Jackson, Karen B.
(2021)
Midwives' decision making during normal labour and birth.
PhD thesis, University of Nottingham.
Abstract
Aim and research question
The aim of this thesis is to explore midwifery decision making during normal labour and birth. The research question posed is: What influences midwives’ decision making during normal labour and birth?
Background
Normal physiological birth leads to improved health outcomes in every possible aspect: physiologically, mentally, emotionally and socially yet it is extremely well documented that rates of medical intervention in childbirth are increasing. How midwives make decisions and what influences those decisions during normal labour and birth might illuminate why this is happening. There is a dearth of research exploring midwifery decision making in clinical practice more widely but in particular decision making during normal labour and birth.
Methods and methodology
An Interpretivist epistemology was chosen and a case-study approach selected which included data collection at 2 case-sites. Three focus group interviews were conducted at each case site labour suite. Eleven observational visits were made at case site 1 (total 92 hours) and ten observational visits (total 84 hours) were made at case site 2. In addition two midwives at case site 1 completed a decision making diary. A documentary review was also conducted. Ethical principles of conducting research were adhered to, including gaining ethical approval. Data was analysed using thematic and cross-case analysis.
Findings and discussion
There were five main themes identified: ‘Woman focussed determinants’ ‘Midwifery specific influences’, ‘environmental and organisational factors’, and ‘intra and inter-professional influences’. The overarching, central theme was the ‘hybrid midwife’. Each theme contained categories. Within the overarching theme, midwives in the case study environments were operating in dualistic belief systems in effect being ‘hybrid midwives’. Some functioning as ‘being with’ midwives, embracing a social model of childbirth and some operating as ‘doing to’ midwives, embracing a biomedical model. In normal, straightforward labour and birth, intuitive- humanistic, phenomenological decision making processes tend to be utilised. However, this study also revealed that in busy labour suite settings, there appeared to be, at times, a dominance of women with complex needs. In higher risk situations hypothetic-deductive, rationalistic decision making models were reported to be used. It was apparent that some midwives struggled to function in this way, in that some ‘being with’ midwives were under organisational pressure to work as ‘doing to’ midwives, even when caring for women in normal childbirth. In addition, ‘low risk’ women’s choices and decisions were sometimes not supported due to the sheer busyness of the labour suite.
Arising from the theme of ‘the hybrid midwife’ I proposed the more constructive concept of the dynamic midwife, who could balance the challenges of decision making when caring for both low risk and high risk childbearing women.
Consequently the situated, dynamic midwifery decision making framework: Focus on straightforward labour and birth was developed as a result of this study. The model consists of two figures, the first based on empirical findings from this study, the second based on a continuum of existing decision making theories, models and influencing factors. This model could be utilised by midwives to enhance their knowledge regarding different types of clinical decision making approaches that can be used in normal childbirth.
Conclusions
Decision making in normal labour and birth is an extremely complex phenomenon, influenced by a multitude of factors as exemplified by the themes identified in the findings. Midwives have to frequently balance decision making strategies that are appropriate for childbearing women in all risk categories.
Further recommendations have been made for research, practice and education to improve knowledge of midwives’ decision making. The situated, dynamic midwifery decision making framework: Focus on straightforward labour and birth would benefit from evaluation in educational settings.
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