Supporting choice and control? Communication and interaction between midwives and women at the antenatal booking visit

Understanding how midwife-led continuity of care can be implemented and under what circumstances: a realist review

OBJECTIVES

To understand how and under what circumstances midwife-led continuity of care (MLCC) can be implemented in high-income countries.

DESIGN

A realist review was conducted to examine interactions between contexts, mechanisms and outcomes.

METHODS

An initial programme theory described a hypothesis of how MLCC might be implemented successfully. Literature from a systematic search on the implementation of MLCC was synthesised and supplemented with unstructured searches to identify literature that reinforced the emerging concepts. The synthesis was an iterative process, endorsed in consultation with stakeholders, leading to a refined programme theory.

RESULTS

A total of 45 documents were included. The mechanisms identified can be grouped around macrolevel challenges, leadership, role ambiguity and conflict, and personal and professional boundaries. Despite strong evidence supporting MLCC, diverse stakeholder interests and power dynamics hinder its implementation. Implementing MLCC disrupts established roles and power structures, creating uncertainty and anxiety at all levels. To successfully navigate healthcare providers through the transition, both formal and informal leaders must demonstrate the courage and vision to challenge existing norms.

CONCLUSIONS

Realist methodology allowed the identification of mechanisms that often remain unnoticed but significantly impact the implementation of MLCC. Concrete policies and guidelines are essential to ensure consistency in care delivery. Collaborative efforts and a shared philosophy among all stakeholders, combined with strong leadership that builds trust and addresses anxiety, can create a supportive environment for MLCC implementation.

PROSPERO REGISTRATION NUMBER

CRD42023446437.

What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature

BACKGROUND

There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model.

METHODS

We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations.

RESULTS

A wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of 'what works for whom, in what circumstances' although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied.

CONCLUSIONS

Mechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors.

REGISTRATION

The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Could a decision support tool be the key to supporting choice for women regarding place of birth?

OBJECTIVE

To assess the effectiveness of using an innovative decision aid, MyBirthplace, to facilitate shared decision-making regarding place of birth.

DESIGN

A quasi-experimental study comparing pre-test and post-test responses from participants who had access to the intervention.

SETTING

A large urban hospital in the south of England.

PARTICIPANTS

All pregnant women who accessed maternity care between April and December 2016.

INTERVENTION

A decision aid (MyBirthplace) designed to provide information and support regarding place of birth. The digital tool (available in both an app and web-based version) was used to facilitate discuss between the women and her midwife at the booking visit.

MEASUREMENTS

Women's stage of decision making as measured by the Stage of Decision Making Scale. A questionnaire was administered before and after using MyBirthplace at booking, and again at 28 weeks gestation.

FINDINGS

Nearly half the women (42.1%) had already decided where they wanted to give birth before the booking appointment, but a third (34.3%) had not yet begun to think about their choices. The introduction of the decision aid during the booking visit was associated with a significant increase in the stage of decision making suggesting that women had greater certainty in their decision P< 0.0001 [SD 1.077]. Women who accessed MyBirthplace had lower decisional conflict after the booking appointment than those women that did not access the decision aid (35.5% compared with 22.0%) but this difference was not statistically significant.

KEY CONCLUSIONS

Decision aids, as a standard part of practice, have the potential to ensure women are informed of their options and encourage shared decision making about place of birth. Women were more confident with their decision following the booking appointment and by 28 weeks; however, further research is needed to identify the role that the decision aid played in building this confidence.

IMPLICATIONS FOR PRACTICE

The introduction of a decision aid, Mybirthplace, within the hospital impacted early discussions between the woman and the midwife and appeared to benefit women's decision making regarding place of birth. Further studies of midwives' use of innovative technologies and their implementation are required.

A Bibliometric Analysis of Research Articles on Midwifery Based on the Web of Science

Objective

This study aimed to bibliometrically analyse the main features of the 100 top-cited articles on the midwifery index on the Web of Science.

Methods

Academic articles on midwifery' research published from 1985 to 2020 were included. VOSviewer 1.6.15, SPSS 22.0 software and a homemade applet were used to identify, analyse and visualise the citation ranking, publication year, journal, country and organisation of origin, authorship, journal impact factor and keywords along with the total link strength of countries, organisations and keywords.

Results

Among the 100 top-cited articles, the highest number of citations of the retrieved articles was 484. The median number of citations per year was 5.16 (interquartile range: 3.74-8.38). Almost two-thirds of the included articles (n = 61) centred on nursing and obstetrics/gynaecology. The top-cited articles were published in 38 different journals, the highest number of which was published by Midwifery (15%). Australia was the most productive country (24%). According to the total link strength, the sequence ran from the United States (28) to England (28) to Australia (19). The University of Technology Sydney and La Trobe University in Australia topped the list with four papers each. Hunter B was the most productive author (n = 4), and the average citations were positively related to the number of authors (r = 0.336, p < 0.05).

Conclusion

This study identified the most influential articles on midwifery and documented the core journals and the most productive countries, organisations and authors along with future research hotspots for this field; the findings may be beneficial to researchers in their publication and scientific cooperation endeavours.

Practice change intervention to improve antenatal care addressing alcohol consumption during pregnancy: a randomised stepped-wedge controlled trial

Background

Clinical guideline recommendations for addressing alcohol consumption during pregnancy are sub-optimally implemented and limited evidence exists to inform practice improvements. The aim of this study was to estimate the effectiveness of a practice change intervention in improving the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services.

