Predictors of Pregnant Women's Decision to Opt for Cesarean Section in Romania.

INTRODUCTION: In Romania, the latest official report indicates that more than half of the births (80,890 cases, representing 52.88% of the total) are performed by cesarean, a rate significantly higher than the World Health Organization (WHO) recommendation of 15-20%. This study aims to identify the predictors associated with women's decisions to opt for cesarean in Romania. MATERIALS AND METHODS:  An analytical cross-sectional observational study was conducted in the general population of Romania. The study was carried out over the course of 2023, with a total duration of four months. During this period, researchers targeted pregnant women from various regions of the country, regardless of their place of residence, age, or education level. The primary data collection tool was a self-administered online questionnaire, distributed via Google Forms, an accessible and efficient platform that allows for automatic response collection. The questionnaire was distributed online, particularly on social media platforms frequented by pregnant women, such as Facebook, Instagram, and TikTok. RESULTS: A total of 1,301 participants were validated. Socio-demographic and clinical factors significantly influence women's decisions to give birth by cesarean. Among these participants, 435 expressed a preference for cesarean delivery. Key predictors include fear of pain and concern for the child's health. Fear of pain at birth is the first predictor in Romanian women to choose cesarean (OR=2.09; 95% CI: 1.62-2.68). Concerns about the child's health do not increase the likelihood of opting for a cesarean. CONCLUSION:  By utilizing valuable resources such as midwives and implementing strategies like birth plans, significant contributions can be made toward reducing the cesarean rate and improving the childbirth experience for women worldwide.

How to promote midwives' recognition and professional autonomy? A document analysis study.

OBJECTIVE: To identify challenges associated with midwives' professional autonomy in Belgium and develop recommendations to promote midwives' recognition and professional autonomy. DESIGN: Through a document analysis study we identified challenges, categorized them into themes and linked them with Greenwood's sociological criteria for a profession. This involved an in-depth synthesis of findings from our published studies to comprehensively examine the challenges to optimizing midwifery autonomy and to develop corresponding recommendations. FINDINGS: We identified challenges related to midwife-led continuity care models, regulation of the midwifery profession, collaboration with stakeholders, professional esteem and professional culture. Based on them, our recommendations include prioritizing midwife-led continuity of care, fostering collaboration, tailoring continuous professional development, increasing public awareness and advocating for policy changes. The attribute of a profession which is lacking the most in midwifery in Belgium is recognized authority, which may result in midwives being undervalued, underutilized and underpaid. KEY CONCLUSIONS: In this paper we identified challenges in Belgian midwives' recognition and professional autonomy and provided recommendations to address them, emphasizing the importance of recognized authority in midwifery. Implementing these recommendations can positively impact midwives' recognition and autonomy in Belgium and potentially in other countries. IMPLICATIONS FOR PRACTICE: It is essential for policy makers to address the issue of the lack of recognized authority in midwifery, as it plays a critical role in facilitating decision-making, policy development, and the professionalization of the field. Implementing the outlined recommendations can drive positive changes in midwifery recognition and autonomy in Belgium and beyond.

Corrigendum: Maternity care in the Brussels Capital Region: Towards a paradigm shift?

[This corrects the article DOI: 10.18332/ejm/186405.].

To participate or not to participate: The troublesome question of nurses' conscientious objection to abortion: A qualitative study.

AIM: To report a study investigating the implementation of the "conscience clause" by practising nurses in two National Health Service Hospital Trusts in the UK. DESIGN: A qualitative study. METHODS: Data were collected from 2018 to 2020 through qualitative face-to-face interviews with 20 nurses, transcribed verbatim and analyzed by thematic analysis. RESULTS: Major themes were developing conscience, negotiating conscience and parameters of participation. CONCLUSION: Participants had varied views on conscientious objection, reflecting a continuum from unwillingness to be near anything related to abortion to being willing to participate in the whole process. Most participants framed involvement as fulfilling their "duty of care" to their patient. Direct experience of witnessing abortion overrode faith-based foundations to shape participants' beliefs as objectors or non-objectors. Non-objectors were supportive of objecting colleagues. IMPLICATIONS FOR THE PROFESSION: The complex nature of conscience as a fundamental human right is inherently related to the cultural and social context of nursing. "Employability" raised important questions over the real world of a nurse's legal right to invoke conscientious objection without consequences. IMPACT: Problem addressed Conscientious objection to abortion continues to affect nursing. Main findings There was little knowledge of the law and a reluctance to make formal objections. Where and on whom will the research have an impact It highlights the need for delineated and implemented guidelines on conscientious objection in practice for nurses. Its findings, while local, may be applicable to other abortion services. PATIENT AND PUBLIC CONTRIBUTION: Representatives of each were key in our advisory group. REPORTING METHOD: COREQ checklist for qualitative research.

