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

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

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.

Midwifing the notion of a 'good' birth: a philosophical analysis.

OBJECTIVE: to ponder afresh what makes a good birth experience in a listening manner. DESIGN: a hermeneutic approach that first explores the nature of how to listen to a story that is already familiar to us and then draws on Heidegger's notion of the fourfold to seek to capture how the components of a'good birth' come together within experience. SETTING: primary birthing centre, New Zealand PARTICIPANTS: the focus of this paper is the story of one participant. It was her second birth; her first birth involved a lot of medical intervention. She had planned to travel one hour to the tertiary birthing unit but in labour chose to stay at the Birth Centre. Her story seems to portray a 'very good birth'. FINDINGS: in talking of birth, the nature of a research approach is commonly to focus on one aspect: the place, the care givers, or the mode of care. In contrast, we took on the challenge of first listening to all that was involved in one woman's story. We came to see that what made her experience 'good' was'everything' gathered together in a coherent and supportive oneness. Heidegger's notion of the fourfold helped reveal that one cannot talk about one thing without at the same time talking about all the other things as well. Confidence was the thread that held the story together. KEY CONCLUSIONS: there is value in putting aside the fragmented approach of explicating birth to recognise the coming together of place, care, situation, and the mystery beyond explanation. Women grow a confidence in place when peers and community encourage the choice based on their own experience. Confidence of caregiver comes in relationship. Feeling confident within 'self' is part of the mystery. When confidence in the different dimensions holds together, birth is 'good'. IMPLICATIONS OR PRACTICE: one cannot simply build a new birthing unit and assume it will offer a good experience of birth. Experience is about so much more. Being mindful of the dimensions of confidence that need to be built up and sheltered is a quest for wise leaders. Protecting the pockets where we know 'good birth' already flourishes is essential.

Planned place of birth in New Zealand: does it affect mode of birth and intervention rates among low-risk women?

BACKGROUND: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. METHODS: Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. RESULTS: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. CONCLUSIONS: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.