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.

Experiences of mothers and significant others in accessing comprehensive healthcare in the first 1000 days of life post-conception during COVID-19 in rural Uganda.

BACKGROUND: COVID-19 presented an unprecedented global public health challenge because of its rapid and relentless spread, and many countries instituted lockdowns to prevent the spread of infection. Although this strategy may have been appropriate to reduce infection, it presented unintended difficulties in rural Uganda, especially in maternal and born newborn care. For example, some services were suspended, meaning the nearest health facility was at a considerable distance. This study explored the experiences of mothers and their significant others of comprehensive care in the first 1000 days of life post-conception during the COVID-19 pandemic in Bunghokho-Mutoto sub-county, Mbale District, Uganda. METHODS: A qualitative exploratory descriptive design was used with data collected in semi-structured interviews. Mothers (pregnant or with a child under 2 years) and their significant others were purposively recruited for this study. The sample size (N = 14) was determined by data saturation. DATA: were analysed using thematic analysis. RESULTS: One theme emerged "Increasing barriers to healthcare", which encompassed six sub-themes: accessing healthcare, distressing situations, living in fear, making forced choices, navigating the gatekeepers, and 'coping with increased poverty. CONCLUSION: This study found that the COVID-19 pandemic increased barriers to accessing healthcare services in the region. Participants' narratives emphasised the lack of access to expert care and the shortage of skilled health workers, especially midwives.

It's about finding a balance exploring conscientious objection to abortion with UK midwives.

BACKGROUND: Despite the right for health professionals to abstain from providing abortion services existing for over 50 years, literature on conscientious objection to abortion scarcely mentions midwives. In addition, little empirical research has been carried out concerning midwives' views surrounding what constitutes participation in abortion and in turn, what areas of care they can withdraw from. AIM: To explore midwives' beliefs regarding the extent of and limitations to the exercising of their legal right to objection to abortion on conscience grounds. DESIGN: Qualitative study with 17 midwives in Glasgow and Liverpool, UK. METHOD: Face to face semi-structured interviews, transcribed verbatim and analysed using a thematic analysis and Human Rights framework for midwifery care. FINDINGS: The extent of and limitations to CO to abortion-related care was reflected in four themes: respecting and protecting, making informed decisions, providing non-discriminatory care and experience and culture. There was an overriding sense of support for midwives to be able to exercise their right to conscientious objection, how this is operationalised in practice however continues to be fraught with complexity, which in turn poses constant challenges to midwives who object, their colleagues and managers. CONCLUSIONS: Midwives' beliefs regarding the exercising of their legal right to object to abortion-related care on conscience grounds can be summarized in the challenge of "finding a balance". A national picture of how to accommodate CO to abortion is needed, so that all midwives can continue to give optimal care to women and receive it themselves, within a human rights framework.

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.

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.

Accommodating conscientious objection in the midwifery workforce: a ratio-data analysis of midwives, birth and late abortions in 18 European countries in 2016.

BACKGROUND: In recent years, the role of a midwife has expanded to include the provision of abortion-related care. The laws on abortion in many European countries allow for those who hold a conscientious objection to participating to refrain from such participation. However, some writers have expressed concerns that this may have a detrimental effect on the workforce and limit women's access to the service. METHOD: The aim of this study was to provide a picture of the potential exposure midwives in Europe have to late abortions, an important factor in the integration of accommodation of conscientious objection to abortion by midwives into workload planning. We collected data from Ministries of Health or government statistical departments in 32 European countries on numbers of births, abortions, late abortions and midwives in 2016. We conducted a ratio-data analysis in those countries that met the inclusion criteria. RESULTS: Eighteen of the 32 countries provided full data; thus, our calculations are based on a total of 4 036 633 live births, 49 834 late abortions and a total of 132 071 midwives. The calculated ratios of live births to midwife, abortions to midwife and late abortions to midwife illustrate the wide variations between countries in relation to ratios of midwives to live births (15.22-53.99) and late abortions (0.17-1.47) CONCLUSIONS: This study provides the first comprehensive insight to ratios relating to birth and abortion, especially late abortion services, with regard to the midwifery workforce. It is essential to improve the reporting of abortion data and access to it within Europe to support evidence-informed decisions on optimising the contribution of the midwifery workforce especially within highly contentious fields such as abortion services. The study's findings suggest that there should be neither be any difficulty for those who are responsible for workload allocation nor compromises to a women's right to abortion services.