The exploration of professional midwifery autonomy: Understanding and experiences of final-year midwifery students.

BACKGROUND: The concept of professional midwifery autonomy holds great significance in midwifery education. Notably, clinical placements play a crucial role in introducing students to its concept. However, the understanding and experiences of students regarding midwifery autonomy are relatively unknown. OBJECTIVES: This study aimed to examine the experiences and understanding of midwifery autonomy among final-year midwifery students. METHODS: A qualitative exploratory study using three focus group interviews with final-year midwifery students from each of the three Belgian regions; Flanders, Walloon and the Brussels Capital Region. Focus groups were recorded, transcribed verbatim and analysed using a thematic analysis. RESULTS: Upon data analysis, five key themes emerged; 1) working independently, 2) positive learning environment, 3) professional context, 4) actions and decisions of others and 5) beneficial for women. Students emphasized the importance of promoting professional midwifery autonomy through the ability to make their own professional decisions and take initiatives. They highlighted the need for a safe and supportive learning environment that encourages independent practice, nurtures self-governance and facilitates personal growth. Additionally, collaborative relationships with other maternity care professionals and increased awareness among women and the broader healthcare community were identified as essential factors in embracing and promoting professional midwifery autonomy. CONCLUSIONS: Our study provides valuable insights into the significance of midwifery autonomy among final-year midwifery students. To empower midwifery students to truly understand and experience professional midwifery autonomy, educators and preceptors should adopt strategies that enhance comprehension, foster independent yet collaborative practice, establish supportive learning environments, and equip students to navigate challenges effectively, ultimately improving maternal and new-born health.

How Do Midwives View Their Professional Autonomy, Now and in Future?

BACKGROUND: Internationally, midwives' professional autonomy is being challenged, resulting in their inability to practice to their full scope of practice. This situation contrasts with the increasing international calls for strengthening the midwifery profession. The aim of this study therefore is to explore Belgian midwives' views on their current and future autonomy. METHODS: An online survey among Belgian midwives was performed. Data were collected and analyzed using a quantitative approach, while quotes from respondents were used to contextualize the quantitative data. RESULTS: Three hundred and twelve midwives from different regions and professional settings in Belgium completed the questionnaire. Eighty-five percentage of respondents believe that they are mostly or completely autonomous. Brussels' midwives feel the most autonomous, while those in Wallonia feel the least. Primary care midwives feel more autonomous than hospital-based midwives. Older midwives and primary care midwives feel less recognized and respected by other professionals in maternity care. The majority of our respondents believe that in future midwives should be able to work more autonomously in constructive collaboration with other professionals. CONCLUSION: While Belgian midwives generally rated their own professional autonomy as high, a significant majority of respondents desire more autonomy in future. In addition, our respondents want to be recognized and respected by society and other health professionals in maternity care. It is recommended to prioritize efforts in enhancing midwives' autonomy, while also addressing the need for increased recognition and respect from society and other maternity care professionals.

Key Maternity Care Stakeholders' Views on Midwives' Professional Autonomy.

