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Confidence: Fundamental to midwives providing labour care in freestanding midwifery-led units
Accepted Manuscript
Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units Marion Hunter , Elizabeth Smythe , Deb Spence PII: DOI: Reference:
S0266-6138(18)30260-2 https://doi.org/10.1016/j.midw.2018.08.016 YMIDW 2335
To appear in:
Midwifery
Received date: Revised date: Accepted date:
6 June 2018 21 August 2018 22 August 2018
Please cite this article as: Marion Hunter , Elizabeth Smythe , Deb Spence , Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units, Midwifery (2018), doi: https://doi.org/10.1016/j.midw.2018.08.016
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ACCEPTED MANUSCRIPT Title Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units Marion Hunter, DHSc, MA (Hons), BA, RM, RGON Senior lecturera*, Elizabeth Smythe, PhD, BA, RM, RN, Professorb,
a
Midwifery Department School of Clinical Sciences, Auckland University of Technology, PB
92006 Wellesley St, Auckland, New Zealand. b
Professor, Associate Head School of Clinical Sciences, Auckland University of Technology,
PB 92006 Wellesley St, Auckland, New Zealand.
Senior Lecturer, School of Clinical Sciences, Auckland University of Technology, . PB
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c
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Deb Spence PhD, RM, RN, Senior Lecturerc
92006 Wellesley St, Auckland, New Zealand.
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*Corresponding Author: Marion Hunter [email protected]
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(1) Conflict of Interest: None declared
(2) Ethical Approval: Auckland University of Technology Ethics Committee 14/364
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(3) Funding Sources: Not Applicable
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Abstract
The aim of this study was to reveal what enables, safeguards and sustains midwives to provide labour care in freestanding midwifery-led units.
Design A hermeneutic phenomenological study was undertaken in the Auckland region of New Zealand. In-depth interviews were conducted with 14 participants: 11 midwives who provide care in freestanding midwifery-led units and three obstetricians who provide antenatal consultations on site in midwifery-led units. 1
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Main findings Confidence is necessary to provide intrapartum care in freestanding midwifery units. This confidence is cultivated by working in the community or freestanding unit and believing this unit is an appropriate space for healthy women to labour and birth. Normal labour and birth are commonplace in this space which in turn reinforces midwives‟ confidence. Maintaining confidence for midwives to work in these units requires trusting relationships in the
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midwifery team. Further, there needs to be mutually respectful relationships with obstetric colleagues. Midwives who have lesser experience, or experience in obstetric unit only, may need support to step into the role of providing labour care in freestanding midwifery units. When the midwife feels supported, when s/he witnesses women and families experiencing their normal birth, one‟s resolve to practising in this manner is strengthened. The midwife
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holds confidence.
Key conclusions and implications for practice
Confidence required to provide labour care in a midwifery-led unit is cultivated through
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immersion in these units.
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Key words: Freestanding midwifery unit, Primary unit, Birthcentre, intrapartum,
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hermeneutic phenomenological, confidence
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Introduction Outside the main cities of Aotearoa-New Zealand is a relatively sparsely populated land with 58,957 births recorded in 2015. This is equivalent to approximately five percent of births in England and Wales which has similar land mass. The maternity system in Aotearoa-New Zealand is state funded for eligible women, however, a minority of women pay fees for private obstetricians. The model is based on a Lead maternity carer who caseloads (with
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back-up) and is available for maternity services over twenty-four hours each day of the week. Midwives are lead maternity carers for over 85% of women (Ministry of Health, 2017) and these midwives have access rights to maternity units in their region. This study was
undertaken in the greater Auckland region, with a population of 1.66 million (Stats NZ). There are four large obstetric units (secondary/tertiary units) and seven freestanding
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midwifery-led units (primary units). Small maternity units have existed since the early 1900s in New Zealand, featuring in both urban and rural localities. While regionalisation of maternity services resulted in a decline in births in these units from 28% in 1982 to 10% in 2015 (Ministry of Health, 2017; Rosenblatt et al., 1985), the remaining freestanding
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midwifery/8-led units provide a unique space for the process of normal labour and birth to unfold (Smythe et al., 2016). Epidural analgesia assisted birth and caesarean operations are
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not available in these units. The National Maternity Monitoring group (2016) targeted the need for district health boards to provide primary maternity unit/s in each region. This strategy promotes options re choice of birthplace and supports usage of existing midwife-led
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units. Women of indigenous Māori ethnicity use primary units at almost double the rate of women of non- Māori ethnicities (Ministry of Health, 2017) indicating these units may be
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culturally acceptable. In New Zealand, along with other high-income countries, most births occur in obstetric units that exist for women with complications providing operative birth and
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neonatal intensive care facilities. Despite research evidence showing that births are safe in midwife-led units (Bailey, 2017; Birthplace in England Collaborative group 2011; Christensen and Overgaard, 2017; Davis et al.2011, Denham, Humphrey and Taylor 2017; Homer et al., 2014), the number of women using this space could be improved (Walsh et al 2018).
Safe outcomes are paramount for women, partners, families and for health professionals working in maternity care. Safety encompasses lack of harm in a multi-faceted manner. The philosophies underpinning practice, including effective working relationships and positive 3
ACCEPTED MANUSCRIPT outcomes appear to be fundamental in enabling midwives to practise in midwife-led units (Edmondson and Walker 2014; Helberget et al., 2016). Laws et al. (2011) found two philosophies were rated as very important by birth centre respondents; commitment to normality of pregnancy and birth and providing midwife-led care. There is a limited body of knowledge about how midwives work confidently in midwife-led units intrapartum. Rayment et al. (2015) suggested that not all midwives have the skills required to support normal birth, despite an assumption this is customary. In a similar manner, Stone (2012) suggested that
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midwives be trained to work in birthcentre settings because the context contrasts markedly with obstetric hospital labour wards. In midwife-led units, midwives pay attention to „softer‟ aspects such as the ambience, attention to privacy and reduction in light and noise (Davis and Homer, 2016). While all practising midwives might be subject to similar skills and guidelines for practice, „place‟ influences midwives. The space of birth is important to generate feelings
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of comfort, the passing of time. McCourt et al. (2016) described a midwifery-led unit as an enclave, a protected space, where midwives felt more relaxed and support is shared. When an environment is calm, midwives are calm and the combination is conducive to women having less analgesia and a more physiological birth (Foureur et al., 2010; Hunter, 2003). Birthing units are associated with increased autonomy for midwives, thus enabling midwives to
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practise „being with‟ women in this setting.
