Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Childbirth experience of migrants in China: a systematic review.

As preliminary research into the childbirth experience of migrants in China, this paper presents a systematic review of Chinese and English literature published between 1999 and 2011 on childbirth in migrants in China. Electronic databases were accessed and papers were found by keyword search. A total of 132 Chinese and 9 English papers were catalogued for review. These papers address migrant maternity issues concerning antenatal, intrapartum, postnatal care, institutional issues, family planning or birth control. Since China's economic reforms, the healthcare infrastructure has been inadequate for childbirth in migrants. They experience more adverse birth outcomes than local residents. This suggests that the effects of change upon childbirth and the existing urban and rural care systems cannot meet the needs of the migrants. There is a lack of research in the childbirth experience of women. Knowledge of their childbirth experience will contribute to the understanding of these needs, informing systems' reform. The medical approach results in many unnecessary interventions and higher costs. It is argued here that a midwifery model of care is most appropriate for the childbirth experience of migrant women.

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study.

AIMS: to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice. SETTING: an urban hospital with 2000-3000 deliveries per year. METHOD: this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically. PARTICIPANTS: the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge. MAIN OUTCOME MEASURE: mode of birth and model of care. FINDINGS: the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as 'two-to-one' care. None of the women labouring in the standard care unit were identified as having a birth companion. DISCUSSION: the concept of 'two-to-one' care emerged as fundamental to women's experiences and utilisation of midwives' skills to promote normal birth and decrease the likelihood of a caesarean section. CONCLUSION: the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women's satisfaction with care within a context of extraordinary high caesarean section rates. IMPLICATIONS FOR PRACTICE: midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.

Views of Chinese women and health professionals about midwife-led care in China.

AIMS: To explore Chinese women's and health professionals' views of the first midwife-led normal birth unit in China to facilitate normal birth and enhance midwifery practice. METHOD: Data collection involved semi-structured interviews, questionnaires and cross-comparison with hospital data. The data were analysed thematically. SETTING: A university teaching hospital in a major city in eastern China. PARTICIPANTS: Purposive sample of 30 women, five midwives and five medical staff who accessed, provided or liaised with the midwife-led service. MAIN OUTCOME MEASURES: Participants' satisfaction, continuity of care/carers, choice and control. FINDINGS: Informants were positive about the unit, largely because the woman was supported by a midwife and a birth companion through the 'two-to-one' model of care. DISCUSSION: The concept of 'two-to-one' care emerged as fundamental to women's experiences and utilisation of midwives' skills to promote normal birth. The high vaginal birth rate and the positive feelings reported suggest that this approach serves to empower women and promote physiological birth. CONCLUSION: Women appreciated the midwife-led service, which provides an environment where they are more likely to aim to give birth without intervention. This model of care is good for its association with increased satisfaction in a context of extraordinarily high caesarean rates. IMPLICATIONS: Midwife-led care can facilitate continuity of care and carer during birth. It offers women choice and control over many aspects of the birth. Further research is required to investigate factors important to women.

Proposed continuing professional education programme for midwives in China: new mothers' and midwives' views.

BACKGROUND: Chinese midwifery is under threat and has been denigrated, with virtually all midwives practising in the labour wards. AIMS: The present study aims to inform the development of a proposed continuing professional education programme. METHOD: Questionnaire surveys and semi-structured interviews were used to investigate the views of new mothers after vaginal births and midwives. The questions focussed on midwives' education, practice and mothers' experience and knowledge of maternity care. Data were analysed using descriptive statistical techniques. PARTICIPANTS: Five researchers, 253 midwives and 214 women. SETTINGS: Ten maternity units/hospitals in seven Chinese cities. FINDINGS: Both mothers and midwives valued continuity of midwifery care. The majority of midwives were obstetric nursing educated; one-fifth had a midwifery background. A smaller minority had a maternity/childcare or obstetric education. Midwifery education is medico/nursing orientated, with only 11.6% of the curriculum midwifery-oriented. DISCUSSION: The perceived different needs reflect the different orientations of the respondents. The programme should be structured to meet mothers' and midwives' needs, cultivate midwives' lifelong learning capacity, and encourage evidence-based practice. CONCLUSION: The study has shown a fundamental problem in Chinese midwifery education, in that midwives do not have access to evidence-based material. Self-directed learning with portfolio assessment is likely to prove useful for the proposed programme; this may facilitate midwives' personal/professional development to update their knowledge, understanding and competence towards their full role as midwives.

