Maternity Care Professionals Research Articles

Birth cohort effects on maternal and child environmental health: a systematic review

This study aimed to review recent findings from birth cohort studies on maternal and child environmental health. Birth cohort studies regarding environmental health outcomes for mothers and their children were investigated through a systematic review. A literature search was conducted in PubMed, CINAHL, the Cochrane Library, Embase, and RISS to identify published studies using the keywords using a combination of the following keywords: maternal exposure, environmental exposure, health, cohort, and birth cohort. Articles were searched and a quality appraisal using the Newcastle-Ottawa Scale for cohort studies was done. A review of the 14 selected studies revealed that prenatal and early life exposure to environmental pollutants had negative impacts on physical, cognitive, and behavioral development among mothers and children up to 12 years later. Environmental pollutants included endocrine disruptors, air pollution (e.g., particulate matter), and heavy metals. This systematic review demonstrated that exposure to environmental pollutants negatively influences maternal and children's environmental health outcomes from pregnancy to the early years of life. Therefore, maternal health care professionals should take steps to reduce mothers' and children's exposure to environmental pollutants.

The importance of nurturing trusting relationships to embed shared decision-making during pregnancy and childbirth

Objective: To generate greater awareness of the contextual and relational factors that influence women's capacity to participate in shared decision-making during childbirth.Methods: A three-phase participatory action research approach involving in-depth interviews and co-operative inquiry meetings.Setting: Dublin, Ireland in a large maternity hospital.Participants: Five postnatal women who gave birth to live healthy babies, and attended obstetric or midwifery-led care and 13 practising midwives.Findings: This paper presents the findings from the third phase of a three-phase action research study exploring the action's women consider necessary to embed informed choice, into practice. The findings reveal that multiple organisational and relational factors influence how women can participate in shared decision-making including the model of care they attended, continuity of carer, power dynamics, hospital policies and trust in self and others. Women's relationships with maternity care professionals reveals that exercising choice is not only defined by but contingent on the degree of trust in their relationships with maternity care professionals.

Women's Participation in Decision-Making in Maternity Care: A Qualitative Exploration of Clients' Health Literacy Skills and Needs for Support.

Shared decision-making requires adequate functional health literacy (HL) skills from clients to understand information, as well as interactive and critical HL skills to obtain, appraise and apply information about available options. This study aimed to explore women’s HL skills and needs for support regarding shared decision-making in maternity care. In-depth interviews were held among women in Dutch maternity care who scored low (n = 10) and high (n = 13) on basic health literacy screening test(s). HL skills and perceived needs for support were identified through thematic analysis. Women appeared to be highly engaged in the decision-making process. They mentioned searching and selecting general information about pregnancy and labor, constructing their preferences based on their own pre-existing knowledge and experiences and by discussions with partners and significant others. However, women with low basic skills and primigravida perceived difficulties in finding reliable information, understanding probabilistic information, constructing preferences based on benefit/harm information and preparing for consultations. Women also emphasized dealing with uncertainties, changing circumstances of pregnancy and labor, and emotions. Maternity care professionals could further support clients by guiding them towards reliable information. To facilitate participation in decision-making, preparing women for consultations (e.g., agenda setting) and supporting them in a timely manner to understand benefit/harm information seem important.

Establishing information needs and research priorities in response to the Covid-19 pandemic in the local maternity setting

The purpose of this project was to identify gaps in the current evidence base and to identify research priorities in the local context during the Covid-19 pandemic. This paper reports on the application and adaptation of the CHNRI methodology which follows a series of criteria setting, filtering and scoring exercises. The views of maternity care professionals, midwifery managers and leaders, women and families were continually sought throughout the project stages. We found the CHNRI methodology to be a useful framework to highlight topics with greater or smaller consensus within a relatively short time frame and with minimal burden to participants. The criteria were defined to focus on research topics where no existing or on-going studies were identified and topics likely to lead to improvements in care with relevance beyond the Covid-19 pandemic.

