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International Journal of Childbimh '

Editors-in-Chief

Denis Walsh, PhD, RM

Division ofMidwijlery

U}iiversity ofNbttingham, tlK

Kerri D. Schuiling, PhD, NP-BC, CNM, IIACNM

School ofMrsiug Nbrthern Michigan Uhiversiip; USA

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Ellen Annandale, BSc, MA, PhD

Maria Helena Bastose

Marie Berg, Phl]), MNSc, MPH,

RN, RMSusan Bewiey MA, MD, FRCOGSheena Byrom, RM, MA

Ng Cheung, PhD, MSc, RM, RGNKYllike Christensson

Hannah Dahlan, RN, RM,

BN(Hons),MCommN, PhD, EACMAnke De Jong, DM, PhD

Raymond De Viries, PhD

Declan Devane, PhD, MSc,

PgDip(Stats), BSc, DipHE,

RGN, RM, RNTNadine Edwards

DeputyEditor

Soo Downe, BA(Hons), RM, MSc, PhDSchool ofPublic Hizalth and Clinical Sciences

Uhiversity ofCentralLancashire, Cll(

Associate Editors

Duncan Fisher

Vivette GIove4 MA, PhD, DSc

Mechthild Gross, RM, RN, MSc

Gil1 Gyte, BSc, MPhi1

Eileen Hutton, RM, RN, PhD

Ken Johnson, PhD

Holly Kennedy

Patrick Laveryl MD

Nicky Leap, DMid, MSc, RM

HeloisaLessa

Lisa Kane Low] PhD, RN, CNM,

IIACNMAns Luyi)en, RM, PGDE, PDM, PhD

MargaretMaimbolwaJayne Marshall, Phl), MA, PGCEA,

ADM, RM, RGNEtsuko Matsuoko, PhD

Chris McCourt, BA, PhD

Marianne Mead, RM, PhD

Judith Merces BSN, MS, DNS

Mary Newburn, BSc, Hons, MSc

Sally Pairman

MallavarapuPrakasamma

Andrea Robertson

Verena Schrnidt, RM, BSc

Julia Seng, PhD, CNM, FAAN

Theresa Ann Sipe, CNM, MPH,

MN, PhDNick Tlaub

Jim Thornton

Octabio Vai gens

Saras Vedam

Kim Wlttts, PhD, PGCAR MSc,

RM, RN

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Copyright @ 201 1 Springer Publishing Compairy; LLC, New Ybrk. ISSN2156-5287

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International Journal of Childbirth

Vblume 1, Numbcr 1, 2011

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EDITORIALInternational Journal of Childbirth

Denis Wblsh, Klerri Schitiling and Soo Dorvne

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ARTICLESCompetence and Competency: Core Concepts for International Midwifery Practice

Judith T Fullerton, AtfGhe'rissi, Peter G, Johnson, and fo7ce B. Thonipson

Becoming a Mother: Wbmen's Journe〉,s From Expectation to Experience in Three European Countries

Ans G, Luyben, Sue R. Kinn, and Vinterie E M, Fleming

General Practitioner Involvement in Remote and Rural Maternity Care:

[Ibo Big a Challenge?

lan Caldoiil Vbnora J-lundteJc Edwin van 7bijlingen, Jbhn Reid; Alice Kige4

lanet lltcken Jilly J}'elan`L Fiona Harris. Jane Fbrmen and Helen Bi;yers

Expanding Postpartttm IIcmorrhage Prevention to the Community in

Resource-Poor Contexts: Critical Considerations and Next Steps

S),dnay A. Spaizgiei; Alissa I〈bski, Deborah Armbrusten and Clynthia Stanton

Struggling to Get Into the 1'oel Room? A Critical Discourse Analysis of Labor IMnrd

Midwives' Experiences of Water Birth

Kitn Rttssell

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COMMENTARYThe Necessity and Challenge of International )vlidwifery Science

Raymond G, De V}'ies, Marianne Nieuwenhuijze, Rcijbei van Crinipen,

and the members of the Mid,vijlery Science Wbrkgro up

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International Journal of Childbirth

The launch of a new childbirth journal is a cause for cel-

abration. It provides an opportunity for researchers, service

users, dnicians, and materniLy service staLreholders to get

their messages out quickLy and more efectively at a time

when maternity provision worldwicLe is changing rapidl}L

In this editorial, wc flag up what we believe are the more

significant influenccs and challeTiges that face us all over the

coming decade; but thirst-why a tiew childbirth journal?

There are currcntly too few childbirth journals that

could be truly described as multidisciplinar}L i clusive of

the developing world perspective, and holistic in scope

regarding all aspects of childbirth. rvIost journals target a

particular audiellce, demographic or professional group,

and this results in `'silo'] thinking with limited cross fertil-

ization ofideas, dissemination ofbest practice, or research,

For example, midwives mav read obstetric journals and

obstetricians may rarely read midwi fery journals. Sociolo-

gists do not often publish in midwifery or obstetric titles,

and service users only occasionally submit to professional

journals. Therefore, an ongoing dialogue in the literature

is ahsent, and when conLrovcrsy docs "breakoue' in major

journals, the debatc is frcqucntly polarized; look no fur-

ther than the heated exchangcs of home birth research,

recently (de Jonge et aL, 2009; Wiix ct al., 201O).

The internationat fournal of Childbirth wM pro-

vide an opportunity for all voiccs and all perspectives to

be heard, The jour'nal's niissien is to:

. Disseminate original research, theoretical insights,

and accounts ofpracticc-based innovations and

organization ofcare

. Provide a fbrum for exploration, debate, and critique

in childbirth research, education, and practice

- Promote multicultural and interdisciplinary perspec-

tives in the examination ofchildbirth experience and

knowledge. Actively promote research, education, and practice

activity in neglccted arcas such as normal birth,

measurement ofwell-being as opposed to pathology;

indigenous childbirth practices and culture, and the

public health consequcnccs of childbirth

. Disseminate original case studies ofnor[nal, although

unusual births, with a significant reflective component

This journal is needed more than ever no"4 because

maternity carc continues to undergo radical change across

theworldinrcsponsctoseveralimperativesandinfiuences.

The high levels ofmaternal and perinatal mortality in thc

developingworldarcunacceptable,particularlywhensolu-

tions exist that would rcduce the rate substantiallM How-

eve4 even within Lhese known shared solutions, there is

tension over whether to address the causes (trade injustice,

povert〉s and the unequai distribution of resources) or treatthe symptoms through technolog}l drugs, and provision of

skillecl attendarits, Which ofthese should take priorit〉s andis a twinned approach realistic and achievable?

This debate reflects another worldwide tension

around how matcrnity services should evolve-should a

social or biomedical model take the lead? In many parts

of the world, the biomedical model dominates and, wherc

it does, esca]ating intervention rates are observed. The

caesarcan epidemic is but one example, Howevec in other

parts of the world, home birth and midwifery led carc

characterizes large sections ofprovision, with a generally

encouraging safeLy and ethcacy record (Hatem, Sandall,

Devane, Soltani, & Gates, 2008). Can the two approaches

coexist with mutual understanding and respect?

There continues to be a debate concerning child-

bearing womenis autonomy choice, and agency, which are

played out within the biomedical and social model, with

voices articulating access to universal elective epidural

proyision and birth centrelhome binh options within these

respective modcls. This debate reverses in sub-Saharan

Mica where homc birth with traditional binh attendants

is blamed for high perinatal mortalit)l and where hospital

provision of epidui'aJ services is patclry at best. In recent

months, anothcr layer of complexity is revealed in initia-

tives, to address obstetric violence in Vlenezuela, where Ieg-

islation has been enacted to make nonconsensual obstetric

procedures illegal (D'Gregorio, 2010), and in the United

States, where inhumane treatment of laboring women is

once again a ncws item (Goeg 201O).

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iN71ERNATiONAL JOURNAL OF CHtLDBtRTH Vblwme 1, lssue 1, 201 1@ 2011 Springer Publlsh[ng Company, LLC v(Lnv,springerpub,comDOiltO,t89112156-5287.IA.2

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The discourse around risk is having a major impact

in many western maternity care systems, and results in

defensivc practice and institutional se] flprotection, Elabo-

rate policies and mechanisms, in an efibrt to shift blame to

women or individLiaL practitioners and away from system

fal1ures, are eviden[e of a system that is in need of change

(MacKenzie Bryers & van 1'eljLingen, 2010). Sociologists

have warncd health services of the dangers of this dis-

course driving change, but litigious, adversarial models of

compensation dominate, currently (Carter, 2010).

Accompanying the aforcmentioncd tensions and

making them werse is the economic argument that is

raging over the affordabilibr and eguity of provision of

carewithinandbctweencountries,Mostnationalmodels

of maternity care have a mixed ecenomy of public and

private provision. Perverse incentives can operate in pri-

vate models that reward intervention and overtreatment.

For example, a recent study has demonstrated the high

financial cost of routine intervention in normal child-

birth in the U.S. system (Conrad, Mackie, & Mehrotra,

2010). Rising use of pharmacology and technology fbr

childbirth in pub]icly funded s〉'stems suggests that soci-cty is willing to expcnd resources in this area, evcn when

the public purse is under intense prcssure. This raises

interesting sociological and organizational questions

that can best be explored by cross-discipiinary investiga-

tion. Givcn this milieu, a journal that publishes papers

acress thc spectrum ofthese challenges and opportuni-

ties is welcome. "le are honored to bc supported by the

International Confederation of Midwives, which has

glebal reach with mere than 80 mernbcr societics,

As editors, we want to encourage the submission

ofpapers related to childbirth from all over thc world

and from many ditl'crent stakcholders.

REFERENCES

Carter, S. (2010). Beyond control: Body and selfin women's

chi]dbearing narratives. Sociology of Health th Illness,

32(7),993-1009.

Conrad, R, Mackie, T,, & Mehrotra, A. (2010). Estimating

the costs of medicalizat'ion. Social Science c}･ Medicine,

70(12),1943-194Z

de Jonge, A,, van der Goes, B., Ravelli, A., Amelink-Vbr-

burg, M., Mol, B., Nijhuis, J,, ... Buitendijk, S. (2009).

Petinatal mortality and morbidity in a nationwide

cohort of 529,688 Iow-risk planned home and hospital

births, BJOG: An Internatiotial Journal of Obstetrics th

(lynaecolQgy, 116(9), lt77-1184. doi:10.1111/j.1471-

05282009.0217S,x

D'Gregorio, R, (201e), Obstetric violence: A new tegal term

introducedinVenezucla[SpecialEditorial].I}tternational

lottrnal of Clynecology and Obstetrics, ll l, 2e l -202.

Goer, II. (2010), Cruelty in maternity warcls: Fifty years later,

k)urnal oj'Ilerinatal Education, I9(3), 33-42.

Hatem,M.,Sandall,J,,Devane,D,,Soltani,H,,&Gates,S,(2008).

Midwife-led versus other models of care Sbr childbear-

ing women. Cochranc Database of Systematic Reviews,

lssue 4. Art No.: Cl)O04667. doi:10,le02/14651858.

CDO04667,pub2

MacKenzieBryers,H.,&vanTleijlingen,E(2010).Ilisk,theor"

social and medical models: A critical analysis of the

concept c)f risk in maternity care, Midivij'erp,, 26(5),

488-496.

Wax, J. R., Lucas, E L., Lamont, M., 1'inette, M. G., Cartin,

A., & Blackstone, J. (2010), Maternal and newborn

outcomes in plannecl home birth vs planned hospital

births: A meta-analysis. American Journal ofObstetrics

c}" (lynaecotogy, 203(3), e1-e8.

Denis Walsh, Co-Editor-in-Chief

KerriSchuiling,Co-Editer-in-Chief

Soo Downe, Deputy Editor

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Competence and Competency: Core Conceptsfor International Midwifery Practice

fttdith T thdlerton, AifGhtirissL Peter G. Jbhnson, andfoyce B. [IIP!ompson

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The global health community has imptemented several initiatives over thc past in the intercst of accel-

erating country-by-countrv progrcss toward the MMennium Deyelopment Geal ef improving maternal

health. Ski11ed attendance at every birth has been recognized as an essential componcnt ofapproaches

for reducing maternal and perinataL morbidity and mortality

Midwives have been acknowlcdged as a preferred cadre of skilled birth attcndant. The lnterna-

tional Confederation ofMidvvives (rCM) speaks for the global community of ftdly qualificd (profes-

sional) midwives, The ICM document entitled Essential Cotnpetenciesfor Basic iXc[idvvijbry Practice is a

core policy statement that defincs the domains and scope of practice for those individuals who meet the

international definition ofmidwife. This article explores the meaning of competencc and competency

as core concepts for the midwifery profession. An understanding of the meaning of these terms can

help midwives speaking individua]ly at the clinical practi[e level and midwifery associations speaking

at the policy level to articulate more clearly the distinction of fu11y qualified midwives within the skMed

birth attendant and sexual and reproductive health workfbrce, Competence and competcncy are funda-

mental to the domains of midwifery education, legislation, and regulation, and to Lhe deployment and

retentionofprofessionalmidwives.

KEYWORDS: professional midwifery; competence; essential competencies; sl(illed attendance

1

INTRODUCTION

The inauguration of the Safe Motherhood Initiative

in the mid-1980s focused the attention of the global

health communibr on the reproductive･and human

rights of women, infants, and families, The Millennium

Development Goals (MDGs) were an ambitious agenda

for improvement in global hea]th concerns that were

adopted by 192 United Nations (UN) member states and

many internationat organizations in 2000 (UN, 2000).

MDGs 4 (reduce child mortality) and 5 (improve rnater-

nal health) emerged as an cxpression of the concerns of

world citizens and governmcnts about the tragedy of

maternal, newborn, and infant death.

A clear consensus has emerged among thoseresponsible fbr tracking movcment toward estab-

lished MDG targets, and that is, that providing skilled

attendance at every birth is an essential component

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of approachcs for reducing maternal and perinata]

morbidity and mortalit}1 and promoting reproductive

health. The availability ofa health provider with specific

midwifery ski11s and competencies, particularly the

lifesaving functions of basic emergency obstetric and

neonatal care (i.e., the skiiled attendant), working within

a supportiye and enabling environment (i.e,, ski11ed

attendance), is acknowledged to be a key componcnt

of any safe motherhood strategy (Bullough et al., 2005;

Carlough & McCall, 2005; Hoimeyr et al., 2009; Lec

etal.,2009).Incrcasingtheproportionofbirthsattended

by ski1led personncl is one ofthe targets established fbr

tracking progress toward achievement of MDG 5.

The globai health community has implementcdseyeral initiatives 6ver the past decade to bring skilled

attendants to the community in the interest of acceler-

ating country-by-country progress toward improving

maternal health (MDG 5) and the target ofreducing the

INTERNATtONAL JOURNAL OF CHiLDBiRra Vblume 1, issue 1, 201 1@ 2011 Springer Publishlng Cornpany, LLC wLnv,springerpub.comDO[110,189112156-5287.1.1.4

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Cvmpetence and Competency/ Core Concepts for [nternationnl Midwlfery Pract]ce Fulferton etal. 5

maternal mortality ratio by 75% by 2015, Many of these

effbrts, particularly in lower resource countries, have

included the education of new cadres of personnel who

are preparcd with a very narrow and limited dotnain of

practicc, tbcused primarily on the knowledge and ski11s

surrounding childbirth and the irnmediate neonatal and

postpartum period. The title of "comrnunity midwife" is

commonly assigned to these birth providers. [,awn et al.

(201O) report that there is some limited, but Iesser qual-

ibr evidence that these providers are effective in reduc-

ing perinatal and neonatal mortality.

The International Confederation of Midwives

(IC)vl) speaks fbr the global community of fully qualified

(professional)midwives,apreferredcadreofskilledbirth

attendants. The role ofthe ICM is to define the concept of

professional midwifery and to work collaborativety with

other global organizations at country levels to promote

and to strengthen thc voice of professional midwifery in

policy and practice arenas. The ICM has promulgated an

international definition ofthe midwife since 1972, with

endorsement by the World Health Organization (WHO)

and the International l`ederation of Obstetricians and

Gynecologists. The most recent revision was in 2005

(ICM, 2005). The ICM has set forth additionaL policy

and practice statements in the ensuing decades that can

assist ICM member associattons to translate the core

beliefs set forth in these documents into regulatory and

worldi]rce policy at Lheir country level.

The ICM document entitled Essential Competen-

cies for Basic Midivijbry Practice (a.k.a. Essential Com-

petencies) (Fullerton, Scverino, Brogan, & Thompson,

2003; ICM, 2002) is (}ne of these core policy state-

ments. The Essential Competencies document defines

the domains and scope of midwifery practicc. The ICM

expects that the Essential Competencies document wil1

be adopted or expanded at the country level to promote

the development of professional midwifery within the

country. 'Uhe ICM published the first set of Essential

Competencies in 2002. A second version, updated to

reflect the emerging state of evidence-based practice

(Fullerton & Thompson, 2005), was approved by the

ICM Board in December, 2010,

The purpose of this article is to review the context

within which the concepts of competence and compe-

tency emerged, to explore the meaning of competency

as a core concept for the midwifery profession, and to

place this gcneral discussion within the specific context

ofprofessional midwifery practice. An understanding of

the meaning of competency can hclp midwives sp eaking

individualLy at the clinical practice level and midwifery

associations speaking at the policy level to articulate

more clearly the distinction of fu11y qualified midwives

within the ski11ed birth attendant and sexual and repro-

ductive health workforce. Competency is fundamental

to the domains of midwifery education, legislation, and

regulation, and to the deployment and retention of all

providers of repro ductive health services,

THE EMERGENCE OF THE CONCEPTS OFCOMPETENCE AND COMPETENCY

De Ketclc (2000) asscrts that the concepts ofcompetence

and competency emerged in thc late 20th century when

economic globalizati'on stirnulated increased competi-

tiveness in the international marketplace. He describes a

growing censciousness among employers that there was

a perceivable association betsveen higher levels of edu-

catlonal attainment of the workforce and the ability to

adapt or conform to job perfbrmance requiremcnts. De

Ketele therefbre described the concept of competency

as one ofseveral successive milestones and an advanced

step on the pathwa}r ef knowledge acquisition.

Employers, motivated by the requiremcnts of

competitiveness and profitabilitM and in search of the

most efficient ways to mobilize a werkfbrce, began to

create their own training units. The aim was to enable

newly hired employccs to learn the job-related tasks, to

perform them with a quality close to "zero defect;' and

further, to be able to identify solutions to problems that

arose during the perforrnance of their job functions. Ib

that end, it was neccssary to craft a precise dclineation

of the activities (tasks) that were associated with any

specific job title, and to identify the associated knowl-

edge and skills (the competencies) that would have to be

acquired to enable satisfactory task performance.

Z/aining units wcre attuned to the need for an inter-

vention that began from the bottom up, The employment

sector worked cooperatively with the education sector

to develop a vocational training system that offered

the opportunity fbr learners to prepare themselves for

emplo〉rment through acquisition ofsmaller units ofskillsets that were both progressive and cumulative. Prereg-

uisite kiiowledge and skills were defined for entry into a

learning unit, The competencies that were to be mastered

as evidence of successfu1 complction of the unit and the

means by which succcssfu1 mastery of the ski11 would be

measured were simi]arly defined.

These initiatives modeled in the vocational and

occupational employment arenas were noted by those

invoLved in professional education (ihcluding health pro-

fessions). Professional task competencies werc identified.

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6 Competence and Competency: Core Concepts for lnternationai Midwifery Practice Fullerton et al.

Crosscutting arid general competencies (e.g., communi-

cationanddecision-makingski11s)thatwouldberequired

across all domains ofprofessional performance were also

acknowledged. The field of professional competency

assessment began to evolve.

viewed as an integrative concept because it considers,

at the same time, the relevant intellectual content, the

activities to be conducted at a specified level of perfor-

mance, and the situations in which those activities are to

be performed (Roegiers & De Ketele, 2000).

THE CORE CONSTRUCTS OF COMPETENCEAND COMPETENCY

An understanding of the meaning of competency first

requires that a distinction be made between the terms

cormpetence and competency. Both terms are multilay-

ered and distinct. Howeve4 simply stated, mairy theo-

rists define competence in relationship to behavioral

tasks, and competency in relationship to the personal

characteristics that underpin the performa,nce of those

tasks (Wbodruffe, 1993).

The literature presents three common approaches

to the description and measurement of competence,

although none of them is precisely distinct from the

other, and none actually crafts a clear distinction

between competence and competency The debate is

summarized by McMuilan et aL (2003) as follows. The

hehavioral lpecformance) approach defines competence

through a description of actions that can be demon-

strated or observed and assessed. In this approach,

successfu1 performance is only possible when the neces-

sary and underlying knowledge and understanding are

present The generic a2proach defines competence as

broad clusters of abilities, such as knowledge or capacity

for critical thinking, that act together to promote expert

performance. This approach ignores the context, assum-

ing that these abilities will serve as well in various cir-

cumstances. The holistic approach combines the general

underlyingattributesofthepractitionerwiththecontext

in which they are applied, and allows the incorporation

of ethics and values as elements in competent perfor-

mance. The Dreyfus model of sldl1 acquisition (Dreyfus

& Dreyfus, 1980), articulated by Benner (1984) in the

context of nursing practice, actually incorporates ele-

ments of each of these three approaches in her descrip-

tion ofcompetence, portraying them as a developmental

sequence in the progression from novice to expert.

CompetencM in its turn, has been variously

described as a multidimensional construct that irrvolves

a complex interaction of cognitive activities related to

the gathering of information, the processing of that

information for translation into action, described as

know-acting (Lasnie4 2000; Le BoterC 2000), orproblem

solvitzg; and followed by enactment. Competency is

COMPETENCE IN THE ACADEMIC ANDCLINICAL CONTEXT OF MtDWIFERYEDUC,orION AND PRACTICE

The qualitative research methodology ofconcept analy-

sis has been used to explore the concept of competence

as it relates to nursing and midwifery education and

clinical practice (AxleM 2008; Chiarella, Thoms, Lau, &

Mclnnes, 2008; Cowan, Norman, & Coopamah, 2007;

Scott-Tillex 2008; Valloze, 2009), These reports con-

firm, at minirnum, a consensus that there is no single,

universally accepted definition of competence. In fact,

the concept itself continues to evolve in pace with

advances in science and technology which challenge

us to keep pace with emerging knowledge and new

evidence-based clinical practices.

Therefbre, various definitions haye been devel-

oped fbr use in a relevant application. The ICM has cho-

sen the holistic definitional approach and has defined

competence in the context of midwifery education and

practice as the combination qfknowlecige, psychomoton

communication, and decision-makiug skills that enable

an individual to pettbrm a specijlc task to a dE}flned level

ofprqflciency (ICM, personal communication, 2010).

MIDWIFERY COMPETENCY

Moving forward in the delineation of these constructs,

an important next step is consideration of the situational

context of professional practice within which compe-

tence is demonstrated (the integrative understanding of

the concept). The definition of midwijler:y competency

emerges as a comhination of knowlecige, projlessional

behavion and specij}c skills that are demonstrated at a

dElflned level ofprqficiency in the context qf midwijlerly

education and practice. Definitions of the fundamental

components of these definitions of competence and

midwifery competency are presented in Figure 1.

Tlie 2002 version of the ICM's Essential Competencies

document delmeates one crosscutting and five practice-

specfic demains ofmidwifery competenc)c The document

detals the knowledge, skills, and behaviors that comprise

the essence of each domain. (A seventh competency

"'t''tt''t"fo"t/i't' '' ttt t ..t.

Competence and Competcncyt Core C/oncepts for ]nternatlonnb Midwifery Practice Eui/erton et aL 7

1

J

Abil"y: The quality of bein gable to perform; a nat"ral or acquircd skill or tn]ent

Attitvde: A person's views (values and beliefs) about a thing, proccss, or anoTher person that often lead to positlve Dr negative reaction.

Behavlor: A person's way of relating or responding to the actions of others or to an environmentaj stimulus.

Compctcnce; The cornbinatjon of knowlcdge, psychomotoq camtnunication, and decision-makins ski[ls that enable an individua]

to perform a spec]fic task to a def]ned leve] of proficienc},.

Compctcncy (midwlfery): A combination of knowledge, professional behnvioq and specific ski]ls that are demonstrated nt a

defined level of proficiency im the context of midwifery education and practice,

Knowledge: A fund of 1nformation that enables an individual to have confident understanding of a subject with the ability to use it

foraspecificpurpose.

t

I

Skill: Abi[ity [earnnd through education and training or acquirad by experience to perform specific actions or tasks to a specified

]evel of measurab[e performancu,

fask: A specific component of a larger body of work.

FIGURE 1 ICM clefinitions,

/

domain related to abortion-related care services was added

to the Essentinl Conrpetencies approved by the ICM Board in

Decembc4 2010). Figure 2 presents a pictorial dcpiction of

the ICM's integrative definition. Theory from the biological

and soctal sciences underpins the acquisition of ktiowledge,

which then enables acquisition of ski11s in the psychomotor

and affectise domains. Thc crosscuttjng content of com-

petency clomain 1 overarches the scope ofclmical practice

(competency domains 2 through 6). Professional behavior

infuses throughout and is essential to the essencc of mid-

Lviferycompetency

Midwifery cducation programs use the kiiowledge

and expected prot'essional behavior statements cited in

the ICM document as an external reference criterion.