Advancement towards the professionalism of midwifery is closely linked to midwives' professional autonomy. Although the perspectives of Belgian midwives on their professional autonomy have been studied, the views of other maternity care stakeholders are a blind spot. The aim of this study, therefore, was to explore maternity care stakeholders' views on Belgian midwives' professional autonomy. A qualitative exploratory study was performed using focus group interviews. A heterogenous group of 27 maternity care stakeholders participated. The variation between midwives, with different levels of autonomy, was reported. The analysis of the data resulted in five themes: (1) The autonomous midwife is adequately educated and committed to continuous professional further education, (2) The autonomous midwife is competent, (3) The autonomous midwife is experienced, (4) The autonomous midwife assures safe and qualitative care, and (5) The autonomous midwife collaborates with all stakeholders in maternity care. A maternity collaborative framework, where all maternity care professionals respect each other's competences and autonomy, is crucial for providing safe and quality care. To achieve this, it is recommended to implement interprofessional education to establish strong foundations for interprofessional collaboration. Additionally, a regulatory body with supervisory powers can help ensure safe and quality care, while also supporting midwives' professional autonomy and professionalisation.

How do Slovenian women perceive midwifery competencies - Pilot study using the Slovenian version of midwifery profiling questionnaire (MidProQ).

OBJECTIVE: The role of the midwife is well defined and midwifery education is precisely prescribed in order that students gain all competencies that derive from the definition of midwifery profession. However in Slovenia, midwives do not practice the full scope midwifery, therefore the aim of the study was to explore whether women are aware of the role that midwives have. DESIGN: In order to study the lay people awareness of midwives' role and competencies, a quanitative survey was performed using the validated Midwifery Profiling Questionnaire (MidProQ), designed by a Belgium research team of midwives, adapted to Slovenian circumstances. SETTING: An online survey was performed, using the software 1KA. The link to the survey was distributed amongst groups of women via social media. PARTICIPANTS: Snow-ball sampling was used, recruiting women via gynaecology and obstetric forums. MEASUREMENTS: The MidProQ is measuring the agreement of women with statements that describe competencies of midwives for prenatal, intrapartum and postnatal period. 228 fully fulfilled questionnaire were analysed with SPSS programme. FINDINGS: Only 43% of participants felt that midwives were capable of managing an uncomplicated pregnancy independently, however they clearly state their role in uncomplicated labour (93%). Most clearly recognised role of midwives in the postnatal period was breastfeeding counselling (89%). The role of the midwife is intertwined with the competencies of the obstetrician, who majority of participants still consider more competent for managing an uncomplicated pregnancy. KEY CONCLUSIONS: Participants were not aware of all the fields where midwife could practice. IMPLICATIONS FOR PRACTICE: More has to be done that lay public will recognize the potential of full scope midwifery practice, like promoting the profession via social media.

EAES rapid guideline: systematic review, meta-analysis, GRADE assessment, and evidence-informed European recommendations on appendicitis in pregnancy.

BACKGROUND: Clinical practice recommendations for the management of acute appendicitis in pregnancy are lacking. OBJECTIVE: To develop an evidence-informed, trustworthy guideline on the management of appendicitis in pregnancy. We aimed to address the questions of conservative or surgical management, and laparoscopic or open surgery for acute appendicitis. METHODS: We performed a systematic review, meta-analysis, and evidence appraisal using the GRADE methodology. A European, multidisciplinary panel of surgeons, obstetricians/gynecologists, a midwife, and 3 patient representatives reached consensus through an evidence-to-decision framework and a Delphi process to formulate the recommendations. The project was developed in an online authoring and publication platform (MAGICapp). RESULTS: Research evidence was of very low certainty. We recommend operative treatment over conservative management in pregnant patients with complicated appendicitis or appendicolith on imaging studies (strong recommendation). We suggest operative treatment over conservative management in pregnant patients with uncomplicated appendicitis and no appendicolith on imaging studies (weak recommendation). We suggest laparoscopic appendectomy in patients with acute appendicitis until the 20th week of gestation, or when the fundus of the uterus is below the level of the umbilicus; and laparoscopic or open appendectomy in patients with acute appendicitis beyond the 20th week of gestation, or when the fundus of the uterus is above the level of the umbilicus, depending on the preference and expertise of the surgeon. CONCLUSION: Through a structured, evidence-informed approach, an interdisciplinary panel provides a strong recommendation to perform appendectomy for complicated appendicitis or appendicolith, and laparoscopic or open appendectomy beyond the 20th week, based on the surgeon's preference and expertise. GUIDELINE REGISTRATION NUMBER: IPGRP-2022CN210.

