- Email: [email protected]
Midwives’ experiences of becoming CenteringPregnancy facilitators: A pilot study in Sydney, Australia
Women and Birth 26 (2013) e31–e36
Contents lists available at SciVerse ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Midwives’ experiences of becoming CenteringPregnancy facilitators: A pilot study in Sydney, Australia Alison Teate, Nicky Leap, Caroline S.E. Homer * Centre for Midwifery, Child and Family Health, University of Technology Sydney, Broadway, NSW, Australia
A R T I C L E I N F O
Article history: Received 11 March 2012 Received in revised form 29 July 2012 Accepted 6 August 2012 Keywords: Pregnancy Group care CenteringPregnancy Prenatal care Midwifery
A B S T R A C T
\Background: A pilot study was undertaken between 2006 and 2008 to explore the feasibility of implementing the CenteringPregnancy model of group antenatal care in Australia. The study was undertaken at two hospital antenatal clinics and two community healthcare centres in southern Sydney. This paper reports on one arm of the pilot study, known as the ‘Midwives’ Study’, which aimed to explore the experiences of the midwives as they moved from providing traditional one-to-one antenatal care to facilitating group antenatal care. Methods: The Australian pilot study used Action Research. Eight midwives, the group facilitators, and three researchers formed the Action Research group. A qualitative descriptive approach was undertaken to describe the experiences of the midwives. Data were collected using focus groups, surveys and checklists and analysed using thematic content analysis. Findings: The midwives’ initial fears and misgivings about undertaking the new role of group antenatal care gave way to a growing confidence in their abilities and group facilitation skills. They appreciated: the benefits of the CenteringPregnancy model for pregnant women; new opportunities to develop positive relationships with women and their colleagues; and the structured support and education throughout all stages of the Action Research process. Conclusion: The midwives were enthusiastic about their experiences of becoming CenteringPregnancy facilitators and described the benefits of this model of care compared to traditional one-to-one antenatal care. Support and education of the midwives through structured Action Research cycles enhanced the effective implementation of this new model. ß 2012 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction In most high-income countries, such as Australia, antenatal care consists of a scheduled program of individual consultations. Group antenatal care takes a different approach combining social support from peers and trained facilitators with the traditional elements of care and education.1 In the United States of America (USA), this model, known as ‘CenteringPregnancy’, has existed for the past decade.1,2 Antenatal care is provided in small groups of 8–12 women with a midwife or doctor specially trained in group facilitation and a co-facilitator. Women of a similar gestational age join a CenteringPregnancy group after their initial one-to-one ‘booking’ appointment and receive the rest of their antenatal care within that group. CenteringPregnancy is founded on a set of core
* Corresponding author at: Centre for Midwifery, Child and Family Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2009, Australia. Tel.: +61 2 9514 4886; fax: +61 2 9514 4835. E-mail address: [email protected] (Caroline S.E. Homer).
concepts known as the ‘Essential Elements of CenteringPregnancy’ (see Fig. 1).2 These elements provide a framework for the groups and are necessary to ensure model fidelity. CenteringPregnancy has been widely implemented and evaluated in North America1,3,4,5,6,7,8 and more recently in Australia,9 the United Kingdom10 and Sweden.11 Based on the promotion of social support and communication, the model enables more time to be spent with the antenatal care provider compared with one-to-one care, with opportunities for information sharing and for learning from, and supporting, one another.6 Two randomised controlled trials of CenteringPregnancy care have been undertaken. The first (n = 1047) demonstrated that women in group care were significantly less likely to have preterm births compared with those who received standard care (9.8% vs. 13.8%; OR 0.67, 95% CI 0.44–0.98) and had higher rates of breastfeeding and satisfaction with care.4 The second trial (n = 322) found that the group model was effective in meeting pregnant women’s needs in a military setting, where it is acknowledged that women personnel and partners of military personnel are often isolated.12 Women in military settings
1871-5192/$ – see front matter ß 2012 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. http://dx.doi.org/10.1016/j.wombi.2012.08.002
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A. Teate et al. / Women and Birth 26 (2013) e31–e36
•
Health assessment occurs within the group space
•
Women are involved in self-care activities
•
There is stability of group leadership
•
A facilitative leadership style is used
•
Each session has an overall plan
•
Attention is given to core content; emphasis may vary
•
The group conduct honours the contribution of each member
•
The group is conducted in a circle and group size is optimal to promote the process
•
The composition of the group is stable, but not rigid
•
Involvement of family support people is optional
•
Group members are offered time to socialise
•
There is on-going evaluation of outcomes Fig. 1. Essential elements of CenteringPregnancy.2
2. Methods
stages made-up the first action cycle. These were: the ‘Development’ of the model to meet the appropriate requirements of the setting; the provision of ‘Information’ about the model to staff at both hospitals; and the ‘Education’ strategies undertaken to enable the midwives to learn about CenteringPregnancy and gain group facilitation skills. The nine subsequent action cycles took place during the ‘Implementation’ of the groups at the five clinic settings. Each of these nine cycles involved the delivery of a CenteringPregnancy group preceded by a Facilitator Meeting. At the Facilitator Meeting, the midwife facilitators and the researchers who formed the Action Research group engaged in a process of reflecting on previous experiences to inform structured planning for the next session. The researchers provided education and skills development activities at each Facilitator Meeting. Specific activities were also introduced in accordance with the CenteringPregnancy framework.
2.1. Setting and participants
3. Data collection
experienced a sense of community in their groups and gained knowledge and power as healthcare consumers. Other nonrandomised studies have demonstrated reductions in social isolation, prematurity, low birth weights and improvements in women’s social and emotional outcomes.3,5,13 Despite these studies, there is very little written about the experiences of midwives and others who facilitate CenteringPregnancy groups. The Australian CenteringPregnancy Pilot Study was conducted in Sydney in 2006–2008 to explore the feasibility of implementing group antenatal care in Australia.9 This paper reports on one arm of the Pilot Study, known as the ‘Midwives’ Study’ which aimed to explore the experiences of the midwives who undertook the new role of group facilitator. Ethical approval for the study was obtained from the area health service and university.
The study was conducted in three antenatal clinics and two community health centres as part of antenatal care provided by two public maternity services in southern Sydney. Eight midwives, all of whom were experienced in providing traditional antenatal care, participated in the study and facilitated the groups. With the researchers, they formed the Action Research group.
