Hungarian midwives and their practice: a national survey

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Longman Group Lid 1994

Hungarian midwives and their practice: a national survey Marie Farrell, Gene Harkless, Louis H. Orzack, Susanna Houd, Ann Oakley and Clara Sovenyi In 1975 the H u n g a r i a n e d u c a t i o n a l system for midwives was s h o r t e n e d f r o m a t h r e e y e a r p r o g r a m m e to o n e o f ten m o n t h s d u r a t i o n in o r d e r to p r o v i d e a m o r e i m m e d i a t e supply o f midwives in a relatively s h o r t p e r i o d o f time, a n d to r e d u c e the costs associated with m i d w i f e r y e d u c a t i o n . T e n years after the e d u c a t i o n a l p r o g r a m m e c h a n g e , a n a t i o n a l survey o f H u n g a r i a n midwives (n=290) was c o n d u c t e d by the E u r o p e a n R e g i o n a l Office o f t h e W o r l d H e a l t h O r g a n i z a t i o n a n d the H u n g a r i a n Ministry o f H e a l t h . T h i s study describes the effects o f the two e d u c a t i o n a l p r o g r a m m e s a n d years o f p r a c t i c e o n H u n g a r i a n midwives' selfp e r c e p t i o n o f c o m p e t e n c y , satisfaction a n d s u m m a t i v e score o f responsibility a n d a u t o n o m y . Significantly d i f f e r e n t g r o u p m e a n scores o n variables r e l a t e d to c o m p e t e n c y a n d satisfaction w e r e f o u n d f o r the two g r o u p s .

INTRODUCTION The purpose of this study was to describe the effects of educational programmes and other Marie Farrell, RN, EdD, MPH. Director of Nursing Research, University of Massachusetts Medical Center, Worcester, MA, Adjunct Professor of Nursing, Harvard School of Public Health, Boston, MA, USA. Gene Harkless, RN, DNSc, FNP. Associate Professor of Nursing, Department of Nursing University of New Hampshire, Durham, NH, USA. Louis H. Orzack, PhD. Professor of Sociology and Public Administration Rutgers University, New Brunswick, N J, USA. Susanna Houd, RM. Program Director Midwifery Program, The Michener Institute Toronto, Ontario, Canada. Ann Oakley, PhD. Professor of Sociology and Social Policy Social Science Research Unit Institute of Education, London, UK. Clara Sovenyi, Chief Nurse. Hungarian Ministry of Health, Budapest, Hungary. (Requests for offprints to MF) Manuscript accepted 29 October 1993

background and work-place variables on the selfreport of competency of midwives in Hungary. It was the first of a two part study which investigated midwives' characteristics and practices in that country (WHO, 1984; Farrell et al, 1991). Even though countries in Europe have relied heavily on the services of the midwife, few investigations have been carried out which examine the variables that affect competent practice. Midwives in Hungary have experienced two educational programmes. Prior to 1977 midwifery education was three years in length. Those graduating in or after 1977 completed a ten month course of study. This change was instituted in order to provide a more immediate supply of midwives in a relatively short period of time, and to reduce the costs associated with midwifery education. Both types of preparation were preceded by education in general nursing either in a four-year vocational secondary school or by two years of full-time education. 67

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METHODS Sample A representative sample of full-time practising midwives participated. All were employed in the state government hospital sector. Ninety-nine percent of all deliveries occurred in hospitals where no variation in level of authority existed for midwives. Seven representative areas throughout the country, including the capital, were selected as they constituted centres in which midwives were employed. All of the 290 midwives asked to participate completed the survey. As Hungarian midwives had never been involved in any survey related to their practice and profession, all were eager to be part of the WHO/Hungarian effort. Ten percent (29) were under 90 years of age, 32% (93) were 20-94 and 60% (174) were 25 years and over. More than one-third (96) had less than five years of practice which confirmed that the profession is relatively young. Educational preparation varied in the sample. Fifty-three percent (154) of the respondents graduated from their basic midwifery preparation after 1976 which means they received a ten month training programme. The pre-1977 midwifery educational programme was three years in length; this was the educational preparation for 47% (136) of the participants.

