Exploring midwives’ perception about their competency during the second and third stages of labour: a qualitative study

Background: Midwives play a vital role in the healthcare system and women’s birthing experience. However, few research studies have focused on midwives’ professional competency, confidence, skills, and knowledge, specifically during the second and third stages of labour. Purpose The study aims to explore midwives’ perception of their competency during the second and third stages of labour. Methods: This was a qualitative descriptive study based on semi-structured in-depth interviews. The participants in this study were six female midwives who worked in the labour room and provided care to pregnant women during delivery. The study was conducted from 20 December 2021 till 9 January 2022 in the Maternal and Child Hospital in Sakaka Aljouf region in Saudi Arabia. Results: Three categories describe the result (1) the perception of competency; (2) the factors that support midwife’s competency; (3) factors that hinder midwives competency. Participants revealed that they learn about competencies through their job policies. Surveyed Midwives consented that professional knowledge is mostly gained from colleagues, work environment, and self-education due to the lack of guidance to support their practice. It is found that university education and training, type of educational program and accumulated experience are important factors in enhancing a midwife’s competency, while lack of the scope of practice, lack of training opportunities and tools, workload, lack of clarity of work policies and procedure, lack of managerial support, management support issues and work security, and rotation inside department are among the most significant barriers to the improvement of midwives' practice. Conclusion: Given the important role of midwives in the healthcare system, it is necessary to enhance supporting factors and remove hinders to help them improving their skills, knowledge, competency, and clinical practice.


Introduction
Midwives' Competency is a critical component and pivotal in the quality of midwifery care.It is also a fundamental part of safe clinical practice.Confidence, knowledge, competence, and skills are required in the midwifery profession midwife competency and confidence can save lives [1,2].A midwife is a healthcare professional who has completed a midwifery education program, acquired the appropriate requirements to be a registered midwife, and demonstrates competency in midwifery practice.Midwives are essential in providing high-quality sexual, reproductive, maternal, and newborn care [3,4].
Competence is "the combination of knowledge, psychomotor, communication, and decision-making abilities that enable an individual to do a specific work to a set level of competency" according to the International Confederation of Midwives (ICM), 2018.This aligns with the WHO's definition of competence in their document outlining sexual and reproductive health core competencies in primary care as: "The successful demonstration of important skills, attitudes, and professional behaviours on a specific task, action, or function in the work setting tying the concepts of competence and professional role together" [5].Competency concerning midwives is defined as the capacity of the qualified midwife to practice effectively safely, and perform her professional responsibilities within her scope of practice described as a continuous connection between knowledge, skills and abilities [6].
The midwife's role as a professional has been recognized by the ICM.In the practice's scope, the midwife is considered a responsible and accountable professional who interacts with women to provide the necessary support, care, and counsel during pregnancy, labour, and postpartum, conducts births independently, and cares for the baby and infant [5].
This work should include antenatal education and preparation for parenthood and may extend to women's health, sexual or reproductive health, and childcare.Furthermore, an assessment of midwives' essential competencies is required to identify areas for improvement [2].The (ICM) International Confederation of Midwives, 2019 is a global federation of midwifery associations [7].ICM has created a list of required competencies for becoming a midwife and a definition of midwives' scope of practice.Training and Education levels differ from country to country, as does the content and status of the curriculum.Midwifery education and training vary from country to country, as does status, curriculum content, length, and level.