The three forms of data collection in the Midwives’ Study were: Pre-study and post-study self-reported surveys Checklists completed after each of the eight CenteringPregnancy group sessions A focus group after all the group sessions had been completed
2.2. Methodological approaches A qualitative design based on two methodological approaches: Qualitative Description and Action Research, was used. Qualitative Description was used to gain an understanding of the midwives’ experiences of providing group antenatal care for the first time. This approach enabled an understanding of the changes experienced by the midwives14 and the collection of a broad selection of data offered an ‘everyday’ description of their experience.15 Action Research provided an iterative framework for the overarching pilot study within which the Midwives’ Study was embedded. A structured, cyclical process of Action Research occurred throughout data collection and analysis, with evaluation, enquiry and action incorporated as integral parts of each action cycle.16,17 Fig. 2 depicts the overall design of the pilot study and the 10 action research cycles, each of which used a process of ‘Reflect, Plan, Act and Observe’, consistent with action research methodology.16,17 The study was divided into four major stages: Development, Information, Education, and Implementation. The first three
3.1. Pre-study and post-study surveys The self-reported pre- and post-study surveys were designed to explore the preconceptions and post-study perceptions of the midwife participants regarding group antenatal care. The content of the two surveys was essentially the same except that the prestudy survey had three additional questions about the midwife’s professional and clinical experience and current role. 3.2. Checklists After each Centering Pregnancy group session, the midwives completed a checklist that explored: their group facilitation skills; the highlights, challenges and issues that had arisen in the session; their perceptions of how facilitative or didactic they had been; how involved they felt the women had been; and their confidence levels. These checklists were used in the Facilitator Meetings to inform each of the Action Research cycles and to plan the Centering
A. Teate et al. / Women and Birth 26 (2013) e31–e36
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Fig. 2. Action Research design.
Pregnancy sessions. Field notes were also made by the researchers each of the Facilitator Meetings. 3.4. Analysis 3.3. Focus groups Focus groups are an important method of data collection for Action Research and aim to facilitate the sharing of experiences, attitudes and opinions between participants.17,18 The focus group was held two weeks after the last Centering Pregnancy group session. Six of the eight facilitators attended the discussion which was audio-recorded and transcribed verbatim. Structured questions guided the focus group.19These were: Why were you interested in being involved in the CenteringPregnancy study? How did you find your experience of learning to facilitate? Working in the CenteringPregnancy model – what are your views feelings/comments? What are your suggestions for future practice?
A simple thematic analysis was used to analyse the pre- and post survey and the checklists. A more structured thematic analysis was used to analyse the focus group data; this involved reading and exploring the similar concepts and meanings and then grouping them together.20 These groups of meaning statements became a meaning unit. Meaning units were then grouped together and became codes. Further analysis of the codes resulted in categories and eventually an overarching theme. The findings from the surveys, checklists and focus group were then synthesised in order to identify patterns and summarise overall findings. 4. Findings The professional experience of the midwives ranged from 1 to 15 years, with most having more than seven years of experience.
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Fig. 3. Theme and codes from the focus group.
Two midwives worked predominantly in the antenatal clinic, two held clinical educator positions and two worked between the antenatal clinic and the birth suite providing antenatal care in a midwives’ clinic. The final two provided midwifery continuity of care in a team midwifery program. 4.1. Survey findings Before the study, midwives were positive about the concept of group antenatal care and believed it would be a ‘rewarding’ experience for women. After facilitating eight group sessions they were convinced that Centering Pregnancy ‘. . . improves support, community and networking’ which was important. For the most part, CenteringPregnancy was described as a rewarding way to work and decreased the repetition of individualised antenatal care. There were, however, some negative comments related to the time required to implement and develop the model. This included, ‘difficulties with rostering’and how planning was ‘a very tiring process for the midwife’. Actually facilitating a group allayed initial concerns, particularly about undertaking the antenatal assessment in the group setting, managing the group processes and facilitating the group discussions. The midwives felt they developed confidence in skills related to group facilitation, for example, their ability to: ‘throw things back to the group – not talk too much myself’. Open-ended questions in the surveys asked about the midwives’ highlights and challenges. The participants were positive about learning new skills and developing relationships with each other. They appreciated being able to share with like-minded and respected colleagues learning new skills: ‘watching my cofacilitator develop’, ‘gaining confidence to facilitate a group’ and ‘being a part of something new and exciting’. The midwives valued the relationships they were able to develop with the women by providing continuity of care through pregnancy: ‘getting to know the women’. They observed the women developing self-confidence and supportive relationships: ‘watching
the women get to know each other and support each other’. They felt this led to ‘long-term support after the birth and a decrease in the need for postnatal care and the loneliness for the women’. 4.2. Findings informed by the checklists The checklists were analysed prior to each Facilitator Meeting. These findings, together with the field notes that were made by the researchers, informed the content and learning topics for the subsequent Facilitator Meeting. The checklists were used predominantly to inform the Action Research element of the over-arching pilot study but they were useful in identifying the growing confidence of the midwives as they experienced group facilitation. 4.3. Focus groups findings The principal theme to arise from the analysis of the focus groups was: ‘Building and maintaining relationships’; this was developed from seven codes: ‘Getting involved’, ‘Giving it a go’, ‘Getting prepared’ ‘Becoming a facilitator’, ‘Meeting together’, ‘Trusting Centering Pregnancy’ and ‘Creating communities and connections’ (Fig. 3). 4.3.1. Getting involved The midwives talked about the process of ‘getting involved’, which for most was not voluntary: ‘I wouldn’t say we initially volunteered for it. We were sent to the two-day workshop. We volunteered after that. We had no understanding of what we were going to do’. One midwife identified the importance of having information about CenteringPregnancy before getting involved: ‘Initially I think, a little bit more explanation about what you are actually getting into would be [have been] good, because I really didn’t have any idea.’