French-speaking Africa and translation: From midwifery to maïeutique?

INTRODUCTION: In the French version of The Lancet Series (2014) midwifery has been translated as maïeutique. Likewise, the term maïeuticien has recently been introduced in some countries to name (male) midwives. This change of terminology has not been the subject of broad stakeholder consultation. The aim of this study is to explore the opinion of African midwives on the use of the terminologies pratique de sage-femme/maïeutique (midwifery) and sage-femme/maïeuticien (midwife). METHODS: A quantitative study was conducted using an online survey among members of francophone professional midwifery associations in 17 French-speaking African countries. RESULTS: From 140 invited midwives, 82 responses were received. The respondents represented 12 francophone African countries. Respondents obviously prefer the terms pratique de sage-femme and sage-femme above maïeutique and maïeuticien. The sage-femme is acknowledged and deeply rooted in African society. Midwifery is comprehensive, while maïeutique does not describe the full scope of midwifery. Though, some respondents believe that maïeutique has the potential to differentiate sages-femmes from other health professionals, can diminishing role ambiguity, and value midwifery practice. Respondents in favor of the term maïeutique are referring to the modernization of the midwifery profession and its scientific evolution. CONCLUSIONS: Internationally, midwives closely follow the developments on the linguistic subject of maïeutique. The results of this study may support current discussion about the evolution and modernization of terminology in the francophone community worldwide. Midwives need to be actively involved in these discussions. Nevertheless, at all times we need to be cautious not to break away from midwives' cherished historical, social, and cultural roots.

Women's experiences with being pregnant and becoming a new mother during the COVID-19 pandemic.

OBJECTIVE: During the COVID-19 pandemic a national quarantine was imposed in Belgium, which led to changes in the maternity care provision. Despite emerging literature, it remains unclear how pregnant women and women who have recently given birth experienced this period. With this study we aim to explore these women's experiences during the COVID-19 pandemic. METHODS: This qualitative study is a part of a large longitudinal study on women's health-related quality of life (HRQoL), during the COVID-19 pandemic. An open-ended question, in an online survey, asking women about their experiences during the perinatal period was analysed using a thematic analysis. RESULTS: Of the 1007 women who participated in the HRQoL-study in June 2020, 556 (55%) women answered the open question. In general, we identified a multiplicity of mixed and interconnected feelings. Many women reported negative feelings; nevertheless, the pandemic also had some positive aspects for respondents. Six overreaching themes were identified: fear of contamination, feeling isolated and unsupported, not able to share experiences, disrupted care, feeling unprepared and experience a peaceful period. CONCLUSION: Although perinatal healthcare professionals did their utmost to provide the necessary care, being pregnant or being a new mother during this pandemic was challenging at times. However, this period was also experienced as a peaceful period with lot of opportunities to rest. Some of the changes such as telework and restricted visiting policies were experienced positively by many. Lessons learned can support perinatal healthcare professionals and policy makers in the organisation of maternity care in the post-pandemic era.

Defining midwifery autonomy in Belgium: Consensus of a modified Delphi study.

AIMS: Although there is substantial literature on autonomy of midwifery, the concept remains vague, and what it exactly constitutes is little clear. Attempts to define this have been carried out, but did not result in a communal understanding. The aim of this study therefore was to define a consistent definition of midwifery autonomy in Belgium. DESIGN: A modified Delphi survey with content experts. METHODS: Critical components of the available definitions on midwifery autonomy were retrieved from the literature, and translated into Dutch and French. An online Delphi panel of content expert assessed components of autonomy in midwifery on clarity and relevance between June and October 2021. From the validated components, a preliminary consolidated definition was generated, which was validated in a final Delphi round. RESULTS: After round one, content experts (n = 27) evaluated 10 out of 17 components to be clear and relevant. Two components were judged inappropriate and therefore removed. After further adaptation four additional components were identified appropriate after the second round, and one component after a third Delphi round. Experts' suggestions for improving the clarity and relevance were taken into account. Finally, experts assessed the preliminary definition. After minor modifications the definition of midwifery autonomy in Belgium was confirmed valid. CONCLUSION: We established a communal definition of midwifery autonomy in Belgium, the creation of such a definition results in a joint understanding of the concept of midwifery autonomy. IMPACT: If midwives internationally want to successfully achieve autonomy, a clear understanding of the concept of midwifery autonomy is needed. The consensus definition of midwifery autonomy in Belgium comprises 15 components related to midwives' work content, professionalism and relationship with others. Our definition of midwifery autonomy has the potential to encourage an international dialogue, grounded in a common understanding of autonomy, enabling stakeholders in maternity care to strengthen professional midwifery autonomy.

