Midwifery 84 (2020) 102653

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Midwifery
journal homepage: www.elsevier.com/locate/midw

A theory of the aims and objectives of midwifery practice: A theory

synthesis ✩
Mirjam Peters a,b,∗, Petra Kolip a, Rainhild Schäfers b
a
Bielefeld University, Bielefeld School of Public Health, Germany
b
The Hochschule für Gesundheit, University of Applied Sciences (hsg), Department of Applied Sciences, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Every discipline has a dichotomous objective by which it recognizes whether its work has
Received 16 November 2018 been successful (Vogd, 2011). For midwifery care, no objective has been set in this way so far. This also
Revised 22 January 2020
has implications for measuring quality, because quality of care is only measurable if objectives have been
Accepted 23 January 2020
identified. This paper aims to contribute to theory formation in midwifery science by analysing exist-
ing concepts and theories and preferences of women to midwifery care to answer the question of the
Keywords: dichotomous objective of midwifery.
Midwifery
Theory synthesis Method and findings: The method of theory synthesis (Walker and Avant, 2011) was used to analyse ex-
Model isting theories and concepts of midwifery care and literature-based preferences of women to midwifery
Midwife care and synthesize them with regard to the objectives of midwifery care. The synthesis took place in the
Birth form of a means-end chain to extract the dichotomous target of midwifery care. In this way, the objec-
Antenatal care tives of midwifery could be compared and linked from both the scientific and from women’s perspective.
Postnatal care The resulting means-end chain model of the process of midwifery describes the aims and objectives of
midwifery from the point of view of women on three levels.
Discussion: The hierarchical model of the process of midwifery presented here is a first attempt to il-
lustrate the aims and objectives of midwifery practice in a means-end chain model in order to facilitate
discussion on the topic and to make the quality of midwifery care measurable. Measurement is a first
step towards improving quality of midwifery care and thereby improving women’s reproductive capabil-
ities.
© 2020 Elsevier Ltd. All rights reserved.

Introduction of one’s own work (Vogd, 2011). For midwifery care, no objective
has been set in this way so far.
According to Vogd’s sociological theory of organized medical Making one’s own goals explicit makes it possible to better rep-
treatment (2011), every discipline has a dichotomous objective by resent one’s profession in relation to other professions and users
which it recognizes whether its work has been successful. In the (Vogd, 2011). In addition this has implications for measuring qual-
medical field, for example, this objective is whether someone has ity, because quality of care is only measurable if objectives have
been cured or not. So as a doctor, a good job was done when the been identified (Deutsche Institut für Normung e.V., 2015). Thus,
patient was cured. The objective of care is whether someone is quality measurement requires comparable goals and objectives, if
cared for, i.e. can be integrated into his family and his culture. As a possible also internationally. Because quality measurement is the
nurse, a good job was done when this objective has been achieved. first step towards quality improvement. This is intended to provide
So this dichotomous goal is primarily aimed at why, at the purpose (even) better care for users (Hoope-Bender et al., 2014).
Very few middle-range or grand theories exist in midwifery sci-
ence (Dickson, 1997; Fleming, 1998; Kennedy, 20 0 0; Renfrew et al.,
2015; Thompson et al., 1989). They use similar and often overlap-
✩
This article is based on the assumption that each individual woman defines the ping concepts, yet rarely identify the objectives of those concepts
term ‘family’ for herself. Subsequently, the term ‘woman’ refers to users of mid-
with regards to midwifery practice.
wifery services, including partners, other children and significant others defined by
a woman as family. This paper aims to contribute to theory formation in midwifery
∗
Corresponding author. science by analysing existing concepts and theories of midwifery
E-mail address: [email protected] (M. Peters). science and literature based preferences of women to midwifery

https://doi.org/10.1016/j.midw.2020.102653
0266-6138/© 2020 Elsevier Ltd. All rights reserved.
2 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653

