Clinical Midwives Research Articles

The Virtual International Day of the Midwife: A Synchronous Open Online Conference for Continuing Professional Development and Learning for Midwives

AIM: To examine the contribution of the Virtual International Day of the Midwife (VIDM) conference to midwives’ continuing professional development (CPD).BACKGROUND: Knowledge and understanding of CPD for midwives as synchronous online learning is limited. Studies of e-learning programs for CPD have underlined the need for interaction with others. The VIDM is a synchronous online 24-hour conference freely available for midwives designed to provide a unique CPD opportunity.METHOD: An online survey with a mix of fixed-response, multiple-response, and open-ended free-text questions was available to participants for 1 month after the conference via the wiki page in 2012 and 2013.FINDINGS: The survey was completed by 239 conference participants. Midwifery students and clinical midwives were the largest groups of attendees. The most common countries of residence were Australia, United Kingdom, and United States. Respondents believed that the conference contributed to their professional development by enabling professional growth, facilitating shared learning, and raising awareness of global issues.CONCLUSION: Offering synchronous events is important to facilitate deeper learning for those engaging in online activities. As an annual synchronous 24-hour, open online conference, the VIDM has become a valuable CPD opportunity for midwives.

Mentoring Characteristics in Competent Clinical Educators who provide new Midwives with Instructions in Delivery Assistance

Background: There are certainly clinical midwives that contribute greatly to the education of new midwives. However, inexperienced midwifery educators have difficulties with education, especially with instructing delivery assistance. Objectives: This study reported the secondary outcome of the authors’ previous study. The purpose of this study was to explore the mentoring characteristics in competent clinical educators who provide new midwives with instructions in delivery assistance. Method: Questionnaires were distributed to 694 midwives who had previously conducted educational activities with new midwives at the 63 facilities whose administrator or nurse manager in charge of all staff consented to participate. Of the 694 midwives, 464 (66.9%) returned the questionnaire and 317 (45.7%) valid responses were analyzed. Midwives were classified into the following three groups; Novice, Beginner and Competent, comparing the scores of the three concepts, nine sub-concepts, each of the 41 MCCM items and total MCCM of the midwives’ responses. Results: The results showed that scores in all domains increased from Novice to Beginner and to Competent. In terms of MCCM score, Competent showed a significantly higher score than that of Novice (Competent: 157.8 ± 21.3; Novice: 141.6 ± 19.5, p<0.01), while there were no significant differences between the scores of Beginner and Competent. As for the concept of “Competency as a professional”, Competent showed significantly higher scores than Novice in every item, but showed significantly higher scores than Beginner in only one item relating to midwifery diagnoses. As for the concept of “Competency as an Educator”, Competent showed significantly higher scores than Novice in all items except items relating to thoughtfulness and empathy for the new midwives. As for the concept of “Personal characteristics”, there were five items that showed no significant differences between Competent and Novice and Beginner. Conclusion: From this study, mentoring characteristics found in “Competent” midwifery educators were concretely revealed.

Co-Sleeping and Bed Sharing in Australian Maternity Units: An Electronic Survey of Midwifery Clinicians’ Knowledge, Practice, and Education

BACKGROUND: There is little published research regarding co-sleeping and bed sharing in maternity units. As primary carers of mothers and infants, midwives’ knowledge and practice may influence co-sleeping and bed sharing.AIM: To assess clinical midwives’ knowledge and practice surrounding co-sleeping and bed sharing in maternity units in the initial postpartum period.METHODS: A nationwide electronic survey assessed clinical knowledge and self-reported clinical practice and personal experiences of co-sleeping and bed sharing.FINDINGS: Eighty-six registered midwives from 48 hospitals responded to the survey. The majority responded with best practice to hypothetical scenarios. Mother–infant co-sleeping/bed sharing in maternity units was observed by 64% of midwives. All midwives reported providing some education to parents and most (80%) had received education on co-sleeping/bed sharing.CONCLUSION: Co-sleeping and bed sharing are relatively common in postnatal maternity units. Clinical practice documents should be consistent with the UNICEF guidelines, and midwives should be supported to implement best practice.

Mary Renfrew: researcher, reformer, midwife

Mary Renfrew: researcher, reformer, midwife

A study of Iranian nurses' and midwives' knowledge, attitudes, and implementation of evidence-based practice: the time for change has arrived.