Methods
A qualitative descriptive phenomenological design was used to explore the midwives' perception of their competency during the second and third stages of labour and find answers to the research questions, which guided the interviews in this study.As the objective of the current study, the researcher aims to explore midwives' knowledge about the competency guiding their practice during labour.Therefore, phenomenological research is a holistic approach and seemed the most appropriate to use in this study as it explores midwives' perceptions about their competency during the second and third stages of labour.An informative description' of individuals' lived experience; phenomenology is considered a method to analyze people's ordinary life experiences based on a philosophical tradition created by Husserl and Heidegger.Further, the study attempts to identify the facilitators and barriers for midwives to work within the competency framework at AlJouf region in Saudi Arabia.
In-depth knowledge of the experiences is sought, with initial emphasis on literal description.The meaning individuals ascribe to their experience is then analyzed and interpreted.Semi-structured interviews as a method of data collection were used.The researcher may want to double-check that their qualitative interview covers a specific set of subjects.In a semi-structured interview, the researcher produces a written topic guide, which is a list of areas or questions to be covered with each participant.Data were collected using semi-structured interviews to direct participants' responses.Face-to-face interviews were conducted with the six midwives.The discussions happened in a private room in the labour unit.With an interview guide focusing on the experiences and personal perspectives of the midwives in their perception of their competency during the second and third stages of labour, the researcher used open-ended questions during the interviews to support the interviewees in describing their experiences and personal perspectives and encouraged them to talk freely.The interview is tape-recorded, and each interview takes about 40-60 minutes, including twenty-fife questions adapted from previous literature reviews and utilized to achieve the purpose of the current study, which is the assessment of midwives' competency in Saudi Arabia.
The participants in this study were six female midwives who worked in the labour room and provided care to pregnant women in delivery.The midwives have met the inclusion criteria and expressed interest in participating in this study.
Qualitative research has no sample size limit as the decisions depend on data saturation.A purposive sampling strategy was used to avail of accessible participants with different demographic profiles (i.e., age, year of experience).Furthermore, midwives working at least six months in the labour room were included in this experience range, as even supported in the literature.Newly qualified midwives may have formal competence, but they lack experience and do not have actual competence.The target of including midwives is those who meet the sample criteria and consent to participate in the study.This sample size is appropriate for this research design as it illustrates that this type of research is about obtaining detail about perceptions and understanding of a particular group of participants and not about making general claims.
The sample was accessed through the attendance of midwives at the hospital.The researcher got access through the nursing department, which facilitated their access to meet with midwives in the workplace and conduct interviews with them face-to-face.They also provided the names and duties roster for the midwives.The participants were contacted and informed about this study.Six eligible participants showed their willingness to participate.During the conduction of the study interviews, two midwives were on vacation.And then exclude them from the sample.
Inclusion criteria: The sample included midwives who fit the following criteria is that, 1. Midwives, 2. Midwives working in labour room DR, 3. Had workplace experience of more than six months in the labour room, 4. Agreed to be part of the study.
Exclusion criteria: 1. Nurses, 2. Midwives who work in antenatal and postnatal, 3. Midwives who have less than six months in the labour room DR.

Data collection
The study was conducted from 20th December 2021 till 9th January 2022 in Maternal and Child Hospital in Sakaka Aljouf region in Saudi Arabia.The duration of data collection was set for three weeks so midwives could choose a suitable time for conducting their interviews, keeping in mind their working schedule.After a brief description of the study was provided to the midwife's participant and each participant agreed to participate and signed a consent form, a semi-structured interview was followed to guide the conversation and respond to the research questions.The consent form asked midwives participants to sign up, and they were informed could withdraw from the project anytime if they wanted to.Consent for recording was obtained.The data were recorded on a digital audio recorder.Given that the consented recordings were saved on the platform, the interview was further used in the analysis process.These recordings were secured in the researcher's professional account with password protections that cannot be easily accessible.

Data analysis
In light of the targeted interview questions, the recorded interviews for six registered midwives were transcribed and analyzed using a thematic analysis approach.By comparing the transcripts to the Submit a manuscript: https://www.tmrjournals.com/inrecorded interviews, the accuracy of the transcripts was ensured.Data saturation was obtained by performing data analysis alongside data collecting until no new data was collected.The data analysis procedure was recursive, and the researcher repeated it several times to get the desired data richness.Before beginning the data analysis procedure, all the phone-recorded interviews were transcribed verbatim and then validated by relistening to the tape and rereading the transcripts (Figure 1).

