Midwives' strategies for coping with barriers to providing quality maternal and neonatal care: a Glaserian grounded theory study

Midwives' views and experiences of maternity care during COVID-19 in Ireland: A qualitative descriptive study

OBJECTIVE

To explore and describe midwives' views and experiences of maternity care during the COVID-19 pandemic in Ireland.

DESIGN

A qualitative descriptive study involving semi-structured interviews to gather data was undertaken. Interviews, which were held between September 2022 and January 2023, were digitally recorded and transcribed verbatim. Thematic analysis was used to analyse the data.

SETTING & PARTICIPANTS

The study setting was a large urban maternity unit (> 8000 births per year) in the Republic of Ireland. Midwives of any grade, who were involved in providing maternity care to women and their families in any area of the hospital during the pandemic were eligible for inclusion. Midwives were invited to take part via the hospital intranet and advertisements that were posted on notice boards throughout the study site.

FINDINGS

Thirteen midwives took part in the study. Four major themes reflective of midwives' views and experiences were identified. These were: 'Ever-evolving goalposts', 'Feeling vulnerable', 'Changing relationships' and 'Challenges to the Philosophy of Midwifery'.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study highlights the need to consider the impact of COVID-19 on midwives and maternity services now and in the future. As a priority, embedding strategies to support midwives to regain and sustain psychological and physical well-being, are required. Attending to these factors may aid in sustainable retention of the midwifery workforce, and, ultimately, act as protective factors for crises that could emerge, potentially, in the future.

Ninety-one years of midwifery continuity of care in low and middle-income countries: a scoping review

BACKGROUND

Midwifery continuity of care during pregnancy, childbirth, and postpartum is essential for improving maternal and neonatal health outcomes. In low- and middle-income countries (LMICs), however, challenges such as healthcare worker shortages, limited infrastructure, poor healthcare access, and cultural barriers often hinder the effective provision of midwifery services. These issues contribute to unsustainable and inadequate care, adversely affecting maternal and newborn health. This study examines the impact of these challenges on the midwifery continuity of care and its subsequent effect on maternal and neonatal outcomes.

METHODS

A scoping review was conducted following Arksey and O'Malley's framework. We analyzed 43 articles published between 1932 and 2023 across four databases. Included studies were conducted in LMICs, focused on continuous care models, and published in English. The review aimed to capture the varied impacts of midwifery care on health outcomes.

RESULTS

The review found that midwifery continuity of care in LMICs significantly improves maternal and newborn health by reducing medical interventions, increasing physiological births, and enhancing maternal satisfaction and breastfeeding rates. The approach also lowers newborn mortality and morbidity. Success factors include community acceptance, midwives' cultural competence, and collaboration with traditional birth attendants. Barriers such as insufficient funding and resistance to change persist. Midwife-led continuity of care (MLCC) was associated with a 16% reduction in neonatal loss and a 24% reduction in pre-term births. Also, MLCC decreases newborn mortality by 10-20% and increases breastfeeding rates by up to 30%. Effective implementation requires integrating midwifery services into existing health systems, securing funding, expanding training, and strengthening community partnerships.

CONCLUSIONS

Midwifery continuity of care enhances maternal and neonatal health in LMICs by minimizing unnecessary medical interventions and improving maternal satisfaction and breastfeeding outcomes. However, cultural and socioeconomic factors influence its acceptance. Further research is needed to integrate traditional birth attendants into formal health systems, overcome resistance to change, and develop strategies for effective collaboration between traditional and professional care providers.

Exploring care quality in midwifery clinical practice settings in Ghana - a qualitative study

BACKGROUND

High-quality care is a significant factor in reducing maternal and neonatal mortality. There are known barriers affecting midwives' ability to provide quality care in low- and middle-income countries. The presence of qualified and competent midwives, coupled with the elimination of barriers, is essential for enhancing care quality, especially in education program clinical practice settings.

AIM

To explore factors that affect Ghanaian midwifery students' provision of high-quality care while on clinical rotation.

METHOD

Six focus-group discussions were conducted with a total of 36 midwifery students in Accra, Ghana. Data were analyzed using deductive content analysis applying a conceptual framework identifying social, economic and professional factors influencing the provision of high-quality care.

