Midwifery Model Research Articles

O25 - Growing Deadly Families in Queensland: First Nations codesigned midwifery models of care

O25 - Growing Deadly Families in Queensland: First Nations codesigned midwifery models of care

O61 - Midwives’ evaluation of working in a rural midwifery model of care: Satisfying and sustainable

O61 - Midwives’ evaluation of working in a rural midwifery model of care: Satisfying and sustainable

Communication Technology Facilitates Quality Care Between Midwives and Their Pregnant Clients Within a Midwifery Continuity of Care Relationship

INTRODUCTION:Communication was identified as a component of high-quality maternity care within an evidence-informed Quality Maternal and Newborn Care framework. Communication technology has been shown to enhance relationships midwives develop with their clients; however, concerns with the safety of the communication have been identified.AIM:This article reports on the contribution that communication technology makes toward quality care when used within a continuity of care relationship between midwives and their pregnant clients.METHODS:This article reports on phase 2A of a multiphase study. Semistructured interviews were conducted with lead maternity carer midwives using the online platform Microsoft Teams. Midwives who had previously undertaken an online survey in phase 1A and had indicated interest in participating in an online interview were emailed an invitation to participate. Fourteen midwives responded to the email invitation. Thematic analysis was used to analyze the interview data.FINDINGS:The findings indicate that communication technology facilitates quality care within a midwifery model of continuity of care. This is achieved in two ways through (a) connectedness and being known and (b) an awareness of challenges which in turn enables midwives to develop strategies for ensuring quality care.DISCUSSION:Communication technology, when used within a continuity of care relationship, facilitates quality care. It does this through enabling a connection continuation of connectedness and knowingness which enables midwives to negotiate safe and appropriate means for contact. It also privileges midwives with knowledge of challenges when using communication technology and enables strategies to be developed.

Midwives' Belief in Normal Birth: The Canadian Survey of Maternity Care Providers’ Attitudes Toward Labour and Birth

Background: Midwifery has been integrated into the health care systems of over half of Canadian provinces and territories. While there are differences in legislation and payment mechanisms, the model of midwifery is fairly similar across the country. This study examined the similarities and differences among midwives' attitudestowardlabourandbirth. Inaddition,wecompareditemswhichrelatedtobeliefsaboutnormal birth between midwives and other care providers.Methods: A national cross-sectional survey was conducted comparing maternity care providers’ beliefs aboutchildbirthandintra-professionalvariationsinmidwives'attitudestowardsbirth. Therewere400 (54%) midwife respondents: 218 from Ontario, 75 from B.C, 53 from Quebec, 48 from the remaining regulated or pre-regulated provinces (six missed information for this field).Results: All midwives were critical of the routine use of interventions such as episiotomy, epidural analgesia andelectronicfetalmonitoring(EFM). Therewasstrongagreementaboutthesafetyofhomebirth,outof hospital birth centres and the importance of women's autonomy and decision-making in pregnancy and birth. However, some regional variations were identified. Quebec midwives were more opposed to epidural analgesia than BC and Ontario (p<.001), and were more likely to believe that cesarean birth is more costly than vaginal birth (p=.005). Ontario midwives were most likely to believe that cesarean birth protects against urinary incontinence (p=.001), and sexual dysfunction (p=.002). Qualitative comments of midwives indicated a strong desire to reduce unnecessary medical intervention and to lower cesarean section rates.Conclusion: Canadian midwives share similar beliefs regarding place of birth, the routine use of episiotomy, EFM, and epidurals, but reported significant attitudinal differences for other issues. Regional differences may be related to midwives' primary practice settings, the historical development of midwifery in their region and the number of new midwives with less than 5 years of clinical experience. A set of core midwifery values was identified that demonstrate a strong belief in normal birth.