A. Teate et al. / Women and Birth 26 (2013) e31–e36
Once the midwives gained an understanding of CenteringPregnancy they engaged positively and were attracted to the philosophy, for example: ‘. . .it’s a wonderful opportunity [for pregnant women] to meet others who are doing the same thing at the same time, to learn from one another and make lifelong friends. . . also a wonderful opportunity to be able to develop your skills in a group’. 4.3.2. Giving it a go ‘Giving it a go’, reflected the air of optimism and hope in the early stages of implementation. Despite their initial reservations, the midwives reflected on embracing the new model positively: ‘It was worth giving it a go. I was willing to try, because you can’t knock something if you haven’t done it’. The midwives wanted to ‘give it a go’ and were positive about the benefits of group care, but they also acknowledged being ‘overwhelmed’ at times. The process of development and implementation of this new model required a great deal of work, time and commitment: ‘Yeah, volunteering the amount of time and energy that would be expected. I didn’t appreciate that’. The midwives were challenged by the process of recruiting women to a model of care that they could not recommend from personal experience: ‘Now I would be able to say it is a great way of actually gaining all their knowledge, developing relationships and a sense of community’. Resistance from colleagues was sometimes described as a negative and confronting experience but this negativity often decreased once colleagues had ‘given it a go’. One midwife who had her colleagues rotate into the co-facilitator role said, ‘after they did a group, they’re like ‘‘This is fabulous!’’[It] totally changed their mindset’. 4.3.3. Getting prepared The importance of ‘getting prepared’ was highlighted. Information sharing about group facilitation was key to gaining confidence. This was linked to the logistics of organising group sessions, such as choosing an appropriate group venue: ‘After the first session we knew we had to move the venue and then once we moved into a bigger venue it just was great’. 4.3.4. Becoming a facilitator The midwives initially found it difficult to ‘trust the process’ of group facilitation: ‘Just practising being a facilitator was very difficult’. They were worried that the women might not readily discuss issues: ‘I was really scared that I wouldn’t have enough information, as in enough prepared, in case they didn’t talk’. After gaining experience with facilitation, the midwives learnt to have faith in the flow of group discussions: ‘It’s hard to learn that facilitator role, like, you know, sometimes you did just want to give the answer, but if you waited, then the women themselves would give the response’. Personal satisfaction with group facilitation skills was reinforced by seeing their group communicating effectively and working together: ‘It was mind-blowing just how much I could just sit back and allow the group to run itself and there was no pressure, it was just easy to facilitate this group. . .’. The process of change and personal growth was described with enthusiasm: ‘I have gained more confidence in myself, in my practice and in what I do know and I don’t doubt myself anymore’. This appreciation extended to their perceptions of their co-facilitators: ‘She just grew. . . it was really fantastic and she could do anything now. I mean she is a really good midwife and has a lot of knowledge, but she just blossomed’. 4.3.5. Meeting together It was important to ‘meet together’ regularly throughout the study. This included the initial CenteringPregnancy ‘Group Skills’ workshops, planning meetings, Facilitator Meetings and extra
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planning and de-briefing meetings with their co-facilitators. They valued coming together as a group to discuss concerns, share experiences and plan for each group session, for example, ‘It was drummed into us at the beginning that it was to be a facilitative process and that we had to sort of throw it back to the group. So we actually got really good at it’. 4.3.6. Trusting CenteringPregnancy In the early days the midwives’ main area of concern was the antenatal assessment component of the model; this was expected to be a focussed process on a mat in the group room just outside of the group circle, with approximately three minutes allocated for individual assessment – abdominal palpation, fundal height measurement, and identification of wellbeing for the woman and her baby. The idea behind this feature is that all discussion and information sharing can take place in the group so that everyone is able to contribute: ‘My issues about the group initially were that I had this thing about this three minute check’. The midwives had a sense that their role as a competent midwife was built on effective oneto-one communication with individual women and not ‘dealing with a group of people. Never done anything like that before. I’m fine with one-on-one but, get a group together and I go to jelly’. As they engaged in ‘Trusting CenteringPregnancy’, the midwives valued the model and their new role in terms of understanding the benefits for women, particularly the educational component of the model: ‘. . . they said they actually got more than when they went to the childbirth classes’; and, ‘I’ve actually had a turnaround with my philosophy with childbirth education; it has completely changed’. 4.3.7. Creating communities and connections ‘Creating communities and connections’ describes how the midwives experienced CenteringPregnancy as a worthwhile journey, enabling them to develop stronger relationships with their peers and the women. This gave them immense job satisfaction: ‘it was rewarding. . . I just enjoyed it immensely’. The midwives described the benefits for midwives, students, pregnant women and their partners in terms of the connections that are fostered: ‘In the end it wasn’t about the education it was about the connection and that connection is really important’. The midwives suggested that students and newly graduated midwives could provide group antenatal care, believing that an understanding of the model and principles of CenteringPregnancy was more important than years of experience in midwifery. A newly qualified midwife reinforced this saying: ‘At the beginning I was ‘absolutely petrified’. Now I feel so much more confident as a midwife. I have learnt so much. It didn’t matter how junior I was to the rest of my colleagues who were also a part of it. You’ve created a relationship with them and we had fun you know, we laughed’. When comparing with standard antenatal care, the midwives thought that CenteringPregnancy provided more learning opportunities for women and a more meaningful way of working for midwives: ‘. . . I worked in Antenatal Clinic for three months. Back then, it just struck me that it was such a waste of time. These poor women would come and sit around for hours, waiting and then they would be seen for five minutes and the person seeing them wouldn’t even know their name.’ An unexpected benefit was that, after being exposed to the opportunity to develop relationships with women in the groups, the midwives found that they were eager to explore how they might provide continuity of care through pregnancy, labour and birth and the postnatal period. The midwives suggested that, ultimately, it was the time and space that the group environment provided women that was most important: ‘And maybe that is actually even more valuable than what we did. The time gave them time to develop a network, which is something that women really struggle with in our community.’
