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A review of the literature: Midwifery decision-making and birth
Women and Birth (2010) 23, 127—134
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
REVIEW
A review of the literature: Midwifery decision-making and birth Elaine Jefford *, Kathleen Fahy, Deborah Sundin Newcastle University, School of Nursing and Midwifery, Callaghan Campus, NSW 2308, Australia Received 9 July 2009; received in revised form 3 February 2010; accepted 3 February 2010
KEYWORDS Decision-making; Birth; Midwives; Decisionimplementation; Second stage
Summary Background: Clinical decision-making was initially studied in medicine where hypotheticodeductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benner’s ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the ‘rational reasoning’ as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman—midwife partnership where the woman is the ultimate decision-maker. Method: CINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review. Findings: Decision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Conclusion: We argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention. # 2010 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
* Corresponding author at: PhD student (midwifery) Newcastle University, School of Nursing and Midwifery, Callaghan Campus, NSW, 2308, Australia. Fax: +61 02 6205 3076; +61 (0)405374536 (mobile). E-mail address: [email protected] (E. Jefford). 1871-5192/$ — see front matter # 2010 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. doi:10.1016/j.wombi.2010.02.001
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Introduction This literature review is focused on clinical decision-making in midwifery; more specifically during birth. The review is guided by the question: what factors influence the processes midwives use when engaging in clinical decision-making during birth? We acknowledge the term birth is sometimes used in a broader sense however, here we define ‘birth’ as ‘the time from the beginning of the second stage of labour up to and including the hour after the birth of the baby’. Second, third and fourth stages of labour is a period of care requiring intense focus of the midwife’s clinical assessment and decision-making skills. Time critical decisions must be made, which will affect the mother, baby or both. At the same time second-, third- and fourth-stage labours are fraught with complex, contextual and multiple variables operating simultaneously; e.g. depending upon the birth setting and employment status of the midwife she may experience conflict in relation to woman-centred care and the policies, procedures and practice standards of the birthing unit. Second-, third- and fourth-stage labours are also a complex time for the childbearing woman. Women who are experiencing a physiological birth may be in an altered conscious state so asking the woman to solve problems and make complex decisions at that time may be problematic for her.1 Other women may be affected by narcotics and not able to think rationally and/or quickly. Thus we argue that the period of second-, third- and fourth-stage labour provide an ideal vehicle to examine the midwife’s clinical decision-making process and those factors impacting upon that process. The International Confederation of Midwives (ICM) outlines a framework for decision-making in midwifery.2 A decision-making framework on scope of practice is also offered by the Australian Nursing and Midwifery Council (ANMC).3 The midwife’s scope of practice is further guided by the Australian College of Midwives (ACM), national midwifery guidelines for consultation and referral.4—6 These documents seek to regulate the degree midwifery autonomy vis-a-vis other health care professional. The documents do not address the complex issues of both clinical reasoning and the interpersonal negotiations between the midwife and the woman and the midwife who is employed by a hospital and is answerable to other maternity care providers who are in the unit during the woman’s birth. Philosophically there is agreement that midwifery clinical decision-making should involve the midwife in negotiating sensitively with the woman with consideration for the environment and the people within it.7 This belief is consistent with the often espoused view that the discipline of midwifery is based on a philosophy of primary health care and partnership with the woman.2,8,9 In this view, pregnancy and birth are seen as normal physiological and social life events, where midwives should work in continuity of care relationships with the women from pre-conception through pregnancy, labour and birth and up to 6 weeks after birth.8,10 This view assumes that midwives use their expertise and evidenced-based knowledge to support and empower women to be the decision-maker during their unique childbearing experience.11 Page and Hutton12 argues that evidenced-based care in midwifery is ‘‘. . .a process of involving women in making decisions about their care and of finding and weighing up
E. Jefford et al. information to help make those decisions’’ (p. 9). Tupara13 has written on midwifery decision-making from a theoretical perspective focusing on descriptive decision theory, concerning cognition and information processing. In the midwifery literature mentioned above no emphasis has yet been given to the clinical reasoning skills of the midwife. This may mean that midwifery, unlike medicine and nursing has not specifically considered the clinical reasoning skills of midwives; for example the 3 main undergraduate textbooks Myles,14 Mayes15 and Pairman et al.16 lack any chapters or major sections on this topic. Further, the midwifery literature above does not address how the midwifery-partnership should occur during the rapidly unfolding events of birth itself (particularly when the midwife and woman are strangers to each other). This gap in the midwifery theoretical literature justifies the present review of research related to our guiding question.
Clinical decision-making The term clinical decision-making is best understood by first considering the more medically accepted term clinical reasoning. Clinical reasoning is a form of hypothetico-deductive logical thinking. Strengths of this approach include the emphasis on development of strong logical cognitive reasoning skills and the emphasis given to basing treatment decisions on knowledge (evidence) and not a rule of thumb or mindlessly following tradition.17 Hypothetico-deductive reasoning focuses on ‘the supposed biophysical facts’, which can be defined, measured and consensually agreed upon. When hypothetico-deductive reasoning is applied in clinical practice it is generally agreed to involve a number of phases (see Box 1). Clinical reasoning has been criticised as being too linear and reductionistic, focussing, as it does, on detail and chains of causal relationships.18 Clinical decision-making is a broader concept which allows for both reductionism and holism at various points in the decision-making process. The definition of clinical
Box 1. Cue acquisition–—sense data collected, i.e.
signs and symptoms; Cue clustering–—all relevant cues joined to-
gether; Generating multiple hypotheses–—explains
cue clusters; interpretation—information is interpreted in the light of the explanations/hypotheses that are under consideration; Focused cue acquisition–—ruling in/ruling out hypothesis; Hypothesis evaluation — based on all available data — differential diagnoses; Evaluation of treatment options; Implementation of preferred treatment plan, and Evaluation of treatment–—to confirm or change diagnosis.52—56
Cue
Midwifery Decision-making and Birth decision-making in midwifery offered in this paper takes account of both hypothetico-deductive and humanisticintuitive approaches and is in harmony with contemporary ideas in midwifery. Clinical decision-making here is defined as a process that may encompass both clinical reasoning and intuitive awareness of the psycho-social—spiritual and environmental factors that are influencing the clinical situation and what the midwife thinks; feels and actually implements. In nursing, Benner19 linked the process of decision-making to five ‘levels’ of experience and practice: novice, advanced beginner, competent, proficient and expert. Benner’s19 research findings were that, clinical decisions by less experienced nurses were strongly based on hypothetico-deductive reasoning. Expert nurses however, Benner19 claimed, used intuition. Intuition involves an automated quick classification, where the expert nurse intuitively screens available options and eliminates options not perceived as relevant. Intuition tells the nurse when something ‘feels’ right or different, without the nurse necessarily being able to articulate what it is.19,20 As a result of these intuitive feelings, the nurse then reaches a judgement and/or decision.19,21 The resultant perceptions are of an intuitive decision-making expert nurse who appears quick and spontaneous while operating with profound understanding, without necessarily being able to articulate that understanding.19,22 Berry and Dienes23 hypothesise part of this process can be referred to as automatic whereby, tacit nursing knowledge acquired through exposure and experience of the usual paths taken by illnesses is subsequently forgotten. Benner19 argues intuition is a valuable part of nurses’ clinical practice. Other researchers go further hypothesising, other health professionals benefit from drawing on intuition in clinical practice.24—27 For expert practitioners, knowing what to do in a particular situation usually depends on intuitive pattern matching. Pattern matching is defined by Mok and Stevens24 as a ‘‘process of making a judgement on the basis of a few critical pieces of information’’ (p. 59) but the accuracy of the assessment and final action is dependant entirely upon the fidelity of the match between successfully managed past situations and the current situation which requires action.17,28 When a midwife uses pattern recognition in a clinical situation her judgement may unknowingly be adversely affected because pattern recognition leaves out crucial steps in clinical reasoning such as: hypothesis formation and hypothesis testing. This means that using intuition to guide action may well be a hallmark of an ‘advanced practitioner’ but it is not an example of clinical reasoning.19 Thus using intuition in rapidly evolving critical situations may actually lead to detrimental actions because systematic decision-making has not been used.
