Thesis (PhD)--University of South Australia, 1999

Serious questions need to be asked about the current status of midwifery in Australia. This doctorate examines the lack of recognition of midwifery as an autonomous profession and its consequential invisibility in Australian maternity care.Despite the significant amount of evidence that continues to accumulate to support the expansion of midwifery models of care, such changes have not been widespread in Australia. An examination of international, national and local health policy and strategic direction in maternity services, together with a critique of contemporary Australian midwifery and the role of the midwife within the public health system, provide the rationale and context for the study. The 'case' for introducing improved systems and models of maternity care is developed with regard to the evidence for increasing the utilisation of midwifery. The doctorate argues for greater visibility and recognition of midwifery in Australia with a focus on the role of midwifery leadership and its potential to improve collaboration. A number of case studies report experiences and insights of leadership and collaboration across different contexts: clinical practice, organisation of health services and health policy leadership in maternity services. The result is a comprehensive understanding of the reasons for the lack of visibility of midwifery and the potential costs of such a situation continuing. The exploration of this situation highlights the barriers to recognising and acknowledging midwifery itself. Attention is drawn to the continuing lack of voice and visible leadership in Australian midwifery, with midwives being absent from decision-making in situations whereothers, predominantly nurses and doctors, speak 'for' them. This work examines the barriers to midwives forming alliances and working to influence government agendas at the social, organisational and political level. Exploration of the power structures and hierarchical constraints that exist reveals particular barriers and highlights what is needed to address the impending decline of the profession in Australia. The enhanced capacity that midwives would experience if their work were to be understood, recognised and valued in the provision of maternity services in Australia, is postulated through the development of a construct called 'professional capital'. Drawing on several theoretical perspectives, it is argued that the notion of 'professional capital' is dependent on a strategy of focused and deliberate leadership and collaboration within maternity services and the creation of positive social networks and affiliations amongst midwives. Professional capital would enable greater visibility and recognition of midwifery and a more effective midwifery contribution to maternity services. It is suggested that improved professional and societal recognition will ultimately enhance the professional performance and self image of midwives. Such developments will enable new and effective ways of supporting and strengthening inter-professional relationships and systems of care that will, in the long term, improve the outcomes and experiences of women who access maternity services.

The partograph, developed over 50 years ago and based on research conducted by Friedman (1954, 1955 & 1956), has been promoted by the World Health Organisation as the “gold” standard for assessing progress in labour. The basic premise of the partograph is that regular vaginal examinations throughout labour that calculate the extent and rate of cervical dilation will be the most reliable indicator of labour progress. A review of the medical and midwifery literature suggested that the progress of labour can also be assessed by observing women’s behavioural responses to labour. This study set out to describe and test the reliability and consistency of these behavioural cues. These cues were derived from published literature and used to construct a “Labour Assessment Tool” (LAT). The LAT was tested and modified using an expert reference group and results of a pilot test. Inter-rater reliability was established during the pilot study and verified with other experienced midwives as data collectors. The LAT recorded partograph observations as well as labour behaviours. The study was undertaken in two Australian hospitals between 1999 and 2002. Women were given information on the study during regular antenatal visits to the hospitals from 30 weeks gestation and invited to participate during one of their antenatal visits between 37 weeks and 42 weeks of pregnancy. There were 21 women of the 225 women approached who declined to participate. The LAT observations were recorded on 203 participants however only 179 participants (94 nulliparous and 85 multiparous women) who generated 47,768 individual observations were suitable for analysis. There were 59 participants (31 nulliparous and 28 multiparous women) who were induced into labour or had their labours augmented. Women excluded from the study included those with complications of pregnancy and labour. Women were also withdrawn from the study at the time an epidural was commenced but their data to that point were retained for analysis. The data were examined from three perspectives. The first was from a ‘phases of labour’ perspective based on the work of Friedman (1954; 1955). Data obtained at the time the women had an internal cervical assessment were allocated to early labour, active labour, transition or full dilation, based on the results of the cervical measurements. The second perspective examined all the descriptors over the course of labour from admission to hospital or the beginning of an induction of labour, to second stage of labour. Frequencies were again generated for each behaviour from admission to hospital until full dilation. They were compared to the mean dilation generated for both parity groups based on the 279 cervical examinations that were performed on the participants. The third perspective examined behavioural patterns observed within each woman’s labour unrelated to the time to full dilation or Friedman’s phases of labour model. Results indicate that specific behavioural descriptors associated with progress were observed before cervical dilation increased. Descriptors indicating cervical dilation was occurring, or had occurred, and descriptors indicating impending second stage as well as second stage itself, were identified. Differences were observed between the labours of multiparous and nulliparous women and induced labours and non induced labours.

