TransfOrming Transnational intErcultural sensitivity for Midwifery students through an inclusive mobility model: A mixed-method evaluation of the TOTEMM project.

BACKGROUND: Contemporary midwifery curricula require that student midwives have insight and understanding of global health practice and intercultural sensitivity. The current mobility model excludes large numbers of students from engaging in transnational learning. OBJECTIVES: 1) to evaluate midwifery students' experiences of blended mobility; 2) to investigate if the combination of virtual and physical mobility activities supported development of intercultural sensitivity and soft skills. DESIGN: Multi-centre mixed-methods study. SETTINGS: Four European Higher Education Institutions located in England, Italy, Estonia and The Netherlands. PARTICIPANTS: Sixty-four midwifery students studying in one of the four partner institutions selected as study sites and who participated in the TOTEMM blended mobility scheme took part in the evaluation. METHODS: Data were collected through two online surveys, face-to-face focus groups and learning analytics. Descriptive summary statistical analysis of survey data was undertaken. Focus group discussions were subjected to thematic analysis. Findings from the quantitative survey and qualitative focus groups were merged using a convergent mixed methods approach. Learning Analytics were interpreted as complementary to the above components, to further triangulate the findings. RESULTS: Both virtual and physical components were evaluated positively by students, with high engagement confirmed by learning analytics. A statistically significant increase in the mean of the Total Intercultural Sensitivity Scale score was seen between the pre- and post-mobility surveys, indicating participation in the TOTEMM mobility model was associated with enhanced intercultural sensitivity. Positive effects on confidence, open-mindedness, empathy, interaction and non-judgment were shared by participants. CONCLUSIONS: TOTEMM is an innovative inclusive approach to enable a diverse student group to benefit from transnational learning, including the development of intercultural sensitivity. The TOTEMM blended mobility model has potential for integration into future midwifery curricula and programmes in the four partner settings involved in TOTEMM and utility for the wider European context.

Midwives' stress and burnout during the Omicron wave in Italy: An observational survey.

AIM: To evaluate midwives' level of stress and burnout during the COVID-19 Omicron phase in Italy. Secondary aims were to explore the impact of the pandemic on midwives' personal dimensions and professional activities and potential supporting strategies. DESIGN: A mixed-methods study was undertaken from July to December 2022. METHODS: Data were collected using a national online observational survey. Descriptive and inferential analyses were performed to evaluate stress, burnout and the impact of the pandemic on personal and professional dimensions. A deductive qualitative approach was used to analyse open-ended responses, that were merged with quantitative data following a convergent mixed-methods approach. RESULTS: A total of 1944 midwives participated in the survey. The stress summary score mean was 10.34, and 562 midwives (28.91%) experienced burnout. The intention to reduce working hours was reported by 202 midwives (10.39%), with 60.40% (n = 122) of them experiencing burnout. The intention to leave clinical practice within the following 2 years was reported by 239 (12.29%), with 68.20% (n = 163) of them experiencing burnout. All the personal dimensions and professional activities considered were defined by more than half of midwives as being impacted 'Moderately' or 'To a great extent' by pandemic. Stress and burnout frequencies increased when the midwives' perception of the pandemic effects was higher. Potential supporting strategies described by midwives as the most important in increasing their ability to cope with the pandemic were 'Women's awareness of the midwives' role' (n = 1072; 55.14%) and 'Family and friends' emotional support' (n = 746; 38.38%). CONCLUSION: Our findings suggested strategies to support a positive and safe working environment for midwives during a pandemic emergency, with potential transferability to similar contexts when human resources are lacking. It is recommended that maternity services provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. IMPACT: Studies conducted during the first COVID-19 pandemic wave showed an increased level of stress, anxiety, burnout, post-traumatic stress disorder and depression experienced by healthcare professionals; moreover, midwives experienced drastic changes in care pathways and policies with struggles identified when providing high-quality woman-centred care following pandemic restrictions. Although it is recommended, there is lack of knowledge about long-term psychological effects of COVID-19 for midwives. Our study highlights that during the Omicron wave midwives experienced a high level of stress and burnout with an impact on individual dimensions and professional activities. Their stress and burnout were influenced by several factors, including restrictions in place, lack of organizational acknowledgement, work overload and need for extra childcare cover. Maternity services should provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. Recommendations on how to facilitate this are suggested. REPORTING METHOD: During the writing process, we referred to 'The Strengthening the Reporting of Observational Studies Epidemiology Statement', the guidelines for reporting observational studies from the Equator network. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Work overload conditions negatively impacted on the quality of maternity services. Improving organizational aspects, reducing working hours, promoting family and friends' emotional support and improving women's awareness of midwife's role were the main strategies reported by midwives. These suggestions for ensuring a positive and safe working environment for midwives during a pandemic emergency could potentially be applied to similar situations where human resources are lacking.

