What is a good midwife? Insights from the literature

OBJECTIVE: to review the literature around what is considered to be a good midwife and in particular what women value in a midwife, in order to identify the gaps in the evidence for future research. DESIGN: this paper reviews the research in the area of interest over the past 30 years. The literature search focused on the concept of good midwife using synonyms and antonyms. The inclusion criteria included language (English or Italian). The examined databases were Medline, Maternity and Infant Care, Applied Social Sciences Index and Abstract and CINAHL. SETTING: studies conducted in high-income countries were taken into account. A focused review of papers which explicitly investigated what a good midwife means and a thematic analysis on what women value in a midwife were carried out. PARTICIPANTS: different standpoints have been considered (midwives, student midwives, women and their partners), focusing in particular on women viewpoint. FINDINGS: the literature review reveals information about what is considered to be a good midwife from a range of perspectives and what women value in a midwife. A good midwife should possess several attributes: theoretical knowledge, professional competencies, personal qualities, communication skills and moral/ethical values. According to the thematic analysis around what childbearing women value in a midwife, frequent key-themes emerging from the literature were: support, possibility of choice, feeling in control and having appropriate information. KEY CONCLUSIONS: the meaning of good midwife might change according to different actors involved in midwifery care and there is no agreement on the definition of what constitutes a good midwife. Furthermore, it is not clear if what women value in a good midwife corresponds to the midwives' perception of themselves as good professionals. There is a dearth of information around women's expectations and experiences specifically of a good midwife, and even less around whether this changes according to where they give birth. IMPLICATIONS FOR PRACTICE: this literature review seeks to stimulate debate and reflection among midwives and professionals involved in the childbearing event, in order to fulfil women's expectations of their midwife and increase their satisfaction with the birth experience. The identification of the gaps in the evidence provided the starting point and allowed the development of research questions and methodology for an ongoing doctoral research. On the basis of the gaps in the evidence, the doctoral research will explore and seek to explain nulliparous women's expectations and experiences of a good midwife in the context of different planned place of birth, using a Grounded Theory methodology. It is also expected that the findings of this literature review will stimulate additional research in this area to ultimately inform midwifery practice and midwifery educational programmes

Midwives’ approaches to early pushing urge in labour

The objectives of this mixed-methods study were: a) to investigate midwives' approaches to early pushing urge (EPU); and b) to explore midwives' perspectives and experiences of helping women cope with EPU. A quantitative observational methodology was adopted to investigate midwives' approaches to EPU in 60 cases. A qualitative phenomenological approach was carried out in order to gain more in-depth understanding of midwives' views and experiences of EPU management strategies. It was found that midwives mainly adopt two approaches in the case of EPU: letting the woman do what she feels, and a stop-pushing technique. The findings are presented as four main domains: a) midwives' approaches to EPU; b) drivers guiding midwives' approaches to EPU; c) influencing factors in helping women cope with EPU; d) variation of midwives' approaches to EPU over time

Childbearing women’s experiences of early pushing urge

AIM: To explore childbearing women’s experiences of early pushing urge (EPU). STUDY DESIGN: A qualitative phenomenological study was undertaken in an Italian maternity hospital. The sample included 8 women that experienced EPU during labor. Data were collected through semi-structured interviews. FINDINGS: The findings are presented as three main themes: (a) women’s perceptions of EPU, (b) bodily sensations versus midwives’ advice: struggling between conflicting messages, and (c) the “a posteriori” feeling of women about midwives’ guidance during EPU. The perception of EPU was characterized by sense of obstruction, bone pain, and different intensity of pushing efforts when compared with those of the expulsive phase. Women found it difficult to follow the midwife’s suggestion to stop pushing because this contradicted their bodily sensations. However, the women recognized a posteriori the importance of the midwife’s support while experiencing EPU. Women appreciated the midwives’ presence and emotional support most of all because they seemed to be more concerned with the personal relationship they formed in labor rather than the usefulness or appropriateness of their advice. CONCLUSION: Midwives should consider women’s physical perceptions to help them cope with EPU, acknowledging that women may struggle when caregivers’ suggestions are in contrast to their physical perceptions. The women’s overall positive experiences of birth suggest that EPU might be considered as a physiological event during labor, reinforcing the hypotheses of previous research. The optimal response to the EPU phenomenon remains unclear and should be studied, considering EPU at different dilatation ranges and related clinical outcomes

Respectful handover: a good alternative when intrapartum continuity of carer cannot be guaranteed