Potential conflicts in midwifery practice regarding conscientious objection to abortions in Scotland.

BACKGROUND:: This study was developed as a result of a court case involving conflicts between midwives' professional practice and their faith when caring for women undergoing abortions in Scotland. RESEARCH QUESTIONS:: What are practising Roman Catholics' perspectives of potential conflicts between midwives' professional practice in Scotland with regard to involvement in abortions and their faith? How relevant is the 'conscience clause' to midwifery practice today? and What are participants' understandings of Canon 1398 in relation to midwifery practice? RESEARCH DESIGN:: The theoretical underpinning of this study was Gadamer's hermeneutic out of which the method developed by Fleming et al. involving a five-stage approach was utilised. PARTICIPANTS AND RESEARCH CONTEXT:: The research was conducted in the south of Scotland. A purposive sampling method was used. Eight participants who were practising Roman Catholics familiar with the subject of conscientious objection who were either midwives, lawyers (civil, canon or both) or priests contributed. ETHICAL CONSIDERATIONS:: The major ethical issues related to respect for autonomy, maintaining confidentiality and obtaining voluntary informed consent. Parish priests agreed to act as gatekeepers to prospective participants. All legal requirements were addressed regarding data collection and storage. Approval was given by the ethics committee of the university with which one of the researchers were associated. FINDINGS:: Three key themes provide an understanding of the situation in which midwives find themselves when considering the care for a woman admitted for an abortion: competing legal systems, competing views of conscience and limits of participation. CONCLUSION:: Clear guidelines for practice should be developed by a multi-professional and consumer group based on an update of the abortion law to reflect the change from a surgical to medical procedure. Clarification of Canon 1398 in relation to what is and is not participation in the procurement of abortion would be of benefit to midwives with a conscientious objection.

Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons.

BACKGROUND: Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion. METHOD: We conducted a systematic review of ethical arguments asking, "What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?" We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000-2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection. RESULTS: Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, "moral reasons" contained the largest number of narrow reasons (n =  58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories. CONCLUSIONS: We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.

Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion.

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women's rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them.

Decision-making in Swiss home-like childbirth: A grounded theory study.

BACKGROUND: Decision-making in midwifery, including a claim for shared decision-making between midwives and women, is of major significance for the health of mother and child. Midwives have little information about how to share decision-making responsibilities with women, especially when complications arise during birth. AIM: To increase understanding of decision-making in complex home-like birth settings by exploring midwives' and women's perspectives and to develop a dynamic model integrating participatory processes for making shared decisions. METHODS: The study, based on grounded theory methodology, analysed 20 interviews of midwives and 20 women who had experienced complications in home-like births. FINDINGS: The central phenomenon that arose from the data was "defining/redefining decision as a joint commitment to healthy childbirth". The sub-indicators that make up this phenomenon were safety, responsibility, mutual and personal commitments. These sub-indicators were also identified to influence temporal conditions of decision-making and to apply different strategies for shared decision-making. Women adopted strategies such as delegating a decision, making the midwife's decision her own, challenging a decision or taking a decision driven by the dynamics of childbirth. Midwives employed strategies such as remaining indecisive, approving a woman's decision, making an informed decision or taking the necessary decision. DISCUSSION AND CONCLUSION: To respond to recommendations for shared responsibility for care, midwives need to strengthen their shared decision-making skills. The visual model of decision-making in childbirth derived from the data provides a framework for transferring clinical reasoning into practice.