Ethical consideration
Ethical approval was requested from the Ethical Nursing Research Committee in the Faculty of Nursing at Umm Al-Qura University (ethical approval number 097).Moreover, permission to conduct the study was obtained from the Ministry of Health, Saudi Arabia, to conduct at the hospital.Written and verbal informed consent was taken from all participants before data collection.Participants were assured that their identities would not be revealed, and they were notified that participation is entirely voluntary, with the option to withdraw at any time.Each participant was given a brief overview of the study's background, goal, and purpose at the start of each interview.They were allowed to ask questions regarding the survey.

Results
The participants that were interviewed in this study included six registered midwives.The average age was 27-40 years, with a range of 4 to 11 years of experience.The study identified three significant labels in the analysis.These factors hinder midwives' practice of adhering to the competencies needed for the second and third stages of labour.The outcome of the thematic analysis revealed eight major themes and other sub-themes, as shown in the subsequent sections (Table 1).Perception of midwives about their competency Unfamiliar concept.Most of the study participants expressed their concept of term competency and most of them were unfamiliar with the terms of competency.The midwife believes that the concept of competence is closely related to the midwife's responsibilities.For example, she must know and learn to become scientifically qualified, have the necessary skills provided, information, knowledge and be aware of the medical terminology.Participants revealed that they learn about competencies through their job and their policy.Anything outside of job policy and procedure, the midwives don't pay attention to.

Figure 1 The Application of Thematic Analysis Process
Professional knowledge.Participants revealed that obtaining and receiving professional knowledge depends entirely on colleagues and healthcare providers.Second, third and fourth midwives in this study agreed that professional knowledge is gained from the same work environment and from colleagues as often the information is transmitted from colleague to colleague and within the department's policies.The midwife believes that achieving professional competence through self-education raises skills and knowledge.Also, the absence of educational resources in Arabic language hindered the digression in science and expansion.Lack of guidance.Most participants reported that the terms competency in the second and third stages of labour and professional competencies were unfamiliar and lacked guidance to support their practice.The midwives know the work precisely but are unaware of the competencies related to labour's second and third stages.They are unaware that midwives must follow standards or competencies because of hospital policies and how they differ from hospital to hospital and region.As a result, the midwife loses some essential competencies.Midwifery became a chore due to often ineffective policies.

Factors supporting midwives practice
The study results revealed the factors that support midwives to perform their practice at competent level.These factors included university education and training, experience, developing practice competency and personal qualities.
University education and training.The participants expressed their disappointment with the university and hospital's lack of chance of education.Most of the participants are technician midwives.The midwife believes that education is the basis of competence.
Conflicting scientific opinions and insufficient knowledge and awareness of the midwife may lead to legal issues.The lack of clarity of protocols during cases and the lack of sufficient knowledge of the midwife may cause harm to the patient too.
Training inside the university provides a great opportunity and gives enough time for exercise which will have an impact on the skill of the staff as well as the training centres inside the hospital.Type of educational program.Most midwives believe the type of educational program affects professional competence of midwives.Most midwives have diploma programs and the effect of the type of program had a great impact on preparing the midwives and providing them with basic information.This had an impact on raising their professional knowledge and thus raising their professional competence.Effect of experience.Most midwives believed that competence emerged from experience and practice.As professional knowledge develops, the course develops.Hence professional competence and not just considering the number of years of experience, is the only factor in developing their competency.Participant mentions that high education and courses are the primary ground for work competency.It is possible for a midwife with high professional qualifications that depends on education with little experience to be more competent than a midwife who has years of practice.Developing competency in clinical practice.Most midwives expressed that for achieving professional competency through practice and to expand the scope of work.Other factors include a suitable environment represented by management.The wrong location of the delivery room, lack of equipment, shortage of staff, and lack of training could negatively affect the development of competency of midwives.Self-confidence.Self-confidence is an essential requirement to achieve any work and achieve professional competence.Most participants revealed that confidence is necessary for a midwife to do her job in a competent way.Adequate knowledge and reasonable confidence can enhance midwives' competency.The absence of midwives' confidence can affect their communication with colleagues.The influence of a confident personality and the exchange of information and experiences can raise professional knowledge and thus increase the competency of the midwife.Moreover, the personality of the midwife affects the performance of her work.Every midwife perceives their competence in the stage as the procedure takes place.The midwife does not know the competencies associated with the second or third stage as a name, but they know the work related to this stage well.