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A. Teate et al. / Women and Birth 26 (2013) e31–e36
4.3.8. Summary of findings Analysis of the data showed that the midwives’ initial fears and misgivings about this new role as a CenteringPregnancy group facilitator had given way to a new confidence in their abilities and skills. The demands placed on the midwives during the implementation phase did impact on their usual work practices and increased their workload. These challenges were, however, offset by their appreciation of: ongoing and structured support provided throughout all stages of the Action Research process; the opportunity to gain new skills; and the development of positive relationships with both women and colleagues. 5. Discussion The Midwives’ Study aimed to describe the experiences of the midwives involved with the implementation of the first CenteringPregnancy groups in Australia. There are few studies about the experience of midwives’ who provide care on an individual basis or within groups.21 Midwifery care is recognised as being deeply rooted in providing one-to-one care to women and the epitome is to develop a trusting relationship between the midwife and the woman through continuity of care through pregnancy, labour and the early postnatal period.22–25 Although the midwives in this study were not providing intrapartum or postnatal care, CenteringPregnancy meant they could provide antenatal care in a way which gave them the opportunity to develop relationships with women and colleagues. This can be explained by the philosophy and structure of CenteringPregnancy, including consistent facilitation which enabled an awareness of women’s individual lives and fostered a sense of knowing in the group.6 As described by the midwives in this study, valuable connectivity can occur where women have time to share their ideas, stories and expertise in a group setting.6,23 The Action Research group played a significant role in providing a framework for supporting the midwives to become confident and effective group facilitators. Peer support and the opportunity to enhance confidence through learning are significant factors in professional and organisational change.26 The Facilitator Meetings provided a forum where they could explore the demanding challenges of undertaking a new model of care on top of their usual clinical role; the resistance they encountered from some colleagues; and their fears about group facilitation. Action Research can be particularly useful when implementing new projects in health care as its approach is problem focused, context specific, participative, involves change intervention and is based in a continuous interaction between research, action, reflection and evaluation.16,17 Through the regular Action Research group meetings the midwives felt valued and supported by their peers in a time of transition; these are known factors that improve job satisfaction for midwives and it has been suggested that adequate resources need to be in place for professional development and support initiatives to foster sustainability.26–29 6. Conclusion This small study adds to the increasing body of knowledge about CenteringPregnancy and group antenatal care. The midwives’ initial fears and misgivings about undertaking the new role of group antenatal care gave way to a growing confidence in their abilities and group facilitation skills. They appreciated: the benefits
of the CenteringPregnancy model for pregnant women; new opportunities to develop positive relationships with women and their colleagues; and the structured support and education initiatives throughout all stages of the Action Research process. References 1. Rising S, Powell Kennedy H, Klima C. Redesigning prenatal care through CenteringPregnancy. Journal of Midwifery and Women’s Health 2004;49(5):398–404. 2. Rising S. CenteringPregnancy: an interdisciplinary model of empowerment. Journal of Nurse-Midwifery 1998;43(1):46–54. 3. Ickovics J, Kershaw T, Westdahl C, Rising S, Klima C, Reynolds H, et al. Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obsterics & Gynecology 2003;102(5):1051–7. 4. Ickovics J, Kershaw T, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics & Gynecology 2007;110(2 Pt 1):330–9. 5. Klima C. CenteringPregnancy: a model for pregnant adolescents. Journal of Midwifery and Women’s Health 2003;48(3):220–5. 6. Massey Z, Rising S, Ickovics J. CenteringPregnancy group prenatal care: promoting relationship-centered care. JOGNN – Journal of Obstetric Gynecologic & Neonatal Nursing 2006;35(2):286–94. 7. Baldwin K. Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care. Journal of Midwifery & Women’s Health 2006;(51):4. 8. Baldwin K, Phillips G. Voices along the journey: midwives perceptions of implementing the CenteringPregnancy model of prenatal care. The Journal of Perinatal Education 2011;20(4):210–7. 9. Teate A, Leap N, Rising S, Homer CSE. Women’s experiences of group antenatal care in Australia – The CenteringPregnancy Pilot Study. Midwifery 2011;27(2):138–45. 10. Gaudion A. Findings from a UK feasibility study of the CenteringPregnancy model. British Journal of Midwifery 2010;19(12):796–802. 11. Wedin K, Molin J, Svalenius E. Group antenatal care: new pedagogic method for antenatal care – a pilot study. Midwifery 2010;26(4):389–93. 12. Kennedy H, Farrell T, Paden R, Hill S, Jolivet R, Willetts J, et al. ‘‘I wasn’t the only one’’: Women’s experience of group prenatal care in the military. Journal of Midwifery & Women’s Health 2009;54(3):176–83. 13. Grady M, Bloom K. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. Journal of Midwifery and Women’s Health 2004;49(5):412–20. 14. Creswell J. Research design: qualitative, quantitative and mixed method approaches. 2nd ed. London: Sage; 2002. 15. Sandelowski M. Using qualitative research. Qualitative Health Research 2004;14(10):1366–86. 16. Reason P, Bradbury H, editors. Handbook of action research. 4th ed. London: Sage; 2006. 17. Somekh B. Action Research: a methodology for change and development. Glasgow: Open University Press; 2006. 18. Hansen E. Successful qualitative health research: a practical introduction. Sydney: Allen and Unwin; 2006. 19. Burns N, Grove S. The practice of nursing research: conduct, critique, and utilization. 5th ed. St. Louis: Elsevier Saunders; 2005. 20. Graneheim U, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 2004;24(2):105–12. 21. Hunter B. Emotion work in midwifery: a review of current knowledge. Journal of Advanced Nursing 2001;34(4):436–44. ´ lafsdo´ttir O ´ ., Kirkham M. Relationships: the 22. Hunter B, Berg M, Lundgren I, O hidden threads in the tapestry of maternity care. Midwifery 2008;24(2):132–7. 23. Leap N. The less we do the more we give. In: Kirkham M, editor. The midwife– mother relationship. 2nd ed. London: Palgrave Macmillan; 2010. [Chapter 2]. 24. Stevens T, McCourt C. Changing practice. One-to-one midwifery practice. Part 3: meaning for midwives. British Journal of Midwifery 2002;10(2):111–5. 25. Homer C, Brodie P, Leap N, editors. Midwifery continuity of care: a practical guide. Sydney: Elsevier; 2008. 26. Ball L, Curtis P, Kirkham M. Why do midwives leave?London: Royal College of Midwives; 2002. 27. Kirkham M, Morgan R, Davies C. Why do midwives stay?Sheffield: Women’s Informed Childbearing and Health Research Group: University of Sheffield; 2006. 28. Sullivan K, Lock L, Homer C. Factors that contribute to midwives staying in midwifery a study in one Area Health Service in New South Wales, vol. 27. Australia: Midwifery; 2011. pp. 331–335. 29. Kirkham M, Stapleton H. Midwives’ support needs as childbirth changes. Journal of Advanced Nursing 2000;32(2):465–72.