Exploring global recognition of quality midwifery education: Vision or fiction?

BACKGROUND: Midwifery education is the foundation for preparing competent midwives to provide a high standard of safe, evidence-based care for women and their newborns. Global competencies and standards for midwifery education have been defined as benchmarks for establishing quality midwifery education and practice worldwide. However, wide variations in type and nature of midwifery education programs exist. AIM: To explore and discuss the opportunities and challenges of a global quality assurance process as a strategy to promote quality midwifery education. DISCUSSION: Accreditation and recognition as two examples of quality assurance processes in education are discussed. A global recognition process, with its opportunities and challenges, is explored from the perspective of four illustrative case studies from Ireland, Kosovo, Latin America and Bangladesh. The discussion highlights that the establishment of a global recognition process may assist in promoting quality of midwifery education programs world-wide, but cannot take the place of formal national accreditation. In addition, a recognition process will not be feasible for many institutions without additional resources, such as financial support or competent evaluators. In order to achieve quality midwifery education through a global recognition process the authors present 5 Essential Challenges for Quality Midwifery Education. CONCLUSION: Quality midwifery education is vital for establishing a competent workforce, and improving maternal and newborn health. Defining a global recognition process could be instrumental in moving toward this goal, but dealing with the identified challenges will be essential.

Naegele's rule revisited.

Recent literature suggests that Franz Carl Naegele's (1778-1851) rule for estimating the date of delivery has been misinterpreted, resulting in this being brought forward by five days. Baskett and Nagele's work underpinning this argument has become widely accepted and quoted in obstetrical and midwifery textbooks. However, our re-examination of Naegele's original statements does not support the recent findings. On the contrary, the original textbooks of Naegele clearly advise taking the first day of menstruation for the calculation of the date of delivery.

Dying at life׳s beginning: Experiences of parents and health professionals in Switzerland when an 'in utero ' diagnosis incompatible with life is made.

OBJECTIVE: The disclosure of a diagnosis during pregnancy of a fetal malformation, which is incompatible with life, normally comes completely unexpectedly to the parents. Although a body of international literature has considered the topic, most of it comes from the United States and little has been generated from Europe. This study aims to illuminate the contemporary treatment associated with such diagnoses, regardless of whether parents decide to terminate or continue the pregnancy. DESIGN: a qualitative design was used with data collected by semi-structured interviews and subjected to a thematic analysis. SETTING: the research was conducted in the German speaking areas of Switzerland with data collected from participants in places of their choice. PARTICIPANTS: 61 interviews were conducted with 32 parents and 29 health professionals. FINDINGS: the theme of 'temporality' identified four main time points from the professionals: diagnosis, decision, birth/death, and afterwards. However, in contrast to these, six major themes in this study, primarily generated from parents and extended from receiving the diagnosis until the interview, were identified: shock, choices and dilemmas, taking responsibility, still being pregnant, forming a relationship with the baby, letting go. Although there was concurrence on many aspects of care at the point of contact, parents expressed major issues as gaps between the points of contact. CONCLUSIONS: care varied regionally but was as sensitive as possible, attempting to give parents the space to accept their loss but fulfil legal requirements. A gap exists between diagnosis and decision with parents feeling pressured to make decisions regarding continuing or terminating their pregnancies although health professionals' testimonies indicated otherwise. A major gap manifested following the decision with no palliative care packages offered. During the birth/death of the baby, care was sensitive but another gap manifested following discharge from hospital.

Developing and validating scenarios to compare midwives' knowledge and skills with the International Confederation of Midwives' essential competencies in four European countries.

