Women and Birth
Volume 20, Issue 2 , Pages 57-63, June 2007

Research priorities of NSW midwives☆

  • Judy Reid

      Affiliations

    • School of Nursing, College of Health and Science, University of Western Sydney (UWS), Australia
    • Sydney South West Area Health Service, Australia
    • Corresponding Author InformationCorresponding author at: Campbelltown Campus, Building 7, School of Nursing, College of Health and Science, University of Western Sydney, Locked Bag 1797, Penrith South DC 1797, NSW, Australia. Tel.: +61 46203325; fax: +61 46254252.
    • ,
  • Rebecca O’Reilly

      Affiliations

    • School of Nursing, College of Health and Science, University of Western Sydney (UWS), Australia
    • ,
  • Barbara Beale

      Affiliations

    • School of Nursing, College of Health and Science, University of Western Sydney (UWS), Australia
    • ,
  • Donna Gillies

      Affiliations

    • Sydney West Area Health Service and UWS, Australia
    • ,
  • Tanya Connell

      Affiliations

    • North Gosford Private Hospital, Australia

Received 18 October 2006; received in revised form 5 March 2007; accepted 6 March 2007.

Article Outline

Summary 

Purpose

Research is vital to achieve optimum health outcomes for pregnant women, children and families. Recently, the benefit of setting research priorities to effectively utilize limited resources has been identified. Currently there is a lack of published Australian research data relevant to the practice of midwifery. Consultation with current practitioners is important to fulfill the National Health and Medical Research Council (NHMRC) key priority for a healthy start to life, ensure limited resources are expended appropriately and promote evidence-based midwifery practice. The aim of this study was to ascertain the perceived research priorities and the research experience of midwives in NSW, Australia.

Procedures

Postal questionnaire sent to the 1000 subscribers of Australian Midwifery, of whom 90% (900) are midwives, in March 2005 with key open-ended questions to ascertain midwifery research priorities and research experience of participants.

Findings

Respondents were all midwives with 95% indicating they were currently practising as a midwife. They identified six priority areas: professional practice; clinical issues; education and support; breastfeeding; psychosocial factors; rural/indigenous issues.

Principle conclusions

Priorities for research were identified and the need for a link between research and professional midwifery practice was highlighted. Midwives were positive about the possibility of becoming more actively involved in research and/or advocates for evidence based practice. The opportunity exists to take the broad priority areas from this study and develop research questions of relevance for the midwifery profession.

Keywords: Midwifery research, Research priorities, Evidence-based practice

 

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Introduction 

Recently, the benefit of setting research priorities to effectively utilize limited resources has been identified.1, 2, 3, 4, 5 Within Australia, the National Health and Medical Research Council (NHMRC) has advocated for urgent research in key priority areas. One of those key areas concerns “research for a healthy start to life”.6 This priority acknowledges the importance of the relationship between health issues which may arise during the prenatal period and early childhood years, to the long term health and illness potential of individuals. Midwives are clearly in a strong position, due to the nature of their relationship with pregnant women and their families, to identify specific research priorities that could ultimately contribute to the improvement of health outcomes for our future generations. Identifying researchable questions that are relevant to clinical practitioners is also critical to building the knowledge base for provision of evidence-based midwifery care.5

Currently there is a lack of published Australian research data which could provide information on priority areas related to the needs of midwives and the practice of midwifery. However, a recent study aiming to uncover “Priorities for Midwifery Research in Perth, Western Australia” has recently been published.7 Using a two round questionnaire and recruiting participants from five metropolitan hospitals, the Perth study generated 17 priority areas for midwifery research in Western Australia (WA).7 The results of the Perth study indicate that Western Australian midwives have similar concerns to midwives in New South Wales, Australia particularly in regard to the delivery and organisation of maternity care and the implementation of evidence-based practice.7

The need to urgently consult current NSW midwifery practitioners to ascertain the optimum direction of future midwifery research was therefore the main impetus for this project. This paper reports the findings of a study surveying 900 midwives statewide in NSW.

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Method and participants 

One thousand surveys and information sheet with reply paid envelope were mailed out in March 2005 to NSW subscribers of Australian Midwifery, the Journal of the Australian College of Midwives Incorporated (ACMI), now entitled “Women and Birth”. Nine hundred (90%) of the subscribers met the inclusion criteria of being a qualified midwife. An advertisement for the project was also placed in The Lamp (the magazine of the NSW Nurses’ Association) calling for interest to participate which resulted in no responses. Participation in the survey was also promoted via direct contact with midwives at conferences and professional meetings.