care to answer the question of the dichotomous objective of mid- Aims within a means-end chain are systematically represented
wifery. The identification of the dichotomous objective of mid- by an objective or vision and several sub-aims or operational
wifery care should promote the discussion and measurement of aims. Each operational aim is a means towards the superior aim.
quality in midwifery care. Since an aim or objective is difficult to measure, operational aims
are used to structure actions and make it easier to measure the
Method achievement of aims. The aims may be complementary, mean-
ing they may complement and reinforce each other mutually.
In this paper the following definitions according to Walker and The means-end chain does not represent a chronological sequence
Avant (2011) were used: “A theory is an internally consistent group (Welge et al., 2017).
of relational statements [about concepts] (…) that presents a sys- The following section is structured according to the three stages
tematic view about a phenomenon and that is useful for descrip- of Walker and Avant (2011). For each stage the procedures and re-
tion, explanation, prediction and control”. (Walker and Avant, 1988, sults are described. In stage three, the final hierarchical model is
p. 22). Concepts are a mental image of a phenomenon, an idea presented.
or a construct. They allow us to classify our experiences mean-
ingfully (Walker and Avant, 2011). Theories are often graphically Stage 1: Identifying key concepts
represented by a model (Walker and Avant, 1988).
The formation of theories relating to a profession serves to de- A systematic review of models, concepts, theories and frame-
velop a logical, systematic and organised version of that profes- works was performed to identify theoretical considerations of the
sion and its aims (Meleis, 1999; Neumann-Ponesch, 2017). These aims and objectives of midwifery practice. The aims and objectives
theories and models function as a melting pot for already existing of midwifery care have been extracted from those concepts, theo-
concepts, which are thus identified, analysed, clearly defined and ries and frameworks identified as relevant. This approach assumed
newly compounded (Meleis, 1999). that most of the aims and objectives relevant to midwifery practice
In order to bring together the existing theories and concepts, have already been written about in midwifery science.
the method of theory synthesis from nursing science according to A systematic literature review was performed in June 2017. The
Walker and Avant (2011) was applied. It enables the organisation following electronic databases were searched for relevant articles:
and integration of a large number of findings in one single theo- MEDLINE via pubmed, The Cochrane Library, CINAHL Complete
retical work. It was developed for theory construction in nursing via EBSCO, PsycINFO via EBSCO, SocINDEX via EBSCO, EMBASE
and has also been used in midwifery science (Halldorsdottir and via OVID, MIDIRS via OVID, Web of Science, Livivo (incl. BASE).
Karlsdottir, 2011). The keywords used were: ((midwif∗ [Title] OR midwiv∗ [Title]))
Theory synthesis is a strategy to combine information about a AND (theor∗ [Title] OR model [Title] OR concept[Title] OR frame-
phenomenon. The method contains three iterative stages: (1) Spec- work[Title]). Included were scientific articles discussing the aims
ification of central concepts of the topic of interest and assump- and objective of midwifery from 1960 onwards.
tions about how they may be interrelated in order to construct The search yielded 1342 articles, 622 of which remained af-
an analytical framework. (2) Review of the literature to identify ter removal of duplicates; these were then screened and 22 full-
concept-related variables and relationships between the concepts, text articles assessed, 11 of which were excluded. Those ex-
possibly using field observations or empirical research. (3) Integra- cluded involved studies solely concerning women’s experiences
tion of the concepts and statements into a new, more efficient rep- (Carolan, 2009; Davis and Walker, 2010), the midwife as an indi-
resentation. Different strategies of theory construction may be ap- vidual, the external circumstances of midwifery practice, the de-
plied within these three iterative stages (Walker and Avant, 2011). velopment of the profession (Casey et al., 2015; Crozier et al.,
The goal of this theory synthesis was to find a dichotomous ob- 2007; Davis, 2010; Fullerton et al., 2011; Noseworthy et al.,
jective for midwifery. Therefore, a model was sought that helps to 2013; Walsh, 2006), articles with no recognisable scientific
sort the results within the theory synthesis. The best transferable method (Rooks, 1999), and articles about implementing a concept
model that was found and meets these requirements is the means- (Ryley and Middleton, 2016; Symon et al., 2016). 20 percent of the
end chain from the field of strategic management. The means- articles were reviewed by a second person. There were no differ-
end chain is a hierarchical model. It helps in structuring by ask- ences of opinion.
ing the question why this objective should be achieved (from bot- The 11 studies remaining are listed chronologically in
tom to top) and how this aim can be achieved (from top to bottom) Table 1 (Berg et al., 2012; Bogossian, 2007; Dickson, 1997;
(Welge et al., 2017) (Fig. 1). Fleming, 1998; Hermansson and Martensson, 2011; Kennedy, 20 0 0;
Lundgren and Berg, 2007; Ménage et al., 2017; Renfrew et al., 2015;
Thompson et al., 1989).
Most of the grand or middle range theories were developed
some time ago (see Table 1). Grand theories within a profes-
sion have a high level of abstraction. They describe the nature,
mission and objectives of a profession and provide an expla-
nation at the level of the entire profession. Middle-range theo-
ries have a medium level of abstraction. They describe a spe-
cific phenomenon that appears in different areas of a profession
(Walker and Avant, 2011). The development from a deductive ra-
tionalistic (Dickson, 1997; Thompson et al., 1989) to an induc-
tive empirical (Fleming, 1998; Kennedy, 20 0 0) theory formation,
as seen in the care profession, can also be observed in mid-
wifery science (Neumann-Ponesch, 2017). The latest and also most
comprehensive theoretical work resulted from a mixed-methods
approach (Renfrew et al., 2015). The other studies provide in-
sights into certain aspects of midwifery practice (Berg et al., 2012;
Fig. 1. Diagram of a means-end chain. Bogossian, 2007; Hermansson and Martensson, 2011; Lundgren and
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 3

Table 1
Theoretical work in midwifery science.

