Midwives' Intercultural Effectiveness Levels and Influencing Factors

INTRODUCTION

Due to globalization, countries around the world are starting to notice diversity in their populations. It is crucial that midwives be able to communicate effectively with women from a variety of cultures to provide them with culturally effective health care.

METHOD

This cross-sectional study was conducted with 394 midwives who work in seven different regions of Türkiye. Data on the intercultural effectiveness and intercultural communication competence of midwives were collected. Data analysis was performed using descriptive statistics, t-tests, analysis of variance, and regression analysis.

RESULTS

Midwives' intercultural effectiveness was influenced by their foreign language proficiency, experiences abroad, having friends from different cultures, following social media platforms in different languages and cultures, providing care to individuals from diverse cultures, and their willingness to do so.

DISCUSSION

Findings suggest that exposure to different cultures enhances the level of intercultural effectiveness. Consequently, it is recommended to make plans to support midwives to have positive experiences with different cultures.

Translating and Validating the Vietnamese Version of the Health Sciences Evidence-Based Practice Questionnaire

No validated instrument is available for assessing the evidence-based practice capacity of Vietnamese health professionals. This study aimed to translate and validate the Health Sciences Evidence-Based Practice questionnaire (HS-EBP) from English to Vietnamese and ascertain its psychometric properties. Data were collected from two obstetric hospitals in Vietnam. Participants: A total of 343 midwives were randomly selected. The HS-EBP questionnaire was translated by a group of bilingual experts into Vietnamese (HS-EBP-V). Content validity was assessed by two experts. Internal consistency and test-retest reliabilities were assessed using Cronbach's α and intraclass correlation (ICC), respectively. Construct validity was assessed using the contrasted groups approach. As a result, the content validity index of the HS-EBP-V reached 1.0. For the individual subscales, Cronbach's α was 0.92-0.97 and ICC was between 0.45 and 0.66. The validity of the contrasted-groups approach showed discrimination by a significant difference in the subscale scores among diploma holders compared with bachelor's degree holders (p < 0.001). The validation of the HS-EBP questionnaire indicated satisfactory psychometric properties. The results indicate that the HS-EBP is a reliable and valid instrument which assesses the competencies of as well as facilitators of and barriers to the five steps of EBP among midwives. The HS-EBP-V was deemed a reliable and validated tool for assessing the competency and application of EBP among Vietnamese healthcare professionals.

Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020

BACKGROUND

Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice.

METHODS

Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice.

RESULTS

The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making.

CONCLUSION

To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Comfort With Touch and Influencing Factors Among Chinese Midwives: A Cross-sectional Survey

The aim of this study was to identify comfort with touch (CT) and influencing factors among Chinese midwives. Midwives (N = 252) from 7 hospitals in Guangdong, China, were asked to complete a self-report questionnaire between November 2018 and April 2019. The questionnaire included the Nurses' Comfort with Touch Scale (NCTS), the Nurses' Perceived Professional Benefits (NPPB) Scale, the Maslach Burnout Inventory-General Survey (MBI-GS), and a self-designed demographic questionnaire. Multivariate linear regression was used to identify influencing factors for CT. Mean NCTS total score was 88.90 ± 14.40, and the mean item score was 5.23 ± 0.91, which indicated a respectable score. Within the NCTS, CT was highest in the comfort support category (5.32 ± 0.29) whereas CT was lowest in the physical comfort category (4.28 ± 0.28). Multivariate regression analysis demonstrated that CT among Chinese midwives was associated with positive experiences or feelings surrounding the patient-nurse relationship (B = 3.239, P < .001), perceived professional benefit (PPB, positive professional identity) (B = 0.240, P < .001), emotional exhaustion (B = -0.414, P < .001), depersonalization (negative attitude toward the work setting) (B = -0.773, P < .001), and personal accomplishment (evaluation of self-worth) (B = 0.170, P = .015). Touch training and educational programs are recommended for Chinese midwives to enhance awareness and acceptance of touch care. In addition, promoting positive patient-nurse relationships, improving PPB, and reducing burnout are recommended to enhance CT among Chinese midwives. Because of the size and racial homogeneity of the sample, further studies are recommended to identify CT and influencing factors in a larger, more diverse population of midwives worldwide.

Out-of-Hospital Birth

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol

BACKGROUND

We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care.

METHODS

Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs.

DISCUSSION

We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project.

TRIAL REGISTRATION

PACTR202006793783148-June 17th, 2020.

What might COVID-19 have taught us about the delivery of Nurse Education, in a post-COVID-19 world?

For Nurse Education in the UK, pre-existing challenges already included the need to develop curricula to align with new Nursing and Midwifery Council (NMC) educational standards; and increased numbers entering pre-registration Nurse Education programmes in order to address workforce deficits. Further disruption due to COVID-19, forced Nurse Educators overnight to rapidly adopt and to innovatively use current and emerging technologies to maintain engagement with, and to continue delivering education to, students during the pandemic. Although the full extent of these enforced changes is unknown at this time, this paper argues that online delivery is a necessary and inevitable transition, addressing some of these pre-existing challenges, and that the pandemic has hastened this. It is therefore crucial that Nurse Educators lead the way in navigating this period of uncertainty, viewing the pandemic as an opportunity to plan for the future, to establish how online teaching and learning can continue to benefit Nurse Education in a post-COVID-19 world, not just in the UK, but across the globe.

Developing operational standards for Midwifery Centers

BACKGROUND

Midwifery centres have been identified in over 56 countries. Consensus was reached on a global definition for midwifery centres, yet there is a lack of standards to assure consistent quality of care is provided.