Methods

A randomised stepped-wedge controlled trial was undertaken with all public maternity services in three sectors (one urban, two regional/rural) of a single local health district in New South Wales, Australia. All antenatal care providers were subject to a seven-month multi-strategy intervention to support the introduction of a recommended model of care. For 35 months (July 2017 – May 2020) outcome data were collected from randomly selected women post an initial, 27–28 weeks and 35–36 weeks gestation antenatal visit. Logistic regression models assessed intervention effectiveness.

Results

Five thousand six hundred ninety-four interviews/online questionnaires were completed by pregnant women. The intervention was effective in increasing women’s reported receipt of: assessment of alcohol consumption (OR: 2.63; 95% CI: 2.26–3.05; p < 0.001), advice not to consume alcohol during pregnancy and of potential risks (OR: 2.07; 95% CI: 1.78–2.41; p < 0.001), complete care relevant to alcohol risk level (advice and referral) (OR: 2.10; 95% CI: 1.80–2.44; p < 0.001) and all guideline elements relevant to alcohol risk level (assessment, advice and referral) (OR: 2.32; 95% CI: 1.94–2.76; p < 0.001). Greater intervention effects were found at the 27–28 and 35–36 weeks gestation visits compared with the initial antenatal visit. No differences by sector were found. Almost all women (98.8%) reported that the model of care was acceptable.

Conclusions

The practice change intervention improved the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. Future research could explore the characteristics of pregnant women and maternity services associated with intervention effectiveness as well as the sustainment of care practices over time to inform the need for, and development of, further tailored practice change support.

Trial registration

Australian and New Zealand Clinical Trials Registry (Registration number: ACTRN12617000882325; Registration date: 16/06/2017) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372985&isReview=true

Strengthening Antenatal Care towards a Salutogenic Approach: A Meta-Ethnography

The aim was to explore how midwives, public health nurses and nurses view caring in antenatal care (ANC) as provided for mothers and fathers/partners. Based on Noblit and Hare (1988), meta-ethnography was used to address meaning by synthesizing knowledge and understanding inductively through selected qualitative studies (n = 16). Four core themes were identified: (1) supporting the parents to awaken to parenthood and creating a firm foundation for early parenting and their new life situation; (2) guiding parents on the path to parenthood and new responsibility; (3) ensuring normality and the bond between baby and parents while protecting life; and (4) promoting the health and wellbeing of the family today and in the future. The overarching theme can be expressed as "helping the woman and her partner prepare for their new life with the child by providing individualized, shared care, firmly grounded and with a view of the future". Caring in antenatal care (ANC) is being totally present, listening and using multidimensional professional competence but also being open-minded to new aspects and knowledge. The health promotion and positive health aspects should be considered an important part of supporting parents and the whole family now and in the future. A more conscious salutogenic approach to ANC would lead to more favorable results and could be a fruitful research topic in the future. There is a need to provide midwives/nurses with enough time to allow them to concentrate on specific needs and support for different kind of families in ANC but also training for midwives to make them more familiar with online and other options.

The importance of nurturing trusting relationships to embed shared decision-making during pregnancy and childbirth

OBJECTIVE

To generate greater awareness of the contextual and relational factors that influence women's capacity to participate in shared decision-making during childbirth.

METHODS

A three-phase participatory action research approach involving in-depth interviews and co-operative inquiry meetings.

SETTING

Dublin, Ireland in a large maternity hospital.

PARTICIPANTS

Five postnatal women who gave birth to live healthy babies, and attended obstetric or midwifery-led care and 13 practising midwives.

FINDINGS

This paper presents the findings from the third phase of a three-phase action research study exploring the action's women consider necessary to embed informed choice, into practice. The findings reveal that multiple organisational and relational factors influence how women can participate in shared decision-making including the model of care they attended, continuity of carer, power dynamics, hospital policies and trust in self and others. Women's relationships with maternity care professionals reveals that exercising choice is not only defined by but contingent on the degree of trust in their relationships with maternity care professionals.

"Cos You're Quite Normal, Aren't You?": Epistemic and Deontic Orientations in the Presentation of Model of Care Talk in Antenatal Consultations

Women's involvement in decision-making around antenatal care is an issue of ongoing debate and discussion. Most research on the topic has used interview and focus group methods to examine women's perspectives. The present study uses a different kind of evidence. By analyzing recordings of actual antenatal consultations, this paper presents a preliminary exploration of model-of-care talk in a hospital setting where a policy of woman-centered care underpinned practice. Conversation Analysis was used to examine how model-of-care pathways were introduced by midwives and discussed with women in consultations. Drawing on interactional work on deontic (i.e., the rights and responsibilities of speakers to determine courses of action) and epistemic (i.e., speakers' claims to knowledge) orientations, this paper offers an account of how woman-centered care is accomplished in a hospital setting. The findings demonstrate how midwives routinely relied on their epistemic knowledge regarding women's health to invoke a "normal" categorization that worked to position midwifery-led care as an appropriate pathway. Examination of model-of-care talk also demonstrated how authority to choose a pathway was typically managed so as to reside with the woman. Talk that topicalized epidural forms of pain management were also examined, as institutional policy around where birth could occur in the hospital system under study restricted women's options (a planned epidural precluded woman access to midwifery-led care during delivery). The findings demonstrate the various ways in which midwives created opportunities for woman-centered care in an institutional setting in which there were logistical restrictions on women's choices.