Factors hindered midwives practice
Lack of the scope of practice.The lack of clarity in policies and procedures, lack of clarity in scope of practice, hospital policies of midwives in the delivery room, and the deficiency of staff directly affect the midwife's competence, significantly affecting the skills of midwives and, therefore, their competency.The difference in policies from hospital to hospital significantly affects and causes some midwives to lose their professional skills and competence.The midwife explains that she wishes to reach no professional competence.She hopes to complete the delivery process.The midwife is ready to take all the risks and performs her work efficiently and professionally.The midwife has no full powers, considering the workload and insufficient training.The midwife is self-reliant and self-taught.
The lack of clarity in the midwife's scope of practice led to her inefficiency in some skills.For example, in the episiotomy, the midwife does not know the scope of practice through her responsibilities and duties, significantly impacting her skill and learning.Then, her competency was affected due to the lack of knowledge and the lack of training courses.
The scope of practice is unclear to midwives due to the significant difference between hospital policies and those approved by the Ministry from region to region.Lack of training opportunities and tools.Most participants express that the absence of educational opportunities in health facilities and hospital affects the quality, follow-up of education and improved professional knowledge and competence of the midwives.The lack of training courses and midwives not updating the knowledge makes it hard to attain professional competency.Workload.The lack of staff numbers affects the quality and care provided to the mother, so there is a strong impact on the professional competence provided.The workload and the lack of preparation represents a major challenge in providing professional competence.Workload affects the delivery competency of midwives.There is a severe shortage of workers, there are resignations, and a lack of support from the administration.Lack of clarity of work policies and procedure.Most midwives do not have enough awareness and follow-up of the department and work policies, so they do not have a sufficient perception of the scope of their work and the competencies that exist in it.They do not know the limits of their work, and like the episiotomy procedure, the midwife one said that when she joined, there was no policy for episiotomy procedure, so she does not have the skill, therefore, she is not competent to do this procedure.The policies followed within the hospitals have a major role in establishing, maintaining, and lacking midwife's competency.The midwife had many skills and competencies in making the rapture of membrane and giving birth to the primary woman in another hospital.Still, when she moved here, she did nothing and became an assistant to the doctor because of policy and procedure.Management support issues and work security.Most participants expressed the job security, and the support of the administration achieves the competency of the midwife, and that the reason for her Submit a manuscript: https://www.tmrjournals.com/inlack of knowledge of the limits of work is that she is assigned to work outside the scope of her work.Also, lack of management support and health staff does not give the full opportunity to achieve competency.The long hours and staff shortage drain the midwife's energy and do not achieve efficiency.If there is management support for the midwife within the scope of practice and not assigning her to other tasks.One midwife said that when a doctor attends during her work and ordered the midwife to do a (fundal pressure -fundal pressure is a procedure prohibited inside hospital) and the midwife refused, doctor submitted a complaint that midwife was not cooperating during the work.Lack of managerial support.The midwives said that they are completely isolated from the rest of the hospital and that the administration does not provide adequate support regarding courses.The clarity of the job description and the support that is represented by the help of the staff.The administration does not provide adequate support to the midwife to exercise her scope of work, and with that, she becomes legally responsible for her violation of this because of the lack of adequate management understanding of her work and giving her rights.Moreover, due to the lack of management support for the midwife's scope of practice and the lack of adequate support, the midwife is afraid of legal issues as well as the issue of not following the commands of the hospital.This makes the midwife afraid of and unable to perform her work competency.Rotation inside department.Most midwives believe rotation expands midwives' knowledge but does not raise its competency in the second and third stages of labour.Still, it is possible to raise their confidence in themselves and raise their general competence.Although competencies before birth can raise and help the competencies provided during the second and third stages, for example, prenatal care for women, midwives can prevent dehydration when a woman is in the stage of childbirth; she can deal with and is active during that stage.