Evidence-based practice (EBP) leads to enhanced quality of care, and the individual and professional development of nurses and midwives. Therefore, it is important for nurses and midwives as well as all other healthcare providers and stakeholders to inform clinical decision-making and implement EBP. This study aimed to determine the EBP knowledge, attitudes, and practice of clinical nurses and midwives in Mashhad public hospitals in Iran. The descriptive cross-sectional study was conducted with a stratified cluster, random sample of 240 employed nurses and midwives (response rate of 96%) in Mashhad, who held a Bachelor of Science degree and had at least 1 year of clinical experience. Two valid and reliable questionnaires were used to collect demographic and EBP data. Data were analyzed using SPSS version 11.5 software and descriptive and inferential statistics calculated. Participants' mean age was 31.0 (SD = 5.5) years and 80% (n = 194) were female. Most participants reported low knowledge or skills and practice of EBP, but moderate attitudes toward EBP. Significant differences between the mean scores on knowledge or skills, attitudes, and practice were identified by field of study. Nurses reported higher knowledge or skills and practice of EBP than midwives (p < .001). Nurses and midwives with master-s degrees displayed greater knowledge or skills and practice of EBP, and more positive attitudes than nurses with bachelor-s degrees (p < .001). Although clinical nurses and midwives apply EBP in clinical settings, it is necessary to develop their knowledge or skills and practice. The results of this study can be applied by educational planners, educational managers, and authorities to enhance the quality and consistency of EBP implementation. The results provide a base for future studies in this field.

Opinions of Maternity Care Professionals About Integration of Care During Labor for “Moderate Risk” Indications: A Delphi Study in The Netherlands

The percentage of referrals during labor from primary midwife-led care to obstetrician-led care has increased over the past years in The Netherlands. Most women are referred for indications with a moderate increase in risk and are looked after by clinical midwives. This study aims to provide insight into the opinions of maternity care professionals about integration of care and involvement of primary care midwives in the intrapartum care of women with "moderate risk" factors. A Delphi study consisting of three rounds was conducted. A purposively selected heterogenic panel of 50 professionals, including obstetricians, primary care midwives, clinical midwives, and obstetric nurses, answered questions anonymously. Although primary care midwives would like to expand their responsibilities and tasks with respect to "moderate risk" indications, consensus among panel members was only reached concerning prolonged rupture of membranes for which the primary care midwife could remain the caregiver. This study shows that most participants support more integration of care during labor. The lack of consensus among Dutch maternity care professionals with regard to the distribution of responsibilities and tasks for "moderate risk" indications is a challenge. Further studies should explore how to deal with differences in opinions among professionals when integrating maternity care systems.

Midwives׳ experiences of workplace resilience

Backgroundmany 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. Objectiveto 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. Designan 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. Settingthe online discussion group was hosted by the Royal College of Midwives, UK online professional networking hub: ‘Communities’. Participants11 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. Findingsthematic 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 conclusionsthis 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 practiceThis study indicates that resilience is a complex phenomenon, which warrants serious consideration from clinical midwives, managers, educators and researchers.

Experiences of mothers with substance dependence: Informing the development of parenting support.

To understand the experiences of women with a history of substance dependence when they attempted to gain parenting support. Becoming a mother provides a window of opportunity to support women with a substance dependence make changes to their lives and the way they will parent their infants and young children. Yet there are many barriers and a constant fear of the removal of their children from their care. Focus groups were conducted using a qualitative interpretive descriptive approach to enable exploration of the women's experiences as mothers with infants and young children. A series of three focus groups were facilitated with three to six women per group. Thirteen women who were substance dependent participated in this study. Semi-structured interviews guided the collection of data. Thematic content analysis was used to work with the data. Four themes were identified: (1) feelings of guilt, (2) judged by others, (3) normalising and (4) support and learning to be a mother. The mothers expressed alienation from mainstream health services. Providing parenting and child health services, which avoid mothers feeling judged by the staff and other mothers, is an important step to enabling these women to appropriately and sensitively care for their infants and young children. Midwives and nurses working with mothers and their infants and young children are well positioned to support women who are or have experienced substance dependence. Working with this group of mothers requires the development of a therapeutic relationship to provide optimum support, education and, if necessary, intervention.

Care providers’ views and experiences of postnatal care in private hospitals in Victoria, Australia

Objectivein Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers’ views and experiences of postnatal care in private hospitals. Designqualitative design using semi-structured interviews and thematic analysis. Settingprivate maternity hospitals in Victoria, Australia. Participantseleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians. Findingstwo global themes were identified: ‘Constrained Care’ and ‘Consumer Care’. ‘Constrained care’ demonstrates the complexity of the provision of postnatal care and encompasses midwives’ feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). ‘Consumer care’ describes care providers’ views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care. Key conclusionsthis study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.