METHODS

Evidence-based standards and guidelines developed from American Association of Birth Centres (USA), Midwifery Unity Network (UK/EU), World Health Organization, International Childbirth Initiative, and White Ribbon Alliance, were gathered, duplicate standards were removed, and language was adapted for global use with sensitivity to low and middle countries (LMIC). An initial list of 52 midwifery centre standards were identified. Through an informal modified Delphi process these were reviewed by global midwifery centres experts, researchers, and midwifery centre staff at focus groups in Haiti, Mexico and Bangladesh for significance, language, and usability. The standards were then piloted at midwifery centres in eight countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda and Trinidad). All feedback was incorporated into the final standards.

RESULTS

A final list of 43 standards, organized into 3 domains including quality standards for care providers, dignity standards for women, and community standards for administration, were agreed on.

CONCLUSION

Midwifery centres are prevalent around the globe. Identifying standards for quality of care provides a foundation for the midwifery centre model to be replicated and ensure consistent quality of care. Evidence based standards for midwifery centres in LMIC, allows systems to embrace and encourage the implementation and growth of midwifery centres to address accessible, acceptable, respectful, woman-centred, community-engaged maternal health care that participates fully in the health care system.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania

BACKGROUND

An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate.

METHODS

This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included.

RESULTS

Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels.

CONCLUSIONS

To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

Local guidelines for admission to UK midwifery units compared with national guidance: A national survey using the UK Midwifery Study System (UKMidSS)

OBJECTIVES

To describe the extent to which local guidelines for admission to UK midwifery units align with national guidance; to describe variation in individual admission criteria; and to describe the extent to which alongside midwifery units (AMUs) are the default option for eligible women.

DESIGN

National cross-sectional survey.

SETTING

All 122 UK maternity services with midwifery units, between October 2018 and February 2019.

OUTCOME MEASURES

Alignment of local admission guidelines with national guidance (NICE CG190); frequency and nature of variation in individual admission criteria; percentage of services with AMU as default birth setting for eligible women.

RESULTS

Admission guidelines were received from 87 maternity services (71%), representing 153 units, and we analysed 85 individual guideline documents. Overall, 92% of local admission guidelines varied from national guidance; 76% contained both some admission criteria that were 'more inclusive' and some that were 'more restrictive' than national guidance. The most common 'more inclusive' admission criteria, occurring in 40-80% of guidelines, were: explicit admission of women with parity ≥4; aged 35-40yrs; with a BMI 30-35kg/m2; selective admission of women with a BMI 35-40kg/m2; Group B Streptococcus carriers; and those undergoing induction of labour. The most common 'more restrictive' admission criteria, occurring in around 30% of guidelines, excluded women who: declined blood products; had experienced female genital cutting; were aged <16yrs; or had not attended for regular antenatal care. Over half of services (59%) reported the AMU as the default option for healthy women with straightforward pregnancies.

CONCLUSIONS

The variation in local midwifery unit admission criteria found in this study represents a potentially confusing and inequitable basis for women making choices about planned place of birth. A review of national guidance may be indicated and where a lack of relevant evidence underlies variation in admission criteria, further research by planned place of birth is required.

Sustaining quality midwifery care in a pandemic and beyond

•Rapid development of COVID-19 has altered healthcare and services around the world; changes have affected women, newborn infants, families, and staff •Restrictive practices have been introduced in maternal and newborn care that limit women's decisions and rights of women and newborn infants, including restrictions on the place of birth, continuity of care, and mother-baby contact •An evidence-informed approach is now developing in some countries in which essential elements of quality can be maintained while also protecting and supporting staff •To keep women, newborn infants, families, and staff safe, balance is needed between the public health, quality care, and human rights agendas •A set of key principles is proposed to inform COVID-relevant quality care and service provision •A pro-active strategy to inform longer-term planning for life during and after the pandemic should be grounded in evidence and co-created with women, families, and staff

Quality of and barriers to routine childbirth care signal functions in primary level facilities of Tigray, Northern Ethiopia: Mixed method study

Background

Efforts to expand access to institutional delivery alone without quality of care do not guarantee better survival. However, little evidence documents the quality of childbirth care in Ethiopia, which limits our ability to improve quality. Therefore, this study assessed the quality of and barriers to routine childbirth care signal functions during intra-partum and immediate postpartum period.

Methods

A sequential explanatory mixed method study was conducted among 225 skilled birth attendants who attended 876 recently delivered women in primary level facilities. A multi stage sampling procedure was used for the quantitative phase whilst purposive sampling was used for the qualitative phase. The quantitative survey recruitment occurred in July to August 2018 and in April 2019 for the qualitative key informant interview and Focus Group Discussions (FGD). A validated quantitative tool from a previous validated measurement study was used to collect quantitative data, whereas an interview guide, informed by the literature and quantitative findings, was used to collect the qualitative data. Principal component analysis and a series of univariate and multivariate linear regression analysis were used to analyze the quantitative data. For the qualitative data, verbatim review of the data was iteratively followed by content analysis and triangulation with the quantitative results.

Results

This study showed that one out of five (20.7%, n = 181) mothers received high quality of care in primary level facilities. Primary hospitals (β = 1.27, 95% CI:0.80,1.84, p = 0.001), facilities which had staff rotation policies (β = 2.19, 95% CI:0.01,4.31, p = 0.019), maternal involvement in care decisions (β = 0.92, 95% CI:0.38,1.47, p = 0.001), facilities with maternal and newborn health quality improvement initiatives (β = 1.58, 95% CI:0.26, 3.43, p = 0.001), compassionate respectful maternity care training (β = 0.08, 95% CI: 0.07,0.88, p = 0.021), client flow for delivery (β = 0.19, 95% CI:-0.34, -0.04, p = 0.012), mentorship (β = 0.02, 95% CI:0.01, 0.78, p = 0.049), and providers’ satisfaction (β = 0.16, 95% CI:0.03, 0.29, p = 0.013) were predictors of quality of care. This is complemented by qualitative research findings that poor quality of care during delivery and immediate postpartum related to: work related burnout, gap between providers’ skill and knowledge, lack of enabling working environment, poor motivation scheme and issues related to retention, poor providers caring behavior, unable translate training into practice, mismatch between number of provider and facility client flow for delivery, and in availability of essential medicine and supplies.

