Our purpose in this study was to explore the midwives' perception of factors obstructing or facilitating their ability to provide quality perinatal care at a central labor ward in Maputo. In-depth interviews were undertaken with 16 midwives and were analyzed according to grounded theory technique. Barriers to provision of quality perinatal care were identified as follows:(i) the unsupportive environment,(ii) nonempowering and limited interaction with women in labor,(iii) a sense of professional inadequacy and inferiority, and (iv) nonappliance of best caring practices. A model based on the midwives' reflections on barriers to quality perinatal care and responses to these were developed. Actions aimed at overcoming the barriers were improvising and identifying areas in need of change. Identified evading actions were holding others accountable and yielding to dysfunction and structural control. In order to improve perinatal care, the midwives need to see themselves as change agents and not as victims of external and internal causal relationships over which they have no influence. It is moreover essential that the midwives chose actions aiming at overcoming barriers to quality perinatal care instead of choosing evading actions, which might jeopardize the health of the unborn and newborn infant. We suggest that local as well as national education programs need to correspond with existing reality, even if they provide knowledge that surpasses the present possibilities in practice. Quality of intrapartum and the immediate newborn care requires a supportive environment, however, which in the context of this study presented such serious obstacles that they need to be addressed on the national level. Structural and administrative changes are difficult to target as these depend on national organization of maternal health care (MHC) services and national health expenditures.

Our aim in this study was to explore women's responses to reported ad-hoc demands for unauthorized user fees during pregnancy and childbirth in Luanda, Angola. Ten focus group discussions were conducted and data were analysed using grounded theory. Women were found to apply six strategies as they "endeavored to cope with demands for unauthorized user fees"(core category):(i) blowing the whistle,(ii) searching for comprehension,(iii) manipulating the system,(iv) bargaining,(v) extending the limits, and (vi) balancing. The system of unauthorized user fees appears to be a symptom of a deeper structural problem, which requires multifaceted and long-term interventions such as insti-tutional reforms and clear policies on accountability and transparency. Better resource availability for the MHC sector is required in order to secure adequate salaries to maternal health care providers. The fact that unethical behavior is unveiled implies that interventions also need to target the national midwifery training.

The aim of this study was to explore how various factors influenced women's decisions regarding place of confinement in Luanda, Angola. Ten focus group discussions were conducted with pregnant and nonpregnant women residing in suburban areas of Luanda and the data were analyzed using the grounded theory technique. Four patterns of action of the main theme,"the molding of women's care-seeking behavior during childbirth," were identified:(I) the "labor process 'on-course' avoiding pattern";(II) the "labor process 'off-course' avoiding pattern";(III) the "labor process 'on-course' approaching pattern"; and (IV) the "labor process 'off-course' approaching pattern." Our findings indicate that personal "courage" and social support empowered women and impacted on their preference for home birth, whereas demand for informal user fees and perceived low quality of care influenced women to avoid institutional care during childbirth, sometimes even in spite of complications. Ability to meet demands for informal user fees and knowledge of childbirth influenced women to seek institutional care. The study highlights the need to improve the quality of available maternal health care addressing the implicit educational, attitudinal, and ethical issues.

BACKGROUND: midwifery is a part of the nursing profession in India. This current study explores and describes the midwifery scope of practice among staff nurses. METHODS: a grounded theory approach was used to develop a model. Twenty-eight service providers from the maternity sections of public health facilities, selected through purposive and theoretical sampling were interviewed in-depth. Unstructured observations in the labour wards were also used for developing the model. FINDINGS: the midwifery practice of staff nurses was limited in scope compared to international standards of midwifery. Their practice was circumstance driven, ranging from extended to marginal depending on the context. Their right to practice was not legally defined, but they were not specifically prohibited from practice. As a consequence, the staff nurses faced loss of skills, and deskilling when their practice was restricted. Their practice was perceived as risky, when the scope of practice was extended because it was not rightfully endorsed, the nurses having no officially recognized right to practice midwifery at that level. The clinical midwifery education of nursing and midwifery students was marginalized because the education of medical students was given priority, and the students only got exposed to the restricted practice of staff nurses. CONCLUSIONS: unclear definitions of the right to practice and the scope of practice have led to the un-utilized potential of staff nurses practising midwifery. This is detrimental because India faces an acute shortage of qualified personnel to meet the need in providing human resources for maternal health.