Methods Design
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A qualitative methodology was chosen to uncover what enables, safeguards and sustains midwives to provide labour care in midwife-led units from the midwives‟ and obstetricians‟
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perspectives. Hermeneutic phenomenology informed by Heidegger (1996) and Gadamer (2012) seeks to reveal meaning in text and language. Gadamer suggested transposing
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ourselves into the historical horizon; in order to understand another situation, we must place ourselves in it. Understandings become a scholarly endeavour and contributes to the hermeneutical situation through the examination of texts. The lead author came to this study with a history of working in both obstetric units and freestanding midwifery units in various roles (employed, community case-loading and educator). She was interviewed prior to commencing this study to surface pre-understandings influencing the project. To maintain rigour, these assumptions were challenged throughout the research process ensuring findings belonged to the meanings uncovered in the data and through the interpretive paradigm of hermeneutic phenomenology. 4
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Data collection Approval was gained from Auckland University of Technology Ethics Committee (14/364). Recruitment occurred through purposive sampling and snowballing; this is congruent with hermeneutic phenomenology whereby all participants have lived the experience (van Manen, 2014). Information was sent to managers of midwifery-led units inviting them to participate in the study and, to make information sheets available to midwives and obstetricians who
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worked in the unit. Interested participants contacted the researcher and a time for interview was arranged. Participants included four case-loading community midwives, seven employed midwives and three obstetricians; all participants provided services in the midwife-led unit. Participants chose a mutually agreeable venue for interview, for instance, a clinic room or midwifery unit. The lead researcher conducted all interviews. Prior to undertaking each
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interview, the consent form was signed, options were given regarding stopping the voice recorder and time commitments were noted. The interviewer sought to gather rich experiential narrative material as a resource for phenomenological reflection. The intention was to gain pre-reflective descriptive accounts from the participants, avoiding opinions and
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judgements (van Manen, 2014). Interviews began with the researcher (lead author) inviting participants to share how they came to work in the midwife-led unit. In keeping with hermeneutic phenomenology, the researcher then sought stories that stayed close to the
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experience of enabling a woman to labour in the unit. Prompting was used to ask “tell me more about that” or to encourage a participant to share another example about enabling a
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woman to commence labour in this unit. Interviews ranged from 30-70 minutes; most interviews were 45 minutes of recorded time. Interviews were transcribed verbatim by a
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transcriber; the lead researcher checked the transcripts for accuracy through listening to
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recordings and adding intonations or missed words.
Data Analysis Hermeneutic phenomenology requires uncovering meanings within the data. Analysis was undertaken through reading the entire transcript and focussing on stories within each transcript that answered the research question. Participants were given the opportunity to review their transcript. Once the participant gave permission to use their transcript, the researcher focussed on the process of „crafting stories‟ to answer the research question and eliciting meaning from the data (Crowther et al., 2016). In hermeneutic phenomenology, data analysis comprises the iterative processes of reading, writing, thinking and re-writing. 5
ACCEPTED MANUSCRIPT Crafting stories is inherent in methods associated with hermeneutic phenomenology and is argued to be part of the dialectic movement between methodology and methods (Crowther et al., 2016; Smythe et al., 2008; van Manen 2014). Smythe et al. (2008) suggested that we are often called by a particular story. It claims our attention because it seems to signal or point to something important. The hermeneutic circle or spiral entails reading, interpreting through writing, re-reading, re-writing further interpretations that seek to uncover taken for granted and/or hidden meanings (Spence 2016). Philosophical insights from Heidegger and Gadamer
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were used to uncover everydayness, to illuminate being-there as Dasein (Heidegger, 1996) in a midwife-led unit. Rigour was achieved through review of processes and findings with
colleagues at hermeneutic readings meetings, feedback from supervisors and presentation at local/national conferences.
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Findings
The following themes reveal how confidence is integral to providing intrapartum care. Stepping into Midwife-led units
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Lynn describes a „baptism of fire‟ that set her up for working in birthing units:
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My first night on call when I was a community midwife was an absolute baptism of fire; my first homebirth witness, then called out to my first homebirth myself. It was an amazing night. As a team midwife, you were able to practise unhindered, the midwives all had a very similar philosophy. It didn’t fill me with any worry working in this midwifery unit because it felt like going back to where I had the most job satisfaction ever working as a midwife. Lynn embraced this „baptism of fire‟ as building her confidence in community midwifery.
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These home births reinforced Lynn‟s penchant for practising „unhindered‟ freely and autonomously, without medical support. Lynn‟s positive experience in community midwifery
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drew her into midwifery-led units to work alongside colleagues with a similar philosophy.
Vivienne echoes the necessity for confidence as a rural lead maternity carer midwife: I think you’ve basically got to be quite confident, it would be difficult if you weren’t confident in your care, confident in how you work and practise as a midwife. And you’ve also got to have collegial support. I think those two things are really important.
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ACCEPTED MANUSCRIPT Vivienne believes it would be difficult for a midwife to conduct the role without confidence in your professional work. Moreover, collegial support is essential for midwives case-loading in rural practice.
Keeping Faith in the normal The following midwives shared their faith in the space of midwifery-led units as the right place for women to labour and birth:
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It is about the belief of what is normal and what women can do. It is the belief that it should be normal and it’s a life event and it’s a physiological thing. We know it doesn’t fall that way for all women but the majority it does. We are used to seeing that every day… we see the good outcomes and you don’t see that in a secondary/tertiary hospital Lynn
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With confidence, it goes right back to believing in our model of care that birthing is normal until proven otherwise…I feel we are the keepers of normal and if we are going to continue to do that, we have got to really work at it. It is like when you see so many normal babies that a baby that is not normal sticks out. It’s pretty much the same with birthing Dianne
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I came from this culture, it feels like the right place to be in your community…It is never boring here, it takes a lot of courage to work here especially if you are used to a large obstetric hospital…there's a faith I get from working here as a midwife Wanda
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I did time in this unit as a student midwife. I saw the benefits of looking after the women in your community and birthing them at the unit. I think the belief that birth is a normal process and it should be treated as normal …Robynne
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I think what gives me confidence to birth in this unit is I still have held on to that belief that birth is safe and is best served, a woman’s chance of having a normal birth is better in a small unit Mary
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Confidence entails phenomena of faith and hope such as belief held in normal birth; trust is required for the midwife‟s anticipation of „normal‟ birth. When a midwife‟s confidence is
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undermined, perhaps when „normal‟ birth does not play out, the faith and courage to provide labour care in a midwifery-led unit can be undermined. When Dianne says, „we are the keepers of normal‟, she signals that „we‟ hold confidence together. When one person‟s confidence is undermined the „we‟ gather around to restore the confidence keeping faith in „normal‟ birth in a midwifery-led unit. The obstetricians held similar faith in the midwiferyled unit as follows: It’s just a natural thing (midwifery units) to me in the way that you have primary medical centres. And there’s more and more research showing that it is safe for low 7
ACCEPTED MANUSCRIPT risk women. I’m very pro woman’s choice, so if that is what the woman wants and she’s low risk then, I would support her to birth in this environment (Obstetrician) I’ve never not thought (midwife-led) units were okay. Most women are supposed to have babies … (Obstetrician). The obstetricians in this study supported these freestanding midwifery units as an appropriate space for healthy women to labour referring to the growing body of research that confirms
preserving normal birth for healthy low-risk women.