Conclusions

There is poor quality of childbirth care in primary level facilities of Tigray. Primary hospitals, facilities with staff rotation, maternal and newborn health quality improvement initiatives, maternal involvement in care decisions, training on compassionate respectful maternity care, mentorship, and high provider satisfaction were found to have significantly increased quality of care. However, client flow for delivery service is negatively associated with quality of care. Efforts must be made to improve the quality of care through catchment-based mentorship to increase providers’ level of adherence to good practices and standards. More attention and thoughtful strategies are required to minimize providers’ work-related burnout.

Disrespect and Abuse Experienced by Women during Childbirth in Midwife-Led Obstetric Units in Tshwane District, South Africa: A Qualitative Study

The disrespect and abuse (D&A) of women during childbirth is common and a great concern in midwifery-led obstetric units (MOUs) in South Africa. This paper used the seven chapters of the Respectful Maternity Care Charter as a framework to explore women's experiences of care during childbirth and examine the occurrence of D&A during childbirth in MOUs. Five focus group interviews were conducted with postnatal women aged 18 to 45 years selected purposively from MOUs in Tshwane District in South Africa. The discussions were audio-recorded, transcribed, and analyzed using a thematic approach and NVivo11 computer software. D&A of women was common during labor and childbirth. Verbal abuse in the form of shouting, labeling, judging, and rude remarks was the common form of D&A. Some of the women were abandoned and neglected, which resulted in their giving birth without assistance. Furthermore, the midwives violated their rights and denied them care such as pain relief medication, birth companions during childbirth, and access to ambulance services. Midwives are at the center of the provision of maternity care in MOUs in South Africa. Therefore, there is a need to strengthen interventions to adopt and implement policies that promotes respectful, nonabusive care during childbirth in MOUs.

Examining validity and reliability of objective structured clinical examination for evaluation of clinical skills of midwifery undergraduate students: a descriptive study

BACKGROUND

Clinical evaluation is one of the main pillars of medical education. The Objective Structured Clinical Examination is one of the commonly adopted practical tools to evaluate clinical and practical skills of medical students. The purpose of the study is to determine validity and reliability of Objective Structured Clinical Examination for evaluation of clinical skills of midwifery undergraduate students.

METHODS

Seven clinical skills were evaluated in this descriptive correlative study using a performance checklist. Census method was used for sampling. Thirty-two midwifery students performed the skills at seven stations each monitored by an observer using an evaluation checklist. Criterion validity was obtained through determining the correlation between the clinical and theoretical courses point and the Objective Structured Clinical Evaluation score. The collected data was analyzed in SPSS (v.20) and logistic regression test.

RESULTS

The correlation score of Objective Structured Clinical Examination was significantly related to the mean score of clinical course "Normal and Abnormal delivery I" (0.399, p = 0.024) and the mean score of clinical course "gynaecology "(0.419, p = 0.017). There was no significant correlation between OSCE scores and the mean score of theoretical courses (0.23, p = 0. 200). The correlation between the total score and mean score of students at the stations showed that out of the seven stations, the correlations of the stations three (communication and collecting medical history) and four (childbirth) were not significant.

CONCLUSION

Although, it appeared that Objective Structured Clinical Examination was one of the effective and efficient ways to evaluate clinical competencies and practical skills of students, the tool could not evaluate all the aspects.

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

Widespread reports of "disrespect and abuse" in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate "respectful" care than the current emphasis on formal rights and respect.

Improving the Clinical Skills and Knowledge of Midwives and Nurses Caring for Late Preterm Neonates

BACKGROUND

Due to changes in funding, late pre-term neonates are no longer admitted to neonatal units unless diagnosed with a specific medical condition. Consequently, neonates born at a gestational age of 35 weeks and 0 days to 36 weeks and 6 days are cared for on postnatal wards. Compared with full-term infants, late preterm neonates are at increased risk of hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulties, respiratory complications, and mortality.

METHOD

An educational intervention focusing on the care of the late preterm neonate was developed, and quantitative data were collected pre- and post-intervention to assess the effect on knowledge, skills, and attitudes.

RESULTS

Of the midwives and nurses who participated, 65% (n = 13) strongly agreed and 35% (n = 7) agreed their knowledge and confidence had increased. The mean score increased from a range of 20 to 25 pre-intervention to 22 to 25 post-intervention.

CONCLUSION

The intervention increased the self-reported confidence and self-reported competence of participants, who also felt more supported caring for late preterm neonates. [J Contin Educ Nurs. 2019;50(12):551-556.].

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study

BACKGROUND

In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres?

METHODS

Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach.

RESULTS

Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable.

CONCLUSIONS

Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives’ motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients’ needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis

BACKGROUND

In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context.

METHODS

Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care.

RESULTS

Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care.

CONCLUSION

We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.

Impact of high fidelity simulation on perceptions and professional skills in obstetrics

BACKGROUND

In our country, the introduction of simulation as a teaching tool for obstetric emergencies is very recent. Several studies are being developed to evaluate its benefit in the continuing education of health professionals.

OBJECTIVE

To evaluate the impact of a continuing medical education program based on High fidelity simulation drills (HFS) on professional skills in obstetrics.