Search strategy The key concepts and words in the research question were identified prior to commencing. Exclusion criteria are also defined (see Box 2). The databases searched were Medline, CINHAL and Cochrane. Two searches were undertaken in the Cochrane database, one using advanced search and key concepts and words and the other using the Mesh facility.
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Box 2. 1st keyword string: decision-making OR reasoning OR judgement OR thinking OR problem solving OR logic OR concept formation OR cognition OR uncertainty. 2nd keyword string: clinical OR practice OR labo(u)r OR labor obstetrics OR delivery OR Natural childbirth OR water birth OR birth OR parturition OR second stage OR third stage OR obstetric emergencies. 3rd keyword string: midwives OR midwife OR student midwife OR nurse midwife OR nurses. Exclusion criteria: non-humans; non-English; >10 years; non-peer reviewed journals; studies pertaining to nursing; studies involving women’s decision-making. N.B. Studies related to professionals who practice within the field of midwifery, but are classified as nurse-midwives within their country were included.
The Mesh facility converts key concepts and words in to terms the database deems most appropriate (see Box 3). The keyword concepts and words made three keywords: strings which related to: decision-making; labo(u)r and midwife. The three
Box 3. 1st keyword string: thinking OR cognition OR uncertainty. Thinking mesh tree: choice, problem solving, concept formation, judgement, decision-making, dissent and disputes esthethics, consciousness and volition. Cognition mesh tree: awareness, cognitive dissonance, intuition, perception, intention, comprehension and imagination. 2nd keyword string: labo(u)r stage OR parturition OR second stage OR third stage OR delivery obstetric OR professional practice. Professional practice mesh tree: clinical competence, guideline adherence, outcome and process assessment, peer review — healthcare, professional review organisation, programme evaluation, quality assurance — healthcare, quality indicators — healthcare and utilisation review. 3rd keyword string: midwives OR midwife OR nurse midwife OR nurses. Nurse midwife mesh tree: nurse practitioner and male nurse. Nurse mesh tree: clinicians, administrators and anaesthetics. N.B. No exclusion criteria was applied.
130 keyword strings were combined; this resulted in the following number of hits:
Medline 168 CINHAL 25 Cochrane 461 Cochrane Mesh 11
Due to the small number of hits from the CINHAL database, no limitations were applied. No limitations were applied to those hits retrieved from the Cochrane database either. Limitations of: humans, English and from January 1998 to May 2009 were applied to those hits from Medline. This reduced the hits to 128. Retrieved results from the three databases were cross-referenced to exclude duplication. Abstracts were read to eliminate any literature not relevant. Where abstracts were ambiguous or unclear further clarity was sought from reading the full text. Four research studies meet the inclusion criteria. A midwifery article that was somewhat related to our guiding question but was excluded because it did not consider the cognitive process of midwives clinical decision-making was Freeman et al.29 Also most famously Kirkham, Stapleton and Levy looked at midwives’ decision-making in the antenatal and postnatal periods and supporting women30—32 but these were excluded as they do not generalise to the context of birth as defined above. A number of articles, concerning midwifery decision-making, focused on the development of midwifery students’ cognitive skills using clinical simulations.33—35 These were excluded because they did not include the complex context of actual practice, they were not focussed on birth. We have included one Cioffi study that did focus on decision-making during birth even though the context was educational simulation.
Summary and critique of existing literature Study 1 The effectiveness of using clinical simulation to teach hypothetico-deductive reasoning was investigated using a cohort design.36 Thirty-six midwifery students were recruited: 18 experienced the intervention of simulation and 18 experienced the standard lecture. The strategy used for allocation of student midwives to groups was not stated. The researchers developed two simulation scenarios involving written and audio-taped information and a set of decision-rules. Midwifery students worked in pairs using thinkaloud techniques, a proven technique to aid understanding through verbalisation.37 The first scenario concerned normal labour, the other concerned neonatal physiological jaundice. The findings indicated, midwifery students who received the simulation strategy collected more clinical information, revisited collected clinical information less, made fewer formative inferences and self-reported higher confidence levels than those student midwives who underwent traditional lectures. Midwifery students who self-completed the posttest for normal labour simulation, were found to undertake more rapid decision-making. Self-reporting posttests, however are subjective and potential for variation of results between cohorts may exist. The limitations of this study in terms of generali-
E. Jefford et al. sability include the small number of midwifery students and the homogeneity of a single student cohort. Further, the lack of definition and description of the simulation intervention makes study replication very difficult. Importantly, the findings of a controlled clinical simulation may not be generalisable to the complex world of real practice where multiple variables operate simultaneously. This is particularly so during birth where rapid decisions are required in a complex, fast changing situation that is strongly influenced by the environment and the people within it. There is limited literature comparing the effectiveness on fitness to practice using simulated environment with the real complex world of clinical midwifery practice.37 This broader environmental context was not considered in the Cioffi et al. study.36
Study 2 An ethnographic study was used to explore complexities of decision-making and how perceptions of risk, uncertainty, relevant knowledge and professional autonomy influence the outcome pre-implementation of a computerised decisionmaking support system.38 The study was conducted at two delivery suites in England. Data collection included direct observation of midwives and doctors and in-depth interviews. Comprehensive details of the 16 people interviewed were not stated. Key findings of the research were that midwives indicated, in this study, they were autonomous in some decisions such as when to consult and/or grant admission to the birth room. The researchers reported decision-making in the studied ‘real world’ of a delivery suite, was influenced in both directions: top down decisions were open to contestation as much as bottom-up decisions could be countermanded. This resulted in decision-making being a socially and culturally negotiated activity. Midwives identified risks and made decisions, however at times, midwives had no power to implement those decisions. Rather the midwives’ action was often to defer to medical professionals to enact ‘formal’ decision-making. Risks identified were defined by the individual midwife or doctor’s perception, which shaped their decision-making. Women were claimed to be central to midwives decision-making, yet the research demonstrated this to be tokenistic. Rather women were generally seen to be passive with the midwives and doctors dominating the decision-making process. Midwife—doctor decisions occurred outside the woman’s room, where as midwife-woman decisions occurred inside the woman’s room. A strength of this observational study was its capture of the real world of practice of midwives for over 500 h. A limitation of this study though is the lack of differentiation between the midwives autonomous scope of practice and the number of times when the midwife was obliged to consult and/or refer to a doctor. The study provides data on the organisational complexity of midwifery work processes and decision-making, but there are no details concerning the way that midwives actually made and enacted their clinical decisions. The study would have been improved if the observational hours were equal at both sites. As it was 500 h of observation was conducted at one site and only 30 h at the other. The different cultural context of England and current different educational training programs for Australian midwives limits transferability to an Australian context.
