Strengthening global midwifery education to improve quality maternity care: Co-designing the World Health Organization Midwifery Assessment Tool for Education (MATE).

AIMS: To describe a three-phase co-designed project to develop a culturally appropriate and relevant education assessment tool, and report on pilot and field-testing phases. BACKGROUND: High-quality midwifery education is essential for high-quality maternity care (WHO 2019); however midwifery education and maternity care vary in quality throughout Europe. To support countries in strengthening their midwifery education, World Health Organization (WHO) European Region commissioned development of the Midwifery Assessment Tool for Education (MATE). The tool was developed over three years, using an iterative, collaborative process with regional experts. Published by WHO in May 2020, MATE provides focused questions and evidence-informed resources to stimulate and inform discussions within country. DESIGN: Three-phase co-design approach to develop, pilot and field-test an education assessment tool. METHODS: Phase 1: initial development of MATE with expert midwifery support; Phase 2: MATE piloting workshops in Czech Republic and Lithuania focusing on clarity, usability and relevance; Phase 3: MATE field-testing workshop in Bulgaria exploring the process of using MATE and its effectiveness for generating discussion. Purposive selection of workshop participants ensured a broad range of perspectives: clinicians, educators, students, policy makers and service users. All participants were invited to give narrative feedback during workshops and via completion of a post-workshop online survey. The XX University Research Ethics Committee advised that formal ethical review was unnecessary. RESULTS: Feedback from collaborators in all phases indicated that engaging with MATE co-design and testing was a positive experience. A 'bottoms up' approach ensured that MATE content was relevant to regional needs, culturally acceptable and appropriate. Seventy-nine individuals participated in Phases 2 and 3 and all were sent a post-workshop online survey, with 31 responses (39 %). Qualitative and quantitative data indicated that the aim of MATE was well understood, and its usability and relevance were evaluated positively. In Phase 2, improvements to wording and format were suggested. MATE was subsequently amended prior to field testing. Phase 3 feedback indicated that MATE was highly effective for generating in-country dialogue and frank discussions about the future of midwifery education and practice. CONCLUSIONS: Using a co-design approach has ensured that MATE is culturally relevant, accessible and appropriate. This initial evaluation indicates that MATE can facilitate in-country dialogue and support the strengthening of midwifery education in accordance with WHO aims. Next steps are a fully evaluated trial of MATE in a selected partner country, where we will continue to work collaboratively to optimise engagement and ensure cultural appropriateness.

Addressing social inequity through improving relational care: A social-ecological model based on the experiences of migrant women and midwives in South Wales.

BACKGROUND: Migrant and ethnic inequalities in maternal and perinatal mortality persist across high-income countries. Addressing social adversity and inequities across the childbirth trajectory cannot be left to chance and the good intentions of practitioners. Robust, evidence-based tools designed to address inequity by enhancing both the quality of provision and the experience of care are needed. METHODS: An inductive modelling approach was used to develop a new evidence-based conceptual model of woman-midwife relationships, drawing on data from an ethnographic study of relationships between migrant Pakistani women and midwives, conducted between 2013 and 2016 in South Wales, UK. Key analytic themes from early data were translated into social-ecological concepts, and a model was developed to represent how these key themes interacted to influence the woman-midwife relationship. RESULTS: Three key concepts influencing the woman-midwife relationship were developed from the three major themes of the underpinning research: (1) Healthcare System; (2) Culture and Religion; and (3) Family Relationships. Two additional weaving concepts appeared to act as a link between these three key concepts: (1) Authoritative Knowledge and (2) Communication of Information. Social and political factors were also considered as contextual factors within the model. A visual representation of this model was developed and presented. CONCLUSIONS: The model presented in this paper, along with future work to further test and refine it in other contexts, has the potential to impact on inequalities by facilitating future discussion on cultural issues, encouraging collaborative learning and knowledge production and providing a framework for future global midwifery practice, education and research. PATIENT OR PUBLIC CONTRIBUTION: At the outset of the underpinning research, a project involvement group was created to contribute to study design and conduct. This group consisted of the three authors, an Advocacy Officer at Race Equality First and an NHS Consultant Midwife. This group met regularly throughout the research process, and members were involved in discussions regarding ethical/cultural/social issues, recruitment methods, the creation of participant information materials, interpretation of data and the dissemination strategy. Ideas for the underpinning research were also discussed with members of the Pakistani community during community events and at meetings with staff from minority ethnic and migrant support charities (BAWSO, Race Equality First, The Mentor Ring). Local midwives contributed to study design through conversations during informal observations of antenatal appointments for asylum seekers and refugees.