Contents lists available at SciVerse ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Midwives’ experiences of becoming CenteringPregnancy facilitators: A pilot study in Sydney, Australia Alison Teate, Nicky Leap, Caroline S.E. Homer * Centre for Midwifery, Child and Family Health, University of Technology Sydney, Broadway, NSW, Australia
A R T I C L E I N F O
Article history: Received 11 March 2012 Received in revised form 29 July 2012 Accepted 6 August 2012 Keywords: Pregnancy Group care CenteringPregnancy Prenatal care Midwifery
A B S T R A C T
\Background: A pilot study was undertaken between 2006 and 2008 to explore the feasibility of implementing the CenteringPregnancy model of group antenatal care in Australia. The study was undertaken at two hospital antenatal clinics and two community healthcare centres in southern Sydney. This paper reports on one arm of the pilot study, known as the ‘Midwives’ Study’, which aimed to explore the experiences of the midwives as they moved from providing traditional one-to-one antenatal care to facilitating group antenatal care. Methods: The Australian pilot study used Action Research. Eight midwives, the group facilitators, and three researchers formed the Action Research group. A qualitative descriptive approach was undertaken to describe the experiences of the midwives. Data were collected using focus groups, surveys and checklists and analysed using thematic content analysis. Findings: The midwives’ initial fears and misgivings about undertaking the new role of group antenatal care gave way to a growing confidence in their abilities and group facilitation skills. They appreciated: the benefits of the CenteringPregnancy model for pregnant women; new opportunities to develop positive relationships with women and their colleagues; and the structured support and education throughout all stages of the Action Research process. Conclusion: The midwives were enthusiastic about their experiences of becoming CenteringPregnancy facilitators and described the benefits of this model of care compared to traditional one-to-one antenatal care. Support and education of the midwives through structured Action Research cycles enhanced the effective implementation of this new model. ß 2012 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction In most high-income countries, such as Australia, antenatal care consists of a scheduled program of individual consultations. Group antenatal care takes a different approach combining social support from peers and trained facilitators with the traditional elements of care and education.1 In the United States of America (USA), this model, known as ‘CenteringPregnancy’, has existed for the past decade.1,2 Antenatal care is provided in small groups of 8–12 women with a midwife or doctor specially trained in group facilitation and a co-facilitator. Women of a similar gestational age join a CenteringPregnancy group after their initial one-to-one ‘booking’ appointment and receive the rest of their antenatal care within that group. CenteringPregnancy is founded on a set of core
* Corresponding author at: Centre for Midwifery, Child and Family Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2009, Australia. Tel.: +61 2 9514 4886; fax: +61 2 9514 4835. E-mail address: [email protected] (Caroline S.E. Homer).
concepts known as the ‘Essential Elements of CenteringPregnancy’ (see Fig. 1).2 These elements provide a framework for the groups and are necessary to ensure model fidelity. CenteringPregnancy has been widely implemented and evaluated in North America1,3,4,5,6,7,8 and more recently in Australia,9 the United Kingdom10 and Sweden.11 Based on the promotion of social support and communication, the model enables more time to be spent with the antenatal care provider compared with one-to-one care, with opportunities for information sharing and for learning from, and supporting, one another.6 Two randomised controlled trials of CenteringPregnancy care have been undertaken. The first (n = 1047) demonstrated that women in group care were significantly less likely to have preterm births compared with those who received standard care (9.8% vs. 13.8%; OR 0.67, 95% CI 0.44–0.98) and had higher rates of breastfeeding and satisfaction with care.4 The second trial (n = 322) found that the group model was effective in meeting pregnant women’s needs in a military setting, where it is acknowledged that women personnel and partners of military personnel are often isolated.12 Women in military settings
1871-5192/$ – see front matter ß 2012 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. http://dx.doi.org/10.1016/j.wombi.2012.08.002
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A. Teate et al. / Women and Birth 26 (2013) e31–e36
•
Health assessment occurs within the group space
•
Women are involved in self-care activities
•
There is stability of group leadership
•
A facilitative leadership style is used
•
Each session has an overall plan
•
Attention is given to core content; emphasis may vary
•
The group conduct honours the contribution of each member
•
The group is conducted in a circle and group size is optimal to promote the process
•
The composition of the group is stable, but not rigid
•
Involvement of family support people is optional
•
Group members are offered time to socialise
•
There is on-going evaluation of outcomes Fig. 1. Essential elements of CenteringPregnancy.2
2. Methods
stages made-up the first action cycle. These were: the ‘Development’ of the model to meet the appropriate requirements of the setting; the provision of ‘Information’ about the model to staff at both hospitals; and the ‘Education’ strategies undertaken to enable the midwives to learn about CenteringPregnancy and gain group facilitation skills. The nine subsequent action cycles took place during the ‘Implementation’ of the groups at the five clinic settings. Each of these nine cycles involved the delivery of a CenteringPregnancy group preceded by a Facilitator Meeting. At the Facilitator Meeting, the midwife facilitators and the researchers who formed the Action Research group engaged in a process of reflecting on previous experiences to inform structured planning for the next session. The researchers provided education and skills development activities at each Facilitator Meeting. Specific activities were also introduced in accordance with the CenteringPregnancy framework.
2.1. Setting and participants
3. Data collection
experienced a sense of community in their groups and gained knowledge and power as healthcare consumers. Other nonrandomised studies have demonstrated reductions in social isolation, prematurity, low birth weights and improvements in women’s social and emotional outcomes.3,5,13 Despite these studies, there is very little written about the experiences of midwives and others who facilitate CenteringPregnancy groups. The Australian CenteringPregnancy Pilot Study was conducted in Sydney in 2006–2008 to explore the feasibility of implementing group antenatal care in Australia.9 This paper reports on one arm of the Pilot Study, known as the ‘Midwives’ Study’ which aimed to explore the experiences of the midwives who undertook the new role of group facilitator. Ethical approval for the study was obtained from the area health service and university.