Similarl" the ICM Essential Competencies document sets

forth thc various clinical skills that would be expected of

a graduate at the time of entry into practice as a profes-

sional midwife. The depth and breadth of the content of

an education program's curriculum of midwifery studies

can be compared to the expected content as delineated

in the ICM doc"ment (a curriculum development and

review method also known as "curriculum mapping").

The specific clinical skiIIs and the associated

knowledge staternents are designated as basic or addi-

tional, A basic dcsignation indicates that the knowledge

or ski11 should be considered to be common to all mid-

wives, Any item of 1〈nowledge or ski11 designated to beadditional can bc included within a curriculum because

of relevance te a country's burden of disease, or it can

be considered to be optional for midwives who wish or

need to acquire it. For example, midwifery cducation

programs located in high-resource countries may con-

sider thc ski11s of colposcop〉r or ultrasonography to be

clinical preventive services that all graduates should be

prepared to offer. Similarl" education programs located

in low-resource settings may find that including certain

ski11s within the basic program of studies (e.g,, manual

vacuum evacuation foIlowing miscarriage) could be

lifesaving for thc women served by program graduates.

Other midwives may wish to acquire certain skills fbr the

sake of increasing women"s access to particular services.

Many midwives have acquired thesc additional

skiIls through continued education and/or in-service

programs, As midwives gain experience and develop

proficiency across the core competencies that are the

core elements of entry-levcl professional practice, they

are ready to take on new expandecl practice roles.

COMPETENCY-BASED EDUCATION

Knowlcdge, skills, and associated professional attitudes and

behaviors for the professional practice of mid"tifery arc

taught and modeled within a competency-based midwifery

education prograin. A competency-based curriculum of

studies forges links betrveen curriculum content and the

expectedoutconiesofaprogramofstudy(Farrand,McMul-

lan, Jowett, & Htimphreys, 2006). The defining attributes of

a competency-based curriculum are the teaching ofknowl-

edge and ski11s in all domains for the practice role, instruc-

tion that focuscs on spccific outcomes er competencies,

alowanceforincreasinglevelsofcompetencxaccountal)ilit〉rof the learne4 practice-based learning, self-assessment, aricl

indiyidualized learning experiences (Scott-Truex 2008).

Guidance documents developed fbr midwifery

education programs b〉r the ICM and the WHO and

as

8 Competence and Competency: Core Concepts for lnternational Midwifery Practice Fullerton et aL

tampetencv #1es"e'E'tol'stienleS;･'puli1ie

hildbeoringfom[ies.

eo[fi'.:'MdiKff¥trci''i"ifi'i':''tt'//i sr/''

Domains of Cornpetenry 1. Ethies, epidemiolegv and infedion prevenfion

- Human [ights

- Legol ond regulatory ftameworks

" Administretien oRd monagement, statisias

CompetennyS2

MiGwivesprevidehigh

qualitv,culturu1lysensMve

heolthetiucottonaed

servicestea1[[nthe

communilyinorderto

premotehealthvfomily

1ffe,plennedpragnondes

andposifueparenting,

Competen{v S3

Midwivesprovidehigh

qualilyantenotoIcoreto

maximiietheheo1th

dvringpregnannyandthot

includesear[ydetedion

endtreotmentoTraferral

ofselected[omplicatiDns.

Competenny#4

Midwhtesprovidehigh

quoliv",avlaurullysensime

caredu[igglabor,conduct

acleonQpdsafedelivery,

ondhondleselected

ernengencysituotiensto

gvmaximiiethehealthef

womeilandthetrnewboms,

Competenny#S

mawhespnvmle

comp[ehensive,high

qvainMeshn1lysemstwe

postpomimco[eforwomen.

CompetennyS6

Midwivesprovidehigh

qualily,comptehensive

carefoTtheessentiallv

healthvinfentfiombirth

to two months Df oge.

Cempstenny#1

MidwivesprovideGrange

ofinrfividuoETed,ou1turolly

senstweabodioorelated

[oreservicesforwomeR

reqummgerexpeEle"[mg

ptegnoncyterminedonor

lessthotare[ongruent

withapp[icob[elawsand

tegulgtionsandiRa[cord

withn"tionalprotocels.

Domainsof

Competencv 2

- Womom's health cere.

-Porenteducotion

" Farnilv plonning

Domairsof

Compatency3

-Antenatal[ere

. PreparatiDn for Iaber,

binhandparenfing

-PnvG

bahains'of'

Competenny 4

tMenagemeRtoflebDT

tMoRogementoflabor

DndiimmediGteposti

ptmbmcompli[ations

" De[ivery skills

bomainsof

CompetenryS

-Poshetalcare

-PostnGtolfomilv

plomning

- [nitiatien ef

bteasffeeding

Domainsef

Competen{y6

- Newborn fissessment

- Newbom care

.Supportof

breostfeeding

bemainsof

Compete"cv7

- Abonion [ounseling,

[areandsupport

t Pesttbonien fomilv

plannin9

Psychomotor Detision-rnaking CommunTcation

-FIGURE 2 ICM Essential Competencies: An integrative concept.

similar global technical assistance agencies often include

recommendations concerning the minimum numbers of

clinical practice experiences that students should acquire

before they are considered eligible fbr graduation. These

minimum numbers have been derived from both anec-

dotalevidenceandformalresearchthathasdemonstrated

an association between progressive Ieyels of experience

and the abdity to demonstrate a p;edetermined level of

skill in task performance. Howeve4 although it is the

case that recommended minimum numbers of experi-

ences are associated with competency development, it is

also the case that acquiring specific numbers of experi-

ences does not necessarily mean that competency has

been achieved by any indMdual learner.

ADDITIONAL CONSIDERATIONS

A first essential corollary to competent midwifery per-

formance is the concept of an enabling environment

fbr practice. An overarching framework of political,

econemic, and sociocultural support for midwives and

midwifery practice must exist before such support can

be translated at the educational and clinical practice

Ievels into pragmatic and tangible concepts, such as

the accessibility of reproductive health guidelines, peer

support for the midwife's day-to-day work performance,

and the supplies and equipment that are essential for the

performance of the task (Morrissey & Schmidt, 2008).

Hussein et al, (2004) have proposed a new methodology

for measuring the proportion of skilled attendance at

childbirth, which goes beyond designating the attendant

by credential, but, instead, creates a composite measure

of delivery care that indicates the degree to which the

attendarit functioned witliin a practice environment,

which facilitated the deliyery of high-quality health care

services. In other words, did the ski11ed provider have

needed supplies, equipment, and transport available

to provide good care? This unique approach takes into

consideration the fact that a ski11ed provider may not be

i'

1

1

:

b

Campeten[e and Competen[y/ Core Conc'epts fer lnternntional /Viidwifery Practice Fuitc'rtoneta/, 9

able to save lives ifshe or he does not have thc reseurces

available to allow thc deliver}r ofclinically proficient care

services-both are necded. Kayongo, Rubardt, Butera,

Mboninyibuika, and Madili (2006) demonstrated that

placing a t'ocus on maintaining functional health facili-

ties aided the providcrs in those facilities to increase the

proportion of emergency obstetrical and neonatal care

services that they were able to otfer.

Additional cero]laries to competent midwifery per-

formance are the allied concepts ofcor!fidence or capability.

The midwife may have demonstrated the ability to per-

form a task to a certain expected tevcl ofteclmical accuracy

at a given time, but m ay not yet have attained any degree of

internal assurance that she or he could do so ifca"ed on to

perform that ski11, and particularly so in emergcncy situa-

tions, or when other skilled assistance is not inimediately

available (Farrand et al., 2006; Gardne4 Hase, Gardner,

Dunn, & Carrye4 2008). Additionatts technical compe-

tency attained for any sLcM and the correlated confidence

related to task perfbrmarice are rarely sustained at the same

level, even from day-to-day (Scotland & Bullough, 2004),

because the conditions, circumstances, and uncommon

situations that affect peak performance change.

Finallyinanyclinicalsituation,competenccmaydif

fer from performance. Competence itselfis onlyofvalue as

a prerequisite for performance in a rcal clinical situation. It

may well be about recognizing one's own limits, which, in

turn, is related to the concept ofprofessional behaviors that

are grounded in the ethics of professional practice, The

competent midivifery practitioner would nlake decisions

considering the human and reproducti e rights of women

and fami1ies, and not bascd on personal attitudes or values

(ICM, 2003; Vanaki & Memarian, 2009).

DISCUSSION

Adelineationofthecompetenciesthatshouldbeexpected

of the fu]ly qualified midwife at entry into practice of the

profession is fundamental to understanding the role

of the professional midivife. It also has ver}r pragmatic

applicattons in academic settings and in the workplace.

Professional inidwifery education programs are

always faccd with the challenge (and sornetimes pres-

sure) of enrolling sufficient numbers of students to

meet country workfbrce needs, This challenge is coun-

terbalanced by the very real resource limitations that

most programs encountcL Such 1imitations may include

faculty!student ratio, classroom, library and skills lab

resources, and access to clinical practice experiences.

In some countries, these challenges include educational

policies that focus on shorter term workfbrce solutions

that include the training ofmore narrowly qualified birth

providers (e.g., the community midwife) who compete

for access to clinical experiences and teaching rcsources.

A commitment to competency-based education should

play some role in helping policy makers andeducational

adrninistrators makc educational policy decisions in the

context ef the rights of students to acquire the knowl-

edge, professional behaviors, and skills relevant to the

professional role, and in the context of the rights of the

clients to expect skiIIed care from their previders.

Simultaneously, it is usefu1 for employers and

employees to have a clear understanding of the scope

of work that can be expected of the midwife in the

workplace, so that midwifery skills can be fully and

appropriatcly used, and that the scope of practice is

neither cxploited nor constrained (Homer et al,, 2007),

The job description for a midwife should bc based on

linkage between thc competency-based education that

the midwife has completed, the reproductive health

guidelines that are in place in the countr" and the mid-

wife's pcrsonal assessment of her or his confidence and

competence to practice that role. For example, midwives

in Brazil were able to advocate fbr a more appropriate

utilization of midwifery practitioners by documenting

the `Cdisconnect'] between their competency-based edu-

cation and the role to which they were assigned in the

public health care system (Narchi, 2009). Doctors, mid-

wives, and other health professionals working in a pub-

lic referral hospital in Palestine identified the fact that

the widely held perception that midwives were at the

lowest level of the health professional hierarchy made

it very difflcult for them to be effective advocates for

improvements in the guality of care offered to women

and infants, including the resources required for quality

service (Hassan-Bitar & Narrainen, 2009).

The ICM encourages countries to adapt the core set

of basic competencies to refiect the particular needs and

circumstances of the country: ,For example, midwives in

Africa collaborated to expand the competencies to reflect

trie role of midwivcs in combating rnalaria and HIVI

AIDS in that region (WI{O, 2006). In a second example,

a Delphi survey of stakeholders in 1[Unisia, including

midwives, health providers, health progratn managers,

women, educators, professional organizations, and deci-

sion makers, explored the centributions that midwives

could makc to meeting health carc needs in that country:

Findings were operationalized through delineation of

core cornpetencies for midwifery practice, thus establish-

ing midwives as a contributing member of the rcproduc-

tive health workfbrce (Gh6rissi. 2008). The (CM also

1O Competence and Competency/ Coro Clemcepts for lnternat[onal Midwifery Practice Fuller[on ot al.

-

urges countries to use thc Essential Competencies as com-

plernentary to the competency delineation documents

produced by and fbr other cadres who also provide sexual

and reproductive health care services (BarrM Allegrante,

Lamarre, Auld, & [faub, 2009; WHO, 201 1),

The cultural andpoliticaL appropriateness ofeach of

the core competencies should aiso be considered (ButleB

Frase4 & Murplry; 2008). tl'he TCM has taken great care to

craft the statement ofcore competcncies with sensitivity

for language and culture. Nevcrthclcss, it is the case that

some of the tasks that have bcen dcfincd as basic knowl-

edge or skill are not yet authorized for midwifery practice

by regulatory policy in certain countries.

In many countries, midwives are also educated and

credentialed as nurses. These combi[ied prograrns may

require a Lenger period of study to acquire competencies

for both professions (e.g., midwifery studies fbllowing

completion of nursing studies), and ma}r, therefore, be

more expensive for stuclents and fbr educational institu-

tions, There is an acknowledgcd advantage to dual prepa-

ration,Individualshavepersonalchoiceinsornecountries

te practice either or both of thosc roles, thus generating

opportunities for job mobility and autonomy in career

choices. ln other countries, graduates must complete

an obligatery period of public service. Human resource

departments have the optien of assigning these dual-

credentialed nurse-inidwives to any setting, based on

the priority workfbrcc needs of the heaLth facility: These

dual-credentialed practitioners are also more broadly

prepared for practice in health faci]ities where only a few

health workers are assigned, for examplc, in rural health

clinics or health posts (Francis, 2009; Hundley et al,, 2007;

Ireland et al,, 2007). On the other hand, tliere is the risk

of de-skilling when practitioners practice one role to the

exclusion of the other. Unless human resource personnel

and supervisors recognize their added value, the advan-

tage ef unique midwifery skills can be lost (Scotland &

Bullough, 2004), SimilarlM it is sometimes the case that

individuals are preparcd as midwives but never actually

work as midwives. This could be viewed as a waste of

precious educational resources.

CONCLUSIONS AND [MPLNCATIONSFOR GLOBAL PRACTICE

A clear understanding of thc concepts of competence

and competency serves an important purpose for indi-

vidual midwives and for the education and practice

communities where they serve. These concepts under-

pin the global cal1 to action to strengthen midwifery te

save lives and promote the health of women and new-

borns (ICM et a]. 201O).

The ICM Essential Competencies prevides the

individual midwife with an external reference criterion

fortheknowledge,professionalbehaviors,andskiIIsthat

define professional midwifery practice, against which

she or he can assess the individual level of need fbr con-

tinued learning. Midwives can also use the concept of

competency as a means to analyze new practices as they

are asked to consider adding them to their practice. For

exarnple, a midwife being asked te assume responsibility

for vacuum extraction can use competency as a logical

framework for exploring whether she or he has suth-

cient access to thc evidence-based information, skiiled

experts, anatomic models, clinical equipment, supplies,

and paticnt experiences needed to obtain the knowl-

edge, communication, clinical decision, and psychomo-

tor skills associated with developing and maintaining

competence in this new area.

Competencies provide educational administrators

with a tneans of ensuring that curriculum and educa-

tional resources are directed toward achieving learning

outcomes that arc consistent with safe, beginning-level

midwifery practice. Thc ICM recently develeped global

standards and guidelincs for midwifery education that

can serve as a framework for strengthening the initial

preparation of fully qualified midwives based on the

ICM Essential Competencies.

Competencies can be used by national regulators,

midwiferycouncils,andrcgionalhealthdistrictandlocal

facility managers responsible for maintaining the guality

of care, A reproductive health care system that relies on

midwives (or any other cadre of birth attendant) who

are Iess than competent to provide care at entry into

practice and over the professional practice ltfetime is

dangerous te women, their families, and cemmunities,

Specifically, midwifery cempetencies can be used to

prioritize delivery of continuing education and ski11s

assessment that arc most needed to ensure that efTective

services arc dclivcrcd by the midwifery workibrce. A

focus can be placed on clinical services that require tlie

most complex set ofslci]Ls, that do not reguire frequent

performance, and that have high potential for morbid-

ity; if not performed competentlM

The conccpts ot' competence, competencM and

competency-based education have received a great deal

ofattention in recent years. Widespread understanding

and application of these essential constructs can lead

to transformative educationaL clinicaL and regulator〉rimprovements in nations struggling to build a quality

midwifery workforcc aimed at meeting relevant MDGs.

g, ,/, .,.".t."sv4.',le.wh '

'

Competence and C/ompetency: Core C/oncepts for lnternational Midwifery Practice Futlefton et al. 11

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Lawn, J,, KinneM M., Lee, A. C., Chopra, M., DonnaF E,

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mannjincturers and administration need? (pp. 15-19).

Brussels, Belgium: Edition De Boeck Universite,

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1'integration,Competencesetintegrationdesacquisdan:

l'enseigement [An integrative pedagogyL Competencie:

and integration ofachievements in teaching], Collectiot

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think their caseload should be to maintain their ski11:

for delivery care? international journal of Clynaecologr

and Obstetrics, 87(3), 301-307.

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analysis. Jburnal of Continuing Education in Ntirsing

39(2),58-64.

United Nations, (2000). Millennium development goals

Retrievedfromhttp://ww.un.orglmillenniumgoals

Vhlloze, J. (2009), Competence: A concept analysis. Iliachiny

and Learning in Nursing, 4(4), 115-118.

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Beyond the clinical competencp fournal ofPrzlt2issiona

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Leadership and Organizational Develqpment journal

14, 29-36,

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Correspondence regarding this article should be directed t(

Judith 1[: Fullerton, 7717 Canyon Point Lane, San Diego, CP

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Iudith [[: Fullerton, Independent Consultant, San Diego, CA.

AtfGherissi, Assistant Professo; Education Science, High

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University:

Peter G. Johnson, Jhpiego-An affiliate of Johns Hopkins

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Joyce B. Thompson, Western Michigan Uhiversity (Emerita),

Uhiversity ofPennsylvania (Emerita), Delton, MI,

..lt"/' ",,AU"L..,as.mb

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Becoming a Mother: Womerfs Journeys

From Expectation to Experience in

Three European Countries

Ans G. Layben, Sue R. Kinn, and 1lalerie E. M FIeming

J

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OBJECTIVH: Tb investigate important aspects of provision of routine antenatal care frem women's

points ofview in thc Netherrands, Scotlalld, and Switzerlanc! tind to construct a conceptual model of

care during pregnancy, informed by women,

DESIGN: Grounded theory using semistructured interyiews to explore women's views, 'l'he interviews

were undertaken in Dutch, English, and German.

FINDINGS: ln the main study, one single cross-national model emerged, which had implications

for women beyond the antenatal pcriod. [tMothering the mother" emerged as a core categorM 'rhere

were two subcategories: "creating a bond" and `tbecoming a mother:' The subcategory of "becoming

a mother," which incorporated the stagcs of "expecting," "familiarizing," and "embarking on moth-

crhQod;' is rel)orted in this artide. Women defined becoming a mether as the aim ofprovision of

maternity care in wliich they described their journeys from creating expectations in early pregnancy to

completing the expcrience approximately a year after childbirth, Mistnatches between expectation and

experience at the end of these journeys indicated cross-national differenccs in the proyision of mater-

nity care, particularly regarding the woman-care provider relationships.

CONC[.USION: The findings from this study suggest that an essential aim of thc maternity services

was to support women in the process of becoming a mother, in the context of their own social svorld.

Supportive conditions include wornan-care provider 1)artnerships, involvetnentof women's individual

social worlds in care provision, and continuity of the ca re proyiding process, These conditions should

be taken into account, whilc designing effective rnodels of maternity care,

KEYWORDS: prenatal carc; effectiveness; women's views; Europe; grounded theory; becoming a mother

1

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tNTRODUCTION

Over the last few decades, how best to approach thc pro-

vision of efflective content of routine antenatal care pro-

grams has been a topic of discussion in Western European

maternity care literature (HaLl, Macintyre, & Porter, 1985J

Heringa, I998; W6rld Health Organization [WHO], 1987).

The United Kingdom's (UK) program ofantcnatal care, in

its present format, was introduced in 1929, with the prin-

cipal aim of reducing higlt rates of maternaL and infant

mortality Other European countries followcd the British

example, initiating very similar programs (Brezinka, 1997;

Heringa, 1998). AIthough, originallM the emphasis was en

educating mothers to take care of themselves and their

babies, a shift toward preventative medicine, and the pro-

fessional supervision of expectant mothers was observed

shordy after Wbrld Whr [. The reduction in matemal and

perinatal mortality and morbidity during the course ofthe

20th century was viewed as evidence ofvaluc ofthese pro-

grams, without taking into consideration other social fac-

tors, which may have affected these figures (Oakleyl l982).

In the early 1970s, howeve4 consumcrs and health

providcrs in the UK bcgan to call for a systematic

evaluation of the effectiveness of maternity care services

tN7EnAVLIIOAL4L JOURAL4L OF CHILDEIR7'H Llotume 1, tssue 1, 2011 @ 2011 Sprlnger Publishing Company, LLC www,spri"gerpub.com DOIIIO,I891X2I56-5287.1.1.13

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14 Becoming a Mother: Women's Journeys From Expectation to Experience in Three European Countries Luyben et at,

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(Cochrane, 1999; Garcia, 1982). Concurrent})g advancing

European integration led to concerted interdisciplinary

concern about the effectiveness of antenatal care. As a

result, antenatal care programs and their content were

subjected to extensive research and evaluation during the

1980s and 1990s, both within Europe and within interna-

tionally (Enldn & Chalmers, 1982; Heringa, 1998; VruaB

Carroli, Khan-Neelofug Piaggio, & Gulmezoglu, 2001).

These studies found that the effectiveness of many proce-

dures used in antenatal care was yet to be proved, and that

a reduction in the number and content of the antenatal

care visits was possible without affecting maternal and

perinatal outcomes (Vmuar et al., 2001). Some of these

evaluations, particularly in the UK, involved women's

experiences and satisfaction. The principal complaints

reported by women were the lack of agreement between

the organizational aspects of antenatal care and their

personal needs, the information they were receiving, a

lack of continuity of care, and the impersonal treatment

received at antenatal care clinics (Garcia, I982; Jacoby &

Cartwright, 1990; Reid & Garcia, 1989).

Researchers, therefore, are currently divided about

the value of antenatal care programs in Wlestern Europe.

Although some studies found that antenatal care led to

better pregnancy outcomes (Richardus et al,, 1997; Vruar

et aL, 2001), others could not find a causal relationship

between the content of a program and its effects (Fink,

Yano, & Goya, 1992), or stated that increased medical con-

tent negatively affected women's health (Heringa, 1998). It

was even suggested that the ritualistic significance of the

antenatal care visits was more important than tlie actual

content (Enldn & Chalmers, 1982; Heringa, 1998). Both

Graham and Oakley (1981) and Field (1990) highlighted

the existence of difflerent perspectives on the aims of

aritenatal care, which would influence the approach to the

evaluation of effectiveness. These researchers remained

among the few to criticize the prevai1ing approach to the

evaluation of effectiveness, and to define the aims of ante-

natal care from women's perspectives,

This study aimed to investigate important aspects

ef provision of antenatal care from women's points of

view in three European countries (the Netherlands.,

Scotland, and Switzerland) with different health care sys-

tems. The objective was to construct a conceptual model

of care during pregnancy informed by women.

METHODOLOGY AND METHODS

GroundedtheorsaccordingtoStraussandCorbin(1998),

was chosen to attain the objectives of this studF because

it offers an inductive appreach through generating theory

from data grounded in every(lay reality: This constructiv-

ist methodology aims to explore analytically the magni-

tude of the research area in which significant themes and

patterns are discovered. During subsequent stages of the

study; it allows for increased focus on these themes whiIe

developing a conceptual framework that underpins theo-

rizing (Strauss & Corbin, 1998). In this way; the chosen

approach took into account the many factors that could

influence provision of antenatal care in the three coun-

tries involved.

From a grounded theory perspective, the research

field had to be addressed as one unit, even though

it involved women in three countries with three dif

ferent languages. Any variable had to earn its place

in the theory based on its relevance. This mearit that

language, for instance, cannot be defined in advance

as a mediating or differentiating factor in the theory

(Glaseg 1978). Howeve4 language has been seen as the

consequence of the creation ofjoint meanings of sym-

bols created through interaction with the social context

and, thus, from this perspective, minimal translation

should take place (Blumeg 1998; Strauss & Corbin

1998). Therefore, based on theoretical sampling in this

studx two or more interviews carried out in the same

language were treated as a unit of meaning ("language

unit"; Glaser & Strauss, 1967; Strauss, 1999). Consis-

tency of meaning was achieved by the construction of

similar concepts among women in each language. After

constant cornparative analysis within each 1anguage

unit, further comparison was used to integrate concepts

from each unit to the whole. This way comparison of

concepts took place at a higher abstractien level (Brislin,

Lonne4 & Thorndike, 1973; Gales, 2010). Through

using language units, theoretical sampling was left intact

within and across countries.

Rigor was ensured in this study by the fact that

one multilingual researcher managed the collected

data in all three languages, The researcher's reflexiv-

ity is an integral element of grounded theory both

to the process of data collection and analysis, and is

guided by memo writing (Strauss & Cerbin, 1998).

Therefbre, the supervisors of the study (VEME SRK)

checked the analysis of the data. [[b further safeguard

and promote reflexivitM the results of this analysis and

the established audit trail of memos, field notes, and

other relevant information were discussed with these

supervisors, as well as two maternity care professionals

in each countrM on a regular basis. Resulting concepts

were validated by checking them with wornen within

and across languages.

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Becomlng n Mother: Women's journeys From Expectation to Experience in Three Eufopean Countries t"yben et aL 15

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SETTING

NVbmen were recruited to the study from three European

countrics: Scotland, Switzertand, and the Nethcrlands.

The localities involved wcre west of Scotland, the

German-speaking part of Switzerland, and the eastern

and wcstern part of the Nctherlands.

SAMPLE

Theparticipantswerehealthywomenatdifferentstagesof

uncompLicated pregnancies. 'J'hey were initially followed

up to 6 months after giving birth. Based on theoretical

samplinb,, this was then extended to a year after giving

birth (see Thble l). Routine antenatal care was defined as

attending the normal contcnt and frcquency of visits, as

set by thc health system of the country involved.

