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Midwifery students’ perceptions and experiences of learning in clinical practice: a qualitative review protocol

Yang, Zhihui 1 ; Li, Xinxin 2 ; Lin, Huanhuan 2 ; Chen, Fanfan 2 ; Zhang, Lili 1 ; Wang, Ning 1

1 PR China Southern Centre for Evidence-based Nursing and Midwifery Practice: A JBI Centre of Excellence, Guangzhou City, Guangdong Province, PR China

2 School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, PR China

Correspondence: Ning Wang, [email protected]

The authors declare no conflict of interest.


This systematic review aims to investigate and synthesize qualitative evidence related to midwifery students’ perceptions and experiences of learning in clinical practice.


Midwifery students are required to develop strong competencies during pre-registration education for future practice. Clinical placements provide a good opportunity for students to build essential practice capacities. Understanding the perceptions and experiences of midwifery students in clinical practice helps develop effective midwifery clinical educational strategies. A qualitative systematic review is therefore proposed to improve midwifery clinical education.

Inclusion criteria: 

This proposed review will consider qualitative studies that have explored midwifery students’ perceptions and experiences of learning in clinical practice in all degrees. The search will be limited to English-language published and unpublished studies to the present.


This review will follow the JBI approach for qualitative systematic reviews. A three-stage search will be conducted to include published and unpublished literature. Databases to be searched include PubMed, Science Direct, Web of Science, CINAHL, PsycINFO, American Nurses Association, Google Scholar, ProQuest Dissertation & Theses, and Index to Theses in Great Britain and Ireland. Identified studies will be screened for inclusion in the review by two independent reviewers. Any disagreements will be resolved through discussion. Data will be extracted using a standardized tool. Data synthesis will adhere to the meta-aggregative approach to categorize findings. The categories will be synthesized into a set of findings that can be used to inform midwifery education.

Systematic review registration number: 

PROSPERO CRD42020208189


Due to strong advocacy for improved health and safety of pregnant women and their babies globally, many countries have made significant progress in increasing the proportion of pregnant women who give birth at health care facilities. 1 However, such effort has not led to the expected level of reduction in maternal and newborn mortality and stillbirths, 2 which can be caused by inadequacies in the quality of care provided in the health care facilities. 3

The delivery of quality and safe midwifery practice requires that health professionals develop strong competencies and high-level accountabilities. Evidence shows that well educated, regulated, and licensed midwives are associated with improved quality of care and rapid and sustained reduction in maternal or neonatal morbidity and mortality. 4 Pre-registration education is an important stage for midwifery students to develop the fundamental professional knowledge, skills, and judgment essential for their future practice. Clinical practice programs as a significant component of midwifery education provide a valuable opportunity for midwifery students to build hands-on capabilities that integrate with classroom theories, and to be socialized into their chosen profession. 5 Specifically, it helps students develop the required professional competencies for registration and ideas about their career preference, as well as smoothly transit to their future career. 6,7 It has been found that education undertaken through clinical placements provides up to 50% of the learning experience for students in pre-registration midwifery courses. 8

Midwifery refers to “skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum throughout pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life.” 9 (p.1130) Midwifery practice involves a wide scope of care activities that are undertaken to pursue the overall well-being of pregnant women. This includes providing continuous support to the women during their antenatal, intrapartum, and postpartum periods, being responsible for conducting births, caring for the newborns, and preventing and managing complications in pregnancy and childbirth. 10 These require that midwives are highly competent in undertaking various work tasks in partnership with the women and to cope with the complex and dynamic nature of the practice environments. 11 To face such challenging learning requirements, midwifery students can become frustrated when they first enter a practice setting. Literature shows that student health professionals often face challenges and experience a high level of stress during their clinical placements, 12,13 and midwifery students experience more stress compared to students in other professions. 14,15 Research has found that the midwifery students’ clinical stress was either due to their low confidence in undertaking care and a fear of making mistakes, or their relationships with clinical educators and colleagues. 16 Negative clinical experiences perceived by the student midwives can pose a potential threat to their effective learning and recognition of their future professional career. 17-19

As a key part of successful midwifery education, a well-designed practice program with a supportive environment is essential for fostering students’ confidence and passion to pursue a future midwifery career and for building competencies for entry to their registrations. 7,20 Students’ perceptions and experiences about their clinical learning are considered a hallmark of quality education. 21 While there is a growing body of knowledge reported in the literature about these elements, a systematic aggregation of such evidence should identify implications for the educational and clinical faculties to develop appropriate and effective clinical training strategies and provide required support to the students. Our literature search has identified three reviews about student professionals’ learning experiences; however, these reviews have focused on the learning experiences of undergraduate nursing rather than midwifery students, 22 a setting other than clinical placements, 23 or the relationship between workplace culture and the practice experience. 24 This review addresses a gap in the literature by aggregating evidence about midwifery students’ perceptions and experiences of learning in clinical settings. The ultimate aim is to improve midwifery educators’ understanding of their students’ clinical experiences.

Review question

What are the perceptions and experiences of midwifery students’ learning in clinical practice?

Inclusion criteria


This review will consider qualitative studies that focus on midwifery students’ perceptions and experiences of learning in clinical practice settings. There will be no limitation regarding age, gender, grade or year, or ethnicity of participants.

Phenomena of interest

The phenomena of interest will be midwifery students’ perceptions and experiences of learning in clinical practice settings.

This review will consider studies conducted in any settings identified as a clinical practice, including clinical placement or internship, in acute care, community care, or simulated learning environments.

Types of studies

This review will consider English-language qualitative studies that describe the perceptions and experiences of midwifery students in their clinical practice. These studies will focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, and action research. Qualitative data from mixed method studies will also be included.

The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. 25 The review has been registered in PROSPERO (CRD42020208189).

Search strategy

The search strategy aims to locate both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed will be undertaken followed by analysis of the text words contained in the titles and abstracts, and of the index terms used to describe the articles. This preliminary search in PubMed will be used to develop a search strategy for this review that will include other databases. A second search using identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. A sample search strategy for PubMed is detailed in Appendix I. There is no date limit for the studies included in this review.

The databases to be searched for published studies include: MEDLINE (PubMed), Science Direct, Web of Science, EBSCO (CINAHL), and EBSCO (PsycINFO). The search for unpublished literature will include Google Scholar, American Nurses Association, ProQuest Dissertation & Theses Database, and Index to Theses in Great Britain and Ireland.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote v.9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). 26 The full text of selected citations will be assessed in detail against the inclusion criteria by the two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. 27

Assessment of methodological quality

Papers selected for retrieval will be assessed by the two independent reviewers for methodological quality prior to inclusion in the review using the standard JBI critical appraisal checklist for qualitative research. 25 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of primary studies will be contacted with questions on missing information or if clarification is needed. The results of the critical appraisal will be reported in narrative form, as well as in a table. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis.

Data extraction

Qualitative data will be extracted from studies included in the review by the two independent reviewers using the standardized JBI qualitative data extraction tool for qualitative evidence (JBI SUMARI). The data extracted will include specific details about the participants, context, geographical location, study methods, and the phenomena of interest relevant to the review question and specific objectives. Findings will be verbatim extractions of the authors’ analytic interpretations, along with relevant illustrations. Each finding will be assigned a level of validity or credibility. Findings will be described as “unequivocal” or “credible,” as recommended in the JBI Manual for Evidence Synthesis . 25 All “unsupported” findings will be excluded from the review. Any disagreements relating to credibility that arise between the reviewers will be resolved through discussion or by a third reviewer.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach. 28 This will involve aggregation or synthesis of findings to generate a set of statements that represents the aggregation, through assembling and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. The categories and synthesized findings will be agreed by discussion among the reviewers to ensure they support the meaning of the data. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing certainty in the findings

The final synthesized findings will be graded according to the ConQual 29 approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings. The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research informing it, score for dependability and credibility, and the overall ConQual score.


The library staff at Southern Medical University for their guidance and support on literature retrieval.

Appendix I: Search strategy

Medline (pubmed).

Search conducted August 2020


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Midwifery Dissertation Topics

Published by Owen Ingram at January 3rd, 2023 , Revised On August 16, 2023

There have been midwives around for decades now. The role of midwives has not changed much with the advent of modern medicine, but their core function remains the same – to provide care and comfort to pregnant women during childbirth.

It is possible to be a midwife in the healthcare industry, but it is not always a rewarding or challenging career. Here are five things you didn’t know about midwifery nursing to help you decide if it could be the right career choice for you.

The profession of midwifery involves caring for women and newborns during pregnancy, childbirth, and the first few days following birth. Registered nurses are trained with four additional years of education along with major research on methods involve in midwifery and writing on midwifery dissertation topics, while midwives provide natural health care for mothers and children.

As a midwife, your role is to promote healthy pregnancies and births while respecting women’s rights and dignity. Midwives provide care to patients at every stage of life, from preconception to postpartum, family planning to home delivery to breastfeeding support.

Important Links: Child Health Nursing Dissertation Topics , Adult Nursing Topics , Critical Care Nursing Dissertation Topics . These links will help you to get a broad experience or knowledge about the latest trends and practices in academics.

Midwifery Is A Good Fit for the Following:

● Those who want to work with women, especially those at risk of giving birth in a                    hospital setting. ● Those who enjoy helping people and solving problems. ● Those who like to be creative and solve complex problems. ● Those who want to help others and make a difference in their lives.

Midwifery is a career with many benefits for both the midwife and the baby. They are well-trained and experienced in caring for pregnant women and newborns and often have access to the exceptional care that other nurses may not have.

Related Links:

  • Evidence-based Practice Nursing Dissertation Topics
  • Child Health Nursing Dissertation Topics
  • Adult Nursing Dissertation Topics
  • Critical Care Nursing Dissertation Topics
  • Dementia Nursing Dissertation Topics
  • Palliative Care Nursing Dissertation Topics
  • Mental Health Nursing Dissertation Topics
  • Nursing Dissertation Topics
  • Coronavirus (COVID-19) Nursing Dissertation Topics

Midwifery Dissertation Topics With Research Aim

Topic:1 adolescence care.

Research Aim: Focus on comprehensive medical, psychological, physical, and mental health assessments to provide a better quality of care to patients.

Topic:2 Alcohol Abuse

Reseasrch Aim: Closely studying different addictions and their treatments to break the habit of drug consumption among individuals.

Topic:3 Birth Planning

Research Aim: Comprehensive birth planning between parents discussing the possible consequences of before, between, and after labour.

Topic:4 Community midwifery

Research Aim: Studying different characters in community midwifery and the midwife’s role in providing care for the infant during the early days of the child’s birth.

Topic:5 Contraception

Research Aim: Understand the simplicity of contraception to prevent pregnancy by stopping egg production that results in the fertilization of egg and sperm in the later stages.

Topic:6 Electronic fetal monitoring

Research Aim: In-depth study of electronic fetal monitoring to track the health of your baby during the womb, record construction per minute, and make a count of your baby’s heart rate.

Topic:7 Family planning

Research Aim: Importance to follow the basic rhythm methods for the couple to prevent pregnancy and use protection during the vaginal sex to plan a family without fertility treatments.

Topic:8 Foetal and newborn care

Research Aim: Expansion of the maternal-fetal and newborn care services to improve the nutritional quality of infants after delivery during their postnatal care time.

Topic:9 Foetal well being

Carefully tracking indications for the rise in heart rate of the fetal by weekly checkups to assess the overall well-being of the fetal.

Topic:10 Gender-based violence

Research Aim: Studying the consequences of male desire for a child that results in gender-based violence, harming the child’s physical and mental health.

Topic:11 Health promotion

Research Aim: Working on practices that help in controlling the amount of pollution of people, taking care of their overall health, and improving quality of life through adapting best health practices.

Topic:12 High-risk pregnancy

Research Aim: Calculating the ordinary risks of a high-risk pregnancy and how it affects a pregnant body resulting in a baby with poor health or any by-birth diseases, increasing the chance for complications.

Topic:13 HIV infection

Research Aim: Common causes of HIV infection and their long-term consequences on the body’s immune system. An in-depth study into the acquired immunodeficiency and the results leading to this.

Topic:14 Human Rights

Creating reports on human rights and their link with the freedom of thought, conscience, religion, belief, and other factors.

Topic:15 Infection prevention and control

Research Aim: Practices for infection prevention and control using efficient approaches for patients and health workers to avoid harmful substances in the environment.

Topic:16 Infertility and pregnancy

Research Aim: Evaluating the percentage of infertility and pregnancy, especially those facing no prior births, and who have high chances of infertility and pregnancy complications.

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Midwives are nurses who provide continuous support to the mother before, during, and after labour. Midwives also help with newborn care and educate parents on how to care for their children.

How Much Do Midwives Make?

The salary of a midwife varies depending on the type of work, location, and experience of the midwife. Midwives generally earn $132,950 per year. The average annual salary for entry-level midwives is $102,390.

The minimum requirement for becoming a midwifery nurse is a bachelor’s degree in nursing, with the option of pursuing a master’s degree.

An accredited educational exam can also lead to certification as a nurse-midwife (CNM). The American College of Nurse-Midwives (ACNM) enables you to practice independently as a midwife.

There are many pros and cons to working as a midwife. As a midwife, you have the following pros and cons:

  • Midwives have the opportunity to help women during one of the most memorable moments in their lives.
  • Midwives can positively impact the health of mothers and their children.
  • Midwives can work in many hospitals, clinics, and homes.
  • In midwifery, there are many opportunities for continuing education and professional development.
  • You will often have to work nights and weekends, which can be mentally draining.
  • You will have to travel a lot since most births occur in hospitals or centres in different areas.
  • You will have to deal with stressors such as complex patients and uncooperative families.
  • You will be dealing with a lot of pain, so you need to be able to handle it without medication or other treatment methods.

A career in midwifery is a great fit for those with a passion for health and wellness, an interest in helping people, and a desire to work in a supportive environment.

It is important to become involved in your local midwifery community if you are contemplating a career in midwifery – the best source of learning is your major research work, along with writing a lengthy thesis document on midwifery dissertation topics that will submit to your university to progress your midwifery career.

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Frequently Asked Questions

How to find midwifery dissertation topics.

To find midwifery dissertation topics:

  • Explore childbirth challenges or trends.
  • Investigate maternal and infant health.
  • Consider cultural or ethical aspects.
  • Review recent research in midwifery.
  • Focus on gaps in knowledge.
  • Choose a topic that resonates with your passion and career goals.

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Midwifery Education

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midwifery education dissertation

  • Joy Kemp 4 ,
  • Gaynor D. Maclean 5 &
  • Nester Moyo 6  

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This chapter describes midwifery pre-service, in-service and continuing education across cultures looking at the types of programmes in different countries; tools available for strengthening midwifery education, factors impacting on midwifery education, challenges and opportunities. Midwifery education is viewed as a process of lifelong learning, for maintaining competence and as a means of acquiring a body of midwifery knowledge. This chapter concludes by examining how to maximise the opportunities, address challenges and consider the implications for policy, research and practice.

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Additional Resources for Reflection and Further Study

Global Health Workforce Alliance (2011) Outcome statement of the second global forum on human resources for health, Bangkok, 27–29 January 2011: http://www.who.int/workforcealliance

The ‘midwifery map’ ICM website. https://www.internationalmidwives.org/icm-publications/map.html compares the available data on midwifery education in several countries. Consider how these interrelate with maternal and newborn mortality statistics in those countries

What is the difference between e-learning and blended learning? https://www.distancelearningportal.com/articles/269/whats-the-difference-between-blended-learning-e-learning-and-online-learning.html

World Health Organisation (2014) Nurse educator competencies. WHO, Geneva

Google Scholar  

Source: International Journal of Emerging Technologies in learning—ISSN:1863-0383, vol 14, no. 03, 2019. Augmented reality and virtual reality in education. Myth or Reality? Noureddine Elmqaddem. https://doi.org/10.3991/ijet.v14i03.9289 . Accessed Aug 2019

XENODU . Virtual environments for personal and social development. Tag Archives: nursing and midwifery training: how virtual reality is transforming nursing and midwifery learning (incl. video) . March 8, 2018. Learning , Virtual Environments medical education , nursing and midwifery training , technology enhanced learning , virtual reality training simulation


Some Examples of Mobile Applications and Some Videos

Giftedmom. http://www.giftedmom.org/ . Accessed 10 Oct 2019. A mobile health provider based in Africa works with NGOs to provide free mobile services to expectant mothers and women with newborn children. A combination of apps and informational text messages, GiftedMom provides a wide range of health services through mobile devices, some of which are donated to women in need of the service. The app was first launched in Cameroon, where more than 7000 women die per year in pregnancy-related complications. To help curb maternal mortality rates in the country, GiftedMom subscribes pregnant women and new mothers to free text messages to educate them on prenatal care, vaccines and reproductive health. The messages also remind mothers of important pregnancy milestones and health services their newborns should be receiving. More than 6700 mothers currently use the app in Cameroon and Nigeria

Zero Mothers Die. https://www.youtube.com/watch?time_continue=15&v=8gdZl8Ac3uY . Accessed Oct 2019. This application provides small mobile phones to women in Africa—specifically Ghana, Gabon, Mali, Nigeria and Zambia—at no cost, with the goal of curbing maternal health care inaccessibility. The phones use SMS text messaging to provide women living in isolated areas with essential information for having a healthy pregnancy and birth. The short, digestible messages help empower women to be active in their own health care, whilst also giving them information they can pass along to women in their communities. The phones come preloaded with calling minutes at no additional cost, which women can use to call local healthcare providers in the event of an emergency. Zero Mothers Die also uses mobile connectivity to help educate healthcare workers through a partner app, increasing their knowledge as well as improving their role in the care of pregnant women

Maymay. http://pulse.psi.org/spring-2015/#maternal . Accessed Oct. Maternal and infant mortality rates in Myanmar are significantly higher than those in neighbouring nations—and the app maymay is helping address it. The free app sends out three tailored health alerts every week to pregnant women, providing tips on having a successful, healthy pregnancy. The app, created by Population Services International, provides a wide array of tips—such as nutritional advice, explanations of early signs and symptoms of pregnancy, and recommendations for safe baby items—catered to a user’s stage in pregnancy. The app also allows pregnant women to find doctors in their area, sorting by specialty and medical institution

Safe Delivery. https://www.maternity.dk/ . Accessed Oct 2019. https://www.youtube.com/watch?time_continue=6&v=qI5PMSYa_BM . Developed by the Maternity Foundation , the Safe Delivery app provides simple instructions to health workers in remote areas on how to assist with non-routine births. The app hopes to strengthen the quality of care and reduce maternal and newborn mortality rates by increasing a birthing attendant’s knowledge in times of crisis. First launched in Ethiopia and Ghana, Safe Delivery uses animated videos to provide instruction to health workers, focusing on what to do when faced with birthing complications, like a newborn who is not breathing or a prolonged labour. The app also has flashcards, so an attendant can self-assess their knowledge outside of emergency situations. Safe Delivery is available in English and regional languages, breaking access barriers with tailored narration

Mama. https://unfoundation.org/ . Accessed Oct 2019. The Mobile Alliance for Maternal Action (MAMA) created an app of the same name that delivers free health messages to new and expectant mothers in Bangladesh, South Africa, India and Nigeria. Women receive stage-based, culturally sensitive messages two to three times per week, which helps empower mothers with the health knowledge they are often denied. The messages address three main areas important to women throughout their experience with motherhood: warning signs, reminders and encouragement. That last point is especially notable: Along with health-based tips and information, users receive affirmation that they are succeeding as mothers—and that can be just as important as hard facts

Mobile Midwife. https://www.youtube.com/watch?time_continue=56&v=USRvTsPwihg . MOTECH Suite: Ghana Mobile Midwife. Accessed Oct 2019. To provide increased healthcare access to women in Ghana, the Mobile Midwife app utilises text messages and pre-recorded voice messages to help spread information to pregnant women, new mothers and their families. The app’s messages are time-specific, providing information relevant to women that hinges on their stage in motherhood. Mobile Midwife is also used in conjunction with a Nurses’ Application, which medical providers use to collect patient data and upload records to a centralised database. Through the application, providers can track patient care and identify those who are due for medical services