How should a video-call service for early labour be provided? A qualitative study of midwives' perspectives in the United Kingdom and Italy.

PROBLEM: Women in early labour are typically encouraged to delay admission to the maternity unit, but they may find this challenging without appropriate professional support. BACKGROUND: Prior to the pandemic, research conducted with midwives and women showed positivity towards using video-technology for early labour, with concerns raised about privacy. AIM: To explore midwives' perspectives on potential use of video-calls during early labour METHODS: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained prior to commencing the study and ethical processes were followed. Seven virtual focus groups were conducted with 36 participants, 17 midwives working in the UK and 19 midwives working in Italy. Line-by-line thematic analysis was performed and themes agreed by the research team. FINDINGS: The findings include three main themes: 1) who, where, when and how: key aspects to consider for an effective video-call service in early labour; 2) video-call content and expected contribution; 3) potential barriers to address. DISCUSSION: Midwives responded positively to the concept of video-calling in early labour and provided detailed suggestions on how an ideal video-call service for early labour should be provided to maximise effectiveness, safety and quality of care. CONCLUSION: Guidance, support and training should be provided to midwives and healthcare professionals, with dedicated resources for an early labour video-call service that is accessible, acceptable, safe, individualised and respectful for mothers and families. Further research should systematically explore clinical, psychosocial and service feasibility and acceptability.

Mothers' perspectives on the potential use of video-calling during early labour in the United Kingdom and Italy: A qualitative study.

PROBLEM: Women in early labour are typically encouraged to delay maternity unit admission, but they may find this challenging without appropriate professional support. BACKGROUND: Despite pre-pandemic research which identified potential advantages of video-calling in early labour, implementation of such service has not been reported. AIM: To explore mothers' perspectives on potential use of video-calls during early labour. METHODS: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained and ethical processes were followed. Six virtual focus groups were conducted with 37 participants, 24 mothers who gave birth in the UK and 13 who gave birth in Italy. Line-by-line thematic analysis was performed and themes agreed. FINDINGS: Two themes emerged: 1) women's expectations of video-calls' content and features; 2) technological challenges and solutions. Mothers responded positively to the concept of video-calling in early labour. Receiving guidance, information on coping with pain and advice on timely access in early labour was perceived as key. Women highlighted the importance of accessible, reliable and user-friendly technology. Equitable access, technological literacy, acceptability and privacy were considered as challenges to implementation, with solutions proposed to overcome disparities. DISCUSSION AND CONCLUSION: Guidance and training should be provided to midwives, with designated resources to build a service that is accessible, acceptable, safe, individualised and respectful for mothers and birth companions. Further research should explore feasibility, acceptability, clinical and cost-effectiveness.

Midwives' experiences of providing maternity care to women and families during the COVID-19 pandemic in Northern Italy.

PROBLEM: The COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values. BACKGROUND: Healthcare professionals' stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic. AIM: To explore midwives' experiences of providing care to women and families during the COVID-19 pandemic. METHODS: Qualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained. FINDINGS: Four themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness. DISCUSSION: Midwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork. CONCLUSION: In the context of a pandemic, optimisation of midwives' physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event.

Care and support during maternity for mothers affected by modern slavery: A scoping review.