AIM: To explore first-time mothers’ expectations and experiences of being cared for by an unknown midwife and their perceptions around continuity of carer during childbirth. DESIGN: Qualitative Straussian grounded theory methodology. SETTING: Three National Health Service Trusts in England providing maternity care that offered women the possibility of giving birth in different settings (home, freestanding midwifery unit and obstetric unit). PARTICIPANTS: Fourteen first-time mothers in good general health with a straightforward singleton pregnancy anticipating a normal birth. METHODS: Ethical approval was obtained. Data were collected through two semi-structured interviews for each participant (before and after birth). The coding process included the constant comparison between data, literature and analytical memos. FINDINGS: Childbearing women’s expectations during pregnancy and experiences during labour are reported in regard to three main themes: a) encountering an unknown midwife during labour; b) familiarity and immediate connection: ‘I felt like I’ve known her for years’; c) change of shift and respectful handover. CONCLUSION: Respectful and efficient handovers between midwives are crucial in guaranteeing a high level of care when continuity of carer cannot be guaranteed. Midwives should, therefore, pay attention to how the handover is done, how information is conveyed to colleagues taking over care and how this is communicated to the labouring woman and her companions present in the room. A handover should actively involve the mother and the birth partner(s) and be essentially respectful of their needs

Adding to the midwifery curriculum through internationalisation and promotion of global mobility

Despite the obvious need for student midwives to be exposed to meaningful learning experiences that consider engagement in the wider context of international health care and the associated benefits, there is a lack of information on how this is achieved within midwifery curricula both nationally and internationally. At the University of Nottingham, work has been undertaken to ensure the midwifery curriculum is internationalised and global mobility is promoted to all midwifery students. Processes and strategies have been put in place to encourage students' mobility including the Erasmus+ programme, elective placements and short-term ad hoc international opportunities. Thanks to the strategies that have been implemented, the Division of Midwifery has seen an increase in students undertaking an international placement from 5% in 2013/14 to 18% in 2015/16. Moving forward, future works will aim to develop ‘virtual mobility’ projects and evaluate the Erasmus+ programme in conjunction with European partners

What is a good midwife? Some historical considerations

AIM: This review takes into account some of the historical considerations around characteristics of a good midwife throughout the centuries in relation to historical and professional factors, tracing changing concepts from the definition of Soranus of Ephesus during the second century AD until the present day. METHOD: A structured literature search was undertaken to obtain information about the concept of the good midwife. Sources searched included historical textbooks, databases (Medline, ASSIA, Maternity and Infant Care, CINAHL) and reference lists. Data from a variety of European countries were considered and a range of primary and secondary sources in English language have been included. With regards to the contemporary literature, a selection of papers was reviewed in order to focus on the specific definition of what a good midwife is. This paper focuses on the historical aspects. FINDINGS: The contemporary concept of a good midwife seems to be mainly related to the combination of the following areas complementing each other: theoretical knowledge; clinical and professional competencies; communication skills; personal qualities; moral and ethical attitude. A connection between the past and present is apparent regarding what constitutes a good midwife with a focus on the competencies and qualities required of a midwife. The idea of good midwife in the past sometimes appears to place greater emphasis on physical characteristics and moral appraisal over theoretical knowledge, professional skills and practical experience. The idea of a ‘good midwife’ inevitably evolved in parallel within the social, cultural, economic, political and historical contexts. LIMITATIONS: This is not a systematic review and is subject to personal bias from interpretation. CONCLUSIONS AND IMPLICATIONS: There is no consensus on what factors are key to determining the qualities of a good midwife and there is continuous tension between the way in which the values associated with personal qualities, academic achievement and professional competencies are weighted. Professionals are encouraged to reflect on future challenges in providing good quality midwifery practice while working towards a more tangible identification of the fundamental characteristics of a good midwife

The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers' perspectives of a good midwife: a grounded theory study

BACKGROUND The literature review reveals information about what makes a good midwife from several perspectives. However, there is a dearth of knowledge around women’s perceptions of a good midwife in different birthplaces. AIM. The aim of the study was to explore and explain first-time mothers’ expectations and experiences of a good midwife during childbirth in the context of different places of birth. METHODS A qualitative grounded theory methodology was undertaken. Fourteen first-time mothers planning to birth in different settings in England (Home, Freestanding Midwifery Unit, Obstetric Unit) were recruited. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos. Ethical approval was gained. Informed consent was obtained from participants and women were free to decline participation or to withdraw at any time. Confidentiality was guaranteed. FINDINGS The model named ‘The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers’ perspectives of a good midwife’ was developed. The model is dynamic and woman-centred, operationalised as the midwife’s characteristics that should adapt to each woman’s individual needs in the context of each specific labour, irrespective of the birth setting. Four pillars of care are encompassed in the care provided by a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. As a kaleidoscopic figure, a good midwife should be multi-coloured and ever changing in the light of the woman’s individual needs, expectations and labour journey (e.g. stage of labour and events occurring during childbirth), in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence. CONCLUSION The model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is more likely to have an optimum experience of birth

