constructs were well above the mid-scale score of 4, indicating strong positive attitudes, high levels of self-efficacy and positive social pressure to use the NLBB and strong intentions to use it in the future. Self-efficacy was the strongest independent predictor (β = 0.45, p < 0.001) of intention to use the NLBB (overall model R2=0.38). A valued consequence of implementing standardised and objective guidelines, highlighted in the focus groups, was the positive impact on clinicians' confidence in their decision-making.

KEY CONCLUSIONS

This study found that midwives and obstetricians were in favour of using a normal labour and birth care bundle and perceived the bundle to align with the expectations of work colleagues and the women they care for. The findings of this study show that clinicians at the health service had strong intentions to use the normal labour and birth care bundle in the future.

IMPLICATIONS FOR PRACTICE

Implementation science is important in embedding and sustaining practice change. Understanding staff perceptions is an essential first step of this process.

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities

OBJECTIVE

To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States.

BACKGROUND

Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision.

METHOD

We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery.

RESULTS

We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates.

CONCLUSIONS

Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.

Evaluating Maternity Units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand-clinical outcomes

OBJECTIVE

To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand.

DESIGN

Prospective cohort study.

PARTICIPANTS

407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010-2011. All of the women planning a TMH birth were 'low risk', and 29 of the PMU cohort had identified risk factors.

PRIMARY OUTCOMES

Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission.

SECONDARY OUTCOMES

labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality.

RESULTS

Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators.

CONCLUSIONS

The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes.

Exploring the strategies that midwives in British Columbia use to promote normal birth

BACKGROUND

Rates of normal birth have been declining steadily over the past 20 years, despite the evidence of the benefits to mother and baby. This is most obvious in steadily increasing caesarean section rates across countries and studies of the factors involved suggest it may be more to do with the organization of maternity care and the preferences of healthcare providers than changes in maternal or demographic conditions. The proportion of women in British Columbia (BC) receiving care from a midwife continues to grow and there is a particular focus on promoting and supporting normal pregnancy and birth in the midwifery philosophy of care. In BC, women receiving care from a midwife are less likely to have a caesarean section and other birth interventions.

METHODS

An interpretive approach, based on interpretive phenomenology was used to explore the experiences of midwives in BC of normal birth and the strategies that they use to keep birth normal. Fourteen experienced midwives were purposively selected from across the range of practice, geographical, and rural/urban contexts to participate in depth interviews. Data were analyzed using Thematic Network Analysis.

RESULTS

Seven key themes were identified in the data: working with women from the early pregnancy, informing choice, the birth environment, careful watching and waiting, managing early labour, helping the woman to cope with labour, and tools in the tool kit.

CONCLUSIONS

Midwives in BC work closely with women from early pregnancy to prepare them for a normal birth, and as "instruments of care" they adopt a range of approaches to support women to achieve this. The emphasis on continuity of care in the BC model of midwifery care plays a vital role in this.

Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting

OBJECTIVE

to identify and describe the design characteristics of hospital birth rooms that support midwives and their practice.

DESIGN

this study used a qualitative exploratory descriptive methodology underpinned by the theoretical approach of critical realism. Data was collected through 21 in-depth, face-to-face photo-elicitation interviews and a thematic analysis guided by study objectives and the aims of exploratory research was undertaken.

SETTING

the study was set at a recently renovated tertiary hospital in a large Australian city.

PARTICIPANTS

participants were 16 registered midwives working in a tertiary hospital; seven in delivery suite and nine in birth centre settings. Experience as a midwife ranged from three to 39 years and the sample included midwives in diverse roles such as educator, student support and unit manager.

FINDINGS

three design characteristics were identified that supported midwifery practice. They were friendliness, functionality and freedom. Friendly rooms reduced stress and increased midwives' feelings of safety. Functional rooms enabled choice and provided options to better meet the needs of labouring women. And freedom allowed for flexible, spontaneous and responsive midwifery practice.

CONCLUSION

hospital birth rooms that possess the characteristics of friendliness, functionality and freedom offer enhanced support for midwives and may therefore increase effective care provision.

IMPLICATIONS FOR PRACTICE

new and existing birth rooms can be designed or adapted to better support the wellbeing and effectiveness of midwives and may thereby enhance the quality of midwifery care delivered in the hospital. Quality midwifery care is associated with positive outcomes and experiences for labouring women. Further research is required to investigate the benefit that may be transmitted to women by implementing design intended to support and enhance midwifery practice.