Instrument A mixed, forced-choice, and open-ended instrument was developed to identify minimum expectations for midwifery. It consisted of six sections which were assessed for face and content validity, reliability, utility, scorability, and economy (cost of each form, and time to complete the instrument). A team of bilingual midwives translated the instrument into Hungarian and then translated it back into English. This procedure was followed in order to ensure similar meanings in both languages. Demographic information including year of graduation, years of experience and age were collected. Five sections of the questionnaire requested that the midwife identify her responsibility and degree of autonomy concerning tasks

and activities during prenatal care, admission to the hospital for delivery, during delivery, and the immediate and later postpartum period. Responsibility and autonomy were assessed using the summative scores of responses obtained for these items. Also, the respondents were asked to judge their role as independent or assistant to the obstetrician during the different phases of the maternity cycle. Team functioning was measured by two individual items stating 'Midwives feel part of a team' and 'I feel part of a team'. Role satisfaction was measured by several individual items: 'Midwives are satisfied with their present role', 'I am satisfied with my present role', 'Midwives are highly satisfied', 'I am highly satisfied', 'Midwives enjoy their work' and 'I enjoy my work'. Lastly, the outcome variable of competency was assessed individually by two items: 'Midwives feel competent' and 'I feel competent'. Participants were informed of the survey's confidential nature and their option to refuse to participate. Immediately prior to collecting the data, the researchers (Farrell, Sovenyi and Houd) trained a Hungarian interpreter by reviewing with her, in detail, the purposes, confidentiality statements, instructions, and terminology of the instrument• The standardised instructions in Hungarian were provided in writing and read to the participants in Hungarian. Participants completed the surveys during their working hours. The Hungarian responses of the completed surveys were translated to English versions by the bilingual Hungarian midwives familiar with terminology in both languages. The researchers carried out all of the above steps on-site, in Hungary.

FINDINGS General practice characteristics The midwives worked with mothers and babies during the intrapartum and immediate postpartum periods, but were not involved in prenatal care, health promotion, health education or follow-up care after the immediate postpartum period. One-third indicated that they carried out an initial physical examination during the period of

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admission in labour; only 5% said they did so with full autonomy. While 88% (255) reported that they carried out the delivery assisted by the physician, only 20% (58) saw themselves as autonomous during this activity. The midwives also indicated that in addition to the above activities, they managed a woman with a complicated labour, admitted women in labour without physician consultation, performed routine predelivery care, such as preparation for delivery, prepared and administered oxytocin, and managed care for women with minor complications. Overall, the midwives appeared to carry considerable responsibility during the intrapartum period for which they had relatively little autonomy. During the immediate postpartum period, 75% (217) reported that they performed routine care with 46% (133) reporting full autonomy. Half (145) reported that they consulted with the woman on breast feeding; only 19% (55) did so with full autonomy. Providing care, teaching or counselling regarding breast feeding was carried out only after an order by a physician. The vast majority of midwives responded affirmatively to seeing their role as the assistant to the obstetrician during the antepartal period (76%; 220), the birthing process (84%; 244), and the postpartum period (75%; 216). This was in agreement with how the midwives perceived the obstetrician's view of their role. Also, in agreement with this perception of the role of midwifery, the participants did not see themselves as independent during the antepartal period (68%; 197), birthing process (83%; 241), and postpartum period (66%; 191). Overall, 85% said they often or always enjoyed their work; however, only 17% (49) were always satisfied with their work. Another 30% (87) reported that they were often satisfied with their roles as midwives. Six out of ten desired change; only 13% (38) 'always' or 'often' wanted things to stay as they were. Overall, the Hungarian midwives enjoyed the kind of work they did but were much less satisfied with their roles and performance. Seventy-five percent (218) felt part of a team yet 90% (261) looked to themselves for satisfaction. Further, while they worked with obstetricians, over 55% (160) reported that the views of obstetricians were different from their own about

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their work. And while they worked with other team members, they reported always looking mainly to women (45%; 130) and always looking mainly to self for accomplishments and satisfaction (68; 197).