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom.

BACKGROUND: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK. METHODS: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data. RESULTS: Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women's awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment. CONCLUSIONS: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives.

Pregnancy and weight monitoring: A feasibility study of weight charts and midwife support.

Around half of pregnant women in the United Kingdom are overweight or obese. The antenatal period provides an opportunity for encouraging women to adopt positive lifestyle changes, and in recent years, this has included development of strategies to support women in avoiding excessive gestational weight gain. The objective of this interventional cohort study was to incorporate individualised gestational weight monitoring charts supported by motivational interviewing (MI)-based conversations into midwifery-led antenatal care and assess potential of the intervention for further development and evaluation. The study setting was a community midwifery team within a large maternity unit. The study explored the facilitators and barriers to engagement with the intervention as experienced by women and midwives; 52 women were recruited, of whom 48 were included in the analysis. A single training session was found adequate to prepare midwives to use antenatal weight charts but was insufficient to result in the incorporation of motivational interview techniques into clinical practice. We did not find sufficient evidence to recommend effectiveness testing of this intervention, and there is currently insufficient evidence to support reintroducing regular weighing of pregnant women into UK antenatal care. Given the public health importance of reducing rates of obesity, future interventions aimed at controlling gestational weight gain should continue to be developed but need to include innovative strategies particularly for women who are already obese or gain weight above that recommended.

"Overwhelmed and out of my depth": Responses from early career midwives in the United Kingdom to the Work, Health and Emotional Lives of Midwives study.

BACKGROUND: Efforts to resolve the longstanding and growing staffing crisis in midwifery in the United Kingdom have been hampered by very poor retention rates, with early career midwives the most likely to report burnout and intention to leave the profession. AIMS: To establish the key, self-described factors of satisfaction and dissatisfaction at work for early career midwives in the United Kingdom, and suggest appropriate and effective retention strategies. METHODS: Thematic analysis was undertaken on a subset of free text responses from midwives who had been qualified for five years or less, collected as part of the United Kingdom arm of the Work, Health and Emotional Lives of Midwives project. FINDINGS: Midwives described feeling immense pressure caused by an unremittingly heavy workload and poor staffing. Where relationships with colleagues were strong, they were described as a protective factor against stress; conversely, negative working relationships compounded pressures. Despite the challenges, many of the midwives reported taking great pleasure in their work, describing it as a source of pride and self-esteem. Midwives valued being treated as individuals and having some control over their shift pattern and area of work. DISCUSSION: These results, which reveal the strain on early career midwives, are consistent with the findings of other large studies on midwives' wellbeing. All available levers should be used to retain and motivate existing staff, and recruit new staff; in the meantime, considerable creativity and effort should be exercised to improve working conditions. CONCLUSION: This analysis provides a 'roadmap' for improving staff wellbeing and potentially retention.

Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff.

OBJECTIVE: To identify factors influencing the use of birth pools. DESIGN: Online discussion groups and semi-structured interviews, analysed thematically. SETTING: United Kingdom. PARTICIPANTS: 85 women and 21 midwives took part in online discussion groups; 14 medical staff participated in interviews. FINDINGS: Factors influencing the use of birth pools were grouped into three overarching categories: resources, unit culture and guidelines, and staff endorsement. Resources encompassed pool availability, efficiency of pool use and availability of waterproof cardiotocograph equipment. Unit culture and guidelines related to eligibility criteria for pool use, medicalisation of birth and differences between midwifery-led and obstetric-led care. Staff endorsement encompassed attitudes towards pool use. KEY CONCLUSIONS: Accessibility of birth pools was often limited by eligibility criteria. While midwifery-led units were generally supportive of pool use, obstetric-led units were described as an over-medicalised environment in which pool use was restricted and relied on maternal request. IMPLICATIONS FOR PRACTICE: Midwives can improve women's access to birth pools by providing information antenatally and proactively offering this as an option in labour. Maternity units should work to implement evidence-based guidelines on pool use, increase pool availability (even where there appears to be low demand), and enhance awareness amongst medical staff of the benefits of water immersion.

Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors.

OBJECTIVE: The overall study aim was to explore the relationship between the emotional wellbeing of UK midwives and their work environment. Specific research questions were to: assess levels of burnout, depression, anxiety and stress experienced by UK midwives; compare levels of burnout, depression, anxiety and stress identified in this sample of UK midwives, with levels reported in Australia, New Zealand and Sweden; identify demographic and work-related factors associated with elevated levels of burnout, depression, anxiety and stress. DESIGN: Cross sectional research design using an online survey. The WHELM survey tool was developed within the Australian maternity context and includes a number of validated measures: The Copenhagen Burnout Inventory (CBI), Depression, Anxiety and Stress Scale (DASS-21), as well as items from the Royal College of Midwives (RCM) 'Why Midwives Leave' study (Ball et al., 2002). SETTING: United Kingdom. PARTICIPANTS: An on-line survey was distributed via the RCM to all full midwife members in 2017 (n = 31,898). DATA ANALYSIS: The demographic and work-related characteristics of the sample were analysed using descriptive analyses. Levels of depression, anxiety, stress and burnout, measured by the CBI and DASS scores, were analysed using non-parametric statistical tests. Comparisons were made between groups based on demographic and work characteristics. Mann-Whitney U tests were used for two group comparisons, and Kruskal Wallis tests were used for groups with 2+ groups. Given the large number of analyses undertaken, statistically significant comparisons were identified with a conservative alpha level (p < .01). FINDINGS: A total of 1997 midwives responded to the survey, representing 16% of the RCM membership. The key results indicate that the UK's midwifery workforce is experiencing significant levels of emotional distress. 83% (n = 1464) of participants scored moderate and above for personal burnout and 67% (n = 1167) recorded moderate and above for work-related burnout. Client-related burnout was low at 15.5% (n = 268). Over one third of participants scored in the moderate/severe/extreme range for stress (36.7%), anxiety (38%) and depression (33%). Personal and work-related burnout scores, and stress, anxiety and depression scores were well above results from other countries in which the WHELM study has been conducted to date. Midwives were more likely to record high levels of burnout, depression, anxiety and stress if they were aged 40 and below; reported having a disability; had less than 10 years' experience; worked in a clinical midwifery setting, particularly if they worked in rotation in hospital and in integrated hospital/community settings. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Many UK midwives are experiencing high levels of stress, burnout, anxiety and depression, which should be of serious concern to the profession and its leaders. NHS employed clinical midwives are at much greater risk of emotional distress than others surveyed, which has serious implications for the delivery of high quality, safe maternity care. It is also of serious concern that younger, more recently qualified midwives recorded some of the highest burnout, stress, anxiety and depression scores, as did midwives who self-reported a disability. There is considerable scope for change across the service. Proactive support needs to be offered to younger, recently qualified midwives and midwives with a disability to help sustain their emotional wellbeing. The profession needs to lobby for systems level changes in how UK maternity care is resourced and provided. Making this happen will require support and commitment from a range of relevant stakeholders, at regional and national levels.

Relationships between working conditions and emotional wellbeing in midwives.

BACKGROUND: Emotional distress in midwives contributes to high attrition. To safeguard midwives' wellbeing, there is a need to identify the impact of workplace variables. AIM: To review the existing evidence on the relationships between working conditions and emotional wellbeing in midwives, and construct an analytic framework for understanding these relationships. METHODS: Systematic search and selection procedures using a range of databases. Results of included studies were synthesised into a thematic literature review of qualitative and quantitative research. FINDINGS: Various types of poor emotional wellbeing in midwives correlate with a variety of interrelated working conditions, including low staffing/high workload, low support from colleagues, lack of continuity of carer, challenging clinical situations and low clinical autonomy. Staffing levels seem to be able to modify the effects of many other variables, and the impact of challenging clinical situations is affected by several other variables. DISCUSSION: These workplace variables can be categorised as modifiable and non-modifiable risk indicators. CONCLUSION: While certain conditions that correlate with midwives' wellbeing are non-modifiable, several crucial variables, such as staffing levels and continuity of carer, are within the control of organisational leadership. Future research and interventions should focus on these modifiable risks. Research design should maximise the chance of establishing causation, while any innovations in this area should anticipate the interrelatedness of these risk factors to avoid unintended negative consequences.

