Autonomy and midwifery.

Autonomy is a concept central to the definition of a midwife: “the midwife is an autonomous practitioner of midwifery, accountable for the care she or he provides” (WHO 1992, P3). However, as a concept, the term ‘autonomy’ is very complex and the degree that midwives are able to demonstrate their autonomy when making decisions in the clinical setting is variable and depends on the extent of authority given to them by their place of practice as well as their own personal willingness to accept such freedom. This study looks at the nature of autonomy within the midwifery profession, the impetus for which, arose from my passion for the art and science of midwifery over the past sixteen years and my constant questioning of the real possibility of autonomous midwifery practice or more specifically of the parameters and limitations entailed with autonomy and how this impacts on midwifery care. The aims of the study were fourfold: 1. To explore and interrogate the nursing, midwifery and medical literature on aspects of autonomous practice. 2. To explore midwives views on the concept of autonomy. 3. To identify factors that might influence autonomy within practice. 4. To explore the effect of different working environments on midwives’ autonomy. Methodology Critical reviews of the literature: The literature reviews, which were confined to a maximum of seven of the more widely, read journals, covering the past twenty years, included: • The scope of midwives’ practice and how this affects autonomy • The impact of supervision on autonomy and freedom of practice • The link between accountability and autonomy within a litigious society. Case study: a qualitative naturalistic research model was used to understand the experiences of midwives and the meaning attached to the concept of autonomy within the profession. A phenomenological approach was selected for this study to guide the research process and to assist the researcher to reach the main aims of the study. Phenomenology is commonly understood in either two ways: as a disciplinary field in philosophy, or as a movement in the history of philosophy. The discipline of phenomenology may be defined initially as the study of structures of experience, or consciousness. Phenomenology was chosen because it allows the study of experiences and the meanings things have in our experiences of events, others and oneself. Qualitative research can be criticised in that it is strongly subject to researcher bias and that the research is so personal to the researcher that there is no guarantee that a different researcher would not come to radically different conclusions. It was crucial in this study to set aside any bias, everyday understandings, theories, beliefs and judgements for myself as well as the interviewees, therefore the method of “bracketing” was utilised; where the phenomenologist is required to put all assumptions aside or into “brackets” to allow the descriptions to arise from the “first-person” point of view in order to ensure that the respective item, in this case autonomy, is described exactly as it is experienced by the participants of the study. The study included twenty-five midwives within the Independent and NHS sector who were selected for interview by utilising purposive and snowball sampling techniques. Five areas of midwifery practice were chosen as each had a different model of care for the women and with regards to the flexibility and range of work for the midwives in each area. These ranged from private midwifery led community care in the woman’s own home to a birth centre and a high-risk obstetric labour ward: • Independent Sector – private midwifery led care in the woman’s own home • Stand-alone birth centre- midwifery led care within an NHS birth centre based in the community setting. • Community – NHS midwifery led care within the community of a multicultural London borough. • Integrated birth centre – midwifery led care in a birth centre that is within an acute hospital setting and attached to an acute obstetric led labour ward. • Labour ward – Acute obstetric led services within an NHS hospital. All midwives and managers working within each area were given the information leaflet informing them of the study and inviting them to take part. There was no exclusion for experience or level of seniority and male and female midwives were included. Midwifery managers were contacted for the various hospitals and working areas within which the research was undertaken. They then facilitated access to recruiting five midwives from each model of care for the research. Semi-structured interviews: All twenty-five midwives were individually interviewed using a semi-structured schedule that was designed and developed in response to the aims of the study. The aim of the interview schedule was to assist me to elicit a comprehensive account of the midwives experiences of the phenomenon and not to direct the interview process. Nine open-ended questions were included in the interview schedule. The design of the questions was done in such a way that they did not influence the formation of answers. Analysis of data: a phenomenological design by Colaizzi (1978) utilising a seven step framework for analysing qualitative data was selected to guide the process of analysing the data collected. This included reading all transcripts to acquire a feeling of the data, reviewing each transcript and extracting significant statements, spelling out the meaning of each significant statement to identify underlying themes, organising the formulated meanings into clusters, integrating the results into an exhaustive description of the phenomenon, formulating an exhaustive description of the phenomenon and asking participants about the findings as a final validating step. Confirmability: as the sole researcher for this study the data was checked by validation of the themes and sub themes by a sample of the interviewees as described earlier and the analysis and results discussed and debated by the research supervisors for this study. Credibility: credibility in this study was ensured by multiple review of the field notes and audiotapes, the neutrality of the researcher doing the interview, careful handling of the emotional expressions and returning transcriptions to interviewees for verification of facts and results. Researcher Bias: Cognisance must be given to the possibility of subjectivity on the part of the researcher who is closely involved with some of the interviewees within independent practice and with autonomous midwifery led care outside of the NHS. Throughout this study the author has borne in mind the need for objectivity in all research activities and to this end, has endeavoured to maintain an impartial stance in all interactions with participants. Ethical Aspects: Consideration was given to the use of and access to NHS premises; consent from the Director of Midwifery for each unit was obtained. Ethical approval was sought from the School of Health and Social Sciences Health Studies Ethics sub-committee at Middlesex University and application made locally to each ethical committee at the hospitals used within my study through the online application with the National Research Ethics Committee (NREC). Authorisation was also obtained from the Research and Development Officer for women’s services at each NHS Trust. An issue for the study was that of confidentiality of information collected and anonymity of respondents. To gain the confidence and co-operation of the midwives involved I approached each participant individually and explained the purpose of the research with an assurance that their identity and the information they provide would not be divulged further. Overall findings: Whilst respondents advocated autonomous practice, the findings did not always support this philosophy. Some responses reflected confusion in the interpretation of autonomy and what equates to autonomous practice. Education was a key issue, both within the profession itself, among NHS management and other relevant professional groups alongside this was the issue surrounding the culture of the working environments regarding hierarchical structure and its impact on the ability to practice with autonomy. Recommendations: The study recommends • In-house professional development programmes to address lack of knowledge regarding the concept of autonomy (to include medics and midwifery managers) • Active involvement in hospital guideline groups and service development programmes, promotion of midwifery led care. • Replication of this study in other areas of the UK to determine any significance to workload and place of practice would seem vital in directing the education of midwives in particular as to where they will eventually practice. • A comparative study of work culture including hierarchical systems to determine significance to autonomous practice

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We construct a catalog, of snowflake type metric circles, that describes all metric quasicircles up to \bl\ equivalence. This is a metric space analog of a result due to Rohde. Our construction also works for all bounded turning metric circles; these need not be doubling. As a byproduct, we show that a metric quasicircle with Assouad dimension strictly less than two is bi-Lipschitz equivalent to a planar quasicircle

Quasicircles and bounded turning circles modulo bi-Lipschitz maps

30 pages, 3 figures, to appear in Rev. Mat. IberoamericanaWe construct a catalog, of snowflake type metric circles, that describes allmetric quasicircles up to \bl\ equivalence. This is a metric space analog of aresult due to Rohde. Our construction also works for all bounded turning metriccircles; these need not be doubling. As a byproduct, we show that a metricquasicircle with Assouad dimension strictly less than two is bi-Lipschitzequivalent to a planar quasicircle.Peer reviewe