The questionnaire collected relevant demographic information about participants including gender, years of experience in midwifery, specific area of practice, clinical and educational qualifications; whether the participant was currently practicing as a midwife and the type and location (city, regional, rural) of the service in which they worked.

The open-ended questions invited respondents to list the research priorities they thought were important to the practice of midwifery. Information regarding previous participation in midwifery research or barriers to participation was also requested.

The questionnaire was refined after piloting with a small group of midwifery clinicians.

Data analysis 

Question one 

The open-ended responses to the question about research priorities were initially analyzed and categorized into codes related to areas of practice, for example antepartum, intrapartum, postpartum. However, this coding did not seem to give full credence to the fundamental research priorities that the midwives articulated and other broad emerging themes were noted. In addition, many midwives provided multiple responses and there was substantial overlap between the various categories which established the need for further analysis. It was then determined that identifying themes that canvassed across areas of practice more accurately reflected the strength of responses and allowed interpretation that was more meaningful and relevant. Responses were ultimately coded according to their relevance to the main themes and sub-themes that had been elicited. Prioritisation of the main themes was based on the number of responses that were coded for each.

Question two 

Responses to the research experience question were coded as follows: active researchers or participants/assistants in research projects and/or quality improvement projects. Coding as an active researcher was based on clear evidence in the response regarding the respondent being fully engaged and responsible in undertaking research project(s).

Themes and demographic data were analysed quantitatively using SPSS 12.0.8

Ethics 

Research approval was provided by the University of Western Sydney (UWS) Human Research Ethics Committee and the study was conducted within the guidelines of the National Health and Medical Research Council (NHMRC) in Australia.

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Results 

The 213 participants who returned the survey were Registered Midwives within NSW, Australia. This represented a response rate of 23.6%. Although low, this compares favourably with the response rate using similar methodologies (i.e. postal questionnaires with no previous contact)9 and the 20% response rate from midwives for the round-one questionnaire in the Perth Delphi study.7

Demographics 

The number of years that respondents had been registered as a midwife ranged from less than 1 year to 40 years.

The mean number of years of registration was 17.0 years (95% confidence interval: 15.7–18.4). The majority of respondents (95%) replied that they were currently practicing as a midwife. Of these, 24% of respondents also identified themselves as a Clinical Nurse Specialist (CNS). There was only one male who responded (Table 1).

Table 1. Demographic data
NumberPercent
Qualifications/current midwifery positions
Registered midwife (RM)11855
Clinical nurse specialist (CNS)5224
Educator115
Clinical nurse consultant (CNC)168
Nursing unit manager (NUM)168
Other2311

Highest education level
Certificate6631
Graduate diploma4019
Bachelor degree3617
Masters degree (coursework)3617
Bachelor (Hons)10.5
Masters (Hons/research)105
PhD63
Other168

Gender
Male10.5
Female21399.5

Area
Antenatal (ward)9846
Birth suite10650
Community nurse2311
Special care/NICU5023
Antenatal (outpatients)7334
Postnatal13061
Child and family2210
Team midwifery157
Other area6028

Type of service
Hospital17185
Community147
Independent31.5
Other136.5

Public or private
Public18288
Private2512

Work location
Capital city9344
Regional centre7737
Rural setting3919

The highest level of education in the majority of cases was a certificate (31%). The number of midwives with Graduate Diploma, Bachelor's degree or coursework Masters degree were roughly equivalent as the highest level of education attained (19%, 17% and 17%, respectively) (Table 1).

The majority of midwives responded that they worked in postnatal care (61%), which was closely followed by inpatient antenatal care (46%) and birth suite (50%). As these figures indicate, many midwives work in more than 1 area (Table 1) and therefore the total percentage is greater than 100.

Eighty-five percent of the respondents indicated that they worked in a hospital, 7% in the community and the remaining 8% in independent practice or other. Eighty-eight percent of all respondents responded that they were employed in the public sector. The number of respondents from capital cities and regional centres were roughly equal (44% and 37%, respectively) with a lower proportion working in rural settings (19%) (Table 1).

Research experience 

Sixty-six percent of respondents replied that they had participated in research. Of those, 38% could be classified as active researchers (see data analysis). Overall, 33% indicated non-participation in research. Reasons given included lack of time, opportunity or motivation (27 responses); lack of support or funds (9); lack of research expertise (10).

Research priorities 

Six key priority areas for research were identified (see data analysis): professional practice; clinical issues; education and support; breastfeeding; psychosocial factors; rural/indigenous issues. The number and type of responses are discussed and prioritized under the main themes as follows (see Fig. 1).

