Left alone with the emotional surge - A qualitative study of midwives' and obstetricians' experiences of severe events on the labour ward.

BACKGROUND: Working on the labour ward entails being responsible for severe events during which a mother or baby may be injured or may die. Such events might affect decision-making, team-working, capacity for empathy, and patient safety. AIM: To explore midwives' and obstetricians' experiences, reactions and interpretations of being part of a severe event on the labour ward. DESIGN: A qualitative study using content analysis of in-depth interviews. PARTICIPANTS: Fourteen Swedish healthcare providers: seven midwives, and seven obstetricians. METHODS: Qualitative content analysis was used to describe and interpret the manifest and latent meaning of the interview text, while remaining close to participants' lived experiences. RESULTS: The overarching theme "Left alone with the emotional surge" was developed around three subthemes, supported by categories and subcategories. Professionals identified factors that had contributed to the course of events that made them perceive that they had been "acting within an illusory system of control and safety". When the severity of the situation became clear, "cognitive and emotional discordance was experienced", and, in the aftermath, the professionals described a "search for internal and external redemption" related to strong emotions of being left alone. CONCLUSIONS: Facing severe obstetric events entails exposure to emotionally demanding situations and hence joint vulnerability. Midwives and obstetricians described a sense of loneliness and perceptions of insecurity regarding the organisational system, managers and colleagues, following a complex, severe event with a woman or her baby during childbirth.

The erratic pathway to regaining a professional self-image after an obstetric work-related trauma: A grounded theory study.

BACKGROUND: It is known that healthcare providers might be affected by severe medical events in which patients are badly hurt. In birth care, escalating situations can result in death or injury to a mother or new-born child. OBJECTIVE: To explore the process that Swedish midwives and obstetricians go through after a severe event in the maternity unit. DESIGN: A modified Constructivist Grounded Theory analysis, based on fourteen in-depth interviews with birth care professionals. PARTICIPANTS: Seven midwives and seven obstetricians. RESULTS: A core category, 'regaining of a professional self-image', was constructed and interpreted as being constituted of six main categories illustrating a frequently erratic pathway to the regaining of a professional self-image. The process included a search for external acceptance for the re-establishment of belongingness by obtaining corroboration from the woman, work colleagues and manager, and the medico-legal system. Media exposure was invariably seen as something negative. Internal processes involved coping with emotions of guilt and shame and the vulnerability that the work entails, as well as contemplating future work. The possibility to fully regain one's professional self-image depended on having a sense of confidence and an urge to support others in similar situations by sharing gained insights. However, the process could also result in reconsidering one's professional self-image by setting up boundaries, creating a better work-life balance, or creating mental back-up plans in case of similar recurrences. For others, the process led to a change of professional identity and a search for roles away from emergency obstetrics or the specialty as such. CONCLUSIONS: Many midwives and obstetricians will experience severe obstetric events that might affect them, sometimes severely. The vulnerability that healthcare professionals are exposed to should not be underestimated and preparedness in terms of collegial support, as well as an awareness in the workplace of how badly affected employees might be, is important. Growth as well as leaving birth care can be the results of the process following a severe event.

Learning the ABCs of pregnancy and newborn care through mobile technology.

BACKGROUND: The diffusion of mobile phones in low- and middle-income countries has taken place faster than any other infrastructural development. Mobile Midwife, a mobile application implemented in Ghana in 2010, sends timely messages in local languages to registered expectant mothers and new parents. The field of mobile health (mHealth) is severely underresearched, yet it can be an alternative for improving health systems and the ways in which health services are delivered. OBJECTIVE: Our goal was to investigate the role that Mobile Midwife technology has played in the lives of pregnant and nursing mothers in Awutu Senya District, Ghana. DESIGN: A total of three focus group discussions and 19 individual interviews were conducted. Discussions and interviews were recorded, transcribed verbatim from the local language to English, and analyzed by means of qualitative content analysis at the manifest and latent levels. RESULTS: The main findings show that while oscillating between modern and traditional practices, women gradually gained trust in Mobile Midwife's counselling and attempted to balance between myths and reality regarding nutrition in pregnancy. In addition, their decisions to seek essential obstetric care were enhanced by Mobile Midwife's advice. Women also felt strengthened in their understanding of the importance of seeking professional care during pregnancy and childbirth as well as recognizing signs of ill health in the newborn. CONCLUSIONS: The findings indicate that Mobile Midwife could be an excellent tool in working towards the improvement of maternal health. Mobile Midwife will hopefully contribute to the stepwise achievement of the Sustainable Development Goals extended from the Millennium Development Goals, which expire at the end of 2015. There is a need for strong political will from key stakeholders, to embark in the field of mHealth as a complementary means to strengthen health systems.

Identifying with a process of change: a qualitative assessment of the components included in a smoking cessation intervention at antenatal clinics in South Africa.