Effect of educational programme and years of experience on self report of competency and satisfaction As described earlier, the respondents were categorised into one of two groups based upon the year of their graduation. Those who graduated prior to 1977 were graduates of a three year programme. Those who finished in 1977 or later completed a ten month programme. Competency was measured by a single item asking 'overall, I would rate myself as a midwife as feeling competent' with the range of responses being 'always' (22%; 63); 'often' (26%; 75), 'sometimes' (37%; 107), 'seldom' (12; 33), and 'never' (4; 13). Satisfaction was measured similarly with a single item 'overall, I would rate myself as a midwife as satisfied with my present role'. The range of responses to this item were 'always' (9%; 26), 'often' (35%; 100), 'sometimes' (31%; 90) 'seldom' (19%; 55) and 'never' (6%; 17). The scoring for these items ranged from 5 for 'always' to 9 for 'never' (the lower the scores, the higher the levels of competence and satisfaction) (this scoring scheme was devised in order to accommodate all possible responses and their coding for use in the computer software program). Using the categorical variable of length of midwifery educational programme to define the groups, two-sample t-tests were performed on the dependent variables of satisfaction, competency, and the summative measure of responsibility and autonomy (Table 1). The alpha error was set at 0.05 and the sample sizes of the two groups allowed for a power of 90% to detect at least 10% of the explained variation attributed to the differences between the two groups. Significant differences (p < 0.05) between the mean scores of the two groups were demonstrated for satisfaction and competency. Midwives completing the three year programme reported higher competency and satisfaction as reflected in their lower mean

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Table 1 Mean scores on competency, satisfaction, and the summative score of responsibility and autonomy by educational programme length Length of programme Three years Variables

Ten m o n t h s (n = 153) M e a n SD

(n = 127) M e a n SD

t-value

I w o u l d rate m y s e l f as a m i d w i f e as

Satisfied with my present role Feeling competent Summative score of responsibility

6.30 5.40

1.56 2.16

6.70 6.16

1.61 1.96

583.53

134.55

606.44

120.41

-2.09* -3.06* -1.5

and a u t o n o m y Response c o d i n g : 5 = ' a l w a y s ' ; 6 = ' o f t e n ' ; 7 = ' s o m e t i m e s ' ; 8 = ' s e l d o m ' ; 9 = ' n e v e r ' * p < 0.05.

scores than those completing the nine month programme. Of note is that the groups did not differ on their mean scores of the summative measure of responsibility and autonomy. It appears that both groups hold similar perceptions of their overall responsibility and autonomy. Years of experience was noted to confound the effects of type of programme the midwife completed, that is, those midwives who graduated from the three year programme reported significantly more years of practice (mean = 18.53; SD = 7.47) than those who completed the ten month programme (mean = 3.78; SD = 2.86), t = 22.50; df= 290 p < 0.0001. When the respondents were further divided into two groups according to years of experience, t-tests revealed significantly different group mean scores on a number of variables related to satisfaction and competence (Table 2). Those midwives with over ten years of experience had significantly different mean scores on six items found not to be significantly different when analysed according to educational programme length grouping. Midwives with more years' experience viewed others in their profession differently from those with less experience. Also, the more experienced midwives with over ten years of experience scored significantly different on the summative measure of responsibility and autonomy than the midwives with ten years or less experience. The more experienced midwives reported higher levels of responsibility and autonomy across midwifery tasks and functions.