Student Attrition in the Ontario Midwifery Education Program: A Qualitative Analysis— Part II: Personal Issues

Student attrition in the health care field is a persistent issue. To identify the factors associated with student midwives leaving their university program, we developed an Internet survey. Participants included senior-level students, graduates of the program, and those students that withdrew prior to graduation. This is phase II of qualitative analysis, and we have analyzed students’ written comments and found that finances, family obligations, and the midwifery model of practice and its associated lifestyle are areas where we might develop interventions to reduce student attrition.

Deconstructing Dissonance: Ontario Midwifery Clients Speak about Their Experiences of Testing Group B Streptococcus–Positive

Group B streptococcus (GBS) is a bacterium commonly found in the vaginal flora and is usually of no consequence to women. However, vertical transmission of GBS to the baby during pregnancy and/or birth can lead to GBS-associated disease, a leading cause of neonatal morbidity and mortality in Canada and throughout the world. Screening for GBS at 35–37 weeks’ gestation and administration of intrapartum antibiotic prophylaxis for colonized women has become standard practice; however, there is little research surrounding clients’ experiences, knowledge, and perceptions of both the test and of testing positive for the bacteria. This phenomenological study used semi-structured interviews guided by open-ended questions to explore the experiences of six midwifery clients in southern Ontario who tested GBS-positive in 2009. Transcribed interviews were analyzed using grounded theory to identify key themes. The diagnosis sharply affected women’s experiences during pregnancy and labour and often led to dissonance for them regarding questions of risk, health, the concept of normal, the midwifery model, their birth plans, and the competence of their midwife. The themes are discussed in terms of their relevance to midwifery practice. This article has been peer reviewed.

Facilitating Birth for Women Who Have Experienced Genital Cutting

Female genital cutting (FGC) is a traditional practice in parts of Africa, the Middle East, and Asia. Due to increasing migration from these areas to Canada and elsewhere, the care of women who have undergone FGC has become both a national and a global concern. It is widely regarded as a public health and human rights issue affecting at least 140 million women worldwide. In Canada, pregnant women who experienced FGC may face more physical and emotional challenges than their nonpregnant counterparts. Their need to access optimal perinatal care is critical, as FGC, particularly that with more extensive cutting (infibulation), is widely considered to be an indirect cause of maternal/ newborn morbidity. The purposes of this article are (1) to provide a deeper insight into challenges confronting affected women seeking maternity care in Canada and their providers and (2) to recommend the appropriateness of the Canadian midwifery model in providing optimal care for women who have experienced FGC. The goal is to support Canadian health care providers in gaining a greater understanding of the historical, cultural, and physical realities of FGC so that they are able to provide maternity care that meets Canadian standards while being sensitive to cultural values and beliefs. This article has been peer reviewed.

Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care. This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023. Perinatal care clinician, namely, a midwife or obstetrician. : Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights. Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77). In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

New Approaches to Brief Intervention on Substance Use during Pregnancy

In Canada, the context for providing brief intervention on substance use during pregnancy is shifting with new opportunities for enhancing discussion of alcohol and other substances, due to the introduction of novel nicotine delivery products (e.g., vaping), the legalization of cannabis, and the crisis in the useof prescription pain medication. The midwifery model of care is very well suited for open, collaborative conversations about substance use, as there are opportunities for ongoing and supportive relationship building throughout pregnancy, labour, birth, and into the postpartum period. The purpose of this paper is to explore the ways in which brief intervention on substance use in the perinatal period can be a key component of midwifery care. This article has been peer reviewed.