Priority one: professional practice (231 responses) 

Professional practice for midwives was the theme that elicited the largest proportion of responses. For the purposes of this paper, professional practice was coded to distinguish items that related to the professional practice of midwives in their day-to-day role. Within this category, sub-themes that arose from the responses included: models of care/continuity of care, workload issues and use of research in practice. In particular, concern was expressed regarding the impact of midwives being replaced by non-midwives and whether women and their families were aware of this. This issue was raised also in the context of increased workplace stress due to under-qualified staff.

These sub-themes are discussed below.

Models of care/continuity of care (143 responses) 

This sub-theme was developed around responses that reflected models within midwifery that guide care including the concept of continuity of care. Responses referred to the need for research concerning the role and value of the midwife. The professional relationships of midwives with mothers and other health professionals was also indicated as an area for research. Responses relating to continuity of care specifically addressed the need for research to ascertain the cost effectiveness and benefits of midwife-led care and issues surrounding caseloads in independent midwifery care. In regard to continuity of care, one midwife commented “A lot of really good research has been done-sometimes several times. I think the issue is that this research is not implemented”.

Leadership, standardisation of practice and impact of workloads and isolation on child and family health nurses was also identified.

Use of research in practice (65 responses) 

The translation of evidence into practice and dissemination of research findings were key issues raised within the responses in this category. One midwife commented: “I believe there is probably good research being done but too time consuming and difficult to access. It would be good if quality research findings could be brought to health care centres and hospitals and made obvious to midwives…” and another “How to have research accepted into practice—why we research the same subject have the same findings and find implementation difficult?”

Workloads (23 responses) 

The impact of staff shortages and workload related time constraints on care provision was a predominant theme. Many respondents also raised concern regarding the effects of heavy workloads on the health and wellbeing of midwives themselves. Poor morale contributing to bullying and horizontal violence in the midwifery workplace was also articulated as a factor related to excessive workloads. One midwife commented “Why do midwives destroy each other especially in rural units where there are no other places to work?”

Priority two: clinical issues (148 responses) 

Clinical issues were determined to be those responses that identified a concern, problem or phenomenon requiring research that could potentially impact on perinatal outcomes for mother or baby.

Sub-themes arising from clinical issues were coded as follows.

Perinatal management of care (83 responses) 

This included any reference for research related specifically to the management of clinical midwifery care in the antepartum, intrapartum or postpartum period. Responses were many and varied but considerable concern was raised regarding the definition of “normal labour” and the continuation of the medicalisation of childbirth. Postnatal midwifery care was clearly identified as the “core-business” of what midwives do and therefore a key area for research. One midwife stated: “We must evaluate clinical care and demonstrate improved outcomes that health managers/politicians will be interested in (let's stop naval gazing)”.

Perinatal assessment and monitoring (31 responses) 

Questions were raised regarding the existence of evidence to support a number of routine clinical practices for example use of cardiotocographs (CTGs); necessity and frequency of vaginal examinations in labour.

Pain management and use of complementary and alternate therapies (CAT) (22 responses) 

Concern was raised about how to effectively manage pain in labour and the role of complementary and alternate therapies. Specifically the effects on the foetus of epidural anaesthetic and other pharmacological methods of pain relief were articulated. One example given was the impact of various pain relief methods on infant feeding.

Induction of labour (12 responses) 

A variety of issues around induction of labour were identified, for example “…impact on mother and babies…”; “…length of time with ruptured membranes before augmentation…”; “…ways of reducing numbers of post-dates inductions…”

Priority three: education and support (63 responses) 

There was substantial overlap between responses within this theme and other themes, particularly breastfeeding. The need for research to determine how to provide appropriate education and support to mothers and their families during pregnancy, childbirth and the postpartum period was clearly identified. The effectiveness of current antenatal education was questioned as was the need to identify strategies to enhance maternal confidence with mothercraft, breastfeeding and parenting skills.

Specific responses indicated the need for research regarding “the compliancy of women in adhering to advice given by midwives after they return home for example breastfeeding rates, sleep & settling issues…” and “what information women feel was most helpful to them”. Concern regarding education and support for current practising clinical midwives and student midwives was also raised in the context of the complexity of midwifery practice and impact of workloads.