First author, year Country Subject Method

Thompson et al. (1989) USA The care Theory building: Seven central concepts of nurse-midwifery:
process Middle-range theory nurse-midwifery care is safe, satisfying, respects human
dignity, respects cultural and ethnic diversity, promotes
self-determination, is family centred, and promotes health.
Dickson (1997) Australia Practical Model Review: Theory Women have physical, psychological, cultural and social
for midwifery, needs. Midwives’ respond to these needs through being
based on present (emotionally, communicating, touching, allowing,
caring concepts listening, reassurance), ensuring client control and building
capacities and capabilities, while respecting specific client
situations and beliefs.
Fleming (1998) UK, Scotland, Model of Grounded theory: The six major categories of this model were: attending and
New Zealand midwifery Conceptual model presencing, supplementing and complementing, reflection
practice and reflexivity, on the basis of reciprocity of the social
process in the midwife-client relationship.
Kennedy (2000) USA Exemplary Delphi Study Essential elements within three dimensions or outcomes:
Midwifery therapeutics, caring, and the profession of midwifery. The
practice process consists of vigilance & attention to detail, creates a
setting that is respectful & reflects the woman’s needs,
supports the normalcy of birth and respects the uniqueness
of the woman & family.
Lundgren (2007) Sweden Midwife- Phenomenological- ‘The relationship between the midwife and the woman is
woman hermeneutic approach: essential for a positive experience for woman during
relationship secondary analysis of childbearing period’ (p.220). Six pairs of concepts are
qualitative studies illuminated from the points of view of both the woman
and the midwife ‘surrender– availability, trust–mediation
of trust, participation–mutuality, loneliness–confirmation,
differentness–support uniqueness, and creation of
meaning–support meaningfulness’.
Bogossian (2007) Netherlands Social support Review and Midwives’ social support consists of emotional,
development of a informational, tangible and comparison support.
model
Halldorsdottir (2011) Iceland Professionalism Theory synthesis The professional midwife cares for the childbearing
in midwifery woman and her family; she has professional wisdom;
professional and interpersonal competence; she develops
herself professionally and personally.
Hermansson (2011) Sweden Empowerment Concept analysis Attributes: Developing a trusting relationship; starting an
awareness process, making it possible to reflect on the
changing situation; acting based on the parents’ situation
on their own terms, getting them involved and able to make
informed choices and confirming the personal significance of
becoming parents (p. 811).
Berg (2012) Sweden and Woman- Hermeneutic The midwife builds a Reciprocal Relationship (Presence,
Iceland centred care in approach: Synthesis of Affirmation, Availability, Participation) and A Birthing
Sweden and review and focus Atmosphere (Calm, Trust, Safety, Strengthening, Supporting
Iceland group interviews normality). For this she respects the woman’s cultural
context.
Renfrew (2014) USA Scope of Mixed-methods Definition of the components of a health system needed
midwifery approach: Scope of by woman and newborn infants: practice categories, the
care/Framework midwifery organisation of care, values, philosophy, and care providers.
Ménage (2017) USA Compassionate Concept analysis Compassionate midwifery is defined as the interrelations
midwifery of authentic presence, noticing suffering, empathy,
connectedness/relationship, emotional work, motivation to
help/support, empowering women and alleviating suffering
through negotiation, knowledge and skills (p. 558).

Berg, 2007; Ménage et al., 2017). The grand or middle-range theo- Stage 2: Developing key concepts and relationships
ries are described below followed by the concepts dealing with a
certain aspect of midwifery. In the first step, the analytical framework was created on the
From these theories the following relevant and related con- basis of theories, concepts and frameworks from the midwife sci-
cepts were extracted: midwife-client relationship; interpersonal ences to identify possible aims and objectives. A further systematic
competence; presence; availability; family-centred; trust; birthing review was performed in the second stage to identify articles on
atmosphere; empathy; awareness process/changing situation; hu- women’s experiences and preferences on midwifery care. The ex-
man dignity; respect (situation; culture, beliefs; uniqueness of periences and preferences identified were used to specify the ex-
the woman/family); promotion of self-determination/ client con- tracted concepts, examine their relationships and to ensure their
trol/ getting them involved; safety; health promotion / therapeu- completeness. Empirical data was used to explore how the con-
tics/ professional wisdom and competence; normalcy of birth/ ex- cepts interact in practice.
pectant management; emotional work; is satisfying; have physi- The literature search was carried out in June 2017 using the
cal, psychological, cultural and social needs; building capabilities. following databases: MEDLINE via pubmed, The Cochrane Library
These concepts were used as an analytical framework for the next (incl. NHS CRD - databanks DARE, HTA, NHS EED), CINAHL Com-
stage. plete via EBSCO, Web of Science, Livivo (incl. BASE), EMBASE via
4 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653