NVdrnen were recruited using convenience and the-

oretical sampling approaches. The first round of inter-

vlews was conducted using a convenience sample and

includcd five women from Scotland, five women from

Switzerland, and seven women from the Netherlands.

As the theory emerged, it became clear that more

data from specific contexts or women were required.

Theoretical sampling was, therefore, used to reflect on

the diflltrent kinds of care providen as well as to dem-

onstrate the evolving process during pregnancx child-

birth, and postpartum and sLLbsequcnt pregnancies (see

1[hble I). This rneant, for example, that three women in

each country were interviewed a year after having their

first child to reflect on the course and completion of the

childbirth and postnatal process, whereas others were

interviewed in theirsecond or third pregnancy to reflect

on the development of this process in subsequent preg-

nancies.Theoreticalsamplingconcerningdifferentkinds

of care providers involved a Swiss wo]nan attending care

with a female care gynecologist, and in Scotland, two

women with an independent midwife. In addition, in

each sarnple of cach countrM one ef the wemen from a

previous sample was again interviewcd up to a period of

5 years after giving birth to verify and discuss the results

ofthe anatysis.

did not require additional ethical approval in the

Netherlands and Switzerland.

Based on the criteria for sampling, recruitment took

place in Scotland by both supervisors of the study and the

care providers, and in Switzerland and the Netherlands,

by the researcher herselfand the care providers.

'['lte women were provided with an infbrma-

tion sheet about the study) and were asked to centact

the researcher if they were interested, No woman

approached refused to participate, and none later with-

drew their consent.

All womcn gave written conscnt to the researcher

befbre the intcrviews took place. The researcher trans-

Iated all information and consent t'orms into the thrcc

languages used; English, German, and Dutch. These

translations were then checked b〉, persons living ineach of the countries involved. A Iist was created with

culturally appropriate first names, and each participant

was assigned one of these names for reporting purp oses,

to aid anorrymity

DATA COLLECTION

The data werc collected through one-on-Dne audio-

tapcd interviews in English, Dutch, or German, as

appropriate, by the researche4 at a convenient place for

the women. Thc interviews were semistructured, using

an interview guideline as a reference, Interviews lasted

froni 2l to 126 minutes. No woman refused tape recoi'd-

ing of the intervie w:

The leading interview question was `CIf 〉rou coulddetcrminethecontentofcareduringpregnancyyoursclL

base(l on your needs and expectations, what would bc

important to you?'] Following this question, the women

werc cncouragcd to tell thcir stories, during which some

topics, such as access to care, werc introduced by thc

interviewer, In the interviews of the women samplcd

theoreticallF new topics from thc emerging categorics

guided the discussion, FieLd notes were made to guide

data collection. Most women were interviewed once,

threc women were intervLewed twlce, and two wornen

were interviewed thrice (see [fablc 1).

ACCESS AND ETHICAL CONSIDERATIONSDATA ANAI:YSIS

Ethical approval was gained from thc Ethics Committee

of Glasgow Caledonian University and the Lanarkshire

Ethics ef Research Committee, Access to the participants

Five procedures contributed to data analysis: transcribins,,

coding,writingmemos,classifyingandcategorizinginone

Ianguage and, finall)g the cross-language comparison and

integration, The interviews were transcribed verbatim,

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16 Becoming a Mother: Wome-'s Journcrys From Expectation to Experlence in Three European Couturies t.uyben et aL

TABLEI CharacteristicsoftheSamples

COUNTRYXNAME PIBIM CAREPROVIDER

NL- Er]n

NL- Mar[anne

NL- Hannah

NL- Mirei[Ie

NL- Saskia

NL- Ariane '

NL- Joelle

NL- Kerstin

NL- Laura

NL- Maren

NL- Eiena

NL- Nicole

SL- Heather

SL- Megan

SL- Nera

SL- Susan

SL- Jan

SL- Lynn

SL-Vanessa SL- Emily

SL- Deborah

' SL- Hol]y

CH- ibola

CH-Yvonne

CH- Li[ian

CH-Ve;enaCH- Barbara

CH-Sarah

CH- Rosemary

CH- Catharina

CH- Lea

111fO

21110

312/1

1/OfO

2/Oll

2/1/O

212/O

511/4

3/210

11110

2/2tO

1fOfO

211fO

110fO

31210

2/210

2/210

5/3f2

4/2f2

1/OfO

211/O

3/31e

2/1/1

/St3fO

2/O/1

2/2!O

31210

212/2

lfOtO

111fO

4/212

Midwife

Midwife

Midwife

Midwife

Midwife

Midwifc

Midwife

Midwife,

Ref birth

Midwifo

/V[dwife,

Refb[rth

GynMidwife

Shared care

Shared care

Shared care

Shared care

Sharedcare

Midwile

Midwife

Shared cnre

Shared care

Shnredcare

GynGyn {mldwife)

Clynlmidwife

Gyntmidwlfe

Midwlfe/birth

center

GynGyn

GynGyn

CH- Sonja 2fl /O Gyn

Nbtes, Countrv: NL = the Nelhcr];mds; Sl.

Midwife = independent rnidwife; Gyn =

interviews: this number is referred to as (1),{

NUMBEROF T]MEDURINGINTERVIEWS PREGNANCY

2

1

3

1

1

1

1

1

1

1

1

1

1

1

1

1

3

1

1

1

1

1

1

2

1

1

1

1

1

1

2

(2} 30 weeks

1 6 weeks

26 weeks

11 weeks

34 weeks

33 weeks

29 weeks

29 weeks

30 weeks

24 weeks

32 weeks

33 weeks

8 weeks

30 weeks

36weeks

22 weeks

TIMEDURINGPOSTPARTUM

(1 ) 2 months

(1)6weeks(2) 16 months

(3) S years

2 weeks

8 weeks

1 year

5 months

S months

{1 ) 2 weeks

{2) 9 months

(3) 5 yenrs

5 months

6 months

8 weeks

5 inonths

(1 } 5 months

{2) 16 months

2 weeks

6 weeks

1 year

(1 ) 8 weeks

(2)3.5 years

REASONS FORTH[ORET)CALSAMPMNG

D[fferencesfirst-second

pregnancy

Verify/discusscategories

Verify/discusstheory

Medical care provision

lterative process in

subsequentpregnancies

Progress ot process

Process and medlca[ care

Variation in [ontrolAet go

Verify/discusscategories

Verifyfdiscusstheory

Different ca re provider

Different ca re provider

Process in first pregnancy

Process until1 year

Iterative process in subse-

'quentpregnancles

Verifyfdiscusscategories

Fema]e care provicler

Process ]n ti rst pregnan-

cy/ Gyn only

Process in first pregnancy

lterative process in subse-

quentpregnanclesVerifyfdiscusscategories

Process unti[1 year

" Scottand; CH = Switzerland; PIBtM = nvmber of prcBnancics, t}irths and rniscarriages; Care proyider:

gyneculog{st (in Switzerland: private practice}; Refbirth = referraL to the hospital during birth; Number of

?.).{3)undertimepregnancytpestpartuni.

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Becoming a Mother: VVomen's Journeys FFom Expectatl on tv Expericnce 'in Three European Countfies L"yben et ai. 17

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and identifying data werc removed. The researcher

herself performed the analysis in each of the languages

concerned. Analysis in each of the language units was

checkcd by the supervisors of the study.

Coding technigues, according to Strauss and

Cerbin (1998), were used, which involved open, axial,

and selective coding, }Vithin each of the language units,

the transcripts of the interviews were coded in a line-

by-line, and somctimes word-by-word, fashion. Codes

were collapsed into concepts and were given a name

in the original Ianguage, fitting the meaning given by

the women in the intervicws. SubsequentlF the con-

cepts that emergcd from the three separate language

units were compared between uiiits, translatcd, and

integrated in an overall cross-natlonal unit; resulting

in concepts at a higher abstraction level (Brtslin et al.,

1973). As a consequence, these concepts could be closely

examined again in a deconstructive way for similarities

and differences in each of the langua.aes, The results

from this examination provided criteria for following

theoreticalsampling.

During axial coding, categories were linked to each

other, renamed, and then, collapsed or subsurned into

larger categories through further comparison. Sclective

coding completcd the construction of the grounded the-

ory through the integration and refincment ofthe theory

at which point, theoretical saturation was achieved. The

final results efthis analysis were verified in an interview

ivith one woman in each of the countries,

RESUUI"S

Thetotalsamplecomprised39interviewswith32women.

TNvclve women were interviewed in the Nethcrlands, 1O

in Scotland, and 10 in Switzerland (see Table 1),

The participating women werc either expecting or

had given birth to their first, second, or third child. 'Ien

women had experienced previous miscarriages. lnterviews

took place in different stages ofpregnancy or up to 5 ycars

after giving birth to their chiIdren. The wemen received

care in difurent models of care by different care providers.

One single cross-national model for women in

three European countries emerged (Luyben, 2008),

which contained three main categories of "mother-

ing the mothcr;' [Ccreating a bond;' and "becoming

a mothez" This model, with its categories and their

relationships, is presented in Figure 1, This highlights a

process of carc that went beyond pregnancy to include

both childbirth and postpartum. On selective analysis,

"mothering the mother" appeared to be the core cat-

egory containing the content that women needed from

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FIGURE 1 The model of content ofcare during pregnanc" childbirth, and

postnatal period that emerged from the study. "Bccoming a mother" describes

the maternal dcvclopmentprocess from the beginning of pregnancy until

approximately ] year after b{rth (J = dccrease, T = increase). The mediating

factor of"Creating a bend" (with care providers) effectively connects content

of caie (core category; "Ntothering the inother") with this process.

'11

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18 Becoming a Mother: Womcri's Journeys From Expectation to Experience in Three EuroE)can Countries Luyben et al.

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Developing awareness

Comparing

Balancing

Adapting

FIGURE2 Theprocessofbecomin

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cs and properties,

maternit}r care. This core catesory subsumed the others,

whereas "becoming a mother;' described the maternal

development process and "creating a bond;' reflected

relationships with carc providers and the social envi-

ronment that women crcatcd to be able to receive the

content of care they needed to undergo "becoming a

mothen" effectiveLy.

This article describes the precess of "becoming a

rnotherr' It involved three stages of "expecting;' "familiar-

izing;' and "embarking on motherhood" (see Figure 2).

BECOMING A MOTHER

expectations of pregnancy3 childbirth, and their future

with a new famjly. The women thernselves were the first

to suspect a pregnancy because of missing a period or

perceiving bodily changes, and confirmed this by per-

fo rmm

g a pregnancy test at home.

I had donc that test; well I am pregnant and hip,

hip, hooray, Ykts, of course, you keep your mouth

shut the first3 months that I'd learn[ed] abit

about that, that you shouldn't sa}r too much the

first 3 inonths.

(Mariannelthe Netherlands)

The data suggested that for thc women in this study, sup-

port in the process of "becoming a rnother" should be

the aim of provision of maternity care, They described

becoming mothers as personal developmental journeys

from creating expectations in early pregnancy until

completing the expericnce durjng the postnatal period,

approximately a ycar after childbirth. These journeys

were iterative processes, which were repeated in subse-

quentpregnancics.1;romtheseprocesses,womengained

confidence and autonomy to take up family responsibil-

ity (see Figure l). "Becoming a mother" involved three

stages and started with the stage of "expectingr'

Expecting

The stage of expecting Iasted f'rom early pregnancy until

childbirth in which women diagnosed their pregnancM

became increasingly aware of themselves and their

pregnant situation, and, conscquently, created several

A few women consulted a known health careprovider to get an objective confirmation, Feeling sure

about being pragnant was an important condition for

inducing a process of increased awareness about their

new situatiDn to precede the process of becoming a

mother. NVDmcn in their first pregnancy described how

they opened up to things related to pregnancF which

was perceived as a new and exciting area.

Bccause it was, everything was new to me, it

was as if someone saying to me you're pregnant,

as if sorneone gave to me this big Christmas

prcsent, it was wonderfu1, and I wanted to know

all about it

(Heather/Scotland)

Becoming awa re was a requirement fbr Iearning and

personal development, and the creation of expectations.

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Becoming a /Viether: Women's )ourneys From Expectation to Experience in Three Eur()pean Countrles Luybef] etal. 19

It was also a condition for actively taking rcsponsibility:

This state of [nind was characterized by increased "think-

ing activities" in which different types ofknowledge, such

as knowledge about daily and family life, cxperiences of

pregnancy and childbirth, and views and beliefs, were

reflected on and comparcd. While prcparing for the

future, this dynamic proccss involved three stages of

interaction with the self ancl with the world: the present,

being pregnant, and having a new famil}c Lilian, in Swit-

zerland, characterized hcr current scenario, thus,

/....

tt t.

We]1, concerning the partnership, it is not

necessarily the simplest composition. And

I think, in regard to culture, my partncr has a

totally different background in regard to having

ahandicapped child. That is a different scenario '

that one is creating then. That Ihave the feeling

that, somehow, I mightbe standing quite alone

there. And, I could uot imagine it that way,

(LilianlSwitzerland)

Creatitrgapictureinvolvcdtheconstructionoffuture

scenarios('[expectations")atdifferentperiodsofpregnanc〉rand childbirth and having a family IXbrnen with previous

experiences used these for crcati g their pictures,

I actualry found this birth even rnore diMcult

than my first child, Whereas, I think, with the

aniount ofpressure and contractions Hiave had

right through my prcgnnncyl I was expecting an

easier birth but, in fact, it was even more diMcult /

(SusanfScotland)

XNlamen with no previous or with different experi-

ences (c.g., a twin pregnancy) created "foreign pictures"

with information from other women in their social envi-

ronment, brochures or books, and care providers; Iike

Mireille in the Netherlands who was told by her general

practitioner to visit a midwife and call a day care center,

Ijust wanted to know more about all the things

I had to do, And not just, that he talked about

going to the midwife, but also right away; 1ike,

take care that you call a children's daycare

centler]. And I suddenly thought iikc, gosh,

I just know that I am pregnant, do I already

have to cal1 aday care cent[erJ now?"

(pt{ireille/theNetherlands)

Because this search for information also created

anxieties, some women, Iike Sonja in Switzerland, chose

not to know too much,

All is, from A to Z, everything is really in there.

But, it can also drive you crazy: If one reads,

everything, The negative. You should not eat

this and that, And then this happens, and that,

and so en.

(SonjatSwitzerland)

These pictures were then used as a reference and

as something to hold on to during pregnancp as Erin, in

the Netherlands, stated,

Thus, you are creating a scenario, Because you

hear from people, like it has to go like that and

that. Normally And that, you like to have it Iike

that yourselq of course.

Finallyi you can hold on to that Bccause

you think, well, end of the pregnancy, you have

to give birth, a birth will be something Iike this.

And that is a picture. And then the rest will fo1-

lowl and that will be approximately like this.

And that is another picturc. Thus, therc you are

living towards that (picture). That is your, your

point to, to hold on to.

(Erin/theNetherlands)

These expcctations coiltained subjects that were

important to women; for example, mode of birth, atti-

tude of care previder, beins, at home with the bab}r,

and their environment Women in Scotland mentioned

a large number of subjects, whereas Swiss women

described enly fewL These cross-national differences

scemed to be related to the amount of information that

women had available or received from care providers,

Expectation pictures provlded women with confi-

dence,describedasafeelingofaninnersecurit}r(Luyben

& Fleming, 2005). A complete picture ofa particular set

of expectations brought women's thinking processes

about that issue to a halt and gave them peace of mind,

Most women, however, fbund gaps in the picture (such

as missing pieces in a jigsaw puzzle), which led to pei:-

ceiviug uncertainiies and continuation of the thinking

process. This was terrned "worrying" in which different

scenaries were considered, but the right `Efit" could not

be found. As women felt responsible, they aimed for a

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20 Becominga Mod]er: Women's Jeurnevs From Expectatlon to Experience '[nThree European Countries Luyberr et al.

reduction of risk and closing the picture with the best

scenario. Vanessa, in Scotland, considcred a home birth,

but also considered the risks to her own 1ife.

/tt ttttttt

I didn'L want to be in a situation where I was

going to put my own life at risk, 'cause that

would be worse fbr Robin, than, than a bit of

jealousy about this new baby,

(VanessalScotland)

As to counteract this sense ofuncertaint" al women

were needing experience that they usually found in a bond

with an experienced maternity care provicler (see Figure 1),

"Expecting;' however, was an iterative process of creating

expectations, which started all over again, ifnew informa-

tion arose. Women, therefore, searchcd this new experi-

ence through a continuity of the bond with their chosen

care provider (scc Figure 1). Thus, thcy aimed to complete

the pictures and restore their feelings of confidence and

autonomy (Luyben & Fleming, 2005), during familiarizing

themselves with the experience ofbecoming a mother,

Familiarizing

Familiarizing meant that women were getting acquainted

with the expericnce ofbeing pregnant, giving birth, and

having a family of one's own aftcr childbirth. Some

Dutch womcn talked about "feeling the reatityr' During

the time, women socialized to motherhood, the expecta-

tion pictures changed into experience pictures, and they

felt "at homc" with this exp erience, FamiliaritM thus, pro-

vided a fecling of confidence, which was refiected in the

SwissandDutchexpressionsof"beingfamiliar:'Expecta-

tions were cognitively built, whereas actual experienciug

involved all the senses, Although Nicole, in the Nether-

lands, was wel]-informed about being pregnant through

reading books and the additional information from her

midwife, her real experience was quite different,

Of coursc, you read sometimes that somebody

has an, an awfu1 pregnancs yes, though you read l'

that not that often. In booklets, is of'ten 1ike, how

great a pregnancy is. Also, if they, if' the tnidwife

is Iike, "o, those nice butterfies in your bellyr'

But well, at 3 o'clock at night, J do not think 1ike,

let's havc a nice play, Yles, that is just annoying,

Because that wakes me up. And T knew that all,

But now that you are really expcriencing that.

(Nicole/thcNetherlands)

Through their experiences, women were develop-

ing arvareness by creating new knowledge, which raised

questions and changed thc way they thought. This led

to the construction of ncw experience pictures, which

they were comparing with the existing expectatien pic-

turc, Joelle, in the Netherlands, compared the experl-

ence ofher secend child with what she knew from the

first one,

X"le11, for examplc, he moved an awfu1 lot {n iny

bellv I thought well, is that, is that normal? The

first one had been quite quiet, and this one, he

just halg kicked iny ribs apart,

(Joelle/theNetherlands)

Women tried to make a new experience fit their

existing picture through balancing both pictures of

cxpectation and experience to maintain equilibrium and

achicve a state of rest. 1'ime to discuss, as well as infbrma-

tion and reassurance from care providers, were factors

nceded to fil1 in missing knowlcdge, Paola, in Switzerland,

had professional friends who she could always ask.

I was luckyL Because I had my own relation-

ship$, I did not feel that unsure. That means

I had unsure, always had Ltnsure moments.

And those unsure moments, Ijust directly

compensated. That meansJ I called someone.

Someone, that I knew really well, a docter.

And there I got my additional informatioii, or

what I lacked. Or I kiiew a midwife.

(PaolalSwitzerland)

New information and experience led to the cxpec-

tation picture belng reconstructed, rejected, or neither,

which led to worrying by the women, XMhile Megan, in

Scotland, chose not to worry about information from her

care provider who thought she was `"small" and expected

her to have complications during childbirth, Marcn's, in

thc Nctherlands, worries increased after giving birth.

Well, my nature is, 1 don't }vorry about that.

I know in other countries, females are much

smaller than I am, and they stil1 have had the

babies. And 1OO years ago, people were much

shorter than they arc now. So, well I don't worry

(Megan/Scotland)

,.b'.;--'･Wttts･･

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Becom]ng a Mother: Women's journeys From Expectation to Experience in Three European Countries Luyben etal, 21

And then suddeniB you have that worrB like oh

god, now you also have such a child. What do

1 do with it? Yes, you have to look after it the

whole time, Is she laying down well, yes, you are

quite nervous, And Iike now, it alljust goes welL

Aftcr a few months, then it al1 is familiar and,

yes, I found it quite scarM

(MarenltheNetherlands)

Balancing, resulting in a ncw developed picture

ef experience, and subsequently adapting, was a nec-

essary activity to achieve personal growth, which

gradually took placc. In this studF womcn having

their first child wcre most affected by this change,

whereas women having a subsequent child experi-

enced more stability Marianne, in the Netherlands

(second pregnancy), and Lea, in Switzerland (after

having her second child), reflected on their personal

changes in becoming a mother.

And if you go for the first, first time, for your

first baby, you are just a ]ay person in that

area. The further pregnancy proceeds, the

more, the more you comc to know, actually.

And now you are, well I won't say an expert,

but you just know an awful lot, maybe eyen a

bit toe much,

(MariannettheNetherlands)

Ybu have to develop a new familiarit}r in your-

sclC because it is a process, you do not know

yourself an)rmore. Ybu have to learn to kt)ow

yourself again. Define new. Yes, you have to

rcally open your eyes,

(LeafSwitzcrland)

During familiarizing, thc bond with more expe-

rienced people, particularly carc providcrs, assisted

women to complete their picturcs of experience to

gain confidence, while maintaining their autonorny

and sharing responsibilit〉T (see Figure 1). The pro-cess of familiarizing was repeated, if new experi-

ences happened. Women, howevcn hardly had time

to adapt their pictures during childbirth and the early

pestnatal period, Therefbre, reflcction and reconstruc-

tion had to take place during the stage ofembarking

on motherhood.

Embarking on Motherhoocl

1[he aim of women's journeys was t[emhatking on moth-

ethood" in which they reflected on their experience,

reconstructed and c]osed their pictures, so that they could

begin the enterprise ofbeing a mother, "bmen, therefore,

had to leave the journcy of "becoming a mother" behind

them physicallB psychologicalIF and emotionally This

stage started some time after chj]dbinh, when women had

a new Iife routine, and ended only after conipleting their

picture approximately a year after birth, but sometimes

longen For Lynn, in Scotland, this process involved three

pregnancies and was related to mccting her expectations.

/ttt

I've come, I've come fuII circ]e. I've got to thc

point where I thought I would be embarking on

motherhood, I suppose my expectations have now

been met. And, it's happened the way I envisaged.

BtLt, it's taken Tne quite a long tirne, a few )rears, to

get to that point It has been a big journeB but I'm

there. I won't. I don't think kvill have any more,

(l;ynntScotland)

While Scottish and Dutch women chose the word

"embarking;' Lea, in Switzerland, preferred a journey as

a metaphor,

Wbll,Ithink that is also, that is, those (bccoming

and being a mother) are two different pair[s] of

shoes. And, I believe, the bigger journey is after-

wards. If the child is there and, then, you are a

mother. Now for me, that with that ship, I would

take a country road. 1･Vhatever; train, bic)rcle, car.

(LeaiSwitzcrland)

In having a routine, women experienced a new

normality in their ever}rday situation, They felt secure

in being with and caring for the babM and experienced

an increascd stability in their Iife. After having her third

babB Holly; in Scotland, had more dithculties finding

this routine than with her first one.

lBut I start to get into my routine and everything

noLsr, T think, because I had, yoti know, I had, my

oldest son to get to nursery. And, I had a, al1 ofa

sudden, I had a new babM a toddler, and a 4-year-

oLd, having to get 1iim up, readyL And I would saty;

J, I felt it more this time, that way Than I did, I

mean, the first, your first prcgnancy

(HollyfScotland)

22 Becoming a Mother: Women's Journeys :'rom Expectation to Experience in Th[ee Eurepean Countries l.uyben et aL

The time needed to find a new routine difft]red

individually and rclated to women's own well-being and

the behavior of the baby Once a routine was achicvcd,

there was a resulting sense of peace and harmony

Women had time to reflect, which they did not have

during childbirth and the early postnatal period. During

this time, they could reconstruct their picture and fiLl in

gaps in their awarcness.

Yl)s, when did I start to do that? I think, that

after, yes, really after a rnonth, that all went well

a bit again, I think, a month of three, four, that

I thought 1ike, gosh, yes, how did it aU go actu-

ally? And does it al1 fit with, Iike what you had

in your heacl a bit, and, also cverything after

that, reall" like, that you are going to work, and

how you expericnce that, and if it is a bit like,

how you have thought it would be.

CErinltheNetherlands)

Some women relied on their shared awareness with

the care providers with whom they had a bond to debrief

them and help them fi11 in the missing pieces to complete

their osvn awareness. Thus, the experience could be under-

stood and integrated, 1ike what Maren had aimed to do,

I harte missed that. It all went very fast, they

(health nurses) came to check me, everything

was fine, Goodbye, gone, I had needed more

from that. Just, some time to taLk with you, how

the birth has taken place. Ybu have so rnany

questions coming up at once, and you can not

deal with that in the first coupLc of days, I could

could not process that,

(rv{arenl the Netherlands)

After reconstruction, women wcre matching their

actual experience with the expectation, and judging it

While reconciling, women came to t/

aspects of their experience, which had not

expectations. This meant that they ha(1

some aspects of their expectations that w

to them, and deal with the loss ef som(

was a balancing activity as described b'

Scotland.

[ think as well you have to balance yc

your perception of how it is going to

the reality of how it did go and kind

to an understanding between the twe

I know that it causes women after thc

lot of kind of psychological problemE

nevcr had a natural birth and there iE

intervention, you know.

