Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England.

BACKGROUND: caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England. OBJECTIVE: to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units. DESIGN: a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews. PARTICIPANTS: twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation. METHODS: collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. FINDINGS: there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline. CONCLUSIONS: it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.

Motherhood, breastfeeding and identity.

Breastfeeding becomes part of a woman's identity as she enters the journey into motherhood. As women face the challenge of balancing the care of a new baby with the rest of life they come across many different ideas about the qualities of a 'good mother' from within their social networks. Throughout their journey into motherhood women weigh up information about breastfeeding in relation to this as they decide what to do. This article identifies the kinds of knowledge women draw on that reinforce their idea of themselves as 'good mothers' and the implications of this for midwifery practice.

Being a 'good mother': managing breastfeeding and merging identities.

Breastfeeding is not simply a technical or practical task but is part of the transition to motherhood, the relationship between mother and baby and the everyday experience of living with a new baby. Discussion of breastfeeding must therefore include the individual's personal and social context. This paper explores how women in England who have chosen to breastfeed their baby accomplish this task during the early stages of motherhood and the relative weight attached to different factors, which impinge on decision-making. Our findings, based on observing 158 interactions between breastfeeding women and midwives or health visitors from one Primary Care Trust in the north of England, UK, and in-depth interviews with a sample of 22 of these women, illustrate the dynamic between breastfeeding, becoming and being a 'good mother' and merging multiple identities as they embrace motherhood. In this context, the value attached to breastfeeding as synonymous with being a 'good mother' is questioned. In managing the balance between ensuring a healthy, contented baby and the reality of their daily lives, women negotiate the moral minefield that defines 'good mothering' and the diverse conceptions and influences that shape it--including health professionals, their social networks and the wider social and structural context of their lives. The implications for policy and practice are discussed.