OVID, PsycINFO via EBSCO, MIDIRS via OVID and socINDEX via questions of why and how and to structure the existing constructs
EBSCO. The following terms were used: (1) “Midwifery[Mesh] OR hierarchically. Further, a proof of concept was conducted in a work-
midwife∗ [tiab] OR midwives∗ [tiab] OR “Nurse Midwives”[Mesh] shop with five academic midwives in January 2018. The model was
(2) “Prenatal Care”[Mesh] OR “Postnatal Care”[Mesh] OR “Perina- presented in its former version and explained on the basis of lit-
tal Care”[Mesh] (3) “prenatal care”[tiab] OR “postnatal care”[tiab] erature. It was discussed which ambiguities appeared. One of the
OR “perinatal care”[tiab] OR “maternal health service∗ ”[tiab] OR main results was that the literature was once again undermined
“childbirth care”[tiab] OR “antenatal care”[tiab] OR “postpartum with regard to physical health promotion, as this seemed to be un-
care”[tiab] OR “intrapartal care”[tiab] or “maternity care”[tiab] (4) derrepresented, but according to the workshop participants should
Experience∗ [tiab] OR Perspec∗ [tiab] OR Expectat∗ [tiab] OR Satisfac- be emphasized more.
tion[tiab] Or View[tiab] Opinion[tiab] OR Perception[tiab] OR “Per- The hierarchical model of the process of midwifery shows that
sonal Satisfaction“[Mesh] OR “Patient Satisfaction“ [Mesh] (5) #1 midwifery care is based on a trusting relationship (Level 1). In or-
AND (#2 OR #3) AND #4. der to establish such a relationship, certain midwifery skills and
Studies with an empirical background which were conducted in practices are required. Based on this relationship, the midwife may
industrial countries in the last 15 years and dealt with the pref- achieve three operational aim on the second level, which them-
erences or experiences of women regarding general provision of selves enhance a trusting relationship. Target 1: The midwife pre-
midwifery care were included. Studies which referred to particular serves and promotes both mental and physical health of women
target groups or specific situations were excluded. Study quality during the reproductive phase of life. This improves women’s
was assessed using the Critical Appraisal Skills Programme - qual- health and offers them a sense of security. Target 2: The mid-
ity assessment tool for qualitative studies (CASP, 2013). Ten percent wife cares for the woman in a respectful and dignified manner
of the articles were reviewed by a second person. There were no and promotes participation in her own care. Both aspects allow the
differences of opinion. woman to stay in control. Target 3: The midwife gives practical ad-
6181 hits were obtained. Those from before 2002 were re- vice and guides the women. She offers information regarding the
moved, as were those, in accordance with the exclusion criteria, change of life circumstances, enabling orientation in a new phase
from non-industrial countries and studies referring to specific sit- of life.
uations or target groups such as stillbirth or teenage pregnancies, The three operational targets on the middle level and the trust-
in a pre-screening with keyword search. After removing duplicates, ing relationship itself support the reproductive capabilities of the
2163 studies remained which were screened and 26 studies were woman (Level 3). Midwives therefore empower women to con-
included (Table 2). struct this phase of life on their own terms. The concepts are de-
scribed individually below:
Stage 3: Organising and presenting
Level one
In the first and second stages, possible aims and objectives were
identified and specified. Possible relationships between aims and Trusting relationship
objectives were observed. The identified aims and objectives were If the midwife is empathetic and accepts to the individual sit-
brought into the model of the means-end chain. For each object, uation of a woman, the woman feels she is being seen and heard.
the question was asked as to why this concept is carried out in The woman gains confidence that she has the leading role and her
midwifery care (relation to the superordinate aim) or which re- preferences will be considered; she can let go of her anxieties and
quirements are required for this (relation to the subordinate aim). relax. This is easier if the woman has had the opportunity to get
Based on these questions, the identified aims and objectives were to know the midwife and/or her care and has had time to build
brought into the hierarchical form of the means-end chain in or- an emotional bond. The woman finds it easier to bring up difficult
der to define a primary aim. Within the iterative process, steps one topics and the relationship feels safe and predictable for her. If the
and step two were repeated to validate the results. In the follow- midwife is a good communicator, the woman can ask questions
ing, the newly synthesized theory is described and illustrated using and understand the answers. She is thus empowered to take re-
Fig. 2: Hierarchical model of the means and targets of midwifery. sponsibility for herself and her child and feels supported and taken
In the third stage the concepts and their relationships were or- seriously. Prompt attention results in less stress and facilitates de-
ganised into one objective and four aims of midwifery on three velopment of maternal confidence. If attention is not prompt dur-
levels. The constructs extracted in the first stage were reflected in ing labour, the woman can feel left alone and ignored. If these
the empirical articles, which also made it possible to answer the requirements are met well, a reciprocal relationship of autonomy
and mutual cooperation results, facilitating reassurance and trust
in the midwife for the woman and enabling shared responsibil-
ity. On this basis health promotion and respectful care has more
capacity (Beake et al., 2005; Berg et al., 2012; Boyle et al., 2016;
Dahlberg et al., 2016; Dickson, 1997; Hermansson and Martens-
son, 2011; Karlstrom et al., 2014; Mattern et al., 2017).
‘People that I knew and who knew my history and I was able to
be absolutely frank with them and I didn’t feel that I was wasting
their time about anything’ (Beake et al., 2005) (online, no page)

Trusting relationship: individual and woman centred care

Every woman is in a unique situation, with specific ex-
periences and wishes; this includes a specific culture, reli-
gion or disability. The midwife accepts and promotes this in-
dividuality. She is non-judgmental, interested in others and
flexible in care. She listens actively and identifies the physi-
Fig. 2. Hierarchical model of the means and targets of midwifery. cal, psychological, cultural and social needs and preferences of
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 5

Table 2
Studies included in the second phase (PNC = postnatal care; ANC = antenatal care).