Background: Modern slavery is a largely hidden crime disproportionately affecting women and girls, with 71% of the world's enslaved people being female and approximately one third estimated to be pregnant. Healthcare professionals experience difficulties in caring for mothers affected by modern slavery, including asking appropriate questions and initiating discussions, making safe referrals, being uncertain about entitlements, and facing obstacles in accessing language support and specialist mental health services. Despite the expectation of cohesive and consistent services, which avoid the recounting of experiences that may re-traumatise, interdisciplinary collaborations between maternity services and non-statutory agencies remain unclear. Objective: To map the available evidence and resources on maternity care provision and non-statutory support to pregnant women and mothers affected by modern slavery. Design: A scoping review was conducted following the JBI methodology for scoping reviews. Methods: Five databases (Applied Social Sciences Index & Abstracts, Cumulated Index to Nursing and Allied Health Literature, Dissertations & Thesis A&I, Embase, Scopus) were searched. Inclusion criteria: English language; published between 2012 and May 2022; related to both maternity care provision and modern slavery; cross-sectional perspectives, including survivor mothers, healthcare professionals, midwives, and non-statutory service staff; any methodology. Exclusion criteria: general healthcare or not maternity related; opinion pieces, letters, book reviews, commentaries. Grey literature was searched using relevant websites reporting theses, blogs, policies, guidelines, and resources. Results: Twelve articles reporting 11 studies and 29 grey literature reports were retained for the scoping review. Three key themes were identified from research studies: a) women's perspectives on barriers to access and engagement with maternity services; b) challenges and needs identified by healthcare professionals; and c) the impact of human trafficking on maternal and neonatal outcomes. The grey literature resources comprised mainly blogs, information sheets, leaflets or webpages, and research or consultation reports. Maternity was being experienced by survivor mothers with the following: unfamiliarity with and lack of access to systems and information across all sectors, barriers to care and entitlements, contemporary threats of violence from partners/traffickers, restricted ability to move freely, issues related to traumatisation, dispersal policies, and dealing with multiple new systems. Conclusions: Although several sources indicate principles that should be adopted, the detail of how optimal care and support during maternity should be provided by healthcare professionals and non-statutory service staff is lacking. Further research is required, from which recommendations for good maternity practice and the effective intersection between statutory and non-statutory services can be derived and subsequently mobilised across different systems and settings.

Assessment of the psychometric properties of the Italian version of the perceptions of empowerment in midwifery practice scale-revised (PEMS-R-IT) in midwives.

INTRODUCTION: A higher degree of midwives' empowerment is associated with greater job satisfaction and better midwifery care outcomes for women and their families. Empowered midwives are able to better empower women who in turn have a positive influence on the midwives' empowerment. The aim of this study was the translation, cultural adaptation, and validation of the perceptions of empowerment in midwifery scale-revised (PEMS-R) in a group of Italian midwives. METHODS: The World Health Organization (WHO) method was adopted to achieve the PEMS-R Italian version. This process involved five steps: 1) forward translation, 2) expert panel translation, 3) back-translation, 4) pre-testing and cognitive interviewing, and 5) final version. The test's internal consistency and validity were assessed by following international guidelines. Internal consistency was examined through Cronbach's alpha (α) coefficient. RESULTS: The PEMS-R-IT was administered to 147 Italian midwives from northern Italy. Factor analysis of the 19 items, extracted 4 factors that explained 74.96% of the variance. The Student's t-test for independent samples was used to identify a possible correlation between a higher/lower perception of empowerment and: 1) the education level, and 2) the years of experience of recruited midwives. No statistically significant differences were obtained in either case. The PEMS-R-IT was found to have a good internal consistency for each of its 4 subscales. CONCLUSIONS: The PEMS-R-IT is a valid and reliable tool, useful to assess midwives' empowerment. It can be used in both clinical practice and research in order to investigate the level of empowerment of midwives within the Italian national context.

The experiences of childbearing women who tested positive to COVID-19 during the pandemic in northern Italy.