The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project

BackgroundMaternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses).Methods/designThis is a cluster randomised controlled trial with the unit of randomisation being the 14 districts of central and northern Malawi (one large district was divided into two giving an overall total of 15). Eight districts will be randomly allocated the intervention. Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme (the intervention). Primary outcome will be maternal and perinatal (defined as until discharge from health facility) mortality. Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project (3–4 years) and comparisons made. In addition a process evaluation using both quantitative and qualitative (e.g. interviews) will be undertaken to evaluate the intervention implementation.DiscussionEducation and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi. Some of the challenges faced are discussed as are the potential limitations. It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training.Trial registrationISRCTN63294155

PP167. A process evaluation of an innovative implementation strategy of the Dutch guidelines on hypertensive disorders in pregnancy using a computerized decision support system

Hypertensive disorders in pregnancy remain the leading cause of maternal mortality in the Netherlands. The Dutch Society of Obstetrics and Gynecology (NVOG) has developed evidence-based guidelines on the management of hypertension in pregnancy. Previous studies showed a low adherence rate to other NVOG guidelines and a large variation in usual care in different hospitals. In the BIG CHANGE trial an innovative implementation strategy of the NVOG guidelines on hypertension using a web-based application (BOS, by Giant Soft, Leeuwarden, The Netherlands) was compared to a common strategy of professional audit and feedback. In this study a process evaluation of BOS has been done, analyzing its efficiency, barriers and formulate improvement points. Gynecologists, residents and clinical midwives from seven hospitals using BOS were asked to fill in the questionnaire. A questionnaire was developed on the following items: efficiency, barriers and improvement. Thirty four completed questionnaires useful for analysis. 63.6% of the respondent also consulted the NVOG guideline or local protocol, mainly for confirmation of information, background information, medication. Technical problems were found in 44.1%. Positive opinions on user friendliness varied from 73.5% to 100%. No significant difference was found between the user frequency of BOS compared to the NVOG guidelines or local protocol, or between the time needed to consult them. Improvements mentioned by the respondents were mainly regarding the lay-out. Most respondents (85.3%) found it useful to make a computer based support system for other guidelines and 79.4% would also use this. BOS is regarded suitable as an instrument for implementing guidelines and respondents find it useful to develop it for other guidelines as well. Technical problems and poor implementation are important areas of improvement.

Supply-related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: evidence from two rural districts

BackgroundSince its introduction in the national antenatal care (ANC) system in Tanzania in 2001, little evidence is documented regarding the motivation and performance of health workers (HWs) in the provision of intermittent preventive treatment of malaria during pregnancy (IPTp) services in the national ANC clinics and the implications such motivation and performance might have had on HWs and services' compliance with the recommended IPTp delivery guidelines. This paper describes the supply-related drivers of motivation and performance of HWs in administering IPTp doses among other ANC services delivered in public and private health facilities (HFs) in Tanzania, using a case study of Mkuranga and Mufindi districts.MethodsInterviews were conducted with 78 HWs participating in the delivery of ANC services in private and public HFs and were supplemented by personal communications with the members of the district council health management team. The research instrument used in the data collection process contained a mixture of closed and open-ended questions. Some of the open-ended questions had to be coded in the form that allowed their analysis quantitatively.ResultsIn both districts, respondents acknowledged IPTp as an essential intervention, but expressed dissatisfaction with their working environments constraining their performance, including health facility (HF) unit understaffing; unsystematic and unfriendly supervision by CHMT members; limited opportunities for HW career development; and poor (HF) infrastructure and staff houses. Data also suggest that poor working conditions negatively affect health workers' motivation to perform for ANC (including IPTp) services. Similarities and differences were noted in terms of motivational factors for ANC service delivery between the HWs employed in private HFs and those in public HFs: those in private facilities were more comfortable with staff residential houses, HF buildings, equipment, availability of water, electricity and cups for clients to use while taking doses under direct observed therapy than their public facility counterparts. Employees in public HFs more acknowledged availability of clinical officers, nurses and midwives than their private facility counterparts. More results are presented and discussed.ConclusionThe study shows conditions related to staffing levels, health infrastructure and essential supplies being among the key determinants or drivers of frontline HWs' motivation to deliver ANC services in both private and public HFs. Efforts of the government to meet the maternal health related Millennium Development Goals and targets for specific interventions need to address challenges related to HWs' motivation to perform their duties at their work-places.