From Midwife-Dominated to Midwifery-Led Antenatal Care: A Meta-Ethnography

Provision of antenatal care includes risk identification, prevention and management of pregnancy-related diseases, but also health education, health promotion, support and guidance to smooth the transition to parenthood. To ensure good perinatal health, high-quality, free and easily accessed antenatal care is essential. The aim of this study was to identify, integrate and synthesize knowledge of midwives' experiences of providing antenatal care, attending to clients' individual needs whilst facing multiple challenges. We conducted a meta-ethnography, which is a seven-step grounded, comparative and interpretative methodology for qualitative evidence synthesis. A lines-of-argument synthesis based on two metaphors was developed, based on refutational themes emerging from an analogous translation of findings in the included 14 papers. The model reflects midwives' wished-for transition from a midwife-dominated caring model toward a midwifery-led model of antenatal care. Structural, societal and personal challenges seemingly influenced midwives' provision of antenatal care. However, it emerged that midwives had the willingness to change rigid systems that maintain routine care. The midwifery-led model of care should be firmly based in midwifery science and evidence-based antenatal care that emphasize reflective practices and listening to each woman and her family. The change from traditional models of antenatal care towards increased use of digitalization no longer seems to be a choice, but a necessity given the ongoing 2020 pandemic.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians

Background

Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic.

Methods

We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts.

Results

Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians.

Conclusions

This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

Women's experiences of decision-making and informed choice about pregnancy and birth care: a systematic review and meta-synthesis of qualitative research

BACKGROUND

The purpose of this systematic review (PROSPERO Ref: CRD42017053264) was to describe and interpret the qualitative research on parent's decision-making and informed choice about their pregnancy and birth care. Given the growing evidence on the benefits of different models of maternity care and the prominence of informed choice in health policy, the review aimed to shed light on the research to date and what the findings indicate.

METHODS

a systematic search and screening of qualitative research concerning parents' decision-making and informed choice experiences about pregnancy and birth care was conducted using PRISMA guidelines. A meta-synthesis approach was taken for the extraction and analysis of data and generation of the findings. Studies from 1990s onwards were included to reflect an era of policies promoting choice in maternity care in high-income countries.

RESULTS

Thirty-seven original studies were included in the review. A multi-dimensional conceptual framework was developed, consisting of three analytical themes ('Uncertainty', 'Bodily autonomy and integrity' and 'Performing good motherhood') and three inter-linking actions ('Information gathering,' 'Aligning with a birth philosophy,' and 'Balancing aspects of a choice').

CONCLUSIONS

Despite the increasing research on decision-making, informed choice is not often a primary research aim, and its development in literature published since the 1990s was difficult to ascertain. The meta-synthesis suggests that decision-making is a dynamic and temporal process, in that it is made within a defined period and invokes both the past, whether this is personal, familial, social or historical, and the future. Our findings also highlighted the importance of embodiment in maternal health experiences, particularly when it comes to decision-making about care. Policymakers and practitioners alike should examine critically current choice frameworks to ascertain whether they truly allow for flexibility in decision-making. Health systems should embrace more fluid, personalised models of care to augment service users' decision-making agency.

A meta-ethnographic synthesis of qualitative research on women's experience of midwifery care

Labor and birth constitute a significant emotional event for a childbearing woman. The aim was to explore women's reflections on their experiences of labor and birth and how these were influenced by the midwifery care they received. A modified version of Noblit and Hare's meta-ethnographic approach was used to develop an inductive and interpretive synthesis of nine qualitative articles. Relevant databases were searched and qualitative articles appraised by means of the Critical Appraisal Skills Program. Two metaphors were identified: The guide-Please share your knowledge and The motherly midwife as an anchor. The comprehensive understanding of the images evoked by the metaphors resulted in an overall metaphoric representation of the women's experiences: The midwife as a birth pilot, that is, a positive labor and birth experience is dependent on the relationship with the midwife. This finding confirms previous knowledge that a trusting relationship results in confidence, while feeling secure leads to a positive birth experience. The metaphors facilitate understanding of the significance of the midwife for women's labor and birth experiences. Knowledge of labor and birth experiences helps to broaden understanding of the necessity of midwives being willing to engage, act, be aware of errors that may affect women's birth experience, and employ tools to predict unexpected adverse events.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Midwives' perceptions of being 'with woman': a phenomenological study

BACKGROUND

Being 'with woman' is a central construct of the midwifery profession however, minimal research has been undertaken to explore the phenomenon from the perspective of midwives. The aim of this study was to describe Western Australian midwives' perceptions of the phenomenon of being 'with woman' during the intrapartum period.

METHODS

Descriptive phenomenology was selected as the methodology for this study. Thirty one midwives working across a variety of care models participated in individual interviews. Giorgi's four stage phenomenological approach was employed to analyse data.

RESULTS

Three themes were extracted 1) Essential to professional identity; 2) Partnership with women; and 3) Woman-Centred Practice. Midwives described the importance of being 'with woman' to the work and identification of midwifery practice. Developing a connection with the woman and providing woman-centred care inclusive of the woman's support people was highlighted.

CONCLUSIONS

For the first time, we are able to offer evidence of how midwives understand and perceive the phenomenon of being 'with woman' which has theoretical and practical utility. Findings from this study provide evidence that supports expert commentary and confirms that midwives conceptualise the phenomenon of being 'with woman' as essential to the identity and practice of the profession. Some previously identified 'good midwifery practices' were revealed as practical manifestations of the phenomenon. This new knowledge facilitates clarity and provides evidence to support statements of professional identity, which is useful for the development of educational curricula as well as supporting graduate and professional midwives. The findings emphasise the importance of the development of language around this important philosophical construct which permeates midwifery practice, enhances professional agency and supports the continued emphasis of being 'with woman' with new understanding of its applied practices in a variety of care models.