Priority four: breastfeeding (59 responses) 

Breastfeeding was a priority research area reported by respondents. This included the effect of education on successful breastfeeding outcomes, the impact of clinical interventions on breastfeeding outcomes, factors around successful breastfeeding such as education for the mothers, effects of early discharge on breastfeeding success and early support for successful breastfeeding. One midwife commented, “Research that could help develop specific clinical guidelines as to how to best assist/support these new mums would be valuable” and another “Women still believe their milk ‘runs out’—need for better education skills in breastfeeding”

It was also noted that some responses, as well as determining sub-themes, overlapped into other major themes such as rural/indigenous issues. Highlighting this was the comment “Consistent breastfeeding and education for women within best practice guidelines—Why doesn’t this happen in rural New South Wales?”10

Priority five: psychosocial factors (37 responses) 

Uncovering strategies to assist disclosure and sensitive follow-up of women who have experienced sexual abuse or domestic violence and the impact of mandatory psychosocial screening of women was expressed in multiple responses. The relationship and importance of life events, birth experience, psychosocial and spiritual health to pregnancy wellbeing and early mothering, and effectiveness of antenatal education in reducing maternal anxiety was also identified. Specifically concern was raised regarding the “Effect of time lapse between LSCS (Cesarean) birth & first time together for mum & baby, & bonding” and “Effects of life events on women during pregnancy and in early mother(hood)”.

Priority six: rural/indigenous issues (33 responses) 

Responses related to this theme included: “I think there is an urgent need to focus strongly on research about indigenous women which is aimed at improving their shameful outcomes”. Concern was also raised regarding the impact of lack of services and choice regarding models of care in regional and rural areas, and the lack of postnatal care by midwives. Resistance to change and belief in myths was also identified as an issue and a possible barrier to implementation of evidence-based practice in rural settings.

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Discussion 

The qualitative results of this study summarise the views of 213 NSW midwives in regards to midwifery research. The major themes also highlight the main concerns and challenges that NSW midwives face in their professional practice. There is a significant similarity with the views of the Perth midwives particularly in regard to concern with the context of care delivery, workloads, workplace stress, horizontal violence, staffing levels/retention and the medicalisation of childbirth which have also been echoed in both Australian and international studies.7 Fortunately, the impetus for change has been accelerated by the Australian Midwifery Action Project (AMAP), an initiative funded by the Commonwealth Government and industry partners with the aim of investigating concerns regarding the standard and quality of midwifery care in Australia.11 A key focus of this project was analysis of maternity service delivery, including models of care.11

In addition, a broad coalition of consumer and midwifery representatives from across Australia, have formulated the National Maternity Action Plan (NMAP).12 The NMAP provides a compelling case for maternity service reform including comprehensive detail of the benefits to be gained from continuity of care and community-based models of care.12 The government has responded positively and now an increasing number of maternity services within NSW are offering women the option of midwifery-led care10, 13 including the caseload model of midwifery care that, as identified in the AMAP research has shown “to be the most effective in producing the best outcomes”.12 Early results from the Ryde Midwifery Group Practice are encouraging with no maternal or neonatal adverse outcomes noted for their first 100 births.14

Whilst there is acknowledgement of the need for practice to be informed by the latest research it is clear that midwives are struggling with their professional obligation in this regard. Excessive workloads and professional and personal responsibilities has clearly been identified by respondents in this study as the reason why midwives find it difficult to find time to access or participate in research. Autonomous practice, recognition by other health professionals, support (from management and colleagues) and having the necessary skills and training have been identified as conditions that are important in facilitating the empowerment of midwives.15 Therefore, another advantage of the implementation of midwifery models of care is that midwives can feel empowered and experience greater satisfaction in their role.16, 17 This also has the potential to attract midwives back to the profession who have left because of dissatisfaction with working in a medical model of care, thereby helping to address the shortage of midwives that has created the current workload issues.12, 18, 19 Although, it must be acknowledged that there is a danger of compromising continuity of care and further burdening midwives, if caseloads and work hours are unreasonable within this model of care.20 The predominance of females in the midwifery profession and the reality that, “despite considerable emancipation they still carry the majority of work and responsibility in the family and home” as emphasised by Page21 means support for midwives (working within any model of care) in meeting competing demands and having a life outside of work is absolutely vital.

Clearly, recruitment and retention of midwifery students is also inherent to overcoming workforce shortages and the findings of the AMAP highlight the changes needed in terms of midwifery education and again reinforce the need for strategies which enhance the status and autonomy of midwives as crucial to stemming the flow of those abandoning the profession.22

In addition to addressing workload issues, there needs to be investigation into how to more effectively disseminate research results to support practitioners in the implementation of evidence-based practice (EBP). The NHMRC has identified this need in its strategic plan.6 Frustration with failure to instigate EBP within an inherently medically-based, interventionist culture is another area where NSW midwives demonstrate congruence with concerns of Perth midwives.7 According to Booth5 an important manifestation of the research-practice gap is “the failure of researchers to address questions of direct relevance to practitioners”. This validates the need to continue the dialogue between researchers and those providing direct care. Stronger links between academics and clinicians are recommended for increasing research activities in the workplace, in the NSW Health First Report on Models of Care.23 Therefore, ongoing consultation and collaboration between academic midwifery researchers and current clinicians would assist in making research more accessible and relevant.

