Attuning to the World of Peace of Mind and Trust: Women's Lived Experience of the Woman-Midwife Relationship in Japan.

In Japan, many pregnant women and mothers suffer from anxiety, depression, and other postnatal issues that can be exacerbated by their birth experiences. While benefiting from advanced medical care, these women's mental and psychological health may be disregarded in their maternity care. Midwives have the potential to play a significant role in improving women's birth experiences. Hence, this study aimed to explore the meaning of the woman-midwife relationship, with a specific focus on sensing peace of mind and trust to improve women's birth experiences. Using a hermeneutic phenomenological approach, 14 Japanese women were interviewed. Sensing peace of mind and trust was one of the significant meanings of the woman-midwife relationship and is articulated across five themes: (1) attuning to the world, (2) different kinds of safety and trust, (3) relying on and entrusting midwives, (4) making a mother, and (5) an emotional bridge. The positive relationship with midwives enhanced the women's mental well-being through allowing the women to attune to the peaceful mind which directed their future perspectives and sustained them in motherhood. They became confident mothers by trusting their midwives. The maternity care system in Japan needs to shift to more relationship-based care to ensure continuity of midwifery care that will improve women's birth experiences and their long-term well-being.

Real life narratives enhance learning about the 'art and science' of midwifery practice.

Health professional educators have long grappled with how to teach the more elusive art of practice alongside the science (a term that encompasses the sort of professional knowledge that can be directly passed on). A competent practitioner is one who knows when, how and for whom to apply knowledge and skills, thereby making the links between theory and practice. They combine art and science in such a way that integrates knowledge with insight. This participatory hermeneutic study explored the experience of teachers and students of implementing a narrative-centred curriculum in undergraduate midwifery education. It revealed that when real life narratives were central to the learning environment, students' learning about the art of midwifery practice was enhanced as they learned about midwifery decisions, reflected on their own values and beliefs and felt an emotional connection with the narrator. Further, art and science became melded together in the context specific wisdom of practice (phronesis).

Narrative pedagogy in midwifery education.

Narrative pedagogy is an approach to midwifery education which can promote strategies for teaching and learning which effectively prepare graduates for the complex nature of midwifery practice. Knowledge and skills are fundamental to midwifery practice, but knowing about how to use them is the art of practice. Teaching and learning midwifery skills and competencies is straight forward in comparison to teaching and learning about the art of midwifery, yet both are essential for safe practice. Narrative pedagogy may be one way that enhances undergraduate midwifery students' learning about the art of practice.

A historical narrative of the development of midwifery education in Indonesia.

AIM: To describe the history of midwifery education, present the current education programmes and explore the ways that have been undertaken to advance the midwifery profession in Indonesia. METHODS: Historical and contemporary government documents were reviewed. FINDINGS: The history of midwifery education in Indonesia shows a complex picture during and since colonisation with government, education institutes and association proposing different ways in which midwives were to be educated. Advocacy from the midwifery profession in Indonesia meant increasingly it is midwives who are determining how midwifery education is provided. Recent initiatives have resulted in a diploma, advanced diploma, bachelor's degree, and a master's degree in midwifery. The work of the midwifery profession advocating for midwifery education culminated in the Midwifery Act 2019. These changes in this Act will ensure that midwifery education meets the needs of women and their families but also lead to competent midwives who have the knowledge and skills to provide midwifery services at all levels of health provision. The history of midwifery in Indonesia illustrates the importance of the ICM pillars of association, regulation, and education. CONCLUSION: The history of midwifery education in Indonesia shows that for too long midwifery education was decided, determined and even regulated by authorities and disciplines other than midwifery. However, when the midwifery association and regulation inform and regulate midwifery education then there is an opportunity to provide care that will make a difference in outcomes for women and their families. The historical analysis of the story of Indonesia midwifery gives insight into what is required for quality education.

Midwifery care for late termination of pregnancy: Integrative review.