Antenatal care for alcohol consumption during pregnancy: pregnant women's reported receipt of care and associated characteristics

Background

Antenatal clinical guidelines recommend that during initial and subsequent antenatal visits all pregnant women: have their alcohol consumption assessed; be advised that it is safest not to consume alcohol during pregnancy and of the potential risks of consumption; and be offered referrals for further support if required. However, the extent to which pregnant women attending public antenatal services receive guideline recommended care at these visits, and the characteristics associated with its receipt, is unknown. The purpose of this study was to examine: 1) pregnant women’s reported receipt of guideline recommended care addressing alcohol consumption during pregnancy; 2) characteristics associated with the receipt of care; and 3) pregnant women’s acceptability of care.

Methods

From July 2017 – February 2018 a survey (telephone or online) was undertaken with 1363 pregnant women who had recently visited a public antenatal service in one health district in Australia. Receipt and acceptability of recommended care were assessed via descriptive statistics and associations via logistic regression analyses.

Results

At the initial antenatal visit, less than two thirds (64.3%) of pregnant women reported that they received an assessment of their alcohol consumption and just over one third (34.9%) received advice and referral appropriate to their self-reported level of alcohol consumption since pregnancy recognition. Less than 10% of women received such care at subsequent antenatal visits. Characteristics that significantly increased the odds of receiving all guideline elements at the initial antenatal visit included: less than university attainment (OR = 1.93; 95% CI:1.12, 3.34), not residing in an advantaged area (OR = 2.11; 95% CI:1.17, 3.79), first pregnancy (OR = 1.91; 95% CI:1.22, 2.99) and regional/rural service location (OR = 2.38; 95% CI:1.26, 4.48); and at subsequent visits: younger age (OR = 0.91; 95% CI:0.84, 0.99) and Aboriginal origin (OR = 3.17; 95% CI:1.22, 8.24). Each of the recommended care elements were highly acceptable to pregnant women (88.3–99.4%).

Conclusions

Although care for alcohol consumption is both recommended by clinical guidelines and highly acceptable to pregnant women, its receipt in public antenatal services is suboptimal. There is a need and an opportunity for interventions to support antenatal care providers to routinely and consistently provide such care to all pregnant women.

"It's what midwifery is all about": Western Australian midwives' experiences of being 'with woman' during labour and birth in the known midwife model

Background

The phenomenon of being ‘with woman’ is fundamental to midwifery as it underpins its philosophy, relationships and practices. There is an identified gap in knowledge around the ‘with woman’ phenomenon from the perspective of midwives providing care in a variety of contexts. As such, the aim of this study was to explore the experiences of being ‘with woman’ during labour and birth from the perspective of midwives’ working in a model where care is provided by a known midwife.

Methods

A descriptive phenomenological design was employed with ten midwives working in a ‘known midwife’ model who described their experiences of being ‘with woman’ during labour and birth. The method was informed by Husserlian philosophy which seeks to explore the same phenomenon through rich descriptions by individuals revealing commonalities of the experience.

Results

Five themes emerged 1) Building relationships; 2) Woman centred care; 3) Impact on the midwife; 4) Impact on the woman; and 5) Challenges in the Known Midwife model. Midwives emphasised the importance of trusting relationships while being ‘with woman’, confirming that this relationship extends beyond the woman – midwife relationship to include the woman’s support people and family. Being ‘with woman’ during labour and birth in the context of the relationship facilitates woman-centred care. Being ‘with woman’ influences midwives, and, it is noted, the women that midwives are working with. Finally, challenges that impact being ‘with woman’ in the known midwife model are shared by midwives.

Conclusions

Findings offer valuable insight into midwives’ experiences of being ‘with woman’ in the context of models that provide care by a known midwife. In this model, the trusting relationship is the conduit for being ‘with woman’ which influences the midwife, the profession of midwifery, as well as women and their families. Descriptions of challenges to being ‘with woman’ provide opportunities for professional development and service review. Rich descriptions from the unique voice of midwives, provided insight into the applied practices of being ‘with woman’ in a known midwife model which adds important knowledge concerning a phenomenon so deeply embedded in the philosophy and practices of the profession of midwifery.

Addressing transition to motherhood, guideline adherence by midwives in prenatal booking visits: Findings from video recordings

OBJECTIVE

To assess if and how primary care midwives adhere to the guideline by addressing transition to motherhood at the first prenatal booking visit and to what extent there was a difference in addressing transition to motherhood between nulliparous and multiparous women.

DESIGN

Cross-sectional observational study of video-recorded prenatal booking visits.

SETTING AND PARTICIPANTS

126 video recordings of prenatal booking visits with 18 primary care midwives in the Netherlands taking place between August 2010 and April 2011.

MEASUREMENTS

Five observers assessed dichotomously if midwives addressed seven topics of transition to motherhood according to the Dutch guideline prenatal midwifery care from the Royal Dutch Organization of Midwives and used six communication techniques. Frequencies and percentages of addressing each topic and communication technique were calculated. Differences between nulliparous and multiparous women were examined with Chi-Square tests or Fischer Exact tests, were appropriate. The agreement between the five observers was quantified using Fleiss' Kappa.