DISCUSSION First, the findings of this study underscore the limited scope of practice of Hungarian midwives. In the European Region, midwifery practice includes tasks such as family planning, prenatal care, and postnatal care of both the mother and baby (Orzack et al, 1990). In contrast, Hungarian midwifery practice appears to be limited to the intrapartum period with most responsibility occurring during the labour and delivery experience. The study's findings suggest that Hungarian midwives' practices preclude women and families receiving the emotional support and physical care needed during the prenatal and postnatal periods. This profile is in stark contrast to other European countries, including the UK, the Netherlands and Denmark, where midwives maintain extensive contact with women and families during these critical periods (Orzack et al, 1990). The panel of Hungarian midwifery experts who contributed to the development of the survey tool included those prepared in prenatal care and later post-birth and follow-up care. Yet the representative sample of the country's midwives reported essentially no responsibilities in these areas. It may be that the unique characteristics of midwifery in Hungary need to be investigated further to ensure that those delivering maternal and child health services share a common vision and expectations of work-performance and outcomes.

MIDWIFERY 71 Table 2 Mean scores on measures of competency, satisfaction, and the summative score of responsibility and autonomy by years of practice

Variables

Years of Practice 11 + years 1-10 years (n = 131) (n = 146) Mean SD Mean SD

t-value

I would rate myself as a midwife as Satisified with my present role Feeling competent Highly satisifed Feeling part of a team Feeling in control of my own discipline

6.21 5.36 6.87 5.45 5.46

1.58 2.17 1.98 1.48 1.52

6.82 6.22 7.39 5.85 5.88

1.49 1.19 1.74 1.34 1.44

-3.28* -3.50* -2.31" -2.31" -2.39*

6.50 5.10 7.11

1.61 2.50 2.16

7.02 6.37 7.70

1.40 1.99 1.52

-2.89* -4.73* -2.69*

616.90 115.42

-2.98*

Overall, midwives Are satisifed with their present role Feel competent Are highly satisfied

Summative scores of

570.77 141.52

Response coding: 5 = 'always'; 6 = 'often'; 7 = 'sometimes'; 8 = 'seldom'; 9 = 'never' * p < 0.05.

One can only question the policy or practice which prevented a midwife from providing even the most basic services, such as breast feeding education, for which she was educated to perform. Breast feeding is perhaps the most expected, normal maternal function of a new mother and one on which midwives are usually the most experienced and knowledgeable. The practices in Hungary must change if the needs of new mothers for routine care and assistance with breast feeding are to be met. It is not surprising that the midwives overwhelmingly saw themselves as assistants to the physician as their practice focused exclusively on the intrapartum period. In circumstances where medicine controls the entire perinatal process, midwives generally have little autonomy. As a recent analysis concluded, midwives' activities throughout the member nations of the European Community have shifted with changes in public regulation and in educational mechanisms for access to the role (Orzack et al, 1990). Similarly, recent changes in the political system of Hungary have no doubt begun to affect maternal health services there. Coupled with

changes in expectations of physicians, of midwives and other health providers, and of families and other members of the public, these factors will almost certainly provide impetus for shifts in the activities of Hungarian midwives. As illustrated by the European Community, regionalisation in arrangements for professional services will ultimately introduce further elements leading to change (WHO, 1986). Although the current findings cannot be extended beyond Hungary, the situation of Hungarian midwifery practice is instructive as it reflects patterns which were pervasive throughout the eastern European Region (Farrell et al, 1991). The challenges to midwifery are considerable if women and their babies are to receive improved care during the childbearing period.

Acknowledgements This research was funded by the Hungarian Ministry of Health and the European Regional Office of the World Health Organization.

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References Farrell M, Orzack L H, Oakley A, et al 1991 Midwives' Characteristics and Practices in Hungary: A National Study. World Health Organization, Copenhagen Orzack L H, Calogero C 1990 Midwives, societal variation and diplomatic discourse in the European Community. In: Lopata H (ed) Current Research on Occupations and Professions 5.Jai Press, Greenwich

WHO 1984 Cooperative Medium-term Program Between the Ministry of Health of the Hungarian People's Republic and the Regional Office for Europe of the World Health Organization, Copenhagen. WHO 1986 Indicators for Monitoring Progress Towards Health for All: Quantitative Indicators for the European Region Copenhagen: World Health Organization Regional Office for Europe, Copenhagen.