Author, year Country Subject Study aim Sample, method and reflection

Aaserud (2017) Norway PNC, home, 1–6 Experiences of short stay the maternity 9 women; convenience sampling;
day postnatal ward Semi-structured interviews; hermeneutic
approach; Based on theory of: empowerment,
coping, autonomy and relationship
Baas (2015) Netherlands Maternity Care Explore suggestions for improvement of 3499 women; Purposive sampling; Question:
maternity care; Part of DELIVER study ‘Do you have any suggestions on how your
midwife could improve his/her provision of
care?; Qualitative thematic content analysis;
Presupposition: Care has a long-lasting effect
on women’s wellbeing
Bäckström (2016) Sweden ANC; incl. classes Perceptions of professional support; 15 women; 36–38 SSW; semi-structured
understand needs of pregnant women interviews, the questions were: What types of
professional support have you received for
childbirth and parenting? How has the
support been, in your experience? What has
the support meant to you?;
Phenomenography approach; Gap between
need und received care
Beake (2005) UK PNC: home and Exploring women’s views 22 women; In-depth semi-structured
hospital interviews; grounded theory; data was
reviewed by co-researcher
Blackwell (2002) USA PNC Women’s perceptions, experiences and 20 women; face-to-face interviews
needs
Bondas (2001) Finland Maternity care Women’s experiences 40 women; Phenomenological approach:
semi-structured interviews, dialogical
interviews and non-participant observation;
Reflective accounts
Borelli (2016) UK Midwifery care First-time mothers’ perspectives of a good 14 women; semi-structured interviews;
midwife; conceptualised in the context of grounded theory; Reflective accounts
different birthplaces
Boyle (2016) UK Maternity Care Explore whether the UK Government 16 women; diary interview method; social
agenda for partnership working and constructivist; hermeneutic approach
choice was realised
Dahlberg (2016) Norway Early PNC, home Deeper understanding of women’s 24 women; Six focus group interviews;
experiences Phenomenological analysis.
Fawsitt (2016) Ireland Maternity care Exploring pregnant women’s preferences 196 women; focus groups; thematic analysis
for alternative models of maternity care
Feeley (2016) UK Birth Exploring why women choose to freebirth 10 women; narrative, semi-structured
interview; hermeneutic-phenomenological
Howarth (2011) New Zealand Birth First time mothers’ experience of birth 10 women; face-to-face interviews;
Phenomenological form of thematic analysis
Karlström (2015) Sweden Birth Meaning of a very positive birth 26 women; focus group; thematic analysis
Kurth (2010) Switzerland PNC Exploring the experience of hospital care 15 women; Participant observation and 2
narrative interviews; phenomenological
approach; Discussion was used
Larkin (2012) Ireland Birth Women’s experiences 25 women; focus groups; evolutionary
concept analysis
Lundgren (2005) Sweden Birth Important aspects of midwifery care 10 women; Phenomenological approach
Luyben (2005) Scotland, ANC Women‘s needs 23 women; Interviews; grounded theory
Netherlands,
Switzerland
Malacrida (2014) Canada Birth Women’s expectations and their birth 22 women; Qualitative semi-structured
experiences narrative interviews;
Mattern (2017) Germany Midwifery care Experiences and wishes of women 50 women; focus groups; hermeneutic
approach
McKinnon (2014) Australia Maternity care Consumer evaluations of maternity care 150 women; Open-text survey: ‘Is there
anything else you’d like to tell us about
having your baby?’; thematic analysis
McLachlan et al., Australia PNC, hospital and Explored participants’ experiences and/or 50 women; Eight focus groups and four
2009; Melender, home expectations, views of alternative interviews; step-by-step approach; Analysis
2006; O’Hare and packages of postnatal care was conducted by two authors and
Fallon, 2011; crosschecked
Parratt and Fahy,
2003; Schneider,
2002; Shu Fen et
al., 2014; Deutsche
Institut für
Normung e.V. 2015
Melender (2006) Finland Birth Women’s perceptions of a good birth 24 women; Semi-structured Interviews;
content analysis
O‘Hare (2011) Irland Birth Experience of control in labour and 9 women; Semi-structured interviews;
childbirth analysed using frameworks influenced by
Smith et al. (2009) and van Manen (1990)
(continued on next page)
6 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653

Table 2 (continued)

Author, year Country Subject Study aim Sample, method and reflection

Parratt (2003) Australia Birth What features of childbirth have a 6 women; In-depth interviews; Telephone,
positive effect on women’s sense of self also some written statements; thematic
analysis
Schneider (2002) Australia Maternity care This paper explores which models of care 13 women; phenomenological interviews;
the women experienced and also how grounded theory