METHODS

91 Learners were able to benefit from HFS continuing education program. Mean job tenure was 7.94 years [1-40].

RESULTS

We were able to highlight a positive impact of level 1 with satisfaction rates of more than 90%. 92% of participants said they left with tools applicable in the function framework. Midwives and emergency physicians were the most satisfied. The general evaluation before the beginning of the training had revealed an average score of 7.12/20 [2/20-13/20]. The variance of scores initially obtained was significantly related to the profession of the learner (p <0.0001, R = 0.61). We found significant improvement in post-training scores (p = 0.0001) and a mean difference of +1.46 [-6, +8.66]. These results highlight a level 2 impact of HFS training on learners' knowledge.

Management of late-term pregnancy in midwifery- and obstetrician-led care

Management of late-term pregnancy in midwifery- and obstetrician-led care.

BACKGROUND

Since there is no consensus regarding the optimal management in late-term pregnancies (≥41.0 weeks), we explored the variety of management strategies in late-term pregnancy in the Netherlands to identify the magnitude of this variety and the attitude towards late-term pregnancy.

METHODS

Two nationwide surveys amongst all midwifery practices (midwifery-led care) and all hospitals with an obstetric unit (obstetrician-led care) were performed with questions on timing, frequency and content of consultations/surveillance in late-term pregnancy and on timing of induction. Propositions about late-term pregnancy were assessed using Likert scale questions.

RESULTS

The response rate was 40% (203/511) in midwifery-led care and 92% (80/87) in obstetrician-led care. All obstetric units made regional protocols with their collaborating midwifery practices about management in late-term pregnancy. Most midwifery-led care practices (93%) refer low-risk women at least once for consultation in obstetrician-led care in late-term pregnancy. The content of consultations varies among hospitals. Membrane sweeping is performed more in midwifery-led care compared to obstetrician-led care (90% vs 31%, p < 0.001). Consultation at 41 weeks should be standard care according to 47% of midwifery-led care practices and 83% of obstetrician-led care units (p < 0.001). Induction of labour at 41.0 weeks is offered less often to women in midwifery-led care in comparison to obstetrician-led care (3% vs 21%, p < 0.001).

CONCLUSIONS

Substantial practice variation exists within and between midwifery-and obstetrician-led care in the Netherlands regarding timing, frequency and content of antenatal monitoring in late-term pregnancy and timing of labour induction. An evidence based interdisciplinary guideline will contribute to a higher level of uniformity in the management in late- term pregnancies.

Postpartum complications in women attended by midwives instead of obstetricians

OBJECTIVE

The aim of this study was to evaluate changes in the frequency of visits to the hospital emergency department due to puerperal complications in low risk postpartum women attended by midwives instead of obstetricians.

DESIGN

A quasi-experimental retrospective study with non-random allocation, comprising two groups: a control group of women attended by obstetricians and an intervention group of women attended by midwives.

SETTING

A level 2 hospital in Madrid (España).

PARTICIPANTS

Low risk postpartum women attended at the maternity unit of the Fuenlabrada University Hospital between 2013 and 2015.

METHODS

We gathered variables to record the homogeneity of the groups and to assess for confounders and interactions. In the case of women with different behaviours and/or who generated confounders or interactions, a multivariate adjustment with logistic regression was performed. The Homer & Lemeshow goodness-of-fit test for logistic regression was used to determine the validity of the model.

MEASUREMENTS AND FINDINGS

The intervention group comprised a total of 1308 women, whereas there were 1313 women in the control group. In the first 40-days postpartum, 33 women in the intervention group (2.5%) attended the hospital emergency department compared to 41 in the control group (3.1%). This difference was not statistically significant (p value 0.354). The relative risk of this decrease was 0.808 (95% CI 0.514; 1.270). The NNT was 167.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Care by midwives of low risk postpartum women did not lead to a worsening of puerperal complications requiring emergency department care. Furthermore, care by midwives was more effective than obstetrician care with lower emergency department attendance rates. Their qualification and capacity to provide health education were determinant factors.

Attention to childbirth and delivery in a university hospital: comparison of practices developed after Network Stork

OBJECTIVE

to compare, after four years of the implementation of the Stork Network, the obstetric practices developed in a university hospital according to the classification of the World Health Organization.

METHOD

cross-sectional study carried out in the year of adherence to the Stork Network (377 women) and replicated four years later (586 women). Data were obtained through medical records and a structured questionnaire. The Chi-square test was used in the analysis.

RESULTS

four years after the implementation of the Stork Network, in Category A practices (demonstrably useful practices/good practices), there was increased frequency of companions, non-pharmacological methods, skin-to-skin contact and breastfeeding stimulation, and decreased freedom of position/movement. In Category B (harmful practices), there was reduction of trichotomy and increased venoclysis. In Category C (practices with no sufficient evidence), there was increase of Kristeller's maneuver. In Category D (improperly used practices), the percentage of digital examinations above the recommended level increased, as well as of analgesics and analgesia, and there was decrease of episiotomy.

CONCLUSION

these findings indicate the maintenance of a technocratic and interventionist assistance and address the need for changes in the obstetric care model. A globally consolidated path is the incorporation of midwife nurses into childbirth for the appropriate use of technologies and the reduction of unnecessary interventions.

Updating quality indicators for low-risk labour care in Japan using current clinical practice guidelines: a modified Delphi method

OBJECTIVES

Quality indicators are measurable elements widely used to assess the quality of care. They are often developed from the results of systematic reviews or clinical practice guidelines. These sources are regularly updated in line with new clinical evidence, but there are few articles on updating quality indicators based on clinical practice guidelines. This study aimed to update the quality indicators developed for low-risk labour care in Japan in 2012, mainly drawing on new or updated clinical practice guidelines, and making the process clearly visible and assessable.

DESIGN AND SETTING

We used a modified Delphi method for the update. The procedure included four steps: (1) updating the definition of low-risk labour; (2) reviewing the literature published between June 2012 and December 2015 using five guidelines and two quality indicator databases to extract potential candidate indicators; (3) formation of a multidisciplinary panel including mothers and (4) panel ratings (two rounds between February and April 2016) on the validity of the candidate indicators, and judging the validity of the previous quality indicators drawing on the new evidence.

