Elsevier

Midwifery

Volume 30, Issue 3, March 2014, Pages e96-e101
Midwifery

Effecting change in midwives' waterbirth practice behaviours on labour ward: An action research study

https://doi.org/10.1016/j.midw.2013.11.001Get rights and content

Abstract

Introduction

the use of water immersion for labour and birth has been shown to be beneficial for women in normal labour (Cluett et al, 2009). It was decided to use problem solving coordinator workshops to change in the way waterbirth practice was promoted and organised on labour ward. Findings from the first Action Research phase (Russell, 2011) led to the development of a waterbirth questionnaire to measure midwives' personal knowledge of waterbirth practice, waterbirth self-efficacy, social support and frequency of hydrotherapy and waterbirth practice. The aim of this paper is to share the questionnaire findings from an on-going action research study.

Method

prior to the first workshop 62 questionnaires were distributed to midwives (Bands 5, 6 and 7) working on labour ward. Subsequent questionnaires (n=53) were sent to Bands 5/6 midwives not involved in the workshops, at four (Group 2) and eight months (Group 3). N.B only Bands 5/6 midwives completed post workshop questionnaires. In total 169 questionnaires were distributed. One-way ANOVA with Tukey post-hoc test and the χ2 test were used to determine statistical significance.

Findings

96 questionnaires were returned (57%). Midwives' personal knowledge of waterbirth practice differed significantly between groups, (F2, 85=3.67, p<0.05) with midwives in Group 1 giving significantly higher scores (X¯=45.6, 95% CI [43.0, 48.2]), than those in Group 3, (X¯=41.7, 95% CI [40.0, 43.3]), p<0.05. Midwives' waterbirth self-efficacy did not differ significantly between groups (F2, 88=3.15, p>0.05). However scores for social support did differ (F2, 75=4.011, p=0.022), with midwives in Group 1 giving significantly lower scores (X¯=8.0, 95% CI [6.4, 9.5]) than those in Group 3 (X¯=10.5, 95% CI [9.4, 11.6]), p=0.016. Fifty-five per cent of Group 1 midwives facilitated a waterbirth in the previous three months compared with 87% in Group 3. Changes in the frequency of waterbirth for these groups were statistically significant (x2=4.369, p<0.05, df=1).

Conclusions

it appears that the co-ordinators were able to influence waterbirth practice because of changes in social support and frequency of waterbirth practice. Given the widespread and continued impact of the intervention, on midwives who attended workshops and those that did not, we feel it likely that a significant proportion of this change could be attributed to the introduction of problem solving waterbirth workshop. The findings from this study suggest that problem solving waterbirth workshops based on an action research format have the potential to normalise midwifery care within medically dominated hospital birthing environments.

Introduction

The use of water immersion for labour and birth was popularised following the Changing Childbirth report (Department of Health, 1993) which recommended that all maternity units in the United Kingdom (UK) provide women with access to a birthing pool. This move led to professional organisations (RCM, 1994, UKCC, 1994) accepting water immersion as part of UK Midwifery Practice. Over the ensuing decades research has established that water immersion enhances the physiology of childbirth (Otigbah et al., 2000, De Sylva et al., 2009), reduces the need for pharmacological analgesia (Geissbhuler and Eberhard, 2000, Eberhard et al., 2005) and supports the use of midwifery normal birth skills (Garland, 2011). Cluett et al. (2009) conclude that water immersion for low risk women is as safe as land birth. A review of maternity services in England (Healthcare Commission Report, 2008) identified that 11% of labouring women used hydrotherapy or gave birth in water and an average of seven waterbirths occurred each month, approximately 80 per year. The national birth place study (Birthplace in England Collaborative Group, 2011) found that women who gave birth in free standing midwifery units were four times more likely to achieve a waterbirth than those giving birth in an obstetric led unit. The differences in waterbirth rates by place of birth, suggest that access to obstetric led birthing pools may be limited by the number of labour ward midwives who advocate this type of care (Russell, 2011).

The aim of this paper is to share the questionnaire findings from an on-going Action Research study, which focused on improving the availability of hydrotherapy and waterbirth on one UK labour ward. Key findings from the first research phase suggested that labour ward midwives lacked confidence (self-efficacy) in waterbirth practice and identified co-ordinators as authority figures who regulated access to the poolroom and controlled less powerful midwives' clinical practice behaviours (Russell, 2011). Following dissemination of these findings to senior midwifery managers it was decided to use problem solving waterbirth co-ordinator workshops to initiate changes in the way waterbirth practice was promoted and organised. A questionnaire was developed to measure labour ward midwives' waterbirth practice (frequency), personal knowledge of waterbirth practice, waterbirth self-efficacy and levels of social support over the three research phases during a 12 month period.

Section snippets

Background

The research enquiry focused on a group of clinical midwives and labour ward co-ordinators working in an English obstetric led hospital. The maternity unit had one labour ward catering for 3800 births a year and was situated within a busy district General Hospital. There was no birth centre or midwife led unit in the locality. The labour ward had one poolroom, three portable pools and a waterbirth rate of 45 per year, prior to the introduction of the workshops. This rate represents half the

Problem solving waterbirth workshops

The main author and a waterbirth co-ordinator from a comparable unit (3900 births per year with no midwife led unit) where the waterbirth rate was 280 per annum facilitated the workshops. The waterbirth co-ordinator agreed to act as an Opinion Leader during the workshops. Opinion Leaders are part of the network of influences, which can convince individuals to adopt proposed changes in their own practice (Doumit et al., 2007). In this instance the Opinion Leader was from outside the organisation

Findings

A total of 169 questionnaires were distributed to labour ward midwives and 96 completed questionnaires were returned (57%). SPSS (version 19) was used to support the analysis of questionnaire data. The item scores for the individual sections were summated to give three new variables. These were called Total Personal Knowledge (Section A), Total Waterbirth Self-efficacy (Section B) and Total Social Support (Section C). Tests for normality on the distribution of scores for Total Personal

Discussion

The most significant change that can be attributed to the intervention is the increase in the levels of social support between Group 1 and Group 3 midwives. The levels of personal waterbirth knowledge, as measured by the questionnaire, decreased slightly. This decrease was not entirely unpredicted as Group 1 was the only group to contain labour ward co-ordinators. Higher personal knowledge scores for this group may indicate that co-ordinating midwives possessed sufficient understanding of

Limitations to the study

Before individuals act on this study, it is important to recognise its limitations. We acknowledge that this study is focused on one group of midwives in one hospital setting; we invite readers to consider how the findings could be applied to similar contexts and other hospital based midwifery services, but recognise that our findings would not apply to all midwifery clinical areas. Action research often needs to be a compromise between the reality of day to day working situations and the needs

Conclusion

The results from the questionnaire and the reported data on waterbirth rates suggest that the action research intervention may have influenced midwives' behaviours and changed organisational practices on labour ward. By encouraging co-ordinators to develop other colleagues, a process of support can be generated which drives changes in clinical practice forward. Given the widespread and continued impact of the intervention, on midwives who attended workshops and those that did not, we feel it

Sources of support

The Royal College of Midwives, Ruth Davies Bursary.

Acknowledgements

I would like to thank the midwives who agreed to take part in the study and my research supervisors for their undying support and belief in my abilities as a researcher.

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