Effecting change in midwives' waterbirth practice behaviours on labour ward: An action research study
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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- 1
Has developed the questionnaire tool, led the research and written the paper as part of her PhD studies.
- 2
The author has contributed to the research design and the writing and editing of the paper.
- 3
The author supervised the analysis of data and contributed to the writing and editing of the paper.