An Exploration of Midwives' and Obstetricians' Perceptions of Risk in Relation to Care Practices For
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An exploration of midwives’ and obstetricians’ perceptions of risk in relation to care practices for low- risk women and normal childbirth Sandra Healy BSc, RM Supervised by Professor Catriona Kennedy and Dr. Eileen Humphreys. From January 2016 Dr. Pauline O’Reilly and Professor Rachel Msetfi joined the team to meet University regulations for internal supervisors. A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy at the University of Limerick Submitted to the University of Limerick, November 2017 Abstract Title of thesis: An exploration of midwives’ and obstetricians’ perceptions of risk in relation to care practices for low-risk women and normal childbirth Author: Sandra Healy, BSc, RM This thesis explores how midwives’ and obstetricians’ perceptions of risk affect care practices for low-risk women and normal childbirth. Four academic papers are incorporated into the thesis. The research aims to provide an understanding of how perceptions of risk may contribute to intervention during birth. Areas investigated include factors that contribute to midwives and obstetricians feeling safe or unsafe when facilitating birth, their trust in physiological birth and their attitudes towards the importance of achieving normal birth A systematic integrative review was undertaken (Paper 1), synthesising data from 13 studies, identified on the basis of a pre-determined search strategy. This review highlighted an assumption of abnormality in the birthing process. Following this, a discussion paper (Paper 2) was published that presented an over-view of the current structures and processes of maternity care, incorporating preliminary results from the primary qualitative study into the discussion. The primary qualitative study (Papers 3 and 4) involved analysing data gathered from semi-structured interviews with 16 midwives and nine obstetricians recruited from hospitals, midwifery-led units and the community. The findings highlight that in the current climate of risk management and intense surveillance of birth, midwives’ professional identity as promoters and protectors of normal birth is in jeopardy. Fear of litigation and implication in adverse outcomes and an increased focus on risk management duties are contributing factors. Apparent is that outcomes, particularly infant and maternal mortality rates, take precedent over compassionate, holistic care where the former are the quality markers currently used to assess maternity care. This thesis concludes that midwifery must become more pro-active in supporting physiological birth. There must be a refocus on how maternity care is organised and reflection on the hierarchy of outcomes if services are to become more woman-centred. Implications of the findings of this thesis on maternity practice and policy are discussed in the final chapter. iii List of Publications: Papers 1 - 4 This thesis is based on the following four papers, three of which are published and one which is under review: Healy, S., Humphreys, E. and Kennedy, C. (2016) ‘Midwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review’, Women and Birth, 29(2), 107-116, available: DOI: http://dx.doi.org/10.1016/j.wombi.2015.08.010 Healy, S., Humphreys, E. and Kennedy, C. (2016) ‘Can maternity care move beyond risk? Implications for midwifery as a profession’, British Journal of Midwifery, 24(3), available: DOI: http://dx.doi.org/10.12968/bjom.2016.24.3.203 Healy, S., Humphreys, E. and Kennedy, C. (2017) ‘A qualitative exploration of how midwives' and obstetricians’ perception of risk affects care practices for low-risk women and normal birth’, Women and Birth, 30(5), 367-375, available: DOI: http://dx.doi.org/10.1016/j.wombi.2017.02.005 Healy, S., Humphreys, E. and Kennedy, C. (2017) ‘Challenges in balancing risk with ‘care’ in maternity practice: A qualitative study of midwives’ and obstetricians’ perceptions of risk’, under review, Midwifery. iv Declaration I declare that this thesis, apart from due acknowledgements, is entirely my own work. My contribution to each of the academic papers, on which this thesis is based, is outlined in Table A. It has not been submitted for another degree at this or any other University. I hereby give permission for this thesis to be lent, copied or requested, with the consent of the librarian, and with due acknowledgement of the author. Signed: ___________________________________ Sandra Healy Date: ___________________________________ v Table A: Author contribution to included research papers Paper Title Authors Contribution of thesis author (SH) to the paper 1 Midwives’ and Healy, S., (SH) ▪ Paper conception and design obstetricians’ Humphreys, E. (EH) & - SH with supervisors CK perceptions of risk and Kennedy, C. (CK) and EH its impact on clinical ▪ Review of literature – SH practice and decision- lead making in labour: An ▪ Drafting of manuscript – SH integrative review was first author and lead ▪ Critical revisions of manuscript - SH with supervisors CK and EH ▪ Final preparation and editing of manuscript and submission to journal - SH 2 Can maternity care Healy, S., (SH) ▪ Paper conception and design move beyond risk? Humphreys, E. (EH) & - SH with supervisors CK Implications for Kennedy, C. (CK) and EH midwifery as a ▪ Drafting of manuscript – SH profession was first author and lead ▪ Critical revisions of manuscript - SH with supervisors CK and EH ▪ Final preparation and editing of manuscript and submission to journal - SH 3 A qualitative Healy, S., (SH) ▪ Paper conception and design exploration of how Humphreys, E. (EH) & - SH with supervisors CK midwives’ and Kennedy, C. (CK) and EH obstetricians’ perception ▪ Data collection and analysis – of risk affects care SH was lead with input from practices for low-risk supervisors CK and EH women and normal birth ▪ Drafting of manuscript – SH was first author and lead ▪ Critical revisions of manuscript - SH with supervisors CK and EH ▪ Final preparation and editing of manuscript and submission to journal - SH 4 Challenges in balancing Healy, S., (SH) ▪ Paper conception and design risk with ‘care’ in Humphreys, E. (EH) & - SH with supervisors CK maternity practice: A Kennedy, C. (CK) and EH qualitative study of ▪ Data collection and analysis – midwives’ and SH was lead with input from obstetricians’ supervisors CK and EH perceptions of risk ▪ Drafting of manuscript – SH was first author and lead ▪ Critical revisions of manuscript - SH with supervisors CK and EH ▪ Final preparation and editing of manuscript and submission to journal - SH vi Acknowledgements I would like to sincerely thank my supervisors Professor Catriona Kennedy and Dr Eileen Humphreys for their time, support and feedback throughout the PhD process. Their influence and guidance has significantly contributed to my development as a researcher. Also, thank you to Dr Pauline O’Reilly and Professor Rachel Msetfi for their input into supervision from January 2016. To all the participants who gave their time for this research, I want to extend a big thank you. Your input was invaluable and I hope this study will contribute to improving care for mothers and babies. Thank you to my midwifery and obstetric colleagues for your interest in my study. Huge thanks to my fellow PhD students who kept me going when the journey sometimes seemed impossible and were always there with advice for both life and PhDs. A special thanks to Dan who was with me from the start. To the Department of Nursing and Midwifery, many thanks, especially all the midwifery team. I gratefully acknowledge the University of Limerick for the funding I was awarded to pursue a PhD. My family have given me unfailing support from the beginning. A heartfelt thank you to my siblings and especially to my parents Donal and Clare. Thanks to my children Sean, Oliver, Kalem and Milla – you each helped me in ways you cannot imagine. And to my grandson Jesse whose arrival earlier this year urged me to the finish line. And finally, thank you to my husband Declan. Without you I never would have started and I most definitely would not have finished but with your endless encouragement, support and love here I am, ready to submit. vii Table of Contents Abstract ........................................................................................................................................ iii List of Publications: Papers 1 - 4 .................................................................................................. iv Declaration .................................................................................................................................... v Acknowledgements ..................................................................................................................... vii Table of Contents ....................................................................................................................... viii List of Tables ................................................................................................................................ xi List of Figures............................................................................................................................... xi List of Abbreviations ................................................................................................................... xii Chapter 1: Introduction .................................................................................................................. 1 1.1