Discussion
This study explored the midwives' perception of their competency during the second and third stages of labour.The main findings in this study were that participants reported the factors they identified and how these factors affected their midwife's professional competency.The analysis was done using qualitative descriptive design.Thematic analysis of the midwives' statements manifests the following themes.The midwives were unfamiliar with the term competency, lack of guidance of competency in the second and third stages of labour and factors that support and hinder midwives from adhering to the competencies.Unfamiliarity with the concept of competency is critical in defining the level experience progression.This study highlights a critical point regarding the progression of midwives' experience in Saudi Arabia.
University education and hospital training majorly impact midwives' competency [8].Education needs and training are essential, and without continuous in-service training, the midwives' competence will recede, threatening the quality of midwifery education and the midwifery profession [4].Lack of opportunity for midwifery education in Saudi Arabia affects their competency and the existing program is insufficient to meet the need of midwives.The follow-up of courses inside a hospital and updating the knowledge also impact their practice and competency [9].
The quality of pre-service midwifery education must be improved with the learning environment and quality assurance systems being strengthened [10].In-service training and mentoring are also necessary to fill competency gaps among new graduates [11].Midwives' self-perceived fundamental competencies are influenced by their major, education level, involvement in teaching and access to training.It is advised that university-based midwifery education and in-service training opportunities be provided to develop the Chinese midwifery workforce to strengthen midwives' essential competencies.Enable midwives to deliver a broader spectrum of care to women, relevant regulations should be implemented [2].
The competence has emerged from experience and practice with basic of education, the effect of experience and hand skill on competency.The midwives considered the feelings of safety and security in the professional role where necessary, and they emphasized that professional experience creates protection.Moreover, most midwives felt safe in their professional position, and there was a link between the amount of hands-on intrapartum experience and increase in confidence and competence [1,6].
Developing competency through clinical practice can be achieved by a suitable environment represented by management.Some other factors may affect the clinical practice too, such as the wrong location of the delivery room, lack of equipment, shortage of staff and lack of training [1].All these factors could affect the development of midwives' competency [12].This is consistent with the study finding that the practice level was directly related to midwives' educational level, training related to active management of the third stage of labour, and knowledge level.To provide successful service to AMTSL, midwives should update their academic level and knowledge and improve their skills.All midwives should receive training from health facilities, and the regional government should improve midwives' educational level [12].
The characteristics related to personality play a significant role in raising professional competency [13].Self-confidence, a sense of responsibility, and communication with colleagues all support its success and its midwives' competency.This is in line with what was mentioned in the Patterson et al., 2000, study, whose findings suggest that personal attributes should be considered and addressed in recruitment and training rather than focusing on academic and clinical competency [14].The update of ICM about the competence for essential midwifery practice considered personal attributes as one of the professional competence components, and personal attributes were endorsed as Essential Competencies for Basic Midwifery Practice (ECS).Similar competencies and components were included in the 2013 version [5].
Midwives in our study reported the lack of clarity in policies and procedures, the lack of clarity in the scope of practice, hospital policies of midwives in the delivery room, and the deficiency of staff is directly linked to the effect on their competence significantly affecting the skills of midwives and therefore, their competency.Lack of clarity of work policies and procedures shows that the midwives do not have enough awareness and follow-up of the department work policies and procedures.This means they do not have sufficient perception of the scope of practice and the competencies that exist in it.In accordance with the present results, previous studies have demonstrated that midwives and nurses play a significant role in health facilities, but they still experience barriers and difficulties in expanding their practice.They must be empowered and enabled to broaden their practice and work within their full scope of practice when patient needs as the service requirements demand it [15].
The participants in our study mentioned that the workload due to the lack of staff numbers affects the quality and care provided to the mother in the delivery room.This also strongly impacts the midwife's professional competence [15].The workload and staff shortage represents a major challenge in providing professional competence.The workload in the unit and inadequate staffing levels made the midwives experience feelings of inadequacy when they had too little time available for the woman in labour.It was difficult for them to provide a continuous presence and they did not always have time to give that level of care [1,16,17].
The most interesting finding in this study was that the management support issue represented by job security and lack of support, because when the midwives remain unempowered, it can directly affect the competency.The midwives expressed several areas that lack managerial support, such as ack of training, increased workload without support with new staff and lack of guidance.The organization must be encouraging and providing support to midwives that will enable to grow their role professionally and make them more competent, acknowledged, and confident in their role [1].
Midwives in this study indicate the rotation inside the department was assigned and the work outside the delivery room expanded their Submit a manuscript: https://www.tmrjournals.com/inknowledge but did not raise its Competency especially in the second and third stage of labour.This result further supports the idea of Bäck et al., (2017) which states that midwives despised internal rotation because they felt it limited their ability to deepen their knowledge and build expertise in a certain profession [2].The midwives thought they weren't being treated as people, and the system divided them between different tasks.