Midwifery Decision-making and Birth The conclusions drawn from this study primarily relate to the ‘real world’ of delivery suites in England pre-implementation of the proposed computerised decision-making support system. Implementing such a system may provide a means of enhancing hypothetico-deductive reasoning, which may enhance midwifery autonomy in decision-making and reduce the hierarchically negotiated aspects of midwifery decision-making.38
Study 3 A Swedish phenomenological study focused on midwives problem solving in critical antenatal and birth situations where no medical assistance was available.39 Seven midwives participated in the research. Participant information was limited to a statement about the midwives range of years since qualifying. Data was collected via in-depth interviews and analysed using thematic analysis. Analysis identified 13 factors deemed necessary to effectively solve critical antenatal and birth situation problems in midwifery (see Box 4). This study reported that initially, the midwives employed a process of hypothetico-deductive reasoning. The midwives listened, observed and assessed women in order to collect cues, from which one or more hypothesis were generated. When interpreting these cues, midwives acknowledged drawing upon theoretical and clinical knowledge and past experiences. Once this happened the midwives claimed they ‘intuitively’ knew how and when to act. Midwives stated they felt confident and safe in this approach as they had the relevant professional knowledge. This resulted in the midwives experiencing feelings of being in control of the unfolding critical situation excluding any irrelevant peripheral social and environmental influences. The midwives claimed to engage in calm negotiation with the woman and peers in order to ensure a positive outcome for mother and baby. When the need arose, midwives indicated they orchestrated collegial and technological support. Further, in anticipation of medical agreement with their decisions the midwives prepared any necessary equipment needed. In these critical clinical situations the midwives reported feeling euphoric when they performed well. An important consideration is that this study took a noncritical view of what midwives said they did during decision-
Box 4. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
To listen; To assess; To make fast decisions; To possess knowledge and experience; Intuition; To identify a problem and find a solution; Cooperation; Engagement; Purposefulness; Concentration; Euphoria; Consideration; and Control.
131 making. We have no way of knowing what midwives actually did. Further transferability of this study to an Australian context may be, restricted because there were only 7 midwifery participants and the cultural context of midwifery in Sweden is quite different from the Australian context. Another limitation is, midwifery problem solving in critical situations was reported to be dependant upon verbal and non-verbal interactions with the women, yet the women’s perspective was not taken in to consideration by the researchers. Because no specific examples were given, it is not possible to tell from this research if midwives engaged in formal hypotheticodeductive reasoning. They may have used heuristics based upon pattern matching and past experiences.
Study 4 Midwives decision-making in relation to accurate diagnosis of active labour was the focus of a Scottish qualitative study.40 Thirteen midwives were allocated to 2 focus groups. The midwives were invited to discuss how they made decisions differentiating women who were in active labour and needed to be admitted, versus early labour when the woman would be sent home. Latent content analysis identified 2 major categories midwives consider when making decisions related to diagnosing labour: the woman and the institution. More specific themes were subsumed under each category. When diagnosing labour and making clinical management decisions midwives indicated they take both categories and all of the subsumed themes into consideration. Midwives diagnostic judgements were found to be predominately based upon linear collection of information cues in order to generate one or more hypothesis. Primary cues such as: those related directly to the diagnosis of labour (observing the women’s physical signs and a vaginal examination) were sought first. This method of information gathering is congruent with hypothetico-deductive reasoning.17 Once the midwife reached a diagnosis, Cheyne et al.40 reported, midwives then took secondary cues into account, which informed decisions about whether or not to admit the woman to the delivery suite. Secondary cues included: the woman and her family’s expectations and the daily contextual environment of the organisation such as: workload, bed allocation and staffing issues. Organisational guidelines, the midwives indicated, placed significant constrictions on their decision-making processes. If a woman was not judged to be in active labour, but the midwife made the decision to admit her, the woman was likely to be exposed to a cascade of intervention. Conversely, some women were thought to be able to benefit from admission even though they were not technically in active labour. Importantly, regardless of which decisions were made, midwives felt the need to justify their actions to colleagues. The researchers conclude, due to competing physical, psycho-social and organisational cues midwifery management decisions are not solely reliant on diagnostic decisions. This demonstrates how midwifery clinical decision-making can be controlled by organisational matters, thus undermining the midwife’s clinical autonomy. The strengths of this study include the identification of how clinical decisions can be made on organisational grounds. The emphasis this research gives to psycho-social and organisational factors are also reflective of the complex reality of midwifery practice. The weaknesses of this study include the
132 group-based nature of the data collection where midwives tend to tell stories placing themselves in a positive light. When midwives sit together they may add to each others’ stories until a holistic picture of the hypothetico-deductive reasoning and compassionate care is presented: this may be a constructed myth rather than a reflection of actual midwifery practice. Focus groups work best when there is diversity of views and positions but there were only 2 focus groups from a single hospital, which again weakens the study.41
Findings The 2 major findings, which can be synthesised from this literature review, are primarily that decision-making in midwifery is socially negotiated involving hierarchies of surveillance and control. Despite a midwife widely being claimed as an autonomous practitioner it was found that she remains dogged by surveillance of her decisions and the resultant actions10,38: Department of Health # Chief Executive Officer # Director of Midwifery # Obstetrician # Doctor # Clinical Midwife Consultant # Midwife
