Ans Luyben

Assessing the performance of maternity care in Europe: a critical exploration of tools and indicators

BackgroundThis paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or “normal birth”. The work formed part of COST Actions IS0907: “Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care” (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care.MethodsA structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions.ResultsA total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or “good” or positive outcomes more generally.ConclusionsThe tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures.

Exploring global recognition of quality midwifery education: Vision or fiction?

BACKGROUND Midwifery education is the foundation for preparing competent midwives to provide a high standard of safe, evidence-based care for women and their newborns. Global competencies and standards for midwifery education have been defined as benchmarks for establishing quality midwifery education and practice worldwide. However, wide variations in type and nature of midwifery education programs exist. AIM To explore and discuss the opportunities and challenges of a global quality assurance process as a strategy to promote quality midwifery education. DISCUSSION Accreditation and recognition as two examples of quality assurance processes in education are discussed. A global recognition process, with its opportunities and challenges, is explored from the perspective of four illustrative case studies from Ireland, Kosovo, Latin America and Bangladesh. The discussion highlights that the establishment of a global recognition process may assist in promoting quality of midwifery education programs world-wide, but cannot take the place of formal national accreditation. In addition, a recognition process will not be feasible for many institutions without additional resources, such as financial support or competent evaluators. In order to achieve quality midwifery education through a global recognition process the authors present 5 Essential Challenges for Quality Midwifery Education. CONCLUSION Quality midwifery education is vital for establishing a competent workforce, and improving maternal and newborn health. Defining a global recognition process could be instrumental in moving toward this goal, but dealing with the identified challenges will be essential.

The current state of midwifery and development of midwifery research in four European countries

OBJECTIVE to describe the current state of midwifery and explore the development of midwifery research during the last two decades in four non-English speaking European countries in order to understand what factors influenced the course of establishing research as a professional activity. DESIGN qualitative collective case study. SETTING Germany, Austria, Switzerland and the Netherlands. FINDINGS with the ICM Workshop in Germany in 1989 as a central starting point for midwifery research in all four countries, different courses, in timing as well as content, characterised its development in the individual countries. Major factors contributing to this development during the last decades involved the history and character of midwifery, initiatives of individual midwifery researchers, alliances with other professions and the transition of midwifery programmes into higher education. Whereas midwifery research is currently established as a professional role in all countries, future challenges involve the creation of its own profile and identity, while building up its own academic workforce and strengthening the role of midwifery in multidisciplinary alliances. KEY CONCLUSIONS AND IMPLICATIONS although a common vision was shared between the four countries in 1989, midwifery research developed as a context-specific phenomenon related to the character of midwifery and education in each country. These factors have to be taken into account in the further development of midwifery as an academic discipline at a national as well as at an international level.

Intrapartum fetal heart rate monitoring: do Swiss midwives implement evidence into practice?

OBJECTIVE Evidence Based Medicine has shown that the results of continuous electronic fetal heart rate (FHR) monitoring are equivalent to those of intermittent auscultation. We were interested in the method midwives preferred to use to monitor FHR during labour and the factors which influenced their choice of method. STUDY DESIGN A questionnaire with Likert scaled questions was sent to 500 German speaking Swiss midwives. Data analysis was performed by using SPSS for Windows. RESULTS The majority of the midwives were confident monitoring FHR using intermittent auscultation as their main method during low risk delivery. The essential factors influencing the choice of method of FHR monitoring were their own personal experience and hospital guidelines. Less important were factors such as risk category, litigation, the mothers preferences, research results, time and staffing levels. CONCLUSIONS Although the skills necessary to implement evidence into obstetrical practice are still available, evidence based research results do not seem to be of great importance, when midwives decide which method to use for intrapartum FHR monitoring. Hospital policies and the professional training received were more important factors. Programs designed to implement evidence in care should reflect the identification and use of these factors in order to facilitate the process of realisation.