Safe Pregnancy and Birth. https://hesperian.org/books-and-resources/safe-pregnancy-and-birth-mobile-app/ . Accessed Oct 2019. An award-winning app for expectant mothers in developing countries, Safe Pregnancy and Birth provides maternal health knowledge to both expectant mothers and healthcare providers. The app focuses on four major points: data collection, patient monitoring, health education or appointment reminders. Available in both English and Spanish, the Safe Pregnancy and Birth app relays information to pregnant women on how to stay healthy during pregnancy, how to recognise prenatal health concerns and what to do in an emergency situation. It also has step-by-step instructions for community health workers, explaining how to perform procedures such as taking blood pressure, treating someone in shock and stopping bleeding post-birth

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Maternal and Newborn Health, Department of Interprofessional Health, Swansea University, Swansea, UK

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Annex 4.1: Distribution of Midwifery Programmes According to Type Amongst 114 ICM Member Countries as of 2017

Type of programme

Number of countries

Brief description

Entry qualification in years of schooling

Duration in months


Global standard

Range in countries

Global standard

Range in countries

Direct entry


Students enter the midwifery education programme without a nursing background to become independent practitioners educated in the discipline of midwifery. Graduates can only work in midwifery settings including in rural areas closest to where women live, thus reclaiming the midwifery turf lost as the profession developed. Advantages include clarity of professional identity

However, it is not practical in those settings where the midwife is the only care provider in the community and is expected to deal with nursing situations. Additionally in some countries direct midwifery graduates had no career pathway as a nursing qualification was demanded for promotion even for some senior midwifery positions. This is gradually changing





Students range from high school and pre-university graduates to include mature individuals who may have been in other professions

In 62 countries, programme duration matches or exceeds global standard

Schools and universities set their own entry requirements in some countries

Direct entry midwifery was related to stability and retention of the midwifery workforce compared to nurse midwifery (Rosskam ). Results of 57 country surveys indicated that direct entry was the most favoured midwifery education method (Global Health Workforce Alliance ), resulting in improved population health outcomes

Post nursing


A nursing qualification is required to enter a midwifery education programme

Graduates can work in both nursing and midwifery settings. Very useful in situations of shortage of staff as graduates can be rotated between departments. Graduates can be posted alone in the periphery to offer both nursing and midwifery care, e.g. in Bangladesh, the severe shortage of nurses limited nurse midwives from being entirely utilised for midwifery activities. ‘Primarily, serving as hospital staff nurses fulfilling vacancies and continually rotating throughout the hospital, registered nurse-midwives often lack specialised in-service training’ (Masoom 2017)

12 + nursing qualification

12 + nursing



42 countries offer the programme at the global standard of 18 months and above

The versatility of nurse midwives is a double-edged sword. Studies showed that rotated care providers experienced serious emotional distress as they tried to fit into the new setting, and it was difficult for them to develop in any one particular direction as they failed to develop a professional identity and to receive relevant in-service trainings

Observations showed that nurse midwives were amongst the most significant groups of healthcare workers who migrate to urban areas and richer countries. Hence, the recommendation was to de-linking nursing and midwifery education for countries to improve workforce retention and reduce migration

Integrated programme

Four known but could be more

Midwifery content is integrated into a nursing curriculum. Graduates qualify with more than one discipline (SANC 2017)





It is difficult to ensure that all competencies for each discipline have been acquired at the end of the programme

Other (shorter courses)

Several LICs

Abbreviated content for nursing, midwifery and other areas is delivered in a shortened programme. Products are usually auxiliary workers of different titles, e.g. nurse midwife technician in Malawi and Zimbabwe; lady health visitor in Pakistan; family welfare volunteers in Bangladesh and maternal and child health aids in Sierra Leone





These programmes do not meet global standards. The content of the programme varies per country. The products in some countries are also called midwives. This leads to confusion in the community

  • Source: International Confederation of Midwives website www.internationalmidwives.org accessed August 2019

Annex 4.2: Education Models, Technological Advances and Innovations Instructional Technologies in Midwifery Education


Brief description

Major benefits



Synchronous systems

Face to face onsite learning

Real-time learning face-to-face with the teacher. Usually teacher and students are in the same place

• Support is there and immediate

• Students and teachers can form personal relationships

• There is peer support

• Teachers can identify students who have problems through direct observation and personal interactions

• The student has to be away from home and work

• Can be expensive in time and money

• Schools can be inaccessible for some, especially if they are only in cities

Modern technological advances are making this approach less necessary

Asynchronous modular systems

Teacher and student are not in the same place. Teacher can post a lesson at one time and students complete it later at a convenient time

• Students can take up the course from anywhere as long as there is connectivity

• Student does not have to be away from the family for prolonged periods of time

• Student does not have to be away from work for blocks of time

• Some asynchronous systems may need electricity and internet connections which may not be available everywhere in some countries

• Requires personal motivation and self-discipline from students

The constraints can be offset by blended approaches where there is fixed schedule of some face-to-face time and some distance learning time

Distance learning


e-learning or web-based learning

Distance learning is also called online learning. Students from one part of the world can take a programme run in another part of the world and become international student without needing to travel

e-learning typically refers to the online interaction between a student and the teacher. Basically, the student receives the training through an online medium, even though the teacher may be in the same building. e-learning can be used in a classroom or an online setting. Additionally, it can be used to simulate and intensify work-based learning situations

• Increased access to midwifery education and degree programmes

• Lectures, assignments, tests are all enabled by virtual platforms. A fully online university degree means the student does not have to travel at all for studies

• Requires a computer and connectivity which may not be available in those areas where the need for midwifery education is greatest

• Very sensitive to civil and other types of population unrest

As the world gets more connected, there is expansion of the availability of electricity, computers and internet

Discussion forums via email, videoconferencing, and live lectures (video streaming) are all possible through the web. Web-based courses may also provide static pages such as printed course materials

Some learner-centred instructional technologies

Competency-based education methodologies

Focus is on the acquisition of pre-determined set of competencies and combines with mastery learning

Acknowledges that individuals learn at different paces and therefore does not focus on the time it takes for the student to be declared competent. Assessment is ongoing and frequent to determine competence. Useful in all learning domains and most observable results are in clinical skills

Low-dose, high-frequency practice where students learn one or two competencies by practising over short periods of time frequently

Some critics are challenging the approach stating that it breaks learning down to too small elements for gestalt (big picture) learning

Problem-based education methodologies

Students learn about a subject through the experience of solving an open-ended problem

It is student centred. Fosters better understanding and retention of knowledge and develops problem-solving skills and critical thinking, self-directed learning and upholds life-long learning

Depending on utilisation of resources which might not be available in most schools of midwifery and tutor facilitation in some settings, the teachers are not familiar with the approach. It is time consuming

Very challenging to students who would have learnt in the previous years that the teacher is the main disseminator of knowledge. Students might therefore spend a lot of time unfocused trying to get to grips with the approach

The problems must be well defined for it to produce the desired effect

Enquiry-based learning

Enquiry-based learning is a form of active learning that starts by posing questions, problems or scenarios. It contrasts with traditional education, which generally relies on the teacher presenting facts and his or her knowledge about the subject

Includes three steps: Question, investigate and communicate results

• There is evidence that inquiry-based learning can motivate students to learn and advance their problem-solving and critical thinking skills

• Students develop stronger relationships with their classmates, improve their communication skills and increase their confidence in their own ideas

The effectiveness of inquiry-based learning depends on the guidance provided by teachers

The teachers have to be conversant with the approach to provide effective guidance to students

In many low-income countries, very few teachers learn using this approach, and it may be difficult for them to guide students to use it. The situation was progressively improving at the time of writing

Simulation learning using a variety of simulators

Low-fidelity models

• Basic low-tech models

• High-tech models designed to look and feel human

• High-fidelity patient simulators

Simple effective and sometimes made by the students in the school. Low cost and therefore affordable and easy to maintain

Look and feel human, thus providing a more realistic experience to the student

Sometimes expensive and difficult to maintain. Some are even difficult to operate

Computerised manikins that simulate real-life scenarios. Long used in medical schools, now quickly becoming essential for many midwifery schools

Simulation provides students with opportunities to practice their clinical and decision-making skills through various real-life situational experiences

With low-fidelity simulators, there is no direct interaction with the model, but interaction can be integrated by having a fellow student acting as the woman. The Mama Natali set, produced by Laerdal Global Health is one effective low-fidelity but highly effective range of such models

High-fidelity simulators may be expensive and difficult to maintain, requiring technicians to maintain them

Not all education institutions in the areas where midwifery education is needed most can afford or have access to models of any level of fidelity

Online platforms, e.g.

• Virtual classroom

• Unfolding case study

• Online return demonstration of clinical skills

An online classroom that allows participants to communicate with one another, view presentations or videos, interact with other participants and engage with resources in workgroups

Uses innovative evidence-based teaching and learning strategies

Available on mobile devices anywhere, thus providing greater flexibility of when and where to learn

Collaborative, interactive and flexible. Attractive to the generation used to gaming as it gamifies learning

Can be omni-synchronous, i.e. at times there can be real-time teacher–student interaction and real-time group session as well as private tutoring

Encourages creativity for teachers to develop more inspiring, engrossing and effective learning content and allow learners to interact with lessons in a new way

Potential to involve more artificial intelligence and virtual reality

Enhances students’ experiences

More students including those in rural and underserved regions who might otherwise have been unable to attend the traditional onsite campus have access to midwifery education at their desired level (certificate, diploma, degree and masters)

Might take time to reach the poorest of the poor

Educators should stay alert to the advent of these new technologies. Not every innovation is successful. It is important to find the right solutions for each course and for the learners sometimes by trial and error. Educators have to be continuing learners too

Students treat them like their messaging apps, and audio lessons are consumed like podcasts and mini quizzes as micro games that can be played during lunch break, given the proliferation of mobile devices in the twenty-first century

Virtual and augmented reality

Augmented reality

A technology that allows the student to immerse her/himself in an artificial world using a virtual reality head set ( 2019). The world can be purely imaginary or a reproduction of the real world. Can be visual, auditory

Augmented reality refers to a virtual interface, in 2D or 3D, that enhances (or augments) what we see by overlaying additional information (digital content) onto the real world. Immersion in the virtual world is not total, because we can always see the real world around us

• Allows the student to manipulate and interact with the object through the use of controllers enabling practice and learning. Allows the doing of tests and experiments without taking physical risks

• Can improve and facilitate learning, increase memory capacity and making

• Enables better decisions whilst working in a stimulating and entertaining environment. Students can ‘see’ internal organs and processes, thus enhancing understanding

• The learner feels more engaged, more motivated and more receptive and ready to learn and communicate with others

• Implementation not yet generalised but it is taking root. Integration of these technologies requires radical changes and new teaching and learning models and a close collaboration between educators and education engineers

Having physical access to all what we learn is not possible, hence the importance of VR, which allows access to everything virtually. This allows a better understanding of things and phenomena with less cognitive efforts on the part of the learner, and less cost for the institute that deals with learning. Virtual reality-based learning has been proven to increase learners’ level of attention by 100% and improve test results by 30%. VR will not only transform the way we entertain ourselves, but it will also completely change the way students learn

Annex 4.3: Resources Available for the Strengthening of Midwifery Education Globally




Global Strategic Directions for Nursing and Midwifery, 2016–2020

Nurse Educator Competencies, 2014

Strengthening Quality Midwifery Education: WHO Meeting Report, 25–26 July 2016

Strengthening Midwifery Education Action Plan, 2016–2030

The global midwifery advocacy strategy

The midwifery services framework

Global Standards for Midwifery Education, 2013

Global Standards for Midwifery Regulation, 2013

Essential Competencies for Basic Midwifery Practice, 2011, reviewed 2017

Model Curriculum Outlines for Midwifery Education, 2013

Midwifery Services Gap Analysis Tools, 2013

Manual on Competency-Based Education Methodologies, 2015

Philosophy and model of midwifery care

 United National Population Fund (UNFPA)


 Global Health workforce Alliance

 1. Canadian Association of Midwives

 2. Japanese midwives association

 3. American College of Nurse Midwives

 4. Royal College of Midwives (United Kingdom)

 5. Royal Dutch Organization of midwives (KNOV)


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Kemp, J., Maclean, G.D., Moyo, N. (2021). Midwifery Education. In: Global Midwifery: Principles, Policy and Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-46765-4_4

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Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth

  • Lucy Lewis 1 , 2 ,
  • Yvonne L. Hauck 1 , 2 ,
  • Janice Butt 2 ,
  • Chloe Western 2 ,
  • Helen Overing 2 ,
  • Corrinne Poletti 2 ,
  • Jessica Priest 2 ,
  • Dawn Hudd 3 &
  • Brooke Thomson 1  

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There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia. Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire. Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth. Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire. Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven. Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth. Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance.

Phase two included two focus groups of seven and five midwives. Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.


This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

Peer Review reports

The provision of water immersion for labour and birth is facilitated by midwives working within low risk midwifery-led models of care who are deemed competent to provide this method of birth [ 1 , 2 ]. The concept of competence is often aligned with confidence [ 3 ], but distinguishing between these two concepts is important as they are not always synonymous. A midwife may be a competent waterbirth practitioner having met all the professional competency requirements, but becoming confident is an individual journey that is dependent upon trust in clinical guidelines, presence of peer support and the challenge of achieving consistent exposure to waterbirth [ 4 ]. Additionally, midwives with extensive experience of conventional birth on land may be challenged to unlearn old skills and develop new practices required for water immersion in labour and birth. Whilst midwives working within low risk continuity of care models where physiological birth was the norm, researchers concluded that a supportive culture assisted in the development of their confidence, irrespective of clinical experience [ 4 ].

Individual midwives can act as gate keepers to water immersion which is more likely to be accepted into an organisation’s culture when it is supported by midwifery managers and championed by experienced waterbirth practitioners [ 5 ]. These champions can mentor midwives who wish to achieve waterbirth competency [ 5 ]. In this situation, mentors may not always be the most senior midwives who have extensive experience with conventional birth on land. Caution is recommended to recognise and consider ways to minimise the possible hierarchical tensions that may occur when experienced midwives are mentored by junior midwives who have achieved waterbirth competency [ 4 ]. Indeed, promoting and sustaining change in midwives’ waterbirth practice can be challenging. A study, undertaken in the United Kingdom (UK), utilised problem solving workshops to identify interventions that could develop and sustain a waterbirth culture. These interventions included: publishing monthly waterbirth statistics; setting a target of 100 waterbirths per annum; keeping portable birthing pools partially inflated; and appointing a waterbirth champion. Co-ordinators were able to positively influence midwifery practice through social support which was found to be pivotal in relation to developing and sustaining a waterbirth culture [ 6 ].

Access to immersion in water for labour and birth is reliant on both the care provider and the policies and procedures that guide clinical practice. Policies and guidelines in relation to water immersion for birth in Australia usually reflect the organisation’s interpretation of the current literature [ 7 ]. Additionally, more evidence is required around the effect of immersion in water on neonatal morbidity [ 1 , 8 , 9 ] and management of the third stage of labour [ 7 ]. A literature review exploring midwives concerns around waterbirth [ 10 ] identified three clinical issues (neonatal water aspiration and neonatal and maternal infection and thermo-regulation) and two practice issues (midwives skills and education and emergency procedures around maternal collapse). The clinical issues were not evidence based and the practice issues could ‘be addressed by appropriate policy, guidelines and practice’ [ 10 ]. Other work exploring how a convenience sample of 249 Australian midwives utilised normal birth guidelines, found that although the majority (90%) were aware that specific guidelines existed, only 71% reported routinely using them to guide their clinical practice [ 11 ].

It has been suggested that the waterbirth environment nurtures woman-centred care by facilitating shared decision making and perceptions of control around their care [ 8 ]. However, recent Australian research found some midwives perceive waterbirth policies and guidelines can limit their scope to facilitate water immersion and did not always support women’s informed choice [ 12 ].

There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. To address this gap in evidence and build our knowledge around this topic, our intention was to obtain a contemporary overview of midwives' experience of their education, knowledge and practice around immersion in water for labour or birth in Western Australia (WA).

The specific aim of this WA study was to assess Midwifery Group Practice (MGP) and Community Midwifery Program (CMP) midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth. This mixed method study was performed in two sequential phases. Phase one incorporated a cross sectional design and examined midwives' perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire; 34 midwives were invited to participate. Phase two employed a qualitative descriptive design to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth; two focus groups were held.

Mixed methods were utilised to provide in-depth knowledge [ 13 , 14 ] relating to the education, knowledge and practice around immersion in water for labour or birth. This methodology offers researchers using quantitative methods the opportunity to utilise qualitative research to gain deeper understanding of the investigated phenomenon [ 15 ]. Utilising this two phase mixed methodology provided a more informative, constructive and thorough integration of the research results, building on the links between methods rather than within methods [ 15 ]. We envisaged being able to utilise both numbers and words would give greater insight into the bigger picture around midwives' experience of their education, knowledge and practice around immersion in water for labour or birth.

Participants and setting

The study was performed at the sole tertiary public maternity hospital in WA, which has approximately 5200 births annually. Women can labour and birth in the tertiary maternity hospital’s Labour Ward and Birth Suite or the Family Birth Centre (an adjacent building within the hospital grounds).

Perinatal data collected in 2016, by King Edward Memorial Hospital (KEMH) in WA confirmed that 5% (228 of 4402) of infants ≥37 weeks gestation were born immersed in water. Currently WA and South Australia are the only Australian states with state-wide policies and guidance supporting immersion in water for labour and birth, although waterbirth is available in every state and territory [ 16 , 17 ]. In WA midwives are guided by state-wide clinical waterbirth guidelines [ 16 ]. Between August and November 2016 we invited the 34 midwives who provided care for women who opted to use water for labour and/or birth to participate. Throughout the study, women choosing to labour and/or birth in water were cared for by midwives working within two publically funded services: the MGP and CMP. These low risk continuity of care models [ 18 ] are ideally suited to provide care for women who labour and/or birth in water, as this model facilitates a shift from high risk obstetric-led care to low risk midwifery-led care [ 18 , 19 ]. Both the MGP and CMP operate their services (antenatal, intrapartum and postnatal care) from the Family Birth Centre (FBC) with the CMP also providing antenatal, intrapartum and postnatal care to women in their homes and local community clinics. In these midwifery care models, a primary midwife is supported by a small team of midwives who provide continuity of care 24 h a day throughout pregnancy, birth and up to two weeks post birth. Perinatal data collected in 2016 at KEMH confirmed MGP and CMP midwives birthed 16% (813 of 5189) of all women at KEMH. Although, no women received immersion in water for labour and birth in the tertiary maternity hospital’s Labour Ward and Birth Suite throughout the duration of the study, in the last two weeks of the study the tertiary maternity hospital agreed that immersion in water for labour and birth could be facilitated in their main Labour and Birth Suite.

Recruitment and data collection

Midwives were invited to participate in the study through an information letter and in-house designed questionnaire (Additional file 1 ), both of which were sent to their workplace mobile phone. Midwives who did not want to complete the online questionnaire were given the option to complete a hard copy and return it to the research team by placing it in a locked box situated in the FBC. Returning a completed questionnaire was deemed implied consent. Ethics approval was gained from the Women and Newborn Health Service Ethics Committee (Approval Number 2016103QK) at the study centre.

The questionnaire was validated through a review process with an expert panel involving a midwifery educator and three midwives who had experience caring for women who had birthed in water. Feedback from the panel resulted in changes to questions around being competent to facilitate water immersion for labour or birth and actively promoting this birth choice for labour and birth. This question was divided into two questions, one focused upon labour and another concerning birth.