The study was conducted in three antenatal clinics and two community health centres as part of antenatal care provided by two public maternity services in southern Sydney. Eight midwives, all of whom were experienced in providing traditional antenatal care, participated in the study and facilitated the groups. With the researchers, they formed the Action Research group.
The three forms of data collection in the Midwives’ Study were: Pre-study and post-study self-reported surveys Checklists completed after each of the eight CenteringPregnancy group sessions A focus group after all the group sessions had been completed
2.2. Methodological approaches A qualitative design based on two methodological approaches: Qualitative Description and Action Research, was used. Qualitative Description was used to gain an understanding of the midwives’ experiences of providing group antenatal care for the first time. This approach enabled an understanding of the changes experienced by the midwives14 and the collection of a broad selection of data offered an ‘everyday’ description of their experience.15 Action Research provided an iterative framework for the overarching pilot study within which the Midwives’ Study was embedded. A structured, cyclical process of Action Research occurred throughout data collection and analysis, with evaluation, enquiry and action incorporated as integral parts of each action cycle.16,17 Fig. 2 depicts the overall design of the pilot study and the 10 action research cycles, each of which used a process of ‘Reflect, Plan, Act and Observe’, consistent with action research methodology.16,17 The study was divided into four major stages: Development, Information, Education, and Implementation. The first three
3.1. Pre-study and post-study surveys The self-reported pre- and post-study surveys were designed to explore the preconceptions and post-study perceptions of the midwife participants regarding group antenatal care. The content of the two surveys was essentially the same except that the prestudy survey had three additional questions about the midwife’s professional and clinical experience and current role. 3.2. Checklists After each Centering Pregnancy group session, the midwives completed a checklist that explored: their group facilitation skills; the highlights, challenges and issues that had arisen in the session; their perceptions of how facilitative or didactic they had been; how involved they felt the women had been; and their confidence levels. These checklists were used in the Facilitator Meetings to inform each of the Action Research cycles and to plan the Centering
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Fig. 2. Action Research design.
Pregnancy sessions. Field notes were also made by the researchers each of the Facilitator Meetings. 3.4. Analysis 3.3. Focus groups Focus groups are an important method of data collection for Action Research and aim to facilitate the sharing of experiences, attitudes and opinions between participants.17,18 The focus group was held two weeks after the last Centering Pregnancy group session. Six of the eight facilitators attended the discussion which was audio-recorded and transcribed verbatim. Structured questions guided the focus group.19These were: Why were you interested in being involved in the CenteringPregnancy study? How did you find your experience of learning to facilitate? Working in the CenteringPregnancy model – what are your views feelings/comments? What are your suggestions for future practice?
A simple thematic analysis was used to analyse the pre- and post survey and the checklists. A more structured thematic analysis was used to analyse the focus group data; this involved reading and exploring the similar concepts and meanings and then grouping them together.20 These groups of meaning statements became a meaning unit. Meaning units were then grouped together and became codes. Further analysis of the codes resulted in categories and eventually an overarching theme. The findings from the surveys, checklists and focus group were then synthesised in order to identify patterns and summarise overall findings. 4. Findings The professional experience of the midwives ranged from 1 to 15 years, with most having more than seven years of experience.
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Fig. 3. Theme and codes from the focus group.
Two midwives worked predominantly in the antenatal clinic, two held clinical educator positions and two worked between the antenatal clinic and the birth suite providing antenatal care in a midwives’ clinic. The final two provided midwifery continuity of care in a team midwifery program. 4.1. Survey findings Before the study, midwives were positive about the concept of group antenatal care and believed it would be a ‘rewarding’ experience for women. After facilitating eight group sessions they were convinced that Centering Pregnancy ‘. . . improves support, community and networking’ which was important. For the most part, CenteringPregnancy was described as a rewarding way to work and decreased the repetition of individualised antenatal care. There were, however, some negative comments related to the time required to implement and develop the model. This included, ‘difficulties with rostering’and how planning was ‘a very tiring process for the midwife’. Actually facilitating a group allayed initial concerns, particularly about undertaking the antenatal assessment in the group setting, managing the group processes and facilitating the group discussions. The midwives felt they developed confidence in skills related to group facilitation, for example, their ability to: ‘throw things back to the group – not talk too much myself’. Open-ended questions in the surveys asked about the midwives’ highlights and challenges. The participants were positive about learning new skills and developing relationships with each other. They appreciated being able to share with like-minded and respected colleagues learning new skills: ‘watching my cofacilitator develop’, ‘gaining confidence to facilitate a group’ and ‘being a part of something new and exciting’. The midwives valued the relationships they were able to develop with the women by providing continuity of care through pregnancy: ‘getting to know the women’. They observed the women developing self-confidence and supportive relationships: ‘watching
the women get to know each other and support each other’. They felt this led to ‘long-term support after the birth and a decrease in the need for postnatal care and the loneliness for the women’. 4.2. Findings informed by the checklists The checklists were analysed prior to each Facilitator Meeting. These findings, together with the field notes that were made by the researchers, informed the content and learning topics for the subsequent Facilitator Meeting. The checklists were used predominantly to inform the Action Research element of the over-arching pilot study but they were useful in identifying the growing confidence of the midwives as they experienced group facilitation. 4.3. Focus groups findings The principal theme to arise from the analysis of the focus groups was: ‘Building and maintaining relationships’; this was developed from seven codes: ‘Getting involved’, ‘Giving it a go’, ‘Getting prepared’ ‘Becoming a facilitator’, ‘Meeting together’, ‘Trusting Centering Pregnancy’ and ‘Creating communities and connections’ (Fig. 3). 4.3.1. Getting involved The midwives talked about the process of ‘getting involved’, which for most was not voluntary: ‘I wouldn’t say we initially volunteered for it. We were sent to the two-day workshop. We volunteered after that. We had no understanding of what we were going to do’. One midwife identified the importance of having information about CenteringPregnancy before getting involved: ‘Initially I think, a little bit more explanation about what you are actually getting into would be [have been] good, because I really didn’t have any idea.’