In this article we describe Tibetan indigenous women's perceptions and experiences of their own health and life situation in Shichuan Province, China. Fifteen focus group discussions (FGDs) and 10 interviews were conducted. Repeat FGDs were used to empower the women and as a tool to collect data. Content analysis was used to analyze the data, and three subthemes were identified:'shouldering responsibility in family life,'"enduring reproductive hardship and ill health" and "reflecting on the future." The main theme,"experiencing aloneness," contained two dimensions:"strength for surviving under extreme living conditions" and "negative influence on women's endeavor to maintain a healthy behavior."

OBJECTIVE: to explore and understand how midwives perceive and experience decision-making about augmentation of labour. DESIGN: focus-group discussions. SETTING: Stockholm, Sweden. PARTICIPANTS: 20 midwives experienced in working in labour wards. FINDINGS: five categories were identified that illustrate the factors considered by the midwives to influence decision-making during augmentation of labour:'regulations and guidelines';'shortage of delivery rooms';'influence of obstetricians';'women in labour'; and 'midwives' professional selves'. The theme identified was how midwives managed to 'navigate' these factors, which provided midwives with a decisive influence during the decision-making process. KEY CONCLUSIONS AND IMPLICATIONS: midwife job satisfaction can result from a sense of professional power over the possibility of navigating factors that influence decision-making during augmentation of labour. This sense of power can subsequently influence co-operation with both obstetricians and women during labour.

OBJECTIVE: to explore Sudanese midwives' motives for and perceptions and experiences of re-infibulation after birth and to elucidate its context and determinants. DESIGN: triangulation of methods, using observational techniques and open-ended interviews. SETTING AND PARTICIPANTS: two government hospitals in Khartoum/Omdurman, Sudan, for the observations and in-depth interviews with 17 midwives. FINDINGS: midwives are among the major stakeholders in the performance of primary female genital cutting (FGC) as well as re-infibulation. Focusing on re-infibulation after birth, midwives were trying to satisfy differing, and sometimes contradictory, perspectives. The practice of re-infibulation (El Adel) represented a considerable source of income for the midwives. The midwives integrated the practice of re-infibulation into a greater whole of doing well for the woman, through an endeavour to increase her value by helping her to maintain her marriage as well as striving for beautification and completion. They were also trying to meet socio-cultural requests, dealing with pressure from the family while balancing on the edge of the law. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the findings confirm that midwives are important stakeholders in perpetuating re-infibulation, and indicate that the motives are more complex than being only economic. The constant balancing between demands from others puts the midwives in a difficult position. Midwives' potential role to influence views in the preventative work against FGC and re-infibulation should be acknowledged in further abolition efforts.

OBJECTIVE:: to describe women's experiences of participating in decision-making related to augmentation of labour. DESIGN:: a qualitative approach using modified grounded theory technique. Open-ended interviews were conducted 1-3 days after childbirth. SETTING:: the interviews were performed in the postnatal wards in five hospitals (tertiary level) in Stockholm, Sweden. PARTICIPANTS:: 20 newly delivered women who had received oxytocin infusion for augmentation of labour during childbirth. FINDINGS AND KEY CONCLUSIONS:: support and guidance from midwives in combination with knowledge and expectations about the intervention seemed to be important for women's satisfaction with decision-making concerning augmentation of labour. Four patterns of decision-making were found. One group of women participated in the decision-making regarding augmentation of labour while a second group was invited, but refrained from participation. These women were satisfied with the decisions made. A third group of women did not participate, but wanted to and they were dissatisfied with the decisions made. The fourth group did not participate in the decision-making-and did not want to. These women accepted the decisions made. The desire for information exceeded the desire for involvement in decision-making and the majority of women had confidence in the midwives' assessment.