PARTICIPANTS

A multidisciplinary panel of 13 clinicians, including obstetricians, paediatricians and midwives, plus 3 non-clinician mothers.

RESULTS

The literature review identified 276 new recommendations from 27 clinical practice guidelines including 2 published in Japan and 21 quality indicators. We developed 13 new candidate indicators from these sources and panel recommendations, 12 of which were approved by the multidisciplinary panel. The panel also accepted all 23 existing quality indicators as still valid, resulting in a total of 35 quality indicators for low-risk labour.

CONCLUSIONS

We successfully updated the quality indicators for low-risk labour care in Japan. The procedure developed may be useful for updating other quality indicators based on new clinical practice guidelines.

Investigating pathways linking women's status and empowerment to skilled attendance at birth in Tanzania: A structural equation modeling approach

Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa where use of a skilled birth attendant (SBA) at delivery has remained low. Despite the recognized importance of women's empowerment as a key determinant of maternal and newborn health, evidence from sub-Saharan Africa is more limited. Using data from the 2010 Tanzania Demographic and Health Survey (n = 4,340), this study employs a robust method-structural equation modeling (SEM)-to investigate the complex and multidimensional pathways through which women's empowerment affects SBA use. The results show that women's education and household decision-making are positively associated with SBA use. However, not all empowerment dimensions have similar effects. Attitudes towards sex negotiation and violence as well as early marriage are not significant factors in Tanzania. Mediation analysis also confirms the indirect effect of education on SBA use only through household decision-making. The findings underscore the utility of structural equation modeling when examining complex and multidimensional constructs, such as empowerment, and demonstrate potential causal inference to better inform policy and programmatic recommendations.

Experiences of women, hospital clinicians and general practitioners with gestational diabetes mellitus postnatal follow-up: A mixed methods approach

PROBLEM

Postnatal screening rates to detect type two diabetes following gestational diabetes are low. The quality of communication is an important element to consider in developing targeted strategies that support women in completing recommended follow-up care.

AIMS

To explore the communication perspectives, practices and preferences of women, hospital clinicians and general practitioners, to determine strategies that may promote completion of recommended postnatal GDM follow-up, in Queensland Australia.

METHOD

We used an exploratory, three-phase, mixed-methods approach, interpreted through intergroup communication theory. Phase one: convergent interviews explored perspectives of the communication experience in GDM care among new mothers (n = 13), hospital clinicians (n = 13) and general practitioners (n = 16). Phase two: a retrospective chart audit assessed current practice in postnatal discharge summaries of women (n = 86). Phase three: an online survey identified the preferences of general practitioners and hospital clinicians who provide maternity care in Queensland. Triangulation of the findings from the interviews, audit and surveys was used to clarify results and increase the robustness of the findings.

RESULTS

Three themes: Seeking information, Written hospital discharge summary (discharge summary) and Clarity of follow-up requirements, provide direction for pragmatic strategies to promote follow-up. Practical recommendations include continued discussion about care with women from the point of GDM diagnosis into the postnatal period; discharge summaries that give primacy to diagnosis and ongoing treatment; and provision of explicit directions for recommended testing and timing.

IMPLICATIONS

This research informs seven practical recommendations to help promote completion of recommended postnatal GDM follow-up.

A focus group study of women's views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England

BACKGROUND

Research suggests that collaboratively delivered maternity care can positively impact health outcomes. However, women's perspectives on models of care involving interprofessional collaboration between midwives and health visitors are not well understood. Accounts of women's maternity care experiences are key to improving maternity services. This study considered women's views and experiences of maternity care as collaboratively provided by midwives and health visitors in England.

METHODS

A qualitative focus group study with an exercise exploring women's ideal maternity care pathway was conducted. Three focus groups were conducted in London, England between June and August 2017 with women who had had a child within 18 months prior to the study. The participants (n = 12) were recruited from two Children's Centres in London, England. Data were analysed using thematic analysis.

RESULTS

Four themes were identified: 'Women's experiences of maternity care from midwives and health visitors', 'Midwife-health visitor communication', 'Midwife-health visitor collaboration for tailored care', and 'Women's ideal maternity care pathway'. Regarding women's experiences of interprofessional collaboration between midwives and health visitors, this was rarely encountered, but welcomed by women. Women's observations of limited tailored care and co-ordination led to several suggestions to improve maternity care, including secure, shared medical recordkeeping systems, clarity on midwives' and health visitors' roles, as well as increased communication.

CONCLUSIONS

Maternity care that is collaboratively delivered by midwives and health visitors, from the perspectives of the women in this study, is not routinely provided. However, women recognise the potential benefits of midwife-health visitor collaboration. Future research should explore service configurations that support integrated maternity care pathways, and evaluate the impact of midwife-health visitor collaboration on health and service outcomes.

Quit-smoking counselling in Dutch midwifery practices: Barriers to the implementation of national guidelines

OBJECTIVE

Although smoking during pregnancy can have severe health consequences for the (unborn) child, 9% of Dutch pregnant women smoke at any time during their pregnancy. Midwives in the Netherlands are a responsible party in the provision of quit-smoking counselling for pregnant women by means of the 7-step `V-MIS' intervention, but in practice the implementation appears to be suboptimal. The purpose of the present study was to assess the provision of quit-smoking counselling by midwives, and to clarify the nature and extent of any existing barriers and needs in the provision of quit-smoking counselling in Dutch midwifery settings.

METHODS

An online questionnaire to the target population of Dutch midwives (N ≈ 3150) was set out in the spring of 2016. The questionnaire included items on the provision of quit-smoking counselling for pregnant women, and on possible barriers and needs regarding the provision of this counselling. Descriptive statistics were used to analyse weighed data from 135 midwives representative for the Dutch setting in terms of age, function, and region.