Assessing knowledge and skills of maternity care professionals regarding neonatal hyperbilirubinaemia: a nationwide survey

BackgroundNeonatal hyperbilirubinaemia is a physiologic phenomenon, but, when severe, may cause lifelong disability. Maternity care assistants (MCAs) play an important role in timely recognition of severe neonatal jaundice. We assessed knowledge and skills of MCAs regarding neonatal hyperbilirubinaemia.MethodsAll Dutch MCAs (n = 9065) were invited to fill out a questionnaire assessing knowledge, expertise, and handling of neonatal jaundice. Additionally, we developed an e-learning and provided training sessions to a subgroup of MCAs (n = 99), and assessed their knowledge on neonatal hyperbilirubinaemia before and after the training.ResultsOne thousand four hundred sixty-five unique online questionnaires were completed (response 16.2%). The median number of correctly answered knowledge questions was 5 (out of six; IQR 1). Knowledge was significantly better when respondents had had in-service training on neonatal hyperbilirubinaemia in the previous year (p = 0.024). Although 82% of respondents felt highly skilled or skilled to assess jaundice, accuracy of estimation of total serum bilirubin levels by assessing skin colour was generally poor and prone to underestimation. Among participants attending a training session, those who completed the e-learning beforehand had higher pre-training scores (5 (IQR 1) vs. 4 (IQR 2); p < 0.001). The median post-training score was higher than pre-training (6 (IQR 1) vs. 5 (IQR 2); p < 0.001).ConclusionsBackground knowledge of MCAs regarding neonatal hyperbilirubinaemia was adequate, but can be improved by further training. Estimation of total serum bilirubin levels based on skin colour was often inadequate. Approaches to improve timely recognition of jaundiced neonates are needed.

Maternal Health Effects of Internet-Based Education Interventions during the Postpartum Period: A Systematic Review

Purpose: This study aimed to investigate the maternal health effects of internet-based education interventions on parturients during the postpartum period through a systematic review of randomized controlled trials. Methods: An electronic literature search of the Cochrane Library, CINAHL, EMBASE, Eric, PsycINFO, PubMed, RISS, and KISS databases was performed, using the combination of keywords such as ‘parenthood education’, ‘*natal education’, ‘*birth intervention’, ‘internet-based intervention’, ‘randomized controlled trial’. The inclusion criteria were peerreviewed papers in English regarding randomized controlled trials of internet-based postnatal education interventions. Educational interventions were delivered through any web, mobile, eHealth, mHealth, virtual reality, short message service, or social networking service platform. Quality appraisal was performed using the Risk of Bias 2 (RoB 2) for randomized controlled trials. Nine articles were yielded, and the intervention effects were analyzed. Results: Internetbased education interventions during the postpartum period affect maternal self-efficacy, postpartum depression, and successive breastfeeding; however, they do not affect maternal satisfaction and parenting confidence. Conclusion: This study demonstrated that internet-based education interventions affect maternal health status in terms of psychological, emotional, and physical wellness. Therefore, maternal health care professionals can utilize remote education using the internet or mobile-based interventions during the postpartum period.

Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients

BackgroundThe aim of this study was to compare rates of induction and subsequent caesarean delivery among nulliparous women with private versus publicly funded health care at a single institution. This is a retrospective cohort study using the electronic booking and delivery records of nulliparous women with singleton pregnancies who delivered between 2010 and 2015 in an Irish Tertiary Maternity Hospital (approx. 9000 deliveries per annum).MethodsData were extracted from the National Maternity Hospital (NMH), Dublin, Patient Administration System (PAS) on all nulliparous women who delivered a liveborn infant at ≥37 weeks gestation during the 6-year period. At NMH, all women in spontaneous labour are managed according to a standardised intrapartum protocol. Twenty-two thousand two hundred thirty-two women met the inclusion criteria. Of these, 2520 (12.8%) were private patients; the remainder (19,712; 87.2%) were public. Mode of and gestational age at delivery, rates of and indications for induction of labour, rates of pre-labour caesarean section, and maternal and neonatal outcomes were examined. Rates of labour intervention and subsequent maternal and neonatal outcomes were compared between those with and without private health cover.ResultsWomen attending privately were more than twice as likely to have a pre-labour caesarean section (12.7% vs. 6.5%, RR = 2.0, [CI 1.8–2.2])); this finding persisted following adjustment for differences in maternal age and body mass index (BMI) (adjusted relative risk 1.74, [CI 1.5–2.0]). Women with private cover were also more likely to have induction of labour and significantly less likely to labour spontaneously. Women who attended privately were significantly more likely to have an operative vaginal delivery, whether labour commenced spontaneously or was induced.ConclusionsThese findings demonstrate significant differences in rates of obstetric intervention between those with private and public health cover. This division is unlikely to be explained by differences in clinical risk factors as no significant difference in outcomes following spontaneous onset of labour were noted. Further research is required to determine the roots of the disparity between private and public decision-making. This should focus on the relative contributions of both mothers and maternity care professionals in clinical decision making, and the potential implications of these choices.

The state of professionalisation of midwifery in Belgium: A discussion paper

AimTo describe the state of the professionalisation of midwifery in Belgium, and to formulate recommendations for advancing the midwifery profession. MethodsA descriptive overview of maternity care in Belgium and the professionalisation of midwifery through an analysis of relevant policy and academic texts, underpinned by Greenwood’s sociological criteria for a profession: (1) own body of knowledge, (2) recognised authority, (3) broader community sanctions, (4) own code of ethics and (5) professional culture sustained by formal professional associations. From these insights, recommendations for advancing the midwifery profession in Belgium are formulated. FindingsCurrent strengths of the professionalisation of midwifery in Belgium included unified midwifery education programmes, progress in midwifery research and overarching national documents for guiding midwifery education, practice and regulation. In contrast however challenges, such as the limited recognition of midwives’ roles by its clientele, limitations of midwives’ competencies and autonomy, lacking development of advanced roles in maternity care practice and a lack of unity of the organisation and its members, were also identified. Based on these, recommendations are made to strengthen Belgian midwifery. ConclusionsRecommendations for advancing the midwifery profession in Belgium includes in particular increasing public awareness of midwives’ roles and competencies, implementing the full scope of midwifery practice and monitoring and advancing this practice. Thus, professional autonomy over both midwifery practice and working conditions should be enhanced. United midwifery organisations, together with women’s groups, other maternity care professionals and policy-makers as equal partners are key to bring about changes in the Belgian maternity care landscape.

Maternal health care provision for refugee women

Abstract Background In the recent past, the number of forcibly displaced people increased worldwide. About 1/3 of the persons seeking asylum in Germany are female. The majority of all refugee women who are coming to Germany are currently of childbearing age. Refugee women are considered a highly vulnerable refugee subgroup, as they frequently experience physical strains and psychological burdens while fleeing their home countries and being pregnant at the same time. Moreover, pregnancy and the following period require specialized care and support in order to allow a transition to maternity without complications. The aim of this project is to analyze maternal health care services for refugee women on the level of interaction with maternal health care professionals in Germany. Methods Maternal health care professionals in outpatient and clinical settings with experiences of caring for refugee women were recruited. Semi-structured interviews were conducted. The interviews were analyzed following the standards of qualitative thematic analysis. Results Maternal health care professionals face challenges in implementing and providing maternal health care concerning their professional practices and interventions. Due to a lack of resources (e.g. translators, time) and other conditions, gynaecologists and midwives are forced to find new solutions that maintain (medical care), adapt (vaginal examination) or miss out on (informed consent) ordinary professional practices. Key messages Maternal health care professionals face different barriers when providing maternal health care to migrant/refugee such as communication barriers and problems in relationship building. The identification of challenges and opportunities for professionals in maternal health care provision may contribute to improve maternal health (care) for refugee women.