(Hcathe

SeveralwomenexperiencedamisrT:expectations and experiences. In thc c

this was often due to antenatal inforrr

they had themselves or from family, fri

providers and had been used to creatc

pictures in "expecting." A few women r

negattve feelings regarding the experi(

complaining, either orally or in writin!

women wrote a letter of complaint, ai

tish woman had considered this. Al

related to the attitude of care provic

however, women altered their expectati

realitv Therefore, although some aspe/

"missed," they generally expressed sati/

the experience.

Consequentls closing the picture al]

to leave the experience behind, so that t

fbr new experiences of being a mothcr

was reused as a reference for creating nc

expectations in a subsequent pregnancy I

Netherlands, closed her picture after tall

midwife.

Andthen comcs the postnatal period. That wil1

be somethh]g like that. And if the picture indeed,

does not match, then you feel, I think, very disap-

pointed, And, if that picture matches, then you

are very happy And my picture matched coinci-

dentdly; But I had ever}rthing really perfect. I havc ･

had a good birth and a good postnatal period. ,

(ErintNetherlands)'

But I could still ask that knd of qucs

then. And that was very impertant to

get the picture complete, Tb get the q

answered, So thatI could leave it bch

it did notmove about in my mind, Ii]

have done that, or if I had done this,

(Kerstinlthe N/

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Bctc/oming a MaTher: Wemen's lvurneys From Expectation to Experience in1hree European Countr]es tuyben et al, 23

Several women in the current study, however,

could not completely close a previous experience, like

Deborah, in Scotland, who reflected on her first experi-

ence duri ng her second pregnancM

Maybe for a ctosure, what [ should have done

was, make an attempt to write a letter of' com-

p!aint about what I felt was wrong with my

care. But I am not very good at getting around,

sort of these kind of things. So,Ijust, so I

probably have taken it with me. Some part ofit '

is closed, and over with, But some part is stru

there, you know.

(DeborahlScotland)

This issue ofnonclosure was not explored further

in the current study/ Through cLosing, women feIt con-

fident to take up family responsibility on their own, and

physically and mentally moved on inte the new experi-

ence of being a mother,

DISCUSSNON

The cnrrent study resulted in the emergence ofone single

cross-nationalconceptualmodelof"becomingamother"

for all women in threc European countries as an aim ef

provision ofmaternity care, From the wemen's perspec-

tive, this highlighted the importance of the development

of women's pictures ot' family responsibility and offered

new perspectives on existing maternity care 1(nowledgc

and pra[tice, The study showed that the grounded theory

approach provides a rigorous frameworl〈 for cross-national research.

Limitations that were encountered wcre mainly

caused by organizational and ]inguistic factors. Becausc

oflimitations in time and financial resourccs, the num-

ber of woinen per language unit had to bc planned in

advance, and not all interviews could be analyzed before

the next interview to()k place in each of the countries,

[lb adhere to the principles of grounded thcorM field

notes werc used to assist data collection. Thc inclusion

ofthree different languages, en the other hand, required

a very detailed analysis within each unit and the use of

concepts at a higher abstraction lcvel for cross-national

comparison, The intensity of this process influenced

the number of women and thc amount of time needed

to achicve the objcctives and, thus, saturation of the

categories. Using concepts at a higher abstraction level

increased the credibility of qualitative cross-national

interpretation, as meanings were validated in each of

the language units befbre being integrated. At the same

time, thcoretical sampling was riche4 as the meanings of

these similarities and differences for the women could

be explored in more depth and verified in thc interviews

in each of the countries involved.

The model of"becoming a mother" jn the current

study described a continuous process of women's per-

sonal development from expectation toward the expe-

rience of their own farnily responsibilityl which lasted

from thc beginning of pregnancy to about a year after

birth and was repcated in subsequent pregnancies.

This process consistcd of thrcc stages of changes in

women's scenarios (or "pictures") in which they changed

physically and emotionallM as did their vicws on their

existing world. This process showed paralleLs with a

socialization or acculturation process (Gudjons, 2003).

Previous studies had addressed only fragmented parts

ofthis process, such as the expectation before and expe-

rience after childbirth (A}rers & Pickering 2005; Green,

Coupland, & Kitzinger, 1990, 1998), becoming a mother

in the iast trimester of pregnancy and the postnatal

period (Martell, 2001; Mercer, 1995; Rogan, Schmied,

Barclayl Everitt, & Wyllie, 1997), or several tasks since

becoming a mother (Merce4 2004; Nelson, 2003; Rubin,

1984). The continuous proccss, as described in this

studM involved a time frorn early pregnancy to a year

er more after childbirth, included women's social world,

and connected expectation to experience. 'Vhis also led

to a different perspective on the meanings of some of

the findings from these previous studies. For instance,

Barcla" Everitt, Rogan, Schnied, and Wyllie (1997)

interpreted "loss" in the early postnatal period in a

negative waF but th is was a normal phenomenon during

reconcitiation within the context of women's transfor-

mative processes in the current study The continuous

social character of these processes highlighted the need

for continuity of the care providing process and involve-

ment of women's social environment in the design and

provisionofcare.

The transfbrrnation of pictures of expectations

into pictures of women's own expcriences of becoming a

mother resembled a biographica], experiential Iearning

precess (Piaget, 1975; Strauss, 2005). Women first expe-

rienced the transition, which generated questions. The}r,

then, sought personal information that assisted them in

developing arid closing their pictures, while sharing this

withtheircareproviders,Closurebroughtpeaceofmind,

even if it was only temporarM until the next disruptive

eventorinformation.]iffectiveprovisionofinformation.

therefbrc, had to be cxperience- and time-related, Thesc

'

24 [lec/oTTiinB n Mother: Women's Iourneys From Expectatlon to Exporicnce in Three European Countrics Luyben et aL

findings arc consistent with the effects ofprovision ot'

information reported in other studies. Several studies

showed the limited effects of antenatal education and

information in preparing womcn fbr being a mother

and emphasized the need for increased information

in the postnatal period (Ho & Holroyd, 2002; Nolan,

1997; Razurel, Bruchon-Schweitze4 Dupanloup, Irion,

& ]tpiney in press), whereas Lcvy (1999) described how

womcn acccpted and rejected information to preserve

the balance in their own world. The results of the cur-

rent study suggest the need for an increase in postnata!

education, but even more for individualized, timely care

packages that rnatch womenis own unique experience

and requirements, and that arc focused on "becoming

mother" and not just on well-being, from a purely

clinical perspective. In this waF a close match between

expectation and experience could bc achieved,

A few researchers have highlighted the irnpor-

tance of women's reconstruction of their pictures in

the postnatal period in which fi11ing in the "missing

pieces" during the postnatal period facilitated women to

reconstruct their childbirth experience (Affbnso, 1977;

Mercer, 1995). Although the importance of closing the

expcricnce to continue liying in a new situation has

been cmphasized (Affbnso, 1977), these findings had

not been related to a continuous process of opening,

sharing, and closing awareness that already startecl in

the beginning of pregnancy as described in the current

studv When maternity care providers assisted women

in completing their pictures, cLosure provided them

each time with confidence, and, thus, an inner securityl

to go a step toward family responsibilityL

wriereas security is well-rccognized as meaning to

reduce anxieties (Melender & Lauri, 2002), most studies

emphasized external sources, and little has been described

about inner sources of security (1";ndress, 2002; Melender

& Lauri, 2002; Petermann, 1996). Erikson (1966), how-

evcr, mentioned trust and rcliance on oneself as a source

ofinncrsecurityduringpsychosocialdevelopment,which

is consistent with the findings in the current studv

Because of the closed pictures cluring the course of the

process ("expectations"), women gained confidence and

were able to express this particu]ar preference and make

decisions in an autonomous way (Luyben & Fleming,

2005). If women stayed uncertain because of conflicting

information, risks, or complications, howeve" they were

likely to rely on their care providcrs and the choices theY

madc. Because this issue was not explored further within

the framework of the current studM further research is

ld. , ,. , ,1 .." .. .../,

Final closure ef the picture of becom

took place at the end of the process, whe[

ence could be left bchind to embark on

of rnotherhood. Although women had c]

minds during the process, they had a fixed

view about their experience after its closu

of the experience involved comparing th

with the expectation. As a result, women

expectations to match rcality and reconcilc/

Thus, they were usually satisfied with th

(e,g,, healthy mothcr, healthy baby) but also

aspects in relationship to their expectations

mode of birth), which has been noticed in

(Bramadat & Driedge4 l993; Porter & Ma`

Proctog1998).'1'hesefindingsindicatethat

care during pregnancy and childbirth, firs

ask for women's satisfaction, but for what

and, second, they should take place only

of the picture. ConcurrentlB "becominJ

provides a basis for development of indicat

ation of this proccss by describing aims, p

outcomes from women's points of view

CONCLUSION

In this article, the subcategory of"becomi

arising from an invcstigation of importa

provision of routine antenatal care from w･

of view in thrcc European countries v

maternity care systems, is described. One s

tual cross-national model for women in tk

emerged, which rcpresented women's jou

family responsibility from creating expect[

pregnancy to cornpleting the experience E

one year after birth. 'I'his rnodel resemb!･

ential learning proccss in which women I

emotionally changed, as did their views on

world. The bond with a maternity care pro

women to reccive the content of care th

complete this process and, thus, create E

between expectation and experience,

Provision of maternit〉F care shouinclude principles of experiential learni

women's process of becoming a motherown social world is a central aim. Support

include sharing care-providing relationshi

of this care during women's processes, an(

of women's indlvidual social worlds. ThE

AL-..11 LA -lm- :--n Apfitt-""- wT-;ln Anp:m

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llecoming a MoL[ior: Womcn's Journeys Frotn Expectation to Experience in Three Eurepean Countries Luyben et al. 25

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Correspondence regarding this article sh,

to Ans G. Luyben, RM, PhD, Department

Uriiversity of Applied Sciences, Murtenstra

Bern, Switzerland. E-mail: ans.luyben@bth.c

Ans G, Luyben, RM, PhD, head of Research

ment MidwiferF Department ofHealth, Ber

of Applied Sciences, Bern, Switzerland.

Sue R. Kinn, BSc, MSc, PhD, team leader an

manage; Department for International Dev･

United Kingdom.

Valerie E, M, Fleming, RM, MA, PhD, Inter.

Consultant for Nursing and Midwifery GIas

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General Practitioner Involvement in Remote and

Rural Maternity Care: Too Big a Challenge?

fan CaldoMl Slanora Hundlq)4 Edwin van [llaijlingen, Jbhn ReicL

AZice Kige4 fanet 71icke4 lilly Irelana Fiona Elarris, Jane Flarme4 and

Helen Btlyers

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BACKGROUND: In the United Kingdoin, general practitioner (Gl') involvement in maternity care has

declined significantly over the past decade. This is particularly so in remote and rural areas where mid-

wives haye stepped up and taken over units to ensure that women in these areas continue to have a ser-

vice. A recent report by the King's Fund argues for a greater role for the GP in maternity care provision;

howcver, this raises questions about whether GPs have the sl〈ills and training to provjde such care.

AIM: 'fo explore the views of GPs on the skills and training required to deliver safe and appropriate

local intrapartum seryices in reniote and rural settings.

rvlETHODS: ]vlixed-method stud)r consisting of qualitative interviews wlth a purposive samp]e of GPs

in six remQte and rurat sites. Tb triangulate the intcrview findings and identify features that might have

been missed in the interviews, a questionnaire was developcd using initial key themes identified.

FINDINGS: Maternity care accounted fbr lcss than 1O% of most reniote and rural GPs' workload, yet

interviewees reported that their i'ole required them to be competent in a wide range of procedures. This

was seen as a major barrier to recruitment and retcntion in rural areas. Although selfreported competence

and confidence was high, several GPs felt cle-skilled and feIt that they were fighting a losing battle to main-

tain skills. GPs regarded iso}ation, need for comprehensive expertise, limited resources, and transportation

diraculties as factors afflecting the decline in their contribution to remote and rural matcrnity carc.

CONCLUSION: Although rural GPs and midwives might traditiona]ly have been in competition, pro-

viding a woman-centered service in remote areas may be easiet to achieve throLigh collaborative workins.

Howcver, if GPs are to play a grcater role, then they will need to be prepared to make a strategic com-

rnitment to the maintcnance of remote and rural maternity care. This wM require innovative methods

of training, special consideration ofeducational needs, and incentives for pracLitioners to settle in rural

areas, but it rnay already be too latc for GPs to have a substantial input into maternity [are.

KEYwaRDS: general practitioncrs; mulLidisciplinary education; midwifery; maternit)r care; remote

and rural setting

:

INTRODUCTION

Although midwives in the United Kingdom attend

morc than half of all births and provide most of the

maternity care (Health Commission, 2008), particu-

larly where xvomen have uncomplicated pregnancies

(National Health Service [NHS] Qualiry Improvement

Scotland, 2007), the role that gencral practitioners (GPs)

play has recently been put back in the spotlight with the

publication of a ncw report by thc King's Fund (S[nith,

Shakespeare, & Dixon, 2010), The report argues for a

greater role for GPs in maternity care, one which might

see them sharing wemen's care with midwives, and

concludcs that changes to medical training are needed

JNTIInNATVObtAL JOURNAL OF CHtLDB"ATi-i Vbiume 1, issue 1. 201 O @ 2011 Springer Publi$hing Company, LLC www.springerpub.com DO[:10,1891i2156-5287.1.1,27

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28 Genera[ Practitioner [nvolvement in Remote and Rura[ Maternity Care: Tbo Big a Chal[enge? Caldbw et al.

to ensure that GPs are "adequately skilled to look after

women safely" (Smith et al., 2010, p. 19). In this article,

we explore GPs' skills and training, and ask the question,

"Is GP involvement in remote and rural maternity care

too big a challenge?"

BACKGROUND

Smith and Jeweil (1999) have reminded us that "com-

plete obstetric care" was very much the role of the GP at

the beginning of the 20th centurs with more than 85%

of women in the Uhited Kingdom birthing under GP

care. The push to move maternity care, and birth in par-

ticular, into facilities was a major factor for declining GP

irrvolvement. ,By 1995, only 18% of GPs surveyed pro-

vided intrapartum care, although 28% wanted to do so

(DeVties, Salvesen, Wiegers, & Williams, 2001). A more

recent study found that only 7% of GPs had attended a

birth within the year (Hewison, 2001). Involvement in

routine antenatal and postnatal care continued to be

much higher at more than 90% (General Medical Ser-

vices Committee, 1992), although in more recent years,

this too has declined (Smith et al., 2010).

In contrast, in remote and rural Scotland, GPs con-

tinued to maintain an intrapartum role for much longer.

Maternity care was often provided in GP units within

district hospitals, although these units also came under

threat in the late 1980s and early 1990s (Murphy-Black,

1992). Early in 1990, there were 65 small GP-led mater-

nity units in England (Smith & Jewell 1991, p. 14) and 28

such units in Scotland with its large rural area but much

smaller population than England (Scottish Oence Home

and Health Department, 1993, pp. 59-61). In Scotland,

the number of all maternity units (i.e., from the largest

academic hospitals to the smallest cottage hospital) fe11

from 52 units in 1995 to 38 in 2008, a drop of 26.9%,

whereas the overail number of births in Scotland over

the same period dropped by only 6,2%, from 60,261 to

56,537 (Information Services Division, 2010).

Changes in service provision and policy at the begin-

ning of this century led to a decline in births in remote

and rural settings (Department of Health, 2003; Scottish

Executive Health Department [SEHD], 2002; Scottish

OMce Department of Health, 1998). Maternity service

prevision was affected by the centralization of obstetric

and anesthetic services in tertiary units (Department of

Health, 2003; Mungall, 2005; SEHD, 2002). This central-

ization, combined witli a decreasing inyolvement of GPs

in intrapartum care (Smith, 1997), meant that many rural

maternity units closed altogether or became midwife-led.

Although the Royal College of General Practitio-

ners (RCGP) and the British Medical Association (BMA)

have both stressed the importance ofpersonal, continu-

ing, and comprehensive care provided by a primary

care maternity team, the BMA has reported a general

withdrawal of GPs from intrapartum care (BMA, 2007;

RCGP Maternity Care Group, 1995). With GP involve-

ment in intrapartum care under threat from falling

birth rates and the centralization of maternity care, the

2003 contract for general medical services removed GP

payments for maternity care, further reducing the likeli-

hood of GP input (The NHS Confederation, 2003).

At the sarne time, the Expert Group on Acute Mater-

nity Services (EGAMS) in Scotland developed a list ofcore

ski11s and competencies that were considered essential for

professionals to have C`to provide effective and safe care

for low-risk women and to manage obstetric emergencies

within remote and non-specialist units" (SEHD, 2002,

p. 22). These are listed in Box 1. The SEHD commissioned

us to conduct a scoping exercise of remote and rural

health professionals involved in maternity care in Scotland

to explore staffviews on the skills and training required to

deliver safe and appropriate local intrapartum services in

rernote and rural settings (Kiger et al., 2003; TUcker et al.,

2005). Within that studF interviews were carried out with

a Iarge number of health professionals, including GPs.

This article situates the GP interviews within the context

of the larger body of data and specifically explores koy

issues raised by GPs workng in those settings,

METHODS

This mixed-methods study comprised a qualitative and

a quantitative stage incorporating GP participation as

follows:

1. Interviewstage

A purposive sample of 10 GPs was identified through

midwife managers at 10 study sites selected following

a telephone census of the 32 rural and remote deliyery

units in Scotland. Each GP was sent an appointment

letter and informadon about the preject. Interviews

toekplaceatanappropriatelocationandlastedfrom15

to 60 minutes, the majority taking 30 to 45 minutes.

An interview schedule, informed by literature

review and experience within the project team and

an advisory group, was designed and reviewed for

content validity (see Box 2). Piloting was under-

taken (van Tleijlingen & HundleM 2005) and minor

amendments were made in response to feedback

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1 General Practitioncr lnve[vement in Remote and Rural Meternity C[ire: foo Big a Chal [enge? Caldbw et aL 29

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BOX1 CoreSkillsorCompetenciesIdentifiedby

Expcrt Group on Acute Maternity Services as Necessary

for Staff Providing Intrapartum Care (Skills included in

the guestionnaire are shown in bold italic)

. Management ofnormaf defivery---supporting normal

[abor ancl ch"dbirth

. Clinicaifucigment and decision-making skills

. Maternai histor,v taking

. Cbunselingandcommunicationskits

. Riskassesstnentnndmanagementskills

. Intravenous aV7 cannulation

. Managing IV fiuld replacement

. Management ofantepartum hemorrhage

. Managementofcordprolapse

. Manngementofshoulderclystocia

. Management ofhreeeh deliverr

. Management ofpostpartum hemorrhage

. Adult resuscitation

. Basic obstetric life sapport

. Neonatal resuscitation-assess, resuscitate, and stabilize

the neonnte prior to ongoing management

. Repair ofperineal trnun]a

. ilain management

. Initial and discharge examination of the newborn-

inspection and detailed examination of the baby

. Prcscn'ption ofch'ugs-such as analgesie in ]abo- drugs

used [n resL]scitation, and those invo]ved in normal

childbirth such as Konakion and anti-D.

Additional competencies required fer remote units-should

be achieved by at least one team member:

. Uttrasonicscanning

.. . Ungertaking.a ventg.use lift-gut de.liyerr

2005), Thcse infbrmed the design ofthe questionnaire.

Second, a full manual analysis ofthe transcribed inter-

view data was carried out, Each transcript was read

and analyzcd by at least two of the authors.

2, Questionnaire stage

Questionnaires wcre sent to the 10 GPs who had been

selected for interview and an additional 8 GPs from

matched rural and remote units. Units were matched

based on the unit size and modcl of service (ranging

from horne delivery to fUll consultant-led maternity

unitwitlineonatalfacMties).Furthermorc,selectionwas

aimed to ensure geographic spread from al1 regions in

ScotLand and to include island and mainland scttings.

Tb triangulate the interview findings and iden-

tify features that might have been missed in the

interviews, a qucstionnaire was developed using

initial key themes identified, Demographic questions

werc included. Most questions were closed and pre-

coded. Likert-type rating scales were used to gauge

agreement with opinions and attitudes elicited in

the interviews. Rcspondents could make additional

comments. The questionnaire was accompanied by

an explanatory cover Iettcr and reply-paid envelope.

Questionnaires contained idcntifying numbers to

allow reminders to be sent after 3 weeks.

Quantitative data were collated and analyzed

using the Statistical Package for the Social Sciences

(SPSS) for Windows, Descriptive statistics were pro-

duced fbr all variables.

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The semistructured interview method gave scope to

develop discussion on the main rescarch questions

(van [[leljIingen & Ireland, 20e3). Interviews, carricd

out by two expcrienced qualitative rcsearchcrs, werc

tape-recorded with consent and transcribed verbatirn.

Field netcs were recordcd to provide further contex-

tnal data on each of the 10 case study sites,

The analysis of the interviews was iterative; first,

emerging themes were identificd as the interviews pro-

gressed (Forrest I〈eenan, van 1"eljlingen, & Pitchforth,

BOX2 Interyiew[[bpics

. Currentcase size flnd mix

. I'erceived and required skills and competencies

. Perceived [ack of skills

. Access to tra[ning

. Existing peer review and supervision structures

. Barriers to training

. Muitidiscip[inary education

. I]rcferences fortraining methods

. aood practlce ]n updating and mainta[ning ski]rs

Ethical Approval

Advice was sought from all relevant research ethics

committees, but ethical approval was not requircd at thc

time because no patient data were used and the commit-

tees, thcrefbre, classed the study as audit

RESUUI'S

Response

Ofthe 1O GPs approached for interview; 2 were unavail-

able, thus 8 GP interviews (8096) were conducted at six

sites. Six GPs had been in post for more than a decade

and the other two fbr 5 years and 18 months respectively,

Most had related qualifications in obstetrics and gynecol-

ogri All had worked in obstetrics fbr at least 6 months and

were cxperienced GPs. The number of deliveries in each

area varied from eccasiona! to 150 per ycar. Maternity

care provision included midwife-lcd units and primary

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30 Generel Practitioner ]"vo[vcmcnt in Remole and Rural Matern[ty Care: foo Big a Chnllengel C/iildow et al.

TABLEI GeneralPractitioners'SVbrkngPractices

l/

Workplace: Community based Both fac[[ity and community

Proport;on of work that

relates to maternlty care;

O-1O% ll-20%

〉20%i HoW Iongsince completed

. .'.ig.as. ig.tra;ning (ycars):

PAR=CIPANTSFROMUNITSSELEorEDFOR LNTERYIEW PHASE(n = 9)

n(%)

5 r56) 4 (44)

7 r78) 2 C22) o Median [iQR] . ..14;E. [8.S, 27.7s]

PART:CIPANTSFROMMATCHED UNITS (ri = 4)

n (%)

2 (50)

2 (50)

4 (100)

Median {IQRI

19 {1 2, 27151

TOIAL

(n ±' 13)

7 (54)

6 (46)

11 (85)

2 "5J

Median [IQR]

16.5 [10, 27.75]

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care teams offbring GPImLdwife or primary care team!

consultant shared care,

Of the 18 questionnaires sent to GPs, 14 were

re turned (78%). One of thesc was not completed ("Sorry

no time available for questionnaires"), giving a response

rate of 72% (13118). Table 1 shows participant GPs'

workingpractices.

Following each of the themes, we have reported

the interview findings supported by guestionnaire find-

ings as appropriate.

Working in a Rural Community

attitudes perceived

features of working

and the absencc ofs

offered a succinct dcscription of his situation:

as emanating from "the center];

and living in a small communit"

pecialist medical support, One GP

It"s the time, it's the distance, it's the geographv,

it's the weather . . . in the wintertime even

heliceptcrs don't flr (GP2)

Distance andprofessionals fi'om s

geography

pecialists.

tended to isolate rural

Interviewees indicated that GPs in rural/remote areas

provide a service for relativcly fow people, yet need a

wide knowledge of medical practice, The questionnaire

showed that for most GPs, matcrnity care accounted fbr

less than 1096 of their workload (Table 1); only two GPs

spent more than 1OO/6 of their time on maternibr care,

From the interviews, it was clear that rural prac-

titioners perceived themselves to have a high level of

responsibility and a nced to be competent in a wide range

of therapeutic areas and situations, Emergencies do not

present every day, yet rural GPs need to be competent in

some skills that urban Gl's no longer require because of

increasing specialization within the medical profession.

. . , we get less practice at things, but we still

have to be competent in a wide range of

procedures. (GPI)

/

If you rLm into problems in an urban practice, you

know that you co uld geta flying squad ,,,probably

in a short spacc of time. If we want a flying squad,

it's going to be in a few hours, (GP3)

Skills in neonatal and maternal resuscitation were

often mentioned as prerequisites to rural practicc. The

main concern ofGPs was wemen who develop problems

with too little time for transfer. Fear of those rare emer-

gencles caused the greatest anxiety,

The things that terrify me are the emergencies,

the crises. (...) I think to have regular updates

en crisis issues is usefuI for rne personallp

Anything that's not urgent, you've got time to

think about...and...take advice on. (GP4)

Interviewees indicated reniote and rural maternity

care incorporated issues about distance and geography,

AII questionnaire respondents agreed that "1eclork-

ing in a rural area, you have to take on more responsibility

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[[ABLE2 ThcChalJengesofWbrkinginaRuralArea(n=13)ge,,, "',//,･･i.".g. i,,. 1'"l,tli, II' ,, '1;･:"' i,;ri" ,,lr'""",/l･ "li.lg･"',ll"'1'//tw/rk//1/1,'1"' S'11gi.'',illJ''''R.oalk1･"1-G.,l,,.li"''ii,l･l'/i,'//i･X,,'d'tiVl･ll/'

tt ' ' ttt tt ttt tt /tt t tt tt t t/ t l When working inarural area, you have to take on more - -- - 61.5 38.S l responsibility than in nn urban area.

