Key words: Midwifery, woman-centred practice, grounded theory, The relationship between midwives and women appears to be a key. midwife-woman relationship. This paper presents a challenge related to the “ cornerstone” and very essence of New Zealand (NZ) midwifery care: partnership. Evidence suggests that women's experiences and expectations of the midwife- woman relationship vary. For example, it has been noted that childbearing.
I can see that some of you are already cringing, but this is the truth. You also need to quantify that risk for the woman in a meaningful way eg. What induction of labour involves and how it is different to physiological labour; and what would happen if she chose to wait eg.
The individual risks for the woman i. Are there other health concerns or issues eg. What a woman needs to know to consent to a routine vaginal examination during labour as per a hospital guideline rather than in response to a situation: It is particularly important to provide clear information when a woman is making decisions outside of recommendations or the norm.
In order to do this she needs to have adequate information. For example, if a woman is choosing to birth at home she needs information about the benefits, risks and other options.
She needs know the difference between home and hospital, including how the setting might alter the management of any complications. Information sharing needs to be documented. Like any aspect of care there needs to be evidence that it happened. Some hospitals are using consent forms for common interventions eg. VE and ARM with a list of risks for the midwife to read out and get the woman to sign.
‘Making a difference’: midwives’ experiences of caring for women | RCM
If you give the woman any information resources — write down what you gave her. This involves being honest with women about your experience and ability to meet her needs. Safety is in the eye of the beholder — it is up to the woman whether she thinks a 1: Which brings us to the issue of bias. Information sharing needs to be unbiased, and this is extremely difficult because we are all biased and have our own beliefs and opinions. However, there are some strategies to avoid transmitting your bias whilst giving information: Present both sides of the coin see above ie.
Ensure that the woman knows you are not invested in her decision, and that you do not want to influence her either way — say this to her. Avoid telling her what you did with your own pregnancy, birth, baby — again, this is not relevant to her. Not only can this influence her decision, but it can also make things problematic if a transfer to that hospital is needed.
A good way to assess whether you are providing un-biased information is to look at what women in your care choose to do. If all of the women you care for choose the same option — you need to consider if you are influencing them. Women are individuals and there should be a range of decisions being made. For example, if a woman declines the offer of a vaginal examination — you simply document her decision and carry on.
You may need to let colleagues know what her decision is and ensure that they respect it. In some settings you may be question or pressured about her decision — but ultimately you are fulfilling your legal responsibilities regarding consent. Making a difference The three categories identified in this theme intertwine, and all relate to midwives connecting with women beyond the physical support and care required in pregnancy, labour and birth.
Building a rapport The need to establish a relationship with women was a priority for many of the midwives interviewed, and considered an important starting point in the midwife-woman interaction: That is routine, blood pressure, temperature, urinalysis, listen to her baby. And you actually build up a rapport with her and you get to know her.
Firstly as a patient and then as a person. This distinction between physical and social activity emulates the roles described by Wilkins — that women value significantly personal and emotional engagement with the midwife more than a narrow professional one in which the woman is objectified and the relationship is functional.
Central concepts in the midwife-woman relationship.
Similarly, Edwards found that women defined their need for support from a holistic viewpoint — they wanted both physical and emotional support from the midwife.
The midwives interviewed in this study identified the importance of both dimensions of care, finding it easier when they had sufficient time to be with the woman, especially in labour.
When the pressure of work prevented their continuous presence, they expressed frustration: I felt bad because I had to leave [one woman]. I had to pop in and pop out, pop in and pop out. I kept apologising to her and then the other woman I was with They also found it easier to build a rapport when they had the opportunity to get to know the woman over a period of time, when they could provide continuity of care.
Continuity It was not only the team midwives who raised the issue of continuity — the core midwives could see definite advantages as well: I did know her antenatally as well and I think that does make a difference.
Debates on continuity of care and carer appear to relate more to organisational efforts required to implement or evaluate its effectiveness rather than in challenging its potential to enhance meaningful relationships between women and midwives. It was special At times, the midwives felt that they were able to make a significant difference to the women in their care, and when this happened they appeared to feel very positive about it: But we just danced And then she got up again and we started dancing right up until the head was almost on the perineum.
The midwives appeared excited when telling these stories, remembering particular births with positive feeling, and the concept of reciprocity Campbell, in the client-professional relationship appears pertinent. Preparing This theme was described somewhat briefly but emphatically in the interviews as a key role of the midwife. The responsibility to prepare the woman for labour, birth and early motherhood, helping her to know what to expect, was dealt with by giving women advice and by teaching them: The suggestion here and in other interviews was that the advice given by the midwife would help the woman to be prepared for the unknown.
However, there appeared to be a reluctance to tell women the truth about the pain of labour or of potential negative outcomes of complications in pregnancy, for example, with respect to pre-eclampsia: The midwives appeared to want to protect women from the reality of the pregnancy or birth experience.
This would seem a paternalistic approach to care, where the practitioner sees it as their responsibility to make decisions for clients based on professional knowledge and expertise, then guiding the person to an understanding of why the decisions have been made McKinstry, There was reticence about taking responsibility for this unrealistic picture: Clearly, this woman did not achieve her expectations — she had hoped for a non-interventionist birth that did not unfold.
Generally, the midwives were aware that it was their responsibility to prepare the woman but seemed unable or unwilling to consistently portray an honest account of labour and birth so the woman could really consider her options. The idea that midwives can actually control the outcome of a pregnancy through their supervision would seem illfounded.
Central concepts in the midwife-woman relationship.
In these descriptions, there is a lack of agency to the woman or her body. There is a dissonance between this potential for control and the relative powerlessness expressed about helping women achieve their expectations. Feeling in control Once again, there were positive descriptions of experiences in practice, but these were defined in relation to the lack of interference by anyone else: Because it was really what the person was doing, it really was a normal delivery.
She delivered the baby, the woman did. We only actually deliver babies when women have sections. Normally, they deliver their babies. Indeed, the fact that things progressed without a need for any specific action was considered particularly pleasing. These positive experiences would seem to reinforce the potential for normality of birth and the value of both non-interventionist midwifery practice and inactivity as mechanisms of support. Not feeling in control There were many descriptions of times when others took over responsibility, leaving midwives feeling angry and frustrated: The midwives said they felt guilty when this happened and that they had let the woman down — again, they seemed to want to protect the woman from unpleasant experiences.
However, they also seemed to lack conviction that women can birth without intervention given the right circumstances and support. Possibly, repeated negative experiences had reduced their confidence, and control by others eroded their authority.
As NHS midwives, they worked in a large, bureaucratic organisation. Street-level bureaucrats normally feel powerless, believing they have little opportunity to take control in a system where policies and protocols are prescribed centrally.
Similar experiences to the two scenarios above were described by other interviewees, when doctors or senior midwives took control. The midwives had not challenged the decisions, but were left feeling impotent and angry. In reality, practitioners have significant power in relationship to the client and can have a profound influence on the way the individual experiences the service.
But in the nonsupportive culture of maternity services Kirkham,this power may prove difficult to use. Although these midwives seemed to want to believe they could really make a difference for women in their care, they did not consistently achieve that outcome due to a variety of external pressures.
Implications for education Although this paper only relates to the initial phase of the research, there are some implications for education. As a relatively small qualitative study, it may be argued that no generalisations can be made from the findings. However, Morse points out that the purposefulness of the sample in a qualitative study means that findings will be based on data provided by participants with a relevant and specific contribution to make, and their meaningfulness increased.
The issues raised would not necessarily be the same had the research been conducted with a different group of midwives and by a different researcher. Yet, the things that these particular midwives shared are important, recognisable by other midwives and useful as a starting point for the development of an educational strategy. The practice environment, where half of UK midwifery education takes place, has a significant impact on learning.
Satisfied midwives who feel they make a substantial contribution to positive outcomes for women are likely to be effective role models for students.
‘Making a difference’: midwives’ experiences of caring for women
Satisfaction for the midwives in this study came at least in part from feeling in control. A consistently supportive culture, where professional groups work harmoniously and collaboratively would seem a preferable learning environment to that described at times in the study.
Opportunities for developing sustained relationships with women, for example through caseload practice, can also have a positive impact on the learning experience for students. The ability to build a rapport with women is an important midwifery skill.
Recognising that it is both easier and more satisfying to look after women already known to the midwife is a powerful rationale for offering students opportunities in continuity schemes. Women deserve to know what to expect of labour and birth, and students deserve to learn what they can realistically achieve as a midwife.
Exploring the potential in the woman-midwife partnership, where knowledge and decisionmaking is shared, could be a useful learning experience for students aiming to achieve woman-centredness. Some recommendations for education emerge from this phase of the study. These relate mainly to an environment of practice learning where students see midwives making a difference for women as effective advocates, helping them to achieve their desired outcomes from labour and birth, and where students have opportunities to build partnership relationships with women, learning to prepare women realistically for their birth experiences in order to lead to fulfilment and to prevent disappointment or frustration.
Conclusion This first phase of the research project highlights a number of positive elements that could usefully be integrated into midwifery education. The midwives were committed to providing satisfactory outcomes for women, identified the need to prepare women appropriately and wanted to make a difference with regard to the quality of the birth experience.
However, the relatively disempowered position of midwives working in a large bureaucracy such as the NHS did not provide consistently strong and positive role modelling for students.
The next phase was conducted with the participation of midwives working outside the NHS, in an attempt to discern the importance and relevance of environment and experience on woman-centred midwifery practice and the implications of these issues for education.
The paper based on the second phase is expected to be published in an upcoming issue of this journal. A study of midwifery communication styles unpublished MSc dissertation. The Practising Midwife 3 1: J Advanced Nursing