AIM: To develop, pilot and validate a number of scenarios which encompass all of the International Confederation of Midwives' (ICM) competency statements and which are of relevance in various European countries, both those in the European Union and those which might become members in the future. DESIGN: 27 Scenarios designed to encompass all ICM competencies were tested using qualitative interviews. SETTING: Slovenia, Germany, Scotland, Kosovo. PARTICIPANTS: 68 Experienced midwives from Slovenia, 58 from Germany, 63 from Scotland and 76 from Kosovo. FINDINGS: Although midwives found it difficult to relate to the scenarios dealing with pre-conception competencies, after revision, all scenarios were appropriate for use in all four countries. KEY CONCLUSIONS: The scenarios embrace all of the ICM's essential competencies for midwives in each of the countries involved. Additionally, they have face validity as shown by the spread of responses to each of the scenarios. IMPLICATIONS FOR PRACTICE: The scenarios may be used with confidence by experienced midwives in each of the areas involved. It is also possible that the scenarios can be used for education and assessment purposes. By considering the European perspective of the project, they also offer the potential to support the mobility of midwives moving between countries within Europe by assessing competence with regard to local practices in the new situation.

Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective.

OBJECTIVE: to explore midwives' experiences of facilitating normal birth in an obstetric-led unit. DESIGN: a feminist approach using semi-structured interviews focusing on midwives' perceptions of normal birth and their ability to facilitate this birth option in an obstetric-led unit. SETTING: Ireland. PARTICIPATION: a purposeful sample of 10 midwives with 6-30 years of midwifery experience. All participants had worked for a minimum of 6 years in a labour ward setting, and had been in their current setting for the previous 2 years. FINDINGS: the midwives' narratives related to the following four concepts of patriarchy: 'hierarchical thinking', 'power and prestige', 'a logic of domination' and 'either/or thinking' (dualisms). Two themes, 'hierarchical thinking' and 'either/or thinking', (dualisms) along with their subthemes are presented in this paper. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study identified some of the reasons why midwives find it difficult to facilitate normal birth in an obstetric unit setting, and identified a need for further research in this area. Midwifery education and supportive management structures are required if midwives are to become confident practitioners of normal birth.

Women's needs from antenatal care in three European countries.

OBJECTIVE: To determine the important aspects of antenatal care from a woman's perspective in order to develop a woman-constructed conceptual model of antenatal care. DESIGN: Grounded theory. SETTING: Three European countries: Scotland, Switzerland and The Netherlands. PARTICIPANTS: 23 women using routine antenatal care in the three countries were interviewed: seven women in Scotland, seven in Switzerland and nine in The Netherlands. MEASUREMENTS AND FINDINGS: Three main categories emerged: 'responsibility', 'establishing a sharing trust relationship' and 'support me to be responsible'. The category of 'responsibility', which incorporated the sub-categories 'feeling confident' and 'feeling autonomous', is reported. Despite the many aspects that the women had in common, a divergence of the categories in each of the countries was clearly observed. The main cross-cultural differences were within the sub-category of 'feeling autonomous'. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Responsibility is the main reason why women seek antenatal care. Feelings of confidence and autonomy are substantial attributes of this responsibility. The cultural background of the women seems to cause the differences within the categories. These findings have implications for both the provision and the evaluation of antenatal care.

[Evidence-based midwifery practice in Scotland: a discussion of the problems]. / Evidenzbasierte Hebammenpraxis in Schottland: Eine Diskussion der Probleme.

In recent years there has been a drive to base all health care provision upon the most recent, appropriate scientific evidence. This has prompted an interest in research by midwives in clinical practice who want to ensure that they are providing the best possible care. Those midwives who do not use evidenced based practice but instead teach, support and demonstrate ritualistic practices without reference to the substantial research available, are limiting women's choice in maternity care. In a recent trial investigating whether routine suturing of perineal lacerations is required, the trial's outcome was jeopardised because of midwives' beliefs about suturing. The rationale for such ritualistic behaviour is not always easy to understand and using a framework of power and it is examined in this article to determine what concepts are influencing these practices. The article concludes by suggesting that some midwives appear to ignore the results of this trial and other research and demonstrate a paternalistic attitude towards their clients.