Midwives provide reproductive healthcare to women, including during termination of pregnancy (TOP) after 12 weeks (late TOP). Their expertise, knowledge and woman-centred care approach sees them ideally placed for this role. However, the medical, social and emotional complexities of late TOP can cause midwives significant distress. An integrative review methodology was used to examine the research on midwifery care for late TOP and identify support strategies and interventions available to midwives in this role. Five databases and reference lists were searched for relevant studies published between 2000 and 2021. A total of 2545 records were identified and 24 research studies included. Synthesis of research findings resulted in three themes: Positive aspects, negative aspects and carers need care. Midwives reported a high level of job satisfaction when caring for women during late TOP. Learning new skills and overcoming challenges were positive aspects of their work. Yet, midwives felt unprepared to deal with challenging aspects of late TOP care such as the grief and the psychological burden of the role. Caring for the baby with dignity had both positive and negative aspects. Midwives relied predominantly on close colleagues for help and debriefing as they felt poorly supported by management, judged by co-workers and lacked appropriate support to reduce the emotional effects of late TOP care. Midwives need support, although current evidence has not identified the most appropriate and effective strategy to support them in this role.

Seeking a connection: Women's lived experience of the woman-midwife relationship in mainstream maternity services in Japan.

PROBLEM: In Japan, women continue to suffer from mental health and other postpartum issues despite good clinical outcomes of maternity care. BACKGROUND: As key care providers, midwives potentially affect women's overall birth experience. Most women in Japan give birth in hospitals or obstetric clinics where different midwives and nurses provide one woman with fragmented care. Women's lived experiences of the woman-midwife in these birth facilities are not well known in Japan. AIM: To understand women's birth experience and relationship with midwives in the mainstream maternity care system in Japan to improve maternity care and women's birth experience. METHODS: Face-to-face individual interviews with 14 mothers were conducted. The data were analysed using van Manen's hermeneutic phenomenological approach, which reveals the meaning of human experience in the everyday world. FINDINGS: Four themes were derived from the hermeneutic phenomenological analysis; 1) Closed hearts and bodies in insecure relationships, 2) Alienation, 3) Hopelessness and helplessness, and 4) Women's vulnerability and desire for positive relationships. DISCUSSION: In institutionalised and fragmented maternity care settings, it is difficult for women and midwives to develop a relationship. In such a care environment, women's birth experience with midwives is negative or even traumatic; yet, women still need and seek the midwife relationship. Respectful care-necessary for women's positive birth experience-requires positive relationship between women and midwives. CONCLUSION: Women's negative birth experience may affect their mental health and parenting. Maternity and midwifery care in Japan needs to develop relationship-based care to improve women's birth experience.

Midwife led randomised controlled trials in Australia and New Zealand: A scoping review.

BACKGROUND: Midwives are the largest workforce involved in caring for pregnant women and their babies, and are well placed to translate research into practice and ensure midwifery priorities are appropriately targeted in researched. Currently, the number and focus of randomised controlled trials led by midwives in Australia and New Zealand is unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established in 2020 to build nursing and midwifery research capacity. To aid this, scoping reviews of the quality and quantity of nurse and midwife led trials were undertaken. AIM: To identify midwife led trials conducted between 2000 and 2021 in Australia and New Zealand. METHODS: This review was informed by the JBI scoping review framework. Medline, Emcare, and Scopus were searched from 2000-August 2021. ANZCTR, NHMRC, MRFF, and HRC (NZ) registries were searched from inception to July 2021. FINDINGS: Of 26,467 randomised controlled trials registered on the Australian and New Zealand Clinical Trials Registry, 50 midwife led trials, and 35 peer-reviewed publications were identified. Publications were of moderate to high quality with scores limited due to an inability to blind participants or clinicians. Blinding of assessors was included in 19 published trials. DISCUSSION: Additional support for midwives to design and conduct trials and publish findings is required. Further support is needed to translate registration of trial protocols into peer reviewed publications. CONCLUSION: These findings will inform the Australasian Nursing and Midwifery Clinical Trials Network plans to promote quality midwife led trials.

The interplay of structural and external factors for strengthening midwifery education in Indonesia.