The aim of the questionnaire was to examine midwives' perceptions of education, knowledge and practice around immersion in water for labour. Midwives were asked about: their employment status (if they worked in the MGP or CMP and how long they had been working as a midwife and facilitating water immersion for labour or birth); their education (training undertaken to facilitate immersion in water for labour or birth and number of births required to develop waterbirth confidence); their practice (two factors they would discuss with women in relation to water immersion for labour or birth); their confidence caring for women immersed in water for labour and birth (in the first, second and third stages of labour); their enjoyment facilitating immersion in water for labour and birth; whether they actively promote water immersion for labour and birth; and their interpretation of four scenarios around antenatal, early labour, birth and third stage clinical care. The scenarios required a written response, were scored and were based on information relating to the state-wide clinical waterbirth guidelines [ 16 ]. It was decided to give midwives completing the questionnaire a website link to the state-wide guidelines [ 16 ], in the information letter accompanying the questionnaire. By providing a website link to this guidance, we were examining how midwives interpreted and applied the guidance in their clinical practice. In relation to confidence and enjoyment, midwives were asked to place a cross on a 10 cm line (where zero was ‘not confident’ or ‘does not enjoy’ and 10 was ‘very confident’ or ‘enjoys’), to quantify their perceptions on the continuum from zero to ten.

An item was included at the end of the questionnaire (phase one) inviting midwives to participate in a focus group to discuss their experiences around immersion in water for labour or birth. The first author conducted the two focus groups. Observations were documented by the fourth author in the form of field notes. Each focus group lasted approximately 45 min. The focus groups were held at the study centre in an interview room that was convenient to all interested midwives. Prior to commencing the focus group, midwives were reminded that their privacy would be maintained by issuing each of them a unique identifier; the discussions linked to an individual’s identity should ‘remain in the room’; and that the focus group would be audio recorded. All midwives verbally consented to these conditions.

The final questions for the focus groups (Additional file 2 ) were based around the results from phase one, with two questions being developed: question one asked ‘What contributes to your enjoyment of waterbirth?’ Two prompts were utilised for this question. The first one addressed the promotion of natural birth and the second was around supporting women’s choice. Question two asked ‘Are there any issues with waterbirth?’ One prompt was utilised around the issue of exploring which stage of labour midwives found most challenging.

Data analysis

Phase one: quantitative data.

Each of the four clinical scenarios was allocated a maximum score according to whether a midwife correctly identified key aspects of clinical practice based on the state-wide clinical waterbirth guidelines [ 16 ]. Four members of the research team independently scored each scenario. The team then met to compare scores. Any disagreement in relation to the scores was discussed and a consensus reached by referring back to the data.

Means, and interquartile ranges were used to summarise continuous data (such as the scores for each scenario). Frequency distributions were used to summarise categorical data (such as feeling equipped to facilitate waterbirth following training). Statistical software (SPSS version 22) was used for analysis.

Phase two: Qualitative data

Transcribed focus groups were subjected to thematic analysis [ 20 ] by five members of the research team, who analysed a cross-section of transcripts and field notes ensuring each data source was reviewed by at least two members [ 21 ]. Analysis required the research team to become submerged in the data. Transcripts and field notes were deconstructed enabling the research team to identify patterns, similarities and themes from the midwives’ words or sentences [ 13 , 20 , 21 ]. The team met weekly over three months to negotiate, clarify and refine the themes. Any disagreements on interpretation were negotiated by referring back to the data. All the researchers were clinical or academic midwives, with varying experiences of facilitating immersion in water for labour or birth. As a process of member checking, preliminary themes were presented to five midwife participants who confirmed agreement with the themes.

Table 1 summarises the midwives’ perception of their education, knowledge and practice around immersion in water for labour and birth. A total of 29 (85%) out of a potential 34 midwives returned a questionnaire. The mean time midwives were qualified was 162 months (13 years and 5 months), with the mean time midwives had been facilitating waterbirth being 83 months (eight years and 9 months). Most (59%; n  = 17) midwives worked in the MGP. The majority (93%; n  = 27) of midwives used the WA state-wide clinical guidelines for waterbirth [ 16 ] for their education and training, with 90% ( n  = 26) accessing the E-learning package developed by the study hospital’s education department. Following waterbirth training, 93% ( n  = 27) felt equipped to facilitate waterbirth with the mean number of waterbirths required to facilitate confidence being seven.

On a scale of 0 to 10 (where zero was ‘not confident’ and 10 was ‘very confident’), midwives were very confident caring for women in water during the first stage of labour (mean score of 10). They were also confident caring for women in the second stage (mean score of 9) and third stage of labour (mean score of 8). The mean score in relation to confidence using the emergency evacuation to get the woman out of the bath was eight. On a scale of 0 to 10 (where zero was ‘does not enjoy’ and 10 was ‘enjoys’), midwives enjoyed facilitating immersion in water and birth, obtaining a mean score of 10. Finally, mean scores for the antenatal, early labour, birth and third stage of labour scenarios indicated midwives were practicing according to the WA state-wide clinical guidelines for waterbirth [ 16 ].

Two focus groups comprising of seven and five midwives were performed. Findings are presented with supportive quotes in italics from the midwives. For confidentiality a pseudo-name was allocated to each midwife.

Caring for women who labour or birth in water

Exploration of what midwives enjoyed about caring for women who labour or birth in water revealed three distinctive themes: instinctive birthing; woman-centred atmosphere; and undisturbed space (Table 2 ).

Instinctive birthing

The theme ‘instinctive birthing’ described how midwives perceived labouring or birthing in water nurtured an instinctive birthing behaviour led by the woman. Anna reflected ‘ You absolutely see the hormones that promote labour take over. You know labour progresses better and the woman relaxes into labour ’. Noreen agreed; they ‘ Really feel what the body is able to do and how birth feels ’, whilst Kate described how she perceived water enabled her to trust a woman’s ability to instinctively birth:

I think they progress really well. I don’t do many vaginal exams, but they are getting in [the water] and they are well established, they are fully before you know it and they don’t push early. Like sometimes with their first grunt the heads on view…They’re not asking for epidurals, they’re not asking for gas.

Jasmine agreed with Kate’s sentiments: ‘ Because you can’t see as the vagina is submerged, the first sign she needs to push is she’s pushing ’ whilst Anna summarised her experience was that ‘ They’re more likely to reach down and lift the baby up themselves ’.

Woman-centred atmosphere

The theme ‘woman-centred atmosphere’ described a labour and birth environment which was woman centred, calm, peaceful and relaxed. Initially midwives discussed how labouring and birthing in water empowered women. Jacquie noted ‘ I feel women have more control ’. Anna agreed suggesting she thought it was to do with power stating ‘ The woman holds more of the power in labour ’. Noreen continued the discussion ‘ the thing is society brings up pictures of women with somebody doing it [the birth] for them, there is a cultural thing of having somebody delivering the baby whilst [with water] there is themselves and their body ’. Bonnie reflected on Noreen’s comments suggesting water promoted a change in the woman’s demeanour ‘ You can see the change in the woman’s face and in her body when she gets in the water, it’s nice and relaxed ’. Beth agreed water ‘ Promotes the environment to be quiet and peaceful ’. Jacquie thought this may be because ‘ The space between contractions is very different from a land birth, they are very much more focused on their breathing and calmer ’. Whilst Noreen shared how a woman’s relaxed state affected the care she gave ‘ You know it’s all relaxed and you can concentrate more on the signs, the natural signs of a woman giving birth ’ . Sophie agreed ‘ It’s so calming for the women. I think it relaxes them which then relaxes us ’.

Undisturbed space

The theme ‘undisturbed space’, described how water creates an undisturbed space where access to the woman is mediated by the water. Jasmine noted that ‘ If you’re in the bath people knock and they stay out, they leave you alone. As far as society is concerned, it’s not acceptable to walk into the room when someone’s in the bath. If someone’s in lithotomy, fine ’. Kerry reflected it also had an impact on how safe the woman felt. ‘ Especially for the women who have a sexual abuse history, they feel safer in the water, they feel like you can’t get at them ’. The topic of safety led to a discussion around privacy with Olivia commenting that ‘ It’s [‘water] their ‘own space and you have to really reach into their space, rather than them being poked and prodded [with a land birth]’. Dorothy agreed stating ‘ It’s more undisturbed ’. Kerry continued ‘ Even though you can see beneath the water and everything, I think for them it just feels, more private under the water ’. Kate reflected on her experiences by recounting a scenario ‘ A woman that came back to the waterbirth study day and spoke about when she got in [the pool] there was a real sense of privacy, even though she had nothing on, the water was like a veil ’. Baily also remarked on how the ‘dynamics’ of a labour in water effects the partner ‘ I get a sense they quite like it too, because they are able to just sit and observe and hold that silent still place…my experience is that even men feel quite comfortable in that space ’.

The challenges midwives experienced with waterbirth

Analysis of the focus group transcripts exploring the question ‘are there any issues with waterbirth’ revealed that issues highlighted by the midwives were perceived as challenges. Two themes were identified: learning through reflection and facilities required to support waterbirth.

Learning through reflection

The theme ‘learning through reflection’ illustrates how midwives learnt by documenting and then reflecting on the clinical challenges encountered during their day to day clinical practice around water immersion for labour and birth. Kerry shared ‘ I didn’t used to but since we’ve been doing group practice… when you look at your records you can see most of them are waterbirths ’. Olivia continued ‘ I don’t remember all of the waterbirths…I’ve got a little book that I just pop them in ’. Kate reflected on her colleagues comments sharing she did not keep records of each waterbirth and that her confidence caring for women in water ‘ took a long time. I’ve probably done, I don’t know over 150 now ’. Kate went on to explain why ‘ You had to flex the head and then move the hand and then sweep the perineum, it was really hands on. But that’s how we were taught. So to move to totally hands off [waterbirth] where you’re not even poised is challenging ’. Olivia agreed with Kate’s sentiments describing a waterbirth scenario where ‘ I remember taking over from somebody else and it was a hypno-birth and so there was no talking…it was a good learning experience ’.

To illustrate, the topic of learning through clinical experience led to a discussion around placental cord snapping. Bonnie shared ‘ I’ve had a few cord snaps now. Like quite a few issues, but it hasn’t changed my feeling of how to perform waterbirth because I know it’s going to be fine and we just deal with it as it comes ’. Kerry empathised, supporting Bonnie by acknowledging ‘ I think a lot of midwives get anxious even though they may pretend they don’t get anxious about waterbirths. They want to get the baby out as fast as possible. But I think if you make them [the women] aware you don’t just yank it [the baby up]… you need to check how long it [the cord] is before you can go yanking’ .

Facilities required to support waterbirth

The theme ‘facilities required to support waterbirth’ related to ensuring waterbirth facilities were suitable, available and accessible for women and identified challenges relating to the provision of infrastructure around waterbirth. Jasmine stated:

If we want this option [waterbirth] open for all women then we need to provide the facilities for that to happen. I have an issue with it being inequitable at the moment. The Birth Centre has the birth pool and blow up pools that are free of charge whilst clients [women] in the main hospital and CMP have to pay and hire their own…how come one group of clients under the same public system get it for nothing and the other group have to pay?

Sophie was also concerned by the rollout of waterbirths to the main hospital but her frustration was around the referral process. ‘ When waterbith was approved in the main hospital…I had a patient come over and say ‘I want a waterbirth but they [the main hospital] won’t facilitate one for me over there and they’ve told me to come to the Birth Centre and I was quite surprised ’. Whilst Kate’s sentiments concerned the content of the waterbirth guidelines. ‘ When it [the waterbirth guideline] was first developed we didn’t have telemetry and now we do. So I think waterbirth telemetry needs to be incorporated into the guideline’ . Other midwives did not appear sure of how often in-service needed to be provided in relation to emergency management, pool evacuation and assessment of blood loss. There was debate between midwives in relation to how often these drills should be performed. Dorothy confirmed ‘ In the CMP we have to do like a quiz, you know we put the blood in the water every six months and estimate it ’. Whilst Jacquie confirmed ‘ We do up a calendar [of available professional development sessions]’ and it was up to individuals to ensure their development was up to date.

This mixed methods study enabled us to explore midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth in WA. Quantitative analysis found the majority of midwives felt equipped following waterbirth training to facilitate labour and birth in water, with scenario responses indicating midwives were practicing according to the WA state-wide guidance. Additionally, midwives were confident and enjoyed caring for women who used water immersion. Qualitative exploration of what midwives enjoyed about caring for women who used water immersion for labour and/or birth revealed three distinctive themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Whilst exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth. Our discussion will focus on what waterbirth offers midwives.

Labouring and birthing in water is centred around the philosophy that pregnancy and birth are normal life events [ 19 ]. The importance of sustaining a waterbirth culture highlighted by these WA midwives aligns with the belief that maintaining low risk birth cultures is essential to meet the needs of healthy, low risk women through recognition and respect of midwives’ contribution [ 22 ]. Midwives in this study were experts in their field, who had been qualified for a mean of 13 years and five months and facilitating waterbirth for a mean of eight years and nine months; similar to other research [ 6 ]. During the study it was agreed that immersion in water for labour and birth could be facilitated in the tertiary Labour and Birth Suite. We suggest this expertise will be integral in relation to supporting midwives in the tertiary Labour and Birth Suite to become skilled waterbirth practitioners. Indeed, an action research study introducing a problem solving waterbirth workshop with UK midwives and their co-ordinators positively affected change in waterbirth practice and was recognised for its potential shift toward normalising low risk midwifery care [ 6 ].

Midwives are guided by the International Confederation of Midwives (ICM) Position Statement on ‘keeping birth normal’ [ 23 ] which asserts that midwives are advocates and experts in low risk childbirth. The ICM acknowledges that ‘women should have access to midwifery-led care, one-to-one support, including the choice of a home birth and immersion in water’ [ 23 ] which aligns with the international recommended pathway towards evidence based respectful maternity care [ 24 ]. Utilising immersion for labour and/or birth provides midwives with an opportunity to facilitate this experience for women.

The theme of ‘learning through reflection’ articulated by the midwives supports the ICM Philosophy of Midwifery Care [ 25 ] ensuring competent midwifery care is informed and guided by continuous education. The association between workplace learning and competence was confirmed in a Japanese study with nurse/midwives who related learning through reflection to their self-reported competence [ 26 ]. Differences were noted based upon level of experience whereby learning from feedback and training were associated with competence for more experienced clinicians compared to learning through practice and from others for self-reported competence for those with less experience [ 26 ]. Fittingly, the Australian national competency standards for the midwife [ 27 ] present domains around the provision of woman-centred care, with one domain suitably entitled ‘reflective and ethical practice’. Midwives in this study reinforce the relevance of this domain in their practice as both the clinical scenarios and focus group findings illustrated they valued having the ability and skills to analyse and reflect in, on and about practice to ultimately maintain clinical competence and confidence. In short, when care is provided by midwives who are educated [ 28 , 29 ], regulated [ 21 , 30 ] and provide respectful evidence based care [ 24 ], the outcomes are improved for women and their infants [ 1 , 24 , 28 , 29 ]. The midwives in this study adhered to these principles empowering women to realise their potential to birth, though the medium of water.

Strengths and limitations

Although the quantitative methods employed provided limited scope to explore the wide range of experiences midwives in our study encountered caring for women who laboured and/or birthed in water, they did provide the research team with an objective starting point for further exploration of specific aspects of the questionnaire [ 21 , 30 ]. For example, utilising a question for the focus groups gleaned from a phase one question asking midwives to score their enjoyment facilitating immersion in water for labour and birth, gave us the opportunity to contextualise what they enjoyed; providing a connection between the quantitative and qualitative components that could not be answered by mono-methods alone. By utilising both numbers and words to explore this topic [ 14 , 15 ], the qualitative and quantitative components became cohesively integrated, producing research findings around midwives enjoyment which were greater than the sum of individual parts of the research [ 31 ]. This approach exposed the importance of instinctive birthing; woman-centred atmosphere; and undisturbed space.

Midwives in this study were self-selected from the MGP and CMP midwives based within the sole tertiary public maternity hospital in WA. Providing midwives with a website link to the WA state-wide waterbirth guidelines may have influenced their responses. This was a self-assessment of competence which is a subjective aptitude. The research would have been strengthened by comparing the midwives responses to their actions. Participating midwives may have been motivated and confident in their waterbirth practice. The sample of midwives included in phase one was small and may not be representative of all midwives who provide care for women who labour and/or birth in water. We acknowledge these factors could have had an impact in relation to the findings and should be considered when interpreting transferability of the findings to other settings.

This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are an integral component in relation to supporting and sustaining a waterbirth culture. Midwives in this WA study were both competent and confident and enjoyed caring for women who used water immersion. Perhaps this was because the medium of water not only empowered women to realise their potential, but also themselves.


Community Midwifery Program

Family Birth Centre

International Confederation of Midwives

King Edward Memorial Hospital

Midwifery Group Practice

United Kindgom

Western Australia

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We would like to thank King Edward Memorial Hospital for providing funding for the research staff and the midwives for graciously sharing their experiences.

The research was not supported by a research grant. King Edward Memorial Hospital provided funding for the research staff to undertake and complete the project with no role in study design, data collection, analysis, interpretation and writing the manuscript.

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We had assured the midwives participating in the study we would maintain their confidentiality and privacy. As there 29 midwives in this study, we were not able to make their supporting data available as we felt their identity may be compromised.

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Lucy Lewis, Yvonne L. Hauck & Brooke Thomson

Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Subiaco, Western Australia, 6008, Australia

Lucy Lewis, Yvonne L. Hauck, Janice Butt, Chloe Western, Helen Overing, Corrinne Poletti & Jessica Priest

Family Birth Centre, Midwifery Group Practice and Community Midwifery Program, King Edward Memorial Hospital, Subiaco, 6008, Western Australia, Australia

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All authors read and approved the final version of the manuscript. LL was responsible for the proposal, ethics approval development of the data collection tool/questions and coordination of the study. For the quantitative data she assisted data entry into SPSS. She also performed the quantitative data analysis. For the qualitative data she ran the focus groups and participated in thematic analysis. She drafted the article and was responsible for the final editing which incorporated the team member’s comments. YH assisted LL with the proposal and ethics approval and development of the data collection tool. For the qualitative data she participated in the thematic analysis. She assisted LL with the drafting of the article. JB assisted with development of the data collection tool/questions and made comments on the final article. CW assisted with the coordination of the study. For the qualitative data she assisted with the focus groups. She made comment on the final article. HO participated in thematic analysis. She made comment on the final article. CP participated in thematic analysis. She made comment on the final article. JP participated in thematic analysis. She made comment on the final article. DH assisted with coordination of the study. She made comment on the final article. BT contributed and approved the final article.

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Correspondence to Lucy Lewis .

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Ethics approval and consent to participate.

Ethics approval was gained from the Women and Newborn Ethics Committee (Approval Number 2016103QK) at the study centre. Returning a completed questionnaire was deemed implied consent. An item was also included at the end of the questionnaire inviting midwives to participate in a focus group to discuss their experiences around immersion in water for labour or birth. Prior to commencing the focus group midwives were reminded that their privacy would be maintained by issuing each of them a unique identifier; the discussions linked to an individual’s identity should ‘remain in the room’; and that the focus group would be audio recorded. All midwives verbally consented to these conditions.

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Midwives satisfaction with waterbirth questionnaire. (PDF 184 kb)

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Focus group questions. (DOCX 12 kb)

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Lewis, L., Hauck, Y.L., Butt, J. et al. Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth. BMC Pregnancy Childbirth 18 , 249 (2018). https://doi.org/10.1186/s12884-018-1823-0

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Received : 01 December 2017

Accepted : 14 May 2018

Published : 19 June 2018

DOI : https://doi.org/10.1186/s12884-018-1823-0

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Doctoral Thesis Collection

midwifery education dissertation

This midwifery PhD thesis collection is an exciting new initiative for the RCM.

The aim of the collection is to provide a platform for midwives to showcase their academic work, and to inspire and support midwives who are considering or who are currently undertaking further academic study. Additionally, the collection will provide a source of open access midwifery generated evidence for everyone to use.

