Tensions Between Ethics and the Law: Examination of a Legal Case by Two Midwives Invoking a Conscientious Objection to Abortion in Scotland.

This paper examines a legal case arising from a workplace grievance that progressed to being heard at the UK's Supreme Court. The case of Doogan and Wood versus Greater Glasgow and Clyde Health Board concerned two senior midwives in Scotland, both practicing Roman Catholics, who exercised their perceived rights in accordance with section 4(1) of the Abortion Act not to participate in the treatment of women undergoing abortions. The key question raised by this case was: "Is Greater Glasgow and Clyde Health Board entitled to require the midwives to delegate, supervise and support staff in the treatment of patients undergoing termination of pregnancy?" The ethical issues concerning conscientious objection to abortion have been much debated although the academic literature is mainly concerned with the position of medical practitioners rather than what the World Health Organization terms "mid-level professionals" such as midwives. This paper examines the arguments put forward by the midwives to justify their refusal to carry out tasks they felt contravened their legal right to make a conscientious objection. We then consider professional codes, UK legislation and church legislation. While the former are given strong weighting the latter was been ignored in this case, although cases in other European countries have been prevented from escalating to such a high level by the intervention of prominent church figures. The paper concludes by stating that the question put to the courts remains as yet unanswered but offers some recommendations for future policy making and research.

A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound.

BACKGROUND: Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives' experiences and views on the role of ultrasound in clinical management of pregnancy. METHODS: A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis. RESULTS: Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only 'perfect' children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children. CONCLUSIONS: Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators' technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents' approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use.

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.

Nurse-midwife and scientist: stuck in the middle?

The nurse-midwife and scientist share similar ethos (fundamental attitudes that guide action); yet, in their respective professional roles, ethos can translate into actions that appear discordant. Discord can lead to resolution, when examined through the primary principles of ethical conduct: autonomy, beneficence, nonmalfeasance, and justice.

Ethics of justice and ethics of care. Values and attitudes among midwifery students on adolescent sexuality and abortion in Vietnam and their implications for midwifery education: a survey by questionnaire and interview.

UNLABELLED: Adolescent's sexuality and related reproductive health and rights problems are sensitive issues in Vietnam. Globalisation has had an impact on the lifestyles of young people, and rising numbers of abortion and STI/HIV risks among youth are posing major health concerns in the country. These problems need to be addressed. Midwives belong to a key category of health personnel in Vietnam, whose task it is to promote adolescents' sexual and reproductive health and prevent reproductive ill health. It is important to understand future midwives' perceptions and attitudes in order to improve their education and training programmes. AIM: The aim of this study was to investigate Vietnamese midwifery students' values and attitudes towards adolescent sexuality, abortion and contraception and their views on professional preparation. METHODS: A quantitative survey including 235 midwifery students from four different secondary medical colleges in northern Vietnam was carried out in 2003. A qualitative study addressing similar questions was performed and 18 midwifery students were individually interviewed. FINDINGS: Findings revealed a general disapproval of adolescent pre-marital sexual relations and abortion-'an ethics of justice'-but also an empathic attitude and willingness to support young women, who bear the consequences of unwanted pregnancies and social condemnation-'an ethics of care'. Gender-based imbalance in sexual relationships, limited knowledge about reproductive health issues among youth, and negative societal attitudes were concerns expressed by the students. The students saw their future tasks mainly related to childbearing and less to other reproductive health issues, such as abortion and prevention of STI/HIV. CONCLUSION: Midwifery education in Vietnam should encourage value-reflective thinking around gender inequality and ethical dilemmas, in order to prepare midwives to address adolescents' reproductive health needs.

Standards for education and training for interagency working in child protection in the UK: implications for nurses, midwives and health visitors.