Determination of foetal sex in pregnancies at risk of haemophilia: a qualitative study exploring the clinical practices and attitudes of health professionals in the United Kingdom

In pregnancies at risk of haemophilia, foetal sex determination is used to plan perinatal management and to guide the offer of invasive testing in pregnancies with a male foetus. Traditionally ultrasound from 12 weeks gestation has been used, but recently options for early foetal sex determination have increased following the introduction of non-invasive prenatal diagnosis (NIPD) using cell free foetal DNA in maternal plasma. This study was conducted to identify clinical practices and examine health professional attitudes regarding NIPD for foetal sex determination. A qualitative approach using one-to-one semi structured interviews was used to enable an in-depth exploration of current practice, introduction and use of NIPD and benefits and disadvantages of offering NIPD. Interviews were conducted with consultant haematologists (N = 7), specialist haemophilia nurses (N = 7), genetic counsellors (N = 6), consultants in clinical genetics (N = 5), specialist midwives (N = 2) and obstetricians (N = 5) from 24 services across the United Kingdom (UK). Key differences in how NIPD for foetal sexing is utilized throughout the UK were identified. Some services routinely offered NIPD to all carriers of haemophilia or to all carriers of severe haemophilia, others discussed the value of NIPD with all or primarily offered NIPD as a first step to invasive testing. This study informs our understanding of how NIPD is being utilized and provides unique insights into current practice. The identification of variation between services in how prenatal testing options are offered has implications for future policy and guidelines for prenatal care.

Struggling to Get Into the Pool Room? A Critical Discourse Analysis of Labor Ward Midwives’ Experiences of Water Birth

RESEARCH AIM: The aim of this article is to share the findings from an ongoing action research study aimed at identifying inequalities in the availability of water birth on one hospital labor ward. Efforts to encourage labor ward midwives to take action and influence the delivery of normal birth care in the maternity concerned are addressed in the larger study.METHODS: Unit midwives who regularly worked on labor wards were invited to take part in focus groups and face-to-face interviews over an 8-month period. Critical discourse analysis was used to identify actual midwifery practices, the social ordering of the water birth discourse, obstacles to water birth, dominant group interests, and solutions to the identified obstacles (Fairclough, 2001).RESULTS: The author conducted a total of five unstructured interviews (35–60 minutes) with labor ward matrons, a consultant midwife, labor ward manager and clinical practice facilitator, and three focus groups (40–60 minutes; 11 midwives) with clinical midwives. Institutional practices focused on the delivery of standardized midwifery care for low-risk women and, therefore, did not promote or encourage water birth practice. The small number of requests and the low water birth rate were used as evidence by some midwives that childbearing women no longer wanted this type of care. The key obstacles to water birth in this setting were coordinators’ priorities, midwives’ negative attitudes, high workloads, and lack of institutional support for this type of care.CONCLUSIONS: Findings suggest that hospital water birth practice is dependent not only on the availability of equipment and midwifery knowledge, but also on the philosophy of care adopted by the organization (Stark &amp; Miller, 2009). Interventions to improve the practice and availability of water birth are more likely to succeed if supported by midwifery managers, championed by coordinators, and led by labor ward practitioners.

The role of hospital midwives in the Netherlands

BackgroundMost midwives in the Netherlands work in primary care where they are the lead professionals providing care to women with 'normal' or uncomplicated pregnancies, while some midwives work in hospitals ("clinical midwives"). The actual involvement of midwives in maternity care in hospitals is unknown, because in all statistics births in secondary care are registered as births assisted by gynaecologists. The aim of this study is to gain insight in the involvement of midwives with births in secondary care, under supervision of a gynaecologist. This is done using data from the PRN (The Netherlands Perinatal Registry), a voluntary registration of births in the Netherlands. The PRN covers 97% to 99% of all births taking place under responsibility of a gynaecologist.MethodsAll births registered in secondary care in the period 1998-2007 (1,102,676, on average 61% of all births) were selected. We analyzed trends in socio-demographic, obstetric and organisational characteristics, associated with the involvement of midwives, using frequency tables and uni- and multivariate logistic regression analyses. As main outcome measure the percentage of births in secondary care with a midwife 'catching' the baby was used.ResultsThe proportion of births attended by a midwife in secondary care increased from 8.3% in 1998 to 26.06% in 2007, the largest increase involving spontaneous births of a second or later child, on weekdays during day shifts (8.00-20.00 hr) from younger mothers with a gestational age (almost) at term. After 2002, parallel to the growing numbers of midwives working in hospitals, the percentage of instrumental births decreased.ConclusionsIn 2007 more midwives are assisting with more births in secondary care than in 1998. Hospital-based midwives are primarily involved with uncomplicated births of women with relatively low risk demographical and obstetrical characteristics. However, they are still only involved with half of the less complicated births, indicating that there may be room for more midwives in hospitals to care for women with relatively uncomplicated births. Whether an association exists between the growing involvement of midwives and the decreasing percentage of instrumental births needs further investigation.