The mood-of-unit
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safety. Thus, obstetricians who consult on-site for risk assessment may contribute to
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The mood or attunement is „felt-space‟ described by the following midwives:
It took me a while to adjust to the smallness of the unit, my colleagues said you are so far away with no back up, no one at the end of a bell....I was mentored extremely well. Diane
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I feel I can work primary here, I can call anyone into the room in the primary unit whereas I don’t feel that in the secondary hospital, I don’t feel as safe there. Kirstin Working in a small team of midwives and relying on the skills of the next midwife who
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comes into the room creates neighbourliness and homeliness in this space. The space enables for preservation of normal birth. The feeling within this space holds confidence steady.
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Building and Maintaining Confidence The following midwife describes working with a colleague in the midwife-led unit:
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I think that the more senior midwives have to provide support to new midwives. I like them to do hands on. I tell them I’m in the background and just recently, I said to this new midwife who I knew had not had a good experience, ‘Now I want you to look after this woman, I’m here’. I didn’t necessarily go into the room actually. I said, ‘I’m here, I want you to do this because you’re very capable of doing this but I’m here’. And if I’d had to go in to the room I would have gone in. Helenmary
The less experienced midwives need to do „hands on‟ intrapartum care and the experienced midwife encourages this by being-there in the background. Another midwife described how confidence could waver: I had an incident where I nearly did lose my confidence (in a large hospital)…afterwards, the obstetrician said to me ‘I want you to know that 8
ACCEPTED MANUSCRIPT nothing you did there was wrong, everything you did was absolutely fine’. And I thanked the obstetrician for telling me that. I said, ‘what will happen if this happens to me in a birthing unit’? The obstetrician said, ‘nothing would have happened. All you would have done is got a couple of lines in, you would have followed the transfer guideline and we would have just dealt with it here and it would have been fine’. And that was really good for me. A senior midwife said the same thing to me. Now I think enough time has elapsed that got me through the hump where I lost confidence. I was shaky and now …I think philosophically I am just a birthing unit person. Mary
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Confidence fluctuates. It can be lost, diminished or strengthened. Obstetricians and senior midwives contribute to building, maintaining and restoring confidence. In this case, the
astuteness of the obstetrician in debriefing with the midwife reassured her. The midwife felt confident that she would do the right thing if a similar situation arose in the isolated midwife-
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led unit.
Working as a team
The isolation of a freestanding midwife-led unit may, in itself, foster working as a team. An obstetrician describes how important it is to know each other:
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We are unique in that we know the LMCs (Lead Maternity Carers), we know the core midwives, we know women are going to be followed up with a scan or blood pressure checks, I know who that is. It’s not just a random name in the ether that might not do that. I know the midwives will ring if there is a problem, so I try to tell the registrars that we have got a unique little family here. They have got good leadership and they have got the support of the obstetric clinic. (Obstetrician)
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The obstetrician likens the team to a “unique little family” with a knowing of one another. This obstetrician trusts that problems are followed up. The midwife is a known person, not
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some random name that might disappear like ether. The relating with the midwives in the unit expands to fostering good relationships with those working in the obstetric led hospital. When a midwife feels known and trusted by her obstetric colleagues, her confidence is
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affirmed. Maintaining the midwife‟s confidence is circular. The midwife needs confidence in self, confidence in colleagues, effective relations with the consulting obstetrician in the midwife-led unit and with those working in the obstetric hospital. Each of these threads are woven together with bonds of trust.
Discussion
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ACCEPTED MANUSCRIPT There is no one thing that breeds confidence, rather a synergistic combination of many factors. Rotenstreich (1972) described the concept of confidence as trust, hope, faith (not defined by religious faith), a certain disposition, an opinion that things will turn out satisfactorily. Yet, confidence can bring disappointment when the future does not turn out as anticipated; the unexpected deviation from „normal‟ might bring disappointment with an accompanying loss of confidence. The congruence of the midwives‟ philosophy of fostering normal birth appears fundamental to enabling confident practise in midwifery-led units and
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supporting one another. Further, Heidegger (1996) described Fursörge as a mode of care encountering the other, leaping ahead as authentic care entails anticipatory thinking, concern and nurturing that lets the other „be‟. In contrast, when a senior midwife „leaps in‟, s/he takes care away from the other by taking over. In leaping ahead, an experienced or mentor midwife frees the less experienced midwife to practise labour care, to develop „selfhood‟ (Stolorow,
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2014) and thus develop one‟s confidence. Building confidence in others is a manner of teaching whereby the teacher is called upon to withdraw and learn to let them learn
(Heidegger, 1976). Teaching or mentoring appears to cement confidence in the experienced midwife and in turn, assists less confident midwives to learn through „doing‟ and
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encouragement.
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New midwives learn that although the unit is small, there is something about being known and knowing others that builds a strong and supportive team. McCourt and Stevens (2009) confirmed the importance of community case loading midwives forming supportive
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relationship with women and colleagues; the community midwives described a greater confidence in their clinical judgement and assertiveness to initiate referral when required. In
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our study, the dwelling space of midwifery units fosters neighbourliness and the mood-ofunit is “to cherish and protect, to preserve and care for” (Heidegger, 1976, p.349); the space
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enables trusting relationships. In such a way, the midwives, midwife managers and obstetricians who consult in these units hold confidence in everyone in their unit. Confident midwives are able to support a woman‟s confidence in her ability to labour and birth in a midwifery-led unit.