useful the women found the information
disseminated at antenatal education
classes.
Shu Fen (2014) Singapore Early PNC Postnatal experiences and support needs 13 women; Semi-structured interviews;
thematic analysis; Three researchers analysed
the data

the woman, recognising the level and type of support each ‘The hospital setting was perceived to provide 24-h midwifery sup-
woman needs and tailoring her care accordingly (Beake et al., port, with access to immediate medical care if needed. These fac-
2005; Borrelli et al., 2016; Dickson, 1997; Feeley and Thom- tors helped alleviate women’s anxiety, with continuous access to
son, 2016; Halldorsdottir and Karlsdottir, 2011; Hermansson and midwifery support seen as essential to building maternal confi-
Martensson, 2011; Lundgren, 2005; Lundgren and Berg, 2007; dence.’ (McLachlan et al., 2009) (p.6.)
Mattern et al., 2017; Renfrew et al., 2015; Thompson et al., 1989).
Trusting relationship: empathy attitude
‘It was important that the midwife considered the woman’s
Women find themselves in a vulnerable situation during preg-
uniqueness and vulnerability, and took her worries seriously what-
nancy, childbirth and postpartum, so midwives need to be em-
ever they were.’ (Bondas, 2002) (p.65)
pathetic. Many adjectives are used to describe the qualities re-
Trusting relationship: interpersonal communication quired in a midwife: friendly, nice, warm, kind, personal, sensi-
Women need time and a relaxed atmosphere which allows tive, considerate, peaceful, humane, not tense, not stressed, nearby,
them to talk and ask questions. They want to be taken seriously patient, nurturing, trustworthy, calm, positive, supportive, gen-
and to feel that the midwife engages with them. Women want to tle and genuinely interested. These qualities also describe the
discuss their experiences, anxieties and worries. Midwives need ‘mothering role’ and are reflected by avoiding disturbance and
to have good communications skills. This means listening care- creating a relaxed, homelike and cosy atmosphere (Baas et al.,
fully to each woman, explaining things so women can understand 2015; Backstrom et al., 2016; Berg et al., 2012; Bondas, 2002;
and allowing time to ask questions. Communication can be ver- Feeley and Thomson, 2016; Hermansson and Martensson, 2011;
bal, tactile or aural. The midwife needs pedagogical creativity to Howarth et al., 2011; Karlstrom et al., 2014; Kennedy, 20 0 0;
make it easier to share information in classes (Baas et al., 2015; Mattern et al., 2017; Ménage et al., 2017).
Backstrom et al., 2016; Dickson, 1997; Halldorsdottir and Karlsdot- ‘Try not to use a childish “tone of voice.” In everyday life I am a
tir, 2011; Hermansson and Martensson, 2011; Mattern et al., 2017; mature professional and despite my upcoming motherhood I would
O’Hare and Fallon, 2011; Renfrew et al., 2015). like to be approached that way.’ (Baas et al., 2015) (p. 373)
‘I want to tell her how I am_ _ _ When she asks and listens she
looks me in the eye and I can feel that she listens.‘ (Bondas, 2002) Level two
(p.65)
Security
Trusting relationship: choice and continuity Midwives promote women’s psychological and physical health
Women want to choose a midwife who suits them. They feel and wellbeing and help them to navigate the psychological and
better if the midwife knows their personal circumstances and physiological processes of the changes they and their bodies
they feel they can trust her. They don’t like repeated examina- are undergoing. Competent medical and psychological knowl-
tions by different examiners and different opinions make them edge and skills increase trust and give a feeling of safety
feel insecure. The midwife enables women to choose their mid- and reassurance, allowing women to relax (Baas et al., 2015;
wife and offer continuity of care or carer (Aaserud et al., 2017; Backstrom et al., 2016; Beake et al., 2005; Berg et al., 2012;
Baas et al., 2015; Beake et al., 2005; Bondas, 2002; Boyle et al., Blackwell, 2002; Bogossian, 2007; Bondas, 2002; Borrelli et al.,
2016; Dahlberg et al., 2016; Fawsitt et al., 2017; Feeley & Thomson, 2016; Feeley and Thomson, 2016; Halldorsdottir and Karlsdot-
20 16; Kurth et al., 2010; Mattern et al., 2017; McLachlan et al., tir, 2011; Hermansson and Martensson, 2011; Karlstrom et al.,
2009). 2014; Kennedy, 20 0 0; Lundgren and Berg, 2007; Mattern et al.,
2017; Renfrew et al., 2015; Thompson et al., 1989).
‘Furthermore, an awareness that it was a ‘lottery’ as to who at-
tended their homebirth, meant that they did not want to take the Many participants felt lonely and unsupported at this time in
risk of having a fearful or unsupportive midwife look after them in the ‘twilight zone” between ‘being in labour and ‘not in labour”’
labour: ‘ (Feeley and Thomson, 2016) (p.6) (Larkin et al., 2012) (p. 101)