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Submit details of your doctoral thesis to be included in the RCM collection

The Incarcerated Pregnancy: An Ethnographic Study of Perinatal Women in English Prisons

Prison Pregnancy, Incarceration Birth


The UK has the highest incarceration rate in Western Europe, with pregnant women making up around 6% of the female prison population. There are limited qualitative studies published that document the experiences of pregnancy whilst serving a prison sentence. This doctoral thesis presents a qualitative, ethnographic interpretation of the pregnancy experience in three English
prisons. The study took place during 2015-2016 and involved semi-structured interviews with 28
female prisoners in England who were pregnant, or had recently given birth whilst imprisoned,
ten members of staff, and ten months of non-participant observation. Follow-up interviews with five women were undertaken as their pregnancies progressed to birth and the post-natal phase.
Using a sociological framework of Sykes’ (1958) ‘pains of imprisonment’, this study builds upon existing knowledge and highlights the institutional responses to the pregnant prisoner. My original contribution to knowledge focuses on the fact that pregnancy is an anomaly within the patriarchal prison system. The main findings of the study can be divided into four broad concepts, namely: (a) ‘institutional thoughtlessness’, whereby prison life continues with little thought for those with unique physical needs, such as pregnant women; and (b) ‘institutional
ignominy’ where the women experience ‘shaming’ as a result of institutional practices which
entail their being displayed in public and characterised with institutional symbols of
imprisonment. The study also reveals new information about the (c) coping strategies adopted
by pregnant prisoners; and (d) elucidates how the women navigate the system to negotiate
entitlements and seek information about their rights. Additionally, a new typology of prison officer has emerged from this study: the ‘maternal’ is a member of prison staff who accompanies pregnant, labouring women to hospital where the role of ‘bed watch officer’ can become that of
a birth supporter. This research has tried to give voice to pregnant imprisoned women and to highlight gaps in existing policy guidelines and occasional blatant disregard for them. In this sense, the study has the potential to springboard future inquiry and to be a vehicle for positive
reform for pregnant women across the prison estate.

Threatened preterm labour: a prospective cohort study for the development of a clinical risk assessment tool and a qualitative exploration of women's experiences of risk assessment and management.

Preterm birth, risk, prediction



Background: Preterm birth (PTB) is a major cause of infant morbidity and mortality, and accurate assessment of women in threatened preterm labour (TPTL) is vital for identifying need for appropriate intervention. Risk assessment in TPTL is challenging, however, due to its complex and multifactoral nature. In many women, TPTL symptoms do not progress to spontaneous PTB (sPTB) so assessment that reassures quickly, often through use of tests, e.g. fetal fibronectin (fFN) and cervical length(CL), may reduce unnecessary intervention and decrease anxiety. Aims: This PhD project had two main objectives: first to improve TPTL risk assessment by further developing the clinical decision support tool, the “QUIPP” mobile phone application, which simplifies risk assessment by calculating individual % risk of sPTB based on risk status, fFN and CL results. The second objective was to understand TPTL from the women’s perspective in order to inform future improvements in care.

Method: The study comprised three components: 1) a prospective cohort study, collecting data on risk factors, test results and interventions. Predictive utility of fFN and CL were investigated, as well as generation and validation of risk prediction algorithms for the second version of QUIPP; 2) a qualitative study of women’s experience of TPTL through one-to-one semi-structured interviews; 3) a qualitative study of clinicians using the first version of QUIPP.

Results: Cohort study: 1186women were recruited at 11 UK hospitals between March 2015 and October 2017, with data available for analysis on 1037. Prevalence of sPTB was 3.9% (40/1037)and 12.1% (125/1037) at <34 and <37 weeks’ gestation, respectively. Validation of QUIPP algorithms, using risk factors and fFN results alone, demonstrated good prediction of sPTB <30 weeks’ gestation (AUC 0.96, 95% CI 0.94-0.99) and at <1 week of testing (AUC 0.91, 95% CI 0.87-0.96). Qualitative study: Four themes emerged following interviews with 19 women: i) coping with uncertainty; ii) dealing with conflicts; iii) aspects of care and iv) interactions with professionals. QUIPP users’ study: 10 clinicians expressed predominantly positive views and suggested improvements.

Conclusion: All components of this project informed development of QUIPP v.2 (algorithms and design), which appears superior in predicting sPTB compared to previously reported predictive utility of fFN, CL and QUIPP v.1 algorithms. The qualitative study was the first exploring women’s experience of TPTL in a UK hospital with a specialist preterm service, and findings further support the need for women of all risk groups to have timely access to advice and information, and continuity of care.

Grading student midwives’ practice: a case study exploring relationships, identity, and authority.

Grading practice, students, Assessment, Midwifery knowledge

Grading students’ practice in the UK is a mandatory requirement of midwifery programmes regulated by the Nursing and Midwifery Council. This thesis explores how grading affects midwifery students, mentors and lecturers’ relationships, identity and authority. Individual and group interviews with fifty-one students, fifteen mentors and five lecturers, recruited from three local NHS Hospital Trusts and a university provided a diversity of views and experiences. This was complemented with documentary data from student practice grades, practice assessment documents and action plans from underperforming students. The analytical framework for this case study draws on Basil Bernstein's pedagogic codes using the concepts of classification and framing. This enabled an exploration of what counted as valid practice knowledge, teaching and learning in clinical practice and the evaluation of learning.Differences between students, with respect to their orientation to midwifery knowledge, types of practice knowledge and relationships between the hospital and community mentors were identified. Despite these, students were consistently awarded high practice grades. The environment seemed to affect the structural and interactional practices between students and mentors and, according to Bernstein’s theory, should have affected the practice grade. However, there was limited stratification of grades. Therefore, the grades have been interpreted as competence rather than performance of midwifery and symbolise acceptance into the profession. Reasons for this were offered. This study provides a unique insight into grading students’ practice, resulting in recommendations such as the separation of the role of mentor from assessor as well asa call for greater assessment of communication skills and evidence to inform midwifery practice. New models of teaching and assessment in clinical practice may enable a change of pedagogic code. Understanding the complexity of the practice area and the types of discourses it produces is necessary to enable all students equal access to midwifery specific knowledge.

Home birth and the English NHS: Exploring the dynamics of institutional change in the context of health care.

Home birth; deinstitutionalisation; midwifery


This study aimed to understand and explain the work involved in creating, maintaining and disrupting divergent models of health service organisation and delivery, with a specific focus on maternity care provided to healthy women who chose to give birth at home. It investigated questions about the priorities that frame the allocation and management of health service resources and sought to understand how opportunities to advance new institutional practices were recognised, created or resisted by different stakeholders. This study drew upon concepts of deinstitutionalisation to examine why the disappearance of older institutional practices [in this instance, home birth] were not always inevitable when a newer practice [such as an obstetric unit birth] became prevalent or dominant. Work examining mature institutional fields exposed to modernising influences has suggested that non-dominant professional groups appear to engage in countervailing activities that maintain the persistence of older institutional practices while making efforts towards reinstitutionalisation. To date, studies have tended to focus attention at the top of organisations or on embedded or dominant occupational groups. This study has expanded and developed understandings of the agentic activity undertaken by a non-dominant professional group that sit largely outside strategic management and funding structures who sought to re-legitimise institutional practices which had been eroded or threatened with extinction. Methodology and methods: This was a multiple case site study that employed a variety of qualitative research methods. This was compatible with institutional theory which has sought to examine how enduring social patterns and arrangements are constructed, become taken for granted and treated as inevitable. This study engaged with three separate organisations providing maternity services and a range of organisations and individuals associated with, or affected by this activity. The case sites were selected to represent a range of settings, conditions and relationships that are recognisable across the English National Health Service (NHS). Intended contribution: The theoretical contribution of this study is to organisational and medical sociology questions about occupational relationships and the priorities that frame the allocation and management of health service resources. This was achieved by identifying institutional work both seeking to reinforce or resist existing medicalised and acute-focused maternity services. Practically, this study engaged with the socio-cultural and political complexities of maternity services’ organisation and delivery. It provides information for policy-makers, service leaders and innovators who are contemplating implementing changes in contexts where home birth services are under-developed or under-performing.

Meeting the health and social needs of pregnant asylum seekers; midwifery students' perspectives.

Critical discourse analysis, midwifery students, problem-based learning as a research method,
pregnant asylum seekers.

Current literature has indicated a concern about standards of maternity care experienced by
pregnant asylum seeking women. As the next generation of midwives, it would appear essential that students are educated in a way that prepares them to effectively care for pregnant asylum seekers. Consequently, this study examined the way in which midwifery students constructed a pregnant asylum seeker’s health and social needs, the discourses that influenced their
constructions and the implications of these findings for midwifery education. For the duration of year two of a pre-registration midwifery programme, eleven midwifery students participated in
the study. Two focus group interviews using a problem based learning (PBL) scenario were conducted. In addition, three students were individually interviewed and two students’ written reflections on practice were used to construct data. 2 Following a critical discourse analysis, dominant discourses were identified which appeared to influence the way that pregnant asylum seekers were perceived. The findings suggested an underpinning discourse around the asylum
seeker as different and of a criminal persuasion. In addition, managerial and medico-scientific discourses were identified, which appeared to influence how midwifery students approach their
care of women in general, at the expense of a woman centred, midwifery perspective. The findings from this study were used to develop “the pregnant woman within the global context” model for midwifery education and it is recommended that this be used in midwifery education, to facilitate the holistic assessment of pregnant asylum seekers’ and other newly arrived migrants’ health and social needs.

Birth Place Decisions: A prospective qualitative study of how women and their partners make sense of risk and safety when choosing where to give birth

Place of birth, risk, narrative, longitudinal

For the past two decades, English health policy has proposed that women should have a choice of place of birth, but despite this, almost all births still take place in hospital. The policy context is one of contested evidence about birth outcomes in relation to place of birth, and of international debate about the safety of birth in non-hospital settings; partly as a consequence of this, ‘birth place decisions’ have become morally and politically charged. Given the perceived lack of consensus about birth place safety, this study sought to explore the experience of making birth place decisions from the perspectives of women and their partners, in the context of contemporary NHS maternity care.

Longitudinal narrative interviews were conducted with 41 women and 15 birth partners recruited from three English NHS trusts, each of which provided different birth place options. Initial interviews were conducted during pregnancy, and follow up interviews took place at the end of pregnancy and again up to three months after the birth. Altogether, 141 interviews were conducted and analysed using a thematic narrative approach.

This research contributes new knowledge about how birth place decisions are undertaken and negotiated, and about the extent to which some are excluded from these choices. Participants’ beliefs about birth place risk originated in upbringing and drew upon normative discourses which positioned hospital as an appropriate setting for birth. Individual worldviews informed conceptualisations of birth place risk, and these were premised upon prioritisation of medical risks of birth, perceived quality of the maternity service or the likelihood that medical intervention would interfere with birth. These beliefs were often enduring and the overall tendency was for women to be increasingly conservative about their birth place options over time, but during their first pregnancies, participants views were most fluid and open to change.

An Interpretive Exploration of the Experiences of Mothers with Obesity and Midwives Who Care for the Mother During Childbirth

Obesity; Childbearing.

Obesity, as defined as a BMI ≥ 30 (kg/m2) had been established as a risk factor for increased morbidity and mortality during childbearing. There was a need for empirical research to explore the experiences of obese women and midwives during childbearing to stimulate debate and inform the delivery of care to this client group. This thesis provides a justification for a qualitative interpretivist study using semi-structured interviews with obese women and midwives. This study found that once an obese mother has been placed on the high-risk medicalised pathway, her choices are reduced and the ability to bring a sense of agency and choice to promote and support her own health is limited. The relationship with the midwife, which could have been focused on promoting the health and wellbeing of mother and baby, instead becomes a relationship of managing risk in a reductionist way. This makes it harder for both mothers and midwives to raise the issue of obesity, resulting in a tendency not to deal with the issue. Subsequently, the opportunities for health promotion offered by the midwife-mother relationship sustained over 7
to 8 months are lost, so that encouraging self-understanding and self-help in managing and reducing obesity cannot be achieved. The findings of this study suggest the need to enhance the health promotion role of the midwife. This thesis suggests reviewing the use of BMI, developing discussions about gestational weight gain and healthy lifestyle choices with women during antenatal care, and listening to mother’s lay theories, perceptions and concerns around weight. Midwifery care, which uses positive discourses and forward-facing care approaches and supported by continuity of carer schemes and access to midwifery-led care, could enhance the midwife’s health promotion role. This could lessen the risk of post-partum weight retention post-birth and enhance a new mother’s physical and emotional wellbeing.

Can an educational web intervention, co-created by service users, affect nulliparous women's experiences of early labour? (A randomised control trial)

Latent, Early, Digital, Experience

Women without complications have less obstetric intervention if they remain at home in early labour, yet report dissatisfaction in doing this, describing a disparity between expectations and the reality of this phase. A dichotomy exists between what is clinically beneficial (remaining at home) and what women require emotionally(support and reassurance). Previous research has been driven by maternity services’ needs, focusing on the transition between labour phases, commonly testing interventions that aim to improve clinical outcomes. Using self-efficacy theory, a web-based intervention was co-created providing early labour advice, alongside videoed, real-experiences of women who have previously had babies. The primary aim of this study was to evaluate the intervention’s impact on women’s self-reported early labour experiences. The intervention was trialled in a pragmatic RCT at an NHS Trust between 2018 and 2020. A total of 140 low-risk, nulliparous, pregnant women were randomised to the intervention group (n=69) or the control group (n=71). Data was collected at 7-28 days postnatally using the pre-validated Early Labour Experience Questionnaire (ELEQ). Secondary, clinical outcomes were also collected, as well as information about the acceptability and usability of the intervention. There were no statistically significant differences in the ELEQ scores between trial arms. The intervention group scored more positively in two of the three ELEQ subscale domains (emotional wellbeing and emotional distress) and less positively in the perceptions of midwifery subscale. Participants in the intervention group were less likely to require labour augmentation. The L-TEL Trial demonstrates that women evaluate aspects of their early labour experience continuum independently: an improved emotional experience does not necessarily equate to an overall improved experience of this phase. Equipping women to have better emotional experiences at home may negatively impact on their perceptions of midwifery care when sought. Further research is recommended on a larger scale to explore this.

A qualitative exploration of the role frontline health workers play in defining the quality of services provided to women experiencing an early miscarriage

Quality of Care, Early Miscarriage, Micro Organisational Theory, Frontline Staff


It is proposed that frontline health care workers in the English National Health Service (NHS) should have an important role in managing the quality of the services they deliver. Formal NHS quality management processes are structured in a highly rationalised way and the extent to which frontline workers have agency to apply their own knowledge to address suboptimal care practices is not well understood. This study explores how frontline NHS workers manage the quality of services offered to women experiencing an early miscarriage using qualitative semi-structured interview data collected from 34 frontline health care workers and managers from three hospitals in the North East of England. Secondary thematic data analysis, informed by micro-organisational theories, was used to explore the role of frontline health care workers in managing the quality of their services. This secondary analysis identified three key themes in the data; (1) the link between the quality gap and the difficulties associated with delivering humane and individualised care, (2) the role of collective understandings in defining the parameters of acceptable versus ideal quality of care, and (3) the use of discretionary practices to manipulate quality of care. These findings suggest that management of health care quality is complex and characterised by bureaucratic constraints that support
narratives of powerlessness and compromise amongst NHS workers. Structures that privilege rational models of organisational management pose a significant challenge to the delivery of relational
aspects of care. This study contributes to the evidence base by providing insight into the unseen discretionary practices frontline workers engage in to improve quality of care whilst also maintaining organisational functionality. These practices, based on collective beliefs about the parameters of “acceptable” quality of care, are paradoxical; they can improve quality for individual
patients but they also support the structures that create quality shortfalls in the first place. The findings of this study offer a model of optimal care for early pregnancy loss that could be used as a
framework on which to base quality improvement activities in this area. They also offer a unique insight into the issues that may result in suboptimal care practices perpetuating in the NHS, especially in relation to the delivery of humane and relational aspects of health care; this finding has implications for frontline clinicians, managers, educationalists and policymakers alike.

‘Practising outside of the box, whilst within the system’: A feminist narrative inquiry of NHS midwives supporting and facilitating women’s alternative physiological birthing choices.

Birth, guidelines, autonomy, midwives

This thesis presents the findings of an original study that explored NHS midwives practice of facilitating women’s alternative physiological birthing choices - defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth’. The premise for this research relates to dominant sociocultural-political discourses of medicalisation, technocratic, risk-averse and institutionalisation that has shaped childbirth practices in the UK. For midwives working in the NHS, sociocultural-political and institutional constraints can negatively impact their ability to provide care to women making alternative birth choices. A meta-ethnography was carried out, highlighting a paucity of literature in this area. Therefore, the aim of this study was to generate practice-based knowledge to answer the broad research question: ‘what are the processes, experiences, and sociocultural-political influences upon NHS midwives’ who self-define as facilitative of women’s alternative birthing choices’.Underpinned by a feminist pragmatist theoretical framework, a narrative methodology was used to conduct this study. Professional stories of practice were collected via self-written narratives and interviews to understand the processes of facilitation (the what, how, why), their experiences of carrying out facilitative actions (subjective sense-making), and what sociocultural-political factors influenced their practice. Through purposive and snowball sampling, a diverse sample of 45 NHS midwives from across the UK was recruited. A sequential, pluralistic narrative approach to data analysis was carried out, and a theoretical model was developed using the whole dataset. The findings were subjected to three levels of analysis.First, ‘Narratives of Doing’ highlight how and what midwives did to facilitate women’s alternative choices. The sub-themes reflect the temporal nature of a wide range of actions/activities involved when caring for women making alternative birthing decisions. The second analysis; ‘Narratives of Experience’ - highlighted the midwives polarised experiences captured as ‘stories of distress’, ‘stories of transition,’ and ‘stories of fulfilment’. For the third level of analysis, a theoretical model of ‘stigmatised to normalised practice’ was developed using notions of stigma/normal, deviance/positive deviance. A six-domain model was developed that accounted for the midwives sociocultural-political working contexts; micro, me so, and macro. The implications of this research related to a number of identified constraints, protective factors, and enabling factors for midwifery practice. Key barriers included negative organisational cultures that restricted both midwives’ and women’s autonomy. Disparities between the midwives’ philosophy and their workplace culture were highlighted as a key stressor and barrier to delivering woman-centred care. Protective factors related to the benefits of working in supportive, like-minded teams that mitigated against their wider stressful working environments. Facilitating factors included positive organisational cultures characterised by strong leadership where midwives were trusted and women’s autonomy was supported.Therefore, this study has captured what has been achieved, and what can be achieved within NHS institutional settings. Through the identification of both challenges and facilitators, the findings can be used to provide maternity professionals and services with insights of how they too can facilitate women’s alternative birthing choices.

Exploring decision making to create an active offer of planned home birth

Active offer, Planned home birth, Decision making, Social networks

Historically, the focus of the UK and international research exploring planned home birth decision making has been largely focused on understanding the experiences of women who decide to birth at home. As a result of high-profile research that suggests that non-OU birth locations are safe for low risk women, there has been a recent shift in focus resulting in research studies that aim to increase the rates of planned home birth, or more often the rates of all non-obstetric unit birth within the UK. However, despite this increased level of attention, the rate of home birth remains stubbornly low. Whilst there is some research to indicate why this might be the case, research that sheds a new light on the issue, and that develops an evidence base for new interventions is required. This thesis illuminates the factors that need to be considered in order to increase women’s abilities to make an informed decision about planned birth. A pragmatic approach, using mixed methods, was used to explore the current way that we offer planned home birth to maternity service users, and to ultimately make suggestions about how this could be improved. The application of active offer theory to the offer of planned home birth has been undertaken for the first time, and this has generated a new and useful perspective on this area of midwifery practice.

The resultant two-stage AOPHB process has the potential for developing midwifery practice in terms of supporting midwives to understand and facilitate women’s decision making around home birth, providing a flexible tool that can be used in clinical practice. This is the first approach that has been developed with the aim of increasing the ability of women to make an informed decision about whether they wish to birth at home.