Stepping into midwifery-led unit requires having the confidence that things will turn out satisfactorily. In this current study, midwives expressed keeping faith in normal that is reinforced by normal birth playing out in most situations. Similarly, Aune et al. (2017) emphasised attitudes of homebirth midwives included believing, trusting and daring to have 10
ACCEPTED MANUSCRIPT faith in normal birth. Gilkison et al. (2018) reported that rural midwives in Scotland and New Zealand require courage, fortitude and confidence in their decision-making. Bedwell et al. (2015) found that midwives‟ confidence is dependent upon the environment, with one midwife stating she needed a year of working in the midwife-led unit before becoming confident that women could give birth normally. It took her a year to change her stance from a problematic approach to a birth as-normal approach during labour care. Bedwell et al. noted that some midwives expressed lack of confidence in low-technology environments after
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working in high-technology units that adopt a technocratic model. In contrast, positive
outcomes from midwives‟ work affirms the value of women labouring in birthing units
(Edmondson and Walker, 2014; Helberget et al., 2016; Laws et al., 2011). The mood-of-unit describes felt-space wherein midwives hold confidence to preserve normal birth. This finding supports the work that reports the influence of oxytocin on a person‟s emotional and social
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behaviour (Hammond et al., 2013; Mondy et al., 2016). When midwives perceive the
birthplace as calm, supportive and friendly, oxytocin is released; the environment enhances connectedness to colleagues and women.
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When the place/space of birth engenders homeliness, midwives described building and maintaining confidence in self and others in their team. Carolan-Olah et al. (2015)
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acknowledged support from other staff, particularly the midwife in charge, as enabling junior midwives to develop skills and confidence to facilitate normal birth. Some doctors are reported to have a lack of trust in normal birth as they only see the birthing process „go
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wrong‟ and use unnecessary obstetric procedures for healthy women (Antannasio and Kozhimannil 2017; Carlson and Lowe 2014; Carolyn-Olah et al., 2015). In the current study,
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the obstetricians contributed toward debriefing, reassuring and uplifting the midwives‟ confidence in providing labour care in midwifery-led units. Additonally, obstetricians in our
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study revealed belief in normal birth in midwifery-led units, provided on-site consultation for „risk‟ according to the national referral guidelines (Ministry of Health, 2012) and bolstered the confidence of midwives working in these units. This is in contrast to common held assumptions, perhaps arising from an era when their voices were strong in favour of closing such units (Donley 1998). McCourt et al. (2014) ethnographic study of alongside midwifery units noted that most obsetricians supported these units, however, some did not have confidence in midwife care except for individual midwives who were known and trusted.
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ACCEPTED MANUSCRIPT The perplexing question is whether experience in large hospitals where midwives gain skills related to a wide range of complications, helps or hinders the preparation of midwives to practise in low technology midwife-led units? Rogers et al. (2015) remarked on midwives‟ astonishment upon learning that the Birthplace in England Collaborative group findings (2011) were contrary to media reports that negated positive aspects of birthcentre care. Moreover, Rogers et al. noted that midwives had difficulty accepting new evidence that challenges previously held beliefs, including that birth centres are safe, if not safer, than
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obstetric units for healthy women. Midwives need to be fully informed of the significant difference in interventions in obstetric units compared with midwifery-led units and the ongoing effects for women after caesarean and operative births. In the current study, a midwife and obstetrician referred to research depicting better outcomes for women in
midwifery units as affirming their view of safety. Midwives may have some influence of
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women and their partners regarding their choice of birthplace (Borrelli et al., 2017; Henshall et al., 2018). It is imperative that midwives relay evidence-based information to consumers.
Sloman et al. (2016) researched midwives‟ experience of breech birth. While this is not
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specific to midwifery-led units, the authors showed that lack of a particular experience translated into lack of confidence. While confidence is linked with competence (Bäck et al.,
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2017; Calvert et al., 2017; Urbute et al., 2017), one must be cautious assuming that competence only arises from extensive experience in high-technology obstetric hospitals. Midwives with extensive experience in obstetric units only, may find it more difficult to gain
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the confidence necessary to support women intrapartum in freestanding midwifery-led units.
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Rotenstreich (1972) suggested that the philosophy of confidence implies reliance or dependence and referred to the philosopher, Aristotle, who placed “the brave man [sic]
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between the two poles of fear and confidence” (p.348). Taking this philosophy to a midwifery context, one might imagine that the midwife is placed between the poles of fear and confidence as s/he provides intrapartum care. The balancing of an appropriate confidence within its proper limits is confidence-as-conviction. Is it possible that the pole of fear prevents some midwives from practising in midwifery-led units? Safe practice in midwiferyled units is captured in the nuance of confidence whereby the practitioner knows the right thing to do. Furthermore, practitioners know that it is fear that prompts them to take action to keep things safe. When safety is maintained, confidence flourishes.
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ACCEPTED MANUSCRIPT Strengths and Limitations The strengths of this study include the congruence between the research question, methodology and methods. Participants included midwives and obstetricians therefore different perspectives were gathered. The process of data collection and analysis occurred over 14 months ensuring that understandings were developed in a dwelling-with-and-between manner. This study is limited to the experience of 14 participants who work within freestanding midwifery units in the greater Auckland region. These participants might be
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unique in that they felt enabled and confident to keep providing labour care. In keeping with hermeneutic phenomenology, there is no claim of transferring findings. The aim is to raise questions, stimulate thinking and ponder possible answers. While steps have been taken to ensure rigour, the interpretations are always a fusion of horizons (Gadamer, 2012) with those
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of the researcher and participants.
Conclusion
Confidence is integral to midwives providing intrapartum care, including practising in freestanding midwifery-led units. A midwife‟s belief in normal birth might emerge from
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immersion in community practice that develops a sense of self-reliance for the „now‟ and future. Growing of confidence comprises trust, disposition of self, alongside support from colleagues. Midwives and obstetricians acknowledge the power of the woman to choose
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labour and birth in a midwife-led unit. The woman‟s faith and confidence likely heighten the midwife‟s confidence as being the „keeper of normal birth‟. There appears to be regeneration
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of confidence by the interplay of having faith, believing and, expecting physiological birth and it playing out in its normality. The authors drew from Heideggerian notions of
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temporality and mood to reveal the interrelated complexity and often hidden dimensions of such confidence in the context of midwifery practice in freestanding midwifery-led units.
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While the current study focused on freestanding midwifery-led units, we understand that the need for confidence is not unique to working in these units. Further work could be undertaken to explore how midwives‟ professional confidence is, or is not built when working in obstetric units and whether obstetric unit experience assists midwives to practise intrapartum care in midwifery-led units. „Confidence-as-conviction‟ is the judicious balancing of fear with confidence that keeps labour and birth safe in these freestanding midwifery units.
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ACCEPTED MANUSCRIPT Acknowledgements Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units
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The authors wish to thank the midwives and obstetricians who participated in this study.