Trusting relationship: prompt attention Security: physical health promotion

Women would like the midwife to be available and to pro- The reproductive life phase is a normal phase in a woman’s
vide prompt attention when needed during labour. Some women life, but it may be associated with health problems or risks.
want the midwife to be continuously present during birth. Mid- Women may need help in this period, although midwives be-
wives provide clear information on their accessibility and con- lieve in the capacity of women to give birth. Midwives have
tinuous access to support. They are reliable (Boyle et al., 2016; scientifically based professional competence. They employ expec-
Lundgren and Berg, 2007; Mattern et al., 2017; McLachlan et al., tant management and intervene only when indicated. Midwives
2009; Renfrew et al., 2015; Shu Fen et al., 2014). help women to find and trust their body, to get a new sense
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 7

of normality and encourage them to promote their own health. Personal control: respect and dignity
They support physiology and avoid intervention, at the same time This refers to respecting the woman, her situation and hu-
preventing injury and death. To this end they perform screen- man dignity. The midwife’s actions demonstrate her acceptance
ing and risk assessment, identify problems, intervene appropri- of the woman and her decisions. The midwife is empathetic, es-
ately and evaluate their care. The midwife is vigilant, gives at- pecially during physical examinations. This also means respect-
tention to detail and provides first line management of compli- ing the woman’s privacy, her vulnerability, her individual needs,
cations. She knows her own limits and refers women to a doctor and taking her concerns seriously. If care is mechanical, judging
if necessary (Berg et al., 2012; Blackwell, 2002; Bogossian, 2007; or rough, women can feel hurt and ashamed (Baas et al., 2015;
Bondas, 2002; Borrelli et al., 2016; Feeley and Thomson, 2016; Beake et al., 2005; Bondas, 2002; Feeley and Thomson, 2016;
Halldorsdottir and Karlsdottir, 2011; Karlstrom et al., 2014; Hermansson and Martensson, 2011; Kennedy, 20 0 0; Larkin et al.,
Kennedy, 20 0 0; Lundgren and Berg, 20 07; Mattern et al., 2017; 2012; Lundgren, 2005; Lundgren and Berg, 2007; Mattern et al.,
Renfrew et al., 2015; Thompson et al., 1989). 2017; McLachlan et al., 2009; Melender, 2006; Ménage et al., 2017;
Parratt and Fahy, 2003; Thompson et al., 1989).
‘I was a very normal case, I didn’t have any particular problems, I
didn’t actually need any help as such, but I just felt like I wanted ‘luckily, it was quick but if it wasn’t quick that I was going to be
someone to come and sort that out’ (Beake et al., 2005) (online) forced into having something that I didn’t want. I had this fear all
the time’ (Larkin et al., 2012) (p.102)
Security: mental health promotion
Becoming a mother is a significant transitional process. Mid- ‘When the woman is not empowered by the midwife to accept un-
wives believe in the mother’s capacity and ability and strengthen inhibited behaviour, the woman may also not accept the spontane-
women’s self-esteem. Talking about birth, emotions and experi- ity required in the bodily response that allows‘releasing the body’
ences helps a woman navigate her changing situation. Prepar- during labour.’ (Parratt and Fahy, 2003) (p.20)
ing women mentally and being unhurried and serene reduces
women’s anxiety. Midwives give emotional and professional sup- Personal control: participation
port, especially after an early pregnancy loss, stillbirth or traumatic Women are self-responsible. They have the right to partici-
birth experience. If necessary they also perform a psychosocial pate and to make decisions which affect them and their child.
risk assessment and intervene/refer as required (Baas et al., 2015; Each woman wants to participate to a varying degree in her
Backstrom et al., 2016; Beake et al., 2005; Halldorsdottir and Karls- care, depending on her situation. Midwives allow room for desires
dottir, 2011; Hermansson and Martensson, 2011; Kennedy, 20 0 0; and preferences, accepting and supporting women’s decisions and
Lundgren and Berg, 2007; Mattern et al., 2017; Renfrew et al., choices. To promote participation, midwives involve the woman
2015; Thompson et al., 1989). through continuous dialogue, by listening to her, offering alterna-
‘In cases where the woman had a traumatic birth experience, she tives, informing her about what is going on and supporting her
pointed out that it was very important that the midwife during in making decisions. Through this process the woman feel more
the home visit appeared calm and left the impression that she was responsible and can take control. Participation can also involve
interested in the woman’s birth experience: I felt that she was so the delegation of choices or giving the midwife the role of ad-
calm and that she gave me time to talk. I could hardly speak after vocate. If their decisions are not respected, women get stressed,
birth because I was so distant, and that she now had time to listen or feel manipulated or bullied (Berg et al., 2012; Boyle et al.,
while not looking at her watch felt really good. I thought the birth 2016; Dickson, 1997; Feeley and Thomson, 2016; Karlstrom et al.,
was going to be easy, but I was shocked. In that way, it was very 2014; Lundgren, 2005; Lundgren and Berg, 2007; Luyben and
nice that she came home to me afterwards as I felt that I needed Fleming, 2005; Malacrida and Boulton, 2014; Mattern et al., 2017;
to talk more about my feelings and birth experience. It was lovely Melender, 2006; O’Hare and Fallon, 2011; Schneider, 2002; Shu Fen
to talk to someone about It, not just my husband. (Dahlberg et al., et al., 2014; Thompson et al., 1989).
2016) (p.59) ‘Ultimately, if I have made the decisions and things go wrong, the
bus stops here. Yeah.. If they have made the decision and things
Personal control
go wrong, how, how do you deal with that?’ (Luyben and Flem-
Being treated with respect facilitates women’s sense of control.
ing, 2005) (p.219)
They feel accepted and able to do what they want. When women
have the feeling they have a choice and are supported in this
choice, they gain confidence and feel they have control. If women Orientation
feel disrespected, that their privacy has been violated, or that they Women feel uncertainty about the new situation and worry
have no choice, they get stressed and may feel humiliated. Feeling about whether they are doing everything right. Knowledge, skills,
accepted and being in control facilitates self-responsibility and let- and guidance help women feel orientated and empowered. They
ting go in the birthing process (Baas et al., 2015; Beake et al., 2005; can better judge what is normal and act autonomously. If women
Berg et al., 2012; Bondas, 2002; Boyle et al., 2016; Dickson, 1997; know what can happen and how to respond, they feel prepared
Feeley and Thomson, 2016; Hermansson and Martensson, 2011; and can relax. The information provided therefore needs to be
Karlstrom et al., 2014; Kennedy, 20 0 0; Larkin et al., 2012; realistic, timely and tailored to each woman. Women feel dis-
Lundgren, 2005; Lundgren and Berg, 2007; Luyben and Flem- tressed when information does not correspond to their situa-
ing, 2005; Malacrida and Boulton, 2014; Mattern et al., 2017; tion (Aaserud et al., 2017; Backstrom et al., 2016; Beake et al.,
McLachlan et al., 2009; Melender, 2006; Ménage et al., 2017; 20 05; Blackwell, 20 02; Bogossian, 20 07; Borrelli et al., 2016;
O’Hare and Fallon, 2011; Parratt and Fahy, 2003; Schneider, 2002; Dickson, 1997; Hermansson and Martensson, 2011; Howarth et al.,
Shu Fen et al., 2014; Thompson et al., 1989). 2011; Karlstrom et al., 2014; Lundgren, 2005; Luyben and
Fleming, 2005; Mattern et al., 2017; O’Hare and Fallon, 2011;
‘At the same time as the women tried to release control, they
Schneider, 2002; Shu Fen et al., 2014).
wanted to retain control over the situation and the course of
events. This may seem contradictory, but, according to the women, ‘I think in hindsight I probably needed to prove to myself I was ca-
a feeling of having control was important when they were releas- pable of doing it before contemplating doing it alone.’ (Feeley and
ing control and letting themselves go’ (Lundgren, 2005) (p.349) Thomson, 2016) (p.7)
8 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653