This surveillance tended to reduce and/or regulate the midwife’s ability to function as autonomously as other health care professionals.10 Decisions and resultant actions were also governed by policies and practices as well as professional organisations such as the Australian College of Midwives and Australian Nurses and Midwifery Council. Secondly, clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Due to the dominant paradigm’s rigid claim to birth as a complex ritual that must be controlled through intervention the complexities of clinical decision-making in midwifery are concerned with different yet related phenomena: the concept of risk and uncertainty and autonomy.42,43 Individual midwives and doctors perceptions of risk shape decisionmaking. Medicine on the whole remains grounded in a biomedical mechanical viewpoint of childbearing where women are seen as inherently faulty and unreliable, needing surveillance and intervention. This is congruent with Modernism which hypothesised such knowing derived though the objective rational self, which is science.44 Science hypothesised superiority of detached rationality over the idea that a human was a complex human-being made up of a mind, body, soul and emotions.44 This is relevant to midwifery as over centuries we have applied science to the understanding of the physiology of childbirth, which was understood as separate from the woman’s spirit and emotions.45 Terms such as non-intervention, supportive environment, encompassing
E. Jefford et al. trust, empowerment and women-centred are all but excluded from consideration in medical textbooks. Medical professionals today continue to inflexibly claim birth as a complex ritual that they control. Their naturally supposed superiority and patriarchal hierarchy were and are to be accepted by women.46 Kitzinger (2005) claims the western world focus of birth is medical and technocratic. She writes from this perspective ‘‘. . .the mother is relevant only in so far as she is the container for the fetus. In fact she is an obstacle to inspection of the fetus’’ (p. 3). From such a stance it is clear to see why doctor’s perception of risk shapes their decision-making. Midwives, however focus on interconnections between mind, body, spirit, family, community and environment. They pay attention to women’s invisible energy flows, obstacles and liberation. Midwives connect with women, respecting and acknowledging their body wisdom by providing them space to experience and value pregnancy and birth.7 Midwives use their expertise and evidence-based knowledge to support and empower women to exercise autonomy during their unique childbearing journey. Nevertheless 3 of the reviewed studies indicated midwives confidence in their clinical judgements was limited and validation was sought from within a hierarchical system where the ultimate decision-maker is the doctor or the health service manager. In one study midwives are presented, via their own positive stories, as skilled in clinical decision-making and in interpersonal skills with women, families and colleagues.39 It is possible that in every instance the midwives were making autonomous decisions and being able to implement their planned action. This study could be seen as an excellent example of midwives being autonomous practitioners, which according to Pairman et al.16 means, a midwife uses her ‘knowledge and skills to provide care independently without a requirement to refer to another health professional’ (p. viii). Beauchamp and Childress47 hypothesise that autonomy equates to an individual controlling their own life and free from controlling interference from others behaving in a rational and moral manner. Consequently, there appears to be incongruence between the concept of an autonomous midwifery practitioner and its implications for decision-making: those decisions midwives must confer about and those that are within the accepted scope of midwifery practice.4,5,10,16 A possible reason for this incongruence is the extent of authority given to a midwife by an organisation and her readiness to accept it.48 This is endorsed by Kirkham49 who believes what decisions midwives actually make are constrained in their implementation by intrapersonal, contextual and institutional/organisational factors.
Key limitations The key weaknesses of these studies are that each study has involved small numbers from only one or two research sites, which limits transferability. Another weakness is, studies using the interpretive paradigm have unacknowledged biases towards presenting idealised versions of how midwives make and implement decisions. Interpretive researchers accepts ‘truth’ is what participants present at interview often without probing and searching for negative examples or cases. 50 Although one study indicates high-fidelity simulators
Midwifery Decision-making and Birth enhanced and improved hypothetico-deductive reasoning and decision-making in student midwives in the educational setting. There was no finding about how these improved reasoning skills may have been transferred to actual practice.
1. Conclusion The guiding question has been: what factors influence the midwife’s clinical decision-making during birth? Previous research in medicine and nursing is not adequate to address decision-making in midwifery because although clinical reasoning is a necessary condition for valid decision-making, it in not sufficient when decisions have to be negotiated with the woman and with other members of the maternity care team. Thus we see clinical reasoning as a sub-component of midwifery clinical decision-making. We specifically reject Benner’s research as providing a basis for understanding and optimising clinical decision-making in midwifery. Her concept of the ‘advanced practitioner’ who uses ‘intuition’ to make decision seems to us to be an oxymoron. Dreyfus and Dreyfus51 claimed that ‘‘experts don’t solve problems and don’t make decisions; they do what normally works’’ (p. 30— 31). Thus, if advanced practitioners do use intuition then they must be less likely to use formal clinical reasoning processes, which make them more prone to errors in decision-making. Clinical decision-making seems to be undervalued in the midwifery literature thus the existing midwifery research provides only a partial answer to the research question. There have been no midwifery studies that have systematically and critically examined clinical decision-making during birth in registered midwives. Further research is needed to explore both clinical reasoning and the intrapersonal and contextual factors that influence midwives actual clinical decision-making and decision-implementation during birth. The role of the woman as decision-maker in her own care and how this is negotiated between the woman and the midwife needs careful analysis. New, critical midwifery research is particularly needed which focuses on labour and birth where decisions are required in a complex, fast changing situations that are strongly influenced by the environment and the people within it.
References 1. Fahy K, Hastie C. Midwifery Guardianship: Reclaiming the Sacred in Birth. In: Fahy K, Foureur M, Hastie C, editors. Birth territory and midwifery guardianship. Glasgow: Elsevier Science; 2008. p. 21—38. 2. International Confederation of Midwives. Definition of The Midwife 2005 (cited 2005—2008). Available from: http://www. internationalmidwives.org. 3. Australian Nursing and Midwifery Council. A national framework for the development of decision-making tools for nursing and midwifery practice: framework. Australia: Australian Nursing and Midwifery Council; 2007. 4. Australian Nursing and Midwifery Council. National competency standards for the midwife. 1st ed. Canberra: Australian Nursing and Midwifery Council; 2006. 5. International Confederation of Midwives. Essential Competencies For Basic Midwifery Practice. 2002 [cited 2008 17 December 2008]. Available from: www.internationalmidwives.org.