The midwife-woman relationship in a South Wales community: Experiences of midwives and migrant Pakistani women in early pregnancy.

BACKGROUND: In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife-woman relationships for migrant and minority ethnic women in the UK. METHODS: A focused ethnography was conducted in South Wales, UK, including semi-structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection. FINDINGS: The midwife-woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health-care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors. CONCLUSIONS: Findings provide new theoretical insights into the complex factors contributing to the health-care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

Eat Well Keep Active: Qualitative findings from a feasibility and acceptability study of a brief midwife led intervention to facilitate healthful dietary and physical activity behaviours in pregnant women.

BACKGROUND: overweight and obesity in the pregnant population is increasing and this is a public health concern. Many women have difficulty in following the recommendation to maintain a healthy diet and to keep active, indeed some identify pregnancy as the start of their concern with being overweight. OBJECTIVE: to assess the feasibility and acceptability of the 'Eat Well Keep Active' intervention programme designed to promote healthy eating and physical activity in pregnant women. This brief midwife led intervention was based upon the Self Determination Theory (SDT) framework and utilised Motivational Interviewing and individualised goal setting. DESIGN: this was a prospective qualitative study to explore women's views on the acceptability and perceived efficacy of the 'Eat Well Keep Active' programme obtained through one-to-one interviews 6 weeks after the delivery of the intervention. Data were also analysed to assess fidelity of the intervention to the psychological constructs of SDT; autonomy, competence and relatedness. SETTING: Wales, UK. PARTICIPANTS: pregnant women suitable for Midwife Led Care and therefore deemed to be 'low risk' were recruited from a large maternity unit in South Wales (n=20). FINDINGS: the results indicated that the 'Eat Well Keep Active' intervention programme was well received by participants who reported that it positively influenced their health behaviours. There was clear evidence of the intervention supporting the three SDT psychological needs. KEY CONCLUSIONS: The Eat Well Keep Active intervention was designed to be incorporated into existing antenatal provision and findings from this study have demonstrated its acceptability. The brief midwife led intervention based on SDT was found to be acceptable by the participants who embraced the opportunity to discuss and explore their lifestyle behaviours with a midwife. IMPLICATIONS FOR PRACTICE: theoretically designed interventions that can facilitate women to pursue a healthy lifestyle during pregnancy are lacking and the 'Eat Well Keep Active' programme has the potential to address this. Further research is needed in order to assess the acceptability of the intervention to midwives and other groups of pregnant women prior to assessing its efficacy in changing and maintaining healthful behaviours.

Sustainability and resilience in midwifery: A discussion paper.

BACKGROUND: midwifery workforce issues are of international concern. Sustainable midwifery practice, and how resilience is a required quality for midwives, have begun to be researched. How these concepts are helpful to midwifery continues to be debated. It is important that such debates are framed so they can be empowering for midwives. Care is required not to conceptually label matters concerning the midwifery workforce without judicious scrutiny and diligence. AIM: the aim of this discussion paper is to explore the concepts of sustainability and resilience now being suggested in midwifery workforce literature. Whether sustainability and resilience are concepts useful in midwifery workforce development is questioned. METHOD: using published primary midwifery research from United Kingdom and New Zealand the concepts of sustainability and resilience are compared, contrasted and explored. FINDINGS: there are obvious differences in models of midwifery care in the United Kingdom and New Zealand. Despite these differences, the concepts of resilience and sustainability emerge as overlapping themes from the respective studies' findings. Comparison between studies provides evidence of what is crucial in sustaining healthy resilient midwifery practice. Four common themes have been identified that traverse the different models of care; Self-determination, ability to self-care, cultivation of relationships both professionally and with women/families, and a passion, joy and love for midwifery. CONCLUSIONS: the impact that midwifery models of care may have on sustainable practice and nurturing healthy resilient behaviors remains uncertain. The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives 'to toughen up' in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife. The findings invite further examination of contextual influences that affect the wellbeing of midwives across different models of care.

Supporting staff to respond effectively to informal complaints: findings from an action research study.