Midwifery students' satisfaction with perinatal simulation-based training.

BACKGROUND: Simulation-based training has proved to be an effective teaching and learning approach in healthcare. Nevertheless, any assessment of its effectiveness should also take the students' perspective into account. AIM: To validate the Satisfaction with Simulation Experience Scale (SSES) for use with midwifery students and evaluate midwifery students' satisfaction with perinatal simulation-based training. METHODS: Satisfaction with simulation was assessed using the SSES, a measurement tool translated from English to Dutch. Data was collected in four consecutive years (2016-19). A mixed methods design was used to capture both qualitative and quantitative data. Using the quantitative data, factor analysis was performed to assess the construct validity, while Cronbach's alpha was used to assess internal consistency. Qualitative data was assessed using thematic content analysis. FINDINGS: 367 SSES questionnaires were completed by 251 students. The exploratory factor analysis resulted in a three-factor model covering debriefing and reflection, clinical reasoning and clinical learning. Cronbach's alpha showed good internal consistency. Students were very satisfied with perinatal simulation-based training for all three factors: 4.30 (SD=0.47) for debriefing and reflection, 3.97 (SD=0.55) for clinical reasoning and 4.10 (SD=0.46) for clinical learning. Satisfaction scores remained high and stable over the years investigated. Thematic content analysis identified 6 categories: simulation-based training is valuable, the need for more simulation-based training, fidelity, students, negative feelings, and preparation is vital. CONCLUSION: Students were satisfied with the simulation-based training, experiencing it as providing added value to their education. Simulations gave them the opportunity to make and learn from mistakes in a safe learning environment.

The state of professionalisation of midwifery in Belgium: A discussion paper.

AIM: To describe the state of the professionalisation of midwifery in Belgium, and to formulate recommendations for advancing the midwifery profession. METHODS: A descriptive overview of maternity care in Belgium and the professionalisation of midwifery through an analysis of relevant policy and academic texts, underpinned by Greenwood's sociological criteria for a profession: (1) own body of knowledge, (2) recognised authority, (3) broader community sanctions, (4) own code of ethics and (5) professional culture sustained by formal professional associations. From these insights, recommendations for advancing the midwifery profession in Belgium are formulated. FINDINGS: Current strengths of the professionalisation of midwifery in Belgium included unified midwifery education programmes, progress in midwifery research and overarching national documents for guiding midwifery education, practice and regulation. In contrast however challenges, such as the limited recognition of midwives' roles by its clientele, limitations of midwives' competencies and autonomy, lacking development of advanced roles in maternity care practice and a lack of unity of the organisation and its members, were also identified. Based on these, recommendations are made to strengthen Belgian midwifery. CONCLUSIONS: Recommendations for advancing the midwifery profession in Belgium includes in particular increasing public awareness of midwives' roles and competencies, implementing the full scope of midwifery practice and monitoring and advancing this practice. Thus, professional autonomy over both midwifery practice and working conditions should be enhanced. United midwifery organisations, together with women's groups, other maternity care professionals and policy-makers as equal partners are key to bring about changes in the Belgian maternity care landscape.

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators.

OBJECTIVE: Development and validation of a set of quality indicators for vulnerable women during the perinatal period. DESIGN: A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals. SETTING: The Flemish Region and the Brussels Capital Region in Belgium. PARTICIPANTS: Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals. FINDINGS: The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.