133 6. Australian College of Midwives. National midwifery guidelines for consultation and referral: guidelines. Australia: Australian College of Midwives; 2003. 7. Davis-Floyd R. Introduction. In: Fyre A, editor. Holisitic midwifery: a comprehensive textbook for midwives in homebirth practice. Portland, Oregon: Labrys Press; 2006. p. 1—8. 8. Australian College of Midwives. Australian College of Midwives: Philosophy Statement for Midwifery (Web page) 2008 (cited 2008 29 August 2008). Available from: www.midwives.org.au. 9. Pairman S. Women-centred midwifery: partnership or professional friendship? In: Kirkham M, editor. The midwife—mother relationship. Basingstoke: MacMillan; 2000. p. 207—26. 10. Pairman S, McAra-Couper J. Theorectical frameworks for midwifery practice. In: Pairman S, Pincombe J, Thorogood C, Tracy S, editors. Midwifery: preparation for practice. Sydney: Churchill Livingstone-Elsevier; 2006. p. 237—57. 11. Kitzinger S. The politics of birth. China: Elsevier; 2005. 12. Page L, Hutton E. Introduction: Setting the scene. In: Page L, Percival P, editors. The new midwifery: science and sensitivity in practice. Edinburgh: Churchill Livingstone; 2000. p. 1—4. 13. Tupara H. Facilitating functional decision-making in midwifery: lessons from decision theory. New Zealand College of Midwives 2008;38:7—11. 14. Myles M. A text book for midwives. 14th ed. Edinburgh: Livingstone; 2003. 15. Sweet B, Tiren D. Mayes midwifery: a textbook for midwives. 12 ed. London: Elsevier Science Ltd; 2002. 16. Pairman S, Pincombe J, Thorogood C, Tracy S. Midwifery: preparation for practice. Sydney: Churchill Livingstone-Elsevier; 2006. 17. Newell A, Simon HA. Human problem solving. Englewood Cliffs: Prentice-Hall Inc; 1972. 18. Tanner C. Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing Education 2006;45(6):204—11. 19. Benner P. From novice to expert: excellence and power in clinical nursing practice: commemorative edition. Upper Saddle River, New Jersey: Prentice-Hall Inc.; 1984/2000. 20. Benner P, Tanner C. Clinical judgment: How expert nurses use intuition. American Journal of Nursing 1987 Jan;87(1):23—31. 21. Verplanken B, Svenson O. Personal involvement in human decision making: Conceptualisation and effects on decision processes. In: Ranyard R, Crozier R, Svenson O, editors. Decision making: cognitive models and explanations. New York: Routledge; 1997. p. 40—57. 22. Dreyfus HL, Dreyfus SE. Uses and abuses of multi-attribute and multi-aspect model of decision-making. In: Benner P, editor. From novice to expert excellence and power in clinical nursing practice: commemorative edition. New Jersey: Prentice-Hall; 1977. 23. Berry D, Dienes Z. Implicit learning: theoretical and empirical issues. Exeter, UK: Lawarence Erlbaun Associates; 1993. 24. Mok H, Stevens P. Models of Decision Making. In: Raynor M, Marshall J, Sullivan A, editors. Decision making in midwifery practice. Edinburgh: Churchill Livingstone-Elsevier; 2005 . p. 53—66. 25. Rew L. Acknowledging intuition in clinical decision making. Journal of Holistic Nursing 2000 Jun;18(2):94—113. 26. Rew L, Agor W, Emery MR, Harper SC. Intuitive skills in crisis management. Nursing Connections 2000 Fall;13(1):45—54. 27. Rew L, Barrow E. State of the Science: Intuition in Nursing: A generation of study in the phenomenon. Advances in Nursing Science 2007;30(1):15—25. 28. Terekina A. Knowledge Organization Studies through analysis of Cognitive Patterns. In: Borcherding K, Larichev O, Messick D, editors. Contemporary issues in decision making. North-Holland: Elsevier Science; 1990. p. 77—90. 29. Freeman L, Adair V, Timperley H, West S. The influence of the birthplace and models of care on midwifery practice for the
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a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
REVIEW
A review of the literature: Midwifery decision-making and birth Elaine Jefford *, Kathleen Fahy, Deborah Sundin Newcastle University, School of Nursing and Midwifery, Callaghan Campus, NSW 2308, Australia Received 9 July 2009; received in revised form 3 February 2010; accepted 3 February 2010
KEYWORDS Decision-making; Birth; Midwives; Decisionimplementation; Second stage
Summary Background: Clinical decision-making was initially studied in medicine where hypotheticodeductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benner’s ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the ‘rational reasoning’ as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman—midwife partnership where the woman is the ultimate decision-maker. Method: CINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review. Findings: Decision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Conclusion: We argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention. # 2010 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
* Corresponding author at: PhD student (midwifery) Newcastle University, School of Nursing and Midwifery, Callaghan Campus, NSW, 2308, Australia. Fax: +61 02 6205 3076; +61 (0)405374536 (mobile). E-mail address: [email protected] (E. Jefford). 1871-5192/$ — see front matter # 2010 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. doi:10.1016/j.wombi.2010.02.001
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Introduction This literature review is focused on clinical decision-making in midwifery; more specifically during birth. The review is guided by the question: what factors influence the processes midwives use when engaging in clinical decision-making during birth? We acknowledge the term birth is sometimes used in a broader sense however, here we define ‘birth’ as ‘the time from the beginning of the second stage of labour up to and including the hour after the birth of the baby’. Second, third and fourth stages of labour is a period of care requiring intense focus of the midwife’s clinical assessment and decision-making skills. Time critical decisions must be made, which will affect the mother, baby or both. At the same time second-, third- and fourth-stage labours are fraught with complex, contextual and multiple variables operating simultaneously; e.g. depending upon the birth setting and employment status of the midwife she may experience conflict in relation to woman-centred care and the policies, procedures and practice standards of the birthing unit. Second-, third- and fourth-stage labours are also a complex time for the childbearing woman. Women who are experiencing a physiological birth may be in an altered conscious state so asking the woman to solve problems and make complex decisions at that time may be problematic for her.1 Other women may be affected by narcotics and not able to think rationally and/or quickly. Thus we argue that the period of second-, third- and fourth-stage labour provide an ideal vehicle to examine the midwife’s clinical decision-making process and those factors impacting upon that process. The International Confederation of Midwives (ICM) outlines a framework for decision-making in midwifery.2 A decision-making framework on scope of practice is also offered by the Australian Nursing and Midwifery Council (ANMC).3 The midwife’s scope of practice is further guided by the Australian College of Midwives (ACM), national midwifery guidelines for consultation and referral.4—6 These documents seek to regulate the degree midwifery autonomy vis-a-vis other health care professional. The documents do not address the complex issues of both clinical reasoning and the interpersonal negotiations between the midwife and the woman and the midwife who is employed by a hospital and is answerable to other maternity care providers who are in the unit during the woman’s birth. Philosophically there is agreement that midwifery clinical decision-making should involve the midwife in negotiating sensitively with the woman with consideration for the environment and the people within it.7 This belief is consistent with the often espoused view that the discipline of midwifery is based on a philosophy of primary health care and partnership with the woman.2,8,9 In this view, pregnancy and birth are seen as normal physiological and social life events, where midwives should work in continuity of care relationships with the women from pre-conception through pregnancy, labour and birth and up to 6 weeks after birth.8,10 This view assumes that midwives use their expertise and evidenced-based knowledge to support and empower women to be the decision-maker during their unique childbearing experience.11 Page and Hutton12 argues that evidenced-based care in midwifery is ‘‘. . .a process of involving women in making decisions about their care and of finding and weighing up
E. Jefford et al. information to help make those decisions’’ (p. 9). Tupara13 has written on midwifery decision-making from a theoretical perspective focusing on descriptive decision theory, concerning cognition and information processing. In the midwifery literature mentioned above no emphasis has yet been given to the clinical reasoning skills of the midwife. This may mean that midwifery, unlike medicine and nursing has not specifically considered the clinical reasoning skills of midwives; for example the 3 main undergraduate textbooks Myles,14 Mayes15 and Pairman et al.16 lack any chapters or major sections on this topic. Further, the midwifery literature above does not address how the midwifery-partnership should occur during the rapidly unfolding events of birth itself (particularly when the midwife and woman are strangers to each other). This gap in the midwifery theoretical literature justifies the present review of research related to our guiding question.