This article presents a discussion of key issues for the education of nurses, midwives and health visitors following the completion of a Department of Health funded project, managed by the General Social Care Council and conducted jointly by two research centres; Salford Centre for Social Work Research and Salford Centre for Nursing, Midwifery and Collaborative Research. The work was initiated in response to Lord Laming's report on the circumstances leading to the death of Victoria Climbié. The project was conducted in relation to specified professions and occupational groups: doctors; health visitors; midwives; nurses; police; teachers, and social workers. It was undertaken in two stages. The first stage mapped existing material about standards in relation to education and training for interagency working. The second stage engaged in an extensive consultation exercise through which a model and a set of proposed standards for interagency education and training for interagency work were developed. The former is detailed fully in this report, while nine examples of standards are presented. The project final report was presented seven months after commencement.

Conducting international research in midwifery: a workshop held at the ICM Congress, Vienna, April 2002.

A workshop on international research in midwifery was held at the triennial International Confederation of Midwives (ICM) Congress in Vienna, April 2002. Thirty-five participants from 12 countries took part. The participants themselves defined the agenda, and subsequent discussion addressed the following issues: international research relationships and collaboration; ethical conduct in international research in midwifery; the role of the ICM in international research; and identifying topics for an international midwifery research agenda. Recommendations arising from this workshop were: that guidelines and a code of ethics for the conduct of international research in midwifery be developed; that the ICM and national midwifery organisations continue to actively support research, and further develop that support; that the ICM support education and capacity building for research at basic and continuing education levels; and that the priorities identified for collaborative international studies be updated on a regular basis.

The perceived problem solving ability and values of student nurses and midwives.

Problem solving is defined as a response given in an important and difficult situation, where critical thinking is required for a solution. Problem solving skills determine a person's ability to relate productively. This research was to determine the perceived problem solving ability and values of student nurses and midwives. It was planned as a descriptive research project in the University of Kocaeli's, Higher School of Health (Nursing and Midwifery School) in order to find out how students perceive their own problem solving skills, and to examine the relationship between problem solving skills and personal values. The data were collected from 218 students by using a questionnaire to determine the characteristics of the students and the "Problem Solving Inventory" (developed by Heppner and Petersen [Journal of Counseling Psychology 29 (1) (1982) 66]) whose reliability and validity for our country had been tested by Sahin et al. (1993) The scores of the subjects were evaluated and analyzed. Students who describe themselves in accordance with the values of truth (14.2%) and human dignity (19.3%) were also found to evaluate themselves successful in problem solving. Students who expressed that they act systematically (44.5%) and decisively (74.3%) in problem solving were also found to evaluate themselves as successful (47.8%) in problem solving. The results of our study have shown that education in professional ethics should provide the development of professional values (especially of truth and human dignity). Concerning value-laden issues education should help students to reach the desired levels of problem solving skills by allowing them to acquire abilities such as self awareness and being inquisitive.

New code is a victory for consensus in the profession, says regulator.

The Nursing and Midwifery Council's code of conduct is at the heart of every nurse's practice, setting out standards of conduct, performance and ethics for the profession.

Student midwives' responses to reproductive ethics: a qualitative focus group approach using case scenarios.

OBJECTIVE: the aim of this study was to gain an understanding of how midwifery students respond to a range of ethical dilemmas which they may encounter in clinical practice in relation to the use of reproductive technologies. DESIGN: during a series of focus groups, student midwives were asked to consider four novel scenarios, which highlighted some of the most controversial issues in contemporary reproductive ethics. These included assisted reproduction for older women, surrogacy and mental health, sex selection and reproductive cloning. SETTING: a University in the East Midlands, England. PARTICIPANTS: purposeful sampling was adopted which resulted in four focus groups with a total of 16 student midwives. FINDINGS: a process of thematic analysis generated four key themes: choice and expectation, consumer society; distributive justice; parental rights and welfare of the child. CONCLUSIONS: our results suggest that student midwives are sensitive to the range of ethical dilemmas associated with the increased use of technology in human reproduction, and construct distinct boundaries in relation to what is considered of benefit or good to the mother, parents, the child and to society and what is considered harmful to the individual, the child and society. They also expressed their opposition to the excessive use of technological intervention, preferring instead to maintain a more naturalistic approach to reproduction. This is especially significant where concerns about the welfare of the child are articulated.