RESULTS

Eighty-one percent of the midwives inquire about smoking profile (V-MIS step 1) but only 10% go through all the V-MIS counselling steps (i.e. up to discussing postnatal passive smoking and smoke free breastfeeding, step 7). Although 74% of the midwives regard it as their task to provide quit-smoking guidance to pregnant women, 77% perceive referral to a professional as a useful strategy (mostly to the GP; 74%). For 61% of the midwives, their clients' lack of motivation undermines the provision of quit-smoking counselling. Other hindering factors are the perceived lack of free brochures (54%), simple tools or gadgets (51%), and financial consequences for the midwife (37%) and/or the client (22%).

CONCLUSION

The smoking cessation intervention strategy currently imposed in Dutch midwifery practices (V-MIS) is being used by midwives, however its implementation may considerably benefit from strengthening skills in motivational interviewing techniques, provision of supporting materials, and structural embedding of GP referral. Based on the study's findings, practical recommendations are made to facilitate the provision of quit-smoking counselling in (international) midwifery settings.

Quality of antenatal care services in Rwanda: assessing practices of health care providers

BACKGROUND

Although most pregnant women in Rwanda visit antenatal care (ANC) clinics, little has been studied about the quality of services being provided. We investigated the ANC providers' (HCPs) current practices in relation to prevention, management and referral of maternal conditions as well as the information provided to pregnant women attending ANC services in Rwanda.

METHODS

This facility-based, cross-sectional study included 312 ANC providers as participants and a review of 605 ANC medical records from 121 health centers. Data collection was performed using an interviewer-administered questionnaire and a structured observation checklist. For the analyses, descriptive statistics and bi-and multivariable logistic regression were used.

RESULTS

Nurses and midwives in ANC services failed to report a number of pregnancy-related conditions that would need urgent referral to a higher level of health care. Midwives did somewhat better than nurses in reporting these conditions. There was no statistically significant difference in how nurses and midwives informed pregnant women about pregnancy-related issues. Ever been trained in how to manage a pregnant woman exposed to violence was reported by 14% of the participants. In 12, 13 and 15% of the medical records there was no report on tetanus immunization, anthelmintic treatment and syphilis testing, respectively.

CONCLUSION

The providers in ANC clinics reported suboptimal practices on conditions of pregnancy that needed urgent referral for adequate management. Information to pregnant women on danger signs of pregnancy, recommended medicines and tests do not seem to be consistently provided. Midwifery training in Rwanda should be expanded so that most of staff at ANC clinics are trained as midwives to help lower maternal and child mortality and morbidity.

What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students

BACKGROUND

With professional midwives being introduced in Bangladesh in 2013, the aim of this study was to describe midwifery students perceptions on midwives' realities in Bangladesh, based on their own experiences.

METHOD

Data were collected through 14 focus group discussions that included a total of 67 third-year diploma midwifery students at public nursing institutes/colleges in different parts of Bangladesh. Data were analyzed deductively using an analytical framework identifying social, professional and economical barriers to the provision of quality care by midwifery personnel.

RESULTS

The social barriers preventing midwifery quality care falls outside the parameters of Bangladeshi cultural norms that have been shaped by beliefs associated with religion, society, and gender norms. This puts midwives in a vulnerable position due to cultural prejudice. Professional barriers include heavy workloads with a shortage of staff who were not utilized to their full capacity within the health system. The reason for this was a lack of recognition in the medical hierarchy, leaving midwives with low levels of autonomy. Economical barriers were reflected by lack of supplies and hospital beds, midwives earning only low and/or irregular salaries, a lack of opportunities for recreation, and personal insecurity related to lack of housing and transportation.

CONCLUSION

Without adequate support for midwives, to strengthen their self-confidence through education and through continuous professional and economic development, little can be achieved in terms of improving quality care of women during the period around early and late pregnancy including childbirth.The findings can be used for discussions aimed to mobilize a midwifery workforce across the continuum of care to deliver quality reproductive health care services. No matter how much adequate support is provided to midwives, to strengthen their self-confidence through education, continuous professional and economic development, addressing the social barriers is a prerequisite for provision of quality care.

Codes of Conduct - A New Era for Nursing and Midwifery in Australia

The Nursing and Midwifery Board of Australia has developed and approved the new Code of Conduct for Nurses and Code of Conduct for Midwives which applies from 1 March 2018. The primary role of the Nursing and Midwifery Board of Australia (NMBA), is to protect the public by ensuring only those who are suitably qualified and trained to practise in a competent and ethical manner are registered. One mechanism by which this objective is achieved is the registration of practitioners who are required not only to meet the mandatory registration standards but also conduct their practice in accordance with the NMBA's standards, codes and guidelines. The language of these new codes clearly articulates the mandatory obligations imposed on nurses and midwives to establish and maintain specified standards of conduct that ensure safe practice. It is therefore important for nurses and midwives not only to read the codes, but incorporate the terms contained therein meaningfully into their practice.

Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa

BACKGROUND

The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams.

METHODS

Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program.

RESULTS

Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations.

CONCLUSIONS

The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

Creating an Optimality Index - Netherlands: a validation study

BACKGROUND

At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL).

METHODS

Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity.

RESULTS

Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences.

CONCLUSION

OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda

BACKGROUND

In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce.

METHODS

The State of the World's Midwifery report 2014 used a broad definition of midwifery ("the health services and health workforce needed to support and care for women and newborns") and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework.

RESULTS

Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation.

CONCLUSIONS

The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued.

Challenges in day-to-day midwifery practice; a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania

BACKGROUND

Maternal and infant mortality rates in Tanzania have decreased over the past decades, but remain high. One of the challenges the country faces, is the lack of skilled health care workers. High fertility rates make midwives and their patients particularly susceptible to stress as a result of understaffing.