FINDINGS

During all visits at least one of the seven topics of transition to motherhood was addressed. The topics mother-to-infant bonding and support were addressed respectively in 2% and 16% of the visits. In almost all visits the topics desirability of the pregnancy, experience with the ultrasound examination or abdominal palpation or hearing the foetal heartbeat and practical preparation were addressed. Open questions for addressing transition to motherhood were used in 6% of the prenatal booking visits. Dutch midwives addressed transition to motherhood mostly by giving information (100%) and by using closed-ended questions (94%) and following woman's initiative (90%). Nulliparous women brought up transition to motherhood on their own initiative more often than multiparous women (97% versus 84%). For the topics 'desirability of the pregnancy 'and' practical preparations' and for conversation techniques 'giving information' and 'closed-ended questions', 100% agreement was achieved. However, the topic 'Support' had poor agreement (kappa = 0.19).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although during every visit the transition of motherhood was addressed, the topics mother-to-infant bonding and support should get more attention. Midwives should improve adherence to the guideline by addressing transition to motherhood and by using more open questions. Furthermore, they should focus on taking the initiative to address the transition to motherhood in multiparous women themselves.

Women's experiences of induction of labour: Qualitative systematic review and thematic synthesis

OBJECTIVES

To explore and synthesise evidence of women's experiences of induction of labour (IoL).

DESIGN

Systematic review and thematic synthesis of peer-reviewed qualitative evidence. Relevant databases were searched from inception to the present day. Study quality was appraised using the Critical Appraisal Skills Programme (CASP) qualitative research appraisal tool.

SETTING AND PARTICIPANTS

Low and high risk women who had experienced IoL in an inpatient or outpatient setting.

FINDINGS

Eleven papers (representing 10 original studies) published between 2010 and 2018 were included for thematic synthesis. Four key analytical themes were identified: ways in which decisions regarding induction were made; women's ownership of the process; women's social needs when undergoing IoL; and the importance of place in the induction process. The review indicates that IoL is a challenging experience for women, which can be understood in terms of the gap between women's needs and the reality of their experience concerning information and decision-making, support, and environment.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Providing good quality appropriately timed information and supporting women's self-efficacy to be involved in decision-making around IoL may benefit women by facilitating a sense of ownership or control of labour. Compassionate support from significant others and healthcare professionals in a comfortable, private and safe environment should be available to all women.

Better together: A qualitative exploration of women's perceptions and experiences of group antenatal care

PROBLEM

Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes.

BACKGROUND

Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes.

AIMS

To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women's experiences of pregnancy and antenatal care, and inform further development and testing of the model.

METHODS

A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically.

FINDINGS

Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions.

CONCLUSIONS

Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners.

Exploring routine hospital antenatal care consultations - An ethnographic study

BACKGROUND

Listening to women as part of their antenatal care has been recognized as valuable in understanding the woman's needs. Conversations as part of routine antenatal interactions offer ideal opportunities for women to express themselves and for midwives to learn about the woman's issues and concerns. The antenatal visit and the convention of antenatal consultations for midwives have not been well explored or defined and much of what takes place replicate medical consultative processes. As a consequence, there is little to assist midwives construct woman-centred care consultations for their routine antenatal care practice. This study showed how some practices were better in promoting the woman's voice and woman-centred care in the hospital setting.

METHOD

Contemporary focused ethnography using both interview and observations, explored how midwives from six different public antenatal clinics in South Australia organized their antenatal care consultations with pregnant women.

FINDINGS

Thematic analysis of the data provided insights into professional interpretation of woman-centred practice. How midwives interacted with women during routine antenatal care events demonstrated that some practices in a hospital setting could either support or undermine a woman-centred philosophy.

CONCLUSION

Individual midwives adopted practices according to their own perceptions of actions and behaviors that were considered to be in accordance with the philosophy of woman-centred care. Information arising from this study has shown ways midwives may arrange antenatal care consultations to maximize women's participation.

The Design, Development, and Evaluation of a Qualitative Data Collection Application for Pregnant Women

PURPOSE

This article explores the development and evaluation of a smartphone mobile software application (app) to collect qualitative data. The app was specifically designed to capture real-time qualitative data from women planning a vaginal birth after caesarean delivery. This article outlines the design and development of the app to include funding, ethics, and the recruitment of an app developer, as well as the evaluation of using the app by seven participants.

ORGANIZING CONSTRUCT

Data collection methods used in qualitative research include interviews and focus groups (either online, face-to-face, or by phone), participant diaries, or observations of interactions. This article identifies an alternative data collection methodology using a smartphone app to collect real-time data.

CONCLUSIONS

The app provides real-time data and instant access to data alongside the ability to access participants from a variety of locations. This allows the researcher to gain insight into the experiences of participants through audio or video recordings in longitudinal studies without the need for constant interactions or interviews with participants.

CLINICAL RELEVANCE

Using smartphone applications can allow researchers to access participants who are traditionally hard to reach and access their data in real time. Evaluating these apps before use in research is invaluable.

Midwives being 'with woman': An integrative review

BACKGROUND

Midwives being 'with woman' is embedded in professional philosophy, standards of practice and partnerships with women. In light of the centrality of being 'with woman' to the profession of midwifery, it is timely to review the literature to gain a contemporary understanding of this phenomenon.

AIM

This review synthesises research and theoretical literature to report on what is known and published about being 'with woman'.