Returning to the Path. A hermeneutic phenomenological study of parental expectations and the meaning of transition to early parenting in couples with a pregnancy conceived using in-vitro fertilisation

In Vitro Fertilisation, Hermeneutic Phenomenology, Pregnancy, Parenthood

Aim: To gain insight into the lived experience of the transition to parenthood for couples with a singleton IVF pregnancy.

Design: Heideggerian hermeneuticphenomenological study.

Methods: Data was collected in 2015, three couples were interviewed on three occasions each, using unstructured interviews; at 34weeks of pregnancy, six weeks and three months postpartum. Interviews lasted 32 -80 minutes (mean: 53) audio data later transcribed. Crafted stories (Crowther et al 2016) were used for analysis and an adaptation of Diekelman et al (1989) on both cross-sectional and longitudinal data.

Findings: The experience of pregnancy and parenting is influenced by the journey to conception and through pregnancy. ‘Returning to the Path’ was identified as the point couples had anticipated being at several years earlier. It drew on three over-arching themes: Seeking the Way, Returning to the Path and Journeying On.

Conclusion: Infertility is a deviation from the life path that a couple anticipated, returning to that path occurs at different times for different couples and is influenced by differing factors. The pregnancy may be experienced as a ‘tentative’ progression, however following birth, parenthood was embraced with an instinctive, baby-led style. Transition to parenthood was aided by social support and reliance on the couple relationship.

Impact: Findings have implications for those who support couples with IVF pregnancies in recognising their, often unspoken, concerns throughout pregnancy, shown as a reluctance to look too far ahead. They also need to appreciate the differing points at which these anxieties can recede.

Twitter: @suzannehardacr1

The experience of pregnant women being offered influenza vaccination by their midwife, a
qualitative descriptive approach

Pregnancy, Vaccination, Influenza, Risk

Aim To explore, interpret and develop an understanding of pregnant women’s experience of
being offered the seasonal influenza vaccination by their midwife and whether this affects the woman’s decision to either accept or decline the vaccine. Research Question ‘Does the
relationship between the woman and the midwife impact on the woman’s decision to accept or
decline the seasonal influenza vaccination in pregnancy?’ Objectives 1 To investigate factors
which when drawn from women’s experience of being offered the seasonal influenza vaccination, influence their decision to accept or decline the vaccine. 2 To explore whether women’s experience of the antenatal environment in which the midwife/ woman discussion takes place has any influence on the decision to accept or decline the vaccine. 3 To identify whether women’s experience differs according to their geographical location.

Methods The study was carried out within five geographical Boroughs within a large University Health Board in South East Wales. Semi-structured interviews were held with twelve pregnant women. A qualitative descriptive approach was used and data were analysed thematically. The theoretical framework of ‘reproductive citizenship’ developed by Wiley et al (2015) was used for interpretation of the study findings

Findings Women’s beliefs conflicted with their actions. Participants believed they were not at risk of influenza yet had the vaccination regardless. Characteristics of wanting to be a good mother and doing the right thing were evident, despite many competing priorities of pregnancy. The environment in which the women had their vaccination was not of concern and they displayed a quiescent approach to the influenza vaccination within the context of their antenatal care. Women placed trust in the midwife, relying on their advice without question. Discussion Fatalism, passive acceptance and influence of the healthcare professional was apparent, and participants spoke warmly of the ‘good midwife’. Magical beliefs and superstition explained the women’s perception of risk, derived from family experience. Fate, luck and perceived lack of control over life events framed women’s views. Women placed trust in the midwife taking comfort in that the knowledgeable professional was making the iii right decision ‘for them’ displaying traits of quiescent reproductive citizenship as characterised by Wiley et al (2015). Conclusion Influenza vaccination and the consequence of disease were perceived to be low down amongst many competing priorities of pregnancy. Participants did not believe that they were at risk of influenza disease and sometimes shifted responsibility for decision making to the midwife, placing trust in the mother / midwife relationship.

Rethinking postnatal care: A Heideggerian hermeneutic phenomenological study of postnatal care in Ireland

Postnatal care; Women's lived experiences; Future postnatal care possibilities; Heideggerian hermeneutical phenomenology

The postnatal period is an important and extremely vulnerable time for new mothers and their infants. Research has outlined the considerable extent of maternal physiological and psychological morbidity following childbirth. The underreporting and undiagnosed aspect of this morbidity has also been highlighted. Newborn infants are totally dependent on their needs being met and are also at risk of newborn conditions particularly if they are undiagnosed, for example neonatal jaundice. There is however, mounting evidence regarding the lack of postnatal support from health professionals, with women continuing to report their dissatisfaction with postnatal care. Research into postnatal care is pre-dominantly quantitative and clinically focused. Few empirical studies have examined the meaning women give to their postnatal care experiences. This research aims to generate a deeper understanding of the meanings, and lived experiences of postnatal care. In addition, it aims to reveal future possibilities to enhance women’s postnatal care experiences. Initially, an in-depth examination of relevant literature is undertaken followed by a presentation of the process and findings from a qualitative meta-synthesis. An in-depth exploration of Martin Heidegger’s biography and explication of his philosophy is then outlined. This research is a Heideggerian hermeneutical phenomenological study of Irish women’s aspirations for, and experiences of, postnatal care. Purposive sampling is utilised in this research, which was undertaken in two phases. Phase one involved group interviews over three different time periods
(between 28-38 weeks gestation, 2-8 weeks and 3-4 months postnatally), with a cohort of primigravid women and a cohort of multigravid women. The second phase involved recruiting two further cohorts of primigravid and multigravid women who participated in individual in-depth interviews over the same longitudinal period. In total nineteen women completed the study. Thirty-three interviews were held in total. The data analysis is guided by Crist and Tanner’s (2003) interpretative hermeneutic framework. The women’s aspirations/expectations for their postnatal care are represented through three interpretive themes: ‘Presencing’, ‘Breastfeeding help and support’ and ‘Dispirited perception of postnatal care’. In addition, five main themes emerged from the data and capture the meanings the women gave to their lived experiences of postnatal care: ‘Becoming Family’, ‘Seen or not seen’, ‘Saying what matters’, ‘Checked in but not always checked out’ and ‘The struggle of postnatal fatigue’. The original insights from this research clearly illuminate the vulnerability women face in the days following birth. A further in-depth interpretation and synthesis of the findings was undertaken. This philosophical-based discussion drew from the work of Heidegger (1962) and Arendt (1998). Engaging with these theoretical perspectives contributed to a new understanding about why some women within a similar context, have positive experiences of postnatal care while others do not. As such, the very nature that midwives and other postnatal carers are human beings has an influence on a woman’s experience of her care. These carers, in their exposition of ‘being’ have the ability to demonstrate ‘inauthentic’ or ‘authentic’ caring practices. It is those who choose to be ‘the sparkling gems’ that
are the postnatal carers who make a difference and stand out from the others. For the women in this study, their postnatal care experiences mattered. While some new mothers reported positive and meaningful experiences others revealed experiences which impacted unnecessarily. The relevance of these findings, recommendations and suggestions for future research are offered.

Conscientization for practice: The design and delivery of an immersive educational programme to
sensitise maternity professionals to the potential for traumatic birth experiences amongst
disadvantaged and vulnerable women.

Critical pedagogy, Birth trauma, immersive education, maternity

Birth is an important time in a woman’s life. While the journey into motherhood can be a
transformational and liminal experience, unfortunately, this is not the case for every woman. It is estimated that approximately 30 % of women experience childbirth as a traumatic event, with up
to 4% of women in community samples developing Post Traumatic Stress Disorder (PTSD) following childbirth. It is also highlighted that women who are vulnerable and disadvantaged, due to complex life situations such as poor mental health, poverty and social isolation, are more
likely to experience birth trauma and PTSD onset. Recent research highlights that women’s subjective experience of birth is one of the most important factors in determining birth trauma, and that negative interactions with health care professionals are a key contributor to its development. The aim of this study was to develop and evaluate a training programme for maternity care providers to raise awareness of birth trauma amongst disadvantaged and
vulnerable women. A critical pedagogical approach was adopted so that the design of the programme would aid reflection, critical thinking and conscientization. This study includes a meta-ethnographic review, empirical interviews and the design and delivery of a tailored educational programme within an NHS Trust. Firstly, a meta- ethnography was undertaken to explore disadvantaged and vulnerable women’s negative experiences of maternity care in high
income countries. Noblit & Hare’s (1988) meta ethnographic approach was used and four themes were identified through the synthesis of eighteen studies; ‘Depersonalisation’
‘Dehumanisation’, ‘Them & us’ and ‘No care in the care’. Secondly, ten local disadvantaged and vulnerable women in North West of England were recruited and interviewed, exploring their
negative experiences of birth. A framework analysis was used to interpret the data, identifying
key triggers for birth trauma, focused on interpersonal interactions with maternity healthcare professionals. These findings were then compared against studies included in the metaethnography. Following these stages an innovative educational programme focused on birth trauma and PTSD was developed and evaluated. Key findings from the meta- ethnography and the empirical interviews informed the content of a filmed childbirth scenario that was embedded within a critical pedagogical framework. The scenario was delivered to participants’ using virtual reality (VR) technology, forming part of a 90- minute educational programme, in which maternity
professionals view the scenario iii from a first-person perspective. Other elements of the education programme involved providing statistical evidence on birth trauma and PTSD, a presentation of qualitative data collected during empirical phases, critical reflections and the development of actionable practice points to change/influence care practice, for self and others. Ten maternity professionals participated in the evaluation, with pre/post questionnaires and a follow-up session used to assess participants attitudes, knowledge and experiences prior, during and following attendance. Findings suggest the immersive educational programme increased participants understanding and knowledge of birth trauma and PTSD, with the use of VR as a tool for knowledge translation found to enhance critical reflection and facilitate praxis. While further research to test the efficacy of the educational programme on women’s birth experiences is needed, simulated first person realities, embedded within a critical pedagogical framework, offer
a unique and innovative approach to addressing interpersonal care in maternity and wider health- related contexts of care.

Twitter: @ClaireHooks

An exploration of student midwives’ attitudes toward substance misusing women following a specialist education programme.

Substance Misuse, Pregnancy, Attitudes, Education

Substance misuse is a complex issue, fraught with many challenges for those affected. Whilst the literature suggests that pregnancy may be a ‘window of
opportunity’ for substance misusing women, it also suggests that there are barriers to women engaging with health care. One of these is fear of being judged and
stigmatised by healthcare professionals, including midwives. Previous research indicates midwives have negative regard toward substance users and that this in turn may lead to stigmatising behaviours and consequential substandard care provision. Midwives however, stress that they do not have appropriate training to effectively provide appropriate care for substance misusers. Research suggests that education is needed in this area to improve attitudes. In this study, the role of education in changing attitude toward substance use in pregnancy was explored using case study methodology. The case was a single delivery of a university degree programme distance learning module ‘Substance Misusing Parents,’ undertaken by 48 final year student midwives across 8 NHS Trusts. The research was carried out in 3 phases, using a mixture of Likert style questionnaires (Jefferson Scale of Physician Empathy and Medical Condition Regard Scale), Virtual Learning Environment discussion board qualitative data and semi structured interviews. The findings of the questionnaires showed empathy toward pregnant drug using women significantly improved following the module (p=0.012). Furthermore, exploration of the students’ experiences of the module demonstrated the importance of sharing and reflecting on practice; the experiences of drug users, both positive and negative; and having an opportunity to make sense of these experiences, as key in influencing their views. Furthermore, the findings indicated value in the mode of delivery, suggesting e-learning to be an effective approach. This research
demonstrates the potential of education in this area but also offers suggestions for educational delivery to reduce stigma in other areas of practice.

Twitter: @ljenkinsmidwife

Recovering the clinical history of the vectis: the role of standardised medical education and changing obstetric practice.

Vectis Education Practice

This thesis explores the use, and later non-use, of the vectis – an instrument invented in the seventeenth century by the Chamberlen family, along with its sister instrument, the forceps. Both instruments were designed to deliver a living baby when birth was obstructed by the head, but their histories were very different. In Britain, the forceps came into the public domain in 1733, the vectis in 1783, after which their respective merits were debated for over a century. Throughout that time, it was clear that both instruments were effective in sufficiently skilled hands, yet the forceps took over so decisively that by the early twentieth century the vectis had disappeared not only from clinical use, but also from the historiography of obstetric instruments. The central question addressed by the thesis is: why did the vectis disappear from clinical use? The thesis argues that the answer to that question is to be sought in the characteristics of clinical practice, skills and training. The vectis required a subtle set of manual skills, and the teaching of such skills was best favoured by individual apprenticeship; the use of the forceps was more easily reduced to rigid rules, and could therefore be taught in large classes. Thus, the shift to such classes around the middle of the nineteenth century favoured the forceps. To reconstruct that shift, this thesis explores the developing debates around medical education in the first half of the nineteenth century, bringing out the hitherto-neglected theme of the importance of midwifery training as a desideratum for the reformers. The link between pedagogic processes and clinical practice reflects the co-construction of users and technology of the Social Construction of Technology (SCOT) model, but requires some modification of that model, not least because the technological consequences of pedagogic change were entirely unintended.

Engaging with the ‘modern birth story’ in pregnancy: A hermeneutic phenomenological study ofwomen’s experiences across two generations

Birth stories, Hermeneutic phenomenology, Heidegger, idle talk

This study considered how women from two different generations came to understand birth inthe context of their own experience but also in the milieu of other women’s stories. For thepurposes of this thesis the birth story (described as the ‘modern birth story’) encompassedpersonal oral stories as well as media and other representations of contemporary childbirth, allof which had the potential to elicit emotional responses and generate meaning in theinterlocutor. The research utilised a hermeneutic phenomenological approach underpinned bythe philosophies of Heidegger and Gadamer. Phenomenological conversations with theparticipants took place in the iterative circle of reading, writing and thinking. This revealed theexperience of ‘being-in-the-world’ of birth for the two generations of women and the way ofcommunicating within that world. From a Heideggerian perspective, the birth story wasconstructed through ‘idle talk’ (the taken for granted assumptions of how things are which comeinto being through language) and took place across a variety of media accessed by women, aswell as through face-to-face conversations. The data revealed that the lifeworld of birth beingsustained in stories (for both generations) was one of product and process, concentrating on thestages and progression of labour and the birth of a healthy baby as the only significantoutcome. This thesis revealed that the information gleaned from birth stories did not in factcreate meaningful knowledge and understanding about birth for these women. The workhighlights a need for further research to qualify the relationship between what women see andhear about birth and their expectation and consequent experience of birth. Further itdemonstrates that women should be given help and guidance to ‘unpack’ and understandnegative stories and portrayals of birth to mitigate the damaging effects of expectant fear.

Twitter: @DrAngelaK

Care of obese women during labour: The development of a midwifery intervention to promote normal birth.

Obesity, Normal birth, Labour, Intervention

Normal birth, defined as birth without induction of labour, anaesthetic, instruments or caesarean section conveys significant maternal and neonatal benefits. Currently one-fifth of women in the United Kingdom are obese. There is evidence of the detrimental effects obesity has on intrapartum outcomes. There is a lack of research on how to minimise the associated risks of obesity through non-medicalised interventions and how to support obese women to maximise their opportunity for normal birth. This thesis aims to provide evidence to address this and develop an evidence-based intervention to promote normal birth. Using a methodological approach aligned with pragmatism, this research was conducted in four parts and underpinned by the MRC framework for the development of complex interventions. Part one was a national survey involving 24 maternity units. Part two was a qualitative study of the experiences of 24 health professionals and part three involved 8 obese women. The final part was a multi-disciplinary workshop that used consensus decision-making to design the intervention. Collectively, the findings suggest that intrapartum care of obese women is medicalised. Health professionals face challenges when caring for obese women but many strive to optimise the potential for normal birth by challenging practice and utilising ‘interventions’ to promote normality. The findings demonstrate that obese women have an intrinsic fear of pregnancy and birth, have a desire for normal birth and ‘obese pregnancy’ presents a window of opportunity for change. The intervention consists of three component parts: an educational aspect, a clinical aspect and a leadership aspect. Whilst acknowledging the importance of safety, increasing intervention during labour for obese women may further increase the risk of complications, with detrimental effects. Addressing intrapartum management of obese women through non-medicalised interventions is of paramount importance to promote normality, maximise the opportunity for normal birth and reduce the associated morbidities.


Las matronas en el Jaén del siglo XX. El caso de la Comarca de Sierra Mágina

Matronas, Género, Historia de las Profesiones Sanitarias

Con la aproximación que hacemos en esta investigación a las matronas, parteras y cultura de nacimiento de la Comarca de Sierra Mágina hemos pretendidocontribuir al estudio de la historia de las mujeres en general, al de las matronas y parteras en particular y recuperar para siempre la historia de la cultura delnacimiento más reciente de la Comarca estudiada, una parcela del saber que estaba en peligro de ser enterrada por la propia actualización científica de lapráctica profesional. Nos hemos acercado a la dimensión socio-familiar, académica, profesional y humana de unas mujeres que jugaron un papel muyimportante en la salud de las mujeres y hombres de la provincia de Jaén. Este acercamiento lo hemos hecho a través de quienes configuraron su espacio derelaciones. El estudio de mujeres, parteras y matronas desde los grupos de discusión, la entrevista en profundidad, las visitas a los pueblos de la Comarca, y lainmersión en documentación archivística nos ha permitido, recoger de cerca, para después contar de lejos, con la objetividad que permiten estosinstrumentos, la experiencia individual de cada matrona y las relaciones que configuraron como consecuencia de su práctica profesional. La segunda parte deesta tesis aborda la cultura popular de nacimiento en una Comarca andaluza de la España rural de mediados del siglo XX.


Twitter: @jayneemarshall

Informed consent during the intrapartum period: an observational study of the interactions between health professionals and women in labour involving consent to procedures.

Informed consent, Medical personnel and patient, Communication on the labour ward, Women in labour

This ethnographic study using participant observation, aimed to explore the issue of informed consent to procedures undertaken during the intrapartum period. It involved recruiting 100 healthy women, who went into labour spontaneously at term, at the point they were admitted to the labour ward. The data collection took place in a large teaching hospital in an East Midlands city from April 1997 until December 1999. The subjects (health professionals and women) were observed throughout the labour until the woman and baby were transferred to the postnatal area. Follow-up interviews were conducted with the woman and midwives, within24 hours, using a semi-structured format based on the observations. The study revealed that it was difficult to obtain informed consent during labour. Contrary to professional belief, not all women wanted to be fully informed about intrapartum care and procedures, or wanted anything other than a pain free and easy labour that they perceived the western medical-technocratic model of care would offer them. Although the midwives' knowledge of legal and ethical issues concerning consent was variable and limited in the majority of cases, they attempted to empower women to make intrapartum choices. However, this was often constrained by the culture of the labour ward environment and the extent to which they adhered to policies and procedures. In cases where medical intervention became necessary, a minority of midwives felt personally disempowered. The obstetricians and paediatricians observed, appeared to be less effective communicators than anaesthetists, often leaving it to the midwife to explain issues to the woman. It is envisaged that these findings, as well as the stereotypical models of the labouring woman and the attending midwife that developed, and the resulting recommendations, be used in partnership between maternity service and education providers to ensure that health professionals not only have effective communication and interpersonal skills, but also are more conversant with the legal and ethical implications of consent.

Voicing the silence: the maternity care experiences of women who were sexually abused in

Childhood sexual abuse, Maternity Care, Feminist research, Narrative


Childhood sexual abuse is a major but hidden public health issue estimated to affect approximately 20% of females and 7% of males. As most women do not disclose to healthcare professionals, midwives may unwittingly care for women who have been sexually abused. The purpose of this study was to address the gap in our understanding of women’s maternity care experiences when they have a history of childhood sexual abuse with the aim of informing healthcare practice. This narrative study from a feminist perspective, explored the maternity care experiences of women who were sexually abused in childhood. In-depth interviews with women, review of their maternity care records and individual and group interviews with maternity care professionals were conducted. The Voice-centred Relational Method (VCRM) was employed to analyse data from the in-depth interviews with women. Thematic analysis synthesised findings, translating the women’s narratives into a more readily accessible form. The main themes identified were: narratives of self, narratives of relationship, narratives of context and the childbirth journey. Medical records provided an additional narrative and data source providing an alternative perspective on the women’s stories. Silence emerged as a key concept in the narratives. This thesis contributes to ‘Voicing the silence’. The particular contribution of the study is its focus on the women’s voices and the use and development of VCRM to listen to them. It highlights where those voices are absent and where they are not heard. Women want their distress to be noticed, even if they do not want to voice their silence. The challenge for those providing maternity care is to listen and respond to their unspoken messages and to hear and receive their spoken ones with sensitivity.