A qualitative review of maternal health care provision for migrant and refugee women

Abstract Background The number migrants increased worldwide. Pregnant migrant/refugee women are considered a vulnerable group. How do professionals manage their care? The aim was to summarize the current evidence regarding maternal health care provision for migrant/refugee women. Methods We conducted a systematic review and searched the databases PubMed (MEDLINE); CINAHL; PSYNDEX, PsycINFO and Cochrane Library. Studies were judged for eligibility: a study had to address maternal health care provision for migrant/refugee women who immigrated to an OECD member state. Publication date was restricted to 1990-2019, and language to English or German. Results 16 primary (qualitative) studies were included. Heterogeneity of the included studies exists regarding e.g. origin of the women, migration background, receiving country. Nevertheless, synthesis can provide valuable information on challenges and how to deal with migrant/refugee women in maternal health care. Communication difficulties pose challenges on professionals (15 studies). Possibilities to deal with them: bridge-languages, non-verbal communication and interpreters. In addition, finding one's way in the unknown health care system is a barrier for women, which professionals can meet by informing the women and coordinating care (8 studies). The perceived diversity of women can lead to conflicts in care (10 studies). While some studies recommend 'cultural recipes', other authors emphasize the individuality of women and prefer a holistic care approach. Conclusions Professionals face different barriers when providing maternal health care to migrant/refugee such as communication barriers, coordinating care and handling women's diversity. Initiating and enhancing public health activities such as training courses for professionals that convey general principles such as woman-centered care, communication techniques are valuable opportunities to improve migrant/refugee women's maternal health care provision. Key messages Maternal health care professionals face different barriers when providing maternal health care to migrant/refugee such as communication barriers, coordinating care and handling women's diversity. Initiating and enhancing public health activities such as training courses for maternal health care professionals are valuable opportunities to improve migrant/refugee women’s maternal care.

Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section

BackgroundUnexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AimTo map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. MethodsA custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 “evidence-based” statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FindingsTotal 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications “valid” compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DiscussionBoth inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. ConclusionGreater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.

An exploratory Interpretative Phenomenological Analysis (IPA) of childbearing women's perceptions of risk associated with having a high Body Mass Index (BMI)

BackgroundIn 2016, the World Health Organization (WHO) labelled 13% of the world's adult population as obese. This increase in obesity is accompanied by mortality and morbidity problems, with maternal obesity and its accompanying risk for mother and infant requiring to be carefully managed. AimTo explore childbearing women with a high BMI (>35 kg/m2) perceptions of risk and its potential impacts upon pregnancy and outcome. MethodQualitative Interpretative Phenomenological Analysis (IPA) was used to gain deeper understanding of the lived experiences of childbearing women with a BMI>35 kg/m2 and perceptions of their risk and potential pregnancy outcome. FindingsOne of the superordinate themes that emerged was (1) Risk or no risk, and its associated three subthemes of (1a) Emotional consequences of her risky position, (1b) Recognition of high-risk complicationsfinally sinking in, and (1c) Accepting the risk body. Recommendations for practiceIn general, health care professionals are uncomfortable about discussing obesity-associated risks with pregnant women. The participants in this study did not classify themselves as obese, with this absence of acknowledgement and 'risky talk' leaving participants' unaware of their obesity-associated risk. This downplaying of obesity related talk requires to be corrected, simply because women in denial will perceive no need to engage with health promotion messages. In response, directives are required to be embedded into policy and practice. ConclusionSpecific training is required to teach maternity care professionals how to have difficult, sensitive conversations about obesity related risks with childbearing women with high BMI's. In addition, this risk information needs to be accompanied by relevant advice and support.