METHODS

A five step framework for conducting an integrative literature reviews was employed. A comprehensive search strategy was utilised that incorporated exploration in electronic databases CINAHL, Scopus, Proquest, Science Direct and Pubmed. The initial search resulted in the retrieval of 2057 publications which were reduced to 32 through a systematic process.

FINDINGS

The outcome of the review revealed three global themes and corresponding subthemes that encompassed 'with woman': (1) philosophy, incorporated two subthemes relating to midwifery philosophy and philosophy and models of care; (2) relationship, that included the relationship with women and the relationship with partners; and (3) practice, that captured midwifery presence, care across the childbirth continuum and practice that empowers women.

CONCLUSION

Research and theoretical sources support the concept that being 'with woman' is a fundamental construct of midwifery practice as evident within the profession's philosophy. Findings suggest that the concept of midwives being 'with woman' is a dynamic and developing construct. The philosophy of being 'with woman' acts as an anchoring force to guide, inform and identify midwifery practice in the context of the rapidly changing modern maternity care landscapes. Gaps in knowledge and recommendations for further research are made.

Content of antenatal care: Does it prepare women for birth?

OBJECTIVE

clinical guidelines for antenatal care recommend informing women about birth. The aim of this study was to explore the content of antenatal care from women's perspective and to establish whether they consider information on birth to be sufficient.

METHOD

the data was gathered in a longitudinal, cross-sectional cohort study known as The Childbirth and Health Study in Iceland. The study group consisted of 765 women attending antenatal care at 26 urban and rural health care centres in Iceland, during the year 2009-2010. They participated by replying to two questionnaires, at 16 gestational weeks and six months after birth. The questions covered objective and subjective aspects of antenatal care, pregnancy, birth, and the postpartum period.

RESULTS

the majority (87%) of the women want to be informed about birth in the antenatal phase of care, and 41% reported 5-6 months post partum that too little time had been spent on this issue, by health care professionals. Post partum, mode of delivery affected women's estimated time spent on information in pregnancy, with women who had planned caesarean section being most satisfied with the time spent on antenatal information about birth. Women who experienced their birth as difficult or very difficult were more likely to report that insufficient time had been spent on information than women who had experienced their birth as easy or very easy.

CONCLUSIONS

antenatal care can play an important role in preparing women for birth. This study shows that information about birth provided during pregnancy is insufficient from women's perspective, although some groups of women do report being more satisfied with this information. The way that this segment of antenatal care is provided leaves room for improvement.

Midwifery care and patient-provider communication in maternity decisions in the United States

To characterize reasons women chose midwives as prenatal care providers and to measure the relationship between midwifery care and patient-provider communication in the U.S.

CONTEXT

Retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 to a single newborn in a U.S. hospital (n = 2,400). We used multivariate logistic regression models to characterize women who received prenatal care from a midwife, to describe the reasons for this choice, and to examine the association between midwife-led prenatal care and women's reports about communication. Preference for a female clinician and having a particular clinician assigned was associated with higher odds of midwifery care (AOR = 2.65, 95 % CI 1.70, 4.14 and AOR = 1.63, 95 % CI 1.04, 2.58). A woman with midwifery care had lower odds of reporting that she held back questions because her preference for care was different from her provider's recommendation (AOR = 0.46, 95 % CI 0.23, 0.89) or because she did not want to be perceived as difficult (AOR = 0.48, 95 % CI 0.28, 0.81). Women receiving midwifery care also had lower odds of reporting that the provider used medical words were hard for them to understand (AOR = 0.58, 95 % CI 0.37, 0.91) and not feeling encouraged to discuss all their concerns (AOR = 0.54, 95 % CI 0.34, 0.89). Women whose prenatal care was provided by midwives report better communication compared with those cared for by other types of clinicians. Systems-level interventions, such as assigning a clinician, may improve access to midwifery care and the associated improvements in patient-provider communication in maternity care.

Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study

BACKGROUND

One in four Australians is born overseas and 47% are either born overseas or have a parent who was. Obstetric and psychosocial risk factors for these women may differ.

METHOD

Data from one Sydney hospital (2012-2013) of all births recorded in the ObstetriX database were analysed (n = 3,092). Demographics, obstetric and psychosocial risk profile, obstetric interventions and complications and selected maternal and neonatal outcomes were examined for women born in Australia and overseas.

RESULTS

Women born in Australia were younger, more likely to be primiparous (28.6 v 27.5%), be obese (32.0% v 21.4%), smoke (19.7 % v 3.0%), have an epidural (26.2% v 20.2%) and were less likely to have gestational diabetes mellitus (GDM) (6.8% v 13.7% when compared to non-Australian born women. The highest rates of GDM, Gestational Hypertension (GH) and maternal anaemia were seen in women born in China, the Philippines and Pakistan respectively. Differences were also seen in psychosocial screening between Australian and non-Australian women with Australian-born women more likely to smoke and report a mental health disorder. There was an association between having an Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 and other psychosocial issues, such as thoughts of self-harm, domestic violence, childhood abuse etc. These women were also less likely to breastfeed. Women with an EPDS ≥ 13 at booking compared to women with EPDS ≤12 had a higher chance of being diagnosed with GDM (AOR 1.85 95% CI 1.14-3.0).

CONCLUSIONS

There are significant differences in obstetric and psychosocial risk profiles and maternal and neonatal outcomes between Australian-born and non-Australian born women. In particular there appears to be an association between an EPDS of ≥13 and developing GDM, which warrants further investigation.

Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark

Background

The large obstetric units typical of industrialised countries have come under criticism for fragmented and depersonalised care and heavy bureaucracy. Interest in midwife-led continuity models of care is growing, but knowledge about the accompanying processes of organisational change is scarce. This study focuses on midwives’ role in introducing and developing caseload midwifery. Sociological studies of midwifery and organisational studies of professional groups were used to capture the strong interests of midwives in caseload midwifery and their key role together with management in negotiating organisational change.

Methods

We studied three hospitals in Denmark as arenas for negotiating the introduction and development of caseload midwifery and the processes, interests and resources involved. A qualitative multi-case design was used and the selection of hospitals aimed at maximising variance. Ten individual and 14 group interviews were conducted in spring 2013. Staff were represented by caseload midwives, ward midwives, obstetricians and health visitors, management by chief midwives and their deputies. Participants were recruited to maximise the diversity of experience. The data analysis adopted a thematic approach, using within- and across-case analysis.

Results

The analysis revealed a highly interdependent interplay between organisational and professional projects in the change processes involved in the introduction and development of caseload midwifery. This was reflected in three ways: first, in the key role of negotiations in all phases; second, in midwives’ and management’s engagement in both types of projects (as evident from their interests and resources); and third in a high capacity for resolving tensions between the two projects. The ward midwives’ role as a third party in organisational change further complicated the process.

Conclusions

For managers tasked with the introduction and development of caseload midwifery, our study underscores the importance of understanding the complexity of the underlying change processes and of activating midwives’ and managers’ interests and resources in addressing the challenges. Further studies of female-dominated professions such as midwifery should offer good opportunities for detailed analysis of the deep-seated interdependence of professional and organisational projects and for identifying the key dimensions of this interdependence.

Midwives' strategies in challenging dietary and weight counselling situations

OBJECTIVE

By enhancing maternal nutritional status, midwives can help women lower the risks of pregnancy complications and adverse birth outcomes as well as improve maternal health during pregnancy and in the long run. Dietary counselling is, on the other hand, not reported to be effective. Poor communication and conflicting messages are identified as possible barriers to adherence with recommendations. Midwives' experiences of providing dietary advice and counselling during pregnancy are sparsely reported. The aim of this study was therefore to explore midwives' strategies when faced with challenging dietary counselling situations.

METHODS

Seventeen midwives from different parts of Sweden and working within antenatal health care were interviewed by telephone. The interviews were analysed using qualitative content analysis.

RESULTS

Challenges were commonly experienced when counselling women who were overweight, obese, had eating disorders or were from different cultures. The midwives talked in terms of "the problematic women" when addressing counselling problems. Strategies used in challenging counselling situations were Getting acquainted; Trying to support and motivate; Pressure to choose "correctly"; Controlling and mastering; and Resigning responsibility.

CONCLUSIONS

The results indicate that Swedish midwives' counselling strategies are quite ambiguous and need to be questioned and that counselling of vulnerable groups of women should be highlighted. We could identify a need for education of practicing midwives to develop person-centred counselling skills.

A comparison of frequency of medical interventions and birth outcomes between the midwife led unit and the obstetric unit in low-risk primiparous women

Introduction: The purpose of this national research was to compare birth, maternal and newborn outcomes in the midwife led unit and the obstetric unit to ascertain whether a midwife led unit reduced medicalisation of childbirth. Methods: A prospective observational case-control study was carried out in Ljubljana Maternity Hospital in the period May - August 2013. The sample comprised 497 labouring women; 154 who attended the midwife led and 343 who attended in the obstetric unit, both matching the same inclusion criteria: low risk primiparous; singleton term pregnancies, normal foetal heart beat, cephalic presentation; spontaneous onset of labour. The primary outcome was the caesarean section rate. Chi-square test was used to compare medical interventions and birth outcomes. Results: Women in the midwife led unit had statistically significant higher spontaneous vaginal births (p < 0.001), less augmentation with oxytocin (p < 0.001), less use of analgesia (p < 0.001), less operative vaginal deliveries (p < 0.001) and less caesarean sections (p < 0.001), lower rates of episiotomy (p < 0.001) and more exclusively breastfed (p = 0.002). Discussion and conclusion: These significant findings showed that in the midwife led unit fewer medical interventions were used. For generalisation of the findings more similar studies in Slovenia are needed.

Framing Options as Choice or Opportunity

Objective. Health professionals must enable patients to make informed decisions about health care choices through unbiased presentation of all options. This study examined whether presenting the decision as “opportunity” rather than “choice” biased individuals’ preferences in the context of trial participation for cancer treatment. Methods. Self-selecting healthy women ( N = 124) were randomly assigned to the following decision frames: opportunity to take part in the trial (opt-in), opportunity to be removed from the trial (opt-out), and choice to have standard treatment or take part in the trial (choice). The computer-based task required women to make a hypothetical choice about a real-world cancer treatment trial. The software presented the framed scenario, recorded initial preference, presented comprehensive and balanced information, traced participants’ use of information during decision making, and recorded final decision. A posttask paper questionnaire assessed perceived risk, attitudes, subjective norm, perceived behavioral control, and satisfaction with decision. Results. Framing influenced women’s immediate preferences. Opportunity frames, whether opt-in or opt-out, introduced a bias as they discouraged women from choosing standard treatment. Using the choice frame avoided this bias. The opt-out opportunity frame also affected women’s perceived social norm; women felt that others endorsed the trial option. The framing bias was not present once participants had had the opportunity to view detailed information on the options within a patient decision aid format. There were no group differences in information acquisition and final decisions. Sixteen percent changed their initial preference after receiving full information. Conclusions. A “choice” frame, where all treatment options are explicit, is less likely to bias preferences. Presentation of full information in parallel, option-by-attribute format is likely to “de-bias” the decision frame. Tailoring of information to initial preferences would be ill-advised as preferences may change following detailed information.