Using a birth ball in the latent phase of labour to reduce pain perception, a randomised controlled trial.

Birth ball, Latent labour, Pain


Hospital admission in the latent phase of labour is associated with higher rates of obstetric intervention, with increased maternal and fetal morbidity. Women sent home from hospital in the latent phase to 'await events' feel anxious and cite pain as their main drive to seeking hospital admission. Using a birth ball to assume upright positions and remain mobile in the latent phase of labour in hospital is associated with less pain and anxiety. However, no research has examined the effect of using birth balls at home in the latent phase on pain perception, hospital admission or obstetric intervention. An animated infomercial was developed to promote birth ball use at home in the latent phase of labour to enhance women's self-efficacy, in order to reduce their pain perception. As a pragmatic randomised controlled single centre trial, 294 low risk women were randomly allocated to two groups. At 36 weeks’ gestation the Intervention Arm accessed the infomercial online and completed a modified Childbirth Self- Efficacy Inventory before and after viewing. They were also offered the loan of a birth ball to use at home. The Control Arm received standard care. On admission to hospital in spontaneous labour, all participants were asked to provide a Visual Analogue Scale score. Both groups were followed up six weeks postpartum with an online questionnaire. Data were analysed on an Intention To Treat basis. A significant increase was found in Outcome Expectancy and Self-efficacy Expectancy after accessing the infomercial and Intervention Arm participants were more likely to be admitted in active labour. No significant differences were found between the VAS scores, or intervention rates. Most respondents (89.2%) described the birth ball as helpful and reported high satisfaction, with comfort, empowerment and progress. The birth ball is a promising intervention to support women in the latent phase. Further research should consider a randomised cluster design.

Life history theory : how the childhood environment affects humans' later life outcomes such as reproductive and marriage behavior, educational attainment and income

Life history theory, Fertility, Female Reproductive Behavior


Human fertility behaviour and reproductive decision-making is highly influenced by social and economic factors and is expected to be driven also by evolutionary processes. The present thesis is looking at human fertility behaviour through the evolutionary lens and therefore provides novel insights to what extent biological, ecological and socio-economic factors shape fertility patterns and reproductive decision-making in different stages of the demographic transition and how they interfere with each other. The first study tests if exposure to high mortality within the natal family in
early childhood leads to faster and riskier reproductive strategies in pre-industrial European society. The results reveal that women who were exposed to high mortality cues within the natal family
were at a greater risk to reproduce earlier and outside a stable union. Giving birth to an illegitimate child served as a proxy for risky sexual behaviour. Further, the study shows that the risk of giving
birth out of wedlock is linked to individual mortality experience rather than to family-level effects. In contrast, adjustments in marital reproductive timing are influenced more by family-level effects than by individual mortality experience. The second study therefore investigates the impact of famine-related high mortality and social factors on union formation in a pretransitional/ transitional
European population. The results show that individuals accelerate their transition to marriage when they were exposed to high mortality cues during early childhood. These results further stress the importance of individual’s early life conditions on their life-history trajectory. The third study considers the findings that fertility behaviour and reproductive decision-making varies across social classes and sheds some light on sex-biased parental investment in a post-transitional Western population. The study reveals that parents bias their parental investment/support depending on their social class towards the sex with the higher expected reproductive success. Low status parents invest more in their daughters’ higher education, whereas high status parents invest more in their sons’ higher education.

Models of maternity care for women with low socioeconomic status and social risk factors: what works, for whom, in what circumstances, and how? A realist synthesis and evaluation

Social risk, models of care, inequality, continuity

Background Factors associated with poor childbirth outcomes and experiences of maternity care include; Black and minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, domestic violence, mental illness and substance abuse. These women struggle to access and engage with services. It is not known what aspects of maternity care work to improve outcomes and experiences for women with social risk factors.

Methods This research aimed to uncover the mechanisms that lead to improved experiences and outcomes through an evaluation of two specialist models of maternity care. One model of care takes a local approach and was placed within an area of significant health inequality. The other was based within a hospital setting and provides care for women based on an inclusion criteria of social risk factors. Using a realist approach a synthesis of qualitative literature and focus groups with midwives working in the specialist models was conducted to develop preliminary theories regarding how, for whom and under what circumstances the model of care is thought to work. Quantitative data on birth outcome and service use measures for 1000 women accessing different models, including standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected analysed using multinominal regression. Longitudinal interviews with 20 women with social risk factors were conducted to refine the theories.

Results The specialist models of care appeared to mitigate the effects of inequality and revealed no adverse outcomes compared to other models of care. Women receiving the specialist models of care were significantly more likely to use water for pain relief in labour, have skin to skin contact with their baby shortly after birth, and be referred to social care and support services. Maternity care based in the community setting was associated with a significant decrease in induction of labour, preterm birth and low birth weight. A subgroup analysis found that the improved preterm birth outcome was particularly significant for women with the highest level of social complexity. The qualitative analysis highlighted possible mechanisms for these findings that were related to access, interpreter services, education, information and choice, continuity of care, social, emotional and practical support and stigma, discrimination, and perceptions of surveillance. Women experienced substandard care when they were not in the presence of a known healthcare professional. Women described the benefits of seeing a known healthcare professional during pregnancy and particularly valued not having to repeat often difficult social and medical histories. They described feeling able to disclose difficult circumstances to a known and trusted midwife. Women in the hospital-based model described a lack of local, community support and had difficulty integrating into unfamiliar support services.

Conclusions Carefully considered place-based care with a focus on continuity can create safe spaces for women and identify their specific needs. The quantitative data highlighted interesting relationships between all community-based models of care and neonatal outcomes that require further testing in future research. The identification of specific mechanisms will allow those developing maternity services to structure models of care around local need without losing the core aspects that lead to improved outcomes.

Mothers Mood Study: women’s and midwives’ experiences of perinatal mental health and service provision

Perinatal mental health, Women

Background: Existing research on poor perinatal mental health largely focuses on recognition and treatment of postnatal depression. Consequently, there is a need to explore antenatal mental health. Aim: To assess poor mental health prevalence in pregnancy, its relationship to sociodemographic characteristics, self-efficacy and perceived support networks. To understand experiences and barriers preventing women with mental health problems from receiving help and explore midwives’ understanding of their role.

Method: Questionnaires were completed by women in early pregnancy. A subset identified to have mental health problems, were interviewed in late pregnancy to explore their experiences and barriers to receiving care. Midwives completed questionnaires exploring their experiences of supporting women with mental health problems and focus groups further discussed the issues raised.

Results: Amongst participants (n=302), the Edinburgh Postnatal Depression Scale (EPDS) identified 8.6%, and the Generalised Anxiety Disorder Assessment (GAD-7) 8.3%, with symptoms of depression or anxiety respectively. Low self-efficacy (p=0.01) and history of previous mental health problems (p<0.01) were most strongly associated with anxiety or depression. Thematic analysis of interviews with women (n=20) identified three themes: ‘past present and future’; ‘expectations and control’; and ‘knowledge and conversations’. Questionnaires were completed by 145 midwives. The three themes identified from the focus groups with midwives were: ‘conversations’; ‘it’s immensely complex’; and ‘there’s another gap in their care’.

Conclusion: Prevalence rates of anxiety and depression amongst women in early pregnancy were found to be similar to those reported in the literature. Low self-efficacy and previous poor mental health were significant predictors of anxiety and depression. Continuity and more time at appointments were suggested by midwives and women to improve discussions regarding mental health. Midwives were keen to support women but lacked knowledge and confidence. Consistent reference was made to the need for training regarding the practical aspects of supporting women’s mental health.

Determinants of late stillbirth Auckland 2006-2009

Stillbirth, Epidemiology, New Zealand


Stillbirth is a devastating and too common outcome of pregnancy; globally there are approximately three million deaths after 28 weeks‟ gestation every year. In New Zealand, as in other high income countries, more than 1 in 200 babies die before birth, and around 1 in 300 die in the last three months of pregnancy. During the mid twentieth century there was a dramatic decline in the rate of stillbirth, however this improvement has not been sustained in recent years. Previous studies have identified certain causes and risk factors for late stillbirth, but over a third of the deaths remain unexplained. The current variation in the rate of stillbirths both across and within high income countries suggests that it is possible to make further improvements in stillbirth rates. We hypothesised that there would be modifiable, but as yet unidentified risk factors for late stillbirth. The Auckland Stillbirth Study was the first case control study to select women with ongoing pregnancies as gestation matched controls. This study found that the disparity in rates of late stillbirth in women from different ethnicities in New Zealand could be attributed to associated factors such as high parity, high body mass index and social deprivation. Regular utilisation of antenatal care was found to be protective, and women who attended at least 50% of recommended antenatal visits had a lower risk of stillbirth compared to those who did not. Antenatal identification of sub-optimal fetal growth was found to be a possible aspect of the benefit of regular antenatal attendance. Maternal perception of fetal movements was also identified as an area of importance, with women who perceived their baby's movements to decrease in the last two weeks of the pregnancy being at greater risk of experiencing a stillbirth. In addition this study found an association between maternal sleep practices and risk of late stillbirth. Most strikingly, the study found that women who went to sleep on their left side on the last night (prior to stillbirth/interview) were half as likely to experience a late stillbirth compared to women who went to sleep in any other position. This study has added a New Zealand perspective to the existing literature on certain known risk factors for late stillbirth (such as high body mass index). It has also identified novel factors that present new possibilities for further research and for the potential for future reductions in the incidence of late stillbirth.

Twitter: @TabibM2

A Different Way of Being The Influence of a Single Antenatal Relaxation Class on Maternal Psychological Wellbeing and Childbirth Experience An Exploratory Sequential Mix-Method Study

Relaxation, Perinatal Psychological Wellbeing, Childbirth Experience, Antenatal Education


Background: Perinatal mental health problems are prevalent, have a wide range of adverse effects on the mother and her child, and are predictors of negative childbirth experiences. Therefore, improving perinatal mental health is a global public health priority and developing services that could promote it must be a priority for maternity services. There is growing evidence that antenatal education incorporating hypnosis or guided imagery techniques may have the potential to promote perinatal mental health and positive childbirth experiences. However, high-quality research in the field is lacking. Aim and objectives: This study aimed to explore the influence of a single 3- hour Antenatal Relaxation Class (ARC), incorporating theory on childbirth physiology, hypnosis and guided imagery, on maternal psychological wellbeing and childbirth experiences. The objectives of the study were to: a) identify the aspects of maternal psychological wellbeing and childbirth experiences that may be influenced by ARC, b) understand ‘why’ and ‘how’ any influence may occur, c) identify the factors that may mitigate the influence of ARC during labour and birth, and d) test the significance of any influence over time.

Methods: The study took an exploratory sequential mixed-method approach. In the initial qualitative phase, a purposive sample of 17 women and 9 birth partners participated in either individual (8 women) or joint (9 women and their birth partners) semi-structured in-depth interviews. The data were analysed using descriptive qualitative and reflexive thematic analysis. The follow up quantitative phase was a prospective longitudinal cohort study that used surveys to further examine childbirth experiences and measure psychological wellbeing in a sample of 91 women at three time points: pre-class, post-class, and post-birth.

Findings: Attending ARC was associated with increased childbirth self-efficacy, reduced fear of childbirth and state and trait anxiety, as well as improved mental wellbeing. These changes were significant and lasted over time, until after the birth. Attitudes towards childbirth changed after attendance at ARC, which motivated wide use of relaxation techniques as a self-care behaviour during pregnancy, labour, birth and beyond. Use of relaxation techniques was perceived to positively influence women’s childbirth experiences and choices including a decline in choice of epidural use for labour pain. The efficacy of the learned techniques in the management of labour pain, however, depended on the ‘birth space’ which encompassed the physical environment, interactions with birth attendants and the clinical picture of the experience.

Conclusion: Incorporating theory on childbirth physiology, hypnosis and guided imagery in childbirth education can enhance perinatal psychological wellbeing and childbirth experiences. Providing relevant education for birth practitioners may contribute to a salutogenic model of childbirth care in which practitioners can facilitate childbirth education as well as a birth space that is conducive to experiencing an altered state of consciousness as a health promoting state.

Unsafe Abortion and Unsupervised Births: Understanding the Challenges of Pregnancy and Childbirth in the Rural Highlands of Papua New Guinea

Unsafe Abortion, Unsupervised Births, Access to Care


Papua New Guinea (PNG) has one of the highest maternal mortality ratios in the world. Postpartum haemorrhage and sepsis related to childbirth and unsafe abortion are the leading causes of death. In PNG around 60% of women give birth unsupervised. This study was conducted the Eastern Highlands of PNG and used a mixed methods approach. This thesis is divided into two themes: unsafe abortion and community experiences and perceptions of pregnancy and childbirth; and describes a community-based intervention to improve maternal health outcomes. Unsafe abortion to end an unwanted pregnancy resulting in severe, acute morbidity was identified among young women presenting to the Eastern Highlands Provincial Hospital. Compared to those women who presented following a spontaneous abortion, those presenting following an induced abortion were significantly more likely to be younger, unmarried and a student (either at school or university). Obtained illegally, misoprostol was the most frequently used method to end pregnancy. Despite knowledge relating to complications that can occur during childbirth, many women continued to give birth, unsupervised in the community. Women faced numerous challenges in accessing care, particularly during childbirth. The implementation of a community-based package of interventions, providing clean birth kits and misoprostol for self-administration was feasible and highly acceptable in this setting. Through review of the findings identified in this thesis, one key factor emerged that influenced maternal health outcomes: access to health care. This key factor underpins the uptake of appropriate health care for two vulnerable groups of women: women with poorly timed pregnancies; and women during pregnancy and childbirth.

Competence and expertise in physiological breech birth

Physiological breech birth, Competence, Delphi, Grounded theory

This doctoral thesis by prospective publication aims to provide pragmatic, evidence-based guidance for the development and evaluation of physiological breech skills and services within the context of contemporary maternity care. The research uses multiple methods to explore development of professional competence and expertise. While skill and experience are acknowledged in multiple national guidelines as important safety factors in vaginal breech birth, prior to this research no guidance existed about how skill and experience should be defined, developed and evaluated. The thesis begins with an integrative review of the efficacy of current breech training methods, highlighting a lack of evidence associating any training methods with improved outcomes for breech births. Following this are two papers reporting the results of a Delphi consensus technique study involving a panel of breech experienced obstetricians, midwives and service user representatives. The first outlines standards of competence, training components and volume of experience recommended to achieve competence and maintain proficiency in upright breech birth. The second outlines principles of practice for physiological breech birth, rooted in relationship and response, and divergent from medicalised practices based on prediction and control. Following this is a grounded theory paper exploring the deliberate acquisition of breech competence among midwives and obstetricians with moderate upright breech experience. The paper reports a theoretical model that can inform development of breech teams and training programmes. The final paper reports a mixed methods analysis of data from the Delphi and grounded theory studies concerning breech expertise. The results present a model of generative expertise, underpinned by affinity, flexibility and relationship, which may function to increase the availability and safety of vaginal breech birth. Each paper is followed by critical analysis and reflection. The thesis ends with a discussion of the implications for practice and research in light of the overall body of work.

The Use of Telemetry to Monitor the Fetal Heart during Labour: A mixed methods study

Labour, telemetry, wireless monitoring, Control


Background: Wireless fetal heart rate monitoring (telemetry) is increasingly being used by maternity units in the UK. Guidelines from the National Institute for Health and Care and Excellence recommend that telemetry is offered to any woman who needs continuous monitoring of the fetal heart in labour. There is no contemporary evidence on the use of telemetry in the UK.

Aims: To gather in-depth knowledge about the experiences of women and midwives using telemetry to monitor the fetal heart in labour and to assess any impact that the use of telemetry may have on clinical outcomes, mobility in labour or control and satisfaction.

Study design: A convergent parallel mixed methods design was chosen.

Methods: Qualitative methods included in-depth interviews with 10 women, 2 partners, 12 midwives and one student midwife from two NHS Trusts in the Northwest of England. A constructivist grounded theory methodology was employed for this phase and used both purposive and theoretical sampling. All interviews were audio-recorded and transcribed verbatim. The quantitative phase recruited 161 women from both sites and compared clinical outcome and mobility data from 74 women who used telemetry during labour and 87 women who had conventional wired monitoring. Women also were asked to complete a questionnaire in the postnatal period on control and satisfaction during labour and birth. Questionnaire data was analysed from 128 women, 64 who used telemetry and 64 who had conventional wired monitoring. Both sets of data were integrated to give an overall broad understanding of telemetry use.

Findings: The grounded theory core category was ‘Telemetry: A Sense of Normality’ and was described by three sub-categories. ‘Being Free’ described women being more mobile when using telemetry in labour and experiencing greater feelings of control, normality, and support. Telemetry also increased dignity for women as they were able to use the bathroom independently and with ease. ‘Enabling and facilitating’ described midwives facilitating the use of telemetry, encouraging mobility and using midwifery skills including caring for women in a birth pool. ‘Culture and Change’ described the different maternity unit cultures and how this impacted on the use of telemetry. Telemetry was viewed as increasing choice and equity for women with more complex pregnancies. Within the quantitative phase there was no difference in the aggregate scores for either the Perceived Control in Childbirth (PCCh) scale or the Satisfaction with Childbirth (SWCh) scale. Sub-group analysis found that women who used telemetry for the majority of the time the fetus was continuously monitored in labour scored a higher aggregate score for perceived control during labour (mean ± SD; 5.3 ±0.8 telemetry vs. 4.9 ± 0.9 wired, p = 0.047). Mobility data found that women using telemetry spentmore time off the bed in labour and adopted more upright positions for birth.

Conclusions: Both qualitative and quantitative findings confirmed that women were more mobile in labour when using telemetry to monitor the fetal heart and integrated findings also found that telemetry increased feelings of control in labour. The use of telemetry had a positive impact on women who required continuous monitoring in labour and engendered a sense of normality for both women and midwives. The use of telemetry contributes to humanising birth for women requiring more complex care in labour and birth.


Keeping the balance: promoting physical activity and healthy dietary behaviour in pregnancy

Motivational Interviewing, Self Determination Theory, Behaviour Change, Pregnancy

Gaining large amounts of weight during pregnancy may contribute to development of obesity and is associated with poor outcomes. Therefore managing gestational weight gain is important to reduce the risk of complications. This thesis aims to explore clinical and personal management of gestational weight gain and to discover how pregnant women can be best supported to maintain physical activity and healthy dietary behaviours. This is achieved through a programme of research comprising three related studies. Study One explored the antenatal clinical management of weight and weight gain through one-to-one interviews with Antenatal Clinical Midwifery Managers across Wales (n=11). Findings showed wide variation in management of weight from unit to unit. Although midwives believed pregnancy to be a perfect opportunity to encourage healthier behaviours, many identified barriers preventing them discussing weight with women. In Study Two semi-structured interviews with pregnant women (n=15) investigated views on personal weight management during pregnancy. Again pregnancy was seen as an ideal time to improve health behaviours due to a perceived increase in motivation and many women identified specific goals. However, in the face of various barriers, it was apparent that the motivation which initially identified healthy lifestyle goals was unable to sustain this behaviour throughout the pregnancy. Finally Study Three looked at the feasibility and acceptability of a midwife-led intervention informed by the two preliminary studies. The ‘Eat Well Keep Active’ intervention programme designed to promote healthy eating and physical activity in pregnant women (n=20) was based upon the Self Determination Theory framework for enhancing and maintaining motivation and utilised motivational interviewing. Results indicated that the intervention was received well by participants who reported that it positively influenced their health behaviours. The ‘Eat Well Keep Active’ programme may be a suitable intervention to encourage and facilitate women to pursue a healthier lifestyle throughout their pregnancy.