OBJECTIVES to describe a theoretical framework developed from the views of midwives in relation to provision of systematic postpartum care. DESIGN qualitative focus group study using grounded theory approach. SETTING Dar es Salaam, Tanzania. PARTICIPANTS 49 nurse-midwives in five focus group discussions each having 9-11 participants. FINDINGS the components of the Basic Social Process of 'Becoming a good resource and support person for the postpartum woman' consisted of 'reflection' as an entry point into the process. Integration, networking, balancing, and dealing with reality, emerged as categories related to process activities. The category of 'defining abilities' required that midwives become aware of their competency and their limitations in reflection and all process activities, so that improvement can be part of 'getting ready', a category that describes what needs to be done at individual and health system level to prepare for systematic postpartum care programmes. The 'caring' category was linked to an outcome of the process 'doing things in the right way', which means providing quality postpartum care. The conditional matrix shows the midwife as an individual affected by several micro and macro conditions. CONCLUSIONS the proposed theoretical framework can be used in understanding the dynamics of work situations and in assisting midwives to achieve the goal of being good resource and support persons for postpartum women. Interventions for midwives should focus on the major components of the framework but also on the concepts that relate the proposed framework to other central concepts in midwifery and nursing, issues in the theory-practice gap, empowerment, political awareness, involvement in policy making, decision making and dealing with job stress.

ABSTRACT: BACKGROUND: The aim of this study was to compare maternal labour and birth outcomes between women who gave birth on a birth seat or in any other position for vaginal birth and further, to study the relationship between synthetic oxytocin augmentation and maternal blood loss, in a stratified sample. METHODS: A re-analysis of a randomized controlled trial in Sweden. An on-treatment analysis was used to study obstetrical outcomes for nulliparous women who gave birth on a birth seat (birth seat group) compared to birth in any other position for vaginal birth (control group). Data were collected between November 2006 and July 2009. The outcome measurements included perineal outcome, post partum blood loss, epidural, synthetic oxytocin augmentation and duration of labour. RESULTS: The major findings of this paper were that women giving birth on the birth seat had shorter duration of labour and were significantly less likely to receive synthetic oxytocin for augmentation in the second stage of labour. Significantly more women had an increased blood loss when giving birth on the birth seat, but had no difference in perineal outcomes. Blood loss was increased regardless of birth position if women had been exposed to synthetic oxytocin augmentation during the first stage of labour. CONCLUSIONS: The results of this analysis imply that women with a straightforward birth process may well benefit from giving birth on a birth seat without risk for any adverse obstetrical outcomes. However it is important to bear in mind that, women who received synthetic oxytocin during the first stage of labour may have an increased risk for greater blood loss when giving birth on a birth seat. Finally it is of vital importance to scrutinize the influence of synthetic oxytocin administered during the first stage of labour on blood loss postpartum, since excessive blood loss is a well-documented cause of maternal mortality worldwide and may cause severe maternal morbidity in high-income countries.Trial registrationUnique Protocol ID: NCT01182038 (register.clinicaltrials.gov).

BACKGROUND Theoretical models for health care practice are important both as tools for guiding daily practice and for explaining the philosophical basis for care. AIM The aim of this study was to define and develop an evidence-based midwifery model of woman-centred care in Sweden and Iceland. METHOD Using a hermeneutic approach we developed a model based on a synthesis of findings from 12 of our own published qualitative studies about women's and/or midwives' experiences of childbirth. For validity testing, the model was assessed in six focus group interviews with 30 practising midwives in Iceland and Sweden. FINDINGS The model includes five main themes. Three central intertwined themes are: a reciprocal relationship; a birthing atmosphere; and grounded knowledge. The remaining two themes, which likewise influence care, are the cultural context (with hindering and promoting norms); and the balancing act involved in facilitating woman-centred care. CONCLUSION The model shows that midwifery care in this era of modern medical technology entails a balancing act for enhancing the culture of care based on midwifery philosophies. The next step will be to implement the model in midwifery programmes and in clinical practice, and to evaluate its applicability.

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Abstract During the last decade, mounting evidence worldwide has heightened awareness that patients with diverse health conditions commonly do not receive recommended care despite the proliferation of clinical practice guidelines. This is a particular problem for patients with chronic obstructive pulmonary disease (COPD), who only receive recommended care during 30-55% of encounters with providers. Considering that COPD is the fourth leading cause of death worldwide, failure to implement guideline-directed care represents a major concern for respiratory professional societies. For other health conditions, inadequacies of care have stimulated public and private agencies to increase provider accountability by linking the results of performance measures to various quality improvement interventions. Despite limited evidence that these interventions improve care, widespread adoption of value-based reimbursement has occurred in the United States and United Kingdom and the prominence of these strategies in healthcare reform suggest future growth and the likely proliferation of the performance measures upon which they are based. Of note, relatively few performance measures exist for COPD as compared with other conditions that have less impact on global health. The lack of COPD measures diminishes public awareness of COPD, allows diversion of quality improvement resources toward other conditions with existing measures, and negatively impacts COPD care. Respiratory professional societies can play an important role in stimulating the development of valid COPD measures derived from COPD practice guidelines, and coordinate future measures to avoid burdensome reporting requirements for physicians if COPD measures are developed by competing payers and agencies in a fragmented or non-patient-centered manner.