Transforming maternity care: obstetric partnerships as a policy instrument for integration

Increasing continuity in Dutch maternity care is considered pivotal to improve safety and client-centeredness. Closer collaboration between the historically relatively autonomous professionals and organizations in maternity care is deemed conditional to reach this goal, both by maternity care professionals and policy makers. Governmental policy therefore strives for organizational and financial integration. One of the policy measures has been to stimulate interprofessional and interorganizational collaboration through local obstetric partnerships. This study aimed to gain insight into whether this policy measure supported professionals in reaching the policy aim of increasing integration in the maternity care system. We therefore conducted 73 semistructured interviews with maternity care professionals in the region Northwest Netherlands, from 2014 to 2016. Respondents expressed much willingness to intensify interprofessional and interorganizational collaboration and experienced obstetric partnerships as contributing to this. As such, stimulating integration through obstetric partnerships can be considered a suitable policy measure. However, collaborating within the partnerships simultaneously highlighted deep-rooted dividing structures (organizational, educational, legal, financial) in the maternity care system, especially at the systemic level. These were experienced to hinder collaboration, but difficult for the professionals to influence, as they lacked knowledge, skills, resources and mandate. A lack of clear and timely guidance and support from policy, counterbalancing these barriers, limited partnerships' potential to unify professionals and integrate their services.

Creating togetherness in a historically divided maternity care system / Zusammengehörigkeit in einem historisch gespaltenen geburtshilflichen Versorgungssystem herstellen

Abstract Improving collaboration in Dutch maternity care is seen as essential to improve continuity of care and thereby safety, client satisfaction, and health outcomes. This study aims to monitor and evaluate whether the regional Maternity Care Network Northwest Netherlands (MCNNN) and its local multidisciplinary obstetric partnerships contributed to collaboration. This mixed-method study followed the methodology of reflexive monitoring in action. Data were collected from 2014 to 2016 through interviews (n=73), questionnaires (n=430), and reflection sessions (n=4) and analyzed inductively and deductively based on a model for interprofessional and interorganizational collaboration. The findings outline (1) MCNNN-activities, (2) experienced collaboration within obstetric partnerships, and (3) MCNNN as supporting structure. The findings showed improvements on both the relational and organizational level of interprofessional and interorganizational collaboration. The MCNNN’s meetings, products, and research projects facilitated knowledge development and dissemination and its obstetric partnerships fostered contact and deliberation among maternity care professionals. However, collaborative challenges were also experienced, including mistrust and difficulties in information sharing, influenced by lacking financial and organizational facilitation. The MCNNN could improve its supporting role in the system innovation toward integration in maternity care by means of a further transformation to a knowledge network that is focused on reflexively overcoming collaborative challenges at all levels in the maternity care system.

The Impact of Refugee Women’s Accommodation on Maternal Health Care Provision

Abstract Background About 1/3 of the persons seeking asylum in Germany are female. The majority of all refugee women in Germany are currently of childbearing age. The maternity period requires specialized care. Maternal health care professionals monitor the physiological processes of maternity and the psychosocial well-being in order to allow an uncomplicated transition to maternity. On arriving in Germany there are different types of accommodation for refugee women: 1) shared reception centers (e.g. tents, containerbuildings, gyms), 2) collective shelters for particularly vulnerable refugees and 3) private apartments. Depending on the woman’s accommodation maternal health care professionals are confronted with different situations and conditions in providing care for these women. The aim is to analyze the impact of refugee women’s accommodation on maternal health care provision and professional’s actions. Methods Structured expert interviews were conducted with maternal health care professionals. The interviews were analyzed following the standards of qualitative thematic analysis with a special focus on refugee women’s accommodation and its impact on maternal health care provision. Results The accommodation situation does impact the provision of maternal health care as well as the actions and doings of maternal health care professionals. On the one hand there is a change in tasks, which are no subject to original maternal health care, such as organizing transportation. On the other hand there are challenges in actually executing particular maternal health care actions, such as taking the medical history or performing examinations where there is no or little privacy. Conclusions Accommodation conditions impact maternal health care provision in various ways. Therefore an enhancement of housing for refugee women may improve maternal health care provision and therefore maternal health for refugee women.