The number of responses in regards to breastfeeding indicates that despite the considerable amount of published literature around this topic midwives are still struggling to find the most effective way to assist women in achieving a successful breastfeeding experience. Although midwives have acknowledged that breastfeeding is an important health priority, workload pressures contribute to their struggle to find time to provide adequate support and education to new parents. Certainly while some factors that promote breastfeeding success have been identified24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 the question is: do midwives have access to this information and do policies, procedures and the workplace environment support best practice?

A study into “How midwives learn about breastfeeding” reveals that many midwives rely on personal and professional experience and continuing education to help them in acquiring skills to assist in breastfeeding.37 This increases the likelihood of “conflicting advice” and other inconsistencies in practice depending on the motivation that an individual midwife has to keep themselves well informed and the role-models that are available to them. It also increases the potential for a culture to develop within units, particularly those that are somewhat isolated, which is counterproductive to breastfeeding success.37, 38, 39 Since breastfeeding is acknowledged as a key factor in enhancing infant health40 and therefore an important component of achieving a “healthy start to life”; it is essential that midwives are provided with the skills to support breastfeeding success. Breastfeeding needs to have greater emphasis in midwifery education programs and strategies need to be employed which ensure all midwives are up-to-date and following best-practice guidelines.

Education and support for new parents cannot be considered in isolation from the psychosocial factors that may potentially impact on the experience of pregnancy, childbirth and the adjustment to parenthood for women and their families and it is clear from this study that midwives are seeking to gain a greater understanding of such phenomenon. While some interesting research has already been published33, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 ongoing investigation is essential to create insightful and effective education and support strategies.

The issues for rural midwives and our indigenous population cannot be underestimated and the need to urgently improve health outcomes has been acknowledged within national health priorities and government initiatives.6, 53 However, there are some issues such as de-skilling and undervaluing of midwives and models of care that are common to midwives working in other areas. Also, the notion that midwives sometime destroy each other is somewhat disturbing and indicates a need to study the professional relationship between midwives themselves in rural practice. Some innovative approaches to educating and supporting rural midwives using information technology are currently being explored and these may help break-down the barrier which isolation from main urban centres can create.54

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Limitations 

While surveying practising midwives via the professional body was the most feasible option to access a large sample size for this study, the authors acknowledge, that this may also be viewed as a limitation. For example, it is possible that members of the ACMI are perhaps more recently educated and more research aware than all practising midwives and therefore their view is not necessarily representative of all midwives in NSW.

Even though the response rate is low, it is still slightly better than other postal surveys where rates are often lower9 and is comparable to the first round of the Perth study which enables interesting comparisons to be made between states. The meanings of some responses were difficult to elicit due to non-specific information, unclear handwriting and use of terminology or abbreviations not familiar to researchers. Asking for both broad areas and/or specific research questions/projects may have created difficulty for some respondents in differentiating between specific research areas and an opportunity to present strongly felt personal opinions.

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Recommendations and conclusions 

This survey has provided insight into NSW midwives’ perceptions of priorities for midwifery research. With 95% of respondents indicating they were currently practising as a midwife and the average years being registered as a midwife standing at 17, it is reassuring to note that this survey accessed the people who are experienced “hands on” practitioners. In addition, the fact that the majority of respondents took the time to provide extensive answers demonstrates that many midwives are very concerned about research and its relationship to their practice. Gratitude was expressed for the opportunity our project gave for participants to have their say in the future direction of midwifery research.

Therefore, the importance of ongoing consultation and collaboration with current midwifery practitioners in determining and undertaking relevant research projects cannot be ignored. Midwives desire and deserve any opportunity to empower and motivate them to become actively involved in research and/or advocates for evidence based practice. The priorities identified from this study can be used to inform future research in midwifery with the ultimate aim of improving outcomes for mothers and babies.

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Acknowledgements 

Midwives who responded to our study; Rebecca Hughes; Child and Family Research Node, School of Nursing (University of Western Sydney); Australian College of Midwives Incorporated; The New South Wales Nurses Association.

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☆ Funding for this project was provided by the Child and Family Research Node, School of Nursing (University of Western Sydney), Australia.

PII: S1871-5192(07)00021-2

doi:10.1016/j.wombi.2007.03.001

Women and Birth
Volume 20, Issue 2 , Pages 57-63, June 2007

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