Elaine Jefford

A review of the literature: midwifery decision-making and birth

BACKGROUNDnClinical decision-making was initially studied in medicine where hypothetico-deductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benners ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the rational reasoning as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman-midwife partnership where the woman is the ultimate decision-maker.nnnMETHODnCINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review.nnnFINDINGSnDecision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision.nnnCONCLUSIONnWe argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwifes legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study

BACKGROUNDnclinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from non-scientific occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology.nnnQUESTIONnto what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour?nnnMETHODSntwenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted.nnnFINDINGSnusing a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data.nnnCONCLUSIONnover half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes intuition as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated.

Post-structural feminist interpretive interactionism

AIMnTo present an adaptation of interpretive interactionism that incorporates and honours feminist values and principles.nnnBACKGROUNDnInterpretive interactionism as described by Denzin can be useful when examining interactive processes. It is especially useful when events affect turning points in peoples lives. When issues of power and power imbalances are of interest, a critical post-structural lens may be of use to the researcher. The authors planned to examine the interactions between midwives and women at the epiphaneal points of decision making during second-stage labour. It became clear that it was necessary to honour and thus incorporate feminist principles and values in their methodology.nnnDATA SOURCESnThis paper draws on a recently completed PhD project to demonstrate the application of post-structural feminist interpretive interactionism. Twenty six midwives representing each state and territory across Australia who were representative of every model of midwifery care offered in Australia were interviewed to gauge their experiences of what they believed represented good and poor case examples of decision making during second-stage labour.nnnREVIEW METHODSnThe authors critique the philosophical underpinnings of interpretive interactionism, and then modify these to acknowledge and incorporate post-structural and feminist ideologies.nnnDISCUSSIONnInterpretive interactionism is a useful methodology when the research question is best addressed by examining interactional processes and the meanings people make of them, especially if these occur at turning points in peoples lives. Interpretive interactionism methodology can and should be improved by taking account of issues of power, feminism and post-structural values.nnnCONCLUSIONnPost-structural feminist interpretative interactionism has much to offer healthcare researchers who want to develop methodologically robust findings.nnnIMPLICATIONS FOR PRACTICE/RESEARCHnPost-structural feminist interpretive interactionism enables the researcher to be more cognisant of the complex social political and historical context of midwifery. Researchers using feminist and post-structural ideologies will enhance research findings when these tools are applied consciously and reflexively.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents different research questions drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on right care, which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Determining the psychometric properties of the Enhancing Decision-making Assessment in Midwifery (EDAM) measure in a cross cultural context

BackgroundThe ability to act on and justify clinical decisions as autonomous accountable midwifery practitioners, is encompassed within many international regulatory frameworks, yet decision-making within midwifery is poorly defined. Decision-making theories from medicine and nursing may have something to offer, but fail to take into consideration midwifery context and philosophy and the decisional autonomy of women. Using an underpinning qualitative methodology, a decision-making framework was developed, which identified Good Clinical Reasoning and Good Midwifery Practice as two conditions necessary to facilitate optimal midwifery decision-making during 2nd stage labour. This study aims to confirm the robustness of the framework and describe the development of Enhancing Decision-making Assessment in Midwifery (EDAM) as a measurement tool through testing of its factor structure, validity and reliability.MethodA cross-sectional design for instrument development and a 2 (country; Australia/UK) x 2 (Decision-making; optimal/sub-optimal) between-subjects design for instrument evaluation using exploratory and confirmatory factor analysis, internal consistency and known-groups validity. Two ‘expert’ maternity panels, based in Australia and the UK, comprising of 42 participants assessed 16 midwifery real care episode vignettes using the empirically derived 26 item framework. Each item was answered on a 5 point likert scale based on the level of agreement to which the participant felt each item was present in each of the vignettes. Participants were then asked to rate the overall decision-making (optimal/sub-optimal).FindingsPost factor analysis the framework was reduced to a 19 item EDAM measure, and confirmed as two distinct scales of ‘Clinical Reasoning’ (CR) and ‘Midwifery Practice’ (MP). The CR scale comprised of two subscales; ‘the clinical reasoning process’ and ‘integration and intervention’. The MP scale also comprised two subscales; women’s relationship with the midwife’ and ‘general midwifery practice’.ConclusionEDAM would generally appear to be a robust, valid and reliable psychometric instrument for measuring midwifery decision-making, which performs consistently across differing international contexts. The ‘women’s relationship with midwife’ subscale marginally failed to meet the threshold for determining good instrument reliability, which may be due to its brevity. Further research using larger samples and in a wider international context to confirm the veracity of the instrument’s measurement properties and its wider global utility, would be advantageous.