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Once the midwives gained an understanding of CenteringPregnancy they engaged positively and were attracted to the philosophy, for example: ‘. . .it’s a wonderful opportunity [for pregnant women] to meet others who are doing the same thing at the same time, to learn from one another and make lifelong friends. . . also a wonderful opportunity to be able to develop your skills in a group’. 4.3.2. Giving it a go ‘Giving it a go’, reflected the air of optimism and hope in the early stages of implementation. Despite their initial reservations, the midwives reflected on embracing the new model positively: ‘It was worth giving it a go. I was willing to try, because you can’t knock something if you haven’t done it’. The midwives wanted to ‘give it a go’ and were positive about the benefits of group care, but they also acknowledged being ‘overwhelmed’ at times. The process of development and implementation of this new model required a great deal of work, time and commitment: ‘Yeah, volunteering the amount of time and energy that would be expected. I didn’t appreciate that’. The midwives were challenged by the process of recruiting women to a model of care that they could not recommend from personal experience: ‘Now I would be able to say it is a great way of actually gaining all their knowledge, developing relationships and a sense of community’. Resistance from colleagues was sometimes described as a negative and confronting experience but this negativity often decreased once colleagues had ‘given it a go’. One midwife who had her colleagues rotate into the co-facilitator role said, ‘after they did a group, they’re like ‘‘This is fabulous!’’[It] totally changed their mindset’. 4.3.3. Getting prepared The importance of ‘getting prepared’ was highlighted. Information sharing about group facilitation was key to gaining confidence. This was linked to the logistics of organising group sessions, such as choosing an appropriate group venue: ‘After the first session we knew we had to move the venue and then once we moved into a bigger venue it just was great’. 4.3.4. Becoming a facilitator The midwives initially found it difficult to ‘trust the process’ of group facilitation: ‘Just practising being a facilitator was very difficult’. They were worried that the women might not readily discuss issues: ‘I was really scared that I wouldn’t have enough information, as in enough prepared, in case they didn’t talk’. After gaining experience with facilitation, the midwives learnt to have faith in the flow of group discussions: ‘It’s hard to learn that facilitator role, like, you know, sometimes you did just want to give the answer, but if you waited, then the women themselves would give the response’. Personal satisfaction with group facilitation skills was reinforced by seeing their group communicating effectively and working together: ‘It was mind-blowing just how much I could just sit back and allow the group to run itself and there was no pressure, it was just easy to facilitate this group. . .’. The process of change and personal growth was described with enthusiasm: ‘I have gained more confidence in myself, in my practice and in what I do know and I don’t doubt myself anymore’. This appreciation extended to their perceptions of their co-facilitators: ‘She just grew. . . it was really fantastic and she could do anything now. I mean she is a really good midwife and has a lot of knowledge, but she just blossomed’. 4.3.5. Meeting together It was important to ‘meet together’ regularly throughout the study. This included the initial CenteringPregnancy ‘Group Skills’ workshops, planning meetings, Facilitator Meetings and extra
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planning and de-briefing meetings with their co-facilitators. They valued coming together as a group to discuss concerns, share experiences and plan for each group session, for example, ‘It was drummed into us at the beginning that it was to be a facilitative process and that we had to sort of throw it back to the group. So we actually got really good at it’. 4.3.6. Trusting CenteringPregnancy In the early days the midwives’ main area of concern was the antenatal assessment component of the model; this was expected to be a focussed process on a mat in the group room just outside of the group circle, with approximately three minutes allocated for individual assessment – abdominal palpation, fundal height measurement, and identification of wellbeing for the woman and her baby. The idea behind this feature is that all discussion and information sharing can take place in the group so that everyone is able to contribute: ‘My issues about the group initially were that I had this thing about this three minute check’. The midwives had a sense that their role as a competent midwife was built on effective oneto-one communication with individual women and not ‘dealing with a group of people. Never done anything like that before. I’m fine with one-on-one but, get a group together and I go to jelly’. As they engaged in ‘Trusting CenteringPregnancy’, the midwives valued the model and their new role in terms of understanding the benefits for women, particularly the educational component of the model: ‘. . . they said they actually got more than when they went to the childbirth classes’; and, ‘I’ve actually had a turnaround with my philosophy with childbirth education; it has completely changed’. 4.3.7. Creating communities and connections ‘Creating communities and connections’ describes how the midwives experienced CenteringPregnancy as a worthwhile journey, enabling them to develop stronger relationships with their peers and the women. This gave them immense job satisfaction: ‘it was rewarding. . . I just enjoyed it immensely’. The midwives described the benefits for midwives, students, pregnant women and their partners in terms of the connections that are fostered: ‘In the end it wasn’t about the education it was about the connection and that connection is really important’. The midwives suggested that students and newly graduated midwives could provide group antenatal care, believing that an understanding of the model and principles of CenteringPregnancy was more important than years of experience in midwifery. A newly qualified midwife reinforced this saying: ‘At the beginning I was ‘absolutely petrified’. Now I feel so much more confident as a midwife. I have learnt so much. It didn’t matter how junior I was to the rest of my colleagues who were also a part of it. You’ve created a relationship with them and we had fun you know, we laughed’. When comparing with standard antenatal care, the midwives thought that CenteringPregnancy provided more learning opportunities for women and a more meaningful way of working for midwives: ‘. . . I worked in Antenatal Clinic for three months. Back then, it just struck me that it was such a waste of time. These poor women would come and sit around for hours, waiting and then they would be seen for five minutes and the person seeing them wouldn’t even know their name.’ An unexpected benefit was that, after being exposed to the opportunity to develop relationships with women in the groups, the midwives found that they were eager to explore how they might provide continuity of care through pregnancy, labour and birth and the postnatal period. The midwives suggested that, ultimately, it was the time and space that the group environment provided women that was most important: ‘And maybe that is actually even more valuable than what we did. The time gave them time to develop a network, which is something that women really struggle with in our community.’