Typescript. Includes vita and abstract. Includes bibliographical references (leaves 153-156). Also available online.

Thesis (M. Nurs.)--University of Hong Kong, 2003. / Includes bibliographical references (leaves 150-173). Also available in print.

No description available.

Labour has been characterized as the most dangerous journey a woman undertakes. The reason being, that although it is a natural process, many labouring women suffer complications during labour and childbirth including prolonged or obstructed labour. These complications can result in maternal and infant morbidity and mortality. The partograph is a monitoring tool that can provide a continuous pictorial overview and is essential to monitor and manage labour. It is recommended by the WHO for use universally by midwives while monitoring labour. However partographs are poorly utilized and most parameters on the partograph are not monitored and findings after reviewing a labouring woman are not documented on the partograph. It is unclear how midwives working in Namibian Health services experience and utilize the partograph during the monitoring of a woman in labour. These may be the factors that hinder the effective utilization of the partograph. The objective of this study was to explore and describe the experiences of midwives regarding the utilization of the partograph for monitoring a labouring woman in a Namibian regional hospital in order to develop guidelines based on the findings to improve the use of the partograph by midwives in order to improve the management of labour. The research design was qualitative, descriptive, explorative and contextual in nature. The research population consisted of midwives working in a regional hospital in Namibia. A purposive and convenient sampling method was used to select participants. Specific inclusion criteria were met and consent was obtained from the participants and from the Regional Health Directorate Management of the hospital where the research was conducted. Interviews were conducted by an independent interviewer within the Department of Health to ensure an unbiased viewpoint. Data were collected by means of semi-structured in depth interviews with a guide, using an audio tape recorder. Field notes were used to record non- verbal communication. As soon as data were saturated, the interviews were stopped. They were then transcribed, verbatim and analysed using the Tesch’s approach as described in (Creswell, 2009:186). The service of an independent coder was utilized to ensure trustworthiness. Trustworthiness was further ensured by using the strategies suggested by Lincoln and Guba’s model, namely credibility, transferability, dependability and confirmability. Ethical considerations were honoured throughout by adhering to ethical principles during the study. These included ensuring that the participants` rights were respected, they were not harmed and fairness were ensured. On completion of the data analysis a literature control was conducted and existing literature was compared to the findings in order to identify similarities and differences and to verify whether the literature supported the findings. Four main themes that emerged during data analysis are:  Theme 1.Midwives found it a positive experience to use the partograph when caring for a woman in labour.  Theme 2. When a midwife experienced problems in using the partograph, it may lead to detrimental outcomes.  Theme 3. Utilizing the partograph evoked differing emotions in midwives.  Theme 4. Midwives` knowledge and skills in the utilization of the partograph should be updated regularly. By describing the lived experienced of midwives in the maternity ward on the use of the partograph, the midwives had a positive attitude to using the partograph, but they also found it difficult to utilize the instrument as was directed by the (WHO) due to challenges experienced such as: unrealistic staff/patient ratio, shortage of staff, time consuming, insufficient knowledge and skills among midwives and lack of appropriate equipment. There is a specific need to prevent further negative emotions by addressing the challenges experienced. Based on the findings, guidelines for partograph utilization which aimed at improving the midwifery care were developed. Recommendations were made regarding midwifery education, clinical midwifery care and midwifery research.

Background and Objectives: To date, no research has examined the prevalence and management of suspected fetal macrosomia in midwifery care, which may provide an alternative approach to cesarean section and induction with improvements in maternal and infant outcomes. The objectives of this study were to 1) determine the prevalence of fetal macrosomia and adverse outcomes that may result from a macrosomic birth in the MANAstats database; 2) identify the maternal characteristics which predict macrosomia; 3) determine the adverse maternal and infant outcome differences among macrosomic and normal weight infants in the MANAstats database. Methods: We analyzed 10,011 midwifery reported pregnancy and birth records from midwives across North America from January 2007- December 2009. After excluding for certain high-risk criteria, we compared the prevalence and adverse outcomes associated with macrosomic infants (4000-4499 grams, 4500-4999 grams, and >5000 grams) to non-macrosomic infants who weighed 3000-3000 grams. Results: The prevalence of macrosomia according to >4000 grams criteria was 24.7% and >4500 grams 5.53%. Maternal risk factors for macrosomia included: Caucasian race, married, maternal age between 15-34 years, and a gestational length greater than 40 weeks. The proportion of obstetric and infant complications showed a progressive and significant increase among the macrosomic birth weight categories with the highest risk at >5000 grams. The risk of shoulder dystocia (4000-4449-g infants: odds ratio, 4.08 [95% CI, 3.27-5.09]; 4500-4999-g infants: odds ratio, 8.31 [95% CI, 6.20-11.14]; and >5000-g infants: odds ratio, 29.92 [95% CI, 17.42-51.39]) and 5-minute Apgar scores 5000-g infants: odds ratio, 10.23 [95% CI, 2.32-45.13]) posed the highest risk in comparison to previous research on this topic. The prevalence of cesarean section among all groups was less than 9% and not found to be statistically significant by birthweight group. Conclusion: It is unclear if the risks shoulder dystocia and 5-minute Apgar scores < 3 outweigh the risks of prophylactic cesarean section on perceived macrosomic infants without jeopardizing maternal and infant health. Until further research regarding the risk versus benefit of alternatives to macrosomic vaginal birth, we recommend that strategies to prevent Grades II and III macrosomia need to be incorporated into the midwifery model of care. / Epidemiology

Yes

This study aimed to explore the lived experience of the working lives of midwives in the UK who practice independently of the NHS. It was designed to understand their motivations for working in this way and to explore their beliefs and values about midwifery care with particular emphasis on their perceptions of building and maintaining relationships with childbearing women. Hermeneutic phenomenology informed the methodology for the study and an adapted biographical narrative interpretive method (Wengraf 2001) was used for data collection. In depth qualitative interviews were carried out with twenty Independent midwives in the UK between 2007 & 2009. Data were analysed using Ricoeur's theory of interpretation (Ricoeur 1981). Keys findings indicate that motivated by a very strong sense of what it means to be 'with woman'; these midwives initially chose a career path in the NHS that enabled them to better enact this philosophy. However, constraints on their ability to enact this philosophy in the NHS combined with a desire to form more meaningful relationships with childbearing women and to support their individual needs informed a final move from the NHS into independent practice. Independent midwifery is experienced as very positive career move which results in considerable job satisfaction and an opportunity to use the full range of midwifery skills. Formation of the mother midwife relationship is perceived as a pivotal midwifery tool which facilitates understanding of individual childbearing women and their needs. Ricoeur's theory of interpretation (1981) is utilized to explain how Independent midwives form relationships with their clients in this context. The concepts of 'time', 'autonomy' and 'risk' are discussed in the light of study findings, contributing a unique insight into the working lives of Independent midwives, the mother midwife relationship and enactment of the 'with woman' philosophy in this context. The study also demonstrates that whilst there are many positive aspects of working as an Independent midwife there are also several constraints and potential vulnerabilities. These include the blurring of work/life boundaries, financial insecurity and the consequences of working with clients who often have very complex needs and particular expectations of the midwife-client relationship. Supporting women's choices, working flexibly to meet the needs of clients and respecting their right to autonomous decision making can place Independent midwives in a position of potential vulnerability and leave them subject to professional criticism.