RESULTS

Social factors identified patient resistance to student midwives, class-based discrimination, traditional practices being preferred over evidence-based care, communication barriers, and poor security. Economic factors were unexpected expenses and inadequate compensation. Professional factors were lack of necessary materials, insufficient number of staff, and a theory-practice gap between classroom learning and hands-on experiences.

CONCLUSION

Factors impacting Ghanaian midwifery students' ability to provide high-quality care in clinical settings were summarized, highlighting social, economic, and professional challenges. Key issues include patient resistance, class-based discrimination, inadequate compensation, theory-practice gaps, and lack of materials. The findings emphasize the need for improved support, resources, and quality clinical learning environments. There needs to be investment in infrastructure and prioritization of pedagogy in clinical settings to enhance midwifery education and care quality in Ghana and more broadly in low- and middle-income countries.

CLINICAL TRIAL NUMBER

Not applicable.

Challenges and coping strategies for providing maternal health care services among health care professionals in rural health facilities in Wolaita Zone, Southern Ethiopia: a qualitative study

BACKGROUND

Many factors can decrease job productivity and cause physical and psychological complications for health care professionals providing maternal care. Information on challenges and coping strategies among healthcare professionals providing maternal healthcare services in rural communities is crucial. However, there needs to be more studies, especially qualitative research, to explore challenges and coping strategies for providing maternal health care services in Ethiopia among health care professionals, particularly in the Wolaita zone.

OBJECTIVE

To explore the challenges and coping strategies of professionals providing maternal health care in rural health facilities in Wolaita Zone, Southern Ethiopia, in 2023.

METHOD

A phenomenological qualitative study design was applied from May 20 to June 20, 2023. The study was conducted in rural areas of the Wolaita Zone, southern Ethiopia. Healthcare professionals from rural areas were selected using purposive sampling, and in-depth interviews were conducted. A qualitative thematic analysis was employed to analyze the data. Field notes were read, recordings were listened to, and each participant's interview was written word for word and analyzed using ATLAS.ti 7 software.

RESULT

Five main themes emerged from the data analysis. These themes included inadequate funding from the government, societal barriers to health and access to health care, professionals' personal life struggles, infrastructure related challenges and health system responsiveness, and coping strategies. Reporting to responsible bodies, teaching mothers about maternal health care services, and helping poor mothers from their pockets were listed among their coping strategies.

CONCLUSION

Healthcare professionals have a crucial role in supporting women in delivering babies safely. This study revealed that they are working under challenging conditions. So, if women's lives matter, then this situation requires a call to action.

A global overview of midwives' working conditions: A rapid review of literature on positive practice environment

BACKGROUND

In the United Kingdom (UK), a critical shortage of midwives puts pressure on the already overworked midwives working in maternity services. Considering the challenges that midwives in the UK face, this rapid review was conducted to inform a larger-scale initiative to improve the working conditions of midwives in an acute NHS Trust in the Midlands area of the UK.

OBJECTIVE

To describe midwives' perceptions and experiences of positive practice environments.

METHODS

A search strategy to identify literature about midwives' perceptions and experiences of positive practice environments was conducted in Medline, CINAHL Plus and Embase databases. Literature screening was conducted independently in two steps using an eligibility tool. The articles' quality assessment was conducted using the Mixed Method Appraisal Tool. Data were extracted using the Job Quality framework and managed using NVivo12.

RESULTS

Seventy articles were included in this review. Midwives' working conditions can be improved in all seven areas of the Job Quality framework. Most articles in the review reported the negative aspects of midwives' working environments, making it challenging for the team to define a positive practice environment for midwives. Despite this, authors discuss that a positive practice environment is at least sustained by ensuring midwives' ability to provide care; providing good employment conditions; developing respectful organisations; and increasing team resources, such as those that improve team resilience.

CONCLUSIONS

Midwives' working conditions are universally challenging. Failure to address the situation will compromise recruitment and retention, increasing the shortage of midwives. Provision of safe and respectful care appears to be directly linked to midwives' safe and respectful working conditions.

Midwives' experiences of the consequences of navigating barriers to maternity care

Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives' ability to provide maternity care can have physiological, psychological, and socioeconomic consequences for midwives. It also negatively impacted maternity care. Implementing new ameliorating measures to mitigate the barriers that Ghanaian midwives encounter, and the consequences that those barriers have on them would improve midwife retention and care quality.