PROBLEM: The COVID-19 pandemic has significantly challenged maternity provision internationally. COVID-19 positive women are one of the childbearing groups most impacted by the pandemic due to drastic changes to maternity care pathways put in place. BACKGROUND: Some quantitative research was conducted on clinical characteristics of pregnant women with COVID-19 and pregnant women's concerns and birth expectations during the COVID-19 pandemic, but no qualitative findings on childbearing women's experiences during the pandemic were published prior to our study. AIM: To explore childbearing experiences of COVID-19 positive mothers who gave birth in the months of March and April 2020 in a Northern Italy maternity hospital. METHODS: A qualitative interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 22 women. Thematic analysis was completed using NVivo software. Ethical approval was obtained from the research site's Ethics Committee prior to commencing the study. FINDINGS: The findings include four main themes: 1) coping with unmet expectations; 2) reacting and adapting to the 'new ordinary'; 3) 'pandemic relationships'; 4) sharing a traumatic experience with long-lasting emotional impact. DISCUSSION: The most traumatic elements of women's experiences were the sudden family separation, self-isolation, transfer to a referral centre, the partner not allowed to be present at birth and limited physical contact with the newborn. CONCLUSION: Key elements of good practice including provision of compassionate care, presence of birth companions and transfer to referral centers only for the most severe COVID-19 cases should be considered when drafting maternity care pathways guidelines in view of future pandemic waves.

Lived experiences of the partners of COVID-19 positive childbearing women: A qualitative study.

PROBLEM: Several maternity units worldwide have rapidly put in place changes to maternity care pathways and restrictive preventive measures in the attempt to limit the spread of COVID-19, resulting in birth companions often not being allowed to be present at birth and throughout hospital admission. BACKGROUND: The WHO strongly recommends that the emotional, practical, advocacy and health benefits of having a chosen birth companion are respected and accommodated, including women with suspected, likely or confirmed COVID-19. AIM: To explore the lived experiences of the partners of COVID-19 positive childbearing women who gave birth during the first pandemic wave (March and April 2020) in a Northern Italy maternity hospital. METHODS: A qualitative study using an interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 14 partners. Thematic data analysis was conducted using NVivo software. Ethical approval was obtained from the relevant Ethics Committee prior to commencing the study. FINDINGS: The findings include five main themes: (1) emotional impact of the pandemic; (2) partner and parent: a dual role; (3) not being present at birth: a 'denied' experience; (4) returning to 'normality'; (5) feedback to 'pandemic' maternity services and policies. DISCUSSION AND CONCLUSION: Key elements of good practice to promote positive childbirth experiences in the context of a pandemic were identified: presence of a birth companion; COVID-19 screening tests for support persons; timely, proactive and comprehensive communication of information to support persons; staggered hospital visiting times; follow-up of socio-psychological wellbeing; antenatal and postnatal home visiting; family-centred policies and services.

Midwifery students' views and experiences of birth on mainstream factual television.

OBJECTIVES: To investigate midwifery students' experiences of viewing childbirth on mainstream factual television and to explore implications for student career intentions and potential pedagogical uses of television excerpts in midwifery education. DESIGN: Twenty-two undergraduate midwifery students at one of two universities took place in focus groups between February and June 2019. Ethical approval was obtained at both sites. Thematic analysis was employed to generate key themes from the data. SETTING: Two UK universities based in the East Midlands and East Yorkshire regions of England. PARTICIPANTS: Twenty-two midwifery students at any stage of their studies. FINDINGS: Researchers generated four key themes from the data a) Changed Perspectives on Televised Childbirth, b) Representations of Midwives and Social Implications, c) Representation of Childbirth and Social Implications and d) The Role of Televising Childbirth in Midwifery Education. KEY CONCLUSIONS: Midwifery students often experience a change of perspective on birth on television as they acquire new knowledge and skills. They recognise the potential social implications of how childbirth and midwifery are represented on television. Pedagogical use of televised birth has potential benefits but needs further investigation in the context of midwifery education. IMPLICATIONS FOR PRACTICE: Midwifery students are likely to begin their studies with pre-existing views and experiences around how birth is represented on mainstream factual television. They may need support to reflect on these to consider their expectations of the profession, to effectively support childbearing women and to potentially influence future production of media images of childbirth.