An investigation of subsequent birth after Obstetric Anal Sphincter Injury

OASI, Perineal Trauma, Subsequent birth


Obstetric anal sphincter injuries (OASIS) are serious complications of vaginal birth with a reported average worldwide incidence of 4%-6%. They are a recognised major risk factor for anal incontinence resulting in concern amongst women who sustain such injuries when considering the most suitable mode of birth in a subsequent pregnancy. This thesis contains three studies; a systematic review and meta-analysis of the published literature exploring the impact of a subsequent birth and it’s mode on bowel function and/or QoL for women with previous OASIS, a follow-up study on the long-term effects of OASIS on bowel function and QoL and finally a prospective cohort study of women with previous OASIS to assess the impact of subsequent birth and its mode on change in bowel function. The work in this thesis demonstrated an increase in incidence of bowel symptoms in women with previous OASIS over time and that short-term bowel symptoms were significantly associated with bowel symptoms and QoL. This thesis also showed that the mode of subsequent birth was not significantly associated with bowel symptoms or QoL and for women with previous OASIS who have normal bowel function and no anal sphincter disruption a subsequent vaginal birth is a suitable option.

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  • Research article
  • Open access
  • Published: 10 June 2021

A survey of midwifery graduates’ opinions about midwifery education in Iran: a cross-sectional study

  • Monireh Toosi   ORCID: orcid.org/0000-0001-6431-8569 1 ,
  • Maryam Modarres   ORCID: orcid.org/0000-0003-0042-7023 2 ,
  • Mitra Amini   ORCID: orcid.org/0000-0002-7332-5151 3 &
  • Mehrnaz Geranmayeh   ORCID: orcid.org/0000-0001-5122-9946 4  

BMC Medical Education volume  21 , Article number:  340 ( 2021 ) Cite this article

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Metrics details

Attaining high-quality education requires continuous evaluation and revision of the curriculum. The view of the graduate students can provide valuable insight into the necessary evaluations and revisions. Therefore, this study aimed to evaluate the opinions of midwifery graduates about midwifery education in Iran

This was a descriptive cross-sectional study and the research data were collected through a census sampling procedure from all (82) midwifery graduates of the Nursing and Midwifery School of Shiraz University of Medical Sciences between 2018 and 2020. The data collection instrument was a validated researcher-made questionnaire derived from the Graduation Questionnaire (GQ) developed by the Association of American Medical Colleges (AAMC). The data were then analyzed using SPSS 22.

In this study, about 62% of the graduates were satisfied with the quality of the midwifery education they had received during the four-year program. Moreover, 61% of the graduates maintained that theoretical courses were well-integrated with the clinical experience they needed. The quality of the internships in different wards and departments was also evaluated from the viewpoints of the graduates, and the results indicated that they were relatively satisfied with their internship experiences. However, only 40% of the graduates were satisfied with the quality of their clinical evaluation, since they faced the most significant challenges in the clinical and maternity wards (47%) with the midwifery staff and gynecology residents and found the quality of facilities in the clinical program to be lacking. According to the participants, the quality of teaching was not good for some courses such as biochemistry and microbiology.

It seems that the midwifery curriculum needs to be constantly revised, aiming to improve student satisfaction with their midwifery education. Some effective measures in this regard are employing experienced professors, developing cooperation between midwifery instructors and clinical departments, and trying to improve the educational environment. Attention to the improvement of facilities and equipment and agreement between the content of the theoretical education and practical topics are also recommended to improve the quality of midwifery education.

Peer Review reports

Human resources constitute the cornerstone of the health system, and midwifery personnel as an integral part of human resources play a major role in promoting community health. Midwifery schools are responsible for training professional staff who can be effective in providing health services and shaping health policies. These educational centers are required to educate individuals with the adequate ability, knowledge, and skills to apply their learnings in practice and have adequate management skills for preventing and dealing with critical situations [ 1 , 2 ] . Iran’s health system and the Ministry of Health have incessantly accentuated the key role of midwives in achieving national and international ideals for reproductive, maternal, neonatal, and infantile health. Given the importance of midwifery education in promoting community health, improving midwifery care, and reducing maternal and neonatal mortality, it is necessary to improve the quality of midwifery education, especially midwifery clinical education [ 3 ]. In Iran, midwifery students are admitted to a four-year university program via a national exam. The midwifery training program has been designed by the Ministry of Health and Medical Education in a single curriculum for all universities across the country. A significant part of the curriculum is devoted to the acquisition of clinical skills, during which students acquire skills in groups of four to eight in clinical settings. The students must participate in at least 60 natural deliveries and successfully pass a comprehensive midwifery exam in order to graduate. The clinical training course is an opportunity to acquire, practice, and develop clinical skills, during which students learn the necessary practical skills for professional midwifery activities [ 4 ]. However, the results of many studies in Iran have shown a relatively deep gap in the theoretical education process and clinical practice of midwifery students. Accordingly, the existing clinical education does not transfer the necessary ability to achieve appropriate clinical competence to students [ 5 ]. Evidence has also indicated that the professional skills of students have decreased compared to the previous decade [ 6 , 7 ]. Accordingly, despite adequate theoretical knowledge, new graduates lack skills and efficiency in clinical settings [ 8 ]. In other words, clinical education has failed in its goals of training skilled people and improving the quality of care services [ 9 ]. In this context, various studies have demonstrated that the existence of multiple problems in clinical settings has prevented the achievement of educational goals [ 10 ]. Therefore, it seems that midwifery education needs fundamental changes [ 11 ]. In 2012, the standard program for the midwifery profession stated that the training provided in the midwifery curriculum should ensure that the students are prepared to practice the profession in accordance with the standards. According to these standards, midwifery students must have an acceptable level of ability to provide clinical services on patients’ bedsides, while the educational goals specified in the curriculum and the theoretical and practical training must ensure the provision of these capabilities. In addition, midwifery students must have the necessary self-efficacy to perform the assigned tasks [ 4 ]. The necessary skills have been established in different countries to train midwifery students. The International Confederation of Midwives published the minimum standards for clinical midwifery education in 2006 and then in 2008 [ 12 ]. Based on these standards, midwifery schools in Iran should educate graduates with the skills necessary for the disease prevention, treatment, and health promotion of mothers and infants. To have maximum efficiency, midwifery students should participate in theoretical classes while also acquiring clinical skills through practice and gaining experience in clinical settings [ 13 ]. The midwifery clinical education in Iran is challenged by certain factors. Due to the shortage of clinical professors with sufficient knowledge and skills for teaching as well as practical and specialized practice, educational managers have tasked clinical personnel with teaching midwifery students through traditional midwifery education methods [ 14 ]. Although most clinical preceptors possess useful clinical experience, when it comes to education, those who adopt the role of clinical teachers should be up to date on the latest scientific information to teach theoretical topics. Still, due to their departure from academic education or because of time restrictions, some clinical personnel change the process of care, eliminate many standard care steps, and create so-called shortcuts in the accurate implementation of care [ 15 ]. However, to meet educational standards, these care practices should be performed in their complete and up-to-date form by the teacher. In the traditional midwifery education model, most students experience educational contrasts and confusions; on the one hand, theoretical topics are transferred to them in their academic form, and on the other hand, they encounter teachers in clinical settings whose performance runs contrary to those theoretical topics. In Iran, clinical settings such as hospitals are separate from academic settings, and midwifery professors are in fact guests in clinical settings and rarely wield administrative power [ 14 ]. These conditions cause conflicts between midwifery professors and the personnel, doctors, and OB/GYNs. To resolve these problems and integrate universities and clinical settings, measures such as the implementation of the Midwifery Clinical Faculty Model (MCFM) have been taken in Iran. In 2014, the clinical education revival project and the deployment of midwifery faculty members at hospitals and clinical settings were notified by the Iranian Ministry of Health and Medical Education (MoHME) to the universities across the country [ 16 ]. To promote the students’ clinical skills and general capabilities, this educational model was piloted in some Iranian universities of medical sciences, including the Shiraz University of Medical Sciences, with the deployment of midwifery faculty members on three shifts (morning, afternoon, night). In the Midwifery Clinical Faculty Program, students are required to provide low-risk mothers with the required care during labor and delivery and to assist in the delivery of high-risk groups under the close supervision of clinical instructors. Students are also responsible for the continuation of maternal and neonatal care in the fourth stage of labor. The Midwifery Clinical Faculty Program, as a competency-based education model, has tried to use new training methods (focus group discussion, problem-solving, etc.) that can help students to achieve optimal performance in clinical environments. Evaluation is an essential part of academic education, and the result of principled evaluation can be a basis for reforming and revising higher education curricula in the country, which can ultimately improve the academic levels of universities [ 17 ]. One of the most appropriate approaches to address educational problems in midwifery departments is to evaluate and determine the satisfaction of the graduates of these disciplines as healthcare providers across the country [ 18 , 19 , 20 ]. Given the importance of promoting midwifery education, especially clinical education, the researchers decided to design and implement the present study to assess the determine the opinions of midwifery graduates about midwifery education in Iran.

This study has two specific objectives:

Assessing the midwifery education and curriculum.

Assessing the midwifery clinical education with an emphasis on the Midwifery Clinical Faculty Program.

Ethical statement

The present study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1398.057). After introducing herself to the participants, the researcher explained the study objectives and assured them about the confidentiality of their information and their authority to reject the invitation or participate/withdraw from the study. She also requested the participants to sign the written informed consent forms.

Study design

This descriptive cross-sectional study included all midwifery program alumnae (82) who were trained through the midwifery clinical faculty program from 2017 to 2019 and were graduated from the Nursing and Midwifery School of Shiraz University of Medical Sciences.

Setting and context

Despite the efforts made in recent decades to promote midwifery education in Iran, research shows little success in achieving the goals envisioned for midwifery education and reports inadequacies in graduates’ capabilities. These problems necessitate effective measures to boost the quality of midwifery clinical education [ 21 ]. Previous studies have shown that midwifery students were not satisfied with their clinical skills, supervision, and access to information before clinical education [ 22 , 23 ]. In Iran, midwifery students are admitted to a four-year university program via a national exam, and only female students are allowed to study midwifery.

From the third semester, their clinical learning is begun under the supervision of clinical instructors or clinical preceptors in clinical settings [ 12 ]. The standard method of clinical education in Iran is teacher-centered, and in some cases, the clinical personnel train midwifery students using traditional midwifery education methods. This method may not convey appropriate clinical experiences to students [ 14 , 22 ]. The traditional midwifery clinical education model included group education with the periodical presence of professors in clinical settings and training provided by the maternity ward personnel. However, in the midwifery clinical faculty model (MCFM), students receive clerkship-based, continuous clinical education in the presence of midwifery professors with one-to-one interaction between the students and professors. Also, when the students clinically practice midwifery and childbirth for the first time, a midwifery teacher continuously explains different stages of childbirth to them [ 16 ].

Subjects and sampling

Due to the limited statistical population, all 82 midwifery graduates of Shiraz University of Medical Sciences from 2017 to 2019 were selected as the research sample through the census method. Sampling started in January 2020 and lasted for ten months until October 2020.

The inclusion criteria included undergraduate midwifery students who have completed the clinical course during the Midwifery Clinical Faculty Program and graduated from Shiraz University of Medical Sciences. The exclusion criteria included graduates who have not received clinical training in the clinical faculty program. Finally, all 80 graduates passed the inclusion/exclusion criteria, and their data was used in statistical analysis.

First, permission from the faculty management was obtained. Next, participants received information about the study and their rights (e.g., the study’s aims, voluntary participation, confidentiality, anonymity, and right to withdraw from the study). Then, participants who had informed consent for the study completed a printed version of anonymous questionnaires distributed by the researchers. Finally, the data were analyzed (response rate: 100%).

Research instruments

The data collection instrument was a researcher-made questionnaire designed based on a Graduate Questionnaire (GQ) developed by the Association of American Medical Colleges. Approved by the medical education and language specialists of Shiraz University of Medical Sciences, the questionnaire was translated for the first time into Persian by the experts in the Center for Medical Development, and Studies in Shiraz University of Medical Sciences validity and reliability were confirmed [ 23 ]. After making the necessary changes to the questionnaire and coordinating its items with the midwifery curriculum, the questionnaire was given to 12 midwifery faculty members, and their comments and suggestions were incorporated into the final version. Accordingly, the face validity and content validity of the questionnaire were confirmed. Moreover, the reliability of the questionnaire was confirmed using the internal consistency method. The internal consistency between the questionnaire items completed by 24 graduates was also confirmed by Cronbach’s alpha (α =0.942). The questionnaire consisted of eight sections as follows: 1) personal characteristics, 2) quality of midwifery education, including quality of courses and internship, 3) quality of other instructions, including clinical decision-making, clinical care, evidence-based midwifery, and community-based midwifery, 4) student services, 5) overall attitude towards the quality of the Clinical Faculty Curriculum, 6) future career plans, 7) general problems of the college years, and 8) midwifery school experiences. Their responses were given on a five-point Likert scale from 1 (poor) to 5 (very good). The questionnaire was administered after obtaining ethical clearance from the authorities (code number: IR.TUMS.FNM.REC.1398.057) and written informed consent from the participants.

Statistical analysis

Next, the data were entered into SPSS 22 and were analyzed using descriptive statistics (mean, frequency). Frequency and percentage were used for describing categorical variables (i.e., age, marital status, year of graduation, and employment). The Kolmogorov-Smirnov test was used to verify the normality of the data. One-way analysis of variance (ANOVA) tests was employed to determine significant variations in their scores in the final clinical exam. All statistical tests were carried out at a 95% confidence level using SPSS 22 and the significance threshold was set at 0.05. (SPSS Inc., Chicago, IL, USA).

This study was conducted on 82 participants (100% female) who graduated from the undergraduate midwifery program at Shiraz University of Medical Sciences between 2017 and 2019 (response rate: 100%). The mean age of the participants was 25 ± 5.9 years (Table  1 ).

Based on the evaluation tool, six indicators related to curriculum goals, curriculum content, curriculum tests, clinical practice, readiness to enter internship, and quality of midwifery education were evaluated from the perspective of the graduates (Table  2 ).

The findings showed that 57.3% (Agree and strongly agree) of the graduates claimed that the midwifery curriculum is clear to students. About 52.4% of the graduates agreed (Agree and strongly agree) to integrate midwifery content into the midwifery curriculum. Overall, 62.4% of the graduates were satisfied with the quality of the midwifery education over the four years.

Regarding the opinion of the graduates about each of the midwifery courses, the highest percentage of answers to the excellent option was related to the pregnancy course 1 (Natural Pregnancy) in 41.5% of cases, and the lowest percentage of the excellent option was related to the biochemistry course with 6.1% (Table  3 ).

According to the graduates, the excellent clinical experience belonged to childbirth internship (45.1%) and gynecological diseases internship (32.9%). However, the graduates believed that radiology internship (11%) and surgery internship (12.2%) had the lowest quality (Table  4 ).

Moreover, 45.1% of the students were satisfied (agree and strongly agree) with student support services of student vice-presidency, 53.7% were satisfied with access to the administration and teaching affairs office of the midwifery school, 43.9% were satisfied with student support and financial services, 37.8% were satisfied with student welfare services, 40.2% were satisfied with student health and insurance services, and 74.4% were satisfied with access to library services (Table  5 ).

Overall, the quality of the Clinical Faculty Curriculum (14.6% Excellent) and the quality of welfare facilities in the Midwifery Clinical Faculty program (4.9% Excellent) were the lowest indicators in the evaluation of the quality of the Clinical Faculty Curriculum from the viewpoints of the midwifery students (Table  6 ).

This study showed significant difference between the final exam scores of midwifery clinical faculty program graduates (2018–2020) and those of graduates who did not participate in the midwifery clinical faculty program (September 2017(.The results of the LSD test showed a significant difference between the final exam scores of the control group (September 2017(and the other groups (2018–2020) participating in the program. Participation in the midwifery clinical faculty program improved graduates’ final exam results (Table  7 ).

According to the findings of this study, the participants had the largest problems in the clinical and maternity wards (47%) with nursing staff and gynecology residents. In response to the question about retaking midwifery as a field of study, about 48% of the participants answered negatively, 37% said that they would opt again for midwifery, and about 15% did not have a particular opinion. This level of dissatisfaction is noteworthy and requires further investigation. Among the participants, 79% were satisfied with the teaching of clinical decision-making and clinical care skills, such as patient interviewing skills, patient examination, diagnosis of diseases, inpatient care, and communication with patients and physicians, and they found these instructions effective. Additionally, 72% of the graduates were satisfied with midwifery education in specific areas, such as midwifery management, healthcare improvement, midwifery data recording, confidentiality, privacy, midwifery economics, and midwifery law. Moreover, 58% of the participants were satisfied with evidence-based midwifery education, such as interpretation of clinical data, interpretation of test results, and decision analysis, and 73% of the graduates evaluated the skill they gained for teamwork with other medical teams as satisfactory. Besides, 89% of the participants acknowledged that they had acquired satisfactory levels of skills in confidentiality, maintaining the patients’ privacy, and observing the midwifery ethics during their internship. In terms of testing and assessment, 96% of the internships were evaluated by clinical professors during the internship. In this regard, 93% of the students had oral exams, while 76% had written exams. Along these lines, 90% of the participants were familiar with logbooks and were evaluated based on their internship logbooks. However, only 40% of the graduates were satisfied with the quality of their clinical evaluation. The findings showed that 61% of the graduates claimed that the topics of theoretical courses were well-integrated with the clinical experience they needed. The quality of the internship in different wards was also evaluated from the graduates’ viewpoints, and the results revealed their moderate satisfaction with all clinical wards. In addition, there was no statistically significant difference in terms of satisfaction and other items of the questionnaire between different groups of midwifery graduates between 2018 and 2020.