Health-system drivers influencing the continuum of care linkages for low-birth-weight infants at the different care levels in Ghana

BACKGROUND

Low birth weight (LBW) is associated with short and long-term consequences including neonatal mortality and disability. Effective linkages in the continuum of care (CoC) for newborns at the health facility, community (primary care) and home care levels have a high tendency of minimizing adverse events associated with LBW. But it is unclear how these linkages work and what factors influence the CoC process in Ghana as literature is scarce on the views of health professionals and families of LBW infants regarding the CoC. Therefore, this study elicited the drivers influencing the CoC for LBW infants in Ghana and how linkages in the CoC could be strengthened to optimize quality of care.

METHODS

A constructivist grounded theory study design was used. Data was collected between September 2020 to February 2021. A total of 25 interviews were conducted with 11 family members of LBW infants born in a secondary referral hospital in Ghana, 9 healthcare professionals and 7 healthcare managers. Audio recordings were transcribed verbatim, analyzed using initial and focused coding. Constant comparative techniques, theoretical memos, and diagramming were employed until theoretical saturation was determined.

RESULTS

Emerging from the analysis was a theoretical model describing ten major themes along the care continuum for LBW infants, broadly categorized into health systems and family-systems drivers. In this paper, we focused on the former. Discharge, review, and referral systems were neither well-structured nor properly coordinated. Efficient dissemination and implementation of guidelines and supportive supervision contributed to higher staff motivation while insufficient investments and coordination of care activities limited training opportunities and human resource. A smooth transition between care levels is hampered by procedural, administrative, logistics, infrastructural and socio-economic barriers.

CONCLUSION

A coordinated care process established on effective communication across different care levels, referral planning, staff supervision, decreased staff shuffling, routine in-service training, staff motivation and institutional commitment are necessary to achieve an effective care continuum for LBW infants and their families.

Barriers and facilitators to the implementation of midwife-led care for childbearing women in low- and middle-income countries: A mixed-methods systematic review

BACKGROUND

Evidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations' Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care.

AIM

This systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders.

METHODS

A mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care.

FINDINGS

A total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

There are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.

Silent Tears of Midwives: 'I Want Every Mother Who Gives Birth to Have Her Baby Alive'-A Narrative Inquiry of Midwives Experiences of Very Early Neonatal Death from Tanzania

BACKGROUND

Midwives working in settings with limited clinical resources experience high rates of very early neonatal deaths. Midwives manage the impact of this grief and trauma almost daily, which may affect patient care and their own well-being.

RESEARCH AIMS

To explore how midwives are impacted by and cope with high rates of very early neonatal deaths. To document midwives' insights and local solutions that may reduce very early neonatal deaths in limited resource settings. To document the stories of midwives in order to create awareness and garner support for midwives and their critical work in low resource settings.

METHODS

Narrative inquiry utilizing semi structured interviews. Twenty-one midwives with at least six months experience who had experienced or witnessed very early neonatal death were interviewed. Data were audio recorded and transcribed, and reflexive thematic analysis of transcripts was conducted.

RESULTS AND DISCUSSION

Three themes were identified: (1) deep sadness resulting from very early neonatal deaths leading to internal struggles; (2) use of spirituality, including prayer and occasional beliefs that unexplainable deaths were 'God's plan'; and (3) development of resilience by seeking solutions, educating themselves, taking accountability and guiding mothers. Participating midwives noted that inadequate staff and high caseloads with limited basic supplies hindered their clinical practice. Participants articulated that they concentrated on active solutions to save babies during labour, such as vigilant foetal rate heart monitoring and partogram. Further, reduction and prevention of very early neonatal death is a complex problem requiring multidisciplinary teams and woman-centred care approaches to address issues contributing to the health of mothers and their new-borns.

CONCLUSIONS

Midwives' narratives highlighted ways of coping with grief and deep sadness, through prayer, and further education of both mothers and fellow colleagues to achieve better antenatal and intrapartum care and outcomes. This study gave midwives an opportunity for their voices to be heard and to generate solutions or insights that can be shared with colleagues in similar low-resource settings.