PURPOSE To examine and describe neonatal resuscitation preparedness, presence of connections to wider systems of care, continuing education activities, presence of trained staff, and other indicators of high performance in rural perinatal microsystems. STUDY DESIGN AND METHODS A nonexperimental, retrospective, descriptive, cross-sectional design was utilized. Rural hospitals (n = 124) providing perinatal services in five southern states were invited to participate. Nurse managers completed the Hospital Neonatal Resuscitation Survey, describing policies, healthcare team members, educational activities, organizational culture, system connections, and process improvement. Descriptive data were also collected. RESULTS A total of 44 (35.1%) hospitals participated. Annual birth volume ranged from 22 to 1,614 (M = 515.53; SD = 336.27). Low birth volume hospitals (<125 births per year) had significantly lower levels of preparedness than high volume hospitals (>125 births per year). Preparedness was not influenced by rurality. One-third (34.1%) did not identify relationships with Level III NICUs. Support of continuing education was universal. Efforts to increase interdisciplinary teamwork were common. Medical provider shortages were prevalent (n = 25: 56.8%), and the presence of midwifery services was infrequent (n = 12; 27.2%). Hospital nursing shortages (n = 35; 81.8%) were widespread. CLINICAL IMPLICATIONS Challenges faced by rural hospitals and healthcare professionals in the delivery of perinatal care emphasize the importance of creating and maintaining high performance microsystems that are responsive to the changing needs of providers and the populations they serve. Lower levels of preparedness and the lack of established relationships with level III NICUs is concerning.

In the face of challenging times, advocates for women and their families in maternal-child health care continue to promote evidence-based and mother-/baby-friendly care. What qualities allow childbirth educators, doulas, nurses, and perinatal care providers to keep going even when the health-care practices around them often do not match their values? This editorial explores the impact of recent trends in which increasing utilization of elective technology in maternity care may affect the individual commitment of childbirth advocates. Borrowing from research on successful advocates in other fields, the author speculates on both why and how childbirth advocates sustain commitment and how "we will prevail."

The delivery of safe high quality patient care is a major issue in clinical settings. However, the implementation of evidence-based practice and educational interventions are not always effective at improving performance. A staff-led behavioral management process was implemented in a large single-site acute (secondary and tertiary) hospital in the North of England for 26 weeks. A quasi-experimental, repeated-measures, within-groups design was used. Measurement focused on quality care behaviors (ie, documentation, charting, hand washing). The results demonstrate the efficacy of a staff-led behavioral management approach for improving quality-care practices. Significant behavioral change (F [6, 19]= 5.37, p < 0.01) was observed. Correspondingly, statistically significant (t-test [t]= 3.49, df = 25, p < 0.01) reductions in methicillin-resistant Staphylococcus aureus (MRSA) were obtained. Discussion focuses on implementation issues.

Evidence-based interventions to ensure a good outcome during childbirth are widely available. Their applicability in various settings depends on local conditions and the resources available. Best practices during normal labour and delivery are described for Zimbabwean health facilities. Practices that have proved value are encouraged and those without benefit are discouraged.

Selective episiotomy and the active management of labor have been shown by numerous studies to benefit women's experience of labor as well as its outcomes. However, many Latin American public hospitals have not updated their clinical practices to reflect these findings. Limited access to new knowledge, limited time and physical resources and attitudes resistant to change are factors limiting the adoption of new practices in such hospitals. Interviews were conducted with three department heads, and focus groups were conducted with 31 physicians and midwives working in 10 public hospitals in Argentina and Uruguay. All were asked about facilitators and barriers to making changes in clinical practice. In addition, three focus groups were conducted with 16 pregnant women served by public hospitals. Responses were grouped according to stages of change in incorporating new evidence into practice. Numerous facilitators and barriers were identified by participants, as well as potential strategies for promoting change that could be incorporated into interventions. Barriers included limited access to information, negative attitudes toward changes in practice, lack of skills in performing new practices, lack of medical resources and explicit guidelines and a perceived need to practice defensive medicine. Changing long-standing clinical practice is difficult. Interventions must be adapted to translate evidence-based approaches to new cultures and contexts. Improving information access, use of role models, skill development and improved resources and support may be effective ways to overcome barriers to change in Latin American obstetric care.