Influencia del desempeño de los profesionales de enfermería en la atención humanizada al parto / The Influence of Nursing Professionals' Performance on Humanized Care during birth labor

RESUMEN Introducción: El parto es atendido de forma directa por el personal de salud, según su perfil o especialización, y el personal de enfermería posee la responsabilidad de la calidad y el logro de la excelencia en la prestación de servicios que brinda de forma humanizada, asumido desde la mejora de su desempeño profesional. Objetivo: Precisar la influencia del desempeño de los profesionales de enfermería en la atención humanizada al parto. Métodos: Se realizó una revisión bibliográfica sistemática para desarrollar un análisis crítico reflexivo del contenido de documentos, se consideraron tesis de doctorado, maestría, artículos originales y de revisión publicados entre 1992 y 2015 en español e inglés. La búsqueda fue realizada en las bases de datos SciELO y Google académico de enero a marzo de 2016, las palabras clave utilizadas fueron "enfermería obstétrica", "parto", "humanización", "desempeño profesional de enfermería" y "valores éticos y humanos". Tras la identificación de los estudios pre-seleccionados se llevó a cabo la lectura de los títulos, resumen y palabras clave, comprobando la pertinencia con el estudio. Conclusión: La atención humanizada al parto es una interacción entre los conocimientos y sentimientos por cada mujer, que permite establecer una asistencia de calidad con expresión humana durante el cuidado ofrecido por enfermería partiendo de la influencia de su modo de actuación, de su hacer, en el logro de la humanización(AU)

ABSTRACT Introduction: Birth labor is attended directly by the health personnel, according to their profile or specialization, while the nursing staff has the responsibility for quality and the achievement of the excellence in the provision of services offered in a humanized way, assumed from the improvement of their professional performance. Objective: To determine the influence of the performance of the nursing professionals in the humanized attention to birth labor. Methods: A systematic bibliographic review was carried out to develop a reflexive critical analysis of the content of documents, Ph.D. and master's dissertations, and original and review articles published between 1992 and 2015 in Spanish and English. The search was made in the academic databases SciELO and Google, from January to March 2016; the key words used in Spanish were enfermería obstétrica [obstetric nursing], parto [birth labor], humanización [humanization], desempeño profesional de enfermería [nursing professional performance], and valores éticos y humanos [ethical and human values]. After the identification of the pre-selected studies, the titles, summary and the key words were read, verifying the relevance with the study. Conclusion: The humanized attention to birth labor is an interaction between the knowledge and feelings for each woman, which allows to establish a quality assistance with human expression during the care offered by nursing initiated in the influence of their way of acting, of doing, and resulting in the achievement of humanization(AU)

Percepção de presidiárias sobre a assistência à saúde materna em uma penitenciária feminina / Percepción de los presos de la atención de la salud materna en una cárcel de mujeres / Prisoners' perception of maternal health care in a women's prison

RESUMO Introdução: o direito à saúde da mulher está definido na Constituição Brasileira e na Lei Orgânica da Saúde, mas todos esses aspectos são discutidos pensando na mulher que goza de liberdade física e jurídica, desconhecendo a realidade de mulheres presidiárias, cujo acesso às informações torna-se mais difícil e que por apresentarem uma história de vida muitas vezes penosa, enfrentam ainda mais o preconceito, devido às várias exposições sociais. Objetivo: analisar e descrever a percepção de presidiárias sobre a assistência à saúde materna em uma penitenciária feminina. Métodos: estudo descritivo e exploratório de abordagem qualitativa, desenvolvido no ano de 2014 numa penitenciária feminina de referência da capital piauiense, Brasil. Participaram 14 presidiárias selecionadas mediante os critérios de inclusão. Coletou-se os dados através de entrevista semiestruturada e foram analisados mediante a técnica de análise de conteúdo. Resultados: a partir da análise emergiram duas categorias temáticas, a saber: O Enfermeiro presente na assistência pré-natal e puerperal das presidiárias; e a falta de assistência humanizada, diante de presidiárias no ciclo gravídico puerperal. Conclusão: as participantes relataram que a Enfermagem é atuante no pré-natal e puerpério, porém queixam-se do atendimento desumano que lhes é prestado, devido ao preconceito dos profissionais de saúde relacionado à sua condição prisional(AU)