Community As Client: A Qualitative Descriptive Study of the Work of Midwives to Increase Access to Midwifery Care

Increasing access to midwifery care for disadvantaged groups was an explicit goal of the regulation of midwifery in Ontario. However, people of low socio-economic status (SES) remain less likely to receive midwifery care. We conducted a qualitative descriptive study to explore the work midwives do to make midwifery care accessible to people of low SES. We interviewed 13 Ontario midwives serving people of low SES, who practiced midwifery in settings ranging from a remote solo practice to a large urban practice. Participants described a broad range of ways in which they work to enhance the approachability, acceptability, availability and accommodation, affordability, and appropriateness of their services for people of low SES. We identified two distinct approaches to increasing access to care: (1) working to maximize the existing beneficial aspects of the midwifery model to whoever presents to care, and (2) stepping outside of the confines of the midwifery model, to provide what we call “community-centred care,” in which midwives are both a part of and responsive to the broader communities that they serve. The intentional, pro-active approach used by midwives providing community-centred care could be implemented more broadly to improve access to midwifery care for people of low SES. This article has been peer reviewed.

Postpartum care for parent-infant dyads: A community midwifery model.

Postpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies. We conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis. A total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest. The community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

Maternity Service Professionals’ Perspectives of “the Good, the Bad, and the Possible” in Australian Maternity Services: A Content Analysis

OBJECTIVE:In 2019, the Australian government released a strategy for maternity care:Woman-centred care strategic directions for Australian maternity services(WCC Strategy), with mixed responses from providers and consumers. A public lecture and expert panel held in March 2021, titled “The Good, the Bad, and the Possible,” facilitated critique and feedback on the WCC Strategy and the Australian maternity system. The aim of this article was to report the findings of a qualitative analysis of participants’ views regarding the current perceptions of Australian maternity care.METHODS:A content analysis of responses to questions posed during the lecture and the commentary provided by participants was undertaken, utilizing a predetermined framework of “the Good, the Bad, and the Possible.”RESULTS:Approximately 700 participants, mainly from Australia, attended the event. The majority were midwives. Under the guiding framework, the category “When it works well” captured “the Good” aspects of maternity care. Under “the Bad,” major categories included “the system is broken,” “roadblock to maternity service reform,” and “not being seen or heard.” Suggestions for improvement, and hope that these will be enacted, were encompassed in “the Possible” categories: “what is needed” and “we’re in this together.”CONCLUSION:Participants identified widespread maternity system issues resulting in women’s needs not being met. Midwives indicated feeling invisible, as their repeated attempts at improvement were thwarted. Hierarchical power imbalances and medical privilege were suggested to be obstructions to respectful partnerships and expansion of midwifery models of care, preventing women from accessing safe birth options of their choice.

From a phenomenology of birth towards an ethics of obstetric care

The aim of this paper is to get from a phenomenology of birth towards an ethics of obstetric care: Human rights violations in obstetrics are currently a globally debated phenomenon. Research suggests that maltreatment is widespread and a global phenomenon. However, the prevalence cannot yet be clearly quantified. In view of this problem, it is necessary to take the subjective perspective of those affected seriously. Narrative and phenomenological accounts of birth experiences could help to foster the dialogue between persons giving birth and health professionals. First, I will present narrative accounts of birth experiences recorded by feminist phenomenologists. Second, I will interpret these narrative accounts within a feminist phenomenological framework in order to contribute to a phenomenology of birth, which, in a third step, shall help to develop an ethics of obstetric care. In engaging with the phenomenology of care outlined by feminist care ethicists, I will analyze the elements and conditions of good care, and draw conclusions for an ethic of obstetric and midwifery care. Drawing additionally on the theory of relational autonomy, my paper argues for a relational implementation of self-determination in childbirth. Lastly, I will discuss to what extent the ethical ideal of care has an affinity to the midwifery model of childbirth, and how the current situation of obstetrics prevents a women-centered birth culture.

Need of integrated care model for positive childbirth experience in Indian maternity care services.