Dealing with obstetric emergencies is a big ski11s issue

in this area,

Dea]ing with neonatal emergencies is a big skiiis issue

in this area.

With few deliveries, you quick[y become de-ski[lecl

when working [n a rural area.

"lt's [ike riding a bike"-nce you have delivered babies,

, youdon'tforgethow. When working in this area, you have to have the confi clence

to make difficult clecisions and stick with them.

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than in an urban area" (Thble 2). The majority agreed that

deaLing with emergencies, whether obstetric or neonatal,

was a big issue fbr their areas, All a!so agreed that "Wbrk-

ing in this area, you have to have the confidence to make

diMcult decisions and stick with tliemr'

SKILLS

Associated with the rare emergencies was the occasional

need to perform instrumental delivcries, Most of the GPs

interviewed were cither not involved in intrapartuin care or

did not use forceps. The need to remain ski11ed in all phases

of maternity care, virttially to the point of specialization,

was scen to be unigue to remote/rural settings, whereas in

urban units, maternity staffmcmbers only had to maintain

their skills in their specialt}T area of practice, Sevcral GPs

felt de-skiIled, believing midwives to be more sldlled at

neonatal resuscitation than they were, for examplc:

I have had to do basic resuscitation on infants

but nothing more than a skilled midwife could

have done...I could not see myseif finding the

time to practice neonatal resuscitation more than

once a year, whereas the midwives established

their own programme with resuscitation training

every 3 months. So there was a recognition that 1

it was going to be impossible to match those

standards...(GP5)

disagreementaboutwhctherthesmarlnumberofdeliver-

ies attended by GPs was a factor in maintaining skills.

"lell, I suppose the reason why we gave up obstet-

rics was that we felt we were fighting a losing battle

to retain ski1ls and that was to do with the numbers

invoked. . . . attending relatively few deliverics,

almost all normal, so having to c]o a forceps

delivcrB probably did one a year maybe. (GP5)

Reasons for not wanting to keep maternity skills

up-to-date included GPs having to make decisions

about attcnding specialist courses based on available

time and the many relcvant specialties,

...in theory there is so much thatIshould be

doing from an educational point of view that I

wouldn't have time to see patients... yeu have

to try...each year,,, to identify what you

think are your core educational needs. (GP6)

'fable 3 shows GPs' self-rated competence and

confidence regarding the competencies identified by

EGAMS (SEHD, 2002). With the exception of ultra-

sound scanning and breech deliver" selfreported cem-

petence and confidencc svere surprisingly high.

/

1]

/

:'

ln rural general practice, maternity and neonatal

care is a small part of GI's' remit, and some feIt this insufl

ficient to maintain their obstetric skil!s, There was some

Recruitment

Interviewees associated with GP-led maternity units

indicated growing recruitment problems caused by

:

/

1

N.t

32 General Practitioner invoivement in Remote and Rura] dVtaternity Cafe/ foo Big a Chal]enge? datdowetal.

rllABLE3 Self:ReportedCompetenceandConfidenceforExpertGrouponAcuteMatemityServices'Identifie

}ig"･ ,, -#gi-''gg 1!agge 'ag-er"''ge 5//.･eSee,.ikiiS.T"ast,.R,,: 7ee"llec'Se?INxD-:fi'liS."M,M.,",",ag･

lt

intravenous(IV}cannulation 12 92 12 Managing lV fluid replacetnent l3 IOO 13 Management of antepartum hemorrhage 11 85 11 U[trasonic scanningn 3 25 3 Management of noTmal delivery 9 75 9 Management of cord pro[apse 11 S5 6 Management of shoulder dystocia 7 58 6 Managementofbreechdelivery 4 31 2 Undertakingaventouse[ift-outdeliveryb 7 54 7 Management of postpartum hemorrhage 11 85 9 Basic obstetric [ife support 12 92 11 Neonatal resuscitation 12 S12 9 Repalr of perineal trauma 10 77 7 Initial and discharge examination of the 12 92 11 newborn P[gficri?tion ofg.rugs. . . .. 13. .. . 10e .. '[3 ...

"In the question on cenfidence, four respendefi Ls stated that this was not appli[ub[e te their role.

hln the questio]i on confiden[e, one respondellt stated that this was not applicnble te his role.

rural practitioners being required to maintain such a

wide range of skills, This is exacerbated by the fact that

basic medical training no longer provides dectors with

sucacient obstetric skills.

Doctors coming through now don't have the

obstetric skills, and even as medical students,

they don't attend or do the number.of deliveries ]

as doctors graduat{ng 20 to 30 years ago would

have. (GPI)

..E

This was confirmcd in the surveB with 11 of the

13 GPs (85%) agreeing, "There is difficulty recruiting

suitab!y qualified staff to work in this locality:' The other

2 GPs responded, `tlo not know;" In some areas, there is

a fragile structure, and ifjust one doctor were to leave,

maternity care would not be sustainable.

"" i

,,. the structure that they've got in place...

is working ok at the moment, but , . . it would

oniy take a couple of doctors to leave and not

be replaced, and the whole system would come

tumbling down. (GP6)

l

T.1 1 !.. .... .r --" AA.. .d..A" n:-n" -..Un" d

area) movcd to another region, thisE

of GP involvement because the GP "

two GPs who supported the midwivc

Lntrapartum care.

TVvelve of the 13 survey responder

that ")glaternity care in this area is dif

because it depends on a few skilled pe`

GP respondcd, [ao not knove"

In contrast, one GJ' suggested,

even going right back to medical s(

think that there should be some fo

ing package for people who want t

rural practice ,

Training

(GP2)

GPs who are keen to preserve thcir mi

ment usually maintained ski11s throue

becoming a trainer. All agreed that tr2

de-skilling and was the best way to sus

even when low numbers of births mea

tice. Frequency of training was viewE

A favoured method was hands-ongain further experience in obstetric p]

r"t"olliT ImooA mafprnitv cprp nrnv;tlpt

t

L

a

l

(]enera[ Prnciitloner involvernent in Rernote and Rural Maternity Care: lbo Big a Cha[lenge? Catdow etaL 33

a short placement in a

suggestcd:

'

large urban hospital. One GP

. . . one problem perhaps is that a lot of medical

schools are centered around teaching hospi-

tals, and theyire not always the best places for

hands-on experience. I think, probabls more

use of the smaller hospitals wo u]d be usei'ut.

(GP4)

More than two th]rds ofthe survey respondents

had undertakcn same form of continuing medical

education (CME) related to maternity care within

the previous year (Tlable 4). Most of these events

were concerned with updating emergency skills.

TWo barriers to CME-"lack of time" and [` getting

staff cover"-were rated as important by all GPs." Distance to training" was an impertant barrier for

nearJy aU GPs.

MuEtidiscipLinary

Many GPstraining as b

Education

regarded multidisciplinary education or

eneficial:

It's (multidisciplinary training) much better

because that is how we work. If we have an

emergency in the matetnity unit, everybody is

working together. (GPI)

However, some felt training and education should

be tarb.eted at specific professienal groups:

I think one of the prablems with multidisci-

plinary training is often that it's diencult to

pitch the cducation at the right level for Lhe

whole audience, (GP5)

The differing views on "It's difficult to have joint

courses (multidlsciplinary) that suLt the needs of all

professions involvcd in matcrnity carc" were echoed in

the survey: Seven (54%) disagreed with this statement

whereas six (46%) agreed. However, all GP respon-

dents agreed that "Multidisciplinary training is usefu1

because it makes you more aware of the role of other

professionsr'

Videoconferencing

If videoconferencing was available, it was not generally

used or recognized as being very useful, although one

GP thought it had potential for training and diagnostic

support.

/

/

1

I need to be conyinced.I think our big lack in

that context is nctworking and making per-

sonal contact, which I don't think you can do

by videoconferencing. (...) It has a value in

talking to people or showing things, or perhaps

taLking through a procedure. The real value of

[T (information technology) is in the transfer

of images, ultrasoulld imagcs or faices of CTGs

(cardiotocograpliy) or, particularIB ultrasound

images in maternity that would be a huge ben-

efit. (GP7)

Most GPs had acccss to videoconferencing facili-

ties (n = ll, 85%). Only 8 (73%) of the 11 GPs with

access to these facilitics knew how to use them, 1'he

facilities tended to bc used on avcrage twice a month

[IQR: O.9, 7], usually for clinical purpose (n = 8, 73%) or

meetings (n = 8, 7396). Less than half the respondents

(n = 5, 45%) reported videoconfercncing being used for

education or training,

DISCUSSION

This study found that maternity care accounts fbr lcss

than 10% of most remote and rural GPs' workload,

yet requires fully skilled, experienced practitioners to

recognize and address complications. Thc fact that the

necd for care around birth is unpredictable, and often

demanding in terms of time and skiIIs required, has

resulted in fewer GPs being invo]ved in intrapartum

care than a few decades ago. A rccent comment by the

RCGPs' chairman suggesting that "many GPs are kecn

to see a return to this worre' raises questions about how

GPs will attain and maintain these skiIls (Ficld, 201O).

Smith et al. (2010) highlight the vital information

that GPs have regarding the medical historics of women

and their famiIics. Our findings confirm that knowlcdge

of the individual woman and what constitutes normality

were regarded as valuable attributes by GPs, facilitat-

ing the ability to react quickly in emergency situations.

Although selfreported competen[e arid confidence for

specific skills was surprisingly high among respondents,

34 General Practitioner lnvolvement in Remote and Rura] Maternity Care: lbo Big n {/hnl[cngot C/iildow et aL

IIABLE4 ContinuingProfessiona

t....-.---･---

1Development

Last attended a continuing professienai deyelopment (CPD) cvent (n =-:- 13)

Within the last month

VVIthin the iast 6 months

Within the last year

Moro than 1 year ago

Event (n =" 13)

Advance Life Support in Obstetrics (ALSO)

Other obstetric emergencies update

Neonntalresuscitation

BASICS parts1and 11

Misce]laneous

GPs who rated tliese barriers to CPD as impertant or very important:

Lack of time (n ='L 12)

C['D not being seen as a priority (n = 1 O)

Maternity care not being seen as a priority Cn = 1O}

Cetting funded to attend (n t= 1 D

Distance to training (n = 12}

Lack of motivationlinterest {n = 1 O)

Getting staff [over (n = 12)

Attitude of staff at unit providing the tra[ning Cn == 1O)

Lack of support from management (n == 1O)

Lack of appropriate train[ng (n = 1 1)

Other" Cn = 3}

n

5

4

4

4

2

1

2

4

12

5

4

8

11

1

12

5

6

8

2

%1....1

38.5

31

31

31

J5

8

15

31

IOO

50

40

73

92

IO

100

50

60

73

67

']Othe]'cemmentsfromthe2GPswhoratedthebarriersasimportantwcre:(]omF)eliJigwithotherstaEmater-

nityc4ireisonlyonepartofthejobandchildcare,TheGPwhosaidthatbarricrsarenotimportantdidnotgive

ncon]nientaboutwhntthataspectwas,

-most reported that de-ski]ling was an issue for them. De-

skilling, reported by GPs with previous maternity experi-

ence, was often attributed to midwives having takon on

new responsibilities, including referring women with

complications directly to secondary or tertiarymaternity

hospitals, Tbgether with the slowly declining number of

births in Scotland, as mentioned previouslM this reduced

the GPs' opportunity to practice (and maintain) mater-

nity care skills. Isolation, the need for comprehensive

expertise, limited resources, and transportation difficul-

ties were considered important factors in the decline of

remote and rural matcrnity activityL

Despite thc cffect of the changing role of the mid-

wife, the GP participants genera]ly accepted the concept

of midwifery-lcd carc, believing that midwives are more

skiIled in low-risk and normal deliveries and, indeed,

in some matcrnity-bascd emergencies. There is liule

evidence to support this assumption. Studies of midwife-

led care hffve predominantly been concerned with units

attached to secondary and tertiary hospitals (Hundley

et aL 1994; MacVicar ct aL, 1993; TUrnbul1 et al,, 1996),

whereas studics that have looked at stand-alone units

have compared GPImidwife care ivith care in a tertiary

unit (Campbe]1, Macfarlane, Hempsall, & Hatchard, 1999;

Klein, Lloyd, Redman, Bull, & 1[Urnbull, 1983a, 1983b;

I.owe, Housc, & Garrett, 1987; Reynolds, Ytidkin, & Bull,

l988). Wb are unaware of any studies comparing GP care

with midwif'e-led care. It is likely that thls separation ol

carc is unhelpfu1, resulting in a move toward niidwifery-

only care and affbcting the team concept ofmaternity care

in thc remote and rural setting, )vlaintaining such intcr-

disciplinary working is often far from easy although there

may be bcnefits from joint learning (Farquha4 Camilleri-

Ferrantc, & 'lbdd, 2000), GPs in our study thought that

multidisciplinary training might be beneficial, but rccog-

nizcd thc challenges in developing such training.

Concern over lack of ski11s among rural GPs is

not unique to Scot]and; a survey in Australia found that

33% of female and 16% of male GPs felt inadequately

trained for the dcmands of rural practice (South Austra-

lian IIealth Commission, as cited in Booth & Lawrance,

2001). Although GPs remain as major maternity care

providers in some areas of Australia, increasingtF thcy

are opting out of intrapartum care, and some areas are

looking toward midwifery models to cover the loss of

community GPs (Sutherland et al,, 2009), A sirnilar sjtu-

ation exists in Canada, where sustaining acute medical

services in small hospitals has become difficult becausc

r -- -- ------ --

t/t

'

'

Gcnernl Practitioner lnvo[vement in Remote and Rura1 Matcrnity Care: lbo Big a Cha[lenge? Calclow et aL 35

ofuniversalmedicalworkfbrceregulationscompounded

with the challenges ofstaff recruitment and retention in

remote and rural areas (Benoit, Carrol, & Millar, 2002),

One respondent in our survey felt that specialist

training fbr rural practice would be beneficiaL This

is interesting as the cvidence points to this as a sig-

nificant factor in the recruitment and retention of

rural GPs (Australian Medical Workl/orce Advisory

Committee, 2005; Laven & Wilkinson, 2003; Mungall,

2004), and arguc that specialist medical training may

be instrumental in reestablishing obstetric services

in rural areas (Caudle et al., 1995). Other studies

indicate the importance of carly exposure of medical

students to rural practicc (Rolfe, Pearson, O'Connell, &

Dickinson, 2005; Wang, 2002), and that training wholly

in consultant units may make them (practitioners)

fearfu1 ofcommunity-based obstetrics (Bafrd, Jewell, &

LAvlalker, 1995).

GPs in our study thought education is thebest way

of combating de-skilling and suggested that this was

best achieved through short training periods working

in maternity hospitals to update technique and practice

skills. Two thirds of respondents reported they had

undertaken some form of maternity care CME within

the last year. HoweveB most faced barriers in attending

such events (time, staff coveg and distance). Lack of

access to CME has been identified as a potential cause of

de-ski11ing, with 219t} ofAustralian GPs reporting dith-

culty accessing CME for obstetrics (Booth & Lawrance,

2001). It has also been found to be a reason for GPs

deciding not to rernain in rural areas (Brookman, 2004;

Gardiner, Sexton, Durbridge, & Garrard, 2005),

Telemedicjne is increasingly being used in mater-

nity care (Ireland ct al., 2007), and Cronin, Cheang,

Hlynka, Adair, and Roberts (2001) in Canada fbund

that videoconferencing enhanced neonatal resuscitation

education in areas where experienced instructors are in

short supply It might, therefore, have been expected that

these technological advanccs would have been seen as a

means ofovercoming some training dithculties, but our

study findings did not indicate this. An Australian study

howeve4 suggests face-to-face contact, which remains

the preferred method of learning (Booth & Lawrance,

2001). It is possiblc that this rclates to the importance

GPs attach to networking and social contact. Some

respondents mentioned the isolation associated with

rural practice and the responsibility of working alone.

Isolation and having fewer colleagues ivith whom to

discuss professional issues have been identified as fac-

tors in GPs' decisions to Ieavc rural practice (Gardiner

et aL, 2005),

Strengths and Limitations of the Study

The strength of the study was the mixed methodology

whereby the qucstionnaire results triangulated the inter-

views. This validated the interview findings and showed

general agreement with the matched sample, One of

the limitations was the small numbers. Although it is

ackiiowledgcd that this was a smal1 sample of GPs, it was

representativc of different rural areas within Scotland.

The reportcd study is part ofa larger study (Kiger et

al., 2003; IIUcker et al., 2005), where 72 interviews were

conductcd with various remote and rural maternity care

providcrs, and the data were enhanced by being situated

within the themes gcnerated by the wider study How-

even caution must be exercised in generalizing from the

study findings given the small number ofGPs involved.

Furthermore, the interviews were conducted in 2003,

and therefbrc, the data can be viewed as slightly dated.

Although GPs views may have changed over time, the

fact that matcrnity care has rnoved away from GPs'

spherc of practice is only likely to have increased the

challengcs that GPs face, Despite these limitations, we

believe that our research findings wM inform the debate

about GP involvement in maternity care, particularly in

remotc and rural arcas.

Implications for Clinical Practice

Reinstating thc GP's rote in maternity care provision is

1ikely to prove difficult without a significant commit-

ment by GPs to retraining and skil1 maintenance, Our

findings shDwed that the perceived numbers of practi-

cal episodes required for competence varied widel)c

The frcqucncy of relevant clinical events in hospital

units might not permit sufficient experience during

attachments, and other health professionals in train-

ing might have priority A further problem is that there

exists insufficient evidence to suggest such training will

be effective. Although life-support training has been

recommended as a means of maintaining competence

with regard to obstctric emergencies (National Instit"te

for Clinical Exccllence, SEHD, & Department of Health,

Social Services and Public Safetyi 2001), a systematic

review found liLtle evidence of whether such courses

improve actual practice, although practitioner confi-

dence can be increased (Black & Brocklehurst, 2003).

Some form ot' tailored return-to-practice course may

be va]uablc, particularly for GPs who intend to provide

maternity care in remote and rural areas, However,

other considerations include barriers to GPs gaining

tl ttt t tt t tttttt

FM"

36 Generil1 Practitloner [nvo]vement ln Remote ilnd Rura[ Maternity Care: foo Big a Challenge? Caidow et ni,

practical cxperience in a hospital environmcnt, because

contracts of employment assuring Crown Indemnity

are not available in maternibr hospitals and because

backfilling in the primary care unit is difficult, Clearly,

the issuc ofhow to go about retraining GPs will require

carefu1 consideration, and the support of other health

professionals, particularly midwives, will be vital.

The withdrawal of GPs from maternity service

provision also has implications fbr the U.K. government's

plans to make GPs central to the commissioning ofhealth

services. Atthough the government proposes that the lead

role in commissioning maternity services wiI1 be taken by

the NHS Commissioning Board (Deparbnent of Health,

2010, p. 13), GP commissioning ivi11 have implications fbr

the wider framework of hea!th care provision in which

the matcrnity services operate. It is essential, therefore,

that GPs work in close partnership with inidwives to

ensure that services remain women-centcrcd.

CONCLUSION

Fewer rural births and problems with recruitment/

retention of professionals have made it more difficult

to staff rural maternity units. "ihere such units have

remained open, midwives have steppcd up and taken

over units to ensure that women in these arcas continue

to havc a service. Although rural GPs and midwives

might traditionally have been in competition in the area

of matcrnity care, providing a woman-centered service

in remote areas may bc easier to achicvc through col-

laborati ve working. Howeve4 if GPs are to have a greater

role, then they will need to be prepared to make a strate-

gic commitment to the maintenance of remote and rural

maternity care. This will require innovative methods of

training, special considcration of educational needs, and

incentives for practitioners to settle in rural areas, but

it may already be teo late for GPs to have a substantial

mput ]nto matermty care,

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Acknoivle4gments. This study was funded by NHS Education

for Scotland (NES; Grant number CP123). We acknowledge

the advicc, support, and assistance of the NES steering group

and the professional advisory group of experts.

Wb would like to thank the secretaries of the Centre of

Academic Primary Care and Dugald Baird Centre forRescarch in Wt)meiis Health, Aberdeen UniversitF for tran-

scribing the int¢rviews. We would also like to thank all headsofScottish maternity units and the general practitioners who

participatcd in thc interviews. We appreciate their valuab[e

time and insight, without which this study would not have

beenpossiblc.

Correspondence regarding this article should be directed to

Vanora Hundley, Nursing, Midwifer〉' and Allied Health Profes-sions Research Unit, University of Stirling, Stirling, FK9 4I,A,

Scotland,UnitedKingdom,E-maiI:vanora,hundley@stir,ae.uk

Jan Caldow, E3Sc, RGN, MSc, fbrmerly University ofAberctcen.

Vlinora HundleM BN. RGN, RM, MSc, PhD, George Mason

Universit" USA and the University ofStirling, UK.

Edwin van 'l'eijlingen, MA, MEd, PhD, Bournemouth

University, UK, and the University of Aberdeen, UK,

John I〈eid, MBChB. MSc (Econ), FRCGR DRCOG,University of Aberdcen, UK.

A]ice Kige; RN, MA, MSc, PhD, University of Aberdeen,

UK, and Visoka SoLa za Zdravstveno Nego Jesenice, Slovenia.

Janet Tucker, BSc, PhD, University ofAberdeen, UK,

Ji]ly Ireland, IUvi, BA, MSc, Dip Psych Poole NHS Foundation

Trust, Poole, and Bournernouth University, UK,

Fiona Harris, MA, PhD, Uniyersity ofStirling, UK.

Jane E:ar;ner, l'hD, La Trobe Rural Health School, Bendigo,

Australia.

Helcn Bryers, RM, BA, MM, PhD, NHS Highland, UK and

thcUniversityofAberdeen,UK.

.-,..,1･L,,.,/･,a-../,,silt-mu--s',whinitGva

,.,:･s 'me

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Expandmg Postpartum Hemorrhage Preventionto the Community in Resource-Poor Contexts:

Critical Considerations and Next Steps

Sydnay A. Spangle4 Alissa Kbski, Dehorah Armbruste4 and

(lynthia Stanton

Increasing the proportion of pregnant women with medically skilled care at childbirth is widely

regarded as the bcst strategy fot reducing maternal mortality and morbidity in resource-poor contexts.

For many countries, however, local conditions nccessitate continuing discussion concerning the role

of targeted, community-based interventions in effbrts to tackle this problem, Onc such intervention

gaining momentum is community-based use ofuLcrotonic drugs to prevent postpartum hemorrhage

(PPH). But how this intervention fits within the lm'ger maternal health agenda sti]I needs addrcssing, as

do questions regarding whether, where, and how to proceed. This artic]e presents a usable framework

fbr coii text-based decision making around PPH prevention, evaluating why and under what circum-

stances it might make sense to implement uterotonic drugs at the community levcl. Using Demographic

and Health Survcys (DHS) data alQng with current evldence, we identify four critical considerations

for policymakers to take inte account: (a) where births are happening, (b) ;vhich women are deliver-

ing in what settings, (c) capacity ofhcalth care systems, and {d) criteria for selecting specific uterotonic

drugs. Incorporating these considerations, we propose a checklist to aid policymal〈ers in deterininingwhat strateg}r realistically suits the neecls of their particular country contexts, Although a large and

rigorous body of evidence sul)ports PPH prevention methods, research gaps remain. Even wiLh suf-

ficient evidence, howeve4 a gLobal consensus may not be reached becausc of the ongoing debates over

community- versLis faci!ity-based interventiens, Despite thesc issues, it is still poss{ble to arrive at policy

decisions on communi".-based use of uterotonic drugs by taking a carefut, context-based approach.

In many settings, implementation of this intervention can be pursued in conjunction with improve-

ments to facility-based care. As a complement to skilled attendance, expanding PPH preyention to the

community can be part efa national push to target the reduction of PPH as an a[hievable goal.

KEYWORDS: maternal health policy; postpartuni hemorrhage; community-based interventions;

uterotonic drugs; maternal mortality

INTRODUCTtON

Death and disabilibr from pregnancy-related complica-

tions remain a significant challenge in resource-poor

contexts. Estimates of maternal mortality worldwide

rangc from 536,OOO in 2005 (Wbrld Health Organiza-

tion LWHOI, 2007a) to 342,900 in 2008 (Hogan et al.,

2010), but agree that the great majority of maternal

deaths occur in sub-Saharan Africa and South Asia.

The global health community recognizes this issue as a

priority problcm; reducing the maternaL mortality ratio

by three-fourths is one of eight UN Mdiennium Devel-

opmcnt Goals (MDGs) to be reached by the year 2015,

Rcgardless ef which estimate is used, progress toward

this goal has been unacceptably slew Between 1990

and 2005, maternal mortality in most devetoping coun-

tries has decreased at rates well below the 5.5% annual

decline needed to achieve MDG-5.

INIERAL4nOAtAL JOURALtlL OF CHILDBIRffI blolume 1, tssue 1, 2011 @ 2011 Springer Publishimg Company, LLC www.springerpub.com DOIilO,189V2156-5287.i].39

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40 Expanding Postpartum Hcmorrhnge Prevention to Community Contexts SPangter et al.