Maternal health care for refugee women in Germany: A qualitative approach on the interaction level

Abstract Background In the recent past, the number of forcibly displaced people increased worldwide. About 1/3 of the persons seeking asylum in Germany are female. The majority of all refugee women who are coming to Germany are currently of childbearing age. Refugee women are considered a highly vulnerable refugee subgroup, as they frequently experience physical strains and psychological burdens while fleeing their home countries and being pregnant at the same time. Moreover, pregnancy and the following period require specialized care and support in order to allow a transition to maternity without complications. The aim of this project is to analyze maternal health care services for refugee women on the level of interaction with maternal health care professionals in Germany. Methods Maternal health care professionals in outpatient and clinical settings with experiences of caring for refugee women were recruited. Semi-structured interviews were conducted. The interviews are currently analyzed following the standards of qualitative thematic analysis. Results Maternal health care professionals experience challenges in executing particular maternal health care actions, such as taking the medical history where there is no communication possible or performing examinations where there is no or little privacy (e.g. in camps). In addition there are changes in tasks, which are no subject to originally maternal health care, such as organizing translation and transportation. Furthermore they face a shortage of resources (e.g. translators, time), which constrains them to find solutions on an individual level. Conclusions Maternal health care professionals provide maternal health care to refugee women under special circumstances (e.g. communication barriers, discontinuity of care). As there are limited resources (e.g. translators, time) they develop solutions and strategies on an individual level. Key messages Challenges and opportunities are disclosed by examining maternal health care professionals’ actions. Maternal health care improves through understanding maternal health care professionals’ strategies.

Traumatic childbirth experiences: practice-based implications for maternity care professionals from the woman's perspective.

To explore women's traumatic childbirth experiences in order to make maternity care professionals more aware of women's intrapartum care needs. A qualitative exploratory study with a constant comparison/grounded theory design was performed. Thirty-six interviews were conducted with women who had given birth in a Dutch birth setting. Three themes, playing a profound role in the occurrence of traumatic birth experiences, emerged: (i) lack of information and consent - maternity care professionals' unilateral decision making during intrapartum care, lacking informed-consent. (ii) feeling excluded - women's mal-adaptive response to the healthcare professionals's one-sided decision making, leaving women feeling distant and estranged from the childbirth event and the experience. (iii) discrepancies - inconsistency between women's expectations and the reality of labour and birth - on an intrapersonal level. Women's intrapartum care needs cohere with the concept of woman-centred care, including personalised care and reflecting humanising values. Care should include informed consent and shared decision-making. Maternity care professionals need to continuously evaluate whether the woman is consistently part of her own childbearing process. Maternity care professionals should maintain an ongoing dialogue with the woman, including women's internalised ideas of birth.

Breastfeeding experiences and support for women who are overweight or obese: A mixed-methods systematic review.

Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence‐based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis.

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives’ motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients’ needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

Hindrances and facilitators in humanitarian migrants' maternity care in Finland: qualitative study applying the three delays model framework.

Humanitarian migration to Finland nearly ten-folded in 2015-2016 from 3326 asylum seekers' yearly average to 32476. Earlier research shows that humanitarian migrants sustain suboptimal maternal health in high-income countries, even though care facilities are available. This study aimed to investigate what factors do maternity care professionals identify as hindrances and facilitators in humanitarian migrants' maternity care process in Finland. Study employed qualitative design. Eighteen midwives and maternity care public health nurses participated in semi-structured qualitative interviews that were audio-recorded and transcribed verbatim. Qualitative content analysis of the interview data produced meaning units, codes and categories. Research plan was reviewed and approved by the ethics committee of the local hospital district. Participants signed an informed consent prior the interviews. Hindrances and facilitators for care were organised in theoretical framework of Three Delays Model. Participants described multiple hindrances for caring process, of which language barrier constantly raised as a significant obstacle for seeking and receiving care, and for perceived quality of care. Correspondingly, interpreters facilitated the caring process at all of its phases. Rural location of asylum centres, long distances and lacking transportation to care hindered reaching the health facility. Complicated bureaucracy was described to affect negatively in receiving adequate care. Refugee and asylum centre workers facilitated decision to seek care, and reaching of health facilities. Interpreters can influence in the caring process in more versatile ways than we might have acknowledged this far. We recommend further research on interpreters' role in the caring process of pregnant humanitarian migrants.