OBJECTIVE

This paper explores the challenges midwives face in their day-to-day practice at a regional referral hospital in Tanzania, and investigates which measures the midwives themselves find necessary to implement to improve their situation.

METHODS

A qualitative study design with focus group discussions (FGDs) was employed to explore which challenges the midwives experienced. Each focus group consisted of five to six midwives. A FGD topic guide covering challenges, consequences, motivation, ideal situation and possible solutions was used. These data were analyzed using Systematic Text Condensation.

RESULTS

A total of 28 Midwives, six men and 22 women, participated in five FGDs. Four categories emerged from the collected material: Feelings of demoralization, shortage of resources, societal challenges and personal struggles. A feeling of demoralization was especially prevalent and was caused by a lack of support from the leaders and little appreciation from the patients. Shortage of resources, and shortage of personnel in particular, was also highlighted as it led to an excessive workload resulting in difficulties with providing adequate care. These difficulties were intensified by lack of equipment, facilities and a non-optimal organization of the healthcare system.

CONCLUSION

The challenges revealed during the FGDs prevent the midwives from providing sufficient midwifery care. To improve the situation, measures such as supportive leadership, reduction of workload, increasing availability of equipment and increasing knowledge of reproductive health in society, should be taken.

The development of a global Midwifery Education Accreditation Programme

BACKGROUND

Many countries are responding to the global shortage of midwives by increasing the student intake to their midwifery schools. At the same time, attention must be paid to the quality of education being provided, so that quality of midwifery care can be assured. Methods of assuring quality of education include accreditation schemes, but capacity to implement such schemes is weak in many countries.

OBJECTIVE

This paper describes the process of developing and pilot testing the International Confederation of Midwives' Midwifery Education Accreditation Programme (ICM MEAP), based on global standards for midwifery education, and discusses the potential contribution it can make to building capacity and improving quality of care for mothers and their newborns.

METHODS

A review of relevant global, regional and national standards and tools informed the development of a set of assessment criteria (which was validated during an international consultation exercise) and a process for applying these criteria to midwifery schools. The process was pilot tested in two countries: Comoros and Trinidad and Tobago.

RESULTS

The assessment criteria and accreditation process were found to be appropriate in both country contexts, but both were refined after the pilot to make them more user-friendly.

CONCLUSION

The ICM MEAP has the potential to contribute to improving health outcomes for women and newborns by building institutional capacity for the provision of high-quality midwifery education and thus improved quality of midwifery care, via improved accountability for the quality of midwifery education.

The communication and emotional support needs to improve women's experience of childbirth care in health facilities in Southwest Nigeria: A qualitative study

OBJECTIVE

To improve women's childbirth experiences in health facilities, their psychosocial and communication needs have to be met. However, what constitutes these specific needs is poorly understood, particularly in Sub-Saharan Africa. This paper explores women's needs for communication and emotional support during facility-based childbirth.

METHODS

Qualitative research was conducted in a large referral maternity hospital and its catchment communities in Akure, Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted among women of reproductive age, midwives, doctors, and facility administrators. Thematic analysis was used to synthesize findings, and then interpreted within the context of this study and existing quality of care framework.

RESULTS

Forty-two IDIs and 10 FGDs are included in this analysis. Participants reported such needs as communication in simple words in local language by healthcare staff, having their husbands as birth companions, spiritual support, and prayers from family members and healthcare providers.

CONCLUSION

To increase, improve, and sustain facility-based childbirth in Nigeria, health systems should appreciate the uniqueness and importance of each woman's needs during childbirth. Practical and sustainable actions should be taken to meet these needs, within the confines of the acceptable sociocultural norms.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

OBJECTIVES

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

SEARCH METHODS

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

SELECTION CRITERIA

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

MAIN RESULTS

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

AUTHORS' CONCLUSIONS

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

How nurses and midwives feel about revalidation: preliminary survey results

The introduction in 2016 of the Nursing and Midwifery Council revalidation process, which involves several standardised steps, has represented a major change for UK nurses and midwives, and is now a compulsory requirement of reregistration. This article presents preliminary results of a survey about revalidation, undertaken in June 2016 at Oxleas NHS Foundation Trust, Dartford, focusing on how nurses and midwives feel about the process. The article considers the effect of different variables, including pay band, seniority and directorate, on nurses' and midwives' perceptions of revalidation, and suggests it is regarded more positively by senior, more experienced staff than by those who are less experienced.

Woman-centred care during pregnancy and birth in Ireland: thematic analysis of women's and clinicians' experiences

BACKGROUND

Recent policy and service provision recommends a woman-centred approach to maternity care. Midwife-led models of care are seen as one important strategy for enhancing women's choice; a core element of woman-centred care. In the Republic of Ireland, an obstetric consultant-led, midwife-managed service model currently predominates and there is limited exploration of the concept of women centred care from the perspectives of those directly involved; that is, women, midwives, general practitioners and obstetricians. This study considers women's and clinicians' views, experiences and perspectives of woman-centred maternity care in Ireland.

METHODS

A descriptive qualitative design. Participants (n = 31) were purposively sampled from two geographically distinct maternity units. Interviews were face-to-face or over the telephone, one-to-one or focus groups. A thematic analysis of the interview data was performed.

RESULTS

Five major themes representing women's and clinicians' views, experiences and perspectives of women-centred care emerged from the data. These were Protecting Normality, Education and Decision Making, Continuity, Empowerment for Women-Centred Care and Building Capacity for Women-Centred Care. Within these major themes, sub-themes emerged that reflect key elements of women-centred care. These were respect, partnership in decision making, information sharing, educational impact, continuity of service, staff continuity and availability, genuine choice, promoting women's autonomy, individualized care, staff competency and practice organization.