Clinical decision-making The term clinical decision-making is best understood by first considering the more medically accepted term clinical reasoning. Clinical reasoning is a form of hypothetico-deductive logical thinking. Strengths of this approach include the emphasis on development of strong logical cognitive reasoning skills and the emphasis given to basing treatment decisions on knowledge (evidence) and not a rule of thumb or mindlessly following tradition.17 Hypothetico-deductive reasoning focuses on ‘the supposed biophysical facts’, which can be defined, measured and consensually agreed upon. When hypothetico-deductive reasoning is applied in clinical practice it is generally agreed to involve a number of phases (see Box 1). Clinical reasoning has been criticised as being too linear and reductionistic, focussing, as it does, on detail and chains of causal relationships.18 Clinical decision-making is a broader concept which allows for both reductionism and holism at various points in the decision-making process. The definition of clinical
Box 1. Cue acquisition–—sense data collected, i.e.
signs and symptoms; Cue clustering–—all relevant cues joined to-
gether; Generating multiple hypotheses–—explains
cue clusters; interpretation—information is interpreted in the light of the explanations/hypotheses that are under consideration; Focused cue acquisition–—ruling in/ruling out hypothesis; Hypothesis evaluation — based on all available data — differential diagnoses; Evaluation of treatment options; Implementation of preferred treatment plan, and Evaluation of treatment–—to confirm or change diagnosis.52—56
Cue
Midwifery Decision-making and Birth decision-making in midwifery offered in this paper takes account of both hypothetico-deductive and humanisticintuitive approaches and is in harmony with contemporary ideas in midwifery. Clinical decision-making here is defined as a process that may encompass both clinical reasoning and intuitive awareness of the psycho-social—spiritual and environmental factors that are influencing the clinical situation and what the midwife thinks; feels and actually implements. In nursing, Benner19 linked the process of decision-making to five ‘levels’ of experience and practice: novice, advanced beginner, competent, proficient and expert. Benner’s19 research findings were that, clinical decisions by less experienced nurses were strongly based on hypothetico-deductive reasoning. Expert nurses however, Benner19 claimed, used intuition. Intuition involves an automated quick classification, where the expert nurse intuitively screens available options and eliminates options not perceived as relevant. Intuition tells the nurse when something ‘feels’ right or different, without the nurse necessarily being able to articulate what it is.19,20 As a result of these intuitive feelings, the nurse then reaches a judgement and/or decision.19,21 The resultant perceptions are of an intuitive decision-making expert nurse who appears quick and spontaneous while operating with profound understanding, without necessarily being able to articulate that understanding.19,22 Berry and Dienes23 hypothesise part of this process can be referred to as automatic whereby, tacit nursing knowledge acquired through exposure and experience of the usual paths taken by illnesses is subsequently forgotten. Benner19 argues intuition is a valuable part of nurses’ clinical practice. Other researchers go further hypothesising, other health professionals benefit from drawing on intuition in clinical practice.24—27 For expert practitioners, knowing what to do in a particular situation usually depends on intuitive pattern matching. Pattern matching is defined by Mok and Stevens24 as a ‘‘process of making a judgement on the basis of a few critical pieces of information’’ (p. 59) but the accuracy of the assessment and final action is dependant entirely upon the fidelity of the match between successfully managed past situations and the current situation which requires action.17,28 When a midwife uses pattern recognition in a clinical situation her judgement may unknowingly be adversely affected because pattern recognition leaves out crucial steps in clinical reasoning such as: hypothesis formation and hypothesis testing. This means that using intuition to guide action may well be a hallmark of an ‘advanced practitioner’ but it is not an example of clinical reasoning.19 Thus using intuition in rapidly evolving critical situations may actually lead to detrimental actions because systematic decision-making has not been used.
Search strategy The key concepts and words in the research question were identified prior to commencing. Exclusion criteria are also defined (see Box 2). The databases searched were Medline, CINHAL and Cochrane. Two searches were undertaken in the Cochrane database, one using advanced search and key concepts and words and the other using the Mesh facility.
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Box 2. 1st keyword string: decision-making OR reasoning OR judgement OR thinking OR problem solving OR logic OR concept formation OR cognition OR uncertainty. 2nd keyword string: clinical OR practice OR labo(u)r OR labor obstetrics OR delivery OR Natural childbirth OR water birth OR birth OR parturition OR second stage OR third stage OR obstetric emergencies. 3rd keyword string: midwives OR midwife OR student midwife OR nurse midwife OR nurses. Exclusion criteria: non-humans; non-English; >10 years; non-peer reviewed journals; studies pertaining to nursing; studies involving women’s decision-making. N.B. Studies related to professionals who practice within the field of midwifery, but are classified as nurse-midwives within their country were included.
The Mesh facility converts key concepts and words in to terms the database deems most appropriate (see Box 3). The keyword concepts and words made three keywords: strings which related to: decision-making; labo(u)r and midwife. The three
Box 3. 1st keyword string: thinking OR cognition OR uncertainty. Thinking mesh tree: choice, problem solving, concept formation, judgement, decision-making, dissent and disputes esthethics, consciousness and volition. Cognition mesh tree: awareness, cognitive dissonance, intuition, perception, intention, comprehension and imagination. 2nd keyword string: labo(u)r stage OR parturition OR second stage OR third stage OR delivery obstetric OR professional practice. Professional practice mesh tree: clinical competence, guideline adherence, outcome and process assessment, peer review — healthcare, professional review organisation, programme evaluation, quality assurance — healthcare, quality indicators — healthcare and utilisation review. 3rd keyword string: midwives OR midwife OR nurse midwife OR nurses. Nurse midwife mesh tree: nurse practitioner and male nurse. Nurse mesh tree: clinicians, administrators and anaesthetics. N.B. No exclusion criteria was applied.
130 keyword strings were combined; this resulted in the following number of hits:
Medline 168 CINHAL 25 Cochrane 461 Cochrane Mesh 11
Due to the small number of hits from the CINHAL database, no limitations were applied. No limitations were applied to those hits retrieved from the Cochrane database either. Limitations of: humans, English and from January 1998 to May 2009 were applied to those hits from Medline. This reduced the hits to 128. Retrieved results from the three databases were cross-referenced to exclude duplication. Abstracts were read to eliminate any literature not relevant. Where abstracts were ambiguous or unclear further clarity was sought from reading the full text. Four research studies meet the inclusion criteria. A midwifery article that was somewhat related to our guiding question but was excluded because it did not consider the cognitive process of midwives clinical decision-making was Freeman et al.29 Also most famously Kirkham, Stapleton and Levy looked at midwives’ decision-making in the antenatal and postnatal periods and supporting women30—32 but these were excluded as they do not generalise to the context of birth as defined above. A number of articles, concerning midwifery decision-making, focused on the development of midwifery students’ cognitive skills using clinical simulations.33—35 These were excluded because they did not include the complex context of actual practice, they were not focussed on birth. We have included one Cioffi study that did focus on decision-making during birth even though the context was educational simulation.