OBJECTIVE To explore the differences in outcome of very preterm pregnancies between two geographically defined populations in Europe with similar socioeconomic characteristics and healthcare provision but different organisational arrangements for perinatal care. DESIGN Prospective cohort study. SETTING Nord Pas-de-Calais (NPC), France, and Trent, UK. PARTICIPANTS All pregnancy outcomes 22(+0) to 32(+6) weeks' gestational age for resident mothers. OUTCOME MEASURES Mortality patterns (antepartum death, intrapartum death, labour ward death and neonatal unit death) among very preterm babies were analysed by region. Multinomial logistic regression was used to model regional differences for a variety of pregnancy outcomes and to adjust for regional differences in the organisation of perinatal care. RESULTS Delivery of very preterm infants was significantly higher in Trent compared with NPC (1.9% v 1.5% of all births, respectively (p<0.001)). Stillbirth rate was significantly higher in NPC than in Trent (23.0%, 95% CI 20.0% to 26.5% v 14.4%, 95% CI 12.3% to 16.6%, respectively (p<0.001)) and survival to discharge was higher in Trent than in NPC (74.6%, 95% CI 71.9% to 77.1% v 66.7%, 95% CI 63.3% to 69.9%, respectively (p<0.001)). Probability of intrapartum and labour ward death in NPC was more than five times higher than Trent (relative risk 5.3, 95% CI 2.2 to 13.1 (p<0.001)). CONCLUSION The high rate of very preterm deliveries and the larger proportion of these infants recorded as live born in Trent appear to be the cause of the excess neonatal mortality seen in the routine statistics. Information about very preterm babies (not usually included in routine statistics) is vital to avoid inappropriate interpretation of international perinatal and infant data. This study highlights the importance of including deaths before transfer to neonatal care and emphasises the need to include the outcome of all pregnancies in a population in any comparative analysis.

OBJECTIVE To identify the factors associated with important (> or =50%) variation in awareness and practice of evidence-based obstetric interventions in an African setting where we have previously reported poor awareness and use of evidence-based reproductive interventions. DESIGN Cross-sectional analysis of data from our Reproductive Health Interventions Study. SETTING North-west province, Cameroon, Africa. POPULATION Health workers including obstetricians, other physicians, midwives, nurses and other staff providing reproductive care. MAIN OUTCOME MEASURES Prevalence ratios (PR) of uniform awareness and practice of four key evidence-based obstetric interventions from the World Health Organization Reproductive Health Library (WHO RHL): antiretrovirals to prevent mother-to-child transmission of HIV/AIDS, antenatal corticosteroids for prematurity, uterotonics to prevent postpartum haemorrhage and magnesium sulphate for seizure prophylaxis. METHODS Comparisons of descriptive covariates, applying logistic regression to estimate independent relationships with awareness and use of evidence-based interventions. RESULTS A total of 15.5%(50/322) of health workers were aware of all the four interventions while only 3.8%(12/312) reported optimal practice. Evidence-based awareness was strongly associated with practice (PR = 15.4; 96% CI: 4.3-55.0). Factors significantly associated with awareness were: attending continuing education, access to the WHO RHL, employment as an obstetrician/gynaecologist and working in autonomous military or National Insurance Fund facilities. Controlling for potential confounding, working as an obstetrician was associated with increased awareness (adjusted prevalence odds ratio [aPOR]= 8.3; 95% CI: 1.3-53.8) as was median work experience of 5-15 years (aPOR = 2.0; 95% CI: 1.0-3.8). Internet access was associated with increased practice (aPOR = 3.4; 95% CI: 1.0-11.8). Other potentially important variations were observed, although they did not attain statistical significance. CONCLUSIONS Several factors including obstetric training and continuous education positively influence evidence-based awareness and practice of key obstetric interventions. Confirmation and application of this information may enhance the effectiveness of programmes to improve maternal and perinatal outcomes.