CONCLUSION

Women centred-care, as perceived by participants in this study, is not routinely provided in Ireland and women subscribe to the dominant culture that views safety as paramount. Women-centred care can best be facilitated through continuity of carer and in particular through midwife led models of care; however, there is potential to provide women-centred care within existing labour wards in terms of consistency of care, education of women, common approaches to care across professions and women's choice. To achieve this, however, future research is required to better understand the role of midwife-led care within existing labour ward settings. While a positive view of women-centred care was found; there is still a difference in approach and imbalance of power between the professions. More research is required to consider how these differences impact care provision and how they might be overcome.

Toward a better judgment of item relevance in progress testing

BACKGROUND

Items must be relevant to ensure item quality and test validity. Since "item relevance" has not been operationalized yet, we developed a rubric to define it. This study explores the influence of this rubric on the assessment of item relevance and on inter-rater agreement.

METHODS

Members of the item review committee (RC) and students, teachers, and alumni (STA) reassessed the relevance of 50 previously used progress test (PT) items and decided about their inclusion using a 5-criteria rubric. Data were analyzed at item level using paired samples t-tests, Intraclass Correlation Coefficients (ICC), and linear regression analysis, and at rater level in a generalizability analysis per group.

RESULTS

The proportion of items that the RC judged relevant enough to be included decreased substantially from 1.00 to 0.72 (p < 0.001). Agreement between the RC and STA was high, with an ICC of >0.7 across items. The relation between inclusion and relevance was strong (correlation = 0.89, p < 0.001), and did not differ between RC and STA. To achieve an acceptable inter-rater reliability for relevance and inclusion, 6 members must serve on the RC.

CONCLUSIONS

Use of the rubric results in a stricter evaluation of items' appropriateness for inclusion in the PT and facilitates agreement between the RC and other stakeholders. Hence, it may help increase the acceptability and validity of the PT.

Quality of Midwife-provided Intrapartum Care in Amhara Regional State, Ethiopia

BACKGROUND

Despite much progress recently, Ethiopia remains one of the largest contributors to the global burden of maternal and newborn deaths and stillbirths. Ethiopia's plan to meet the sustainable development goals for maternal and child health includes unprecedented emphasis on improving quality of care. The purpose of this study was to assess the quality of midwifery care during labor, delivery and immediate postpartum period.

METHODS

A cross-sectional study using multiple data collection methods and a 2-stage cluster sampling technique was conducted from January 25 to February 14, 2015 in government health facilities of the Amhara National Regional State of Ethiopia. Direct observation of performance was used to determine competence of midwives in providing care during labor, delivery, and the first 6 h after childbirth. Inventory of drugs, medical equipment, supplies, and infrastructure was conducted to identify availability of resources in health facilities. Structured interview was done to assess availability of resources and performance improvement opportunities. Data analysis involved calculating percentages, means and chi-square tests.

RESULTS

A total of 150 midwives and 56 health facilities were included in the study. The performance assessment showed 16.5% of midwives were incompetent, 72.4% were competent, and 11.1% were outstanding in providing routine intrapartum care. Forty five midwives were observed while managing 54 obstetric and newborn complications and 41 (91%) of them were rated competent. Inventory of resources found that the proportion of facilities with more than 75% of the items in each category was 32.6% for drugs, 73.1% for equipment, 65.4% for supplies, 47.9% for infection prevention materials, and 43.6% for records and forms. Opportunities for performance improvement were inadequate, with 31.3% reporting emergency obstetric and newborn care training, and 44.7% quarterly or more frequent supportive supervision. Health centers fared worse in provider competence, physical resources, and quality improvement practices except for supportive supervision visits and in-service training.

CONCLUSIONS

Although our findings indicate most midwives are competent in giving routine and emergency intrapartum care, the major gaps in the enabling environment and the significant proportion of midwives with unsatisfactory performance suggest that the conditions for providing quality intrapartum care are not optimal.

Effects of limited midwifery clinical education and practice standardisation of student preparedness

AIM

To explore the perceptions of midwifery educators regarding effects of limited standardisation of midwifery clinical education and practice on clinical preparedness of midwifery students.

BACKGROUND

Investigation of levels of clinical competency of students is a critical need in the current era. Such competency levels are especially important in midwifery practice in South Africa as there is a significant increase of maternal deaths and litigations in the country. Most of the deaths are in the primary healthcare level maternity units where the newly qualified midwives practise. These areas are mainly run by midwives only. The current article seeks to report the findings of the study that was conducted to investigate how midwifery educators prepare students adequately for clinical readiness.

SETTINGS

The study was conducted amongst midwifery nurse educators on three campuses of the Nursing College in the Eastern Cape.

DESIGN

A qualitative, explorative, descriptive and contextual research design was used for the study.

DATA SOURCES AND METHODS

Seventeen purposively selected midwifery educators, with the researcher using set criteria, from a Nursing college in the Eastern Cape, were the participants in the study. Data was collected using focus-group interviews that were captured by means of an audio-voice recorder. Tesch's data-analysis method was used to develop themes and sub-themes. Trustworthiness of the study was ensured using the criteria of credibility, transferability, dependability and confirmability.

RESULTS

Inconsistent clinical practice amongst midwifery educators in their clinical teaching and assessment were found to be the major factors resulting from limited standardisation. The inconsistent clinical practice and assessments of midwifery educators was found to lead to loss of the necessary skills required by the students which led them to perform poorly in their final clinical assessments.

CONCLUSION

There are some barriers in the current clinical teaching and education strategy used in this college that prohibit the production of confident, independent, and safe practitioners as planned. Midwifery educators need to be assisted in reviewing the current teaching strategy. Furthermore management should be involved if not the initiators of that reviewing and should put in-place new measures to support the teaching of the clinical module.