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4.3.8. Summary of findings Analysis of the data showed that the midwives’ initial fears and misgivings about this new role as a CenteringPregnancy group facilitator had given way to a new confidence in their abilities and skills. The demands placed on the midwives during the implementation phase did impact on their usual work practices and increased their workload. These challenges were, however, offset by their appreciation of: ongoing and structured support provided throughout all stages of the Action Research process; the opportunity to gain new skills; and the development of positive relationships with both women and colleagues. 5. Discussion The Midwives’ Study aimed to describe the experiences of the midwives involved with the implementation of the first CenteringPregnancy groups in Australia. There are few studies about the experience of midwives’ who provide care on an individual basis or within groups.21 Midwifery care is recognised as being deeply rooted in providing one-to-one care to women and the epitome is to develop a trusting relationship between the midwife and the woman through continuity of care through pregnancy, labour and the early postnatal period.22–25 Although the midwives in this study were not providing intrapartum or postnatal care, CenteringPregnancy meant they could provide antenatal care in a way which gave them the opportunity to develop relationships with women and colleagues. This can be explained by the philosophy and structure of CenteringPregnancy, including consistent facilitation which enabled an awareness of women’s individual lives and fostered a sense of knowing in the group.6 As described by the midwives in this study, valuable connectivity can occur where women have time to share their ideas, stories and expertise in a group setting.6,23 The Action Research group played a significant role in providing a framework for supporting the midwives to become confident and effective group facilitators. Peer support and the opportunity to enhance confidence through learning are significant factors in professional and organisational change.26 The Facilitator Meetings provided a forum where they could explore the demanding challenges of undertaking a new model of care on top of their usual clinical role; the resistance they encountered from some colleagues; and their fears about group facilitation. Action Research can be particularly useful when implementing new projects in health care as its approach is problem focused, context specific, participative, involves change intervention and is based in a continuous interaction between research, action, reflection and evaluation.16,17 Through the regular Action Research group meetings the midwives felt valued and supported by their peers in a time of transition; these are known factors that improve job satisfaction for midwives and it has been suggested that adequate resources need to be in place for professional development and support initiatives to foster sustainability.26–29 6. Conclusion This small study adds to the increasing body of knowledge about CenteringPregnancy and group antenatal care. The midwives’ initial fears and misgivings about undertaking the new role of group antenatal care gave way to a growing confidence in their abilities and group facilitation skills. They appreciated: the benefits
of the CenteringPregnancy model for pregnant women; new opportunities to develop positive relationships with women and their colleagues; and the structured support and education initiatives throughout all stages of the Action Research process. References 1. Rising S, Powell Kennedy H, Klima C. Redesigning prenatal care through CenteringPregnancy. Journal of Midwifery and Women’s Health 2004;49(5):398–404. 2. Rising S. CenteringPregnancy: an interdisciplinary model of empowerment. Journal of Nurse-Midwifery 1998;43(1):46–54. 3. Ickovics J, Kershaw T, Westdahl C, Rising S, Klima C, Reynolds H, et al. Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obsterics & Gynecology 2003;102(5):1051–7. 4. Ickovics J, Kershaw T, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics & Gynecology 2007;110(2 Pt 1):330–9. 5. Klima C. CenteringPregnancy: a model for pregnant adolescents. Journal of Midwifery and Women’s Health 2003;48(3):220–5. 6. Massey Z, Rising S, Ickovics J. CenteringPregnancy group prenatal care: promoting relationship-centered care. JOGNN – Journal of Obstetric Gynecologic & Neonatal Nursing 2006;35(2):286–94. 7. Baldwin K. Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care. Journal of Midwifery & Women’s Health 2006;(51):4. 8. Baldwin K, Phillips G. Voices along the journey: midwives perceptions of implementing the CenteringPregnancy model of prenatal care. The Journal of Perinatal Education 2011;20(4):210–7. 9. Teate A, Leap N, Rising S, Homer CSE. Women’s experiences of group antenatal care in Australia – The CenteringPregnancy Pilot Study. Midwifery 2011;27(2):138–45. 10. Gaudion A. Findings from a UK feasibility study of the CenteringPregnancy model. British Journal of Midwifery 2010;19(12):796–802. 11. Wedin K, Molin J, Svalenius E. Group antenatal care: new pedagogic method for antenatal care – a pilot study. Midwifery 2010;26(4):389–93. 12. Kennedy H, Farrell T, Paden R, Hill S, Jolivet R, Willetts J, et al. ‘‘I wasn’t the only one’’: Women’s experience of group prenatal care in the military. Journal of Midwifery & Women’s Health 2009;54(3):176–83. 13. Grady M, Bloom K. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. Journal of Midwifery and Women’s Health 2004;49(5):412–20. 14. Creswell J. Research design: qualitative, quantitative and mixed method approaches. 2nd ed. London: Sage; 2002. 15. Sandelowski M. Using qualitative research. Qualitative Health Research 2004;14(10):1366–86. 16. Reason P, Bradbury H, editors. Handbook of action research. 4th ed. London: Sage; 2006. 17. Somekh B. Action Research: a methodology for change and development. Glasgow: Open University Press; 2006. 18. Hansen E. Successful qualitative health research: a practical introduction. Sydney: Allen and Unwin; 2006. 19. Burns N, Grove S. The practice of nursing research: conduct, critique, and utilization. 5th ed. St. Louis: Elsevier Saunders; 2005. 20. Graneheim U, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 2004;24(2):105–12. 21. Hunter B. Emotion work in midwifery: a review of current knowledge. Journal of Advanced Nursing 2001;34(4):436–44. ´ lafsdo´ttir O ´ ., Kirkham M. Relationships: the 22. Hunter B, Berg M, Lundgren I, O hidden threads in the tapestry of maternity care. Midwifery 2008;24(2):132–7. 23. Leap N. The less we do the more we give. In: Kirkham M, editor. The midwife– mother relationship. 2nd ed. London: Palgrave Macmillan; 2010. [Chapter 2]. 24. Stevens T, McCourt C. Changing practice. One-to-one midwifery practice. Part 3: meaning for midwives. British Journal of Midwifery 2002;10(2):111–5. 25. Homer C, Brodie P, Leap N, editors. Midwifery continuity of care: a practical guide. Sydney: Elsevier; 2008. 26. Ball L, Curtis P, Kirkham M. Why do midwives leave?London: Royal College of Midwives; 2002. 27. Kirkham M, Morgan R, Davies C. Why do midwives stay?Sheffield: Women’s Informed Childbearing and Health Research Group: University of Sheffield; 2006. 28. Sullivan K, Lock L, Homer C. Factors that contribute to midwives staying in midwifery a study in one Area Health Service in New South Wales, vol. 27. Australia: Midwifery; 2011. pp. 331–335. 29. Kirkham M, Stapleton H. Midwives’ support needs as childbirth changes. Journal of Advanced Nursing 2000;32(2):465–72.