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour.

AIMS: To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour. DESIGN: Mixed-methods systematic review. DATA SOURCES: A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected. RESULTS: Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent. REVIEW METHODS: Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced. CONCLUSION: Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth. IMPACT: The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.

Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives' experiences in Northern Italy.

OBJECTIVE: To explore midwives' experiences of the management of the second stage of labour in women with epidural analgesia. DESIGN: Descriptive qualitative study using semi-structured face-to-face interviews. PARTICIPANTS: Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years' experience on labour ward and six were junior midwives with less than five years' experience on labour ward. FINDINGS: The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time 'allowed' by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees' opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives' sense of 'usefulness' when caring for women not experiencing labour pain. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians' opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of 'uselessness'. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units' protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.

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.

Women's expectations and experiences of rupture of membranes and views of the potential use of reagent pads for detecting amniotic fluid.

AIMS: To explore first-time mothers' expectations and experiences regarding rupture of membranes at term and their views on the potential use of reagent pads that detect amniotic fluid. BACKGROUND: There is little information available on women's experiences of spontaneous rupture of membranes, or interest in using methods to confirm rupture of membranes (e.g. reagent pads). DESIGN: Descriptive qualitative study, using focus groups and telephone interviews with women during pregnancy and after the birth of their first baby. Thematic analysis was undertaken to analyse women's responses. METHODS: Ethics committee approval was obtained. Twenty-five women participated in the study of whom 13 contributed both during pregnancy and postpartum between October 2015-March 2016. FINDINGS: Three overarching themes were identified from the data from women's expectations and experiences: uncertainty in how, when and where membranes may rupture; information which was felt to be limited and confirmation of rupture of membranes. The potential use of reagent pads met with varied responses. CONCLUSION: Women were interested in having facts and figures regarding rupture of membranes, such as characteristics of liquor; volume and probability of membranes rupturing spontaneously at term. Use of a pad as a means of confirmation was viewed as helpful, although the potential for increasing anxiety was raised.

First-time mothers' choice of birthplace: influencing factors, expectations of the midwife's role and perceived safety.

AIM: To explore first-time pregnant women's expectations and factors influencing their choice of birthplace. BACKGROUND: Although outcomes and advantages for low-risk childbearing women giving birth in midwifery-led units and home compared with obstetric units have been investigated previously, there is little information on the factors that influence women's choice of place of birth. DESIGN: A qualitative Straussian grounded theory methodology was adopted. Fourteen women expecting their first baby were recruited from three large National Health Service organizations that provided maternity services free at the point of care. The three organizations offered the following birthplace options: home, freestanding midwifery unit and obstetric unit. Ethical approvals were obtained and informed consent was gained from each participant. METHODS: Data collection was undertaken in 2013-2014. One tape-recorded face-to-face semistructured interview was conducted with each woman in the third trimester of pregnancy. FINDINGS: Findings are presented as three main themes: (i) influencing factors on the choice of birthplace; (ii) expectations on the midwife's 'being' and 'doing' roles; (iii) perceptions of safety. CONCLUSION: Midwives should consider each woman's expectations and approach to birth beyond the planned birthplace, as these are often influenced by the intersection of various influencing factors. Several birthplace options should be made available to women in each maternity service and the alternatives should be shared with women by healthcare professionals during pregnancy to allow an informed choice. Virtual tours or visits to the birth units could also be offered to women to help them familiarize with the chosen setting.

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

BACKGROUND: The literature review reveals general information about a good midwife from a range of perspectives and what childbearing women generally value in a midwife, but there is a lack of information around mothers' perspectives of what makes a good midwife specifically during labour and birth, and even less in the context of different places of birth. AIM: To conceptualise first-time mothers' expectations and experiences of a good midwife during childbirth in the context of different birthplaces. 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 gained. 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. FINDINGS: The model named 'The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth' was developed. The model is dynamic and woman-centred, and is operationalised as the midwife adapts to each woman's individual needs in the context of each specific labour. Four pillars of intrapartum care were identified for a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. The metaphor of a kaleidoscopic figure is used to describe a midwife who is 'multi-coloured' and ever changing in the light of the woman's individual needs, expectations and labour journey, 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 likely to have an optimum experience of birth. Future research is necessary to tease out individual components of the model in a variety of practice settings.