Conclusion
To conclude, the purpose of the current study was to explore the midwife's perception of their competency during the second and third stages of labour.This study found that midwives were generally not familiar with the term competency in the second and third stages of labour.This is mainly due to the midwives being dependent on obtaining and receiving professional knowledge through colleagues and healthcare providers and lack of knowledge resources available.Another reason is the lack of guidance and support to their practice.An attention needs to be made towards midwives knowledge development in Saudi Arabia.Work settings are required to establish policies that empower midwives to continue education in the field through in-service training and education to upgrade their clinical knowledge.One of the most interesting findings in this study was that the management support issue, such as lack of job security and direct support in the case of the midwife's empowerment, would directly affect their competency.Finally, the findings of this research highlight the importance of midwives' competency and the factors that support and hinder midwives' competency.

Table 1 Interview code labels, themes, and quotations themes
Registered midwife 1: "To be familiar with specialty and occupation to be familiar with practical and paperwork to be efficient in that when I excellently perform work."Registeredmidwife 4: "The competency is when I assess the patient, for example, mother came, from the size of her abdomen, so I have a look through my experience."For the midwife at this stage to be able to assess the fetus's pulse or call for surgical intervention and see any abnormal condition and assess the situation of the pregnant woman, and her role during childbirth, the application of infection control standards, how many cases did she receive per month".Registeredmidwife 1: "I do not have an exact conception of the competencies at this stage, but I know that when the woman becomes at this stage, I check if any fetal distress and when the pregnant women were transferred to the operations".Such as the lack of tools, this is outside the midwife's ability, and therefore affects her efficiency.If the midwife gets her role in training, she will get competence -there is a lack of training courses here." Registered midwife 4: "The workload through the number of cases received, we have 2midwives only in shift.We received 9 cases."  Registered midwife 4: "There are midwives who have more than ten years' experience, but they have not reached the stage of competence time, and years are not an indicator of competence only."Registered midwife 2: "When I worked ahead of the department, I expend the scope of practice to get more skills and competency."Registered midwife 1: "Confidence brings competence and also competence brings confidence -confidence is an important and essential factor in midwifery work."Registered midwife 5: "When I have confidence in myself, I will deal with high risk and normal."Registered midwife 4: "The traits associated with the personality build a strong relationship with the mother and help in a safe and targeted intervention for the mother and give care efficiently."Factorsthat hinder midwives' practice to adhere to the competencies Lack of scope of practice clarity  Registered midwife 2: "Previously I was working in a different hospital I was doing every process even episiotomy, but when I transferred to this hospital the policy is not allowed to staff doing whole procedure now after four years, I lose the skill before I was doing." Registered midwife 3: "There is no clear job description.I moved between departments because of the lack of clarity in the job description.I have the right to know how to be directed and what things are.I want to know a clear path  Registered midwife 2: "I am a diploma graduate.I think that my competence is lower than that of my female colleagues who have a master's degree." Registered midwife 4: "If we were allowed to us to complete the study, I am a technician, and the study is for three years, I would not have obtained all the knowledge to become a perfectional." Registered midwife 2: " Registered midwife 6: "We suffer from staff shortage and administration people they do not know the scope of work and do not know how the work is going on and they do not provide support.There is a midwife on the counter on the files and another midwife with the cases."Submit a manuscript: https://www.tmrjournals.com/in