Decision-making regarding place of birth in high-risk pregnancy: a qualitative study

INTRODUCTION

Women consider factors including safety and the psychological impact of their chosen location when deciding whether to give birth in hospital or at home. The same is true for women with high-risk pregnancies who may plan homebirths against medical advice. This study investigated women's decision-making during high-risk pregnancies. Half the participants were planning hospital births and half were planning homebirths.

METHODS

A qualitative study using semi-structured interviews set in a hospital maternity department in the UK. Twenty-six participants with high-risk pregnancies, at least 32 weeks pregnant. Results were analysed using systematic thematic analysis.

RESULTS

Three themes emerged: perceptions of birth at home and hospital; beliefs about how birth should be; and the decision process. Both groups were concerned about safety but they expressed different concerns. Women drew psychological comfort from their chosen birth location. Women planning homebirths displayed faith in the natural birth process and stressed the quality of the birth experience. Women planning hospital births believed the access to medical care outweighed their misgivings about the physical environment.

DISCUSSION

Although women from both groups expressed similar concerns about safety they reached different decisions about how these should be addressed regarding birth location. These differences may be related to beliefs about the birth process. Commitment to their decisions may have helped reduce cognitive stress.

Midwives' attitudes towards supporting normal labour and birth - A cross-sectional study in South Germany

OBJECTIVE

supporting healthy and normal physiological birth is part of the global maternity care agenda. Rising rates of interventions have been attributed to several factors, including characteristics, attitudes and preferences of childbearing women and their care providers. In this paper, the application of a scale that measures midwives' attitudes towards supporting normal labour and birth is described as well as factors that are associated with favourable attitudes, such as general self-efficacy, years in midwifery practice, and primary practice setting.

DESIGN

in this cross-sectional study an online questionnaire was sent out via e-mail to midwives in two regions of South Germany. The questionnaire contained a validated general self-efficacy scale, a 38-item instrument that measures attitudes towards supporting normal birth among German midwives and questions about midwives' practice experiences and educational preparation.

FINDINGS

on average, participants (n=188) were 39 years old (SD=10.3), and had 12 years of experience caring for women during labour and birth (SD=9.6). Multivariate modelling revealed that higher general self-efficacy, working primarily in out-of-hospital settings and having provided intrapartum care for fewer years were significantly associated with midwives' favourable attitudes towards supporting physiological birth (variance explained R(2)=29.0%, n=184). General self-efficacy (1.4%) and years of work experience (3.3%) contributed less of the variance in the outcome than work setting (24.5%). Sources of knowledge about normal birth were not significantly associated with the outcome and reduced the overall variance explained by 0.2%.

CONCLUSIONS

the study has shown that, compared to work setting, the general self-efficacy of German midwives, years providing intrapartum care and sources of knowledge about normal birth had comparatively little impact on their attitude towards supporting normal physiologic birth. Increasing exposure to out-of-hospital birth among German midwives throughout education and practice and fostering the skills and confidence necessary to support normal birth in hospital settings are important strategies to decrease unnecessary obstetric interventions.

Birthplace as the midwife's work place: How does place of birth impact on midwives?

BACKGROUND

In, many high and middle-income countries, childbearing women have a variety of birthplaces available to them including home, birth centres and traditional labour wards. There is good evidence indicating that birthplace impacts on outcomes for women but less is known about the impact on midwives.

AIM

To explore the way that birthplace impacts on midwives in Australia and the United Kingdom.

METHOD

A qualitative descriptive study was undertaken. Data were gathered through focus groups conducted with midwives in Australia and in the United Kingdom who worked in publicly-funded maternity services and who provided labour and birth care in at least two different settings.

FINDINGS

Five themes surfaced relating to midwifery and place including: 1. practising with the same principles; 2. creating ambience: controlling the environment; 3. workplace culture: being watched 4. Workplace culture: "busy work" versus "being with"; and 5. midwives' response to place.

DISCUSSION

While midwives demonstrate a capacity to be versatile in relation to the physicality of birthplaces, workplace culture presents a challenge to their capacity to "be with" women.

CONCLUSION

Given the excellent outcomes of midwifery led care, we should focus on how we can facilitate the work of midwives in all settings. This study suggests that the culture of the birthplace rather than the physicality is the highest priority.