Elsevier

Midwifery

Volume 77, October 2019, Pages 95-100
Midwifery

Midwives’ responsibility with normal birth in interprofessional teams: A Swedish interview study

https://doi.org/10.1016/j.midw.2019.07.003Get rights and content

Introduction

Interprofessional working methods and learning processes have become central priorities within health care (Zwarenstein et al., 2009). A literature review describes interprofessional collaboration as the process in which different professional groups work together to positively impact health care (San Martín-Rodríguez et al., 2005). Moreover, improved communication and teamwork between professionals are advocated by healthcare graduates as strategies to solve challenges as inevitable errors and communication failures associated with the healthcare system (Thomson et al., 2015). Interprofessional working occurs constantly during the provision of maternity care. Midwifery care frequently includes interprofessional relationships and requires negotiation between two autonomous professions including midwives and obstetricians (Leonard et al., 2004, Zwarenstein et al., 2009). However, the lack of teamwork and communication between these professionals and rigid adherence to professional hierarchies and differing approaches to care create challenges and impact patient safety and maternal health outcomes (Leonard et al., 2004, Zwarenstein et al., 2009).

Differences between professional cultures can be a barrier for interprofessional collaboration (Hall, 2005, Macdonald et al., 2015, Romijn et al., 2018). Well functioning teams, having mutual dialogue between professionals, contribute to highly valued patient care. Collaboration also involves a socialisation process when different professional cultures work together (Farrell et al., 2015). Problematic power dynamics, poor communication and lack of understanding of one's own and others’ roles are negative factors within healthcare. Further, responsibilities and conflicts caused by varied approaches to patient care are factors that could have negative impact on patient care (Hall, 2005). Obstetricians and midwives are known to have different views on childbirth, arising from differences in education and responsibilities e.g. diverse opinions about induction for post-term pregnancy (Reime et al., 2004). The differences originate from the medical/obstetric view of pregnancy, implying that childbirth is a potentially pathological process (Salam et al., 2014). The midwifery philosophy views pregnancy and childbirth as normal life-events, best managed by the woman herself, with assistance from, rather than controlled by, professionals (Bryar and Sinclair, 2011). In this light, midwives take care of women with low-risk pregnancies who require minimal medical intervention. Obstetricians take charge and become involved when complications arise during pregnancy or childbirth (Amelink-Verburg and Buitendijk, 2010, D'Amour et al., 2005, De Vries et al., 2013, Ratti et al., 2014). Differences between professional cultures can negatively affect open communication, mutual trust, work towards shared goals, and a clear understanding of each team member's tasks and responsibilities (D'Amour et al., 2005, Hall, 2005, Leonard et al., 2004, Macdonald et al., 2015).

A previous Swedish study reported that the midwife's role and responsibility has changed (Larsson et al., 2009). Specifically, obstetricians and auxiliary nurses had partly taken over some of the tasks from midwives, technology was more frequently used and the workload had increased. However, the midwives experienced that the quality of care improved in line with the academic development in midwifery with education at university level and increased research focus. This strengthened confidence and professional competence among midwives and created a platform for mutual dialogue with the obstetricians. The midwives’ expressed a strong professional identity based on self-confidence and experience even though handcraft skills such as determining the fetal position with the midwife's hands and clinical experience had become less valued over time (Larsson et al., 2009).

Interdisciplinary teamwork is a common model in the Swedish healthcare system. Maternity care in Sweden is mainly provided through the tax-financed public health care system. Some private providers exist, but they all have an agreement with the regional authorities in the regions where they operate, so the cost for clients/patients is the same. However, most maternity care, for example antenatal care, is free of charge. Almost all births in Sweden, 98%, take place in hospitals, but a healthy woman without complications is likely to have all her antenatal, childbirth and postnatal care conducted by a midwife with access to an obstetrician in case of need.

Swedish hospitals and clinics have high autonomy to create their own clinical guidelines and clinical organization structures including the composition of the team working with childbirth care, and no formal policy exists. Some clinics have only midwives and obstetricians employed, whereas others also have included auxiliary nurses in the team. Auxiliary nurses in Sweden have a shorter education than nurses. In some delivery wards they work together with midwives in supporting the women during labour and birth, for example with food and beverage, they assist the midwife during delivery and they are also responsible for cleaning.

During childbirth, the midwife is in charge of taking appropriate measures and assessing when cooperation is needed with other professions (Ahlberg et al., 2015). Problems and conflicts in relationships between younger and older midwives with conflicting theories and opinions regarding midwifery practice have been suggested (van der Putten, 2008).

A UK investigation reported major shortcomings in the care of mother and child in a dysfunctional maternity unit (Wise, 2015). The report described a lack of skills in general, but especially a lack of effective collaboration between midwives, obstetricians and paediatricians, which led to unnecessary death among babies and mothers.

Even if the differences in professional cultures in obstetric care are well known, very little is known about perceptions among midwives and their experience of responsibility and interprofessional collaboration for care during normal births. The aim of the study was to gain deeper understanding of midwives’ work with, and responsibility for, care in normal births within interprofessional working teams.

Section snippets

Design

The study was explorative and had a descriptive and qualitative design using focus group interviews. A focus group interview is a research method suitable for collecting data from a homogeneous group of people on a specific predetermined topic, especially on unexplored areas. Interaction is the key to the method, and participants are encouraged to reveal experiences and viewpoints that would be less accessible in individual interviews. The informants can compare opinions and experiences. The

Findings

Twenty midwives, aged 28–64 years, participated in four focus groups interviews. All the involved midwives worked in multidisciplinary teams and had worked as a midwife between one to 32 years. The midwives generously shared their experience of care during childbirth at the hospitals. In general, the focus group discussions had a natural flow, and the participants showed interest and willingness to share their experiences. The analysis resulted in one overarching theme, three categories and

Local guidelines and organizational routines enhance and challenge teamwork

Local guidelines for care during childbirth were mainly seen as supporting tools to ensure high quality of care. However, some participants expressed the opinion that such documents could threaten the midwives’ own judgement and professional competence.

Work environment and professional relationships are important in midwifery

The participating midwives pointed out that a heavy workload and stress reduced the time for reflection among colleagues and other professions. They wished for less hierarchy and more equal cooperation between different professionals in the clinical work, but also for respecting each other's professional competence.

Discussion

The midwives were responsible and cared for women during a normal birth and performed their role independently, when they used their own knowledge and experiences but also the expertise within the midwifery team. Larsson et al. (2009) found that midwives did not consult each other as they used to do because the obstetricians were constantly present during the day. Moreover, the administrative area was crowded with different people and the midwives could not talk in peace that would facilitate

Conclusion

The midwives were independently responsible for care during normal birth and used their own knowledge and experiences but also the expertise within the midwifery team. However, the midwives’ responsibility and independence was partly undermined by obstetricians even when providing care during normal births. The obstetricians have to trust the midwives’ evidence-based knowledge and competence to handle a normal birth and therefore refrain from interfering.

Conflict of interest

No conflict of interest.

Ethical approval

Not applicable.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.

Acknowledgment

None.

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