AIM AND OBJECTIVE: To understand how nurses and midwives manage informal complaints at ward level. BACKGROUND: The provision of high quality, compassionate clinical nursing and midwifery is a global priority. Complaints management systems have been established within the National Health Service in the UK to improve patient experience yet little is known about effective responses to informal complaints in clinical practice by nurses and midwives. DESIGN: Collaborative action research. METHODS: Four phases of data collection and analysis relating to primarily one National Health Service trust during 2011-2014 including: scoping of complaints data, interviews with five service users and six key stakeholders and eight reflective discussion groups with six midwives over a period of nine months, two sessions of communications training with separate groups of midwives and one focus group with four nurses in the collaborating trust. RESULTS: Three key themes emerged from these data: multiple and domino complaints; ward staff need support; and unclear complaints systems. CONCLUSIONS: Current research does not capture the complexities of complaints and the nursing and midwifery response to informal complaints. RELEVANCE TO CLINICAL PRACTICE: Robust systems are required to support clinical staff to improve their response to informal complaints and thereby improve the patient experience.

Gatekeeping access to the midwifery unit: Managing complaints by bending the rules.

While poor communication between service users and front-line staff causes many service user complaints in the British National Health Service, staff rarely reflect on the causes of these complaints. We discuss findings from an action research project with midwives which suggest that the midwives struggled to fully understand complaints from women, their partners and families particularly about restricted visiting and the locked door to the midwifery unit. They responded to individual requests to visit out of hours while maintaining the general policy of restricted visiting. In this way, the door was a gatekeeping device which allowed access to the unit within certain rules. The locked door remained a barrier to women and their families and as a result was a common source of informal complaints. We argue that the locked door and restricted visiting to the midwifery unit were forms of gatekeeping and boundary making by midwives which reveals a tension between their espoused woman-centred care and contemporary midwifery practice which is increasingly constrained by institutional values.

Midwives׳ experiences of workplace resilience.

BACKGROUND: many UK midwives experience workplace adversity resulting from a national shortage of midwives, rise in birth rate and increased numbers of women entering pregnancy with complex care needs. Research evidence suggests that workplace pressures, and the emotional demands of the job, may increase midwives׳ experience of stress and contribute to low morale, sickness and attrition. Much less is known about midwives who demonstrate resilience in the face of adversity. Resilience has been investigated in studies of other health and social care workers, but there is a gap in knowledge regarding midwives׳ experiences. OBJECTIVE: to explore clinical midwives׳ understanding and experience of professional resilience and to identify the personal, professional and contextual factors considered to contribute to or act as barriers to resilience. DESIGN: an exploratory qualitative descriptive study. In Stage One, a closed online professional discussion group was conducted over a one month period. Midwives discussed workplace adversity and their resilient responses to this. In Stage Two, the data were discussed with an Expert Panel with representatives from midwifery workforce and resilience research, in order to enhance data interpretation and refine the concept modelling. SETTING: the online discussion group was hosted by the Royal College of Midwives, UK online professional networking hub: 'Communities'. PARTICIPANTS: 11 practising midwives with 15 or more years of 'hands on clinical experience', and who self-identified as being resilient, took part in the online discussion group. FINDINGS: thematic analysis of the data identified four themes: challenges to resilience, managing and coping, self-awareness and building resilience. The participants identified 'critical moments' in their careers when midwives were especially vulnerable to workplace adversity. Resilience was seen as a learned process which was facilitated by a range of coping strategies, including accessing support and developing self-awareness and protection of self. The participants identified the importance of a strong sense of professional identity for building resilience. KEY CONCLUSIONS: this study provides important new insights into resilience within UK midwifery, of relevance to the wider profession. Some findings echo those of other resilience studies; however, there are new insights such as the importance of professional identity which may be relevant to other health care workers. Through understanding more about resilience, it may be possible to facilitate positive adaptation by midwives and ameliorate the effects of workplace adversity. IMPLICATIONS FOR PRACTICE: This study indicates that resilience is a complex phenomenon, which warrants serious consideration from clinical midwives, managers, educators and researchers.

Renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour.

This article presents findings from a study of a clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK. The study was conducted between 2004 and 2006. The pathway aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. This article focuses on how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors. Data are drawn from semi-participant observation, focus groups and semi-structured interviews with 41 midwives, and semi-structured interviews with five midwifery managers and six doctors, working in two research sites. Whereas some studies have shown how clinical pathways may act as 'boundary objects', dissolving professional boundaries, promoting interdisciplinary care and de-differentiating professional identities, the 'normal labour pathway' was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal.