Background
Methods
Research setting
Demographic variables | Number of participants |
---|---|
Age | |
30 to 40 | 2 |
41 to 50 | 5 |
50 to 60 | 3 |
Years of experience as a midwife | |
< 5 years | 1 |
5 to 10 years | 3 |
11 to 15 | 3 |
16 to 20 | |
21 to 25 | 1 |
26 to 30 | 1 |
31 to 35 | 1 |
Method of midwifery education | |
Hospital – based diploma | 3 |
Undergraduate midwifery degree | 3 |
Postgraduate midwifery qualification | 4 |
Country of midwifery education | |
Australia | 6 |
United Kingdom | 3 |
New Zealand | 1 |
Previous midwifery model | |
Public hospital non-continuity model | 10 |
Private hospital obstetric model | 1 |
Current midwifery model | |
Privately practicing midwife | 2 |
Midwifery group practice | 8 |
Total | 10 |
Data collection
Data analysis
Results
Building relationships
Trusting relationship between woman and midwife
This trusting relationship, sometimes conveyed as a partnership or professional friendship, was acknowledged by midwives as the key to the success to being ‘with woman’ during labour and birth in the ‘known midwife’ model: I think first and foremost it’s the relationship … it becomes close to a friendship type of relationship … a respectful partnership and relationship between the midwives and the women (P2).… you have that trust, a real trust in each other that was developed over time that you both rely on actually. She trusts you to make the right call and you trust her for her body to work efficiently and do what is necessary in the space that you’ve created (P9).
Midwives felt the relationship that developed, enhanced their ability to connect with the woman and her journey rather than being associated with a set of clinical tasks: Your relationship with the woman grows like the baby grows: It’s a journey you make as well with the woman it’s not just the woman and her family but it’s really the partnership with them (P7). Building the relationship during pregnancy contributed to the commitment and ‘knowing’ required to offer support during labour and birth: … having that journey beforehand that helps you feel that commitment and that onus to do well … in birth I guess for that woman (P8).It’s like you’ve got that friendship already before you go in the room … as soon as you walk in the room the atmosphere’s different. We know each other and it’s relaxed and it’s, happy … my experience on MGP has been much better of having that sense of being with woman because I’ve had that continuity (P4).
Relationship inclusive of partner and family
Woman centred care is safer
Intuitive and individualised care founded in ‘knowing’
Another midwife characterised this process as being in tune with the woman, almost like a reciprocal dance where the midwife could respond appropriately to the woman’s needs.… it was just literally eye contact, me knowing that lady, knowing what she wanted, where she wanted to be … watching her body, watching what she was doing … I could pick up on that and jump in when it was relevant (P4).
A final example reflects how the midwife can facilitate a woman’s individual path in choosing a different course of action than might be initially recommended: … [if] that approach is not going to work for her … I’ll try one other thing … I think if you’re a midwife who is working ‘with woman’ … you will become the midwife who writes ‘declined’ (P2).You’ve had plenty of time and you know what her worries are but you also know what her insecurities are, you also know what her medical problems are and how you can look for that … you’re in tune with all of that it just forges the path forward and just makes it kind of clear and open so she’s able to walk that path with you by her side having that awareness (P9).
I feel safer looking after women who I know because I know their history very well. I know them inside out. I know what their normal situation is, what their medical history is; little things to look out for and know when to move, when to kind of change direction, when to think ok now we need to do something different (P9).
Addresses complexity of needs
… particularly if you’ve got women that have complex issues, you’ve got a full 4, 5 months of being with them to learn more about that problem rather than trying to be thrown in the deep end with someone in labour … you know their story, you know what they want, you get to spend more time with them, physically supporting them as opposed to have to sit there and read through their volume of notes to find out why does this woman not want this (P5).
Cultural safety
Impact on the midwife
Personal investment in professional practice
Midwives acknowledged that being ‘with woman’ in the ‘known midwife’ model did come at a ‘cost’. There’s a cost in terms of sleep and exhaustion and family time and being on call, yes there’s lots of costs to do that (P8). The connectedness that develops through the relationship results in an investment that sees midwives riding the highs and lows with the women.I know the hours I spend looking after women in the continuity of care model, if I spent those hours in a medical model … I would earn a lot, financially I would be so much better off but I know I would hate myself (P1).
Sometimes you take it home at the end of the day it can be draining … the hours are unsociable, they’re often long. You know it can be physically and emotionally draining (P5) but then also note: … it’s more than made up for when I work in a model that like I’m in now … when you’ve had that full experience from beginning to end with a family … It definitely makes up for it (P5).
Enhances confidence
… being able to recognise a situation and change it enough to help her achieve what she wants to gives you almost as much confidence as having the baby yourself you know … So I think that [being with woman] would give midwives more confidence to speak out and I think it’s important for women (P2).
Recognition of importance to midwifery
Midwives acknowledged the privilege of working with women and their families: I was talking to my sister last night about how privileged our job is and that you share in the most amazing moments (P6) and that this sustains a commitment to the profession: I can’t really imagine doing anything else (P3).… my experiences of being with woman are better for me on MGP … to know I’ve had that with woman … the fact that I’ve made that difference is really, gives me really good job satisfaction (P4). This is echoed by another midwife … it’s [being with woman] why you do the job … I feel I get more out of my job when I have known them before (P5).
Impact on the woman
Reported benefits to women
… the other thing women say is, you knew exactly what to say at the right times (P6). According to midwives, women also reflected upon the relationship and how it sustained them during times of difficulty I get a lot of feedback from women that say ‘oh my God that’s what got me through (P6). Being ‘with woman’ in the context of the professional relationship contributed to women sharing with their midwife: She (the woman) said ‘I felt like I was in control, I felt like I made decisions’ … she said to me ‘I never thought I’d have a relationship with my midwife like I have with you’ (P6). Midwives observed women being empowered: That’s what you’ve done by being with woman … she will labour efficiently and she’ll feel so proud of herself afterwards to have done it under her own steam (P9).
For many women, the stories shared with midwives confirm how the relationship with the midwife provided a source of healing and reconciliation of previous traumatic birth experiences: She was very vocal about that [previous experience] and she was like ‘that was just such a healing birth for me’ … That to me was what being with woman was about (P5).Women who have had experience in both models will actually tell you that there is a difference. It was so important for her to achieve a VBAC [Vaginal Birth after Caesarean]. It couldn’t have actually worked out any better … She says ‘I cannot even begin to tell you the experience’, she says ‘they were incomparable … the whole experience, but particularly the birth’ (P3).
Challenges in the known midwife model
‘Systems’ approach to childbearing
Midwives shared how the requirement for medical involvement in the care of women impacts the relationship between midwives and women … within the hospital system, that relationship constantly gets eroded and women must be aware of that (P2).… the lack of understanding on the establishment side and the medical side of midwifery-only care ... hospitals’ lack of willingness to work with midwives that choose to work in this model is a really big inhibitor … it’s worked … in the UK, where the medical obstetric profession and midwifery are very much on an even level and they’ve worked together forever … we’re all her carer, so long as she gets the right care that’s what matters. I still find it absolutely frustrating the way the system dictates to women you will or won’t have and that midwives can or cannot … that’s the biggest inhibitor to working in this model (P1).
Another midwife expressed frustration with communicating the importance of being ‘with woman’.… it’s [with woman] not supported in the majority of places where midwives work or models of care that midwives work in it’s not an acknowledged skill really. It’s not considered important, it’s not evidence based, it’s not scientific … it’s not supported and it’s not promoted as valuable (P2).
Midwives recounted a blurring of the lines of accountability when unknown practitioners enter the woman’s birth space and interrupt being ‘with woman’.… it’s a matter of, for us to be able to put it [with woman] in a language that doesn’t seem so tree hugging … what we do is both an art and a science, so how do you find that, for something that we know (P3).
This contrasts with descriptions of when labour and birth occurs at a birth centre, or the woman’s home: Your role is going to be different when you’re at home and everything’s going well, she’s in the zone and things are really smooth then you’re really her support, facilitator and guardian, making sure it all goes according to plan (P9).We’re in labour ward but we have other members of staff on labour ward. So you have the coordinator and you have the GPs [general practitioners] and you have the specialist obstetricians and sometimes I think when that model [medically-led care] comes into my room with my woman that affects me being with woman (P4).
Another limitation was seen as the rationalising of antenatal visits in some services.I think that one of the other things that’s really impacted upon my ability to be able to be there with women is that the demand for our services is outstripping the supply and it’s very hard to say to a woman I’m sorry but you haven’t made it on the programme … that’s been a challenge not to be able to give every woman that service (P3).
It’s continuity of care of course but then we see them at 15 weeks and then we don’t see her, then ‘til 24 weeks. So it could be better, could be earlier … for some women they need more time to build the relationship (P7).
Midwives as the ‘vehicle’ for ‘with woman’
Midwives spoke about how their own fears from past personal or professional experiences, influenced their ability to be with woman and how they learned to overcome this: … we project our own fears and our own baggage into what the woman is saying but this is not your journey this is her journey … I learned a lot about, not projecting what I felt or what experience (P7). Fear of ridicule from colleagues was also acknowledged as a challenge: I think then there’s the scared of being told that they’re weird or there’s no science behind that, like being fobbed off because they do they make you feel unintelligent or because you believe in that [being with woman] (P2).When you’re not feeling up to it and you have to put yourself in the right mood but as soon as it [labour] starts it gathers momentum and becomes easier and flows really nicely … if you’re not in the right space then it doesn’t take much to flick you over and see the power and the beauty of what’s before you and help to make that happen [being with woman] if you’re in your ‘with woman’ zone it helps the woman to be in her zone (P9).
Women who are not known or don’t want to be ‘known’
Although, not commonly reported in this research, midwives described how a woman can dismiss and not recognise the relationship opportunity in a ‘known midwife’ model. Women who may decline ‘relationship’ are still offered respectful care during labour and birth: … there’s other women who as long as you’re clinically there and doing everything right and everything’s getting addressed they don’t have that ‘with woman’ connection … doesn’t matter which midwife they had (P4). Another midwife shared a scenario where: … she just was a woman who actually she didn’t want me in her space, she didn’t want me to be involved, she just wanted me to do the birth … she didn’t want her husband or … no input from him and you know she said just don’t f***ing touch me (P6). Midwives acknowledged how being ‘with woman’ in these situations means being respectful of a woman’s wishes by providing care less focussed on the relational aspects of care.… it is different but … even if we haven’t met the woman specifically, we all know something about each other’s women … we’re all continuously talking so most of the time even if I haven’t met the woman I know something of her and something of her wishes (P5).