Beginning an action research project to investigate the feasibility of a midwife-led normal birthing unit in China.

AIM: To explore issues arising during preliminary stages of a research project in order to consider the feasibility of a midwife-led normal birthing unit in mainland China. BACKGROUND: Midwife-led normal birthing units, as a route to ensuring normality, have become a feature of western maternity care, but are unknown in China. DESIGN: Action research, using a qualitative descriptive approach, was performed. Data were collected at meetings, by non-participant observation and by face-to-face semi-structured interviews. Observation was undertaken in the midwife-led normal birthing unit and a standard care setting. Data analysis was by thematic analysis using constant comparison techniques. METHODS: In the labour ward of a large general hospital in a major city, stakeholders included midwifery staff, managers, university staff and researchers. Childbearing women proved keen to use this service, but were unable to participate in the planning. The midwife-led normal birthing unit sought to provide one-to-one care in labour and support by a birth companion. Routine interventions were to be avoided. RESULTS: The midwives in the midwife-led normal birthing unit created a more suitable environment for supportive care. The midwives demonstrated high-quality communication skills. The woman's choice of position/mobility was limited. Difficulties with staffing were identified. CONCLUSIONS: The preliminary findings suggest that continuation of the project is feasible. The woman's role demonstrates passivity. The perception of staff shortage has serious implications. RELEVANCE TO CLINICAL PRACTICE: This action research project suggests that a study of a midwife-led normal birthing unit in China is feasible, with some attention to staffing issues.

Chinese midwifery: the history and modernity.

AIM: to investigate how and why Chinese midwife numbers are dwindling, and to help understand the role of midwives in society in general. METHOD: to critically examine Chinese midwifery in three stages: (1) historical literature overview; (2) identification and reinterpretation of Chinese midwifery and its development; (3) placing issues that have arisen within a sociological context (i.e. the modernisation of obstetric technologies and the meaning of modernity). FINDINGS: no books on the history of Chinese midwifery were found. History was classified into three stages: (1) before 1929, a period of an indigenous model; (2) 1929-1996, the highs and lows of the bio-medical model; (3) after 1996, the demise of Chinese midwives. The issues identified were the legitimacy and professionalisation of Chinese midwives, the meaning of modernity and the reasons for the decline of Chinese midwifery. CONCLUSION: no sufficient evidence-based research was conducted to support the recent changes made to Chinese midwifery. The modernisation of maternity care in China took place amid dramatic social and cultural changes within society. As a consequence, midwifery as a profession in China has been marginalised. The modernisation of maternity care has failed to deliver on personal choice, quality of service and professional diversity. IMPLICATIONS FOR PRACTICE: evidence-based research and the state's responsibility are essential to ensure the quality of maternity care and to protect the interests of women. The state's responsibilities include legislation regarding the role of midwives, code of practice, professional standards, responsibility and accountability in order to make midwifery care a true choice for women.

Chinese midwives' views on a proposed midwife-led normal birth unit.