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Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units Marion Hunter , Elizabeth Smythe , Deb Spence PII: DOI: Reference:
S0266-6138(18)30260-2 https://doi.org/10.1016/j.midw.2018.08.016 YMIDW 2335
To appear in:
Midwifery
Received date: Revised date: Accepted date:
6 June 2018 21 August 2018 22 August 2018
Please cite this article as: Marion Hunter , Elizabeth Smythe , Deb Spence , Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units, Midwifery (2018), doi: https://doi.org/10.1016/j.midw.2018.08.016
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ACCEPTED MANUSCRIPT Title Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units Marion Hunter, DHSc, MA (Hons), BA, RM, RGON Senior lecturera*, Elizabeth Smythe, PhD, BA, RM, RN, Professorb,
a
Midwifery Department School of Clinical Sciences, Auckland University of Technology, PB
92006 Wellesley St, Auckland, New Zealand. b
Professor, Associate Head School of Clinical Sciences, Auckland University of Technology,
PB 92006 Wellesley St, Auckland, New Zealand.
Senior Lecturer, School of Clinical Sciences, Auckland University of Technology, . PB
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c
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Deb Spence PhD, RM, RN, Senior Lecturerc
92006 Wellesley St, Auckland, New Zealand.
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*Corresponding Author: Marion Hunter [email protected]
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(1) Conflict of Interest: None declared
(2) Ethical Approval: Auckland University of Technology Ethics Committee 14/364
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(3) Funding Sources: Not Applicable
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Abstract
The aim of this study was to reveal what enables, safeguards and sustains midwives to provide labour care in freestanding midwifery-led units.
Design A hermeneutic phenomenological study was undertaken in the Auckland region of New Zealand. In-depth interviews were conducted with 14 participants: 11 midwives who provide care in freestanding midwifery-led units and three obstetricians who provide antenatal consultations on site in midwifery-led units. 1
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Main findings Confidence is necessary to provide intrapartum care in freestanding midwifery units. This confidence is cultivated by working in the community or freestanding unit and believing this unit is an appropriate space for healthy women to labour and birth. Normal labour and birth are commonplace in this space which in turn reinforces midwives‟ confidence. Maintaining confidence for midwives to work in these units requires trusting relationships in the
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midwifery team. Further, there needs to be mutually respectful relationships with obstetric colleagues. Midwives who have lesser experience, or experience in obstetric unit only, may need support to step into the role of providing labour care in freestanding midwifery units. When the midwife feels supported, when s/he witnesses women and families experiencing their normal birth, one‟s resolve to practising in this manner is strengthened. The midwife
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holds confidence.
Key conclusions and implications for practice
Confidence required to provide labour care in a midwifery-led unit is cultivated through
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immersion in these units.
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Key words: Freestanding midwifery unit, Primary unit, Birthcentre, intrapartum,
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hermeneutic phenomenological, confidence
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Introduction Outside the main cities of Aotearoa-New Zealand is a relatively sparsely populated land with 58,957 births recorded in 2015. This is equivalent to approximately five percent of births in England and Wales which has similar land mass. The maternity system in Aotearoa-New Zealand is state funded for eligible women, however, a minority of women pay fees for private obstetricians. The model is based on a Lead maternity carer who caseloads (with
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back-up) and is available for maternity services over twenty-four hours each day of the week. Midwives are lead maternity carers for over 85% of women (Ministry of Health, 2017) and these midwives have access rights to maternity units in their region. This study was
undertaken in the greater Auckland region, with a population of 1.66 million (Stats NZ). There are four large obstetric units (secondary/tertiary units) and seven freestanding
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midwifery-led units (primary units). Small maternity units have existed since the early 1900s in New Zealand, featuring in both urban and rural localities. While regionalisation of maternity services resulted in a decline in births in these units from 28% in 1982 to 10% in 2015 (Ministry of Health, 2017; Rosenblatt et al., 1985), the remaining freestanding
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midwifery/8-led units provide a unique space for the process of normal labour and birth to unfold (Smythe et al., 2016). Epidural analgesia assisted birth and caesarean operations are
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not available in these units. The National Maternity Monitoring group (2016) targeted the need for district health boards to provide primary maternity unit/s in each region. This strategy promotes options re choice of birthplace and supports usage of existing midwife-led
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units. Women of indigenous Māori ethnicity use primary units at almost double the rate of women of non- Māori ethnicities (Ministry of Health, 2017) indicating these units may be
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culturally acceptable. In New Zealand, along with other high-income countries, most births occur in obstetric units that exist for women with complications providing operative birth and
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neonatal intensive care facilities. Despite research evidence showing that births are safe in midwife-led units (Bailey, 2017; Birthplace in England Collaborative group 2011; Christensen and Overgaard, 2017; Davis et al.2011, Denham, Humphrey and Taylor 2017; Homer et al., 2014), the number of women using this space could be improved (Walsh et al 2018).
Safe outcomes are paramount for women, partners, families and for health professionals working in maternity care. Safety encompasses lack of harm in a multi-faceted manner. The philosophies underpinning practice, including effective working relationships and positive 3
ACCEPTED MANUSCRIPT outcomes appear to be fundamental in enabling midwives to practise in midwife-led units (Edmondson and Walker 2014; Helberget et al., 2016). Laws et al. (2011) found two philosophies were rated as very important by birth centre respondents; commitment to normality of pregnancy and birth and providing midwife-led care. There is a limited body of knowledge about how midwives work confidently in midwife-led units intrapartum. Rayment et al. (2015) suggested that not all midwives have the skills required to support normal birth, despite an assumption this is customary. In a similar manner, Stone (2012) suggested that
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midwives be trained to work in birthcentre settings because the context contrasts markedly with obstetric hospital labour wards. In midwife-led units, midwives pay attention to „softer‟ aspects such as the ambience, attention to privacy and reduction in light and noise (Davis and Homer, 2016). While all practising midwives might be subject to similar skills and guidelines for practice, „place‟ influences midwives. The space of birth is important to generate feelings
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of comfort, the passing of time. McCourt et al. (2016) described a midwifery-led unit as an enclave, a protected space, where midwives felt more relaxed and support is shared. When an environment is calm, midwives are calm and the combination is conducive to women having less analgesia and a more physiological birth (Foureur et al., 2010; Hunter, 2003). Birthing units are associated with increased autonomy for midwives, thus enabling midwives to
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practise „being with‟ women in this setting.