Summary and critique of existing literature Study 1 The effectiveness of using clinical simulation to teach hypothetico-deductive reasoning was investigated using a cohort design.36 Thirty-six midwifery students were recruited: 18 experienced the intervention of simulation and 18 experienced the standard lecture. The strategy used for allocation of student midwives to groups was not stated. The researchers developed two simulation scenarios involving written and audio-taped information and a set of decision-rules. Midwifery students worked in pairs using thinkaloud techniques, a proven technique to aid understanding through verbalisation.37 The first scenario concerned normal labour, the other concerned neonatal physiological jaundice. The findings indicated, midwifery students who received the simulation strategy collected more clinical information, revisited collected clinical information less, made fewer formative inferences and self-reported higher confidence levels than those student midwives who underwent traditional lectures. Midwifery students who self-completed the posttest for normal labour simulation, were found to undertake more rapid decision-making. Self-reporting posttests, however are subjective and potential for variation of results between cohorts may exist. The limitations of this study in terms of generali-
E. Jefford et al. sability include the small number of midwifery students and the homogeneity of a single student cohort. Further, the lack of definition and description of the simulation intervention makes study replication very difficult. Importantly, the findings of a controlled clinical simulation may not be generalisable to the complex world of real practice where multiple variables operate simultaneously. This is particularly so during birth where rapid decisions are required in a complex, fast changing situation that is strongly influenced by the environment and the people within it. There is limited literature comparing the effectiveness on fitness to practice using simulated environment with the real complex world of clinical midwifery practice.37 This broader environmental context was not considered in the Cioffi et al. study.36
Study 2 An ethnographic study was used to explore complexities of decision-making and how perceptions of risk, uncertainty, relevant knowledge and professional autonomy influence the outcome pre-implementation of a computerised decisionmaking support system.38 The study was conducted at two delivery suites in England. Data collection included direct observation of midwives and doctors and in-depth interviews. Comprehensive details of the 16 people interviewed were not stated. Key findings of the research were that midwives indicated, in this study, they were autonomous in some decisions such as when to consult and/or grant admission to the birth room. The researchers reported decision-making in the studied ‘real world’ of a delivery suite, was influenced in both directions: top down decisions were open to contestation as much as bottom-up decisions could be countermanded. This resulted in decision-making being a socially and culturally negotiated activity. Midwives identified risks and made decisions, however at times, midwives had no power to implement those decisions. Rather the midwives’ action was often to defer to medical professionals to enact ‘formal’ decision-making. Risks identified were defined by the individual midwife or doctor’s perception, which shaped their decision-making. Women were claimed to be central to midwives decision-making, yet the research demonstrated this to be tokenistic. Rather women were generally seen to be passive with the midwives and doctors dominating the decision-making process. Midwife—doctor decisions occurred outside the woman’s room, where as midwife-woman decisions occurred inside the woman’s room. A strength of this observational study was its capture of the real world of practice of midwives for over 500 h. A limitation of this study though is the lack of differentiation between the midwives autonomous scope of practice and the number of times when the midwife was obliged to consult and/or refer to a doctor. The study provides data on the organisational complexity of midwifery work processes and decision-making, but there are no details concerning the way that midwives actually made and enacted their clinical decisions. The study would have been improved if the observational hours were equal at both sites. As it was 500 h of observation was conducted at one site and only 30 h at the other. The different cultural context of England and current different educational training programs for Australian midwives limits transferability to an Australian context.
Midwifery Decision-making and Birth The conclusions drawn from this study primarily relate to the ‘real world’ of delivery suites in England pre-implementation of the proposed computerised decision-making support system. Implementing such a system may provide a means of enhancing hypothetico-deductive reasoning, which may enhance midwifery autonomy in decision-making and reduce the hierarchically negotiated aspects of midwifery decision-making.38
Study 3 A Swedish phenomenological study focused on midwives problem solving in critical antenatal and birth situations where no medical assistance was available.39 Seven midwives participated in the research. Participant information was limited to a statement about the midwives range of years since qualifying. Data was collected via in-depth interviews and analysed using thematic analysis. Analysis identified 13 factors deemed necessary to effectively solve critical antenatal and birth situation problems in midwifery (see Box 4). This study reported that initially, the midwives employed a process of hypothetico-deductive reasoning. The midwives listened, observed and assessed women in order to collect cues, from which one or more hypothesis were generated. When interpreting these cues, midwives acknowledged drawing upon theoretical and clinical knowledge and past experiences. Once this happened the midwives claimed they ‘intuitively’ knew how and when to act. Midwives stated they felt confident and safe in this approach as they had the relevant professional knowledge. This resulted in the midwives experiencing feelings of being in control of the unfolding critical situation excluding any irrelevant peripheral social and environmental influences. The midwives claimed to engage in calm negotiation with the woman and peers in order to ensure a positive outcome for mother and baby. When the need arose, midwives indicated they orchestrated collegial and technological support. Further, in anticipation of medical agreement with their decisions the midwives prepared any necessary equipment needed. In these critical clinical situations the midwives reported feeling euphoric when they performed well. An important consideration is that this study took a noncritical view of what midwives said they did during decision-
Box 4. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
To listen; To assess; To make fast decisions; To possess knowledge and experience; Intuition; To identify a problem and find a solution; Cooperation; Engagement; Purposefulness; Concentration; Euphoria; Consideration; and Control.
131 making. We have no way of knowing what midwives actually did. Further transferability of this study to an Australian context may be, restricted because there were only 7 midwifery participants and the cultural context of midwifery in Sweden is quite different from the Australian context. Another limitation is, midwifery problem solving in critical situations was reported to be dependant upon verbal and non-verbal interactions with the women, yet the women’s perspective was not taken in to consideration by the researchers. Because no specific examples were given, it is not possible to tell from this research if midwives engaged in formal hypotheticodeductive reasoning. They may have used heuristics based upon pattern matching and past experiences.