Integrated care (IC) models are an emerging trend in healthcare reforms worldwide, especially in the maternal healthcare system. This research focuses on the scope of an integrated model for intrapartum care of women and explores the experience of birth under two intrapartum care models-biomedical and midwifery models, respectively. The term positive childbirth experience (PCE) is a concept defined by the World Health Organization (WHO) in the recommendations on intrapartum care for a PCE. This study is convinced to employ a qualitative approach to explore how birth is experienced by women under maternity healthcare services in Kerala. A semi-structured interview was conducted to tap into the lived reality of birthing of sixteen first-time mothers (primipara) aged between 20 and 30 years under these two models. Furthermore, five participants have been specifically interviewed after their vaginal birth after a C-section (VBAC) experience. To achieve a systematic cross-case thematic analysis, systematic text condensation (STC) has been employed as a data analysis method. Four main categories were identified through the analysis as follows: (1) information and knowledge, (2) confidence, (3) quality of care, and (4) health-promoting perspective. These central themes evolved from 11 subthemes. The data analysis reveals both negative and positive experiences under two care models. It emphasizes the urgent need to reframe the biomedical-focused care model and adopt an integrated approach that aligns with the global intrapartum care model proposed by the World Health Organization (WHO) in 2018 and the definition of IC mentioned in the paper.

Perspectives of Certified Nurse-Midwives and Physicians on the Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in the San Francisco Bay Area.

Black birthing people in the United States disproportionately endure inequitable experiences and outcomes during pregnancy and childbirth via structural, interpersonal, and obstetric racism. In this study, the researchers explore provider perspectives of how racism is perpetuated in institutional perinatal and reproductive health care. Critical Race Theory, Reproductive Justice, and midwifery theory were operationalized through secondary thematic analysis of existing qualitative data from the Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Twenty-four perinatal providers (certified nurse-midwives [n = 7] and physicians [n = 17]) voluntarily participated in interviews. A comparative approach was used to determine how professional identity and model of care influence physicians' and certified nurse-midwives' perceptions of equity. Thematic analysis produced 5 themes: racism as a comorbidity, health care systems' inability to address the needs of Black birthing people, health care systems prioritizing providers over patients are failed systems, patients are the experts in the optimal health care model, and benefits of interprofessional teams grounded in Reproductive Justice. Additionally, both physicians and midwives expressed a need for a new care model. With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift the experience and outcomes of perinatal and reproductive health care and reduce mortality. Using a human rights approach to care, a Reproductive Justice-Public Health Critical Race praxis-informed midwifery model may be operationalized by all perinatal and reproductive health care providers. This novel model reflects an iterative process that may offer institutions and providers methods to build on past research supporting midwifery-centered care for improving outcomes for all patients by specifically focusing on improving care of Black birthing people. The implications of this work offer broad application in current clinical practice, quality improvement, research, technology, and patient resources.

Risk assessments and ethnicity in maternity care: looking through the wrong end of the telescope?

Many Black and brown women are classified as ‘high risk’ and follow obstetric-led pathways. This may be the result of social determinants of health, or over pathologisation as a result of racial bias by healthcare providers and systems. There may be times when social determinants are mistaken for innate physiological differences, leading to iatrogenic harm. There is both over and underdiagnosis resulting from racial bias in midwifery care. Women with intermediate risk factors may benefit from midwifery-led care, especially Black and brown women. Community-based, relational, women-centred midwifery models of care can reduce the problems of pathologisation and redress some social inequalities.

Immigrant men 's perceptions and experiences of accompanying their partner for contraceptive counselling provided by midwives in Sweden- a qualitative study.