Methods Design
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A qualitative methodology was chosen to uncover what enables, safeguards and sustains midwives to provide labour care in midwife-led units from the midwives‟ and obstetricians‟
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perspectives. Hermeneutic phenomenology informed by Heidegger (1996) and Gadamer (2012) seeks to reveal meaning in text and language. Gadamer suggested transposing
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ourselves into the historical horizon; in order to understand another situation, we must place ourselves in it. Understandings become a scholarly endeavour and contributes to the hermeneutical situation through the examination of texts. The lead author came to this study with a history of working in both obstetric units and freestanding midwifery units in various roles (employed, community case-loading and educator). She was interviewed prior to commencing this study to surface pre-understandings influencing the project. To maintain rigour, these assumptions were challenged throughout the research process ensuring findings belonged to the meanings uncovered in the data and through the interpretive paradigm of hermeneutic phenomenology. 4
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Data collection Approval was gained from Auckland University of Technology Ethics Committee (14/364). Recruitment occurred through purposive sampling and snowballing; this is congruent with hermeneutic phenomenology whereby all participants have lived the experience (van Manen, 2014). Information was sent to managers of midwifery-led units inviting them to participate in the study and, to make information sheets available to midwives and obstetricians who
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worked in the unit. Interested participants contacted the researcher and a time for interview was arranged. Participants included four case-loading community midwives, seven employed midwives and three obstetricians; all participants provided services in the midwife-led unit. Participants chose a mutually agreeable venue for interview, for instance, a clinic room or midwifery unit. The lead researcher conducted all interviews. Prior to undertaking each
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interview, the consent form was signed, options were given regarding stopping the voice recorder and time commitments were noted. The interviewer sought to gather rich experiential narrative material as a resource for phenomenological reflection. The intention was to gain pre-reflective descriptive accounts from the participants, avoiding opinions and
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judgements (van Manen, 2014). Interviews began with the researcher (lead author) inviting participants to share how they came to work in the midwife-led unit. In keeping with hermeneutic phenomenology, the researcher then sought stories that stayed close to the
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experience of enabling a woman to labour in the unit. Prompting was used to ask “tell me more about that” or to encourage a participant to share another example about enabling a
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woman to commence labour in this unit. Interviews ranged from 30-70 minutes; most interviews were 45 minutes of recorded time. Interviews were transcribed verbatim by a
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transcriber; the lead researcher checked the transcripts for accuracy through listening to
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recordings and adding intonations or missed words.
Data Analysis Hermeneutic phenomenology requires uncovering meanings within the data. Analysis was undertaken through reading the entire transcript and focussing on stories within each transcript that answered the research question. Participants were given the opportunity to review their transcript. Once the participant gave permission to use their transcript, the researcher focussed on the process of „crafting stories‟ to answer the research question and eliciting meaning from the data (Crowther et al., 2016). In hermeneutic phenomenology, data analysis comprises the iterative processes of reading, writing, thinking and re-writing. 5
ACCEPTED MANUSCRIPT Crafting stories is inherent in methods associated with hermeneutic phenomenology and is argued to be part of the dialectic movement between methodology and methods (Crowther et al., 2016; Smythe et al., 2008; van Manen 2014). Smythe et al. (2008) suggested that we are often called by a particular story. It claims our attention because it seems to signal or point to something important. The hermeneutic circle or spiral entails reading, interpreting through writing, re-reading, re-writing further interpretations that seek to uncover taken for granted and/or hidden meanings (Spence 2016). Philosophical insights from Heidegger and Gadamer
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were used to uncover everydayness, to illuminate being-there as Dasein (Heidegger, 1996) in a midwife-led unit. Rigour was achieved through review of processes and findings with
colleagues at hermeneutic readings meetings, feedback from supervisors and presentation at local/national conferences.
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Findings
The following themes reveal how confidence is integral to providing intrapartum care. Stepping into Midwife-led units
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Lynn describes a „baptism of fire‟ that set her up for working in birthing units:
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My first night on call when I was a community midwife was an absolute baptism of fire; my first homebirth witness, then called out to my first homebirth myself. It was an amazing night. As a team midwife, you were able to practise unhindered, the midwives all had a very similar philosophy. It didn’t fill me with any worry working in this midwifery unit because it felt like going back to where I had the most job satisfaction ever working as a midwife. Lynn embraced this „baptism of fire‟ as building her confidence in community midwifery.
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These home births reinforced Lynn‟s penchant for practising „unhindered‟ freely and autonomously, without medical support. Lynn‟s positive experience in community midwifery
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drew her into midwifery-led units to work alongside colleagues with a similar philosophy.
Vivienne echoes the necessity for confidence as a rural lead maternity carer midwife: I think you’ve basically got to be quite confident, it would be difficult if you weren’t confident in your care, confident in how you work and practise as a midwife. And you’ve also got to have collegial support. I think those two things are really important.
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ACCEPTED MANUSCRIPT Vivienne believes it would be difficult for a midwife to conduct the role without confidence in your professional work. Moreover, collegial support is essential for midwives case-loading in rural practice.
Keeping Faith in the normal The following midwives shared their faith in the space of midwifery-led units as the right place for women to labour and birth:
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It is about the belief of what is normal and what women can do. It is the belief that it should be normal and it’s a life event and it’s a physiological thing. We know it doesn’t fall that way for all women but the majority it does. We are used to seeing that every day… we see the good outcomes and you don’t see that in a secondary/tertiary hospital Lynn
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With confidence, it goes right back to believing in our model of care that birthing is normal until proven otherwise…I feel we are the keepers of normal and if we are going to continue to do that, we have got to really work at it. It is like when you see so many normal babies that a baby that is not normal sticks out. It’s pretty much the same with birthing Dianne
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I came from this culture, it feels like the right place to be in your community…It is never boring here, it takes a lot of courage to work here especially if you are used to a large obstetric hospital…there's a faith I get from working here as a midwife Wanda
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I did time in this unit as a student midwife. I saw the benefits of looking after the women in your community and birthing them at the unit. I think the belief that birth is a normal process and it should be treated as normal …Robynne
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I think what gives me confidence to birth in this unit is I still have held on to that belief that birth is safe and is best served, a woman’s chance of having a normal birth is better in a small unit Mary
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Confidence entails phenomena of faith and hope such as belief held in normal birth; trust is required for the midwife‟s anticipation of „normal‟ birth. When a midwife‟s confidence is
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undermined, perhaps when „normal‟ birth does not play out, the faith and courage to provide labour care in a midwifery-led unit can be undermined. When Dianne says, „we are the keepers of normal‟, she signals that „we‟ hold confidence together. When one person‟s confidence is undermined the „we‟ gather around to restore the confidence keeping faith in „normal‟ birth in a midwifery-led unit. The obstetricians held similar faith in the midwiferyled unit as follows: It’s just a natural thing (midwifery units) to me in the way that you have primary medical centres. And there’s more and more research showing that it is safe for low 7
ACCEPTED MANUSCRIPT risk women. I’m very pro woman’s choice, so if that is what the woman wants and she’s low risk then, I would support her to birth in this environment (Obstetrician) I’ve never not thought (midwife-led) units were okay. Most women are supposed to have babies … (Obstetrician). The obstetricians in this study supported these freestanding midwifery units as an appropriate space for healthy women to labour referring to the growing body of research that confirms
preserving normal birth for healthy low-risk women.