OBJECTIVES: This study aimed to identify the barriers to and enablers of the strengthening of midwifery education in Indonesia. Indonesia has a long history of midwifery education. In 1996, midwifery education in Indonesia had a three-year direct-entry pathway leading to a higher education level to meet international standards. The quality of midwifery education is deemed essential for preparing competent midwives. METHODS: A qualitative design was undertaken in 12 midwifery schools in eight cities in six provinces involving 37 participants. Data were gathered using in-depth interviews. Data were analysed using thematic analysis. RESULTS: Several intertwined factors were found to play a vital role in midwifery education. This article focuses on results on "structural and external factors", a theme which contained three sub-themes: "the structures of midwifery programmes", "midwifery accreditation impacts on midwifery education", and "the Midwifery Act". CONCLUSION: The structure of midwifery programmes, the accreditation of midwifery programmes, and establishment of the Midwifery Act contribute to the strengthening of midwifery education in Indonesia. This study highlights the challenges faced and the scheme required to strengthen midwifery education in producing competent newly graduated midwives who improve the midwifery workforce in Indonesia.

The un-silencing of Japanese women's voices in maternity care: A hermeneutic phenomenological study of the woman-midwife relationship.

OBJECTIVE: The purpose of this article is to understand the meaning of the woman-midwife relationship, with the overall aim to improve maternity care and women's birth experiences in Japan. To better understand the meaning of the woman-midwife relationship, this article presents women's and midwives' experiences of having or not having a voice in maternity care. RESEARCH DESIGN: Hermeneutic phenomenology, as described by Max van Manen, helped to uncover the meaning of the phenomenon-the woman-midwife relationship-through participants' lived experience. Individual interviews were conducted with 14 women and 10 midwives living in Japan. The interview data were interpreted and thematically analysed to reveal the meaning of the woman-midwife relationship. FINDINGS: 'Having a voice' emerged as a central theme underpinning the meaning of the woman-midwife relationship; aspects of which included, 1) being unheard, 2) losing a voice, 3) having a voice, and 4) midwives speaking for women. Although having a voice should be a legitimate right for women in maternity care, some women's voices were unheard or lost in the experience with midwives. Conversely, some women gained a voice, especially when they positively and continuously developed their relationship with their midwife. How the woman and the midwife related to each other clearly affected their experience of having a voice in maternity care. KEY CONCLUSION: Having a voice, which portrays dimensions of choice, control, and autonomy, in their own maternity care is vital for women's positive birth experience. The woman-midwife relationship is critical in enabling women to have a voice and midwives to speak for women. Women and midwives need to develop their relationship. Moreover, the maternity care system needs to allow sufficient time and space, for instance, by ensuring midwife continuity of care to develop a positive woman-midwife relationship.

Strengthening midwifery education through clinical experience: Findings from a qualitative study in Indonesia.

BACKGROUND: One of the Indonesian Government's strategies to reduce maternal mortality rates has been to place a midwife in every village to provide midwifery care and facilitate essential primary healthcare services. To increase the numbers of midwives, the Indonesian Government began opening midwifery schools. However, Indonesia's maternal mortality rates remained high. This raises the question of the quality of midwifery education in Indonesia and how this education could be strengthened so that midwifery plays a key role in reducing maternal mortality rates. AIM OF THE RESEARCH: The aim of this study was to identify the barriers and enablers to strengthening midwifery education in Indonesia. METHODS: A qualitative descriptive approach and in-depth interviews was the method used with 37 participants from 12 midwifery schools in eight cities situated in six provinces in Indonesia. Indonesian midwives, midwifery lecturers, midwifery students, newly graduated midwives, and obstetricians were interviewed in Bahasa Indonesia. Interviews were transcribed, translated, and thematically analysed following Braun and Clark (2006). FINDINGS: This article focuses on findings on "midwifery clinical experience", a theme which contained four sub-themes: "effective hands-on clinical experience", "theory-practice gap", "role of the mentor in practice", and "the system in the clinical environment". CONCLUSION: This study highlights barriers to preparing midwifery students for obtaining adequate midwifery knowledge and skills during clinical placement. Quality clinical experience would improve knowledge and skills for better preparedness for students to competently meet their role as midwives, contributing to the strengthening of midwifery education in Indonesia.

New Zealand maternity and midwifery services and the COVID-19 response: A systematic scoping review.