First-time mothers' experiences of early labour in Italian maternity care services.

OBJECTIVE: The aim of this study is to explore first-time mothers' experiences of early labour in Italian maternity care services when admitted to hospital or advised to return home after maternity triage assessment. SETTING: The study was conducted in a second-level maternity hospital in northern Italy with an obstetric unit for both low- and high-risk women. PARTICIPANTS: The participants included 15 first-time mothers in good general health with spontaneous labour at term of a low-risk pregnancy who accessed maternity triage during early labour, and were either admitted to hospital or advised to return home. DESIGN: A qualitative interpretive phenomenological study was conducted. A face-to-face recorded semi-structured interview was conducted with each participant 48-72h after birth. FINDINGS: Four key themes emerged from the interviews: (a) recognising signs of early labour; (b) coping with pain at home; (c) seeking reassurance from healthcare professionals; and (d) being admitted to hospital versus returning home. Uncertainty about the progression of labour and the need for reassurance were cited by women as the main reasons for hospital visit in early labour. An ambivalent feeling was reported by the participants when admitted to hospital in early labour. In fact, while the women felt reassured in the first instance, some women subsequently felt dissatisfied due to the absence of one-to-one dedicated care during early labour. When advised to return home, a number of women reported feelings of disappointment, anger, fear, discouragement and anxiety about not being admitted to hospital; however, some of these women reported a subsequent feeling of comfort due to being at home and putting in place the suggestions made by the midwives during the maternity triage assessment. The guidance provided by midwives during triage assessment seemed to be the key factor influencing women׳s satisfaction when advised either to return home or to stay at the hospital during early labour. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: During antenatal classes and clinics, midwives should provide clear information and advice about early labour in order to increase women׳s confidence and self-efficacy, and decrease their anxiety and fear. During early labour, appropriate maternity care services should be offered according to individual needs. When home visits are not provided by midwives, a telephone triage run by midwives should be considered as a routine service for the first point of contact with women during early labour.

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.

Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital.

OBJECTIVE: to investigate the early pushing urge (EPU) incidence in one maternity unit and explore how it is managed by midwives. The relation to some obstetric outcomes was also observed but not analysed in depth. DESIGN: prospective observational study. SETTING: Italian maternity hospital. SAMPLE: 60 women (44 nullips and 16 multips) experiencing EPU during labour. FINDINGS: the total EPU incidence percentage was 7.6%. The single midwives' incidences range had a very wide margin, noting an inverse proportion between the number of diagnoses of EPU and midwife's waiting time between urge to push and vaginal examination. Two care policies were adopted in relation to the phenomenon: the stop pushing technique (n=52/60) and the 'let the woman do what she feels' technique (n=8/60). In case of stop pushing techniques, midwives proposed several combined techniques (change of maternal position, blowing breath, vocalisation, use of the bath). The EPU diagnosis at less than 8cm of cervical dilatation was associated with more medical interventions. Maternal and neonatal outcomes were within the range of normal physiology. An association between the dilatation at EPU diagnosis and obstetric outcomes was observed, in particular the modality of childbirth and perineal outcomes. CONCLUSIONS AND IMPLICATION FOR PRACTICE: this paper contributes new knowledge to the body of literature around the EPU phenomenon during labour and midwifery practices adopted in response to it. Overall, it could be argued that EPU is a physiologic variation in labour if maternal and fetal conditions are good. Midwives might suggest techniques to woman to help her to stay with the pain, such as change of position, blowing breath, vocalisation and use of the bath. However, the impact of policies, guidelines and culture on midwifery practices of the specific setting are a limitation of the study because it is not representative of other similar maternity units. Thus, a larger scale work should be considered, including different units and settings. The optimal response to the phenomenon should be studied, considering EPU at different dilatation ranges. Future investigations could also focus on qualitative analysis of women and midwives' personal experience in relation to the phenomenon.