The mood-of-unit
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safety. Thus, obstetricians who consult on-site for risk assessment may contribute to
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The mood or attunement is „felt-space‟ described by the following midwives:
It took me a while to adjust to the smallness of the unit, my colleagues said you are so far away with no back up, no one at the end of a bell....I was mentored extremely well. Diane
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I feel I can work primary here, I can call anyone into the room in the primary unit whereas I don’t feel that in the secondary hospital, I don’t feel as safe there. Kirstin Working in a small team of midwives and relying on the skills of the next midwife who
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comes into the room creates neighbourliness and homeliness in this space. The space enables for preservation of normal birth. The feeling within this space holds confidence steady.
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Building and Maintaining Confidence The following midwife describes working with a colleague in the midwife-led unit:
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I think that the more senior midwives have to provide support to new midwives. I like them to do hands on. I tell them I’m in the background and just recently, I said to this new midwife who I knew had not had a good experience, ‘Now I want you to look after this woman, I’m here’. I didn’t necessarily go into the room actually. I said, ‘I’m here, I want you to do this because you’re very capable of doing this but I’m here’. And if I’d had to go in to the room I would have gone in. Helenmary
The less experienced midwives need to do „hands on‟ intrapartum care and the experienced midwife encourages this by being-there in the background. Another midwife described how confidence could waver: I had an incident where I nearly did lose my confidence (in a large hospital)…afterwards, the obstetrician said to me ‘I want you to know that 8
ACCEPTED MANUSCRIPT nothing you did there was wrong, everything you did was absolutely fine’. And I thanked the obstetrician for telling me that. I said, ‘what will happen if this happens to me in a birthing unit’? The obstetrician said, ‘nothing would have happened. All you would have done is got a couple of lines in, you would have followed the transfer guideline and we would have just dealt with it here and it would have been fine’. And that was really good for me. A senior midwife said the same thing to me. Now I think enough time has elapsed that got me through the hump where I lost confidence. I was shaky and now …I think philosophically I am just a birthing unit person. Mary
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Confidence fluctuates. It can be lost, diminished or strengthened. Obstetricians and senior midwives contribute to building, maintaining and restoring confidence. In this case, the
astuteness of the obstetrician in debriefing with the midwife reassured her. The midwife felt confident that she would do the right thing if a similar situation arose in the isolated midwife-
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led unit.
Working as a team
The isolation of a freestanding midwife-led unit may, in itself, foster working as a team. An obstetrician describes how important it is to know each other:
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We are unique in that we know the LMCs (Lead Maternity Carers), we know the core midwives, we know women are going to be followed up with a scan or blood pressure checks, I know who that is. It’s not just a random name in the ether that might not do that. I know the midwives will ring if there is a problem, so I try to tell the registrars that we have got a unique little family here. They have got good leadership and they have got the support of the obstetric clinic. (Obstetrician)
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The obstetrician likens the team to a “unique little family” with a knowing of one another. This obstetrician trusts that problems are followed up. The midwife is a known person, not
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some random name that might disappear like ether. The relating with the midwives in the unit expands to fostering good relationships with those working in the obstetric led hospital. When a midwife feels known and trusted by her obstetric colleagues, her confidence is
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affirmed. Maintaining the midwife‟s confidence is circular. The midwife needs confidence in self, confidence in colleagues, effective relations with the consulting obstetrician in the midwife-led unit and with those working in the obstetric hospital. Each of these threads are woven together with bonds of trust.
Discussion
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ACCEPTED MANUSCRIPT There is no one thing that breeds confidence, rather a synergistic combination of many factors. Rotenstreich (1972) described the concept of confidence as trust, hope, faith (not defined by religious faith), a certain disposition, an opinion that things will turn out satisfactorily. Yet, confidence can bring disappointment when the future does not turn out as anticipated; the unexpected deviation from „normal‟ might bring disappointment with an accompanying loss of confidence. The congruence of the midwives‟ philosophy of fostering normal birth appears fundamental to enabling confident practise in midwifery-led units and
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supporting one another. Further, Heidegger (1996) described Fursörge as a mode of care encountering the other, leaping ahead as authentic care entails anticipatory thinking, concern and nurturing that lets the other „be‟. In contrast, when a senior midwife „leaps in‟, s/he takes care away from the other by taking over. In leaping ahead, an experienced or mentor midwife frees the less experienced midwife to practise labour care, to develop „selfhood‟ (Stolorow,
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2014) and thus develop one‟s confidence. Building confidence in others is a manner of teaching whereby the teacher is called upon to withdraw and learn to let them learn
(Heidegger, 1976). Teaching or mentoring appears to cement confidence in the experienced midwife and in turn, assists less confident midwives to learn through „doing‟ and
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encouragement.
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New midwives learn that although the unit is small, there is something about being known and knowing others that builds a strong and supportive team. McCourt and Stevens (2009) confirmed the importance of community case loading midwives forming supportive
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relationship with women and colleagues; the community midwives described a greater confidence in their clinical judgement and assertiveness to initiate referral when required. In
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our study, the dwelling space of midwifery units fosters neighbourliness and the mood-ofunit is “to cherish and protect, to preserve and care for” (Heidegger, 1976, p.349); the space
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enables trusting relationships. In such a way, the midwives, midwife managers and obstetricians who consult in these units hold confidence in everyone in their unit. Confident midwives are able to support a woman‟s confidence in her ability to labour and birth in a midwifery-led unit.