Study 4 Midwives decision-making in relation to accurate diagnosis of active labour was the focus of a Scottish qualitative study.40 Thirteen midwives were allocated to 2 focus groups. The midwives were invited to discuss how they made decisions differentiating women who were in active labour and needed to be admitted, versus early labour when the woman would be sent home. Latent content analysis identified 2 major categories midwives consider when making decisions related to diagnosing labour: the woman and the institution. More specific themes were subsumed under each category. When diagnosing labour and making clinical management decisions midwives indicated they take both categories and all of the subsumed themes into consideration. Midwives diagnostic judgements were found to be predominately based upon linear collection of information cues in order to generate one or more hypothesis. Primary cues such as: those related directly to the diagnosis of labour (observing the women’s physical signs and a vaginal examination) were sought first. This method of information gathering is congruent with hypothetico-deductive reasoning.17 Once the midwife reached a diagnosis, Cheyne et al.40 reported, midwives then took secondary cues into account, which informed decisions about whether or not to admit the woman to the delivery suite. Secondary cues included: the woman and her family’s expectations and the daily contextual environment of the organisation such as: workload, bed allocation and staffing issues. Organisational guidelines, the midwives indicated, placed significant constrictions on their decision-making processes. If a woman was not judged to be in active labour, but the midwife made the decision to admit her, the woman was likely to be exposed to a cascade of intervention. Conversely, some women were thought to be able to benefit from admission even though they were not technically in active labour. Importantly, regardless of which decisions were made, midwives felt the need to justify their actions to colleagues. The researchers conclude, due to competing physical, psycho-social and organisational cues midwifery management decisions are not solely reliant on diagnostic decisions. This demonstrates how midwifery clinical decision-making can be controlled by organisational matters, thus undermining the midwife’s clinical autonomy. The strengths of this study include the identification of how clinical decisions can be made on organisational grounds. The emphasis this research gives to psycho-social and organisational factors are also reflective of the complex reality of midwifery practice. The weaknesses of this study include the
132 group-based nature of the data collection where midwives tend to tell stories placing themselves in a positive light. When midwives sit together they may add to each others’ stories until a holistic picture of the hypothetico-deductive reasoning and compassionate care is presented: this may be a constructed myth rather than a reflection of actual midwifery practice. Focus groups work best when there is diversity of views and positions but there were only 2 focus groups from a single hospital, which again weakens the study.41
Findings The 2 major findings, which can be synthesised from this literature review, are primarily that decision-making in midwifery is socially negotiated involving hierarchies of surveillance and control. Despite a midwife widely being claimed as an autonomous practitioner it was found that she remains dogged by surveillance of her decisions and the resultant actions10,38: Department of Health # Chief Executive Officer # Director of Midwifery # Obstetrician # Doctor # Clinical Midwife Consultant # Midwife
This surveillance tended to reduce and/or regulate the midwife’s ability to function as autonomously as other health care professionals.10 Decisions and resultant actions were also governed by policies and practices as well as professional organisations such as the Australian College of Midwives and Australian Nurses and Midwifery Council. Secondly, clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. Due to the dominant paradigm’s rigid claim to birth as a complex ritual that must be controlled through intervention the complexities of clinical decision-making in midwifery are concerned with different yet related phenomena: the concept of risk and uncertainty and autonomy.42,43 Individual midwives and doctors perceptions of risk shape decisionmaking. Medicine on the whole remains grounded in a biomedical mechanical viewpoint of childbearing where women are seen as inherently faulty and unreliable, needing surveillance and intervention. This is congruent with Modernism which hypothesised such knowing derived though the objective rational self, which is science.44 Science hypothesised superiority of detached rationality over the idea that a human was a complex human-being made up of a mind, body, soul and emotions.44 This is relevant to midwifery as over centuries we have applied science to the understanding of the physiology of childbirth, which was understood as separate from the woman’s spirit and emotions.45 Terms such as non-intervention, supportive environment, encompassing
E. Jefford et al. trust, empowerment and women-centred are all but excluded from consideration in medical textbooks. Medical professionals today continue to inflexibly claim birth as a complex ritual that they control. Their naturally supposed superiority and patriarchal hierarchy were and are to be accepted by women.46 Kitzinger (2005) claims the western world focus of birth is medical and technocratic. She writes from this perspective ‘‘. . .the mother is relevant only in so far as she is the container for the fetus. In fact she is an obstacle to inspection of the fetus’’ (p. 3). From such a stance it is clear to see why doctor’s perception of risk shapes their decision-making. Midwives, however focus on interconnections between mind, body, spirit, family, community and environment. They pay attention to women’s invisible energy flows, obstacles and liberation. Midwives connect with women, respecting and acknowledging their body wisdom by providing them space to experience and value pregnancy and birth.7 Midwives use their expertise and evidence-based knowledge to support and empower women to exercise autonomy during their unique childbearing journey. Nevertheless 3 of the reviewed studies indicated midwives confidence in their clinical judgements was limited and validation was sought from within a hierarchical system where the ultimate decision-maker is the doctor or the health service manager. In one study midwives are presented, via their own positive stories, as skilled in clinical decision-making and in interpersonal skills with women, families and colleagues.39 It is possible that in every instance the midwives were making autonomous decisions and being able to implement their planned action. This study could be seen as an excellent example of midwives being autonomous practitioners, which according to Pairman et al.16 means, a midwife uses her ‘knowledge and skills to provide care independently without a requirement to refer to another health professional’ (p. viii). Beauchamp and Childress47 hypothesise that autonomy equates to an individual controlling their own life and free from controlling interference from others behaving in a rational and moral manner. Consequently, there appears to be incongruence between the concept of an autonomous midwifery practitioner and its implications for decision-making: those decisions midwives must confer about and those that are within the accepted scope of midwifery practice.4,5,10,16 A possible reason for this incongruence is the extent of authority given to a midwife by an organisation and her readiness to accept it.48 This is endorsed by Kirkham49 who believes what decisions midwives actually make are constrained in their implementation by intrapersonal, contextual and institutional/organisational factors.
Key limitations The key weaknesses of these studies are that each study has involved small numbers from only one or two research sites, which limits transferability. Another weakness is, studies using the interpretive paradigm have unacknowledged biases towards presenting idealised versions of how midwives make and implement decisions. Interpretive researchers accepts ‘truth’ is what participants present at interview often without probing and searching for negative examples or cases. 50 Although one study indicates high-fidelity simulators
Midwifery Decision-making and Birth enhanced and improved hypothetico-deductive reasoning and decision-making in student midwives in the educational setting. There was no finding about how these improved reasoning skills may have been transferred to actual practice.
1. Conclusion The guiding question has been: what factors influence the midwife’s clinical decision-making during birth? Previous research in medicine and nursing is not adequate to address decision-making in midwifery because although clinical reasoning is a necessary condition for valid decision-making, it in not sufficient when decisions have to be negotiated with the woman and with other members of the maternity care team. Thus we see clinical reasoning as a sub-component of midwifery clinical decision-making. We specifically reject Benner’s research as providing a basis for understanding and optimising clinical decision-making in midwifery. Her concept of the ‘advanced practitioner’ who uses ‘intuition’ to make decision seems to us to be an oxymoron. Dreyfus and Dreyfus51 claimed that ‘‘experts don’t solve problems and don’t make decisions; they do what normally works’’ (p. 30— 31). Thus, if advanced practitioners do use intuition then they must be less likely to use formal clinical reasoning processes, which make them more prone to errors in decision-making. Clinical decision-making seems to be undervalued in the midwifery literature thus the existing midwifery research provides only a partial answer to the research question. There have been no midwifery studies that have systematically and critically examined clinical decision-making during birth in registered midwives. Further research is needed to explore both clinical reasoning and the intrapersonal and contextual factors that influence midwives actual clinical decision-making and decision-implementation during birth. The role of the woman as decision-maker in her own care and how this is negotiated between the woman and the midwife needs careful analysis. New, critical midwifery research is particularly needed which focuses on labour and birth where decisions are required in a complex, fast changing situations that are strongly influenced by the environment and the people within it.
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