Global workshops in midwifery competency-based educational methodologies: lessons learned

The Lancet Series on Midwifery and The State of the World’s Midwifery 2014 called on countries to expand the midwifery workforce as a key strategy to improve the health of women and newborns and lower maternal and newborn morbidity and mortality. Well-prepared midwife teachers and preceptors are required to prepare midwives to provide competent, high quality care for women and childbearing families. This article describes the design of competency-based education (CBE) capacity development workshops building on the International Confederation of Midwives’ (ICM) essential competencies and education standards, led by eight English-, Spanish-, and French-speaking CBE Master Educators (MEs). Common content and processes used in three English, one Spanish, and one French workshop are briefly described, noting the influence of participants’ backgrounds, location, and teacher preferences in modifications to common content. As of December 2016, 30 CBE Master Teachers and 22 CBE Teachers have attended a CBE capacity development workshop and, in turn, have provided CBE continuing education (CE) sessions for more than 300 midwife teachers and preceptors in over 20 countries in the Caribbean, Latin America, and Anglophone and Francophone Africa. Lessons learned are shared along with suggestions for next steps in assessment and evaluation of the use of CBE in midwifery education programs.

Women, Midwives, and a Medical Model of Maternity Care in Switzerland

This article presents a case study on the organization of maternity health care in Switzerland. Switzerland has a costly health care system with high intervention rates within an obstetric-led maternity care model. Evidence has shown that midwifery care is associated with lower cost, higher satisfaction rates among women, and less intervention. However, in this model, midwives are both marginalized and underused. The article focuses on the distribution of power and knowledge between midwives, women, and the medical profession. The varying power structures that shape the maternity care system in Switzerland are examined, using a case study approach that draws on Foucault’s concepts of the gaze, surveillance, disciplinary power, and the docile body. This article critically analyzes the model of maternity care received by women in Switzerland and how it negatively impacts on both women’s personal and midwives’ professional autonomy while simultaneously driving up costs. A better understanding of the underlying power structures operating within the maternity care system may facilitate the implementation of more midwifery-led care currently being endorsed by the Swiss Midwifery Association and some government agencies. This could result in reduced cost and lower intervention rates with reduced associated morbidity.

What is next?: Midwifery education building partnerships for tomorrow's maternal and neonatal health care

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Establishing a Europe-wide foundation for high quality midwifery education: the role of the European Midwives Association (EMA)

A cornerstone of European policy involves freedom of movement of individuals between member countries, which applies equally to those who use and provide maternity care. To promote and support safe, high quality maternity care, minimum standards for midwifery education and practice have been published, including Directives EEC/80/154 and EEC/80/155 which support the recognition of professional qualifications. These Directives established a minimum standard for midwifery education, including the duration and content of theoretical and practical education. Annex V of the Directives established a framework of professional activities to define and guide the scope of midwifery practice in EU member countries. The Directives were updated in 2013, with the European Midwives Association (EMA) an important partner in this process. While the degree of implementation of the Directives at individual country level varies, EMA has an ongoing role in ensuring, promoting and advancing high quality midwifery education and practice throughout the EU.

A Needs Assessment for Recognizing Midwifery Educational Programs That Meet the International Confederation of Midwives Global Educational Standards

BACKGROUND: Quality midwifery education globally is essential to improving maternal and infant outcomes worldwide. PURPOSE: Determine midwife educators’ perceptions of the need for an international recognition program identifying a midwifery educational program having met the International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education. STUDY DESIGN: A descriptive web-based survey available in English, French, and Spanish. Midwife educators were asked about (a) perceived need for a recognition program identifying programs meeting ICM Education Standards, (b) ability and resources to complete a self-evaluation report, (c) kinds of verification activities expected and needed resources, and (d) willingness of local educators to be trained as evaluators. RESULTS: Surveys completed from 52 countries and all four ICM regions (n = 197) with 14% from low-/lower middle income countries. Majority of respondents (79%) endorsed a need for a recognition program. Most were capable of creating a self-evaluation report (88%), only 18% identified not needing any additional resources. The vast majority favored an on-site process to verify the report with over 81% stating local midwife educators would volunteer to be trained as validators. CONCLUSION: There is a perceived need for an international process that recognizes midwifery education programs that meet the ICM Education Standards.