INTRODUCTION: previous research has suggested that pregnant women prefer a person-centred approach for smoking cessation interventions. However few studies have illustrated the mechanism through which such an approach has an influence on quitting or reduction rates among pregnant women in resource poor settings. PURPOSE: to explore the role of different components included in a smoking cessation intervention delivered to disadvantaged pregnant women with high smoking rates attending public health antenatal clinics in South Africa. METHODS: a qualitative design consisting of focus-group discussion with women exposed to the intervention was used. Women were purposively selected from four antenatal clinics and one tertiary hospital to represent different experiences of the intervention. Focus group discussions with four groups of smokers and four groups of quitters were conducted and a total of 41 women were interviewed. Data were analysed using content analysis. MAIN FINDINGS: the main theme describing the intervention effect that emerged from the interviews was, 'Making identification with change possible'. The categories 'An impulse for change', 'An achievable recipe', 'A physical reminder' and 'A compassionate companion' further described how each intervention component was perceived by women and how it contributed to behaviour change. CONCLUSIONS: behaviour change interventions that are directly informed by the target population with regards to its design, content and delivery offer great opportunities for positive behaviour change. Women positively evaluated all the components employed in this intervention but rated the social support they received from peer-counsellors as the overriding aspect of the intervention.

Scolders, carers or friends: South African midwives' contrasting styles of communication when discussing smoking cessation with pregnant women.

OBJECTIVE: to investigate how midwives are currently communicating with women about smoking during pregnancy with a view to involving them in a smoking cessation intervention in antenatal clinics. DESIGN: a qualitative study using individual, in-depth interviews for data collection. SETTING AND PARTICIPANTS: 24 nurses providing antenatal care to pregnant smokers attending public sector clinics in five major cities in South Africa. FINDINGS: three archetypes of midwives, characterised by different styles of communication and approaches to smoking cessation, emerged from the analysis of the interview data. These were described as the 'Angry Scolders', the 'Benign Carers' and the 'Enthusiastic Friends'. The first type conformed to the traditional, authoritarian style of communication, where the midwife assumed a dominant, expert role. When women failed to comply with their advice, these midwives typically became angry and confrontational. The second type of midwife used a paternalistic communication style and emphasised the role of education in changing behaviour. However, these midwives had little confidence that they could influence women to quit. The third type embraced a patient-centred approach, consciously encouraging more interaction with their patients and attempting to understand change from their point of view. These midwives were optimistic of women's capacity to change and more satisfied with their current health education efforts than the first two types. The Benign Carers and Enthusiastic Friends were more open to participation in the potential intervention than the Angry Scolders. KEY CONCLUSIONS: the prevailing traditional, authoritarian style of communication is inappropriate for smoking cessation education and counselling as it provokes resistance and avoidance on the part of pregnant smokers. The paternalistic approach appears to be largely ineffectual, whereas the patient-centred approach elicits the most positive response from pregnant women and enhances the possibility of a trusting and cooperative relationship with the midwife. Midwives using this style are more open to fulfilling their role in smoking cessation. IMPLICATIONS FOR PRACTICE: smoking cessation interventions need to attend to not only what midwives say to pregnant women about smoking, but also how they communicate about the issue. The use of a patient-centred approach, such as brief motivational interviewing, is recommended as a means of improving counselling outcomes among pregnant smokers.

HIV-positive women's experiences of a PMTCT programme in rural Malawi.

OBJECTIVE: to explore women's experiences of a prevention of mother-to-child transmission (PMTCT) programme in rural Malawi. DESIGN, SETTING AND PARTICIPANTS: an exploratory, qualitative study using in-depth interviews with 24 purposively selected women infected with human immunodeficiency virus (HIV). The women were in three groups of eight: (1) those who delivered at the hospital and took nevirapine (NVP) before birth and whose babies received NVP within 72 hours of birth; (2) those who birthed at home and took NVP before birth but their babies never received NVP; and (3) those who birthed at home and did not take NVP and whose babies did not receive NVP. Data were analysed using content analysis. FINDINGS: four themes emerged: (1) 'a wish to confirm and protect' refers to women's decisions to take the HIV test, (2) 'a revelation for action' is an illustration of how the testing may be part of an empowering process, (3) 'a dilemma between silence and openness' points to the dilemma that women are facing in their decision to share or not to share their HIV status with spouse, family, friends and community, and (4) 'a desire challenged by circumstances, chance and tradition' refers to the circumstances and actions which prevent these women from actually delivering at the hospital to protect their babies from HIV infection. CONCLUSIONS: the PMTCT programme influences women's lives profoundly, and the importance of quality counselling and strengthening male involvement is stressed as the programme is implemented by an increasing number of service providers.

Possibilities for transparency and trust in the communication between midwives and pregnant women: the case of smoking.

OBJECTIVE: to explore barriers to and possibilities for interactive communication between midwives and pregnant women regarding smoking behaviour during pregnancy. DESIGN: the study was based on a qualitative research design aiming at a Grounded Theory analysis of interviews with pregnant women. SETTING: public sector antenatal clinics in Cape Town, South Africa predominantly providing care to women of mixed ancestry. INFORMANTS: in-depth interviews with 12 pregnant women purposively selected on the basis of smoking behaviour, age and marital status to reach maximum variation. FINDINGS: the findings indicated low levels of transparency and trust in antenatal visits. Lack of trust was related to categories such as conflicting personal capabilities and socio-cultural and medical expectations, combined with a didactic approach from caregivers. The unworthy woman was identified as the core category of the interviews describing how women feel in their relationship with midwives. A theoretical model illustrates possibilities for change in relation to an ideal situation where a supportive caregiver, congruent expectations and capabilities result in women feeling visible. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: culturally appropriate smoking cessation interventions should be of high priority. Training in patient-centred counselling for midwives is necessary for creating an open dialogue with pregnant mothers about their smoking habits. The time constraint experienced by midwives also suggests that other methods apart from midwife counselling should be investigated for inclusion in the clinical setting.