Information giving and education in pregnancy: a review of qualitative studies

Studies of childbirth education have universally failed to take into account the quality of the education provided to women and their families and whether its style of delivery meets women's preferences and needs. The present study sought to determine which educational approaches are most welcomed by women and most helpful to them in learning about labor, birth, and early parenting. A systematic survey of peer-reviewed studies on antenatal education, published in English from 1996-2006 and which sought women's views and experiences, was conducted. Findings confirm women's preference for a small-group learning environment in which they can talk to each other as well as the educator and can relate information to their individual circumstances.

Caseload midwifery in a multi-ethnic community: the women's experiences

OBJECTIVE

to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area.

DESIGN AND SETTING

semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery.

FINDINGS

key themes from previous work fitted well with the themes that emerged from this study. Themes included 'knowing and being known', 'person-centred care', 'social support', 'gaining trust and confidence', 'quality and sensitivity of care' and 'communication'.

KEY CONCLUSIONS AND IMPLICATIONS

women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.

Approaches used in investigating family support in transition to parenthood

Early support has been acknowledged to be needed in the phase of transition to parenthood, and increasing knowledge is available on the factors enhancing this transition. The issue is to translate the knowledge into practices of preventive care. In this article, our aim is to map out recent research on supporting parents in maternity and child health care and to analyse how the subject of family support has been studied. The data consist of 98 scientific articles published in peer-reviewed journals during 2000-09. Most of the reported research was Anglo-American, and fell within the academic fields of nursing studies, medicine and public health. The studies were categorized into three groups according to the epistemic perspective that was taken on the subject of family support, the studies focusing on (i) views and perceptions on family support of both clients and professionals (63 studies), (ii) the effectiveness of interventions (27 studies) and (iii) activities in the practices and processes of MCH (8 studies). First, the groups were described with regard to the study participants and the data and methods used. A bias towards the perspectives of risk groups and mothers was detected. Second, we examined the potential of different epistemic perspectives to describe care practices. The article contributes to the discussion about how to examine the practices and processes of health promotion and preventive care in such a way that the 'good practices' identified could be implemented in other contexts than the one studied.

Engagement: an indicator of difference in the perceptions of antenatal care for pregnant women from diverse socioeconomic backgrounds

BACKGROUND

Socioeconomically deprived women are at greater risk of adverse pregnancy outcomes. Research tends to focus on access of services. Yet access may not equate with the equity of services for women from different socioeconomic backgrounds.

OBJECTIVES

To determine whether pregnant women's perceptions of antenatal provision differed in relation to their socioeconomic deprivation ranking (determined by the Scottish Index of Multiple Deprivation 2006).

DESIGN

A longitudinal, qualitative study with comparative antenatal case studies between January 2007 and April 2009.

SETTING/PARTICIPANTS

Cases were primigravida women from 'least deprived' (n=9) and 'most deprived' (n=12) geographical areas within one local authority in Scotland.

ANALYSIS

Data were analysed using case study replication analysis.

RESULTS

There was little difference in access to antenatal services between the 'least' and 'most' deprived groups. Perception of care differed in relation to the level of 'engagement' (defined using constructs of: language and personalization of care; power and relationships; and health literacy). Engagement was evidenced in most of the 'least deprived' cases and almost none of the 'most deprived' cases. Specifically, socioeconomically deprived women described less evidence of personal connection to their own care, effective communication and the opportunity for shared decision making.

CONCLUSION

In women from socioeconomically deprived areas, access may be a less useful indicator than engagement when assessing antenatal service quality. As engagement levels may be one method by which to predict and improve health outcomes, a more equitable antenatal service may need to be developed through the early identification of those women at risk of non-engagement.

An Observational Study to Explore the Power and Effect of the Labor Ward Culture on Consent to Intrapartum Procedures

AIM:To explore the concept of informed consent to intrapartum procedures within a hospital labor ward.

DESIGN:An ethnographic study using participant observation and follow-up semistructured interviews with women and the attending midwives. Data analysis used principles of grounded theory assisted by the computer-assisted qualitative data analysis software (CAQDAS) package, Non-numerical Unstructured Data Indexing, Searching, and Theorizing (NUD*IST). The study was approved by the Local Research Ethics Committee.

PARTICIPANTS AND SETTING:100 healthy English-speaking women in spontaneous labor who were to give birth within the labor ward of a large teaching hospital in England and the attending health professionals.

FINDINGS:

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CONCLUSIONS:The study revealed that true choices to childbearing women were limited andinformedconsent was rarely obtained. Further exploration is required to establish the optimal timing of information disclosure to gain consent to intrapartum practices prior to the onset of labor, because during labor is not ideal. The 2 typologies may be used by midwives to examine how the culture of the birthing environment can affect women’s choice and the obtaining of informed consent to intrapartum procedures, especially where care is fragmented. Until birth is viewed through a holistic birthing model, health professionals will continue to control the birth experience. However, what is provided in practice should be congruent with the needs and expectations of childbearing women.