OBJECTIVE: to investigate and assess Chinese midwives' views of their roles and ability to practice in a proposed midwife-led normal birth unit (MNBU). DESIGN: a self-completed questionnaire supplemented with semi-structured telephone interviews. Memos, diaries, correspondence and comments of Chinese collaborators were also accessed. SETTING: six hospitals in Hangzhou, the capital of Zhejiang province. PARTICIPANTS: 143 midwives were contacted and completed the questionnaire survey. Three midwives were subsequently interviewed. FINDINGS: the response rate was 100%; 86% of midwives supported the development of an MNBU, and 94.4% expressed confidence that they would be able to practice in an MNBU. The study shed new light on: (1) the meaning of an MNBU in the Chinese context; (2) the need for development of an MNBU; (3) role conflicts among midwives, doulas, nurses and obstetricians; (4) professional expertise and tension; and (5) the low status of Chinese midwives. CONCLUSION: the proposed MNBU is welcomed by Chinese midwives. Their consensus and confidence show that there is enthusiasm for this project to proceed. However, the Chinese have never thought of MNBU services before. There is a need to develop well-structured philosophy, policy, procedures and outcome measures. IMPLICATIONS FOR PRACTICE: the findings highlight the importance of an MNBU to re-establish Chinese midwives' support of physiological childbirth. The extent to which Chinese midwives understand an MNBU could be further explored. The result may provide a possible route to the continuity of midwifery care and support.

'Zuoyuezi' after caesarean in China: an interview survey.

While studying caesarean decision-making in China, the increasing popularity of 'zuoyuezi' emerged. This paper addresses this development, the reasons and implications. We tape-recorded semi-structured interviews in three industrial cities in China. The three groups of informants comprised women in the first-week after caesarean, women eight months after caesarean and health-workers/others. Mandarin or local dialects were used. The data were transcribed and analysed in Chinese and then selected quotes were translated into English. We found that the re-emergence and social modification of zuoyuezi is closely associated with the rising caesarean rate. This custom has been regarded as a crucial rite-of-passage for the woman's recovery and transition to motherhood after childbirth. Its particular importance after caesarean became apparent in this study. Conclusions are drawn about the place of ritual and tradition in 21st century China.

The cultural and social meanings of childbearing for Chinese and Scottish women in Scotland.

OBJECTIVE: to analyse the meanings that women gave to their childbearing experiences in order to provide some useful insights as to how their experiences might be improved. SETTING: maternity units in Scotland. DESIGN: four semi-structured interviews with each of ten Chinese and ten Scottish women in their own language; and unstructured interviews with 45 health workers, women's relatives and their friends. FINDINGS: having children was meaningful to Scottish and Chinese women in Scotland in different ways which were related to their social positions, beliefs and practices involved and the change in social status on the birth of a child. Different meanings demanded different coping strategies in healthy childbearing. Scottish women took greater interest in their sense of control over their childbearing. Some Chinese women were experiencing more extensive cultural conflicts and changes as they tried to identify with the new culture, while the others were experiencing gradual changes over a period of time consciously or unconsciously. Both Chinese and Scottish women in the study were in a struggle between autonomy and control over their childbearing--between the mind and the body. CONCLUSION: childbearing is socially shaped and culturally specific. Maternity services need to consider ways in which cultural sensitive care can be provided to women in a multi-ethnic modern society.

Choice and control as experienced by Chinese and Scottish childbearing women in Scotland.

OBJECTIVE: to provide some insights as to how women's childbearing experiences might be improved. DESIGN: a qualitative comparative approach. SETTING: maternity units in Scotland. METHOD: two case comparison, four tape-recorded semi-structured interviews with each of ten Chinese and ten Scottish women, and one unstructured interview with 45 health workers, women's relatives and friends. This study was set against the background of existing literature and the author's personal experience as a midwife in both Chinese and Scottish societies and as a Chinese mother having her first baby in Scotland. FINDINGS: the issues of 'choice' and 'control' in childbearing regulated the social relationships between women, women's bodies, their babies, health workers, obstetric technology and the wider social context. Although the Chinese and Scottish women under investigation were in Scotland, their different cultural backgrounds gave them different expectations, choices and experiences. These differences are further examples of the social and cultural construction of choice and control. CONCLUSION: 'choice' and 'control' offered some new dimension for the women to achieve; for the health workers and society to facilitate a new dynamic and stimulating childbearing experience. Women's bodies' cues, their babies and their feeling of being in control could be important in the management and their experience of care.