RESUMEN Introducción: el derecho a la salud de la mujer se define en la Constitución brasileña y la Ley Orgánica de Salud, pero todos estos aspectos se discuten pensando en la mujer que disfruta de la libertad física y jurídica, haciendo caso omiso de la realidad de las internas, en cuyo acceso a la información tornados más duro y que presentan una historia de vida a menudo dolorosa, aún más de cara al perjuicio debido a diversas exposiciones sociales. Objetivo: analizar y describir la percepción de los presos en la atención de la salud materna en una cárcel de mujeres. Métodos: estudio descriptivo y exploratorio de abordaje cualitativo, desarrollado en 2014 una hembra de capital penitenciario referencia Piauí, Brasil. Los participantes fueron 14 prisioneros seleccionados por los criterios de inclusión. Hemos recogido los datos a través de entrevistas semiestructuradas y se analizaron mediante análisis de contenido. Resultados: del análisis surgieron dos categorías temáticas: la enfermera presente en el prenatal y puerperal a los presos; y la falta de asistencia humana, antes de prisioneros en el ciclo de embarazo puerperales. Conclusión: el estudio permitió conocer la percepción del grupo estudiado. Los participantes informaron que la enfermería está activa en prenatal y posparto, pero se quejan de la atención inhumana que se les proporciona a ellos, debido a la tendencia de los profesionales de salud relacionados con su condición de prisión(AU)

ABSTRACT Introduction: The right to health of women is defined in the Brazilian Constitution and the Organic Law of Health, but all of these aspects are discussed thinking about the woman who enjoys physical and legal freedom, ignoring the reality of female prisoners, whose access to information torna-harder and that they present a life story often painful, even more face prejudice due to various social exhibits. Objective: To analyze and describe the perception of prisoners on the maternal health care in a women's prison. Methods: Descriptive and exploratory study of qualitative approach, developed in 2014 a female reference penitentiary capital Piaui, Brazil. Participants were 14 prisoners selected by the inclusion criteria. We collected the data through semi-structured interviews and were analyzed by using content analysis. Results: From the analysis emerged two thematic categories, namely: The nurse present in the prenatal and puerperal of prisoners; and the lack of human assistance, before prisoners in the puerperal pregnancy cycle. Conclusion: The survey allowed to know the perception of the group studied. Participants reported that nursing is active in prenatal and postpartum, but complain about the inhumane care that is provided to them, due to the bias of health professionals related to his prison condition(AU)

Assessing women's sexual life after childbirth: the role of the postnatal check.

OBJECTIVE: to describe midwives' reflections on counselling women at the postnatal check with special focus on sexual life after childbirth. DESIGN: qualitative descriptive study with focus group discussions as the method of data collection. SETTING: antenatal clinics in Stockholm greater catchments' area. PARTICIPANTS: during 2006 and 2007, a voluntary sample of midwives from 10 different antenatal clinics were invited. ANALYSIS: content analysis was undertaken through identification of codes, categories and themes. FINDINGS: Two themes emerged: balancing between personal perceptions of the woman's needs and the health system restrictions and strategies for counselling about sexual life after childbirth'. The midwives tried to create a picture for themselves of the woman coming for the postnatal check and her needs before the consultation. This picture guided the midwives, but lack of time and knowledge restricted them when counselling on sexual life after childbirth. Two different strategies in counselling were identified, one task-oriented and one subject-oriented. Demands and time restrictions led midwives to distance themselves from their clients. A task-oriented approach was more visible in midwives' encounters with foreign-born women, where linguistic difficulties, cultural diversity and narrow time frames restricted the midwives' effectiveness and/or sensitivity as caregivers. In contrast, the subject-oriented strategy meant 'getting in tune', i.e. listening to the woman when she expressed her feelings and emotions, encouraging the woman to be an active participant in decisions involving her care. This strategy is used for women who arouse midwives' empathy and when there is some form of recognition and understanding. CONCLUSION: The picture created of the woman and her needs guided the midwives, but lack of knowledge and time limitations restricted counselling on sexual life after childbirth. Two counselling strategies were identified, one task-oriented and one subject-oriented. Balancing these two counselling strategies improves both the ethical aspects and the quality of the counselling.