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

Objective to pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk. Design a multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records. Setting a maternity unit of an inner city teaching hospital in England. Participants clinical midwives, research midwives, midwifery lecturers and consultant obstetricians ( n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care. Measurements and findings when the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US. Key conclusions the following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancy Implications for practice availability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparision of background risk and outcomes across a range of care settings.

Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda

BackgroundTo increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted.MethodsThe Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics.ResultsThirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p < 0.001). Sixty-four percent of the people who prescribed antiretroviral therapy were not doctors. Among professionals who prescribed it, 76% of doctors, 62% of clinical officers, 62% of nurses and 51% of midwives were trained in initiating patients on antiretroviral therapy (p = 0.457); 73%, 46%, 50% and 23%, respectively, were trained in monitoring patients on the therapy (p = 0.017). Seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives assessed that their overall knowledge of antiretroviral therapy was lower than good (p = 0.001).ConclusionTraining initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.

Indications and results of labour induction in nulliparous women: An interview among obstetricians, residents and clinical midwives

Objective To investigate which clinical factors are important in management decisions that clinicians make in the process of labour induction, and which clinical factors they estimate as predictive of labour outcome after induction. Study design A written interview was conducted among obstetricians, residents and clinical midwives in five teaching hospitals in the south of the Netherlands. Sixteen fictive vignettes were constructed of pregnant nulliparous women who were candidates for induction of labour. The vignettes differed on eight clinical variables: maternal age, BMI, gestational age, indication for induction (maternal request vs mild pre-eclampsia), dilation, position, consistency and effacement of the cervix. For each case presentation, the inclination to induce labour was calculated for the three groups, and their estimates of the probability of a spontaneous vaginal delivery or a caesarean delivery were analyzed. Results Of the 80 questionnaires sent, 60 (75%) were completed. Mild pre-eclampsia and post-term pregnancy were the most important clinical factors for the decision to induce or not in all three groups. Gestational age, effacement and dilation of the cervix were considered as the most important predictors of labour outcome after induction. Conclusions In this interview, obstetricians, residents and clinical midwives based their decision-making whether or not to induce labour predominantly on medical indications. Outcome of labour after induction was estimated to depend on gestational age and cervical status at the start of induction.

‘She sort of shines’: midwives’ accounts of ‘good’ midwifery and ‘good’ leadership

Objectiveto explore midwives’ accounts of the characteristics of ‘good’ leadership and ‘good’ midwifery. Design and methodsa phenomenological interview survey. Participants were asked about what made both good and poor midwives and leaders. Settingtwo maternity departments within National Health Service trusts in the North West of England. Participantsqualified midwives, selected by random sampling stratified to encompass senior and junior grades. Analysisthematic analysis, carried out manually. Findingsten midwives were interviewed. Sixteen codes and six sub-themes were generated. Across the responses, two clear dimensions (themes) were identified, relating on the one hand to aspects of knowledge, skill and competence (termed ‘skilled competence’), and on the other hand to specific personality characteristics (termed ‘emotional intelligence’). This study suggests that the ability to act knowledgeably, safely and competently was seen as a basic requirement for both clinical midwives and midwife leaders. The added element which made both the midwife and the leader ‘good’ was the extent of their emotional capability. Conclusions and implications for practicethis small-scale in-depth study could form the basis for hypothesis generation for larger scale work in this area in future. The findings offer some reinforcement for the potential applicability of theories of transformational leadership to midwifery management and practice.

Current issues in midwifery

The British Journal of Midwifery fifth national conference on current issues in midwifery took place last month at Birmingham Children's hospital. Organized by our joint Editor-in-Chiefs, Professor Tina lavender and Yana Richens and aimed at clinical midwives, student midwives, professors of midwifery, consultant midwives and supervisors, to name just a few, it proved to be a very successful two days. The delegates were treated to an enlightening programme covering good practices around normal birth, pregnancy and public health, and the factors that create a good environment for midwives, students and women. It aimed to alert delegates to the current national midwifery issues and give them an appreciation of the research underpinning midwifery practice.