PROBLEM: COVID-19 guidance from professional and health organisations created uncertainty leading to professional and personal stress impacting on midwives providing continuity of care in New Zealand (NZ). The COVID-19 pandemic resulted in massive amounts of international and national information and guidance. This guidance was often conflicting and not suited to New Zealand midwifery. AIM: To examine and map the national and international guidance and information provided to midwifery regarding COVID-19 and foreground learnt lessons for future similar crises. METHODS: A systematic scoping review informed by Arksey and O'Malley's five-stage framework. A range of sources from grey and empirical literature was identified and 257 sources included. FINDINGS: Four categories were identified and discussed: (1) guidance for provision of maternity care in the community; (2) guidance for provision of primary labour and birth care; (3) Guidance for midwifery care to women/wahine with confirmed/suspected COVID-19 infection, including screening processes and management of neonates of infected women/wahine (4) Guidance for midwives on protecting self and own families and whanau (extended family) from COVID-19 exposure. CONCLUSION: Guidance was mainly targeted and tailored for hospital-based services. This was at odds with the NZ context, where primary continuity of care underpins practice. It is evident that those providing continuity of care constantly needed to navigate an evolving situation to mitigate interruptions and restrictions to midwifery care, often without fully knowing the personal risk to themselves and their own families. A key message is the need for a single source of evidence-based guidance, regularly updated and timestamped to show where advice changes over time.

Midwives holding the space for women undergoing termination of pregnancy: A qualitative inquiry.

PROBLEM: Hospital midwives are the main care givers for women undergoing termination of pregnancy after 20 weeks. Midwives' role and potential impact of regular involvement in termination of pregnancy (TOP) are poorly understood. SETTING: New Zealand. BACKGROUND: TOP after 20 weeks may be performed to save a woman's life or preserve her physical and mental health. Throughout the process midwives play a key role in supporting women's complex psychological and clinical needs. OBJECTIVE: To gain a deeper understanding of the role of midwives in TOP care after 20 weeks, including the support they might need and the impacts caring for women who are having a TOP may have on them. METHODS: Eight midwives from two District Health Boards were interviewed about their experiences of caring for women having a TOP after 20 weeks. Transcripts were analysed by applying a hermeneutic-phenomenological lens. FINDINGS: Three themes emerged: "A different kind of midwife", "Staying true to oneself" and "Melting an Iceberg". TOP care is a different role within midwifery as midwives facilitate death in the space of birth. Immersing themselves in women's emotional space they create meaningful connections to support their complex needs and provide a positive birth experience. Yet, midwives are unprepared for the emotional effects of repeatedly caring for women undergoing TOP. Lacking appropriate support they can experience increasing, lasting grief. CONCLUSION: Midwives' experiences of providing TOP care are complex, intense and have lifelong impact. Their role in the context of TOP is highly specialised and must be valued and supported.

Midwifery Job Autonomy in New Zealand: I do it all the time.

INTRODUCTION: This research aimed to identify what supports and what hinders job autonomy for midwives in New Zealand. METHODS: Registered midwives participated in an open-ended, online survey in 2019. Anonymised participants were asked to describe an incident when they felt they were using their professional judgement and/or initiative to make decisions and the resultant actions. The data was analysed thematically. FINDINGS: The participants identified that autonomy is embedded within midwifery practice in New Zealand. Self-employed midwives who provide continuity of care as Lead Maternity Carers, identified they practice autonomously 'all the time'. The relationship with women and their family, and informed decision making, motivated the midwife to advocate for the woman - regardless of the midwife's work setting. Midwifery expertise, skills, and knowledge were intrinsic to autonomy. Collegial relationships could support or hinder the midwives' autonomy while a negative hospital work culture could hinder job autonomy. DISCUSSION: Midwives identified that autonomous practice is embedded in their day to day work. It strengthens and is strengthened by their relationships with the woman/whanau and when their body of knowledge is acknowledged by their colleagues. Job autonomy was described when midwifery decisions were challenged by health professionals in hospital settings and these challenges could be viewed as obstructing job autonomy. CONCLUSION: The high job autonomy that New Zealand midwives enjoy is supported by their expertise, the women and colleagues that understand and respect their scope of practice. When their autonomy is hindered by institutional culture and professional differences provision of woman-centred care can suffer.

When Maintaining Relationships and Social Connectivity Matter: The Case of New Zealand Midwives and COVID-19.