'You can drop dead': midwives bullying women.

BACKGROUND: This paper describes how women experienced what came to be labelled as 'bullying' by a small number of midwives when they were evacuated from their rural and remote areas of NSW, Australia to a maternity unit to birth. RESEARCH QUESTION: What is the experience of women who are required to travel away from their NSW rural/remote communities to birth? PARTICIPANTS AND METHODS: Forty-two participants together with a number of their partners/support people were interviewed in depth for this qualitative, exploratory study. Upon thematic analysis of the transcribed interviews, an unexpected finding was that four participants (plus one partner) described experiences which were interpreted as bullying, by a small number of midwives working with them. Women identifying as Aboriginal were especially likely to share stories of midwifery bullying. RESULTS, DISCUSSION AND CONCLUSION: Emotional and cultural safety of women must be a prime consideration of midwives. Strategies to reverse power differentials between midwives and women are urgently required to eradicate bullying by any midwife.

Screening de primer trimestre de preeclampsia tardía en gestantes de bajo riesgo en un centro de bajo volumen obstétrico: validación externa de un modelo predictivo / First trimester screening of late-onset preeclampsia in a low risk and low volume obstetrical setting: external validation of a predictive model

Fundamento: La validación externa de un modelo predictivo de predicción de preeclampsia tardía en un centro de bajo volumen obstétrico en gestantes de bajo riesgo obstétrico. Métodos: Estudio prospectivo de 174 gestaciones únicas de 11+0 a 13+6 semanas de gestación en la Clínica Universidad de Navarra desde septiembre 2011 a marzo de 2013, que fue considerado como una cohorte de validación de un modelo descrito anteriormente para preeclampsia tardía en el hospital Clínic de Barcelona). Resultados: Un total de 7 (4%) mujeres desarrollaron PE tardía. En la cohorte de validación el área bajo la curva del modelo fue de 0,69 (IC del 95% 0,45 a 0,93). Las tasas de detección para un 5, 10 y 15% de tasas de falsos positivos fueron 21,9, 31,4 y 38,6%. Al comparar las áreas bajo la curva de la cohorte de validación con la cohorte de la construcción, no se encontraron diferencias estadísticamente significativas (p = 0,68). Conclusión: La combinación de la historia clínica materna, la proteína placentaria A-asociada al embarazo y presión arterial media es moderadamente útil para predecir preeclampsia tardía en gestantes de bajo riesgo y en un centro de bajo volumen obstétrico. El modelo predictivo del hospital Clinic de Barcelona es una herramienta válida para predecir preeclampsia tardía en este entorno (AU)

Background: The external validation of predictive model of late preeclampsia in a low volume and low risk obstetrical setting. Methods: A cohort was created of 174 singleton pregnancies of 11+0-13+6 gestational weeks at Clinica Universidad Navarra from September 2011 to March 2013, which was considered as a validation cohort of a previously described model for late PE (Hospital Clinic, Barcelona). Results: A total of 7 (4%) women developed late PE. In the validation cohort the area under the curve of the model was 0.69 (95% CI 0.45-0.93). Detection rates for a 5, 10 and 15% of false positive rates were 21.9, 31.4% and 38.6% respectively. When comparing the areas under the curve of the validation cohort with the construction cohort, no statistical differences were found (p=0.68). Conclusion: The combination of maternal history, pregnancy associated plasma protein-A and mean arterial pressure is moderately useful to predict preeclampsia in a low risk and low volume obstetrical setting. The predictive model of the Clinic Hospital of Barcelona is a valid tool in predicting late preeclampsia in this setting (AU)