Development and validation of the Australian version of the Birth Satisfaction Scale-Revised (BSS-R)

Abstract Objective and background: The 10-item Birth Satisfaction Scale-Revised (BSS-R) has recently been endorsed by international expert consensus for global use as the birth satisfaction outcome measure of choice. English-language versions of the tool include validated UK and US versions; however, the instrument has not, to date, been contextualised and validated in an Australian English-language version. The current investigation sought to develop and validate an English-language version of the tool for use within the Australian context. Methods: A two-stage study. Following review and modification by expert panel, the Australian BSS-R (A-BSS-R) was (Stage 1) evaluated for factor structure, internal consistency, known-groups discriminant validity and divergent validity. Stage 2 directly compared the A-BSS-R data set with the original UK data set to determine the invariance characteristics of the new instrument. Participants were a purposive sample of Australian postnatal women (n = 198). Results: The A-BSS-R offered a good fit to data consistent with the BSS-R tridimensional measurement model and was found to be conceptually and measurement equivalent to the UK version. The A-BSS-R demonstrated excellent known-groups discriminant validity, generally good divergent validity and overall good internal consistency. Conclusion: The A-BSS-R represents a robust and valid measure of the birth satisfaction concept suitable for use within Australia and appropriate for application to International comparative studies.

“Midwifery Abdication”: A Finding From an Interpretive Study

BACKGROUND: Good clinical reasoning in midwifery is essential for the safety and quality of the care for women and babies. Midwives, as autonomous practitioners, are held legally and professionally accountable for their clinical reasoning, decisions, and the care they provide. Yet there is contested space between being accountable to the woman (and her birth experience) and being accountable to legal and professional frameworks and regulations. This places the midwife in a vulnerable position. This vulnerability is explored in this article. METHODOLOGY: The narratives of 6 midwives who were interviewed as part of a larger study were subjected to an inductive thematic analysis. Trustworthiness and rigor of the study was assured by careful monitoring of the research process and data checking. RESULTS: Although potentially unpalatable to the midwifery profession, we feel it is important to acknowledge that a concept called Midwifery Abdication does perhaps exist. Our assertion is underpinned by 3 key themes: “internalized perceptions of midwifery practice,” “knowing but failing to act,” and “prioritization of the woman’s needs.” Although this may be an unconscious act, it may be part of a conscious thought process which is influenced by internal and external factors. The result is loss of one’s professional voice. Midwifery Abdication introduces a level of risk, in changing clinical situations, which require a reconsideration and potential renegotiation of maternal choices and decisions. CONCLUSION: Some midwives appear to abdicate their professional decision-making role. Midwives must practice within their country’s legislative framework, which is complemented by their regulatory authority codes of professional conduct, standards, and ethics. Midwifery Abdication undermines the safety and efficacy of midwifery practice and thus destabilizes our right to claim professional autonomy.

Applying a midwifery-specific decision making tool to midwives clinical reasoning and midwifery practice when managing a woman's perineum in labour: An exploratory study

Introduction: Many of the risk factors for perineal trauma are modifiable, and midwives are in an ideal position to mitigate such risks. To date, no investigation using a midwifery-specific decision-making tool has sought to determine how midwives make decisions within a midwifery philosophy/context or identify the factors that may contribute to that decision making about perineal management. We sought to apply such a tool to midwives’ narratives and explore their clinical reasoning and midwifery practice when managing a woman’s perineum in labor. Methods: A qualitative interview-based study with practicing midwives in one regional Australian maternity unit was conducted. The decision-making matrix specified by a psychometrically robust and validated measure of clinical decision making and midwifery practice-guided analysis. Results: Effective clinical decision making in response to perineal trauma is contingent on a heuristic and individualized “working hypothesis” that combines distinct elements of an optimal clinical decision-making process. Midwives’ narratives highlighted their ability to engage in some form of clinical reasoning. Some elements of midwifery practice was lacking within several midwives’ narratives, thus resulting in them abdicating their professional role. Conclusion: The manner and processes by which midwives engage effectively with perineal management are complex. However, a significant influence on this process appears to be recollections from original training in perineal management, which appears to be largely rote and taught by example. We recommend balance between practical experience and synthesis with current evidence within a midwifery philosophy to optimize perineal care and risk modification.