New Zealand's response to COVID-19 was go hard and go early into Level 4 lockdown on 25th March 2020. This rapid response has resulted in low rates of infection and deaths. For New Zealand midwives, the sudden changes to how they work with women and families during pregnancy, birth and postnatally, especially in the community, required unprecedented innovation and adaptation. The volume of information coming from many different sources, and the speed with which it was changing and updating, added further stress to the delivery of a midwifery model of care underpinned by partnership, collaboration, informed choice, safety and relational continuity. Despite the uncertainties, midwives continued their care for women and their families across all settings. In the rapidly changing landscape of the pandemic, news media provided a real time account of midwives' and families' challenges and experiences. This article provides background and discussion of these events and reports on a content analysis of media reporting the impact on the maternity system in New Zealand during the initial surge of the COVID-19 pandemic. We found that the New Zealand midwife was a major influencer and initiator for relational care to occur uninterrupted at the frontline throughout the COVID-19 lockdown, despite the personal risk. The initial 5-week lockdown in March 2020 involved stringent restrictions requiring all New Zealanders, other than essential workers such as midwives, to remain at home. Midwives kept women, their families and communities central to the conversation throughout lockdown whilst juggling their concerns about keeping themselves and their own families safe. Insights gained from the media analysis suggest that despite the significant stress and upheaval experienced by midwives and wahine/women, relational continuity facilitates quality and consistent care that honors women's choices and cultural needs even during situations of national crisis.

Identifying the priorities for midwifery education across Australia and New Zealand: A Delphi study.

PROBLEM: In countries where education programmes are assessed as meeting international standards there is limited knowledge about the challenges facing midwifery education. BACKGROUND/AIM: The positive impact of quality midwifery education on maternal and newborn health is acknowledged by the World Health Organisation. However, there is limited research identifying the issues faced in providing quality midwifery education. The aim of this study was to identify the challenges and determine priority projects to strengthen midwifery education across Australia and New Zealand. METHODS: A two-round Delphi study with experts in midwifery education was undertaken. FINDINGS: In round one, 85 participants identified an initial 366 issues for midwifery education. Through thematic content analysis these were categorised into 89 statements reflecting five major themes: In round two, 105 midwifery experts from Australia n=86 (79%) and New Zealand n=23 (21%) rated the 89 statements in order of priority. Across the combined data (Australia and New Zealand) a total of 19 statements gained consensus of ≥80%. DISCUSSION: Five priority themes were identified including; (1) enabling success of First Peoples/Maori midwifery students; (2) increasing the visibility and influence of midwifery within regulation, accreditation and university governance; (3) determining how best to deliver the clinical practicum component of programmes; (4) reviewing midwifery programmes to enhance design, content and delivery; and (5) ongoing education and support for the midwifery workforce. CONCLUSION: In Australia and New Zealand, it is imperative that collaborative work is undertaken to design and action identified projects addressing these priorities.

Acknowledging the primacy of continuity of care experiences in midwifery education.

BACKGROUND: Continuity of midwifery care is the best maternity care model for women at any risk level, and there is a global imperative to improve access to midwifery-led care. However, diverse perspectives about how best to prepare graduates for working in midwifery continuity of care models persist. The continuity of care experience standard in Australia was anticipated to address this. AIM: To challenge the dearth of published information about the structures and processes in midwifery education programs by identifying: the educational value and pedagogical intent of the continuity of care experience; issues with the implementation, completion and assessment of learning associated with continuity of care experience; and discuss curriculum models that facilitate optimal learning outcomes associated with this experience. We discuss the primacy of continuity of care experience in midwifery education programs in Australia. DISCUSSION: The inclusion of continuity of care experience in midwifery programs in Australia became mandatory in 2010 requiring 20, however this number was reduced to 10 in 2014. Research has shown the beneficial outcomes of continuity of care experience to both students and women. Continuity of care experience builds mutual support and nurturing between women and students, fosters clinical confidence, resilience, and influences career goals. We require curriculum coherence with both structural and conceptual elements focusing on continuity of care experience. IMPLICATIONS AND RECOMMENDATIONS: Education standards that preference continuity of care experience as the optimal clinical education model with measurable learning outcomes, and alignment to a whole of program philosophy and program learning outcomes is required.

Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study.

BACKGROUND: Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear. AIM: To study the significance of relationships in rural midwifery and provide insights to inform midwifery education. METHODS/DESIGN: Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data. FINDINGS: Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships. CONCLUSIONS: To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice. IMPLICATIONS: Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland.

OBJECTIVE: the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN: online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS: 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS: underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS: rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE: findings will inform the preparation of midwives for rural midwifery practice.