‘A kind of support thing, you know, because if you weren’t sure ‘All occasions of birth trauma occurred during a hospital birth.
you always know that she will be coming sometime today and Repeated incidents of women ‘being ignored’, ‘left alone’ or con-
you can ask her’ (Beake et al., 2005) (online) versely ‘harassed’ by hospital midwives and doctors left the
women feeling ‘abandoned’, ‘disempowered’, ‘out of control’ and
‘frightened’. Non-consensual acts were carried out including vagi-
Orientation: practical help
nal examinations and IV lines being inserted where the women
Women worry about their ability to give birth and care for the
reported being ‘done to’, rather than being a part of an in-
baby. Besides information, women need practical help and hands
formed process. These experiences often evoked ‘shame’ wherein
on practice. They want to learn how to breathe, to relax and to
the women seemed to internalise the actions of the maternity staff
breastfeed and care for the baby. During labour midwives give in-
and blamed themselves for not stopping the’ (Feeley and Thom-
structions about breathing, positions in labour, relaxing, and han-
son, 2016) (p.5)
dling the pain as well as providing practical assistance. In ad-
‘Information about how the women could prepare for childbirth
dition, they facilitate new social contacts, promote partner in-
contributed to mental preparedness When the women perceived
volvement and inform women about social and financial resources
that they had received satisfactory information about how best to
(Aaserud et al., 2017; Backstrom et al., 2016; Beake et al., 2005;
prepare for birth and parenting, this information contributed to
Bogossian, 2007; Mattern et al., 2017; O’Hare and Fallon, 2011;
their mental preparedness. The information might involve practi-
Shu Fen et al., 2014)
cal tips for handling pain or tips on how to think during labour;
‘I was prepared, I knew how to breath (during birth) and how to such tips could help the women create an individual goal that they
breastfeed.’ (Karlstrom et al., 2014) (p.10) could then use during difficult parts of pregnancy or labour: It
means very much, because then I know that. . . if I have reached
‘When you read all these things on the internet, books, most of the that goal, then I have managed to give birth. . . and. . . it is very
things you already know. I think I would prefer something more important for . . . getting rid of my fear. . . well, I can’t completely
practical, more useful.’ (Shu Fen et al., 2014) (p.775) get rid of it, but I can make my goal bigger than my fear. . . so . . .
it is very important . . . it means a lot.’ (Backstrom et al., 2016)
Orientation: information (p.115)
Women find themselves in a new situation. They need edu-
cation, information about resources, and advice. Midwives pro- Discussion
vide information about physical changes, the normal process, de-
viations and how to respond them. During birth they continu- The hierarchical model of the process of midwifery practice
ously provide information about what is happening and guide presented here is based on known concepts in midwifery science
women through the labour process. Education may include role and research into women’s preferences and experiences. It illus-
playing, illustrations and humour to be better able to imag- trates the multidimensional and complex work of midwives in sup-
ine what it is like to give birth and feel mentally prepared porting women’s reproductive capabilities. The model illustrates
(Aaserud et al., 2017; Backstrom et al., 2016; Beake et al., that prevention of morbidity and mortality are not the only aims of
20 05; Blackwell, 20 02; Bogossian, 20 07; Borrelli et al., 2016; midwifery practice. An equally important aim is the preservation
Dickson, 1997; Hermansson and Martensson, 2011; Howarth et al., of personal control of a woman by supporting participation and
2011; Karlstrom et al., 2014; Lundgren, 2005; Luyben and offering respectful care. Additionally, the midwife provides orien-
Fleming, 2005; Mattern et al., 2017; O’Hare and Fallon, 2011; tation in a new phase of life by informing and guiding the woman.
Schneider, 2002). Finally, the model illustrates the importance of a trusting relation-
ship, which needs time to take effect. Thus a step has been taken
‘Yeah, yeah, yeah she was really good. Yeah, and also, um, quite here to describe the dichotomous goal of midwifery care and thus
respectful of our wishes and wants with different things, like she to explain the “why,” the purpose of one’s own work, explicitly.
would often, she was slow to offer advice but very quick to of- This work could be a step towards better explaining and clari-
fer sort of information or resources um, but with perhaps a heavy fying one’s own work to other professions and to users. This could
emphasis on us making the decision or us trusting our intuition, also apply to teaching. It can also help to clarify one’s own goals
or um, or reading up and finding out, but she would, she would and thus contribute to the reflection of one’s own work. For exam-
be there to offer information and I, I don’t think she ever would’ve ple, the question can be asked whether midwifery care with un-
made a decision on our behalf.’ (Howarth et al., 2011) (p.8) known women is more challenging, because the midwife has to
build a trusting relationship in a very short time. It is also possible
‘In particular, most women found the onset of labour distressing
to argue for more time for midwifery care, to enable the devel-
because it did not correspond with what they had been told - a
opment of a trusting relationship, and to meet women’s wish for
unanimous complaint was that ‘it didn’t happen at all like they said’.
prompt attention. It also potentially highlights neglected areas of
(Schneider, 2002) (p.36)
midwifery care.
The main aim was to make the quality of midwifery work mea-
Level three surable. A primary objective was identified and in addition some
sub-aims or process steps to the primary objective were identified.
Reproductive capabilities The primary objective remains relatively abstract, so that the ques-
The objective of midwifery care is the facilitation of women’s tion arises whether the primary objective can be used to measure
Reproductive capabilities. These capabilities are multidimensional quality or rather the sub-objectives identified. If this work can be
and not limited to physical health, but include social and psycho- used as a basis for quality measurement, it could serve quality de-
logical needs. This implies that the midwife offers the aids and velopment and thus better care. In this study theoretical work is
competencies described. The woman decides which are relevant perceived as a continuing discourse requiring constant adaptation
for her, and the midwife enables the woman to have the best and change. The possibilities of this work therefore also depend on
birth possible (Berg et al., 2012; Dickson, 1997; Feeley and Thom- its further development.
son, 2016; Hermansson and Martensson, 2011; Kennedy, 20 0 0; Walker and Avant (2011) theory synthesis seems to be a suit-
Lundgren, 2005; Renfrew et al., 2015). able method for theory development in midwifery science. It en-
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 9

ables the inclusion of theories and empirical data regarding mid- Backstrom, C.A., Martensson, L.B., Golsater, M.H., Thorstensson, S.A., 2016. "It’s like
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Declaration of Competing Interest Hoope-Bender, Petra ten, Bernis, Luc de, Campbell, James, Downe, Soo, Fauveau, Vin-
cent, Fogstad, Helga, et al., 2014. Improvement of maternal and newborn
None Declared. health through midwifery. The Lancet 384 (9949), 1226–1235. doi:10.1016/
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The authors gratefully acknowledge all midwives who gener- experience. J. Paediatr. Child Health 50, 91.
ously participated in our workshop and who are a continuously Kennedy, H.P., 20 0 0. A model of exemplary midwifery practice: results of a Delphi
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