Stepping into midwifery-led unit requires having the confidence that things will turn out satisfactorily. In this current study, midwives expressed keeping faith in normal that is reinforced by normal birth playing out in most situations. Similarly, Aune et al. (2017) emphasised attitudes of homebirth midwives included believing, trusting and daring to have 10
ACCEPTED MANUSCRIPT faith in normal birth. Gilkison et al. (2018) reported that rural midwives in Scotland and New Zealand require courage, fortitude and confidence in their decision-making. Bedwell et al. (2015) found that midwives‟ confidence is dependent upon the environment, with one midwife stating she needed a year of working in the midwife-led unit before becoming confident that women could give birth normally. It took her a year to change her stance from a problematic approach to a birth as-normal approach during labour care. Bedwell et al. noted that some midwives expressed lack of confidence in low-technology environments after
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working in high-technology units that adopt a technocratic model. In contrast, positive
outcomes from midwives‟ work affirms the value of women labouring in birthing units
(Edmondson and Walker, 2014; Helberget et al., 2016; Laws et al., 2011). The mood-of-unit describes felt-space wherein midwives hold confidence to preserve normal birth. This finding supports the work that reports the influence of oxytocin on a person‟s emotional and social
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behaviour (Hammond et al., 2013; Mondy et al., 2016). When midwives perceive the
birthplace as calm, supportive and friendly, oxytocin is released; the environment enhances connectedness to colleagues and women.
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When the place/space of birth engenders homeliness, midwives described building and maintaining confidence in self and others in their team. Carolan-Olah et al. (2015)
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acknowledged support from other staff, particularly the midwife in charge, as enabling junior midwives to develop skills and confidence to facilitate normal birth. Some doctors are reported to have a lack of trust in normal birth as they only see the birthing process „go
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wrong‟ and use unnecessary obstetric procedures for healthy women (Antannasio and Kozhimannil 2017; Carlson and Lowe 2014; Carolyn-Olah et al., 2015). In the current study,
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the obstetricians contributed toward debriefing, reassuring and uplifting the midwives‟ confidence in providing labour care in midwifery-led units. Additonally, obstetricians in our
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study revealed belief in normal birth in midwifery-led units, provided on-site consultation for „risk‟ according to the national referral guidelines (Ministry of Health, 2012) and bolstered the confidence of midwives working in these units. This is in contrast to common held assumptions, perhaps arising from an era when their voices were strong in favour of closing such units (Donley 1998). McCourt et al. (2014) ethnographic study of alongside midwifery units noted that most obsetricians supported these units, however, some did not have confidence in midwife care except for individual midwives who were known and trusted.
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ACCEPTED MANUSCRIPT The perplexing question is whether experience in large hospitals where midwives gain skills related to a wide range of complications, helps or hinders the preparation of midwives to practise in low technology midwife-led units? Rogers et al. (2015) remarked on midwives‟ astonishment upon learning that the Birthplace in England Collaborative group findings (2011) were contrary to media reports that negated positive aspects of birthcentre care. Moreover, Rogers et al. noted that midwives had difficulty accepting new evidence that challenges previously held beliefs, including that birth centres are safe, if not safer, than
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obstetric units for healthy women. Midwives need to be fully informed of the significant difference in interventions in obstetric units compared with midwifery-led units and the ongoing effects for women after caesarean and operative births. In the current study, a midwife and obstetrician referred to research depicting better outcomes for women in
midwifery units as affirming their view of safety. Midwives may have some influence of
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women and their partners regarding their choice of birthplace (Borrelli et al., 2017; Henshall et al., 2018). It is imperative that midwives relay evidence-based information to consumers.
Sloman et al. (2016) researched midwives‟ experience of breech birth. While this is not
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specific to midwifery-led units, the authors showed that lack of a particular experience translated into lack of confidence. While confidence is linked with competence (Bäck et al.,
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2017; Calvert et al., 2017; Urbute et al., 2017), one must be cautious assuming that competence only arises from extensive experience in high-technology obstetric hospitals. Midwives with extensive experience in obstetric units only, may find it more difficult to gain
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the confidence necessary to support women intrapartum in freestanding midwifery-led units.
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Rotenstreich (1972) suggested that the philosophy of confidence implies reliance or dependence and referred to the philosopher, Aristotle, who placed “the brave man [sic]
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between the two poles of fear and confidence” (p.348). Taking this philosophy to a midwifery context, one might imagine that the midwife is placed between the poles of fear and confidence as s/he provides intrapartum care. The balancing of an appropriate confidence within its proper limits is confidence-as-conviction. Is it possible that the pole of fear prevents some midwives from practising in midwifery-led units? Safe practice in midwiferyled units is captured in the nuance of confidence whereby the practitioner knows the right thing to do. Furthermore, practitioners know that it is fear that prompts them to take action to keep things safe. When safety is maintained, confidence flourishes.
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ACCEPTED MANUSCRIPT Strengths and Limitations The strengths of this study include the congruence between the research question, methodology and methods. Participants included midwives and obstetricians therefore different perspectives were gathered. The process of data collection and analysis occurred over 14 months ensuring that understandings were developed in a dwelling-with-and-between manner. This study is limited to the experience of 14 participants who work within freestanding midwifery units in the greater Auckland region. These participants might be
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unique in that they felt enabled and confident to keep providing labour care. In keeping with hermeneutic phenomenology, there is no claim of transferring findings. The aim is to raise questions, stimulate thinking and ponder possible answers. While steps have been taken to ensure rigour, the interpretations are always a fusion of horizons (Gadamer, 2012) with those
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of the researcher and participants.
Conclusion
Confidence is integral to midwives providing intrapartum care, including practising in freestanding midwifery-led units. A midwife‟s belief in normal birth might emerge from
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immersion in community practice that develops a sense of self-reliance for the „now‟ and future. Growing of confidence comprises trust, disposition of self, alongside support from colleagues. Midwives and obstetricians acknowledge the power of the woman to choose
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labour and birth in a midwife-led unit. The woman‟s faith and confidence likely heighten the midwife‟s confidence as being the „keeper of normal birth‟. There appears to be regeneration
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of confidence by the interplay of having faith, believing and, expecting physiological birth and it playing out in its normality. The authors drew from Heideggerian notions of
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temporality and mood to reveal the interrelated complexity and often hidden dimensions of such confidence in the context of midwifery practice in freestanding midwifery-led units.
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While the current study focused on freestanding midwifery-led units, we understand that the need for confidence is not unique to working in these units. Further work could be undertaken to explore how midwives‟ professional confidence is, or is not built when working in obstetric units and whether obstetric unit experience assists midwives to practise intrapartum care in midwifery-led units. „Confidence-as-conviction‟ is the judicious balancing of fear with confidence that keeps labour and birth safe in these freestanding midwifery units.
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ACCEPTED MANUSCRIPT Acknowledgements Confidence: fundamental to midwives providing labour care in freestanding midwifery-led units
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The authors wish to thank the midwives and obstetricians who participated in this study.
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