Because ]ife-threatening maternal complications

tend to occur near deliverM researchers and advocates

largely agree that incrcasing the proportion ofbirths with

medicaily skilled carc is critical for alleviating this crisis

(Campbell & Graham, 2006). 'l'he }VHO, international

Confederation of Midwives (ICM), and International

Federation of Gynecology and Obstetrics (FIGO) define

a skilled birth attendant as an accredited health profes-

sional (such as a midwife, docton or nurse) trained to

proficiency in the skills nccdcd to rnanage uncomplicated

pregnancies and childbirth, as well as to identifY, manage,

and refer complications in women and newi]orns (WHO,

Department ofReproductivc Health and Research [RHR],

2004). But despitc its thcoretical appeal and inclusion of

a broad array of hcalth professionals, local conditions in

many countries limiL the extent to which this care can be

made available, Whether because ofproblems with mater-

nity care coverage, quality of services, or care-seekmg

behavio4 many women are not reaching skilIed care and

are not 1ikely to reach it in the near future, This reality

necessitates centinuing discussion regarding the role of

targeted, community-based interventions in effbrts to

promote safe motherhood, whcrc "comrnunity" refers to

low-level health facilitics (nonsurgical, nonphysician, geo-

graphically rcmotc f'rom referral-level care) as well as to

homes. Howcve4 which interventions to prornote, in what

particular contcxts, and by whom, remains a controversy

in research, policM and program arenas.

One comrnunity-bascd intervention that deserves

carefu1 consideration is prcvcntion of PPH with utero-

tonic drugs. Usc of these drugs in homes and low-level

facdities is currently gaining momentum in both research

and practice, But thc place ofthis intervention within the

global agendia for maternal-newborn health stM needs

addressing, as do questions on whethe4 where, and how to

proceed, The purpose ofthis article is to present a context-

based framework for decision making on expanding PPH

prevention to tlic community, Secondary objectives are to

summarize what is known about PPH and its prevention,

identify important gaps in the evidence base, and suggest

next steps for future research. 'rhroughout this article, we

view comniun ity-bascd PPH prcvention as a complement

to the broadcr stratcgy of ski11ed attendance-as a means

of augmenting health systems in places that are still far

from making the ideal carc available to every woman.

POSTRARTUM HEMORRHAGE PREVENTION

Obstetric hemorrhage is among the leading causes of

maternal death in the developing world, representing

34% and 319'o of maternal mortality in Africa and Asia

respectively (Klian, Mlojdyla, Sa〉r, Gulmezoglu, & VaiLook, 2006). fVthough it is difficult to determine wha

part ef obstetric hemorrhage is attributable to postpartun

complications-and even rnore clifflcult to distinguisl

these compLications from each other-it is safe to sa]

PI'H is the most common type of obstetric hemorrhage

and that uterine atony is a predominant cause of PPII

Wortdwide incidence of PPH is estimated at 10,5% of liv`

births annuall" which equates to nearly 14 million case/

per year (WHO, 2005), Survivors of PPH may face sever`

or chronic anemia, rcsulting in reduced capacity to executt

daily activities, susceptibility to infection, and poor out

corncs in fttturc prcgnancies (1[blentino & Friedman, 2007

Wblvekar & Virkud, 2e06). Given that PPH is preventabte

these figures represent nothing less than a tragedv

The most effective intervention known fbr PP}

prevention is active management of the third stage o

Jabor by a skilled attendant, shown to reduce thc risl

of PI)H by more than 6096 (Prendiville, Elbourne, 8

palcDonald, 2000). This intervention is currently define(

as administration ofa uterotonic drug within 1 minute o

newborn deliverM controlled cord traction with placenta

delivcrB and uterine massage after placental deliver]

(ICM & F]GO, 2003). Although the relative contribution:

of cord traction and uterine massage are unlmown, utero･

tonic drugs can cfll]ctively prevent PPH in the absence o

these components (Cotte4 Ness, & [[blosa, 2001; Dermai

et al., 2006). In settings where active management of th`

third stage cannot be implemented because of a lack o

skilled attendants, WHO strongly recemmends that :

uteretonic drug still be offered by a health worker traine(

in its usc fbr PPH prevention (WHO, 2007b),

Uterotonic drugs may operate through differen

mechanisms efaction, but all essentiallywork to increasc

uterine contractility and inhibit bleeding from the site o

placental separation. WHO recommends oxytocin as tlu

most effective uterotonic drug with the fewest advers4

sidc cffbcts (WHO, 2007b), Howeve4 a recent review o

this drug calls for more evidence to better assess trade

offs and benefits (Cotter et al., 2001). Although als(

effective, use of misoprostol for PPH prevention ma]

result in maternal feveB shivering, or more cases ofsevert

PPH that require therapeutic uterotonics (Giilrnczoglu

Forna, VillaB & Hoime}rr3 2007). Ergometrine and Syn

tometrine (a combined ergometrine and oxytocin drug

can cause nausea or vomiting and are contraindicated ii

the presence of heart disease or hypertension, The bal

ance of evidence does not support use of ergot alkaloid,

alone to prevcnt PPH (Cotter et al,, 2001; Liabsuetrakul

Choobun, Pecyananjarassri, & Islam, 2007),

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Expandlng Pestpartum Hemotrhage Preventien to Community Contexts Spangleretal, 41

Besides effectiveness and side effects, uterotonic

drugs also differ with respect to route ofadministration,

storage requiremcnts, and costs. Oxytocin is typicaly

given via intramuscular injection or intravcnous drip,

and loses potency in temperatures higher than 30eC

(Hogerzeil, NVlalker, & de Goeje, 1993), Ergometrine is

also given parenterallM but is Iess stable than oxytocin

in high tcmperatures and is sensitive to light (Hogerzeil

& XValkcr, 1996). Administratjon routes for misoprosto]

includc oraL sublingual, buccal, or rectaL but the pre-

ferred reute remains unclear. This drug is stable with

respect to both heat and light. Whereas the acquisition

costs of uterotonics vary by context, the administra-

tion costs of misoprestol may be Iower than for drugs

requiring injection. Because misoprostol does not need

a cold chain, its storage costs are also likely to be less

than those ofother uterotonics.

CRtTICAL CONSIDERMIONS FOR EXIIANDINGPPH PREVENTION TO THE COMMUNITY LEVEL

1tt this point, we return to the question-should PPH pre-

vention methods be expanded to the community level? By

taking a context-based approach (i.e,, realizing the answer

"till not be the sanie in all placcs and at all times), we can

pethaps put fonh a more practical inquir}r: Where and

underwhatcircumstancesdoesltinakasensetoimplement

uterotonics at the communi"r level? XVhich drug should be

used in what settings? [Ib address these questions, we iden-

tify four critical considerations to take into account when

making decisions regarding PPH prevention.

Where is Childbirth Happening?

According to nationally representative survcys, the pro-

portion ofbirths attended by an accredited health profes-

sional(midwife,doctoBnurse)isabout62%indeveloping

regions. By convention, the global health community

refers to these births as taking place with a skilled atten-

dant, although data on the specific ski11s and training

of these providers are lacking. Ulsing this definitien,

births with a ski11ed attendant appear to be increasing

in ali rcgions except in sub-Saharan Afi:ica and Oceania,

where usc remains stagnant or has decreased over time

(WHO, RHR, 2008). With few exceptions, dclivery with

a health professional translates into facility-based birth.

Howeveq data on births attended by health pro fessionals

do not indicate at what kind of facility births are occur-

ring. rLb cxplore this issue, we examine DHS data from 15

geographically representative countries in sub-Saharan

Africa and South Asia (DHS, 2008a). Given the data

source, we acknowledge that some misclassification is

possiblc between public low-level facilities and govern-

ment hospitals. In addition, fa[ilities labeled "privatc"

can encompass anything from one-room dispensaries to

fully fimctional hospitals.

Figures 1 and 2 give the pcrcent distributions for

delivery place, Most notablM a good deal of childbirth

occurs at the community leveL Among the African

countries, Ethiopia has the highest proportion of home

binhs at an estimatcd S8%, whereas Nigeria is at 66% and

Ghana, '1'anzania, Uganda, and Zambia hover around the

midpoint. Adding public low-level facthties, community

births are more than 60% in evcry country except South

Aftica. Deliveries in government hospitals vary from 6%

DRC Ethiepia(2007) (2005)

FIGURE 1

Nigcria

(2ooa)

'I'anzania

(2004-05)

IJgnnda

(2006)

Percent distributions tbv place of dcl lver

Zambia(2ee7)

- Othe[ Location

- Private FacMty

D Govcrnment Hospital

1 Public [.ow-Leve] Facility

l Homc

yrsub-SaharanAfrica.

/tttt

42 Expanding Postpartum Hemorrhage Preventlon to Community Contexts SPangter et aL

FIGURE 2 Percent distributions fbr place of deliverltSouth Asia.

te 69%, but in rnost countries fall between 10% and 20%.

An even greater majority of births take place in the com-

munity among South Asian countries, with home births in

Bangladesh and Nepal reaching 83% and 81%, respectively

wrth the exception of Vietnam, deliveries in public low-

level facihties are minimal, varying from only 1% to 5%.

Tbeends in home births for the cited countries with

at least three DHS surveys over the past 20 years are

shown in Figures 3 and 4 (DHS, 2008b). The picture in

sub-Saharan Africa is varied. Ghana shows a decrease

of 15 percentage points in home births between 2003

and 2008. From the early 1990s through 2007, the

proportions ofhome births in Zambia and Uganda have

remained essentially unchanged. Nigeria and 1[hnzania

exhibit increases, jurnping eight percentage points in

Nigeria and five percentage points in [fanzania between

the early 1990s and the middle of the current decade.

In contrast, South Asian countries show steady declines

for this period, dropping from 23 percentage points in

Indonesia to 10 percentage points in Nepal. Although

these trends cannot absolutely predict where births will

occur in the future, when put into economic and politi-

cal context, they rnay give a sense of what is 1ikely to

happen in the short term.

FIGURE 3 Irends in home delivery-Sub-Saharan Africa.

Ghana

Nigeria

fanzania

Uganda

Zambia

r-v

Expanding Postpartum Ftemorrhage E'revcntion to Community Contexts Spangleret aL 43

IOO

90

80

70

60

50

40

30

20

!o

FIGURE4 'Frendsin] iome delivery-SouthAsia.

Banoladesh

lndia

lndonesia

Nepal

1'hilippines

Although place of delivery does not speak to

quality of services, it does indicate the type of care

women are accessLng in particular localities. Provided

that the data give a fair depiction, fbcusing efforts on

public low-level facilities may not greatly increase PPH

preventton in some countries, but the rnajority could

benefit from home-based intervcntion. Besides nation-

al-lcvel data, policymakers may also want to consider

delivery place at the district ievel or among even more

distinct communities within their jurisdiction.

Which Wbmen are Delivering Where?

Por a given lecalit$ it is necessary to consider vvhich

women are receiving what services by econemic and

sociodemographic characteristics. Analyses of DHS

data in up to 56 countries find enormous differences

between wealthy and poor groups in proportion of

deliveries with health professionals-a gap greater than

that of any other maternaL reproductive, or child

hcalth service examined (Gwatldn, Bhuiya, & Victora,

2004; Houweling, Ro nsmans, Campbell, & K"nst, 2007).

Country-$pecific studies also report significant positive

associations between economic status and deliveries

with health professionals or in health facilities (Anwar,

Killewo, Chowdhur" & Dasgupta, 2005; Mrisho ctal., 2007; Say & Raine, 2007; fann et al., 2007; Thind,

Mehani, Banerjee, & Hagigi, 2008; Yhnagisawa, Oum,

& Wakai, 2006).

Averaged across the 15 countries we have been

cxamining, Figures 5 and 6 give the percent distribu-

tions of delivery place by wealth quintiles. ClearlM

FIGURE5 Percentdistributions forplace ofd cliver yby wea]th quintiles-S

- Othcr

D Private FaciUty

o Govcmment Hospltal

- Public Lew-Levcl Facility

- Home

ub-Saharan Mica.

ma,lt./.

44 Expanding Postpartum Hemorrhage Prevention to Community Contexts ij)angter et al,

FIGURE6 Percentdistributions fo r placc of deliver

- Other

m Iirivate Faeilits,

m Cloveunrnent HDspital

- Pubtic Lew-Level Facility

- Home

y by wealth quinti]es-South Asia.

home delivery is inversely related to wealth. In the Afri-

can countrics, S6% ofwomen deliver at home, but these

births occur among approximatcly 75% of the poorest

group and 19% of the wealthiest, About 67% ofbirths

in the South Asian countries take place at home, but

these occur among 899'e of the poorest and 29% of the

wealthiest. In contrast, deliveries in government hospi-

tals and private facilities increasc up the wealth spec-

trum in both regions. Births at public low-level facilities

are relativcly consistent across wealth quintiles, ranging

from 15% to 20% fbr African countries and 2% to 8%

f6r South Asian countries,

Figures 7 and 8 show percent distributions of

delivery place by area of residence averaged across the

selectedcountrics,indicatingthatmosturbanbirthstake

place in govcrnment or private faci1ities, and most rural

births occur at homc. A number of studies documcnt

the cffect ofrural rcsidence on delivery care (Houweling

et al., 2007; Say & Raine, 2007; Stephenson, Baschieri,

Clcments, Hennink, & Madise, 2006; Thind et al., 2008),

Additional sociodemographic factors associated with

the use ofhealth facilities or health pro fessionals at birth

include education, age, parity3 marital status, occupa-

Lion, women's autonomB cthnicity; and religion-where

the direction and strength ofassociations are spccific to

context (Anwar et al., 2005; Bloom, Wypij`, & Das Gupta,

20el; Glei, Goldman, & Rodriguez, 2003; Mekonnen &

Mekonnen, 2003; Mpembcn{ et al., 2007; Mrisho et al,,

2007; Paul & Rumsex 2002; Stekelenburg, Kyanamina,

Mukelabai, Mlolffers, & van Roosmalen, 2004; Stephen-

son et aL, 2006; Tann et al., 2007; Thind et al., 2008;

Ylinagisawa et al., 2006).

FIGURE7 Percentdistributionsfo r place ofdelivcry by area of residence-Sub-SaharanAfrica.

eu･'

Expanding Postpartum Hemerrhage Prevention [o Community Contexts 51)angler etaL 45

90V,

80W,

70W,

60%

50%

40,%

30W,

20Y"

IOW,

oys

FIGURE8 Perccntdistributionsfo r place of delivery by area of resi

- Other

m I'rivate F:tcility

o Government Hespital

- Public Low-Levc] ];aeility

- Home

dence-SouthAsia.

Thus, cven in countries where institutional birth

appears on the rise, certain women are not receiving

this care. Better-off women receive care in higher level

faciliti'es with more highly skilled attendants, whereas

disadvantaged women deliver in the community with

attendants lacking in formal medical training. Without

explicit effbrts to reach these groups, irnplementation

ofthe strategy to increase medicaLly skilled care at birth

could be supporting inequitable outcomes (Gwatkin,

2005). HoweveB services that target excluded popula-

tions could mitigate this result-such as providing PPH

prevention in the communits whcre most marginalized

women are delivering,

Capacity ofLocal Hbalth Care Elystems to Provide

ObstetricServices

Coverage of obstetric scrvices in public and private

sectors must be assessed. If coverage is low and home

births are high, commuiiity-based PPH prevention

seems a reasonable plan. If coverage is high, the best

approach may be to improve access to this care and

ensure arrailabllity of uterotonics in facilities. Although

skilled attendance is the ideal package of services, as an

intervention it can be difficult to assess. Competencies

of skilled attendants may not match up with evidence-

based standards (Harveyct al., 2007), and guidelines t'or

whether an environment is enabling are not available.

Emergency obstetric care (EmOC) might offl]r a more

practical means of assessment becausc its monitoring

tools categorize facilities according to nine signal func-

tions, The recommended level for adequate coverage is

five EmOC facilities per 500,OOO population, at least one

ofwhich must qualify as cemprehensive EmOC (WHO,

United Nations Population Fund [UNFPA], United

Nations Children's Fund [UNICEFI, & Averting Mater-

nal Death and Disabilit}r [ArvlDD], 2009). VVle caution,

howeve4 that such assessment does not speak to quality

ofcare or to the capacity to proyide PPH prevention,

Coverage ofhcalth professionals and their skiIls in

safe delivery should also be taken into account. In 2008,

47% of women in Africa and 6S% of wornen in Asia

were attended by a health professional (WHO, 2008),

although the proportion of womcn receiving PPH pre-

vention is unknown. Making activc management ofthc

third stage of Iabor part of standardized curricula for

pre- and in-service training could increasc PPH preven-

tion coverage considerably. However, training in physi-

ological management for improving quality and safety

should not be neglected, especia!I〉F in settings that donot or cannot consistentiy employ active management.

For contexts where skilled health professionals are in

short supplB the potential for task shifting PPH prc-

vention to an existing lower skilled (fbrmally trained)

health worker cadre should be assessed-particularly

for injectable drugs but also for administering miso-

prostol, In adclition to health workers, local resources

such as women's groups, health advocacy committees,

community lcaders, and traditional birth attendants

(TBAs) should be recognized fbr their ability to assist

with sensitization as well as logistics.

Other important issucs that deserve consideration

involvc processes ofdrug registration, distribution, and

storage, Oxytocin and ergot alkaleids are registered

in most countries for PPH prevcntion and treatment,

althoughnotnecessarilyoxytocinT"inUniject,Misopros-

tol is widely rcgistercd for gastric ulcers and unspecified

obstetriclgynecological cenditions but is registered for

PPHin only 11 countries ofsub-Saharan Africa and four

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46 Expanding Postpnrtum 1-lemorrhage Prevention to Community Contexts Spangleret al.

countries ofSouth Asia (Vcnture Strategies Innovations,

2010). Although off-label use is common, Ministries of

Health that choose to strategically promote misoprostol

fbr PPH prevention will necd to officially register it for

this purpose, Distribution pathways from dru.a manu-

facturers to recipicnts inust also be assessed, especially

transportation and storage mechanisms for drugs that

are sensitive to heat or light-including the potential to

upgrade the supply chain in this respect.

oriteria for Selecting Specijic Uterotonic Drugs

At a minimum, criteria for the selection of uterotonic

drugs include effectiveness, safet" feasibility; cost-

effectiveness, and acccptabilitv Effectiveness essentially

refers to the ability of the intervention to decrease

PPH incidence in real world settings, As noted in the

background section, the literature supports ox〉tocin asthe most effective uterotonic drug for PPH prevention,

However, misoprostol also exhibits a credible degree

of effectiveness and is often recommended for settings

where ox}tocin is unavailable despite its side effects of

fever and shivering (Alfirevic, Blum, Walraven, Weeks,

& Winikoff; 2007; 1,angcnbach, 2006; WHO, 2007b).

Ergot alkaloids are comparablc to o)cytocin in effective-

ness, but are gencra1ly not preferable because of the risks

of nausea, vomiting, and clcvatcd blood pressure.

Safety refers to the likclihood of adverse events

such as dosage errors, ncedtc sticks, and mistimed

administration or inappropriate use of uterotonics-

the latter of which can potentially contribute to fetal

asphyxia or uterine rupturc. Three observational studies

in Tanzania, Nepal, and Afghanistan evaluate the safety

of community-based misoprostol with measures of dos-

age, timing, and side effects (Prata, Mbaruku, Gross-

man, Holston, Hsieh, 2009; Rajbhandari et al,, 2010;

Sanghvi et al., 2010); aU conclude the intervention is

safe, but none spccify a safety threshold for the param-

eters assessed. The WI IO's published statements on use

of misoprostol at the community level stress that it has

withheld recommending distribution during pregnancy

for use after delivery because its potential benefits and

harmsareunknown(WHO,RHR,201O).Severalstudiesdocument misuse of uteretonics for labor augmentation

(Flandermeye4 Stanton, & Armbrusteg 2010; Fronc-

zak, Arifeen, Moran, Caulficld, & Baqui, 2007; IyengaB

lyengar, Martines, Dashora, & Deora, 2008; Jeffery Das,

Dasgupta, & Jeffery 2007). "1'hese studies collectively

suggestthatintramuscularjnjectionofox〉tocinbybirthattendants lacking formal medical training is especially

common in South Asia. Establishing the risk of this

practice for health outcomes at the population level

needs furthcr research.

Feasibility refers to the capability of a given con-

text to properly implement uterotonics in communi-

ties, including storage, distribution, administration, and

disposal. To improve feasibility of oxytocin in terrns of

storagc, TI Pharma has initiated a program to deyelop a

heat-stablc formulation (Hawe et al., 2009). Meanwhile,

oxytocin'" in Uniject (a device designed to ensure cor-

rect dosing and minimal needle reuse) is equipped with

a timc-tcmpcrature indicator that increases its utility in

the field (PATII, 2008). Irljectable oxytocin also requires

that someone trained to administer this drug is present

at birth, and there is not a standard solution for needle

disposal in home settings, The cited studies in Nepal and

AfghanistandistributedmisoprostolforPPHprevention

through Iow-lcvcl hcalth workers or community volun-

teers; from womcn's self-reports, the former study found

that utcrotonic coverage in the study site increased

from about 12% to 2496, whereas the latter found that

nearly 70% of women offered with misoprostol, used it

(Rajbhandari et aL, 2010; Sanghvi et aL, 2010).

Although a component of feasibility, cost-effectiveness or efficiency is critical enough to deservc

its own mention. Different methods of giving oxytocin,

misoprostol, ergometrine, and Syntometrine at facility-

based births in developing countries have all been fbund

to bc cost-ethctive, but a comparative study reports

oxytocin to be the most eencient-although differences

betwecn somc methods had little practical significance

(Seligman & Liu, 2006). An anarysis of misoprostol fbr

PPH prevention at home births in India demonstrated

a 38% decrease in maternal deaths, with an incremen-

tal cost of $1,401 per life saved, compared to $IO,532

per life saved fbr comprehensive EmOC (Sutherland

& Bishai, 2009). Another model based on countries

in sub-Saharan Africa confirms the cost-effectiveness

of misoprostol at home births (Prata, Sreenivas, et al.,

201O). Still needed is a tool for cost-effectiveness evalua-

tion that can be adjusted to suit the changing conditions

ofspccific country contexts.

FinallF cven ifa particular intervention is shown

to be etTective, safe, feasible, and eMcient, the ques-

tion remains as to whcther it will be acceptable. At the

national policy level, some countries may be reluctant

to initiaLe community-based activities when facility-

based births arc bcing promoted Misoprostol may face

political barrlers over concerns about its abortifacient

propcrtics, Reccntlyl two key articles shed light on how

political priority for maternal mortalit〉T is generated(Shiffman, 2007) and how research is translated into

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Expanding Postpartum Hemorrhage Prevention to Communlty Contexts Spangler etal. 47

policy in poor and transitional countries (Woelk,

Daniets, et al,, 2009), The critcrion of acceptability a!so

applies to health workers, childbcaring womcn, and

their families, At all levels, in-depth evidencc on the

acceptability of community-based uteretonics for PPH

prevention is limited, ･

NEXT STEPS

By addressing the earlier considerations, policymakcrs

can begin to identify where and under what circum-

stances PPH preyention might be expanded to the com-

munit}c Such contexts might include places with high

proportions of deliveries in homes or low-ievel facilities,

poor ceverage of obstetric services, and low ljkelihood

of a rapid shift to facility births. Even in contexts whcre

fewer women deliver at home, if these women are sys-

tematically disadvantaged, tliey should not be excluded

fi:om PPH prevention interventiop, Lastly, lecal condi-

tions must be favorable for a specific uterotonic drug;

that is, a drug considered safe, feasible, and acceptable.

As Gwatkin, Wagstaffl and Yazbeck (Gwatldn, Wagstaff]

et al., 20e5) state in the "brld Bank Report Reaching the

Poor, `CThe challenge is to find the approach that works

best in a particular setting in dealing with a particular

issuc" (p. 47).

Although a large and rigorous body of evidence

supports methods of PPH prevention, research gaps

remain, Some research priorities spec]fied by WHO

inciude determining whether oxytocin cari be safely

administered by unskilled attendants, understanding

which components of active management of the third

stage of labor are rnost effective, establishing the best

doselrouteofadministrationformisoprosLoLandexplor-

ing the role of buccal or sublingual exytocin (NVbrld

Health Organization, 2007). More information is also

needed on the safety of introducing uterotonic drugs to

communities, sustainable soluLions for feasibilit}g cost-

effectiveness of various options in particular localitics,

and the acccptability of7demand for communiLy-based

PPH prevention among policymakers, health workers,

and intended recipients of this intervention.

Another gap involves the potential implications

of community-based PPH prevention for other mater-

nal health interventions, Rajbhandari et al,'s (2010)

observational study examining the distribution of

misoprostol in Nepal rcported an increase of four per-

centage points in institutional delivery over the coursc

of the implementation period (Rajbhandari, Hodgins,

et al., 2010). Asidc from this exampie, eyidence for the

effect of community-based interventions on facility-

ba$ed care is scarce-an implication that should be

bettcr understood, evcn if it can't be well predictcd.

As uterotonics can be cmployed for multiple purposes,

the potential for misuse should also be seriously con-

sidered, If uterotonics are widely available, how often

rnight they be used unsafely for labor induction or aug-

mentation? Might an education or other kind ofinter-

vention effectively prevent such ]nisuse? Lastl)1 there

are implications for active management of the third

stage of labor and PI'H treatment If a uterotonic is

routinely being glven by someone trained to administer

it, could this person also be trained to perform uterine

massage? "rhen, where, and how should treatment be

initiated when prevention is being implementcd? Thcse

questions still need to be addressed.