Knowing graduates’ views on the appropriateness of the goals of the curriculum and the way they are implemented in midwifery schools can provide educational planners and policymakers with valid information. The results of the evaluation of the alumnae’s views demonstrated that 62% of the graduates were satisfied with the quality of the midwifery education they had received over the four-year program. In a study on the relationship between communication skills and course satisfaction among midwifery students, Etebari asl et al. found that most midwifery students were engrossed in their field of study and were relatively satisfied with the quality of their curriculum [ 24 ]. Jamilian et al. found that the midwifery students were relatively satisfied with the educational quality of their curricula and the mean score of satisfaction with the field of study was moderate among the students [ 24 ]. Vanaki reported that students in Ahvaz were discontent with the educational quality of their curriculum [ 25 ]. The discrepancy among these results might be due to the influence of different environmental circumstances on students’ perceptions. The results of the present study showed that the graduates evaluated the quality of midwifery education in theoretical and practical courses as relatively satisfactory. Moreover, the quality of students’ clinical skills education was found to be satisfactory in the clinical faculty program. Yet, further measures are required to achieve excellence in the quantity and quality of services. Clinical learning is the main part of the midwifery curriculum [ 26 ]. A key strategy for ameliorating clinical education is to use capable instructors both in theoretical and clinical courses. The present study results also showed that 60% of the graduates assessed the presence and teaching of professors in the Clinical Faculty Curriculum as appropriate. One of the most critical expectations of students in effective clinical education is the availability of midwifery instructors and their adequate communication and interaction with the students [ 27 ]. Adequate relationship with students is effective in motivating them and raising their interest in clinical education. It is one of the most important agents for inhibiting stress in midwifery students and the stressful delivery room environment [ 28 ]. Such circumstances can pave the way for better learning and will allow for greater coordination between the instructors and students [ 29 ]. Such circumstances can pave the way for better learning and will allow for greater coordination between the instructors and students [ 29 , 30 ]. Similarly, Dehghani et al. found that appropriate professional relationships could create a positive environment for trainees. Additionally, the involvement of professors and clinical staff in student support and training was identified as contributing to promoting clinical education and enhancing student confidence [ 28 ]. Iranian midwifery students have a slim chance of acquiring independent experiences in clinical learning. This condition leads to unpleasant fears and stress [ 21 ]. So, the support provided by instructors and clinical staff is essential for positive learning experiences [ 26 ]. Midwifery students are greatly influenced by their professors’ teaching methods and expectations. Experts believe that clinical educators have a significant effect on enhancing the quality of clinical education and can make clinical experiences enjoyable for students [ 31 ]. Being publicly criticized by their clinical instructor causes fear and increases the stress levels of the students. Iranian students sometimes face such issues, which remain unnoticed by the instructors [ 21 , 31 ]. A practical clinical instructor should create appropriate communication and a supportive emotional climate to create a favorable environment for learning [ 32 , 33 ]. Experienced instructors know how to communicate effectively with students and choose the right time and place for criticism and recommendations. Otherwise, these can damage students’ self-confidence and personality [ 33 , 34 ]. Proper interaction and collaboration among clinical professors, staff, and students can play an important role in creating an appropriate clinical environment conducive to high-quality training of students [ 35 , 36 ]. The gap between theory and practice and the clinical staff’s negative view of clinical instructors may also be among the causes of ineffective clinical education. Lukasse et al. showed that many clinical staff have a negative view of midwifery instructors who have not been in clinical practice for many years or are not updated. Old and outdated teaching methods lead to a gap between theory and practice [ 37 ]. Although one goal of the Midwifery Clinical Faculty Program was to boost the relationship between the educational and clinical environments, the alumnae believed that other clinical staff had poor cooperation with the students. Most of the problems encountered by the students in the clinical and maternity wards (47%) were related to the clinical staff and gynecology residents, indicating a deep gap between clinical and educational staff. A study in Ghana showed that environmental factors and interpersonal and academic relationships could negatively affect midwifery students, with the interpersonal stressors being the most potent [ 37 ]. Midwifery students experience certain problems during their academic and clinical education that may lead to uncertainty, dissatisfaction, and failure to adapt to their profession [ 38 ]. Most of these problems are driven by a wide range of potential issues in the clinical learning environment and interpersonal relationships that can affect students’ learning. While midwifery students usually have vast knowledge, they lack sufficient clinical skills, and they are unsuccessful in applying their theoretical knowledge in a stressful environment [ 39 , 40 ]. The results of Ahmadi’s study showed that staff attitude toward midwifery students was evaluated at a moderate level and the students believed that the medical staff in the wards did not cooperate well in clinical settings [ 41 ]. Mutual interaction with other medical groups, common understanding, and shared objectives are essential for creating positive experiences for students in a learning environment [ 42 ]. The majority of midwifery graduates in the current study acknowledged that although their professors had empowered them regarding teamwork with medical workers from other disciplines in emergencies and to adhere to the principles of midwifery ethics in these special situations, midwifery staff and gynecology residents created many problems for them in the clinical and maternity wards. This indicated that the ward staff did not treat the students well and that they were not actively involved in training the students. In such an atmosphere, the students cannot communicate properly with the staff and often suffer from tensions. Since one of the goals of the clinical faculty curriculum is to reduce the gap between educational and clinical settings, it is necessary to put more effort into achieving this goal. A study conducted at Golestan University of Medical Sciences on the stressful experiences of midwifery students during clinical education in the labor room showed that the characteristics of the individuals who worked in the clinical wards and the educational environment where students spent their clinical experience had a great impact on their stress levels and the quality of their internship [ 29 ]. A study in Iran showed high levels of stress in midwifery students in clinical settings, with the stressors associated with the instructors causing more stress [ 43 ]. Another study seeking students’ evaluation of certain factors in the clinical learning environment at a Slovakian university revealed that a positive attitude and an appropriate collaborative atmosphere improved the students’ learning [ 44 ]. Inappropriate behaviors of ward staff with students, medical group interventions including gynecology residents, and lack of amenities in clinical departments were among the challenging factors in acquiring clinical skills in the present study, some of which were also reported by Rezaei [ 41 ]. To achieve the goals of the clinical faculty curriculum and to succeed in implementing this curriculum, efforts should be made to resolve this problem with other medical departments and to stabilize the position of midwifery instructors and students in the clinic. Elo’s study on students’ experiences in the clinical setting revealed that poor communication between staff and students could lead to the students’ disinterest in learning and their negative attitudes [ 45 ]. Ghafourifard also referred to barriers against the achievement of clinical goals, including lack of consistency between theoretical knowledge and clinical skills, vague internship goals, stressful clinical environment, reluctance of experienced professors to attend the clinic, lack of realistic evaluation, and lack of educational facilities [ 46 ]. In the current study, 65% of the graduates believed that they were ready to start their compulsory medical service program or enter the job market. This was consistent with the results of the research performed by Olga on students’ perceptions of their professional competencies in a Spanish university [ 46 ]. In contrast to the present study’s results, indicating that the graduates were prepared to enter the compulsory service program, Mousavi et al. reported that midwifery students believed they were poorly and moderately ready to enter the clinic and begin clinical practice [ 27 ]. The difference between these two findings could be attributed to the differences in the educational and clinical settings of the two studies. The presence of empowered faculty in the clinical faculty curriculum provides the opportunity to empower students and prepare them for entering the job market. In the present study, 73% of the graduates evaluated the library services of the midwifery school as appropriate. Furthermore, the availability of academic library resources and appropriate educational facilities of the school were referred to as one of the most important elements affecting the quality of education. Of course, an assessment of the viewpoints of the midwifery graduates in Shiraz indicated that the educational facilities of the faculty itself were more satisfactory in comparison to the educational conditions of the clinical centers. Graduates in Qazvin also evaluated the educational facilities of the school higher than those in clinical centers [ 32 ]. Another study conducted by Mousavi on clinical education problems in midwifery showed that the participants considered environmental factors in clinical settings as obstacles to achieving clinical education goals [ 27 ]. Ahmadnia and Salehabadi also disclosed that environmental factors, such as the great number of midwifery students in internships and the shortage of equipment, were barriers to clinical education [ 8 , 47 ]. Evaluation of the Clinical Faculty Curriculum graduates in the current study indicated that the welfare and educational conditions and facilities of the clinical settings were not quite satisfactory. This finding highlighted the necessity to pay more attention to the improvement of clinical environments for the promotion of students’ learning. The results also showed that although 96% of clinical internships were evaluated by clinical professors, the evaluation system was not adequately satisfactory, and the majority of midwifery students were dissatisfied with the evaluation procedure and lack of ongoing feedback to students as well as non-standard and subjective evaluation procedures. Rezaei also reported dissatisfaction with the evaluation of internships and clinical educational environments and staff’s behaviors towards students [ 41 ]. In a study by Ahmadnia et al., students referred to the disconformity between evaluation forms and the existing conditions as well as different methods of evaluation by the instructors as educational problems and pointed to poor clinical evaluation procedures [ 47 ]. In the same line, Graham reported that non-standard evaluation was one of the most common barriers to clinical education from the students’ perspective [ 36 ]. In another study, Helminen found that the assessment process of students’ clinical practice lacked consistency. Great variety in the quality of assessment and differences in the perceptions of the mentors of the assessment forms were among the student assessment challenges [ 48 ]. Given the importance of the Clinical Faculty Curriculum in improving students’ educational conditions, it is necessary to review and change the students’ clinical assessment system in this curriculum.

The current study results showed that 62% of the graduates were satisfied with the quality of the midwifery education they had received over the four-year program. Presenting some courses such as obstetrics and gynecology is desirable for students, but some courses such as biochemistry and microbiology need to be further reviewed and revised. Moreover, 61% of the graduates supported the integration of theoretical courses with clinical topics. Also, the level of student services from the students’ point of view in some cases, such as access to the vice chancellor for education and support and counseling services, has been at a moderate level. In contrast, welfare services have failed to reach a desirable level. This study clarifies some aspects of the curriculum to be further developed by the faculty to prepare midwifery graduates for clinical work. The results of this study showed that although the Clinical Faculty Curriculum at Shiraz University of Medical Sciences was in its incipient stage, the graduates were relatively satisfied with the quality of education. However, there were some deficiencies requiring revision at the discretion of educational planners. The effective implementation of the Clinical Faculty Curriculum requires the elimination of deficiencies such as poor communication between the staff of other medical departments and students in the clinic, poor quality of educational and clinical facilities, and poor quality of the students’ clinical assessment system. Since high-quality curricula can lead to the development of competent and capable students in the field of healthcare services, it is necessary to constantly evaluate and monitor the educational programs and review midwifery curricula with an emphasis on the elimination of weaknesses. The results of this study can act as a guide for midwifery education professionals in the revision of the curriculum of other universities. These can also help educators to design strategies for more effective clinical teaching. Given the complexity of the field of midwifery, using modern clinical training methods, such as the clinical faculty program, may enhance the efficiency of clinical training in Iran. It is recommended that school managers assess the students’ learning during clinical education, employ experienced instructors, and improve educational facilities and equipment. Future studies are recommended to evaluate concurrently the views of students, instructors, midwives, and school managers using a larger sample.


Due to the limited resources, time, location, and wide distribution of midwifery graduates, this study could not cover large groups of graduates. The small sample (limited to one university) and the cross-sectional survey design are the limitations of this study, affecting its generalizability. However, to our knowledge, this is the first study to evaluate the opinions of the midwifery graduates about midwifery education and the Midwifery Clinical Faculty Program in Iran.

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Data would be available by contacting the corresponding author.


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This paper was extracted from a PhD dissertation in Reproductive Health (IR.TUMS.FNM.REC.1398.057) approved by Tehran University of Medical Sciences. The authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript and much appreciation goes to the midwifery graduates who participated in this study.

This study is funded by Tehran University of Medical Sciences. Project number (IR.TUMS.FNM.REC.1398.057). The role of funders in this research was capacity building.

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Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

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Maryam Modarres

Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Mitra Amini

Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, 1419733171, Iran

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MG, MM, MA and MT contributed to the design of the study. MG, MM, MA and MT contributed to the implementation and analysis plan. MG, MM and MT has written the first draft of this article and all authors have critically read the text and contributed with inputs and revisions, and all authors read and approved the final manuscript.

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Toosi, M., Modarres, M., Amini, M. et al. A survey of midwifery graduates’ opinions about midwifery education in Iran: a cross-sectional study. BMC Med Educ 21 , 340 (2021). https://doi.org/10.1186/s12909-021-02764-y

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Midwifery Dissertation Topics List (30 Examples) For Your Research

Mark Dec 14, 2019 Jun 5, 2020 Midwifery , Nursing No Comments

As a student, if you are finding Midwifery dissertation topics, you have visited the right site. We offer a wide range of midwifery dissertation topics and project topics on midwifery. As the field has evolved, the research topics on midwifery are based on new and emerging concepts and ideas. You can choose any of the […]

midwifery dissertation topics

As a student, if you are finding midwifery dissertation topics, you have visited the right site. We offer a wide range of midwifery dissertation topics and project topics on midwifery. As the field has evolved, the research topics on midwifery are based on the new and emerging concepts and ideas.

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To analyse the role of perinatal care to pregnant women.

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Conducting a systematic review on how midwifery students plan their career.

Strategies adopted by midwives to advise pregnant women about nutritional values and healthy food consumption.

Studying the impact of Hepatitis B in pregnant women.

Analysing how frequent miscarriages are linked with higher anticardiolip antibodies.

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Evaluating the attitude of women related to the implementation of basic immunisation programs in village.

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Exploring the global trends in nursing and midwifery education.

Analysing the role of optimal midwifery decision-making during second-stage labour.

To study the integration of clinical reasoning into midwifery practice.

A literature review on labouring in water.

Exploring the experiences of mothers in caring for children with complex needs.

An ethnography of independent midwifery in Asian countries.

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Culturally Appropriate Care In Midwifery Education

This is the third blog in our series on maternity inequalities and comes from midwifery educators Olamide Solanke and Joanna Andrews. T his week considers how we might realise equity in care through Education.

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What is Cultural Competence?

Culturally appropriate care is a crucial component in providing effective healthcare services to diverse populations (1). Culture encompasses shared patterns of behaviour, interactions, cognitive constructs, and affective understanding learned through socialisation. Competence, as defined by the World Health Organization (2), is “the combination of knowledge, psychomotor, communication, and decision-making skills that enable an individual to perform a specific task to a defined level of proficiency.” The term “cultural competence” emerged in the early 1980s in social work, later entering counselling psychology and nursing literature in the 1990s (1). Leininger (3) describes cultural competence as “care that is meaningful and fits cultural beliefs and lifeways.”

In midwifery, cultural competence involves “knowledge of how to promote respectful and responsive midwifery care in cross-cultural settings that reflects the cultural and linguistic needs of the diverse population” (4). Contemporary literature is shifting towards terms like cultural appropriateness or transcultural care, focusing on ongoing knowledge development rather than training as an endpoint.

The Need for Culturally Sensitive Care in Midwifery

Culturally appropriate care is integrated into midwifery through various statutory and policy documents. The International Confederation of Midwives (5) highlights that midwifery promotes, protects, and supports women’s human, reproductive, and sexual health, and rights, respecting ethnic and cultural diversity. The ICM’s code of ethics, 2008 (6) mandates that midwives provide care respecting cultural diversity while working to eliminate harmful cultural practices.

The UK’s Nursing and Midwifery Council (7) advises registrants to consider cultural sensitivities to better meet individuals’ personal and health needs. Midwives should integrate clinical knowledge with interpersonal and culturally appropriate care skills to ensure quality and safety in maternity care. They should demonstrate an understanding of cultural contexts, provide culturally sensitive care, and assess, plan, and deliver care that promotes cultural safety across the continuum of care.

How to Embed Culturally Sensitive Care in Midwifery Education?

WHO (2) stresses that midwifery education should extend beyond task-specific training to include values like good communication, individualised care, and cultural understanding. The ICM (8) asserts that midwives should support women in making individual care choices, understanding cultural norms and practices related to sexuality, reproductive health, marriage, the childbearing continuum, and parenting.

Addressing cultural diversity in healthcare education is crucial for improving care quality and eliminating disparities. However, implementing a culturally appropriate care curriculum is often fragmented, and educators may lack clarity on necessary content (9, 1). WHO (2) advocates for midwifery education that involves women and communities, ensuring the curriculum reflects women’s rights and needs, and includes their voices. This approach involves collaborating with community care providers and promoting culturally appropriate, respectful care to empower women and avoid the over-medicalisation of birth.

A multifaceted approach involving educators, students, birthing people, and local communities can enhance cultural competence education. Researchers have argued that culturally appropriate care should be a continuous process rather than a set of educational goals (9). Reflective practice is crucial as it helps student midwives learn from their experiences. Specific training methods, such as role play, group discussions, case scenarios, mini-lectures, and sharing personal experiences, significantly improve healthcare providers’ cultural awareness (10).

Currently, efforts to improve culturally appropriate care education in midwifery include novel programs like an eLearning ‘culturally appropriate care training’ introduced by King in a UK NHS Trust (11). In Turkey, a 28-hour ‘Transcultural Midwifery’ course was positively evaluated by final-year student midwives and suggested to be made compulsory (12). Key reports, such as the Black maternity experience surveys (13) and the NHS Race Observatory report on neonatal assessment (14), have been incorporated into the midwifery curriculum, offering first-hand insights into clinical experiences. Educators can use these insights to integrate culturally appropriate care aspects into the curriculum. For example, avatars are used in midwifery curricula to discuss the value of culturally appropriate care for women and birthing people (15).

In conclusion, fostering cultural competence in midwifery is essential for delivering safe and quality care that meets the diverse needs of women and their families. Integrating comprehensive cultural appropriate care training into midwifery education prepares future midwives to provide respectful, responsive, and effective care in diverse cultural settings. While there are ongoing efforts to improve understanding and implementation of culturally appropriate care, a more collaborative approach between institutions could yield better outcomes for students, educators, and birthing people.

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Linkedin: @Joanna Andrews  @Ola Solanke

  • Shen, Z. (2015). Cultural Competence Models and Cultural Competence Assessment Instruments in Nursing: A Literature Review.  Journal of Transcultural Nursing ,  26 (3), 308–321. https://doi.org/10.1177/1043659614524790
  • WHO (2019) Strengthening quality midwifery education for Universal Health Coverage 2030: framework for action.
  • Leininger, M. M. (1999). What is Transcultural Nursing and Culturally Competent Care?  Journal of Transcultural Nursing ,  10 (1), 9–9. https://doi.org/10.1177/104365969901000105
  • NMC (2019) Standards of proficiency for midwives – The Nursing and Midwifery Council (nmc.org.uk) , 61
  • ICM (2011) Core document: International Definition of the Midwife. Accessed on 21/05/2024 08l_en_international-definition-of-the-midwife.pdf (internationalmidwives.org)
  • ICM (2008) International Code of Ethics for Midwives International Code of Ethics for Midwives  | International Confederation of Midwives (internationalmidwives.org)
  • NMC (2015) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates – The Nursing and Midwifery Council (nmc.org.uk)
  • ICM (2019) Essential Competencies for Midwifery Practice Essential Competencies for Midwifery Practice | International Confederation of Midwives (internationalmidwives.org)
  • Seeleman C, Suurmond J, Stronks K. (2009) Cultural competence: a conceptual framework for teaching and learning. Med Educ . Mar 2009;43(3):229-37.
  • Fair, F., Soltani, H., Raben, L., van Streun, Y., Sioti, E., Papadakaki, M., Burke, C., Watson, H., Jokinen, M., Shaw, E., Triantafyllou, E., van den Muijsenbergh, M., & Vivilaki, V. (2021). Midwives’ experiences of cultural competency training and providing perinatal care for migrant women a mixed methods study: Operational Refugee and Migrant Maternal Approach (ORAMMA) project.  BMC Pregnancy and Childbirth ,  21 (1), 340–340.
  • King HA. MIDIRS Midwifery Digest: The use of Cultural Safety Huddle and Handover guides to improve care delivery for Black, Asian, and Minority Ethnic patients. MIDIRS Midwifery Digest. Vol 31, no 1, March 2021, pp 46-51.
  • Güner, S., Bülez, A. (2023). Improving the cultural competence of midwifery students: an evaluative study. European Journal of Midwifery, 7(Supplement 1). https://doi.org/10.18332/ejm/172371
  • Awe T, Abe C, Peter M, Wheeler R. (2022)The Black maternity experiences survey: a nationwide study of black women’s experiences of maternity services in the United Kingdom.London: Five X More; 2022.
  • Furness, A., Fair, F., Higginbottom, G. et al. A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates. BMC Pediatr 24, 198 (2024). https://doi.org/10.1186/s12887-024-04692-4
  • Solanke, O., & Todd, S. (2022). UTILISING SOCIAL MEDIA IN MIDWIFERY EDUCATION. Practising Midwife, 25(10).

To view other blogs in this series please see:

Empowering Change: The Association of South Asian Midwives Advocating for Equitable Maternity Care


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midwifery education dissertation

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Amazing experience. Years ago Nancy Draznin supported me as my Doula as I delivered my firstborn son Richard!!! Nancy was there with me for almost 24 hours I believe. She was amazing and it was so wonderful to have her there with me to lean on!!! It sure doesn’t seem like it was that long ago! Your presence at my birth made it a wonderful and amazing experience and I am so glad that I had you there to share it with me! Thank you for all you do for all of us mama’s Nancy! ~ Judy 

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I absolutely adore Nancy. She has a warm and gentle presence that helped me feel at home with her from day one. I really feel like the calm and trust in my body that she helped lead me to was a big factor in my ability to have such a great pregnancy, birth, and postpartum. I think if I had had the exact same birth in a hospital I’d have been pressured into several interventions, but instead she used her wisdom to guide me into different positions that helped my son and I along when I was “stuck.” She was the perfect person to nurture me into motherhood. ~ MB

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