Disorientation, self-awareness and ongoing learning: student midwives’ experiences of clinical placements in Italy

Objective: To explore student midwives’ perspectives, experiences and concerns regarding clinical placements in the Italian setting. Design: A qualitative phenomenological study was undertaken, with data collected through semi-structured interviews and diaries. Ethical approval was obtained. Data analysis was conducted using a thematic analysis approach. Setting: One university in Northern Italy including a midwifery undergraduate programme. Participants: Purposeful sample of 19 third-year student midwives. Findings: Four themes emerged from the data: a) becoming a midwife: disorientation, self-awareness and ongoing learning; b) mentor as key figure; c) practice and theory: a ‘chicken and egg’ situation; d) clinical placements: a window on the uniqueness of the midwifery profession. Student midwives reported a journey through different learning phases within clinical placements, from feeling disoriented while facing initial challenges in the first year of the course to having increasing awareness of their role in the second and third year of the programme. The phase of disorientation was mainly due to not being aware of the theoretical evidence behind practice, not feeling part of the team, not knowing what their role was and lack of appropriate supervision from mentors. A positive relationship with the mentor encouraged students to share perspectives and doubts, stimulating a problem solving approach. The students found it helpful when the mentor involved them in the decision making and praised them when they deserved it. A good rapport with the midwife was reported by the participants as inspiring self-confidence and cognitive enquiries; it also allowed the students to feel part of the multidisciplinary team. An overall sense of ongoing learning was still present at the end of the midwifery programme. Key conclusions and implications for practice: Continuity of mentorship and mentors’ commitment to supporting students emerged as key aspects for a positive and fruitful learning experience within practice settings. Other pivotal elements to be considered by mentors are making the students feel welcome and part of the team; orienting them on the first day of placement; allowing some time for familiarisation with the placement area and clinical policies; involving the students in the decision-making process and care planning/implementation/ evaluation. Appropriate national mandatory training should be put in place for mentors to allow a more effective learning experience in practice settings for student midwives

Early labour midwifery care in Italy: local and cross-cultural challenges

INTRODUCTION. The definition of early labour and its management are debatable issues at a local, national and international level. In Italy, this issue is also of concern. APPROACH. This is a descriptive discussion paper designed to portray the cross-cultural issues and the comparisons between Italian and international early labour care. KEY ISSUES. Many of the issues regarding early labour care in Italy resonate with what emerged from the international literature. These include the dilemmas of diagnosis and management of early labour, appropriate timing for women’s admission to hospitals in the latent phase and the type of maternity service available to women in early labour. The lack of a mapping of the geographically variable services offered to women in the Italian peninsula makes the task of offering national data to international research on early labour care challenging as little is known about the availability, efficiency and effectiveness of triage systems for women in the latent phase of labour. THE WAY FORWARD. The organisation of maternity services within the Italian national health system requires a review to consider how best to meet women’s needs during early labour. Research in this field needs to be carried out in Italian birthing settings in order to be able to understand what would work best for women within the specific socio-cultural context and what is required to enhance midwifery knowledge and skill

First-time mothers’ expectations of the unknown territory of childbirth: uncertainties, coping strategies and ‘going with the flow’

Objective. To explore first-time mothers’ expectations of labour and birth, coping strategies they adopt during pregnancy towards childbirth and coping strategies they expect to use during labour and birth.Design. A qualitative Straussian grounded theory methodology was adopted, with data collected through semi-structured interviews in the third trimester of pregnancy. Ethical approval was gained. Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos. Setting. Three National Health Service (NHS) Trusts in England offering the choice of various birth settings including home, Freestanding Midwifery Unit (FMU) and Obstetric Unit (OU).Participants. Fourteen first-time pregnant women in good general health with a straightforward pregnancy (single fetus) and anticipating a normal birth.Findings. Three themes were identified in regard to women’s expectations of childbirth and coping strategies: a) the unknown territory of labour and birth; b) waiting for the unknown: coping strategies; c) going with the flow. First-time mothers acknowledged labour and birth was an unknown territory, irrespective of the planned place of birth. While waiting for the unknown, the women put in place a number of coping strategies during pregnancy: preparing; avoiding; thinking about childbirth as a shared experience among women; relying on maternal instinct; relying on pharmacological pain relief; considering birth partner(s) as voice of reason. Overall, women were flexible in regard to their birth plan and open to change if needed, referring to this open-minded state as ‘going with the flow’.Key conclusions and implications for practice. Women and their families may appreciate receiving accurate and realistic information from caregivers starting in pregnancy and continuing during labour and birth to alleviate the state of uncertainty typical of the childbearing event. The midwife should address the woman’s uncertainties and help her ‘go with the flow’ in the labour continuum. The birth plan should also be revised by the midwife and woman together if they can no longer adhere to the original one