Male involvement in maternal health care has proven to be beneficial for improving maternal and child health and is often crucial in areas of family planning and contraceptive use. However, compared to male involvement in maternal health care, male involvement in contraceptive counselling is complex and controversial and thus faces certain challenges. Immigrant men in Sweden are often accompanying their partner for contraceptive counselling. Little is known about their presence and role. To explore how immigrant men from the Middle East and Afghanistan perceive and experience accompanying their partner for contraceptive counselling provided by midwives in Sweden. Inductive qualitative content analysis guided the interpretation of data based on 21 individual in-depth interviews. Balancing conflicting values and norms about sexual and reproductive health and rights including family planning was challenging and confusing when living in Sweden. Contraceptive counselling was perceived as a joint visit, and men were often acting as decision makers. The midwife's role as a contraceptive counsellor was perceived as trusted, but knowledge was lacking about the Swedish midwifery model and the Swedish healthcare system. Providers' ways of communicating sensitive information were crucial. Without marriage contraceptive counselling was unthinkable. Highlighting male engagement and including men's sexual and reproductive health at policy levels are necessary for improving women's sexual and reproductive health and rights. Additional and new ways of contraceptive counselling and midwifery services, such as outreach work and joint visits, are needed in order to reach both men and women.

‘These people are on your side... this is a safe space.’ Aboriginal women’s stories of having a baby through culturally tailored continuity of midwife care programs in Naarm (Melbourne), Australia

BackgroundPerinatal inequities experienced by Aboriginal and Torres Strait Islander (First Nations) women and newborns are impacted by colonisation. As a redress, government health policies recommend the implementation of evidence-based, co-designed models of care. Maternity services that are committed to meeting the needs of First Nations communities must centre the voices of First Nations women in program planning, implementation, and evaluation. The purpose of the study was to explore the views and experiences of First Nations women who gave birth at one of the health services where new models had been implemented. MethodsThe study design was developed with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), the partner sites, staff from their respective Aboriginal Health Units and the project Aboriginal Advisory Committee. Using an overall framework underpinned by Critical Race Theory and Indigenous methodologies, a descriptive qualitative design integrated with ‘yarning’ was used. Women were interviewed by a First Nations researcher and data analysed thematically. Main findingsTen women participated in an interview. Overall, women reported having very positive experiences of the culturally tailored caseload midwifery models. Key contributing factors were ‘relationships’ (continuity and accessibility of their known midwife), ‘trust’ (with their midwife and the program) and ‘culture’ (acknowledging identity and a safe space). These elements were considered as essential for culturally safe maternity care. Women reported challenges within the broader maternity system if trust, relationships or culture were missing. Women also reported that support and care from First Nations staff was important. Principal conclusionsWomen in this study endorsed the implementation of culturally tailored continuity of midwife models of care. Trust, relationships and culture were the trifecta for a safe and positive maternity care experience.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia.

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken. The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers. The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services. The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'. All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals. This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

Examining the Impact of the Whole-Process Companionship and Responsible Midwifery Model on Delivery Outcomes

Objective: To explore and analyze the impact of the whole-process companionship and responsible midwiferymodel on delivery outcomes. Methods: 200 women who were about to give birth admitted to Lianyungang Maternal and Child Health Hospital’s Obstetrics and Gynecology Department from May 2021 to May 2023 were recruited and divided into whole process and ordinary groups by flipping a coin, with 100 cases in each group. The whole process group implemented the whole process companionship and responsible midwifery model, while the ordinary group implemented the conventional midwifery model. The duration of labor, delivery outcomes, psychological status, postpartum bleeding volume, and incidence of adverse neonatal outcomes were compared between groups. Results: All three stages of labor in the whole process group were significantly shorter than those in the ordinary group (P < 0.05). The natural delivery rate and cesarean section rate in the whole process group were significantly better than those in the ordinary group (P < 0.05). The difference was not statistically significant after comparing the lateral incision rate between the whole process group and the ordinary group (P > 0.05). Before the intervention, the anxiety and depression scores between the groups weresimilar (P > 0.05); after the intervention, the anxiety and depression scores in the whole process group were significantly lower than in the ordinary group (P < 0.05). The amount of postpartum hemorrhage and the incidence of adverse neonatal outcomes in the whole process group were significantly better than those in the ordinary group (P < 0.05). Conclusion: The whole-process companionship and responsible midwifery model has specific positive significance for delivery outcomes, and this midwifery model deserves to be widely used and promoted in clinical practice.