More research is needed before global recommen-

dations can be issued (i.e,, implementing community-

based PPH prevention where more than SO% ofbirths

occur at home, or where more than 759'o of the poor-

est women delivcr at home). But even with surncient

evidcnce to support PPH prevention, it is possible

that a global consensus will not bc reached bccause of

the ongoing debate over commvnit〉T- versus facility-based intcrventions. In the meantime, stakeholders in

resource-poor countries continue to shape maternal

health policies. We propose Figure 9 as a checklist to aid

in assessing crltical considerations for cemmunity-based

PPII prevention. Not all countries will be able to com-

plete the checklist in fuII, but by using what data is avail-

able, this tool can assist policymakers in determining

what realistically suits their needs. In particular, it can

help answer the questions of where and among which

populations a specific intervention will likely produce

the greatest benefit. We stress that these considerations

should be applied to district or community levels as well

as to the national level because varying contexts within

a country may warrant different approaches to PPH

.PreVelltlOll.

CONCLUSION

Communit〉r-based PPH prevention can act as a com-plement or a supplement to skil]ed attendance. This

intervention is not a replacement for, a move away

from, or a reinterpretation of more comprehensive

strategies. Rather, it is a targeted action for augment-

ing health systcms that can be adapted to chang-

ing cenditions; if facility births increase in a given

poputation, it can be scaied back accordinglyL PPH

maC/,/1..'h･,i,',tt/

48 Expanding Postpartum Hemorrhage Prevention to Community Contexts SPangler et al.

PlaceofBirth

Proportienofbirthsoccurringathome

Proportionofbirthsoccurringinhealthfacilities

Publicfacilities

-Hospitals

-Healthcenters

-Healthpostsordispensaries

Privatefacilities

-Hospitals

-Healthcenters

-Healthpostsordispensaries

PlaceofBirthbySociodemographicCharacteristics

Proportionofbirthsoccurringathomebywealthquintiles

Proportionofbirthsoccurringathomebyothercharacteristicsthatmaybesalientforaparticularcontext

-Age

-Parity

-Ethnicity

-Education

-Indicatorsofwomen'sautonomy

ObstetricServicesDistribution

CoverageofEmOCfacilitiesper500,OOOpepulation

-ComprehensiveEmOCfacilities

-BasicEmOCfacilities

UterotonicDrugRegistrationforPPHPreventionandOtherUsesOxytocin

Misoprostol

Otheruterotonicdrug(specify)

SupplyChainReliabledistributionofdrugstopointsofservice

-Availabilityofuterotonicdrugsinruralareas

Coldchainforgeneraldrugdistributionandstorage

-Extensivetoremoteruralareas?

-Inclusiveofoxytocin?

HealthWorkersSki11edattendants:doctors,nurse-midwives,nurses,andotherprofessionalhealthworkerstrainedinsafedeliveryskills

-Coverageperpopulation

-CurrentlytrainedinPPHpreventionfAMTSL?

Community-levelhealthworkers:existingcadretrainedtoprovidePPHprevention(orcadrethatcouldbetrainedinthisskil1),

-Coverageperpopulation

-Legallyallowedtogiveinjections?

SpecificUterotonicDrugsforLow-LeyelFacilitiesandHomeSettings(oxytocin,misoprostol,otherdrugs)

Safeimplementation

Feasibleferservicedelivery

Cost-effective

Acceptableamongpolicymakers,healthworkers,andpopulation

Nbtes.AMTSL,activemanagementofthethirdstageoflabor;EmOC,emergencyobstetriccare;PPH,postpartumhemorrhage.

FIGURE9 Criticalconsiderationsforcommunity-basedPPHprevention.

Expanding Posti)nrturn Hemoirhage Ptovention to Community Contexts Sl)nngler et al. 49

prevention is in no way a final solution fbr PPH, but

it is capable of rcducing the incidencc ofthe problem,

and its use in communities can be implemented in

conjunction with improving access to and quality of

referral-level carc. After alt, community-level inter-

yentions and facility-focuscd services are not either-or

propositiens, NVith increasing evidence to suggest

that investing rcsources in community interventions

can reduce maternal mortality (KidneM Winter, et al.,

2e09; Pagel, Lewycka, et al., 2009), the two strategies

should be pursued alongside each other as dictated by

the needs ofa given context.

MultipleoptionsexistevensvithinPPHprcvention-

there is no one solution for all countries and individual

countries need not adopt a singular approach, Buekens and

Althabc (Buekens & Althabe, 2010) argue that although

oxytocin is the drug of choice, at this point in time, both

oxytocin and misoprostol have a place in preventing PPH.

Fundamentall〉r, the geal is to expand a medical advancethat improves maternal health and suwival to women

who are not reaching skilled care-in whatever ways this

goal can be effLtctively accomplished. Despitc a lack of

clear guidelines, we advocate fbr a carefu1, context-based

approach to determining whcre and how such expansion

might bc carried out, Commimity-based PPH prevention

can be part ofa national push to target reduction ofPPH as

an achicvable goaL Decisions with respect to this interven-

tion need not be postponed awaiting a global consensus

that may never be achieved.

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Sydiiey A. Spangla; PhD, CNM, Johns Hopkns School efPublic

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AIissa Koski, Ml'H, Johns Hopkins School ofPublic Health.

Deborah Armbruster, CNM, MPH, Pi¥rH Maternal and

Child Health and Nutrition.

Cynthia Stanton, PhD, MPH, Johns Hopkins School of

Pub]ic Health.

,,. ua{-ti-wttt

Struggling to Get Into the Pool Room

Discourse Analysis of Labor Ward Mi

Experiences of Water Birth

i

? A Critical

dwives'

Kim Russell

RESEARCH AIM: 'rhe aim oi' this article is to share the (indings from an ongoing action research

stud}, aimed at identifying inequalities in the availability of water birth on one hospital labor ward,

Efforts to encoL"'age labor ward midwives to take actio] and infiuence the delivery of normal birth care

in the maternity concerned are addressed in the larger study.

METHODS: Unit midwives who regularly werked on Iabor wards werc invited to tal〈c part in focusgroups and face-to-face interviews over an 8-month period. Critical discourse anal}rsis "'as used to

idcntify actual niidwifery practices, the social ordering of the water birLh discourse, obstacles to water

birth, dominant group intercsts, and solutions to the identified obstaclcs (Fairclough, 2001).

RESUI:I]S: The author conducted a total of tivc unstructured interviews (35-60 rninutes) with ]abor

ward matrons, a consultant midwife, labor ward managcr and clinical practice facilitator, and three

focus groups (40-60 minutes; 1 i midwives) with clinical midwives. Institutional pracLices focused on

the dc[ivery of standardized midwifery care for low-risk women and, therefore, did not promote or

encourage water birth practicc. The small number of requests and the low water birth rate were used

as evidence by soJne midwives that childbearing women no longer wanted this t)rpe of care. The key

obstacles to water birth in th{s setting werc coordinators' priorities, m{dwives' negatiye attitudes,high

wor]doads, and ]ad〈 of institutional support for this type of care.

CONCLUSIONS: 1:indings stiggest that hospital water birth practice is dependent not only on the

availability of equipment and midwifery knowledge, but also on the philosophy ef care adopted by

the organization (Stark & rvlillcr, 2009), Interycntions to improve the practice and availability of water

birth are more ]ikely to succccd if supportcd by midwifery managers, championed by coordinators, and

led by labor ward practitioners.

INTRODUCTION

'

Labor ward culture "is built on a contradiction.

[t allows individuals, in isolation, to practice

midwifery skills of care and support but can-

not acknowledge the empowering potential of

those skills for midwives" and mothers, Thus,

the voice of midwifery is muted, and midwives

"experience a professional state of leamed help-

lessness and guilt" (Kirkham, 1999, p. 738).

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This statement captures some of the key political issuc

surrounding thc delivery of midwifery care in th

United Kingdom todav It implies that tnidwives' know]

edge and skiIIs are undervalued within UK midwifer

services (Downe, 2005). Use of the terms "muted" ani

"hclplessness" portray midwives as an oppressed groul

Stapleton, Kirkham, and Thomas (2002) and Kirkhan

(1999) argue that some midwives are in the unenviabl

posiLion of trying to work from a woman-centerei

perspective and empower women from a disempow

ered position. They describe a National Health Servic

tNTERAM"OAtALJOURNAL OF CHILD81RTH Vbtume 1, tssue 1, 2011@ 2011 Springer Pubtishing Company, LLC www,springerpub.comDOI:10.IB91f2156-52B7.1.1.52

.. -- /

Struggling to Get into the Pool Room? A Critical D[scourse Anaiysis of Labor N,Vard Midwives' Experien[es of VVater Blrth Russetl 53

'

(NHS) punctuated by "service" and "sacrificc" in which

midwives are denied the rights and choices they are

expected to offer to women in their care. It appears that

the NHS midwife has becorne the [`pi.agy in the middle";

caught bctween maternity policies, employers, col-

leagues, and women's diverse needs (Murphy-I.awless,

1998; O'Connell & Downe, 2009), Research has shown

that midwifery care can support the develDpment of

therapeutic and meaningfu1 relationsbips (Mander,

2001; Siddiqui, 1999), reduce the need for pharma-

cological analgesia (Eberhard, Stein, & Geissbuelheg

2005; Law & Lamb, 1999), improve vaginal birth rates

(McCourt, Page, Hewisen, & VaiL 1998; Rooks, 1997),

and decrease the length of labor and need for medical

intervention (Hodnett et aL, 2002), However, the rise

in the medica]ization of childbirth and the impact of

technology on hospital midwives' role has led many to

challenge the netion efmidwives as autonomous prac-

titioners of normal birth (Green, 2005; Hollins Martin,

& Bull, 2008; O'Connell & Downe, 2009), Normalbirth is defined as "birth without induction, without

the use of instruments, not caesarean scction, and

without gcneral, spinal, or cpidural anesthcsia before

or during delivery" (Maternity Care Working Group,

2007, p, 1). However, the boundaries between normal

and abnormal birth have become blurred, resulting in

obstetricians and midwives caring for high- and low-

risk women (ArneM 1982; Witz, 1992), and birth being

redefined as potentially pathological (Oakle〉r, 1984),In recent decades, normal birth rates in the United

Kingdom have fa11en from 60% in 1990 to 48% in 2006

(BirthChoiceUK, 2009),

The aim of this article is to share the fi ndings from

an ongoing action research study to the provision and

availability ofwater birth on ene UK laber ward. Effbrts

to encourage labor ward midwives to take action and

influence thc delivery ofnormal birth care arc addressed

in the Iargcr study

of' the Marxist phjlosopher Felix Weil (Brown & Jones,

2001). The main aim of the school was to stimulate the

development of radical dernocracies aimed at address-

ing social inequa!ity (Cohen, Manion, & rvlorrison, 2000;

Reason & Bradburx 2006), Habermas (1976) developed

the term critical theory to describe a secial philosophy;

which seeks to operate at a theorctical and practical level

(Crotty; 1998).

The rescarch inquiry fbcused on a group of dini-

cal midwives, midwifery coordinators, and managers

working in a UK hospital. 1'hc chosen unit had 3,600

births a year and was situated within a busy district gen-

cra! hospital in central England. All clinlcal midwives

rotated every 6 months betsveen the labor, postnataL

an(l antenatal wards, For this reason, all unit midwives

were invited to take part in the study (118 midwives).

METHODS

Clinical midwives were invited to take part in focus

groups, whereas labor ward coordinators (expcrienced

inidwives who were in charge of the day-to-day run-

ning of the ward area) and mangers (usually nonclinical

midwives who were responsible for monitoring and

implementing unit policies) were invited to take part

in face-to-facc intcrviews. These methods were chosen

because they support reflection and social interaction

within groups (Cohen et al., 2000), Senior midwives

and clinical midwives were interviewed separatety to

allow individuals to express opinions within a safe envi-

ronment (Krueger, 2000). Intervicws and focus groups

were conducted in a private room away from thc clini-

cal area, at the end or beginning of the working day An

interview and focus group gutde (discussion topics and

prompts for the interviewer) was used (Kruegcr, 2000)

to maintain focus and elicit participants' everyday expe-

riences of water birth practice.

L

METHODOLOGY ETHICAL CONSIDERATIONS

Action research has become a popular method for intro-

ducing change in health care practice (Hart & Bond,

1995; Hope, 1998) but has been criticized for failing

to recognize inequalities, which constrain individual

agency (Badgeg 2000; Williamson & Prosser, 2002). For

these reasons, critical theory was chosen to underpin the

research methodology: Critical theory is synonymous

with the Frankfurt School, which began in 1924 as the

German Institute forSocial Research under the direction

Bartunek and I.ouis (1996) rccomrnend that action

researchersidentifyhowpreexistingrelationshipsorinter-

ests may affect the research process (Herr & Anderson,

2005), I have been a midivifery lecturer at the local uni-

versity since thc year 2000. AJthough I was known to the

inidwives in the unit, I had not worked closely with them

as an educator or midwife becauseI was alink tutor fbr

community midwifer}r tearns. 'Ib ensure that midivives

participation was completely voluntarM I posted and

54 Struggling to Get lnto the Poo[ RoomlA Critica[ Discourse Ana[ysis of 1.nbor Ward Midwives' ExT)c-wiences of Water Birth Russell

e-mailed invitation letters along with a participants"

information sheet, consent form, reply slip, and a stamped

addressed cnvelope to all unit midwives. written consent

was sought individualy prior to interviews/focus groups,

and participants were informed that they could withdraw

this consent at any time, Anonymity was insured by

removing any identifying characteristics during tran-

scription and by storing all ofthe data on a secured, pass-

word-protected computer, Ethical approval was granted

by the rcgional NHS Ethics Committee and the Hospital

Tlrusts' Rcscarch and Development Unlt prior to com-

mencemcnt of the studv Following the interviews and

focus groups, transcripts were sent to thc participants for

validation and comment.

over an 8-month period. Despite sending individua

letters and e-mails to all midwives concerned and adver-

tising the study via unit meetings and posters, only e

small number of participants volunteered to take part

This may have been caused by the lack of intcrest in thc

research topic or difficulties accessing the fbcus groupE

during work time. However, the quality ef the data gen-

erated during the focus groups and intervicws meani

that data saturation was achieved,

ACTUAL TYPES OF MIDWIFERY PRACTICE

Medical intervention and high-risk care took priorit〉r ortheday-to-dayrunningofthelaborward,Thismeantthal

the care ofwomen in normal labor was marginalized.

DATA ANALYSIS

Critical discourse analysis (CDA) differs from other types

ofdiscoursc analysis in that it is concerned with the iden-

tification ofdiscursive practices and ideological assump-

tions hidden in written or spoken specch (Fairclough,

1989). It is important to note that in CDA, the term

discourse is used to describe the language and actions

(practicc) ofa particular social greup (Fairclough, 1989).

Data analysis oftext takes placc in two separate stages:

. Structural analysis aims to specify the social struc-

turing or order ofa particular group through the

identification ofcommon sense assumptions about

everyday activities,

. Interactionai analysis allews for a social analysis

of interaction by focusing on the identification

of cultural norms, values, and social identities

(Fairclough, 2001).

SeniorMidwde: Ybu have four inductions of labor

every day ...you have three rooms occupied purely

with inductions, high-risk women normally , . . So

you've got a heck ofa lot before you even begin airy

Iow risk . , . you have left-over inductions from the

night before who'll be on syntocinon and haye an

epidural-they need one-to-one care without a doubt

. . . so your al)thty to give care to women coming in

spontaneously is already set . . . {:Iitterview)

High workloads made it dicacult for practitieners

to provide one-to-one care for women in ]abor and

offer alternatives to standardizecl midwifery care. I'Nlatei

birth was viewed as more labor intensiye and, therefore,

more likely to intcrfere with the smooth running ofthe

labor ward.

'I'hese stages of analysis lead to actual practices,

the social Drdcring of the discourse, and obstacles to

differcnt types ofpractice being identified. The analyst

is then asked to critically reflect on these preliminary

findings in relation to dominant group interests and to

find ways past the obstacles (Fairclough. 2001).

RESUUS

The author conducted a total of five unstructured

interviews (35-60 rninutes) with labor ward matrons,

a consultant midwife, labor ward manager and clinical

practice facilitato4 together with three focus groups

(40-60 minutes; 11 midwives) with cLinical midwives

Midwijle 3; I think when you've got somebody in the

pool, you've got the luxury ofstaying in the room

with them, which you wouldn't necessarily . . , you

kno}" if they're on the monitor, you have to stay in

the room , . . if they weren]t in the pool, you'd be

doing other things as well, but generallM when you've

got somebody in the pool, you stay in ther[el,

intervievver: Is that a problem?

Midwijle 3: Staying in there? No, It's not a problem

for the midwife, but it might be for the ward.

(Focus Group)

Labor ward coordinators played a central rolc in

controlling midwifery-lcd care. All participants described

L

Struggling to Get lnto the Pool ]〈oomlA Critica] Discourse Analysis of r.abor Ward Midwives' Experiences of Water Birth Russetl 55

'

how some coordinators would "block" the use of the

pool room by saying r'no" to requests from midivives and

women, putting high-rjsk women in the pool room and,

in one extreme case, writing a `Cbogus name" on the labor

progressboard.

, Midwijle 4: The one thing that used to be very

frustrating was, because of thc situation of the pool

room, if you run out of side rooms, they would use

, the pool room as the ncxt one for an induction of

l. Iabororsomebodycomingin,APH,PPH.

interviewer: So that would block the room?

' Miclintijle 4: Yes, and that was Lised on the premise

that, well, it's nearest t]]e desk if we'rc needed, so

that used to be very, vcry, very frustrating, and then

somebody would be in the room, so if somebody had

wanted to use it, that was taken away from them , . ,

Midwijle 6: There are a few senior midwives on

here that-you know-you say water birth and they

take a deep breath and say, "NoI)'.,.I think they

(women) are often .persuaded for various reasons

l not to use the pool or a bogus person gets written

up on the pool room on the beard so you can't use

the room ,.. (Fbcus group)

time consuming than other types of practice, A rnajor

concern among participants was how they might manage

obstetric emergencies in waten

Midwijli 1O: Ybu sort of end up 1ike kneeling on the

floor, so you end up having to put a pdiow down

because your knees hurt and your sort of reaching

over-you ktiow-you've got to try and listen in to

auscultate with a water-proof sonic aid. Ies ab a little

bit awkward; you end up geuing wet ...because your

arms are in the water and you get redly wet, So, that

might put midwivcs off actually

Midwijb 8: And if thefve got a bad back-it's

that leaning over into the pool on this unit ...

(Fbcusgroup)

SeniorMidivijle: I have worked ivith pools that have

been much, much better for the woman, and much

better fbr us to use than this one.,,if there ls aprob-

Iem, 1 thiiik it would be hard to attend to an emer-

gency in the pool ...it can be very traumatic for the

woman nnd for the midwives who have been looking

after her; so, you knowl I'PH' s [postpartum hemor-

rhagcs], collapses, I've seen stillbirths, I've seen al of ,

the sorts of horrcndous things in the water: (1}tterview)

Staying in the pool room with Iaboring women

for long periods was vicwed as `Cselfisrr' by some hos-

pital midwives. Others felt that being able to stay with

laboring women for long periods was a "luxury" rather

than the norm,

Midivijle J: [rb bc fair, it is doNvn to who the midwife

is, because one of the reasons why some of them

clearl}t do not 1ike watcr births is because you have to

listen in regular1}r and you have to be in the room . . ,

which is fine, I have no quaims about it, but some

l. midwives lilce to stay in their room all night, abso-

lutely fine, but that doesn't help management of the

ward-kay? Aiid then you get the other midwife

who is quite happy to sit on desk and pop in and do

their little bit when it's necessarB se they're the ones

who don't like watcr births . . . (R)cus Group)

Participants felt that most labor ward midwives

lackedthenecessaryskjllstDt'acilitatewaterbirthbecause

of limited opportunities to witness or learn about this

type of practice, This may explain why many midwives

feltthatcaringforwomeninwaterwasdifficultandmore

THE ORDER OF THE WMER BI RTH DISCOURSE

Tb identit'y how hospital midwifery care was organized

and prioritized within the maternity unit, data analysis

fbcusedontheidentificationoftherules,whichgoverned

midwifery practice, social interactions, and midwives

social identities.

THE nRULES" OF HOSPITAL MIDWIFERY CARE

Data analysis led to the identification of socially con-

structcd "rules;' which governed the types of hospital

midwifery practicc. The "labor ward rules" not only

restrictedmidwives'waterbirthpractice,butalsoencour-

aged them to offer standardized care (see fable 1).

Sociat lnteractions

Interactions With iVbmen During Childbirth

In general, clinical midwives did not discuss the use of

water as one of the birth options and, 〉ret, believed thatall women had the right to make choices about the care

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56 Struggling to Get [nte the Poel Room? A CriLical DisceurseAnalvsis of Labor Ward Midwives' Expcricnces of Water Birth Russetl

TABLE 1 Rules ofHospital NVater Birth Care

Must care for more than one Iabori ng woman at a time and

be active[y engaged in care.

Coordinators can overru]e requests (from women and '

midwives) to use the birthing pools.

Must put roam working and the needs of most women ffrst,

Cannot [eave laboring women a]one in a bi rthing pool, but

can [eave women receiving otheF types of care unattended,

Are allowed to "opt out" of water birth provision, but must

be ski"ed in aH other aspects of standard care.

Must be able to care for high- and [ow-risk women.

they received, 1'he small number of requests and the

low water-birth rate were used as evidence by some

midwives that childbearing womcn no longer wanted

this typc ofcare. Therefbre, women who requested water

birth wcrc more likely to be supported in their choice

than thosc who did not request this type of care.

Midwijb 1; It's likealot of things,Ithink, it (water

birth) goes in phases ,,,

Midivijii 3: You don't get many people asking for

them, I den't think . . . It (ssTater birth) only happens

if the micLwife suggests it . . . or they've had a previous'

waterbirt]i.

(iabor ward) is sometimes really busy and there's I

[a] lot of people expected to come in-quitc oftcn ,

they (coordinator) saF "No, no:' (1iocus Group)

Midwijle 2: But it's not always the staff that, the

quantity of staff; either is it, it's sometimes the staff

in charge that can, not saying you can't do it even if

you want to ,.,

Mid}i,ife 3: They (coordinator) can swing it, can't

they...

Midwijb 2: Yes, because yeu get the vibes, don't

you? And you know thc person probably woutdn't

be keen. (Fbcus Group)

Midwives'Socialldetitity

Social identities are comprised of selfvalue and trust

in one's own abilities and l〈nowledge at a personal andgroup (institutional) level (}-Iollins Martin & BuL], 2005,

2006). The characteristics associated with hospital mid-

wives' social identity are summarized as follows:

A busy, hard-working individual who runs from room

to room, actively involved in the doing, and com-

pleting tasks,

/

1

-

Midwijb l; Ybs. NOt many people come in and say; "Is

the pool free?" 1ike they used to ..,in the past they used

to ring up and saB "I"m coming in, is the pool free?" I

donit think they do that anymore , . . it's not the same,

Midwijle 4: But then it's a difft:rent gencration, per-

, haps, coming through now, (Fbcus Groirp)

Clinical Midwives Irtteractions Witli

CoordinatorsLManagers

Most of thc particip ants agreed that thc coordinators were

responsible for managing the workload. It was generally

accepted that the coordtnators had the authority to over-

ride midwives' and women's requesLs for water bitth if the

unit was busy. Midwives didn't challenge these decisions,

even ifthey didn't agree with the coordinaton because of

concerns about making their jobs more stressfu1.

Midwifb 4: If you've gotsomebody that wants to

go in the pool, sometimes you might get a little bit

of negative input from the G grade (coordinator)

because they aren't thaFyou knuw keenHlelivery

Mithvijle 1: Because if you're in a unit that has a lot

ofaugmentation and things, and a busy unit, that

〉,ou're hands on the majority of the time, to actuallysit there with your hands behind your back . . . it]s

a different situation, isn't it? A lot of the rnidwives

do, sort og think of themselves as obstetric nurscs,

rather than midwives. (liocus GrouR)

SeniorMldvvijle: But we just haven't got the time to

offer water birth to everyone-I mean, they're run-

ningaround Iike hcadlcss chickens half the timc ...

antervieioj

A team player who is loyal to the tearn leader (coordinator)

and the needs of thc institution,

'

Midii,ijb Z If the ward's busy3 they know that

if that midwife goes in that room, (pool room)

they've lost her ,.. She doesn't come out again, so

that;s taken a member of staff away, whereas if we've

got somebody on a bed with an epidural and a CTG

(fetal monitor), you can come out occasionally and

admit somebody clse. (Fbc"s Grotrp)

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StruggLing to Get lnto lhe PooL Room? A Critlca[ Discou[seAnaLysis of Labor Ward Midwives' Experienccs of Water Bi[th Russelt 57

11

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, Midii,ij2i3: I thidik, when I was a student, Ijust

thought about rne and the woman; now, as a quali-

fiecl midsvife, I thinlc about my colleagues, and I

think about the safety ofother woinen on the unit,

so if there are ... if therc's only onc midwife fo[

three women, I wM spread n",self between the tlrree

women and try and keep everyone on the unit safe

that was and support my colleagucs. (}loctds Grotrp)

A caring person who wants to do the best for women in her

carc, and who believed in normal childbirth and choicc.

Midwijle IO: 1t's always qLiite disappointing for me,

because a lot of the time, when womcn ask to use the

pool, I hexTe to say"no;' ancL I think that's such a shame.

Therc's so much pressure oTi resources, and there'1l be

somebody in the room who isn't in the pool, perhaps,

Midwijb 11; Wlien I worked in DAU (Da)rAsscss-

ment Unit) 6 wccks ago, J had a lady come in, and she

said, `"I'cl lilce to have a water birth, how do I book it:t"

And [ said, "I'm terribly sorryl you can't book a water

birth, its pot-luck"...I felt awfu1 ... (R)cus Grot{tij

1[leam working was central to midwivcs' social

identitF because working as a unit was viewed as a more

productive way of getting through the work and caring

fortheneedsofmostlaboringwomen.Wordslike"busF""hardworking;' and "running" were found frequently in

the data. This suggests that hospital midwivcs' social

identities were consistent with task-orientated carc,

rather than women-centered midwifery practice.

OBSTACLES TO HOSPIIIAL WMER BIRTH

Obstacles to the proviston and availability of water

birth on the unit were identified from the network of

practices evident in the transcribed texts, The obstacles

to water birth practice were arrangcd at organizational.

individual, and consumer level to highlight the hierar-

chical nature of the barriers to this type ofpractice and

to assist in the identification ofsolutions (see Table 2).

DISCUSSION

The labor ward discourse portrayed the provision of

water birth as an alternative to mainstream rnidwifery

TABLE2 SummaryoftheObstaclestoHospital Wltter Birth Practice

ORGANIZATtONALLEVEL

Midwives' negative attitudes to wate[ birth

Fda rs around coping with emergencies in the pool

Water birth not offered as a choice!]a[k of awareness

Cannotofferone-on-onecare Lack of ski]Is and experience of water birth

/1.. ...lt.. .././ltt. . ...lt. . ... t/.//. . . .t.t. INDIVIDUAL LEVEL

Lad〈 of encouragementand support from the coordinators Unavailabi[ity of the pool room

No incentive to offer yL,ater birth as a rea] choice to women

Water birth "has gone out of fashion"-women no longer

wantthistypeofcare

f '':"' ''･ll-,･ ...1//. . ...,. 1 CONSUMER LEVEL

Women do not ask foi a water birth

Women do not want wa ter birth

practice, Participants believed in principle that the

midwives' role was concerned with promoting normal

birth and s"pporting women's birth choices, but in

reality, midwives' everyday practice focused en `C getting

through the work" as efficiently as possible (}Iunt

& Symonds, 1995). Consequentl" hospital midwives'

social identities were consistent with task-orientated

practitioners rather than autonomous midwifery prac-

tice. Fear ofwhat might go wreng when wornen labored

or gave birth in water was cornmon among participants,

They were particularly anxious about being unab]e to

help women out of the birthing pool if she collapsed

or ifa fetus is compromised. AII of which led to a

belief that wornen who used the birthing pool cou!d

not be left unattended. Irrational beliefs ernanate from

practitioners' previous experienccs of labor and birth

(Grcipp, 1992). Stark and Miller (2009) found that

practitioners who had Iimited experience of water

birth practicc were more likely to create belief systems

around the dangers of water birth. CIuett, Nikodem,

rvlcCandlish, and Burns (2009) also found institutional

settings prevented access to water on safety grounds

despite conclusive evidence to the contrary being

available, Recognizable belief systems place limits on

people's ideas and behaviors because they help define

what is right and what is wrong, what is normal and

what is not (deviant); and, by doing so, make alternative

opinions or actions to those previously defi ned absurd

(Foucault, 1977). For example, it was acceptable to ofR)r

an "ad hoc" water birth service, but epidurals had to be

available 24 hours a day

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58 Struggling to Get tnto tho Pool Room? A Critical Discourse Analysis of Labor WHrd Midwives' Experiences of Water Birth Russell

The social ordering of hospital midwifery prac-

tice meant that water births were not promoted or

encouraged as a part of everyday midwife-led care,

This led to the acccpted midwifery view that water

births are an unpopLilar, unnecessary; difficult, time-

consuming, and potentially dangerous type of care,

Midwives' everyday practices were dominated by the

needs ofhigh-rislc care, and, therefore, a medical view

of birth was accepted as ccntral to hospital midwives'

role (Davis-Floyd, 1992). Most midwives were unfa-

miliar with the sl〈ills of "watching and waiting" tofacilitate physiological birth, leading some practitio-

ners to be fearfut ofundertaking Water births. Hospital

midwifery carc scrvcd the interests of the status quo

where selflprescrvation, collective decision making,

the promotlon of bed birth, pharmacological analge-

sia, and anesthesia were considered part of normal

midwifery practice, Midwives' sphere of autonomous

practice was dependent on the amount ofpower given

by the coordinators and the degree to which individu-

als fbllowed the labor ward rules,

The coordinators were viewed as authority figures,

responsible for controlling the day-to-day running of

labor ward and thc allocation of work, Green (2005)

found that coordinators ensured adherence to expected

norms, such as tbur hourly vaginal examinations, by

seeking out and challcnging midwives who didn't con-

form to expected mcdical protocols, Midwives accepted

that coordinators could prevent them using the birthing

pooL Acceptance of this Lype of behavior legitimizes

the actions ofauthority figures (Miligram, 1974), giving

them a mandate to control the actions of the less pow-

erful (Fairclough, I989). This fbrm of power is known

as hagemony (Gramsci, 1971). Hegemony is a form of

power, which opcrates through acceptance b〉r a socialgroup of a particular ideology. This type ofpower also

includesnotionsof"moralandphilosophicalleadershii'

(Bocock, 1986, p, 11), achieved through the manufac-

ture of consent by authority figures (Fairclough, 1989),

The presence of t`powerfu1 situational fbrces" (Hollins

Martin, & Bull, 200S, 2006) cnsures that behaviors,

which adversely affect thc smooth running of the ward,

were controlled (e.g., going against the coordinators'

decision to use the birthing I)ool may lead to confronta-

tion and an incrcasc in workload fbr other members of

the team). Dcviant acts like these introduce uncertainty

to the relationship between the midwife and coordinator

(Hollins Martin, & Bull, 2008), and may leave individu-

als in fear ofsocial exclusion (Kirkham, 1999),

Institutional practices, such as "blocking" the

pool and not promoting water birth with women on

admission, restricted access to the birthing poo]. Red

wood (1999) argues that institutional control of wate

birth is used by authority figures "to allow ft)r th

expression of a measure of unrest without disturbin

the prcsent unequal power relationships." Howeve r, hos

pital midwives valued choice for childbearing wome/

and belicvcd in their role as practitioners of norme

birth. It is also clear that clinical midwiyes and manag

crs recognized that the low rate of water birth on th

unit was a problem and wanted to take steps to improv

currcnt provision. Participants suggested the followin/

ways past the obstacles to water birth practice withi]

the unit:

.

.

.

Organize water birth worksheps for all midwives

with thc aim of improving midwives' knowledge,

skills, ancl confidence.

Appoint a water birth midwife coordinator to

support individual midwives, disseminate good

practice, and raise awareness of the benefits of this

typeofcare.

Improve pregnant women's knowledge of this type ot

care by previding infbrmation (DVD) at booking an`

offering antenatal water birth classes on labor ward.

CONCLUSION

Water birth enhances the physiology of childbirt}

and promotes midwifery practice in normalitM Ye

it is known to be underused in UK hospital-base(

maternity units (Royal College of Obstetricians an(

Gynaecologists [RCOG]IRoyal College of Midwive

[RCMI, 2006). The key obstacles to water birth in thi

settingwerecoordinators' priorities,midwives'ncgativ･

attitudes, high workloads, and lack of institutional sup

port for this type ofcare. This suggests that promotio]

of hospital water birth is dependent not only on avail

ability of equipment and midwifery knowledge, bu

also on thc philosophy of care adopted by the organi

zation (Stark & MilleB 2009). Cluett, Pickering, Getlic

and Saunders (2004, p. 6) agree, stating that water birtl

is a C`packagc, which includes not only the actua] watei

but also the environment in which it is offered, and thi

interactions of the women and the caregiver." There

fbre, ways of addressing the obstacles to the practic/

of water birth in the un!t are only likely to succee(

if innovatiDns are supported by midwifery managers

championed by coordinators, and led by labor wart

practttioners.

:

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Strugg[ing to Get 1nt{} the Pool Room? A Crltica[ Discourse Analysis of Labor Wu[cJ Midwives' Experiences of Water Birth Russe" 59

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Correspondence rcgarding this article should be directcd t,

Kim Russe]1, MA, BSc(Hons), RM, RGN, Institute of Health E

Society,TheDepartmentofAlliedHealthSciences,Universit

of Worcester, Henwick Grove, IVorcester, LVR2 6AJ, UK.

Kim Russell, MA, BSc(Hons), RM, RGN, senior lecturer

Midwifery & Wornen's Health, Institute ofHealth & Society,

The Dcpartment efAIIied Health Sciences, Universit}r of

Miorccster, UI(.

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The Necessity and Challenge

Midwifery Science

of International

Raymond G. De V}'ies, Marianne Nieurvenhuijze, Rcijbet van

and the members ofthe Midwijbry Science Workgroup¥

Crimpen,

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What is the best way to provide care during the repro-

ductive process? What have we learncd from centuries

of experiencc and from the application of the tools of

science to thc practice Qf maternity care? Those who

consult the history and science of maternity care wil1

discover that the answers to these straightforward ques-

tions are anything but straightforward. Reading the

history ofmaternity care can be quite cenfusing. There

are histories that celebrate medical progress in reduc-

ing maternal and infant mortality (O'Dowd & Philipp,

2000), and there are histories that describc benighted

doctors unwi]]ing to wash their germ-laden hands

before attending women in birth (Nuland, 2004), There

are historles that document how professional societies

of obstetricians improved care for women (Peel, 1976),

and histories that show how those same societies limited

care to women by oppressing midwives (De Brouwere,

2007). The rcadcr ofthese histories will be awed by the

knowledge and skitl that improved care for women and

babies in distress but baffled by thc many interventions

intended to make birth "easier"-C[ prophylactic forceps;'

"trvilight sleep;' routine use of episiotomy-that were

introduced, widely used, and then discarded when

fbund unsafe and unhelpfu1 (Wertz & Wertz, 1989).

Reading the scientific literature on maternity care is

even more disorienting. Not only will the reader discever

that there are great differences in the way maternity care

is done-in ditft)rent countries and in difl'erent regions of

the same country-but also wM be puzzled by apparent

contradictions in conclusions about the safety and ethcacy

of those practices. Within the past yeaB for example, the

peer-reviewed litcrature has shown that planned home

birth is as safe as planned hospital birth (de Jonge et al.,

" Marlein Ausems, I,uc Bude, Darie Daemers, Marijke Hendrix,

Irene Korstjcns, Evelien van Lirnbeek, Hennie Wljnen, and

Bert Zeegers

20e9; Janssen et al., 2009), and that planned homc birth,

when compared to hospital birth, "is associated with a tri-

pling of the neonatal mortality rate" (Wax et al., 201O).

Of course, experienced readers of history and sci-

encc are aware that variations and contradictions in the

literature are not uncomrnon. Histories vary according to

who is doing the writing: Conquerors and the conquered

tcll very different storics about the same war, In science,

progress is made by thc process of assertion and refttta-

tion: Today's findings are tomorrow's discarded theories.

But there is something peculiar about the science

of birth, Obstetrics is the only discipline in medicine

where something happens by itself and, in most cases,

wtth no intervention, everything ends well. This allows

maternity care to become a canvas onto which mid-

wivcs, obstetricians, gencral practitioners, researchers,

and pregnant women can paint their own versions of

the "best care." Thus, in the United States, one-third of

alt births are done surgically and fewer than 1% of births

happen at home, whereas in thc Netherlands, more than

259'o of women birth their babies at home and 14% of

births are accomplished surgically (Centraal Bureau

voor de Statistiek, 2007; Menacker & Hamilton, 2010).

The late Dutch obstetrician Gerritt-Jan Kloosterman,

reacting to the strong rcsistance to his effbrts to cham-

pion midwifery and home birth, suggested that a science

ofmaternity care may be impossible.

Obstetrics is wider and broader than pure medicine.

It has to do ivith the whole oflife, the way you look at

life, makng objective discussion dicacult. Ybu are almost

unable to split the problem off into pure science; always

your outlook on life is involvcd. (De Viries, 2005, p. I80)

Kloosterman calls attention to the way our cultural

belicfs about birth and thc pcrspective we acquire as

professional caregivers and researchers create a bias that

distorts scientific studies of materni"r care. This fact

rnakes it ver〉r difficult to identify best practices forbirth,

INIEF?NATIOALAL JOURAML OF CHtLDBIR'IH Vbl"me 1, tssue 1, 20VI @ 2011 Springer Publlshing Company, LLC www.springerpub,com DOI:10.1891/2t56-5287.1.1.61

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62 The Necessity and C/hnllenge ef 1nternational Midvvifery Science De 1firies et at.

How should we caregiyers and researchers respond

to the peculiari ty ofbirthcare with its conflicting histories,

contrar〉r findings, and built-in bias? -Ve could give up-itseems an objective science ofmaternity care is impossible,

so why bother? Mle could become partisans-choose a

point of view on what is the best birth and set out to prove

we are right. Or wc could build a new science of maternity

care-midwijiirly science-that capitalizes on the history of

midwifery and thc variations in maternity care to develop

a research agenda that prometes optimal care for women

and babies, care that takes into account their plrysical con-

dition and their culturaL and social situations.

WHY MIDWtFERY SCIENCEI

W}ryisrnidwiferyscicncethebestresponsetothepeculiar

problems that beset rescarch on maternity care practices?

Some researchers will arguc that a better, more expansive

obstetric sciencc should take on this task, The preference

for midwifer〉r over obstetric science lies in the differencebetsveen the tsvo approaches to materni"r care,

Histories of maternLty care-as varied as they

are-teach us two things: (1) Much progress has been

made in responding to thc complications of birth;

arid (2) interventions that alter uncotmplicated birth to

improve the process havc bccn largely unsuccessfu1,

Members of the obstetric specialty-dedicated to find-

ing ways to reduce the morbidity and mortality associ-

atedwithchildbirth-haverightlyfocusedonpathology

Midwifery begins with a fi.)cus on " physiologs" the bio-

logical and s6cial features ofundisturbed and uncompli-

cated reproduction, birth, and postpartum,

The division of labor in materni"r care should

reflect the fact that most births proceed ivithout compli-

cation, The governing science of maternity care should

focus on the factors that promote (and hinder) physiologi-

cal birth and on the early recognition of the indicators of

pathology that require specialist care, These are precisel〉rthe features of midwifery science. The goal of midwifery

science is to discover and develop basic and applied

knowledge about the dynamics of reproduction and child-

birth. Basic research-the creation and testing of tlieories

that promote greater understanding of the pbysiological

reproductive proccss-provides the basis for the develop-

ment of innovations in practicc. Applied research exam-

ines current and innovative practices, allowing quality

improvement and ensuring proper care fbr motheB child,

and fhriiilv Research in midwifery science examines:

. Factors that promete health in the short and Iong term;

. Methods for equipping the transition process to

parenthood;

. The organization of obstetric care; and

. The sociaL production ofboth scientific and Iay

knowlec{ge about maternity care, including aspects

of medicai and popular culture that encourage and

discourage physiological birth.

'1'hose who do midwifery science use theories and

methods developed in various disciplines, including mid-

wifer" public health, obstetrics, gynecolog〉l neonatolog"genetics, embryology anatornF (patho)physiology; medi-

cine, cthics, psychology sexology; sociolog}s information

sciencc, and organizational science.

Noticctwoimportantdiffiorencesbetweenmidwkry

science and obstetric science: (1) Because of its f[)cus on

physiological birth, midsvifery science is concerned with

enriching our understandmg of the process ef pregnancy

and birth experienced by the mcijoritl, ofwomen; and (2) the

interdiscipltnary approach ofmidivifery science extends tts

work beyond the bocly of the birthing woman to the birth-

ing woman herscLfl The interest of midwifery science in the

contexts In which birth occurs leads to an appreciation of

the situated naturc of knowledge about reproduction and

birth. 'lhc cxpectations of clients and their interpretations

of rcality-and noL just the signs measured by the techiiolo-

gies ofmedicine-arc taken seriously in research.

Progrcss in maternity care requires research in both

pathological and physiological birth, but the "first science"

of maternity carc should be midwifery science. Promo-

tion of thc bcst care for al1 must begin with a science that

considers the social and psychological situation of women

and famMes tmd examines how culture and societal struc-

tures infiuencc reproduction, the delivery of care and, Iast

but not least, the production and use of data on maternit〉rcare. ' I'here is an interesting historical irony here. Care at

birth was once the sole domain of midivives, But becausc

of denied access to advances in obstetric science and thc

new tcchnologies ofbimh, midwives concerned themsclves

with physiologicaL birth. Obstetricians gradualy took over

the management of pathological binh, whereas midwives

gained expertise on uncomplicated birth, expertise that

is dcsperately needed to improve care where medical

resources are scarcc, atid to lmit umecessary interventions

where mcdical resources are overused (Betrdn et al., 2007).

WHY INTERNMIONAL?

. The physiological reproductive process;

. Factors-bio]ogical, psychological, and social-that

promote the physiological process;

Our description ofmidwifery science hints at the neces-

sity ofan international midwifery science, Care practices

fbt' birth vary widel〉f around the globe. This fact offers us

The Necessity and Challcnge of [nLernalional Midwifery Science De V7ies et al. 63

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a laboratory fbr studying the sources and consequences

of diversity in maternity care and provides a unique

position fbr informed critiquc Dfbirthcare. The science

of obstetrics has madc significant progress by studying

and treating the pathologies of birth without regard for

the social and cultural caTitext of the birthing woman.

This strategy has been successfuL in developing therapies

to intervene in problem births, but it does not promote

critical reflection on `Cprogress" in inaternity care (which

often means the extension oftherapies for pathology and

irrvasive preventive survcillance to healthy women).

Midwiferysciencccxplorestheconnectionsbetween

culture, birth practiccs, and oLttcomes of birth, generating

data that can reveal problems with the medical "improve-

mene' ofbinh. An intemationaL focus and respect for var-

ied approaches to attending birth creates opportunities for

maternity caregivers to learnJ}'om each other and to learn

ivith each other, Thjs ensures that mid}vifery research and

its results are accessible to othcrs arid, hence, can be used to

stimulate reflection on rnidwifery models, the organization

ofcare, and the pros and cons ofobstetric intervention,

The international orientation of midwifery science

allows a rich understanding of how physiological birth

is shaped by the many ways societics organize care for

birthing women, Efforts to promote optimal care at birth

must proceed with a clear sense of how organizational

systems and cultural ideas ar¢ implicated in birthcare.For example, the varied divisions ot' Iabor in maternity

care-including differing scopes of caregiver practice and

different ratios of midwives to gynccologists and obste-

tricians-are associated with the kind of care offered to

birthing women, And cultural notions about birth shape

the desires and choices of women in birthcare and the

content and results ofscicntific studies ofbirth (De Vlries,

Kane Lou; & Bogdan-I,ovis, 2008).

A second challengc is the organizational and cul-

tural dominance of obstetric science, Obstetric science

has gained powcr and prestige by virtue of its claim

to objective science and its embrace of technological

solutions to the problems of birth, In modern societies,

the empirical knowledge of rnidwives, often gleaned

from cxperience, is not highly valued. IIb gain respect

in contemporary societp midwifery knowledge must

be validaled by science. Effbrts to create midwifery sci-

ence, coming Iater te the disciplines of medical science,

often seem to be "obstetrics light;' a pale imitation ofthe

hard science of obstetricians, beholden to the quantita-

tive, positivist methods of medicine (Black, 1996). This

makes the reccipt of funding and public respect morc

diMcult.

'L'he incrcasing use of technology in all aspects of

our lives presents a third challenge to midwifery science.

IIlechnology surrounds us and promises to make our

lives easier-we have come to depend on computers, the

Internet `Csmart" phones, and global positioning devices.

The presence and friendliness of these technologies make

it more difficult to convince women, the public, and

fimders of research that less technological approachcs

to birth may bc prcf'crable. Furthermore, public apprc-

ciatlon of tcchnology lcads to public acceptance ofinter-

ventive, instead of watchful, medicine. It is no longer

enough for carcgivers to wait until a symptom emergcs

before rcsponding. In today's world, we expect preemp-

tive intcrvention: We want the problem to be discovered

bojbre it is a problcm. And although this approach to

health care can be harmftil-most recentl$ we learned of

thehealthdangersofearlyscreeningforbreastcancer-it

is the current model of medicine and stands as a chal-

lenge to the more watchfu1 approach of mid"dfery and

midwiferyscience.

/ THE CHALLENGE(S) OF MIDWIFERY SCIENCECONCLUSION

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There is something seductivc about an obstetric sci-

ence that looks solely on the bodily mechanics of birth.

After all, a human uLerus in Marrakesh is identical to a

human uterus in Manhattan. It is much more compli-

cated to build a sciencc around the recognition that a

uterus is part of a thinking, feeling woman's body that

lives together with others in communities that shape the

experience and mcaning of reproduction and the type

and quality of care during pregnancy and birth. This is

the first among the several challenges of midwifery sci-

ence: Understanding thc man〉r birth practices aroundthe world, situating them in their cultural and orga-

nizational environment, and assessing the quality and

transferabili"r of those practices,

The problcms of maternity care in today's world-too

much unnecessary intervention in birth in many high

resource countries and too little needed intervention

in the countries of the global south-reguire a sci-

ence that does more than study pathology: Midwifery

science with its historical, social, cultural, and clinical

focus ofli]rs a way forward for the improvement of

birthing care for women in all societies. This will neces-

sarily involve morc informed midwifery practices, an

improved divisiDn of labor betsveen those who provide

maternity care (in terms of numbers and responsi-

bilities), and better cooperatien betsveen midwives and

obstetricianfgynccologists.

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64 The Necessity and Cha[ienge of lnternational Midwifery Science De Vries et al.

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De Vties, R. G. (2005), A pleasing birth: Midwijlery and matett-

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United Kingdom: Cambridge University Press.

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& Lee, S. K, (2009). Outcomes of planned home birth

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with midwife or physician. Canadian Adedical Associa-

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Menacken E, & Hamilton, B. E. (2elO). Recent trends in

cesarean delivery in the United States. NCHS Data

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Nuland, S. B, (2004). Ilhe doctors' plague: Germs, childbed

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A,, & Blackstone, J. (2010). Maternal and newborn

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Correspondence regarding this article should be directed to

Raymond G, De Vicies, University ofMichigan Medical School,

CA 92126. E-mail: rdevries@umich.edu

Raymond G. De Vlries, Marianne Nieuwenhuijze, and

Rafael van Crimpen, Midwifery Science Wdrkgroup,

Academie Verloskunde Maastricht, the Netherlands.

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AuthorGuidelines

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The lhternational Jburnal of Childbirth is a quarterlM peer-reviewed publication with a global fbcus on childbearing,

The journal invites the subrnrssion ofrnanuscripts that address research, practice, educatiQn, and theory as well as case

reports, personal narratives, and commentaries on all aspects of childbirth.

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The fo11owing presentation style should be observed when submitting manuscripts:

/

. Clinical and Basic Science Research articles should include an Abstract, Introduction, Material and Methods,

Case History (if appltcable), Results, Discussion, Conclusion, and References.

. Review articles should provide a comprchensive synthesis of the availablc information on their chosen topic.

They must include headings and reference citations.

. Case Reports should be brief reviews ef either typical or atypical births and should include an Abstract,

Introduction, Case Report data and findings, Discussien, Conclusion, and References,

. Personal Narratives should first-hand accounts of childbirth experiences. References are not required but may be

included when needed to support data or quotatiens from published sources.

ManuscriptPreparation

The manuscripts should be prepared in accordance with the Publication Manual of the American Psycholqgical

Association, which should be consulted for matter ofstyle and fbrmatting, including text, references, and tables.

Length. Submissions are generally expected to be 15 to 25 pages in length; however, the journal considers manuscripts

that are longer or shorter.

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Coyer Pagc. A cover page separate from the main manuscript must include the article's title and the names, academic

degrees, mailing addresses, and e-mail addresses of each of the contributing authors,

Abstract. Research articles. review articles, and case report$ should include an abstract of between 125 to 200 words

that concisely states the article's purpose, the stuc})r design, major findings, and rnain conclusion.

'

Summary. When an abstract is not appropriate for the type of article submitted, authors should include a summary of

between 12S to 200 words that provides a synopsis ef the article's thesis and conclusions,

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Appendices, Instruments or large tables of data may be included as an appendix to the manuscript, The publication

of appendices is at the discretion of the editors.

1Letters to the Editon Letters to the editor should be concise comrnents regarding anicles published in the journal and

may include references, Letters should be under 300 word$. Those accepted fbr publication may be edited or abridged.

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Photographs, Drawings, and Graphs. Illustrations should be submitted as individual, high resolutiQn images in jpg,

tiff; or eps graphics Me formats (graphs created in Excel are also acceptablc). Digital images should include the figure

number in the Me name. AdditionallM a copy of each illustration should be embedded at the end of the manuscript

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Submission

b Authors should submit manuscripts by e-mail to Denis.Whlsh@nottingham.ac.uk,

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The fo11owing dated agreement signed by all authors must accompany each manuscript submitted for publication:

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The undersigned author(s) transfers all copyright ownership of the arttcle entitled [insert the title of7our article]

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